12 January 2010. The Alzforum picked sports concussions as a risk factor for dementia as a Top Trend of 2009 (see ARF related news story) partly because of the extensive coverage the topic garnered in the popular press. That coverage was touched off by preliminary evidence suggesting that retired professional football players suffer dementia at rates far higher than the general population (see ARF Live Discussion; ARF related news story). A flurry of events in the past two weeks has advanced the story further. Bending to joint pressure from Congress, doctors, and the media, the National Football League recently took steps to protect players with head injuries and to bolster independent research on the effect of repetitive concussions. In particular, the Center for the Study of Traumatic Encephalopathy (CSTE) at Boston University will benefit from the league’s change of heart, with both financial support and a boost to enrollment for their studies of the long-term effects of head trauma. The CTE is also beginning biomarker studies to broaden its research on the topic, and the focus on young athletes is intensifying.
The changes came on the heels of a Congressional hearing last October, where testimony from former players, medical experts, and league officials sparked a blitz of negative media coverage about the potential for long-term disability among their players and the NFL’s culture of denial (e.g., this story and others in The New York Times).
By late December, the NFL had instituted several changes to its policies on head injury. Most importantly, the league banned players with signs of concussion from returning to a game or practice on the day of their injury. The league also pledged $1 million support for the BU researchers. CSTE co-chairs Anne McKee and Robert Stern, in collaboration with the Sports Legacy Institute, were among the first to show cases of traumatic encephalopathy in retired professional football players and wrestlers. The condition involves pathological deposits of tau protein, and had previously only been described in boxers and non-athletes with a history of repetitive concussions.
The NFL and the NFL Players Association both encouraged current and former players to participate in the center’s ongoing research. Potential participants include a cohort of about 100 former players who draw benefits from the league because of dementia. Given that NFL-affiliated researchers had previously ignored or belittled outside research, the turnabout is significant. “These are two huge accomplishments that will really promote our work and move this field forward,” said McKee.
Stern told ARF that the center researchers insisted on a “no strings attached” unrestricted grant that would preserve their research independence before they would consider accepting the money. “We need to stay free of any real or perceived conflict of interest in our work,” he said. Such conflicts pervaded, and have compromised, some of the league’s own research on concussions. Currently, Stern is awaiting institutional review of the grant terms.
The CSTE’s research includes a brain donation registry of athletes who participate in yearly phone interviews to report clinical symptoms and injuries and have pledged their brains to the center upon their death. The registry now has 250-plus athletes, split between amateurs and professionals, and representing many sports with and without head trauma. The group includes four current and many retired NFL players.
Enrollment has increased since the NFL got behind the research, Stern said. “These are wonderful changes, but what’s important now is that we not rest on our laurels. From our point of view, we have science to do. We’re only at the infancy of understanding chronic traumatic encephalopathy. There’s so much more neuropathological and mechanistic work that needs to be done,” Stern said.
Stern told ARF that the center is just starting an additional, pilot study that will include extensive neuroimaging, cerebrospinal fluid assessments, and clinical examinations of a small number of athletes, and the center is seeking NIH funding for a similar, but much larger study of football players. That study would measure an array of potential biomarkers in CSF and blood, electrophysiology, and imaging.
While having access to football players will speed the research, it is not just about football, Stern said. “The study of CTE will hopefully tell us a huge amount about Alzheimer and other neurodegenerative diseases, because CTE is a clear tauopathy with a clear cause. We are going to be able to study it in groups of people we know are at the greatest risk of developing it.”
In another sign of the NFL’s changing stance, in December the league began running a public service announcement during televised games about concussion safety. Made in conjunction with the CDC, the spot begins to address one of McKee’s biggest concerns, which is the safety of younger players. She has seen focal tau deposits in the brain of an 18-year-old high school football player, and evidence of CTE in four of four college football players she has examined as well. “Kids, players, coaches—they all imitate the NFL, so it makes a huge difference for the NFL to take this so seriously,” McKee says.
There is a lot more to do, McKee and Stern both say, to educate parents and coaches of younger athletes about the dangers of repetitive hits to the head. The message is trickling down, though—a second congressional hearing on January 6 featured testimony from college and high school sports officials about their concussion policies, and plans to review the same. The hearing also included testimony from Ira Casson, former co-chair of the NFL’s concussion committee. Casson had headed a now-halted study on retired players, which had been criticized as poorly designed and rife with conflicts of interest. Casson, and the league, had drawn fire for his absence from the October hearing, and for his denigration of outside research, including the work of McKee and colleagues. In his testimony last week, Casson held fast to his stance that there were insufficient data to support a causative relationship between head injury in football players and later cognitive issues including dementia, despite the fact that the NFL itself acknowledged the link.
According to The New York Times, Michigan Congressman John Conyers is planning a third hearing, to be held on February 1, to focus specifically on the handling of head injuries in high school and college football.—Pat McCaffrey.