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Chronic Traumatic Encephalopathy Facts and Fiction

by Stephen Propatier

January 16, 2014

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Donate CTE or Chronic Traumatic Encephalopathy has become a relatively large issue for sports athletes and military personnel. It has garnered a lot of press notably in high risk concussion sports like American Football. Recently JAMA published a review of military personnel and found a increased risk for life long morbidity complications.

CTE is a complicated medical syndrome thus far difficult to treat and diagnose. Similar to other poorly defined chronic syndromes, CTE is a morass of real medicine, half truths, legal battles and woo chicanery. I will try to peel back some of the layers of the onion to help people understand what is known about this disease. What works and what are the risks for those that suffer from high risk for head injuries.
"Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head. CTE has been known to affect boxers since the 1920s. However, recent reports have been published of neuropathologically confirmed CTE in retired professional football players and other athletes who have a history of repetitive brain trauma. This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau. These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement. The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia."

This is not really a new syndrome, "Punch Drunk" is the common amorpharism for this syndrome in Boxers. The new aspects of this syndrome are the recent correlations drawn between mental and physical disorders that may be directly caused by the head trauma. No one denies that multiple blows to the head can easily result in brain damage. The controversy lies in the sequlae or long term outcomes for a high risk professions.

Media reports are full of fear inducing headlines like "NFL concussion crisis" or "Brain Blow Leaves Life Long Dangers"butheadlines do not equate with accuracy. Often what is really understood about this disorder is lost in the translation. Either that or the research is presented as the one study/one answer syndrome. A common media failing. Reporters often fail to consider that each tiny bit of research is part of the whole picture. Not the picture itself. The concensus may be vastly different than the individual study results. Media outlets present the individual research as the "New Truth" about the subject. Falsely assuming that the new research replaces old.

New research adds to what we know about a disease, it doesn't negate old research.

To complicate matters the woo purveyors put their own spin on things. Some are self deluded, some are quacks trying to make a buck off the hysteria. Dr. Sponaugle MD anesthesiologist, is one who uses unproven and questionable treatments for CTE. Among other things he uses a "proprietary" but untested IV drip. His treatment was notably lauded by NFL quarterback Bernie Kosar. He claimed that the IV drip cured his CTE in a public interview. Months after the interview he has resumed some of the erratic and problematic behavior that characterizes CTE. Still Bernie extols the benefits of this treatment. Anecdote and personal experience are no substitute for good medical research.

CTE is a compelling story for reporters. The medical truth is not quite so cut and dried. Recently a JAMA study has raised cerebral trauma back into the public eye. I thought it would be a good idea to take a look at the science and the pseudoscience.

What is firmly known about CTE.
  1. The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia.

  2. It appears to come from repetitive brain trauma.

  3. There appears to be a genetic predisposition.

  4. To date, the diagnosis can only be confirmed after death.

  5. CTE is distinctly different than other dementia like Alzheimer disease.

  6. There is no effective treatment for any neurodegenerative disease.

What is largely speculative.
  1. risk factors for the development of the disease, and how to diagnose the disease during life.

  2. post concussive syndrome does not seem to be a predictor of CTE.

  3. Asymptomatic concussions, so called sub-concussions may play a role.

  4. Helmets may help

Scientifically implausible and/or useless, possibly dangerous.
  1. Untested IV formulas.

  2. Vestibular treatment chairs.

  3. Acupuncture, homeopathy et al...

Truth is that despite the hysteria, media focus, and lawsuits there are too many unknowns at this time. We are not sure of the cause or the treatment at this time.

To a lay person this sounds pretty weak. Seems simple concussion = CTE and severe concussion = severe CTE, Right?

No, not really, the factors are very complicated. Sports athletes, military personnel are generally risk takers by nature. They may experience injuries in their personal life that they hide from others.They tend to push their physical limits and they are encouraged to ignore their bodies warning signs. In the sports community there is pressure to use performance enhancing drugs, high rates of illicit drug use, alcoholism, and violence. There are strong societal and legal pressure to hide these behaviors. It is unclear at this time what effect these issues may have upon acquiring the disease.

It is more than just lifestyle issues. Boxers suffer more concussions than any sport, yet the CTE rate is the same or slightly less than NFL players or military personnel. Boxers also seem to lack the huge depression/suicide component that is so prevalent in hockey, military and NFL players. World wide the sport, Football (in america soccer) has a very high concussion rate yet paradoxically low rates of CTE and sequelae.

The most depressing part about this disease is prevention. We don"t really know what to do to prevent CTE. Experience with boxers shows us that fewer concussions lowers risk, but does not eliminate that risk. Helmets seem like a good idea. Helmets soften blows but they don't fully protect from concussions. There is some truth to the idea that helmets prevent unexpected injuries, but that they give people a false sense of security. In some cases it may make a person wearing one more aggressive and careless. Concussion protocols are another guess. We don't really know if passing a neuro exam means that they have suffered less damage and can return to play. We don't really know how long we should take the sufferers out of action. There appears to be a genetic predisposition for CTE, but we can't say how much of a role that plays. Bottom line, current prevention methods are groping in the dark.

Like all medical issues, this problem and its treatment, will most likely be multi-factoral.

My opinion. I think that the cross sports data does not support the disease's reported depression/suicide component. You see correlations consistently in the NFL and Military cases but very low rates in boxing and soccer. You see higher average rates of depression and suicide in NFL players and Military personnel overall. Although compelling stories, the deaths of Jr. Seau, andDave Duerson, are not very convincing evidence of a direct link between CTE and suicide. If it was found post mortem that Jr Seau had liver disease( he did apparently), would you blame his liver disease for his death. I am not so certain about a causal relationship with suicide and CTE. I am not saying that it is impossible, just there is no consistent pattern in the epidemiology. Suicide cases are also self selecting for the only true diagnosis method at this point, post mortum examination.

So what we really have at this point is a disease poorly understood, and lacking any effective treatment or prevention. We have a lot of questions and no good answers.

JAMA correlational studies are not revealing, interesting, but not revealing. Good stories like Jr Seau and the JAMA study attract eyes and eyes are money now a days.

Simple rule for all good critical thinkers. If it is medical problem, and the answers look a little simplistic you have good reason to be skeptical.

Science is not I know, science is I want to know.


by Stephen Propatier

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