Contact Sports Increase the Risk of CTE

Abstract

Traumatic brain injury (TBI), also called craniocerebral trauma, is classified as a brain laceration stemming from an external force, usually a blow to the head. A traumatic brain injury can be minute or severe, altering functionality of the brain, ultimately affecting the individual. Traumatic brain injuries accounts for one-third of all injury related deaths and are extremely common within all societies, affecting 52,000 lives annually and 57 million patients worldwide. In fact, Zhang (2015) states that traumatic brain injuries are one of the most common causes of morbidity and mortality of young adults less than 45 years of age. This type of injury can well lead to the outcomes of physical inactivity such as obesity, diabetes, and heart disease. The World Health Organization anticipates that TBI’s will be a dominant cause of death and disability by the year 2020. However, in 1976, Braham Teasdale and Bryan J. Jennett introduced a method to diagnose traumatic brain injuries called the Glasgow Coma Scale (GCS) which is an assessment of brain pathologies measuring stimulated verbal, motor, or eye-opening responses. The GCS classifies a TBI as either mild, moderate, or severe, using scores of 13-15, 9-12, and 3-8. Furthermore, there are new neuroimaging techniques that improve the accuracy of the diagnosis and prognosis of TBI such as: diffusion-tensor-imaging, magnetoencephalography, and single-photon-emission-computed-tomography. In fact, there are many neurological injuries that can account for a traumatic brain injury with some being: coup-contrecoup brain injury, brain contusion, diffuse axonal injury, second impact syndrome, shaken baby, and a penetrating injury. However, the most common brain injury that affects thousands of individuals every day, is a concussion.

The American Academy of Neurology defines concussion as “trauma-induced alteration in mental status that may or may not involve loss of consciousness.” (WOLTER) Concussions are usually triggered by biomechanical forces (a direct blow to the head or elsewhere on the body with an impulsive force transmitted to the head) that induce functional alterations rather than structural injuries and result in a graded set of neurological symptoms with or without the loss of consciousness. (WEBER) There are three grades of concussions that rank the severity of trauma induced to the brain, categorized as grade 1, grade 2, and grade 3. A grade 1 concussion is known to be a mild form lasting less than 15 minutes with transient confusion, no loss of consciousness, and resolution of mental-status abnormalities. Next, a grade 2 concussion is moderate and retains concussion symptoms and mental status abnormalities with amnesia for more than 15 minutes. Lastly, grade 3 is the most severe case with the person losing consciousness for a few seconds. Concussions can cause a variety of symptoms, including dizziness, nausea, headache, sleep problems, cognitive difficulties and irritability. Ocular symptoms include visual blur, visual field loss, diplopia and photosensitivity. Moreover, these categories of brain injuries are most common within athletes participating in contact sports.

Athletes who participate in sports are constantly sacrificing their minds and bodies in return for game and glory. Athletes are known to be extremely competitive, having a unique passion to win and succeed in what lies in front of them. The most intense form of competition lies within contact sports. Contact sports are an athletic activity that requires the form of contact between participants to be used. When participating in these athletic events, there is much to come from it but also much to lose. Most importantly, contact sports such as boxing, BMX, football, soccer, rugby, martial arts, wrestling, and ice hockey can increase the likelihood of brain injury through concussions. Sport-related concussions have become an increasingly acute medical and social problem (MALCOLM). It is believed that each year there are 1.6 – 3.8 million sport-related concussions in the United States and 2.1 million sport-related concussions in youth football globally.

Forces generated through contact sports listed above can often be life threatening. For example, boxing is ranked most life-threatening, with many types of severe impairments. Among injuries that boxers are susceptible to, CTE stemming from concussions, is most common. In boxing, the main objective is to hit your opponent directly and effectively in the head. The goal is to render them unconscious. Because fighters more often than not, experience blows above the neck, degenerative brain disease transpires. According to Dr. Charles Bernick, in a recent study, it was proven that “among fighters with more than nine years’ experience, those who fought the most times annually, performed worse on thinking and memory tests.” This illuminates the idea that brain volume of boxers is often lesser than that of the average individual. When brain volume decreases, there is a significant decline in DHA levels, or Docosahexaenoic acid, leading to severe memory loss. Furthermore, the Journal of Combative Sport has stated there was 488 boxing deaths between January 1960 to August 2011, with 66 percent of the reported deaths being from head, brain, or neck injuries. In addition to boxing, mixed martial arts and wrestling can have the same impact on an individual’s brain. The connection here is the early symptoms of Chronic Traumatic Encephalopathy, which includes loss of memory most similar to that of Alzheimer’s disease.

Furthermore, the sport of American football is widely known as America’s most popular sport and noted as being severely dangerous to the player. Whether it be in practice or in a game, full helmet to helmet contact can cause a concussion, but can be more severe for the athlete if left untreated. In 2002, a Nigerian-American physician and forensic pathologist discovered CTE in a former football player for the Pittsburgh Steelers, Mike Webster. This finding followed by many more have led to the book and movie “Concussion.” This is stated by Linda Hepler, who also declared that concussion rates for football athletes under 19 years of age has doubled over the last decade and occurs most during practices. Now, the National Football League has put their best foot forward in helping athletes prevent the occurrence of a concussion by limiting the head to head contact in game. If a player leads with the crown of their head, looking to target their opponent, they are automatically penalized and fined. However, in college football, targeting is not only a penalty but an automatic disqualification from the game. Moreover, helmet technology has only gotten better over the years, but it takes one simple mistake to cause a life-threatening disease.

However, in soccer, the head of the athlete is at severe risk of injury through contact with another player’s head, elbow, knee, or foot and even with a violent fall to the floor. In soccer, the greatest chance of impact through play is within contested headers and corner kicks. Nevertheless, when a player comes into contact with another player, whiplash can occur and cause a concussion through the violent force transfer throughout the neck and head of the athlete. When these actions happen, players are running, jumping, and moving with extreme force to attain the goal of scoring and winning the competition. According to CPSC statistics, 40 percent of soccer concussions are attributed to head to player contact; 10.3 percent are head to ground or goal post; 12.6 percent are head to soccer ball; and 37 percent is not specified, stated by the American Association of Neurological Surgeons. To sum up, it is extremely important to tend to the athlete if he or she is at risk of a concussion because about 50% of concussions go unreported.

In addition to the fact that a vast majority of concussions go underreported, the reported concussion rates in the National Hockey League (NHL) in the last 5 years is more than triple that of the previous decade, stated by Wennberg (20). The doubling and tripling of incidents reported is potentially due to bigger, faster players, new equipment, and harder boards and glass. The leading form of concussion in ice hockey is through body checking, allowing the player to strike another opponent with their shoulder or hip to stop them from advancing with the puck. Agel and Harvey (2) had recorded a study that stated the concussion rate in females were higher than expected but still cannot compare with that of the males. Player contact is the leading form of concussion with reported statistics of 41% rate of concussion for females and an astounding 72% concussion rate for males. Moreover, Cusimano et al. (10) researched that when body checking is allowed to young athletes competing in Pee Wee ice hockey games, the risk of injury and concussion was higher among these athletes of the ages 11 and 12. Due to these statistics, it is found that in 2011, the USA Hockey’s board of directors passed the Progressive Checking Skill Development Program, known to have successfully changed the pace of game, deeming it safer for athletes. In order to reduce the rate of concussion and provide a safer play of game for ice hockey players, the implementation of helmet standards, use of face guards, and rules regarding body contact has changed to protect the athlete for the long-term effects of such a common injury.

Next, rugby is also a sport where there is violence between clubs and head injury is easy to come by. In rugby, players have to possess the ball without being tackled and if they are tackled, the force generated can bring about a concussion. Lastly, in BMX, drivers are continuously doing stunts or riding at high speeds where one fall or accident can put them in a severe state. BMX legend, Dave Mirra was diagnosed with chronic traumatic encephalopathy during an autopsy after he had committed suicide. It was known that Mirra was facing symptoms of brain degeneration which led to his passing.

Repetitive blows to the head, resulting in multiple concussions, can soon open a path onto CTE, or chronic traumatic encephalopathy, a neurodegenerative disease associated with head trauma. This process forms from a protein called Tau which clumps and slowly spreads throughout the brain, killing brain cells. It is found in athletes, military veterans, and others with constant brain trauma. Moreover, in the human brain, there are over 90 billion neurons that connect in a complex network, allowing individuals to interpret and react to our environment. Neurons are known as the building blocks of the brain made up of three parts: cell body, axon, and axon terminal. When an individual is impaired with a forceful concussion, it directly alters the shape of the axon which is so fragile due to its slim structure. The altered shape of the axons makes them difficult for cells to distribute chemicals and materials to all areas of the cell (WEBSITE). Tau proteins that help keep everything together are changed and fall apart, diseasing the human brain. During injury, microtubules break down causing Tau to float freely throughout the cell, changing shape and clumping together due to phosphorylation. It takes a long time for the disease to generate, but once Tau clumps are formed, they are slowly spread and linger throughout the brain, regardless of any future head injuries.

Looking forward, patients of CTE may experience issues with thinking and memory, such as: memory loss, impaired judgement, confusion, and progressive dementia. Symptoms revolving around the cognition appear in a patient’s 40s or 50s. These conditions can worsen with time or may be stable for years. Early symptoms of CTE appear in an individual within the ages of 20-30 and affects their mood or behavior. Further, aggression, depression, impulse control problems, and paranoia all stem from this ​

As stated (Gabriele), after a single traumatic brain injury, focal neurologic signs and neurocognitive symptoms can last for months or longer. A traumatic brain injury of moderate to severe intensity can accelerate age-related neurodegenerations such as: Alzheimer’s disease, Parkinson’s disease, and motor neuron disease also known as ALS. All of these diseases begin with axonal injury, which alters the shape of the cell further leading to neurodegeneration. At first, in 1928 Harrison S. Martland described these neurological effects of sports-related head trauma as “punch drunk” syndrome. Later, in 1937 Millspaugh referred this condition as “dementia puglistica.” Lastly, in 1949, neurologic, behavioral, and cognitive specific features were described in literature, deeming this condition “chronic traumatic encephalopathy.”

Individuals who are confirmed with chronic traumatic encephalopathy and experience its effects are known to have a history of repetitive head trauma. However, not everyone who experiences a head injury develops neurodegeneration or is likely to have CTE. Clinical symptoms within four domains of mood, behavior, cognition, and motor, can appear years or decades after exposure to head trauma. Further, it is stated by ( PAGE 149 BALNEO ) that mood features include: depression, irritability, hopelessness, anxiety, fearfulness, high rate of suicidal ideas, insomnia, apathy, flat affect, and loss of interest or fatigue. Next, behavioral symptoms include: impulsivity, explosivity, loss of control, aggression, rage, short fuse, physical or verbal violence, disinhibited speech or behavior, childish behavior, personality changes, paranoid ideas, and psychosis. Moreover, cognitive features can include: memory loss, executive dysfunction, dementia in advanced stages, but also impaired attention and concentration, visuospatial difficulties or language troubles. Lastly, motor signs include: parkinsonism, ataxia, dysarthria, gait troubles, tremor or spasticity. To conclude, all of the signs and symptoms described above do not happen quickly, yet they progressively evolve slowly over decades of time. The cases of CTE involving impairment of motor skills were predominantly boxers and the cases involving mood and cognitive features were predominantly American football players.

The prevention of any disease may seem farfetched to an individual; however, the likelihood of a brain injury can be prevented at a young age. Children are introduced to sports, especially contact sports, in their early life. Children attain a role model through the sport that interests them, making the individual more like their desired athlete. For instance, children who are introduced to sports such as football, boxing, hockey, and soccer, increase the likelihood of injury. During these stages of life, the brain is not fully developed, making very little room for error for any type of injury, being potentially life threatening as life takes it course. When the human brain is not fully developed, it increases the chance of an injury. The internal and external features of children are underdeveloped such as: neck strength, cognitive ability, and physical strength. In fact, data has shown that the rates of hospital admissions for children are higher in that of adolescents. Bancroft NeuroRehab states, by the time children reach 10 years of age, 16 percent will have at least one head injury that requires medical attention (Zemek, R.L., 2013). Next, the majority of sport-related concussion occurs in children 18 years old or younger (Comstock & Logan, 2012). Lastly, it is important to take note of possible concussions and seek medical attention to limit the damage of any internal injuries.

The dangerous disease of chronic traumatic encephalopathy takes its toll on the life of the individual affected and the lives of their family members. In 2011, former National Football League superstar Dave Duerson committed suicide with a self-inflicted gun wound, found to be in relation with the disease of CTE. Duerson had been suffering from the effects of CTE for two years before it became too much to handle. Before his death, Duerson told family and friends that he wanted his brain to be examined so the findings can help prevent the disease in the future, especially for NFL players. Shortly after Duerson’s death, doctors at Boston University had confirmed that what Dave had been suffering from was in fact, chronic traumatic encephalopathy. With the passing of his father, Tregg Duerson was motivated to make an impact for the lives of current and future football athletes. Tregg proceeded in writing the Duerson Act which proposes to ban tackle football for children under 12 years old in the state of Illinois. The Duerson family believes in order to stop CTE from developing, equipment does not have to be advanced, but physical contact has to be eliminated.

On the other hand, technological products are being designed by companies to address the issues of sport-related concussions. The “Head Impact Monitor System” (HIMS), is being designed by Prevent Biometrics, introducing a sensor-laden mouth guard that detects collisions immediately. This technological design promotes the care of athletes on the sideline following a impactful blow to the body on the playing field. Alternatively, the NFL has worked to reduce the rates of concussions and long-term injury by implementing a concussion protocol on the field, employing independent doctors to be on call in case of a traumatic injury. Riddell, a well-known helmet company that has been around the National Football League for years, developed both a Precision-Fit helmet and its InSite training tool. The Precision-Fit helmet is personalized for the athlete’s need, providing extreme protection geared up for the force of impact. Its InSite training tool is described to be a sensor within the helmet that tracks impact data, sending it to coaches and athletic trainers on call. This type of technology can adjust an athlete’s playing technique, making it safer for them and their opponent.

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