By Stephen Laming

Chronic Traumatic Encephalopathy. CTE. The degenerative brain disorder appearing in headlines over the last decade. CTE is an emerging field of study, and so much still remains unknown, but neuroscientists agree on the basics: CTE is a degenerative brain disorder caused by multiple head traumas. These traumas can take the form of concussions, but often they are not as obvious. Multiple smaller hits to the head or spine that are not large enough to cause a concussion, called subconcussive hits, can build up and also lead to the development of CTE. In addition, what makes these smaller hits more complicated is that symptoms often do not occur for a subconcussive injury, making them difficult to diagnose. Soldiers have even been found to have CTE from proximity to large explosive blasts. Also, emerging research is showing subconcussive hits could play a greater role in the development of CTE than actual concussions, which is concerning, since subconcussive hits can come from such a large variety of activities.

The health risk of CTE comes from a brain protein called tau. Imbalance of tau proteins has already been linked to other degenerative brain disorders, including Alzheimer’s and dementia, but is different in CTE. Tau in itself is not harmful and is actually extremely important for a healthy brain. Tau is found in nerve cells and helps to stabilize the area and keep cells in the correct alignment. But in patients with CTE, tau collects in the brain at a much higher rate than normal. An overabundance of tau causes clumps in the brain’s nerve cells, which eventually kills them. The brain begins to lose mass – and brain function – once nerve cells begin to die. Brains of deceased former NFL players who had CTE have been dissected and studied, and the brain mass loss from CTE is clear. The difference between a healthy brain and one with CTE can easily be seen, even by someone without a medical background.

A healthy brain compared to a brain with CTE. Source: Boston University Center for the Study of Traumatic Encephalopathy, via Wikimedia Commons.

As CTE progresses through the brain, the symptoms are classified into four categories (I – IV), mild to severe.

Stage I:

This is the mildest stage. Symptoms are not as obvious, and could be caused by other variables. The most common symptoms are headaches, trouble staying attentive, and possible short-term memory problems.

Stage II:

Symptoms of Stage I are still persistent and worsening. Continuing headaches growing in severity, short-term memory loss, depression, and rapid mood swings are the most common symptoms.

Stage III:

Once in Stage III, memory loss becomes very apparent. Mood swings, especially aggressive or angry outbreaks, along with depression are also very common. Stage III patients also begin to lose executive function, such as motivation, ability to plan, problem solving, multi-tasking, social behavior, and comprehending information. Due to these symptoms, 75 percent of Stage III patients are deemed significantly cognitively impaired.

Stage IV:

The final stage, Stage IV has symptoms very similar to the advanced stages of dementia. Extreme aggression, severe memory loss, paranoia, and almost complete lack of attention define this stage. In some cases, physical movement is also impaired.

Although CTE symptoms have been classified, up until recently obtaining a formal CTE diagnosis was only possible post-mortem, as the brain needs to be thoroughly examined. In November, preliminary research was published on identifying CTE in a living patient. A new process of scanning a player’s brain can show sign of CTE, but has only been confirmed by autopsy in one patient so far. In addition, CTE is a very difficult to work with because it is a relatively new field of study. Research is very limited, and many of the causes of CTE are still unclear. CTE is caused by repetitive head injury, but it is unclear why certain people develop CTE while others do not. Many NFL players who have had long careers in football have lived their entire life without any issues, yet at least one case exists of severe CTE before the age of 30.

Aaron Hernandez being hit in a game. Photo credit: Jared Wickerham via Getty Images.

That headline-making case was Aaron Hernandez. The star New England Patriots player was in prison for the murder of one of his close friends when he killed himself at the age of 27. According to his lawyer, his autopsy revealed, “the most severe case [of CTE that doctors] had ever seen in someone Aaron’s age.” Hernandez was long known to have behavioral issues off the field; in addition to being convicted of one murder, he was charged with two more, though he was never found guilty. But even though CTE is known to cause aggressive behavior and mood swings, it is hard to make a link between CTE and Hernandez’s violent behavior. Dr. Kathryn Holloway, a local neurosurgeon at the VCU Medical Center, addressed this: “The mood disturbances [from CTE] are hard to tell from normal problems” she says, “because football already suits to people with aggressive behavior, which makes [diagnosis] complicated.”

In a case that was closer to the Collegiate community, Ray Easterling (’68) is another example of CTE. Easterling was a football player in the Collegiate class of 1968 and is a member of Collegiate’s athletic hall of fame. After playing for University of Richmond, Easterling went on to the NFL and played eight seasons as a safety for the Atlanta Falcons. In the later years of his life, he became forgetful and depressed, ultimately leading to his suicide at the age of 62 in April 2012. His autopsy confirmed suspicions and showed he had moderately severe CTE, and his CTE was blamed for the increase mental struggles he had later in his life.

Ray Easterling while playing at the University of Richmond. Photo credit: University of Richmond Athletics.

CTE was initially brought to the attention of doctors and the public through football. Mike Webster—Steelers center, nine-time Pro Bowler, and four-time Super Bowl champion—was case zero. After his professional career ended, Webster’s personal life deteriorated very quickly. By the age of 49, he was living out of his truck, occasionally using a taser on himself to fall asleep. By age 50, he was dead.

At the time of his death, the local coroner working in Webster’s home of Allegheny County was Dr. Bennet Omalu. He had no idea what he was getting into when Webster’s body arrived on his table on September 24, 2002. He did not know that he would become famous, with his story even being made into Concussion, a Will Smith movie. Omalu just wanted to know what happened to Webster.

While performing a standard autopsy, Omalu did not find anything out of the ordinary. The cause of death was found to be a heart attack. Omalu examined the brain to look for signs of dementia or Alzheimer’s, but none of the expected symptoms associated with these conditions were found. Fortunately, Omalu could not walk away without satisfying his curiosity, so he dug deeper.

Omalu analyzed Webster’s brain in every way imaginable, but had trouble finding anything out of the ordinary. Omalu ordered so many tests on Webster he had to start paying for them with his own money. Finally, after ordering a specially stained set of microscope slides, he found what he was looking for. Webster’s brain was covered in red and brown spots, later found to be the tau protein buildups CTE causes. This was the beginning of CTE, but also the NFL’s battle fighting it.

Mike Webster in his Steeler’s uniform. Photo credit: Pittsburg Steelers.

The NFL is an $8 billion dollar industry that relies on hard-hitting, action-packed moments. So, logically, they vigorously fought claims that recurring hits to the head lead to debilitating diseases. When Omalu first published an article with his findings linking playing in the NFL to CTE, the NFL sent a response letter written by three scientists on the NFL payroll demanding a retraction of the article. They stated that Omalu’s article had serious flaws and was not scientifically accurate. Although none of the three NFL scientists who wrote the letter to Omalu were neuropathologists, they believed they understood Omalu’s neuropathological tests better than Omalu.

Currently, the NFL is involved in a lawsuit regarding long-term effects of playing professional football. In the five year long, billion dollar case, almost 4,500 former players have accused the NFL of hiding the truth about long-term brain injuries. The NFL did not publicly state they believed repetitive concussions could cause degenerative brain disorders until March 2016. In December 2016, the NFL settled the case outside of court. In this landmark settlement, the NFL denies any wrongdoing but has agreed to pay former players up to $5 million dollars in medical compensation. Unfortunately, the vast majority of players have yet to receive any of the money associated with the suit. Fighting between the various lawyers representing the former players regarding payment is causing delays.

As more evidence revealing the dangers of concussions, especially at a young age, emerges, it is increasingly important for schools and teams to be taking the appropriate steps to protect their athletes and students. Collegiate is no exception.

Collegiate’s athletic training program employs two full-time trainers licensed to evaluate concussions, Shannon Winston and Jason Engle. Winston and Engle use four individual concussion testing procedures to make sure no concussion goes untreated.

Shannon Winston examining an athlete’s ankle. Photo courtesy of Collegiate School.

For in-game sideline testing, Collegiate uses three different tests. First, trainers will use the SCAT3 (Sport Concussion Assesment Tool), a verbal test that evaluates general cognitive and verbal ability. Through a series of questions and tasks, this test will identify the red flags of a major concussion in minutes, so help – usually a trip to the hospital – can be provided.

If a student is showing mixed signals, the trainers will then go into deeper, more specific testing. The King-Devick test is a verbal-visual test that measures eye movement and visual tracking. Students are tasked with reading a list of numbers in increasingly confusing arrangements. If a student struggles to get through this test, they will most likely be removed from play and be further evaluated.

Finally, to measure concussion risk through balance analysis, trainers use the Sway balance test. Using an iPhone’s built-in motion sensors, trainers can see reaction time and postural sway data in under two minutes and again use this to determine if an athlete can return to play.

After a student has sustained a concussion, Collegiate uses the ImPACT (Immediate Post-Concussion and Cognitive test) to determine when a student is healthy enough to resume play. This is an online test for students, with the goal being to measure “Immediate and delayed memory, reaction time, processing speed and concentration.” It is a two-part, baseline test. First, the student takes the test at the beginning of the season while healthy, and his or her test results are saved as baseline data. If a student sustains a concussion, after resting and going through the appropriate recovery, they take the test again. The trainers then analyze the discrepancies in the baseline data and the post-concussion data to decide if the student’s recovery time was sufficient or if more time is needed.

Most importantly, Collegiate is committed to preventing a concussion in the first place. Upper School Dean of Students and head of the football program Mark Palyo understands this: “A Collegiate student’s future is their brain, and its safety is my number one priority.” Palyo has set strict rules for varsity football regarding hitting in practice; once the regular season starts, hitting in practice is limited – only in games does full contact tackling occur.

Collegiate football is also keeping up with the latest research to keep its players safe. In 2016, Collegiate invested in new Riddell SpeedFlex helmets, rated in the top three safest football helmets on the market by Virginia Tech Helmet Ratings. Along with advanced safety gear, proper tackling technique is stressed in practice. “Never leading with the crown of your head is one of the most important things we teach our players,” Palyo says. Collegiate has also adopted rear-hip tackling, or “Hawk” tackling. Named after the team that came up with the concept, the Seattle Seahawks, Hawk tackling has been described as a “Tackling Technique That’s Revolutionizing Football Safety.” Traditional tackling teaches kids to put their heads in front of the person they are tackling. The idea was to use the head as another point of contact to drive the opposing player to the ground. Hawk tackling instead focuses on putting a player’s shoulder into the opposing player’s thigh, and removing the head from contact. Although safe, it is still just as effective in bringing a player to the ground.

While discussion about sports, CTE, and concussions often gravitate towards football, other sports have concerns as well, and it is important they are not overshadowed. In soccer, heading the ball is an integral part of the game, but it also has the highest risk of brain injury. Heading a ball is a prime example of a low-contact, subconcussive hit. Research has already shown in the immediate time after a player heads a ball their motor skills are impaired. Even traditional non-contact sports pose a risk to the brain. Collegiate’s Iain Moore (‘19) sustained a very serious concussion during a warmup for a swim meet. He was kicked in the head by a fellow swimmer and was out of the pool for the next four weeks. Like many of us, Moore did not expect swimming to be a high-risk sport, saying “I actually started swimming because I had previous issues with concussions in soccer.”

When addressing injuries, especially to the brain, it is always important that whenever there is doubt, take the most cautious route possible. While talking with Dr. Holloway, she had advice for every student-athlete, “Don’t hide a concussion, and definitely let people know when you are still having symptoms.” Missing one game is never worth it.

Featured image credit: University of New Hampshire.