Concussion, CTE and what we don’t know

Monday, May 14, 2018

What we wish we knew about concussion and CTE would make life easier for athletes, their parents, coaches and league administrators. It’s tough to remember that concussion research is in its infancy and the final answers about the way the brain reacts to injury, both in the short term and long term is still a mystery. Regardless of the headlines, there are many things we don’t understand. What should be common sense, may or may not be true.


The only way to diagnosis chronic Traumatic Encephalopathy is after death, by autopsy, and using special techniques to look for abnormal proteins in brain tissue. Tau proteins are located in the brain and help stabilize microtubules inside brain cells called neurons. Abnormalities of an enzyme may cause tau proteins to fold abnormally and clump into “neurofibrillary tangles”. Other brains cells may also be affected.

While the diagnosis of CTE may be suspected because of symptoms like depression, suicidal thoughts, confusion, and short term memory loss, there is no test available for patients to confirm the diagnosis while they are alive.

The pathology findings under the microscope suggest that there is a difference between Alzheimer disease and CTE based on where the tau tangles occur and the presence of amyloid plaque (a sticky protein) seen in Alzheimer.


The relationship between head injury and CTE seems to be well established. Using boxing research, it may be the number of hits to the head that make a difference as opposed to whether a concussion occurred. Studies suggest that “punch drunk syndrome” leading to dementia pugilistica found that it was the number of rounds boxed that was the important factor in determining long term brain issues, rather than the number of concussion.

This presumes that we know how to make the diagnosis of concussion and the answer is that we don’t. There is no test to confirm that a concussion has occurred. We know a concussion when we see it: a player who is temporarily confused or knocked unconscious, has a brief seizure or has an abnormal neurologic exam is an easy diagnosis. Many times, the symptoms of concussion may be delayed by hours and those symptoms may be subtle, involving sleep disturbance, ability to concentrate or minor changes in personality.

A concussion may be caused by a direct blow to the head, face or neck or it may be caused when a force to another part of the body is transmitted to the head. Imagine a car wreck where the seat belt holds the body in place but the head whips back and forth.

Not only can we not diagnosis a concussion with certainty, we also do not know when the brain has healed itself from injury and has returned to “normal”.

Cause and Effect

Making the link between head injury, concussion and CTE seems to have occurred, but the question there are plenty of questions left to answer. Does CTE risk increase with the number of concussions or does is it the age of the brain when that first concussion occurs?  Contact sports increase the risk of head injury and the prevalence of CTE in NFL players has led to lawsuits to care for players who develop debilitating symptoms after their careers have ended.

In soccer, recent research suggests that heading the ball affects brain function more than head injury caused by collision. This supports the concept that the number of minor hits may be as important or perhaps more important than a single concussion.

Newer recommendations from research have suggested that concussed brains that are not fully developed are at higher risk for future behavior problems and decreased executive thinking, including initiating activities, problem solving, and planning and organizing. The suggestion is that between the ages of 10 and 12, the brain is undergoing major growth and development and may be particularly vulnerable to injury. Recommendations suggest that tackle football should be avoided before age 12.


The NFL and NHL rightly are concerned about the long-term consequences of head injury to their players. Those who make it to the pro level have played more games at a higher level and presumably with more exposure to violence than those who didn’t make it to the college level and beyond. A case study published this year found that an 18-year-old high school football player with multiple concussions had, on autopsy, already developed abnormal tau protein tangles in his brain.It may be that the die has been cast for the pro…what happens in the major leagues may be inconsequential as to the development of abnormalities in the brain that are associated with CTE…or, it’s those concessions that occur because of collisions with larger and faster opponents may be the culprit.

The bottom line is that research teaches us much as to the consequences of head trauma and the potential for long term brain dysfunction. It also reminds us that we don’t know what we don’t know.

Protecting players at all levels of competition is a reasonable approach, but that risk of concussion will never be zero, and because of that the risk of CTE will never be zero. Asking the NFL, NHL, NCAA and high school leagues to alter the game maybe appropriate, but there is no way to know whether it will actually make a difference.

We can’t make the diagnosis of concussion. We can’t make the diagnosis of CTE. We don’t know how many concussions it takes to develop CTE and we don’t know if the brain has the ability to fix itself if it has been hurt.welcome to the world of science.

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the cost of medicine

Monday, March 5, 2018

Hope springs eternal this time of year for sports fans. Baseball teams have invaded Florida and Arizona to get ready for the season, while the NFL Combine in Indianapolis showcased top college football players. General managers, scouts and coaches have to evaluate the talent and their potential to lead a team to victory. But there is a difference in their decision making. Each NFL team has a salary cap and any extra money spent on a star quarterback is money not spent on a lineman to protect him, or a defensive player, or even a punter. In baseball, there is no cap (though there is a luxury tax for owners who are to extravagant) and teams are freer to spend as they choose to try to win a World Series.

As it turns out this difference in philosophy also plays out in the basic economics of medicine. The United States spends an almost unlimited amount of money to provide medical care, while other countries tend to be more frugal in their spending, having a budget (or in NFL terms, a spending cap) to provide medical services to their population. Whether one system is better than another is up for interpretation, but it is clear that different approaches exist.


There seems to be an unlimited demand for medical care, and as research finds new ways to treat diseases that were once thought to be uniformly deadly, the demand for new therapies, technologies and medications will continue to grow.

Another problem with unlimited demand is that some of the illnesses and injuries are self-inflicted, and there is no easy way to refuse care to those in need. Smoking has no positive benefit to the smoker and is a major risk factor for heart attack, stroke, COPD, and cancer. Second hand smoke increases asthma in infants and children and is increases the risk of cancer. Drinking and driving kills thousands and injures millions every year in the US. Marijuana use may increase the risk of pedestrian injuries.


If there is an increasing demand, there should be an increasing supply of services to provide the care needed, and this is where one might compare the NFL and baseball. Please know that there is no right or wrong, but rather, different approaches to care for people.

The NFL salary cap model

Imagine the Canadian system, where a single payer (the provincial government) has to decide how to allocate its budget to provide all medical care, from well-baby visits and immunizations to ambulance/helicopter transports and trauma centers plus everything in between. A need of one community has to be balanced with the need in another and not everybody gets what they want. The medical resources have to be allocated to meet all needs. This works in a society where people are willing to wait their turn for care and to be bumped in line if somebody sicker comes along to take their place.

Each province lists its waiting times based on procedure and location, from heart bypass surgery to hip replacement to cancer surgery. Emergency room wait times are also available on line. This is Ontario’s link.

Sometimes, the decisions are harsher. Red Deer is a small city of 100,000 people located half way between Edmonton and Calgary. Should somebody have a heart attack, their hospital does not have the capability of doing heart catheterizations to reopen a blocked artery. That patient has to be transported to either of the larger cities for a heart cath and mortality rate is 50% higher. Alberta Health Care has decided not to build a lab in Red Deer; medical funds are allocated elsewhere.

The Major League Baseball payment system

In the US, health care funding is a complicated mess with public and private insurance that does not provide coverage to all and often leaves people bankrupt due to illness and injury. People without insurance often forgo basic preventive exams like mammogram and colonoscopy, or blood pressure and diabetes screening, because of the price and inability to pay, only to then be diagnosed late when treatment is less effective and much more expensive.

Rationing of medical care does not occur at the governmental level but at the provider level, where people are turned away because of the inability to pay. How sad that federal laws were required (EMTALA: Emergency Medical Treatment and Active Labor act passed in 1986) to demand hospitals care for women in labor and people who may be in the midst of a medical emergency. Appreciate that hospitals are just buildings where care occurs, but the law was needed to remind the business managers that people came before profit.

Like baseball, every city and town is different and the owners of the local health care delivery decide how much or how little they will invest in the community. Not every team spends like the Yankees and Red Sox, and the quality of care across the country is not uniform.


The cost of health care is independent of the system that delivers it. It’s all about supply. Hoe many kids can you immunize for each alcohol-induced liver failure? How many more people might survive breast cancer if the money spent on opioid addiction research were redirected? Rationing and reallocation of medical resources occurs regardless of geography and payment model. It all depends on whether you like baseball or football.





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