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The NFL's CTE Clock Is Beginning to Tick in Real Time

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January is always an exciting time for the NFL with the playoffs taking place culminating with the Super Bowl. This year, however, the excitement was tempered as the issue of brain trauma created headlines twice during the month. This was followed by the ongoing question about what the league is doing to keep players healthy. Let's explore these issues beginning with the two stories that made the news.

On January 10, the results of Junior Seau's brain autopsy were made public confirming he suffered from chronic traumatic encephalopathy (CTE). This was followed by a landmark study by Dr. Gary Small, published in The American Journal of Geriatric Psychiatry on January 22, which showed the presence of CTE in retired NFL players.

Junior Seau's results confirmed what everybody already knew -- his brain was seriously diseased. Dr. Small's research, however, broke new ground by expanding the CTE conversation beyond suicides and autopsies.

Conducted at Semel Institute for Neuroscience and Human Behavior at U.C.L.A., Dr. Small's pilot study found tau protein, the signature of CTE, in the brains of five former NFL players. By injecting a chemical marker which attaches itself to the protein into the players and then subjecting them to PET scans, they found greater quantities of the marker in the players than is typically found in healthy men. The players included a quarterback, defensive lineman, linebacker, guard and center, and each sustained at least one concussion during their career. The data also show a linear relationship between number of concussions and amount of tau protein. The more that occurred, the greater the evidence of the chemical marker.

There's a great deal to be said about Dr. Small's study, but let's begin with the obligatory qualifications. First, it's a very small sample, so one must be cautious about extrapolation. Second, it's a self-selected sample, thus it is not representative of the general population. And third, we are still at the beginning of the process of understanding this disease so, at best, we should be cautiously optimistic.

Every disease has two core issues -- prevention and cure. With diseases like cancer and Alzheimer's, healthy lifestyle management can minimize their occurrence, while we continue to wait for research to find cures.

CTE, however, is an entirely different organism. It is a violence based disease and, for the most part, preventable. Avoid collision sports, fighting of any kind and combat, and your probability of contracting it is near zero.

Concussions and CTE reflect the short and long-term effects of blows to the head. Measuring and monitoring impact is central to understanding both. It took a while for the NFL to begin appropriate protocols to deal with concussions as evidenced by the multi-billion dollar class action suit filed by over 4000 former players claiming negligence on the part of the league. Yet, there appears no sense of urgency on the part of the league to expand on the quality work it has begun with concussions.

Given the importance of impact studies, it is baffling as to why the NFL has not already been doing what other researchers at lower levels have been doing for years. Since 2003 Stefan Duma, engineering professor at Virginia Tech, has placed sensors in the helmets of football players to measure the number and severity of hits they take. It is called the Head Impact Telemetry system (HIT). The information gets translated to a sideline computer so medical staff can be alerted to look for concussion signs. The HIT database currently contains over 200,000 hits. Dartmouth, Brown, North Carolina and Oklahoma have also begun using this technology.

Impact studies have not been limited to colleges. In 2010, researchers at Purdue University, using helmet sensor technology discovered that some high school football players suffered undiagnosed changes in brain functioning and continued to play even while still impaired. In other words, there appears to be a form of subliminal damage (my term) that occasionally occurs. Scans showed they were hurt, but traditional concussion protocols failed to detect it. The sensor data is being used to help connect the dots to further understand the brain injuries that are flying below radar.

Pop Warner football has begun doing sensor-based research as well. The results of an initial pilot study of players 6-8 years old found that one out of every twenty plays resulted in an impact equivalent to a car crash. As a consequence of this study, a larger research project is now underway collecting data on 240 players on six youth football teams in Virginia and North Carolina.

So, we now have impact research occurring on every level of football except the NFL! Why?

When asked why the HIT system isn't more widely used, Stefan Duma cited cost as one factor, but he also said the following: "I think some people maybe don't want to know what the data says. I think it might raise some concerns if you looked at the data objectively."

You don't have to be a member of Mensa to know the NFL is in no hurry to find out whether the HIT, or any other impact measuring system, works. Given what the research at the other levels showed, one can only imagine the g-force numbers that will pop up on the sensor screens when the NFL is wired.

Dr. Richard Ellenbogin, the co-chair of the NFL's Head, Neck and Spine Medical Committee in January of 2012 said, "we don't want to trot this out and find out it's not accurate... bad data or wrong data is worse than no data." The irony is, it's the good data that is going to be the most problematic for the league. That's why the NFL is taking its time researching impact.

So what exactly is the NFL doing?

There are two rumors floating around. The first has the league monitoring impact through sensors embedded in mouth guards. The second, and more probable according to an article in Forbes in July of 2012 by Lance Madden, has the NFL, beginning next season, using a variation of a helmet the army uses in gathering data on head trauma. To date, the league has not confirmed this study.

Every year that goes by without real-time impact measurement is costly for current and future NFL players. Think how much individual player, as well as position data, is lost because the league isn't wired. This information -- the type, frequency and intensity of hits -- could, potentially, provide algorithms for who should, or should not, be playing. Is there any issue more important than this?

By creating a protocol that couples impact data with periodic PET scans modeled after Gary Small's pioneering work, both ends of the real-time continuum are covered -- immediate and cumulative. Real time measurement has to be the NFL's mantra going forward in order to maintain its credibility.

While researchers and the media were expressing their excitement over the results of the Semel Institute PET scan study, a wave of anxiety rippled through the entire NFL community. It was not good news for the league as the issue of concussions and CTE, once again, became a front page story. But it was the players, however, who experienced the results of this study on a much more profound level. Yes, it was a very small sample, but all five players in the study tested positive for the CTE marker!

If this doesn't rattle your nerves, nothing will.

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