Impact of Chronic Traumatic Encephalopathy on American Football

Content

1 Introduction

2 New public awareness for CTE in American football based on the discoveries by Dr. Bennet Om
2.1 A brief history and new public awareness for Chronic Traumatic Encephalopathy (CTE)
2.2 Definition, classification and demarcation of Chronic Traumatic Encephalopathy (CTE)
2.3 Causes, risk factors, stages and symptoms of CTE
2.4 Diagnosis and therapy

3. Social, cultural and economic importance of American football in the USA
3.1 Economical Importance ofAmerican football
3.2 Social and cultural importance ofAmerican football

4 Assessment and impact of CTE on professional and amateur American football8
4.1 Improvement of personal protection equipment
4.2 Adoption and changes inthe rules of the game

5 Conclusion

6. Table of Illustrations

7. References

Introduction

The topic of chronic traumatic encephalopathy (CTE) fueled my interest because I have been playing handball for many years and played one season as wide receiver in the junior varsity football team at Fort Dorchester High School, North Charleston, South Carolina. Furthermore, the movie “Concussion” starring Will Smith inspired me to look into the topic more thoroughly. Football and handball are considered contact sports and may have effects on an athlete’s brain as described and analyzed in the following essay “Assessment of the impact of Chronic Traumatic Encephalopathy (CTE) on the US Number 1 SportAmerican football”.

Head injuries are not a new phenomenon in the history of contact sports. The results of the autopsy of three well-known football players by Dr. Bennet Omalu in 2002 and the results of a research study lead by Dr. Ann McKee of the Boston University in 2017 stirred the USA football nation seriously and created a new awareness of the risks of the sport.

Chapter 2 gives a brief historic overview on the research of head injuries, defines the disease, analyses symptoms, risk factors and stages ofCTE as well as the current medical therapies. Football is not only a multi-million-dollar business but represents the American dream and way of life like no other sport. An overview of the different involved stakeholders and their economic and individual interestswill be given. This economic and cultural importance of football forthe nation will be highlighted and explored in chapter 3.

Chapter 4 explores the impact of CTE on the sport. This covers the current research and development of new materials and future technologies in personal protection equipment and also changes in the rules and format of the game. Consequences of awareness campaigns and controversial debates will be highlighted.

Chapter 5 evaluates the different aspects, discusses the impact CTE will have on American football and gives an outlook forthe future of the game.

2 New public awareness for CTE in American football based on the discoveries by Dr. Bennet Omalu

2.1 A brief history and new public awareness for Chronic Traumatic Encephalopathy (CTE)

Severe head injuries and traumas in intense and violent contact sports similar to football go back to ancient times of mankind and have a long history. A prominent example is Boxing, an Olympic game since 688 BC becoming a professional sport in England in the early 1700s. Since those early times scientists and doctors have been investigating head and cervical spinal injuries primarily focusing on fractures, but already reporting concussions and head traumas without fractures ofthe skull.¹

It took until the 1920s of last century that the effects of intense hits to the head in boxing were more in depth researched for the first time. The forensic pathologist Dr. Harrison Stanley Martland was one ofthe first to describe a disease initially referred to as punch-drunk and later called dementia pugilistica.²

At this time the consequences of repetitive concussions were not at all a topic in football but seen as a natural part ofthe game. Still in 1912 football coaches like the legendary Glenn Warner, member ofthe College Football Hall of Fame was ofthe opinion that wearing helmets would lead to less confidence of players and would not save heads from hard knocks or torn ears. Only in 1940 the National Football League (NFL) made helmets mandatory for players. It took another 30 years until the mid-1970s to develop today’s sophisticated helmets. Since then severe life-threatening skull fractures and cerebral hemorrhage were almost nonexistent in the game. Though it turned out that helmet development gave a wrong sense of safety.³

In 1994 the NFL created the Mild Brain Injury Committee to investigate the issue of concussions. In 2009 more than 10 years later NFL spokesman Greg Aiello accepts that concussions may lead to long-term physical effects.⁴

Dr. Bennet Omalu a forensic pathologist and neuropathologist was the first to discover Chronic Traumatic Encephalopathy (CTE) in the year 2002. His first autopsies from 2002 until 2006 of Mike Webster, center, Terry Long, lineman both ofthe Pittsburgh Steelers and Andre Waters, safety ofthe Philadelphia Eagles all showed symptoms ofCTE.⁵

In 2015 Dr. Omalu’s discovery of CTE was featured in the movie “Concussion” directed by Peter Landesman, starring Will Smith as Omalu. This discovery and the movie led to a controversial debate, high public awareness and intensified research that continues in the USA.

The most recent and currently largest case study was published in July 2017 in the Journal of the American Medical Association (JAMA). A Boston University lead researcher team examined in total 202 donated brains from families of deceased football players including NFL, college and high school athletes. 87 percent (177) showed signs ofCTE.

The study included 111 brains of former NFL players of all positions. 99 percent (110) were diagnosed with CTE. Of these 40 percent (44) were lineman, who are most likely to experience head shocks during a game.^{6 7}

Although the study is still discussed controversially there now seems to be clear evidence of CTE nowadays. The following chapters will define CTE, describe causes and risk factors as well as symptoms and the current status of treatments afterthe diagnosis of CTE.

2.2 Definition, classification and demarcation of Chronic Traumatic Encephalopathy (CTE)

Different definitions of Chronic Traumatic Encephalopathy, also called CTE, exist.

In general, Chronic Traumatic Encephalopathy is considered to be a neurodegenerative disease with progressive decline in brain functions which is mostly found in brains of athletes or in military veterans. Most cases have a history of repetitive hits to the head in common.⁸

CTE is also defined “as a progressive neurodegenerative syndrome, which can be caused by single, episodic, or repetitive blunt force impacts to the head and transfer of acceleration­deceleration forces to the brain.”⁹

CTE has to be clearly differentiated from concussion. In the media and public discussion concussion and CTE are often mentioned in the same context and no real differentiation is made. Concussion is a reversible brain injury based on a single incident whereas CTE has a history of numerous injuries of the brain leading to a continuous worsening degenerative condition of the patient’s brain.¹⁰

The symptoms of CTE are very similar to those of Alzheimer’s disease (AD), according to researchers the main difference is that CTE has an external, environmental cause (repeated concussions and brain trauma) whereas AD has predominantly a genetic cause.¹¹

2.3 Causes, risk factors, stages and symptoms of CTE

Currently the best available evidence is that CTE is likely to be caused by repetitive head trauma and injuries from hits and punches, fights and checks, throws with high amplitude or blasts and explosions sustained over a period ofseveral years.

Especially American football has been in the focus of researchers and studies in the past mainly because of prominent professional football players suffering from the disease. Nevertheless, athletes participating in other contact sports such as rugby, boxing, wrestling, soccer and ice hockey may carry a higher risk to develop the disease as well¹².

Besides athletes, military in active duty and veterans as well as victims of domestic abuse might be affected. The following table shows an overview on contact sports and causes for professional sports, military and other areas of private life where CTE has been found.¹³

Abbildung in dieser Leseprobe nicht enthalten

Today there is no test available that allows a diagnosis of CTE during a patient’s life time. A reliable diagnosis of CTE is only possible post-mortem. In a complex autopsy CTE can be identified by the abnormal accumulation and pattern of proteins (amyloid and tau) in various regions ofthe brain and significant loss and death of brain cells over all regions ofthe brain. This makes it distinct from other forms of dementia (s. below images).¹⁴

Abbildung in dieser Leseprobe nicht enthalten

Images of Phosphorylated Tau Pathology at CTE Pathological Stages I to IV indicating CTE^{15 16 17}

Researchers at the University of Boston have classified four behavioral phases defining specific and most common symptoms to detect CTE. Affected patients may suffer milder consequences such as headaches, loss of attention concentration in the first stage, up to suicide thoughts, severe cognition problems and loss of memory. The following table provides an overview ofthe four different stages and its related, typical symptoms.

Abbildung in dieser Leseprobe nicht enthalten

Not everyone who suffered repetitive head traumas will develop CTE. There are several risk factors such as duration of playing and age of first exposure which might increase the probability of developing CTE. Athletes with long careers in contact sports and who start playing at an early age are more likely to be exposed. Several studies show that children starting before age 12 are more at risk with worse symptoms and outcomes than children starting at a later age.¹⁸

Eventually, the hope is to use a range of neuropsychological tests, brain imaging and biomarkers to diagnose CTE. In particular, imaging of amyloid and tau proteins will aid in diagnosis.¹⁹

2.4 Diagnosis and therapy

As described in the previous chapter a number of symptoms may give indication that a person suffers of the disease but CTE can be reliably diagnosed only after a person’s death. A regular CT scan or MRI studies of the brain will not reveal the disease. Therefore, it is very likely that many cases will never be discovered. Researchers will also have to rely on brain donations. Only a direct tissue autopsy of the brain, which may take several months remains todays standard and reliable medical evidence of the disease. In such an autopsy the brain is cut into thin layers, special chemicals are then used to make tau clumps visible, which are a clear evidence of CTE.²⁰ Today no curative drug therapy or any other treatment for CTE exists. The only existing approach is to take preventive measures to protect the head in order to avoid concussions. Supportive care for patients showing symptoms of CTE are similar to dementia patients and may include games and thinking activities, repetitive rituals (esp. at nighttime), regular exercise, modified tasks and calming environment.²¹

CTE might have an impact on the way American football is perceived by the public in the future. The economic and cultural importance will be analyzed in the following chapter.

3 Social, cultural and economic importance of American football in the USA

American football has become a global multibillion-dollar business. Major players and industries in the business are properties (NFL, NCAA, AAC etc.) along with media and television broadcasting (CBS, ESBN, ABC), corporations (sponsoring and marketing), video gaming (EA SPORTS, Madden-NFL), hotel and transportation business, sportswear merchandising and licensing (Nike, Starter, Logo One), individuals (football team owners, professional athletes etc.).

3.1 Economical Importance of American football

The National Football League (NFL) is sports world champion in sales turnover. In the season 2016 the NFL achieved a turnover of 11 billion Euro compared to 3 billion Euro in sales of the German Bundesliga.²² The prices for a 30 second TV commercial during a Super Bowl game significantly increased in the past 20 years by roughly 5 times from 810,000 Euro in 1995 to 4.1 Million Euro in 2017. In contrastthe price fora 30 second commercial on the German TV Station ZDF during the soccer world championship 2014 was 16.5 times lower (250,000 Euro).²³

Abbildung in dieser Leseprobe nicht enthalten

Globally approximately 800 million viewers followed the 2017 Super Bowl Final compared to 400 million viewers of the European Champions League Final 2017. Ticket prices were starting at 405 Euro forthe Super Bowl Final 2017 and 70 Euro forthe European Champions League Final in the same year.²⁴ Merchandising has become an important economic factor. A football fan may easily spend 235 USD for his basic fan equipment (i.e. cap, scarf and jersey)²⁵.

3.2 Social and cultural importance of American football

At the same time American football has tremendous importance for the athletic, social and cultural life ofthe nation.

Traditionally American football is a family event. Events such as the Super Bowl have the character of a national holiday and other football events are linked to national holidays. On Thanksgiving family get togethers, turkey and football go together as a long American tradition, New Year’s Day is dedicated to several college football bowl games. One ofthe most well- known is the Rose Bowl.

Every social class from a steelworker’s family to the president follows, watches or plays football. From an early age on almost everyone is exposed in some way to American Football starting in high school, continuing in college and up to professional football. Many people keep a long-term bond to the NFL team where their former high school or college heroes play, this even beyond the point when they retired from the team.²⁶

The 2015/2016 high school athletics participation survey published by the National Federation ofState High School Associations (NFHS) shows that almost 1,1 million high school students played tackle football at more than 15,000 high schools nationwide. American football remains the number 1 high school sports in the USA.²⁷

For many students football gives the opportunity to receive scholarships at Colleges and University and allow for an education enabling a professional career.

Another important contribution of football is the aspect of volunteering and donating. Many prominent players fund their former high schools. There they are highly respected persons and for most of the students a dream comes true to see an NFL player at their school and not just in TV.

Some players also carry their own charity and fundraising foundations and give an important support for socially disadvantaged families, education, medical research and surgery or aid after natural catastrophes.

In spring 2017 approximately 17.09 million Americans played football. The game unites and excites millions of people ofdifferent origins.²⁸

The following remarks deal with the question to keep the spirit of the game alive without neglecting the health and protection of amateur and professional players.

4 Assessment and impact of CTE on professional and amateur American football

The discovery of CTE has become a major issue for professional and amateur American football. Avast numberof different players is involved in this context, i.e. school organizations on an amateur level, the NFL on a professional level, but also medical researchers and organizations, sports equipment manufacturers including startup companies, media and public etc. Today’s approach is focused to make playing football safer. This includes the improvement of personal protection equipment, changes of the rules in the game and medical research. A number ofcampaigns are raising awareness especially in youth football including the approach to prohibit tackle football. Therefore, the explanations will concentrate on the following aspects:

- Improvement of personal protection equipment
- Adoption and changes in the rules of the game
- Awareness campaigns for parents, coaches and players

The NFL program “Play Smart. Play Safe”²⁹ launched in 2016with a financial budget of 100 million dollar supports the above topics. Thereof 60 million dollars are dedicated to the so called “Engineering Roadmap” for the development of advanced technologies including new helmets to protect head injuries.³⁰

4.1 Improvement of personal protection equipment

The improvement of personal protection equipment focuses on product innovations for helmets, mouth guards and neck protection.

Head protection and gear

Today’s helmets design basically dates back to the standards set by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) in 1973. The helmets were constructed with a rigid, polycarbonate shell, a steel face mask and padding on the inside of the helmet. These hard-shelled helmets were designed to protect players from cerebral hematoma and cervical fractures, protection against concussions was not in focus.

Although Riddel and Schutt are the leading helmet manufacturers in the USA, the most advanced helmet is the Zerol produced by the startup company VICIS.³¹ This helmet was rated number 1 for reducing head impact severity compliant to the standards of the NOCSAE³² in 2017.³³ The Zero 1 consists of four different layers. The soft outer shell (Lode Shell) compresses and rebounds like a car bumper. Below this outer shell is a layer (Core Layer) of small polymer columns designed to mitigate collisions from multiple directions. A hard-inner plastic shell (Arch Layer) prevents skull fractures and cerebral hemorrhage.³⁴ Other

[...]

---

¹ (Bennet, 2014 pp. 29-31)

² (Bennet, 2008 p. 11)

³ (Bennet, 2008 pp. 7-10)

⁴ (Public Broadcasting Service)

⁵ (Bennet, 2008 p. 67ff)

⁶ (Mez, et al.,2017)

⁷ (s. Results of Boston University study, illustration 1,p.13)

⁸ (Concussion Legacy Foundation)

⁹ (Bennet, 2014 p. 11)

¹⁰ (Robitzski, Dan, 2017)

¹¹ (Bennet, 2014 p. 12)

¹² (Bennet, 2008 pp. 14-15)

¹³ (Concussion Legacy Foundation)

¹⁴ (Bennet, 2008 p. 32)

¹⁵ (Mez, et al., 2017 pp. 364-365)

¹⁶ (Marathon Medical Communications, Inc.)

¹⁷ (The CTE Society)

¹⁸ (Concussion Legacy Foundation)

¹⁹ (Mayo Foundation for Medical Education and Research)

²⁰ (Bennet, 2008 pp. 33-34)

²¹ (Mayo Foundation for Medical Education and Research)

²² (Klemm, et al., 2018)

²³ (Klemm, et al., 2018)

²⁴ (Klemm, et al., 2018)

²⁵ (Official Eagles Pro Shop)

²⁶ (Esume, et al., 2017 pp. 238-239)

²⁷ (National Federation of State High School Associations p. 53)

²⁸ (Statista GmbH)

²⁹ (NFL Enterprises LLC)

³⁰ (Belson, 2016)

³¹ (s. Helmet laboratory testing performance, illustration 2, p. 14)

³² National Operating Committee on Standards for Athletic Equipment (NOCSAE)

³³ (NFL Enterprises LLC)

³⁴ (VICIS Inc.)