THE SPORTS CONCUSSION & CTE CRISIS: HOW NEW RESEARCH … Injury... · 2018-10-23 · •One concussion = Parkinson’s 56% – Gardner RC et al. Mild TBI and risk of Parkinson disease:

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CHRIS NOWINSKI, PH.D.

THE SPORTS CONCUSSION & CTE CRISIS: HOW NEW

RESEARCH IS CHANGING HOW WE VIEW HEAD IMPACTS



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MY HISTORY



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CHRIS HARVARD IN IOWA



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LIFE CHANGING IMPACT



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DR. CANTU CHANGES MY LIFE

>2 in football

Dr. Robert Cantu 4 in wrestling



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DR. CANTU’S 3 LESSONS

1. Dings are concussions

2. Immediate remove from play is essential, and no return until symptoms clear (and cleared by a doctor)

3. There may be long-term effects



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NEW REVELATIONS?

“During the past 7 years the practice has been too prevalent of allowing players to continue playing after a concussion. Again this year this is true. Sports demanding personal contact should be avoided after a concussion.”

1937 – Proceedings of the 17th annual American Football Coaches Association meeting



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I DIG INTO CONCUSSIONS TO FIX MYSELF

I should write a book!

Advance:

$4,000

Insurance:

$21,000



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HEAD GAMES



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• November 20, 2006

• “I think I lost count at 15.” He later added: “I just wouldn’t say anything. I’d sniff some smelling salts, then go back in there.”

12

ANDRE WATERS COMMITS SUICIDE



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CONCUSSION LEGACY FOUNDATION



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CONNOR MARTIN, OREGON

Oregon high school football player sues for $38 million after suffering concussion.

15

Suffered a concussion, cleared 4 days later, suffered another, symptoms may be permanent.



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RASHAUN COUNCIL AWARDED $7M

Instead of calling 911, the coach called Rashaun’s mother, the lawsuit states.

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The boy’s father, Terry Council, arrived to find Rashaun on the ground, slumped over with his head between his legs, covered in his own vomit. His father took him to an emergency room, and Rashaun was diagnosed with a concussion and a subdural hematoma, a collection of blood between the brain and its outer covering.



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COMPLICATIONS – SHORT AND LONG TERM

Weeks Months Years

Second Impact Syndrome

Post Concussion Syndrome

CTE?

Delayed Return to Play



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SECOND IMPACT SYNDROME

• Second Impact Syndrome occurs when an athlete, who has already sustained a head injury, sustains a second head injury before symptoms have cleared from the first injury

• This second blow to the head, sometimes minor, can result in a loss of auto-regulation of the brain's blood supply, leading to rapid brain swelling.

• 50% of SIS sufferers die, and the survivors rarely recover fully. It usually occurs to athletes <21 years old, although it can happen to older athletes

Source: NY Times, Cantu, R. C. (1996). Head injuries in sport. British Journal of Sports Medicine, 30, 289-296.



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CONCUSSION RATES BY SPORT

0 2 4 6 8 10 12

Football

Ice Hockey (M)

Ice Hockey (W)

Lacrosse (W)

Lacrosse (M)

Soccer (W)

Soccer (M)

Wrestling

Field Hockey

Basketball (W)

Basketball (M)

Softball

Baseball

Volleyball

College High School Source – Institute of Medicine

Fake News



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CONCUSSION EPIDEMIOLOGY

• 730 Division I FCS football players

• Questions: – How many concussions did you have last season?

– How many additional concussions did you think you had but did not report?

– How many dings or bell-ringers did you have?

1 6 21Source: Baugh et al (2014)



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DELAYED SYMPTOMS, DELAYED DIAGNOSIS• 3 Division FBS Football Programs

• Average diagnosis was 17 hours later

Timing of Diagnosis Percent

Immediately or within minutes 17%

Later the same day 41%

Next day 22%

2-4 days later 20%



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PATRICK CHUNG



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CHUNG KO’D



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LONG-TERM EFFECTS

• One concussion = Parkinson’s 56%– Gardner RC et al. Mild TBI and risk of Parkinson disease: A Chronic Effects of Neurotrauma

Consortium Study. Neurology 2018.

• One concussion (no LOC) = Dementia 136% – Barnes DE et al. Association of Mild Traumatic Brain Injury With and Without Loss of

Consciousness With Dementia in US Military Veterans. JAMA Neurology 2018.



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CHRONIC TRAUMATIC

ENCEPHALOPATHY



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VA-BU-CLF BRAIN BANK

• Founded in September 2008, the first center in the world dedicated to CTE research

• Pathological, clinical, and basic science research

• The world’s largest CTE brain bank now contains 630 brains and nearly 400 new cases of CTE



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THE RESEARCH TEAM



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PUNCH-DRUNK

• First named in 1928 by

Dr. Harrison Martland



@ChrisNowinski1 29

Primary Trauma Source 45

Boxing 39

Soccer 1

Battered spouse 1

Head banging behavior 2

Circus clown 1

Epilepsy 1

• Prior to 2005, there were only 45 cases of CTE in the medical literature!

* Source: McKeet et al. 2009 © 2011 SLI

A NEGLECTED DISEASE?



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Sign up at: ConcussionFoundation.org/Pledge



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2015 NINDS CTE CRITERIA

• In CTE, the tau lesion considered pathognomonic is an abnormal perivascular accumulation of tau in neurons, astrocytes, and cell processes in an irregular pattern at the depths of the cortical sulci.

Tau antibody staining of neurons and

neurites in perivascular pattern (arrow

pointing to blood vessel).

Lower field photo illustrating the

focal nature of the tau staining at

depth of sulci (asterisk at bottom

of sulcus).



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Videos courtesy of Dr. Joel Stitzel, Wake Forest University - [email protected]



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“I don't think there's any wiggle room. It's pretty clear this is due to head injury. Whether there are other things involved, and when it starts, that's hard to know, but I don't think there's any question that it's related to head injury.”

March 6, 2014. ESPN

Walter J. Koroshetz, M.D.National Institutes of HealthDirector, National Institute of Neurological Disorders and Stroke



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“CTE is only seen in the setting of repeated head trauma. At the end of the day, this is produced by head trauma. I'm sorry, that's what all the research says.”

March 6, 2014. ESPN

Daniel Perl, M.D.ProfessorDirector of CTE ResearchDepartment of DefenseUniformed Services University



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DAVE DUERSON



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PATRICK GRANGE



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PATRICK AT AGE 29



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PATRICK GRANGE’S BRAIN



@ChrisNowinski141

• Co-Captain of 2010 Penn Football Team

• Began playing football at 9 years old

• Committed suicide April 26, 2010, at the age of 21

• No history of concussion• No history of mental illness• Mentioned doing poorly in two classes

to his parents the day before hanging himself in his off-campus apartment

CTE in an Active College Football Player



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Owen Thomas had CTE



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Eric Pelly, 18 Years-Old

© 2011 SLI



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MILD CTEReported symptoms:

Stage I: (mean age 28)Headaches and issues related to attention and concentration

Stage II: (age 44)Symptoms expand to include depression, explosivity and short-term memory impairment



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SEVERE CTE

Stage III: (age 56)Cognitive impairment and

problems with executive functions, specifically planning, organization, multitasking and judgment

Stage IV: (age 77)Full-blown dementia (i.e., memory and cognitive impairments severe enough to impact daily living) in 90%



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JAMA JULY 2018



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NEW YORK TIMES



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NFL LEGEND NICK BUONICONTI

• Nick, age 76 and in a wheelchair, has probable CTE



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THANK YOU

To reach me:[email protected]

• @ChrisNowinski1

• @ChristopherNowinski

Books available:

mailto:[email protected]



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HOW SHOULD WE RESPOND TO THIS

DATA?



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Individuals may have a higher risk of developing CTE in the future if they engage in activities that increase their chances of having repetitive hits to the head.

Researchers currently do not know the incidence and prevalence of CTE, but they do know that CTE does not occur only in athletes. The greatest risk factor for CTE is the number of years of exposure to repeated head or brain injuries (subconcussions in particular).



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RISK FACTORS –ENVIRONMENTAL EXPOSURE

Smoking CTE

1 Packs per Day Hits per Season

2 Age at First Exposure Age of First Exposure

3 Years of Smoking Years of Brain Trauma



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PITCH COUNTS



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Smoking CTE






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WHAT IS THE EFFECT OF AGE?



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Gender OR <20 OR ≥ 20

Men 12.7 6.0

• Men who started smoking before 20 had are 2x as likely to get lung cancer as those starting later



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AGE OF FIRST EXPOSURE ASSOCIATED WITH COGNITIVE IMPAIRMENT



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AGE OF FIRST EXPOSURE TO TACKLE FOOTBALL AND CHRONIC TRAUMATIC ENCEPHALOPATHY• Alosco M, Mez J, McKee AC et al. Annals of Neurology,

2018.

• 246 American football players– 211 CTE (126 CTE-only)

– 35 without CTE (26 with progressive pathologies, 34 with symptoms)



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AGE OF FIRST EXPOSURE TO TACKLE FOOTBALL AND CHRONIC TRAUMATIC ENCEPHALOPATHY• Football players have been starting tackle younger



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AGE OF FIRST EXPOSURE TO TACKLE FOOTBALL AND CHRONIC TRAUMATIC ENCEPHALOPATHY

• Each additional year of youth tackle football was associated with earlier cognitive sx by 2.4 years & behavioral/mood sx of 2.5.

• Starting before age 12 was associated with an onset of symptoms 13 years earlier.



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Smoking CTE






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LEGEND STUDY –BEHAVIORAL DYSREG

• Cumulative Head Impact Exposure Predicts Later-Life Depression, Apathy, Executive Dysfunction, and Cognitive Impairment in Former High School and College Football Players. Montenigro PH, Alosco ML, Martin B, Daneshvar DH, Mez J, Chaisson C, Nowinski CJ, Au R, McKee AC, Cantu RC, McClean MD, Stern RA, Tripodis Y. J Neurotrauma. 2016 Mar 30.



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META-COGNITION



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EXECUTIVE DYSFUNCTION



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DEPRESSION



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APATHY



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COGNITIVE IMPAIRMENT



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FLAG FOOTBALL UNDER 14



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BIANJ VISION STATEMENT

Our vision is a world where all individuals with brain injury and their caregivers maximize their quality of life, the consequences of all unavoidable brain injuries are minimized and all preventable brain injuries are prevented.



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FlagFootbal lu14.org



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BENEFITS UNIQUE TO TACKLE FOOTBALL?

The consensus top 5 NFL players all-time did not play football until high school

1. Jerry Rice2. Jim Brown3. Tom Brady4. Lawrence Taylor5. Walter Payton



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EXPERTS DISCOURAGE YOUTH TACKLE



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FACT VS FICTION

• A law has been proposed in New Jersey to ban tackle football before 12.

• What are the arguments against flag football under 14/tackle football bans?



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“The pathology and link between head impacts and long-term neurological conditions such as CTE is still unclear, with questions of causation yet to be settled.”



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• >1,700 brains, CTE in 21/66 contact sport athletes (32%)

• 0/165 with CTE in controls without brain trauma or contact sports

• 0/33 brains with CTE with a single TBI

• Strong evidence linking contact sports to CTE

ExposureCTE

PresentCTE

AbsentTotal

Contact Sports 21 45 66

No Contact Sports 0 198 198

Total 21 243 264

p = 1.44 x 10-14



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“CTE pathology in the brain has been shown by British pathologists to be present in approximately 12 percent of normal healthy aged people who died at an average age of 81 years (Ling et al. Acta Neuropathologica)…. To be clear, CTE pathology could be present in a normal person.”



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13% of normal individuals have CTE pathology?

Ling, H., J. L. Holton, K. Shaw, K. Davey, T. Lashley and T. Revesz (2015). "Histological evidence of chronic traumatic encephalopathy in a large series of neurodegenerative diseases." Acta Neuropathol 2015. 130(6): 891-893.

DO 13% OF CONTROLS HAVE CTE?

Slide courtesy of John Crary



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Diagnostic CTE injury Age-related changes

Brain atrophy in CTE Microscopic – neurofibrillary tangles

PART

ARTAG

Slide courtesy of John Crary

CTE IS STILL CONFUSED WITH ARTAG & PART



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FACT VS FICTION

• What are the arguments against flag football under 14/tackle football bans?

• Kids don’t hit hard enough.

• “The science, in fact, concludes that it is the continuation of playingthat could contribute to the risk of developing CTE or other problems. That continual playing is specifically at the highest energy levels found in college and professional football, most certainly not at the lowest energy levels of youth football.” – President of the largest youth tackle football program in Illinois



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PUSHBACK BASED ON FICTIONS• Kids don’t hit hard enough to hurt each other.

• Mean impact of a 7 year-old is ~80% as hard as college football players

1. Daniel RW, Rowson S, Duma SM. Head impact exposure in youth football: middle school ages Munce TA, 12-14 years. J Biomech Eng. 2014;136(9):094501. PubMed PMID: 24950298

2. Daniel RW, Rowson S, Duma SM. Head acceleration measurements in middle school football. Biomed Sci Instrum. 2014;50:291-6. PubMed PMID: 25405436

3. Dorman JC, Thompson PA, Valentine VD, Bergeron MF. Head Impact Exposure and Neurologic Function of Youth Football Players. Med Sci Sports Exerc. 2015;47(8):1567-76. PubMed PMID: 25437194

FICTION



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WHEN HUMAN BOBBLEHEADS COLLIDE



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“The scientific evidence linking youth casual sports play to brain injury, brain injury to CTE, and CTE to dementia is not strong.”



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DOES WAITING PUT THEM AT RISK?• If we pass such a bill and tackling begins at age

12, might we be increasing the injury risk?

• Is it better to start teaching such skills when children are less strong, lighter, and more equal in size?

FICTION



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LET’S USE COMMON SENSE

1. Do I really have to convince you that hitting a child in the head hundreds of times is a bad idea?

2. Audience survey

1. Does anyone hit their own kids in the head?

2. How about yourself?

3. Of course we don’t get hit in the head voluntarily! We know it is a terrible idea.

1. 17% of adults smoke, but ~0% expose themselves to repetitive head impacts!



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WOULD YOU SIGN UP FOR THIS?



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THANK YOU

To reach me:[email protected]

• @ChrisNowinski1

• @ChristopherNowinski

Books available:

mailto:[email protected]



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WHAT IS THE PREVALENCE?

Data Percent

NFL 110 of 111 99%

College 48 of 53 91%

HS 3 of 14 21%

• CTE cannot be diagnosed with any established accuracy in a living person

• How do we interpret this data?• Controls



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• The Mayo Clinic reviewed 4,711 cases collected over 18 years



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@ChrisNowinski1

WHAT IS THE PREVALENCE?

Data Percent

NFL 110 of 111 99%

College 48 of 53 91%

HS 3 of 14 21%

• CTE cannot be diagnosed with any established accuracy in a living person

• How do we interpret this data?• Controls• Diagnostic accuracy of similar diseases

• ~9% of former NFL players who died during the study period



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IRRELEVANT POINTS

• Not all athletes with multiple brain traumas develop CTE.

• There are cases of CTE in non-athletes with no history of brain trauma.

• The suicide rate in retired professional NFL players is less than that of men

in the general population.

• Playing competitive professional football, with repeated subconcussive

head blows, is a much different scenario than that of a youth in community

or school sports.

• Many factors can be associated with CTE beside multiple head injuries,

such as genetic, physical health, mental health, behavior, risky health

behaviors and habits.



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THE SPORTS CONCUSSION & CTE CRISIS: HOW NEW RESEARCH … Injury... · 2018-10-23 · •One concussion = Parkinson’s 56% – Gardner RC et al. Mild TBI and risk of Parkinson disease:

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