Foot­ball’s loom­ing day of reck­on­ing

The Denver Post - - PERSPECTIVE - By Joe No­cera

On va­ca­tion the past two weeks, I some­times felt as though ev­ery time I checked in on the news, I came across yet an­other story about foot­ball and CTE, the ter­ri­ble neu­rode­gen­er­a­tive brain dis­ease that af­flicts way too many foot­ball play­ers. Its for­mal name is chronic trau­matic en­cephalopa­thy, and it can only be di­ag­nosed af­ter some­one dies and their brain is cut open.

The most im­por­tant of these sto­ries, which ran in late July, re­ported on the re­cent find­ings of Dr. Ann Mc­kee, a neu­ropathol­o­gist who leads Bos­ton Uni­ver­sity’s CTE Cen­ter. Mc­kee had ex­am­ined the brains of 202 for­mer foot­ball play­ers and had found ev­i­dence of CTE in 177 of them, in­clud­ing some ath­letes whose foot­ball days ended af­ter high school. The real stun­ner, though, was that 111 of those brains had resided in for­mer NFL play­ers — and 110 had CTE.

The New York Times even pub­lished pho­to­graphs of some of the brains, so that you could see the in­va­sive ef­fect of the tau pro­tein that causes CTE, vis­i­ble be­cause the brain be­comes darker in the ar­eas where tau ac­cu­mu­lates. The Times also noted that among the pro play­ers whose brains Mc­kee ex­am­ined, the pre­pon­der­ance were line­men. This makes per­fect sense. Although in the pub­lic mind CTE is as­so­ci­ated with con­cus­sions — and that is un­ques­tion­ably a se­ri­ous prob­lem — the big­ger is­sue is sub-con­cus­sive trauma, the re­peated blows to the head that line­men es­pe­cially en­dure, and in­flict, in ev­ery game.

That story was fol­lowed two days later by the news that John Urschel, 26, a line­man with the Bal­ti­more Ravens, was re­tir­ing from foot­ball af­ter only three sea­sons. A math­e­ma­ti­cian who is cur­rently a PH.D. can­di­date at the Mas- sachusetts In­sti­tute of Tech­nol­ogy, Urschel has ca­reer op­tions that most of his foot­ballplay­ing peers don’t. But he clearly loved play­ing foot­ball, once de­scrib­ing the rush he got from hit­ting op­pos­ing play­ers as “a feel­ing I’m (for lack of a bet­ter word) ad­dicted to.”

But while Urschel and his agent down­played the med­i­cal sig­nif­i­cance of his re­tire­ment, sev­eral news out­lets re­ported that the Mc­kee study had height­ened his con­cern that con­tin­u­ing to play foot­ball would ham­per his men­tal fa­cil­i­ties and jeop­ar­dize his abil­ity to do math.

There was also a flood of fright­ened com­men­tary from for­mer play­ers, with the for­mer Den­ver Bron­cos run­ning back Ter­rell Davis telling The Den­ver Post — just prior to his in­duc­tion into the Hall of Fame — that “we’re all scared,” and 44-year-old War­ren Sapp, an­other Hall of Famer, telling the Play­ers Tri­bune that he was do­nat­ing his brain to CTE re­searchers. “My mem­ory ain’t what it used to be,” he said. Boomer Esi­a­son, the re­tired pro quar­ter­back and cur­rent sports broad­caster, said on his ra­dio show that he “most likely” had CTE — and that “all foot­ball play­ers prob­a­bly have it.”

And fi­nally, last Fri­day, The Times re­ported that 28 months af­ter a Cte-re­lated le­gal set­tle­ment be­tween the Na­tional Foot­ball League and for­mer play­ers was ap­proved by fed­eral district court judge Anita Brody, pay­ments were fi­nally be­ing is­sued to some of the 21,000 for­mer play­ers who were part of the plain­tiff class. (More about that shortly.)

All of which mo­ti­vated me to seek out one of Mc­kee’s Bos­ton Uni­ver­sity School of Medicine col­leagues, Robert Stern, a pro­fes­sor of neu­rol­ogy and neu­ro­surgery who re­searches Alzheimer’s as well as CTE. One of his main fo­cuses over the past few years has been search­ing for ways to de­tect and di­ag­nose CTE dur­ing life, work that is be­ing funded by the Na­tional In­sti­tutes of Health. (The NFL was orig­i­nally go­ing to fund some of the CTE re­search through the NIH, but the gov­ern­ment wound up pro­vid­ing all the fund­ing. NPR re­cently re­ported that the NIH and the NFL ended their re­search part­ner­ship with mil­lion un­spent.)

What all these re­cent sto­ries about CTE made me won­der was whether Stern and other sci­en­tists in­volved in this work were mak­ing progress in their quest. When I got him on the phone, Stern could not have been more up­beat.

“We are mak­ing in­cred­i­ble progress,” he be­gan. Then he con­tin­ued:

“It is re­ally an ex­cit­ing time in the de­vel­op­ment of ob­jec­tive biomark­ers for neu­rode­gen­er­a­tive dis­eases. Alzheimer’s is the most com­mon neu­rode­gen­er­a­tive dis­ease, of course. It is scary com­mon. Well over 5 mil­lion peo­ple have it. CTE is very sim­i­lar to Alzheimer’s. And all of the ad­vances in di­ag­nos­ing Alzheimer’s dur­ing life ac­cel­er­ate our abil­ity to do the same with CTE. Just in the last two years, there have been tremen­dous strides in new blood-based biomark­ers with these dis­eases, as well as new neu­roimag­ing ap­proaches.

“For years and years, it was be­lieved that you could only di­ag­nose Alzheimer’s af­ter death. But be­cause so many hun­dreds of thou­sands of peo­ple were stud­ied over the years, and thou­sands of brains, sci­en­tists got good at di­ag­nos­ing it in life. Blood-based and spinal fluid-based biomark­ers as well as spe­cific PET scans can di­ag­nose it quite ac­cu­rately, even be­fore some­one has sig­nif­i­cant symp­toms – in­deed even be­fore some­one has any symp­toms at all. Things have changed so dra­mat­i­cally with Alzheimer’s, it al­lows us to feel con­fi­dent about CTE. I run a reg­istry of older in­di­vid­u­als who we ex­am­ine ev­ery year. Af­ter they pass, we ex­am­ine their brains, and we can look at the re­la­tion­ship be­tween what they were like in life and what changes are seen in their brains post-mortem. We don’t have that lux­ury yet with CTE, where we’ve only looked at hun­dreds of brains, and haven’t ex­am­ined any­where near the num­ber of peo­ple. It’s re­mark­able that we have made the gains we have.”

When I asked Stern how long he thought it would be be­fore CTE could be di­ag­nosed dur­ing life, he an­swered, “be­tween five and 10 years,” with the for­mer more likely than the lat­ter. But when I asked the ob­vi­ous fol­lowup ques­tion – what will a di­ag­nos­tic tool for CTE mean for the game of foot­ball? – he gave a sci­en­tist’s re­sponse. “That’s beyond my fo­cus,” he said.

Surely, though, the im­pli­ca­tions are pro­found. One im­pli­ca­tion is that once CTE can be di­ag­nosed, sci­en­tists can work on de­vel­op­ing drugs to treat the symp­toms, as is cur­rently hap­pen­ing with Alzheimers. But that will take years, and in the mean­time, there will be other likely con­se­quences that won’t be so pleas­ant to con­tem­plate.

Take, for in­stance, that class-ac­tion set­tle­ment be­tween the ex-play­ers and the NFL. It’s es­ti­mated that pro foot­ball will ul­ti­mately pay out $1 bil­lion or more to play­ers who show cer­tain symp­toms of brain dis­ease dur­ing their lives. But the symp­toms laid out in the set­tle­ment — Alzheimer’s, Parkin­son’s dis­ease, and ALS among them — don’t nec­es­sar­ily cor­re­late to CTE. In­deed, there’s zero ev­i­dence that Alzheimer’s is a symp­tom of CTE, and not much ev­i­dence that Parkin­son’s is re­lated ei­ther.

Mean­while, signs that some­one does have CTE — in­clud­ing mood swings, un­con­trolled anger, de­pres­sion and sui­ci­dal ten­den­cies — are nowhere to be found in the set­tle­ment. And the agree­ment be­tween the NFL and the plain­tiffs — or, rather, their lawyers, who stand to gain as much as mil­lion for their ef­forts — takes no ac­count of the pos­si­bil­ity that CTE will one day be di­ag­nosed dur­ing life.

Thus you will have a sit­u­a­tion where for­mer play­ers who have been di­ag­nosed with CTE will get noth­ing be­cause they have the “wrong” symp­toms, while other for­mer play­ers who don’t have CTE will be com­pen­sated be­cause they came down with Alzheimer’s, just like mil­lions of peo­ple who never played foot­ball. Even though the set­tle­ment is iron­clad in the sense that it pre­vents fu­ture Cte-re­lated law­suits — which of course is why the NFL agreed to it — I sus­pect that this sit­u­a­tion will be un­ten­able. Play­ers and ex-play­ers are un­likely to sit still as the ab­sur­dity of the sit­u­a­tion be­comes clear. There’s likely to be some kind of re­volt.

The other, even more im­por­tant im­pli­ca­tion will be on the game it­self, of course. Esi­a­son is surely wrong when he says that ev­ery­one who played the game has CTE. But once a di­ag­nos­tic tool is de­vel­oped, re­searchers will be able to cal­cu­late the per­cent­age of play­ers in high school, col­lege and the pros who will get the dis­ease. Sup­pose they find that half of for­mer NFL play­ers have it, and maybe an­other 10 per­cent of col­lege play­ers — num­bers that seem plau­si­ble, given Mc­kee’s find­ings. Even with­out know­ing the pre­cise odds, NFL play­ers now re­al­ize that foot­ball is a crap­shoot that might well lead to an early death. How will they re­act once they know how high the odds truly are?

What do play­ers do once they know they can be di­ag­nosed even be­fore they show any symp­toms? Do they get tested? Or do they avoid get­ting tested, not want­ing to know? Or do they de­cide not to play at all? Will a line­man who gets through col­lege with­out con­tract­ing CTE de­cide it’s not worth the risk of go­ing pro? And par­ents — what do they do when they know the odds? Will they still let their kids grav­i­tate to foot­ball, even in foot­ball-mad places like Texas and Alabama?

Will the ex­is­tence of a di­ag­nos­tic tool for CTE cre­ate an ex­is­ten­tial cri­sis for the NFL and the sport of foot­ball? I think that’s pretty likely.

For all the re­cent sto­ries about CTE and foot­ball — for all the fear CTE has cre­ated among play­ers and ex-play­ers — the game’s mo­ment of truth has not yet ar­rived. If Stern and his fel­low sci­en­tists have any­thing to do with it, it should get here some­time be­tween five and 10 years.

Ron Sch­wane, The As­so­ci­ated Press

For­mer Bron­cos run­ning back Ter­rell Davis speaks dur­ing his in­duc­tion into the Pro Foot­ball Hall of Fame ear­lier this month in Can­ton, Ohio. Re­gard­ing re­search show­ing CTE in the brains of 110 of 111 de­ceased play­ers, Davis re­cently said, “I can’t lie, we’re all scared. We’re con­cerned be­cause we don’t know what the fu­ture holds.”

Ann Mc­kee, Bos­ton Uni­ver­sity via AP

Sec­tions from a nor­mal brain, top, and from the brain of for­mer Uni­ver­sity of Texas foot­ball player Greg Ploetz, bot­tom, in stage IV of CTE.

Joe No­cera is a Bloomberg View colum­nist. Fol­low him on Twit­ter: @No­cer­abv

Tom Avril, Philadel­phia In­quirer/tns file

John Urschel teaches in­te­gral vec­tor cal­cu­lus to a class of Penn State un­der­grad­u­ates in 2013. Urschel, who played for the Bal­ti­more Ravens from 201416, abruptly re­tired from foot­ball last month in light of a med­i­cal study show­ing CTE in nearly 99 per­cent of de­ceased NFL play­ers’ brains.

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