Op-Ed: We Should Warn Patients About Participation in Football

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Introduction

Chronic Traumatic Encephalopathy (CTE), a pathological finding of brain injury from repeated head traumas, has been a hot-button topic in recent years since it was first described in 2005 by Dr. Bennet Omalu. He described this pathology in a National Football League (NFL) player after that player experienced what is now known as the pathognomonic personality changes associated with CTE: depressed mood, mood lability, aggressive behavior including physical violence, and suicidal ideation. Since that time, CTE has been the headline of myriad news articles and has brought the NFL under intense scrutiny to enhance player safety. However, it wasn’t until an article was published in the Journal of the American Medical Association (JAMA) in 2017, which found a 99% prevalence of CTE in a sample of 101 deceased NFL players, that brought the media frenzy on the subject to fruition.

I was a second-year medical student eagerly parsing through my JAMA subscription when I came across that article two years ago. Admittedly, I am also a lifelong Kansas City Chiefs fan, NFL enthusiast and Fantasy Football zealot. Imagine the internal conundrum it created to discover that the sport that I have watched my whole life was now at the forefront of criticism by the profession I am actively pursuing. This op-ed article is meant to bring to attention to the growing problem of CTE and catalyze discussions amongst the next generation of physicians about how we will help shape the future, or lack thereof, of football.

Disclaimer: I am in no way affiliated with the ongoing research of CTE research or the NFL. My viewpoints do not necessarily reflect the viewpoints of my home institution, my colleagues, or the team at MedSchoolInsiders. Any mention of specific cases of CTE are solely for informative and educational purposes, and sincerest condolences are offered to the families of those involved. The information contained in this blog post may be triggering to some individuals.

 

Background

CTE is a neurodegenerative syndrome found in patients who have suffered repeated blunt force impacts and acceleration-deceleration head injuries. Its symptoms have been characterized to include behavioral and mood disorders, cognitive impairment, and sensorimotor alterations. It has been described in NFL players, boxers, and military personnel who have suffered repetitive concussions, traumatic brain injuries (TBIs), or other head traumas. Current detection of this pathology, at the time this article was written, can only be definitively diagnosed through autopsy and examination of the brain, but its clinical ‘symptoms’ manifest years prior to death. Current research to find biomarkers, i.e. proteins or enzymes in the blood, that could indicate the presence of the disease has been thus far unsuccessful.

The idea that repeated head injury, especially associated with football players, causes irreversible brain trauma and long-term negative effects is not new. In fact, a committee (Mild Traumatic Brain Injury Committee [mTBI]) was formed in 1994 to study and intervene on the rising incidence of post-concussion syndrome that was described in NFL players. I’ll briefly quote Dr. Elliott Pellman, former head of the NFL’s mTBI committee, who described the symptoms of post-concussion syndrome as:

‘…persistent headaches, vertigo, lightheadedness, loss of balance, unsteadiness, syncope, near-syncope, cognitive dysfunction, memory disturbance, hearing loss, tinnitus, blurred vision, diplopia, visual loss, personality change, drowsiness, lethargy, fatigue, and inability to perform usual daily activities’

Interestingly, less than a year after it was formed, that committee recommended that the NFL pursue independent research on how to prevent this syndrome. Fast forward to 2005 when Dr. Omalu published his paper first describing CTE in an NFL player who had committed suicide approximately 12 years after retirement due to symptoms consistent with CTE. Other prominent cases made headlines in 2005, 2006, 2011, and multiple in 2012. By this time, multiple class-action lawsuits had been brought against the NFL including more than 4,000 plaintiffs, accusing the NFL of negligence by not notifying players of the link between repeated concusses and long term degenerative brain disease, in addition to at least two wrongful death lawsuits for Junior Seau and Dave Duerson (2012). Will Smith even starred in a movie, Concussion, highlighting the disease and the struggle of Dr. Omalu versus the NFL organization. Since its inception, the NFL’s mTBI committee has adamantly denied and discounted claims that playing in the NFL increases your risk for CTE, and even suggested that playing football is protective from this particular neurodegenerative disease. It was not until 2016 when an NFL executive, Jeff Miller, acknowledged a correlation between playing in the NFL and developing CTE: 11 years after Dr. Omalu first suggested the correlation.

Notably, the NFL has responded to the growing body of research and media coverage by donating large sums of money to fund research to develop new ways of preventing and diagnosing head injuries. They have implemented a plethora of rule changes to try to enhance player protection, penalizing helmet-to-helmet contact, protecting “defenseless” receivers, shortening (and threatening to abolish) the iconic kickoff, and many more. Preliminary data showed at least a 30% drop in the number of concussions from 2017 to 2018 after the implementation of the aforementioned changes. It’s no exaggeration to say that the game has vastly changed, for better or worse, since the knowledge of CTE has been brought to the forefront of the public’s attention.

This is by no means an exhaustive list of the history of CTE. Honestly, it barely scratches the surface. However, I want to turn the focus of this blog post to the ramifications that this disease has on current and future physicians.

 

Anticipatory Guidance

The idea of anticipatory guidance is to provide the parents of pediatric patients with understanding the expected growth, development, and milestones that they will reach in certain stages of life. Along with this comes advice on precautions to take to help the patients avoid potentially dangerous circumstances (i.e. make sure there’s a fence around the pool; wear bicycle helmets always; proper car seat safety; weight management solutions; etc). Anticipatory guidance is usually used by pediatricians, but also used by emergency physicians and other specialties when patients are discharged from the hospital.

By now, you must be thinking, ‘I see where he’s going with this.’ So here is the big question of this post: What is our role as physicians in giving appropriate anticipatory guidance to patients with regards to participation in football?

To even entertain the idea of this question, we have to make a few assumptions, and they are LARGE assumptions:

  1. We must assume that the correlative evidence that has been shown in studies since 2005 will lead to more advanced research and eventually reveal that participating in these activities directly causes CTE.
  2. We must assume that the incidence of CTE not only affects NFL players but also is translatable to non-professional athletes. Obviously, the majority of players do not go on to play professionally, but it is not at all uncommon to play for 10-20 years at the non-professional level.
  3. The JAMA article published in 2017 carries a huge selection bias – the brains analyzed were donated to this purpose by the patient and their families likely because the patient was exhibiting symptoms prior to death. This would be like finding out that out of 100 people with right-upper-quadrant abdominal pain, 98 of them have gallstones; similarly, it would be like discovering that out of 100 people with burning with urination, 98 have urinary tract infections. Those are astronomically high statistics – but imagine you take a carefully selected 100 patients with or without pain: would you expect to find that 98% had gallstones or a UTI, respectively? Highly unlikely. This selection bias is a massive limitation to this paper published in JAMA. We would have to assume that the incidence of CTE found in this study directly correlates with the incidence of CTE in the general NFL population, regardless of the presence of pre-mortem symptoms.

As I stated above, these are HUGE assumptions! In the current “evidence-based approach” to medicine, how could we ever adopt this into our current anticipatory guidance? But in a similar vein, how could we deny this correlation?

 

Next Steps and Call to Action

The purpose of this op-ed, written by a medical professional AND football fan, is to enhance the discussion for where we go from here. Do we start warning our pediatric patients and their parents to NOT participate in football at all? Is there some safe duration of play that minimizes the risk of subsequently developing CTE? I argue that we should mention the ongoing research and current findings to patients who play sports that have repeated head trauma (and their guardians, if they are minors). Furthermore, the NFL, professional boxing leagues, and the military should acknowledge the research and findings thus far, effectively educating its participants on the subject and potential risks associated with it. In a staggering ethical simile, NFL players could be called the modern-day gladiator: athletes suffering from this horrible disease and early death for the entertainment of millions of people in the US and around the world. They should be made aware of the risks of playing their sport before stepping into the arena, but the choice to participate despite such risks should reside with them. This strong correlation between repetitive head injury and head trauma is undeniable, but the epidemiology, pathophysiology, risk factors, and prevalence have yet to be fully delineated. Advising families of the possibility of this devastating pathology affecting those involved with those sports puts the decision in their hands – it admits that we do not have all the answers and presents the information honestly. Partnering with patients and their families is the subject of countless lectures in medical school, and this approach accomplishes that teaching.t

 

Final Thoughts

CTE is a devastating neurodegenerative disease that has been associated with repetitive traumatic brain injury, often seen in football players, boxers, and military personnel. I propose that future generations of physicians demand better studies on this topic to fully understand the course of the disease and the exact risk factors that predispose patients to it; likewise, I advocate for better studies with proper control groups to understand the true incidence and prevalence of the disease. Until that time, I suggest that medical professionals warn school-age and adolescent children (and their families) of the correlation between head injuries and CTE, and advise them to research the topic further themselves to decide whether or not children should remain in these activities.

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