CTE in Football

INTRO

In 2005, Dr. Bennet Omalu reported evidence of Chronic Traumatic Encephalopathy in

the first American football player, Mike Webster.1 Since then, research and studies of this

devastating illness have become more extensive. Chronic Traumatic Encephalopathy or “CTE” is

a progressive degenerative disease of the brain, found in people with a history of repetitive head

trauma. CTE is associated with the buildup of an abnormal protein called tau, and can potentially

lead to memory loss, impaired judgments, confusion, impulse control issues, aggression,

parkinsonism, depression, and/or dementia. This disease is most commonly found in athletes,

particularly those participants in sports such as hockey, football, and boxing, but it is also often

found in veterans who have suffered multiple brain traumas. Although CTE has just recently

become prevalent in society, the effects have been documented in boxers since the 1920’s when

it was referred to as “punch drunk syndrome”.

The Concussion Legacy Foundation has formed the VA-BU-CLF Brain Bank. This

organization includes researchers from Boston University and the Veterans Administration, and

currently houses 70% of global CTE cases. Up until now, CTE has only been diagnosed in brains

donated to research posthumously. In the VA-BU-CLF Brain Bank, over 250 out of the 400 plus

brains have been discovered to have CTE. Even more surprising is that 110 out of 111 NFL

players studied have been tested CTE-positive.2 These results emerge from a collection that

represents selection bias because it is more likely that a person showing CTE symptoms before

they pass are more likely to donate their brain to research. This statistic still demonstrates that

this disease is not as rare as once believed, and shows the likelihood of a relationship between

playing football and the development of CTE. In the same study, traces of the tau protein was
also found in 48 of 53 college players (91 percent), and 3 of 14 high school players (21 percent).2

The youngest of the participants studied was 17 showing the implications of sports-related head

trauma from a younger age. The most severe cases, however, were found in the professional and

semi-professional players, in comparison to the younger players who showed mild pathology. As

the concern about concussions and their possible long term effects begin to grow, the

participation in football begins to decline. At the high school level, 11-player football

participation by boys in 2016-17 fell to 1,057,3823 from 1,080,6933 in 2015-16 according to the

National Federation of State High School Associations. This is a drop of 23,311 boys

participating in 11-player football within a year, and is the sixth yearly decline in seven years.5

Many parents, and even players themselves, are fearing the long term consequences of the sport

and therefore participation in ‘dangerous’ contact sports is declining both at the elementary and

high school levels. The avoidance of a potentially character building activity based on fear can

have too many drawbacks as well. Chronic Traumatic Encephalopathy can be the cause of

debilitating physical and mental problems for football players, but the risk of developing CTE

can be lessened with the implementation of a standardized definition of a concussion,

educational programs to improve coaching techniques and encourage proper tackling, and the

introduction of technically advanced headgear all of which limit the likelihood of repeated head

trauma.

Background

According to the Concussion Legacy Foundation, the most CTE diagnosed brains, 200

plus cases in their brain bank, were found in those donated by people who experienced head

trauma through tackle football. The next highest being 25 plus cases because of involvement in
the military.6 Tackle football, although a staple of American culture, has been the cause of

suffering by a great number of people. Despite the selection bias of the study, Boston researchers

found cases of the disease in 99% (110/111) of donated brains to their research, all from former

players in the National Football League.2

This high number of discovered cases is alarming, and clearly shows a connection between CTE

and participation in football. The same study found that a neurodegenerative-related cause of

death was the leading cause of death in former players with the more severe stages of the disease.

Even those with mild cases, 26 out of 27, had behavioral and/or mood issues prior to death.7

Although CTE has only been more recently studied, there appears to be a connection

between CTE patients and their tendency towards death by alcohol or drug abuse, or suicide. In

the study by Boston researchers, 27% of the players in their sample died by suicide, and this was

the leading cause of death amongst all those with stages 1-2 (mild).7 The suicide deaths of Junior

Seau, Ray Easterling and Dave Duerson have brought the urgency of CTE and chronic head

injury sustained through participation in football to attention.8 Concussions in sports has always
been an issue and while more preventative measures have been put into place, athletes are still

exposed to dangerous collisions toward the head.

The increasing prevalence of CTE negatively

affects is the decline in participation in football. In the

past year, the National Football League had a net worth

of 13.16 billion United States dollars and 136.37 million

people watched an NFL game on TV.9 It is safe to say

that American football is not going to completely

disappear in the near future, but less young people are

getting involved due to parents’ fear of the consequences

of participation in a high contact sport. Although an easy

and effective way to limit the likelihood of suffering

from serious head trauma, avoiding the sport has

unnecessary drawbacks considering there are other ways

to limit CTE in players. Playing organized football, even

at youth and high school levels, provide health benefits

such as improved speed, agility, strength, endurance, and hand-eye coordination. There are other

learning opportunities as team sports teach how to work with others, accountability for decisions

and actions, and discipline.

The Problem

The development of CTE causes serious symptoms that affect the lives of the afflicted

person and their entire family. The emergence of the symptoms; concentration issues,
disorientation, memory problems, dizziness, headaches, anger and other erratic behaviors, can

appear months or years after the last head injury, and currently the progression of the symptoms

can not be stopped.

Testing:

Concussion symptoms are very wide ranging, and many doctors will diagnose based

solely on a headache, which alone does not always signify there is a concussion. On the other

hand, a doctor only knows as much as a patient is willing to share. Therefore, there are those

who downplay symptoms in order to keep themselves from missing out on future games. The

inconsistency in the diagnosing of concussions can lead to under reporting which does not aid in

CTE research. The current concussion protocol is not strictly enforced nearly enough as some

players are cleared to play despite obvious concussion signs such as the Texans quarterback,

Tom Savage. Tom did not get up immediately after a huge hit, and had extended arms that

resembled the “fencing response”, a clear indication of a concussion. When he was diagnosed

with a concussion, it was not until after he had finished playing in the game.11 Misdiagnosis

means that more players are sent back into play, which can possibly lead to repeated head

trauma.

Education:

The ability to prevent head injury and CTE can be aided by the way the athletes play the

game, and how coaches teach and run practice. Many head injuries in football result from poor

tackling techniques including leading with the head or lowering the shoulder. Other common

mistakes in tackling include proper body placement, one-on-one tracking situations using

incorrect leverage points, and using improper strike points. These mistakes happen in

inexperienced players and therefore, through consistent coaching and use of specific drills, can
be fixed. If coaches can improve the athlete’s ability to tackle properly and safely, the amount of

head injuries would be reduced.

Equipment:

The type of helmet that is required to participate in football should be researched and

improved upon. There is no set standard for player equipment and unfortunately, it is up to the

players themselves to purchase which puts an extra cost concern on families. Schools and players

purchase many different types of helmets, and these can vary in price and effectiveness. At a

minimum the protective headgear with technological advances should be required and available

to all players despite cost.

The increasing prevalence of CTE is problematic as it is currently an incurable disease.

Although there is support and treatment for symptoms, most afflicted goes untreated because

their diagnosis occurs after death. Currently, the best option in approaching the problem is

through preventative measures. The love of the sport of football (and other major links to CTE

such as boxing and hockey) makes it unlikely that society as a whole will stop playing and being

spectators. However, it is important to start preventing such a horrible and destructive disease

and there are ways to lessen the impact of CTE on a large majority of football players. The

effects of CTE are detrimental to the patient and this issue must be addressed.

The Solution

Testing:

There is no standardization of concussion diagnosis across all levels, and the evaluation

processes that are in place are not always followed. In 2007, a concussion protocol was put into

place that requires four independent medical professionals, two athletic trainers, and an

unaffiliated neurological consultant be assigned to each team. When a player has had contact to
the head, there is an initial “sideline survey”. The sideline survey is a series of questions

including “Maddock’s questions”-a standard set of questions in sports concussion tests such as

repeated months in reverse order. Secondly, there is a neurological exam including an evaluation

of speech, sight, memory and the spine.10 At this point the player is either sent to the locker room

for a more extensive exam, or they are cleared to return to the game. Both the NCAA and high

school athletic conferences need to follow a more standard and equal protocol when it comes to

testing for concussions. These standardizations should include testing for balance or attention

impairments after a blow to the head, and a stricter guideline for returning to play immediately

after a head injury.

Education:

Researchers, including Erik E. Swartz, have been studying the effectiveness of

helmetless-tackling intervention (HuTT) in preventing head injuries in football players. This

study is meant to improve tackling behavior by holding practices without the use of helmets, and

therefore reducing head-impact exposure. The most significant finding was that “a helmetless-

tackling training program reduced head impacts by 28% in collegiate football players after only 1

season”.14 The study had two groups, 25 athletes assigned to the intervention group, and 25

assigned to the control group. The intervention group was exposed to five minute tackling drills

without their helmets and shoulder pads, and these drills occured twice a week during preseason,

and once a week during the competitive season.15 The education of coaches and athletes about

the seriousness and possible implications of repeated concussions will help reduce the likelihood

of developing CTE. There needs to be more programs dedicated to educating coaches, players

and parents, and implementing programs such as the helmetless-tackling practices.

Equipment:
 Helmets have been created with the ability to crumple after impact which slows down the

said impact, and lessens the force towards the head. An example of this new technology is the

Vicis Zero1 helmet “with a soft outer layer that crumples (and bounces back) after impact”, but

costs $1,500 making it inaccessible to a number of players at a lower level.12 Another

technology has been researched at UCLA called Architected Lattice. This research is dedicated

to developing “a novel, energy-absorbing microlattice material” which will replace the foam

inside football helmets, and will help prevent brain trauma by absorbing more energy from the

impact and limiting peak loads.12 The co-founder of Architected Materials, Alan Jacobsen, stated

that “one of the key innovations with our Architected Lattice technology is that it can be

manufactured quickly and cost-effectively”.13 Other research includes a “bristly textile with

spring-like fibers….that would allow the helmet to move independently of the outer layer”.12

This type of helmet design would be beneficial because many concussions are caused by the

movement of the neck not just a strong force to the head. Research needs to account for the thin

line that exists between the helmets creating improvement and making things worse. For

example if helmets are too heavy they can increase the acceleration because there is more mass

to the head which can increase the chance of head injury. The same increased risk of neck injury

can result from the soft shells that decrease the magnitude of the force, but increase the duration

of the impact. The amount of research being done to prevent head injury is extensive, and any

and all beneficial advances in helmet design should not only be required, but accessible to all

football athletes at every levels. This can be done by using cheaper materials that are just as

effective and implementing a mandatory use of such technologies within 5 years.

Conclusion
 Chronic Traumatic Encephalopathy has affected many football players, and by extension,

their families. It causes serious physical and mental health problems including dizziness,

attention deficits, anger and impulse problems, depression, and severe headaches. It is

debilitating, irreversibale and incurable, and therefore needs to be addressed with preventative

measures. Football is a staple of the American culture and committees within the NFL, NCAA,

and high school athletic programs must seriously consider a variety of improved approaches in

order to prevent injury to many of their athletes. This includes a more standardized and strict

concussion protocol in order to allow for correct diagnosis, prevention of early re-entry into a

game, and to keep research data correct. Also, the helmet designs with advance technologies

which continue to be researched must be mandatory for all players, and accessible to every level

of player. Finally, the education of all those involved in football, or any sport for that matter,

about concussions and CTE must be increased. Awareness and improved coaching techniques

such as helmetless-tackling practices can be implemented to encourage proper tackling in games.

If any combination of these techniques are put into effect on all levels of football, then the

amount of reported cases of CTE will be diagnosed and more lives would be spared.
 Works Cited

1. “Frequently Asked Questions about CTE.” Frequently Asked Questions about CTE | CTE
Center, BU Research Center, www.bu.edu/cte/about/frequently-asked-questions/.
2. “VA-BU-CLF Brain Bank.” Concussion Legacy Foundation, 26 Mar. 2018,
concussionfoundation.org/CTE-resources/brain-bank.
3. “2016-17 High School Athletics Participation Survey.” NFHS Handbook,
doi:10.1037/e307962005-001.
4. “2015-16 High School Athletics Participation Survey.” NFHS Handbook,
doi:10.1037/e307962005-001.
5. Cook, Bob. “Football Deathwatch: High School Edition.” Forbes, Forbes Magazine, 8
Aug. 2017, www.forbes.com/sites/bobcook/2017/08/07/football-deathwatch-high-school-
edition/#46133ed83d98.
6. “What Is CTE?” Concussion Legacy Foundation, 13 Apr. 2018,
concussionfoundation.org/CTE-resources/what-is-
CTE?gclid=Cj0KCQjwtOLVBRCZARIsADPLtJ3_X878tx8HLgJEEVER7VNn6bOBBA
qyHV2yXHzcxfY_soPA3xT5bbYaAsvyEALw_wcB.
7. Perez, A.J. “Study: CTE Diagnosed in 99% of Former NFL Players Studied by
Researchers.” USA Today, Gannett Satellite Information Network, 25 July 2017,
www.usatoday.com/story/sports/nfl/2017/07/25/cte-diagnosed-99-percent-former-nfl-
players-according-study/507634001/.
8. Wedro, Benjamin. “Chronic Traumatic Encephalopathy (CTE).” MedicineNet,
www.medicinenet.com/script/main/art.asp?articlekey=157953.
9. Fuller, Steve. “Topic: National Football League (NFL).” Www.statista.com,
www.statista.com/topics/963/national-football-league/.
10. Seifert, Kevin. “How Is the NFL Concussion Protocol Supposed to Work?” ESPN, ESPN
Internet Ventures, 11 Dec. 2017, www.espn.com/blog/nflnation/post/_/id/261317/how-is-
the-nfl-concussion-protocol-supposed-to-work.
11. Wagner-McGough, Sean. “Texans' Tom Savage Briefly Returns despite Suffering Scary-
Looking Concussion.” CBSSports.com, 11 Dec. 2017,
www.cbssports.com/nfl/news/texans-tom-savage-briefly-returns-despite-suffering-scary-
looking-concussion/.
12. Kubota, Taylor. “5 Ways Science Could Make Football Safer.” Live Science, 30 Mar.
2016, www.livescience.com/54239-how-to-make-football-safer.html.
13. Chin, Mathew. “UCLA-Led Team Wins Grant to Tackle Concussions Among Football
Players.” UCLA Engineering, 13 Nov. 2014, samueli.ucla.edu/ucla-led-team-wins-grant-
to-tackle-concussions-among-football-players/.
14. Swartz, Erik E. “Early Results of a Helmetless-Tackling Intervention to Decrease Head
Impacts in Football Players.” Journal of Athletic Training, National Athletic Trainers'
Association, natajournals.org/doi/pdf/10.4085/1062-6050-51.1.06?code=nata-site.
15. “Helmetless Tackling and Blocking Drills Lead to Decreased Head Impacts in Collegiate
Football Players.” NATA, 21 Dec. 2015, www.nata.org/press-release/121815/helmetless-
tackling-and-blocking-drills-lead-decreased-head-impacts-collegiate.