“You see all those brown little things?” Ann McKee asked me as I looked through a microscope. I was viewing a slide sample of the brain of Dave Duerson, the Notre Dame All-American defensive back who won Super Bowls with the 1985 Chicago Bears and the 1990 New York Giants. Duerson was a Notre Dame trustee, a National Football League Man of the Year for community service and an economics major who completed a management program at Harvard Business School. Early in his football retirement, he nearly tripled the annual sales of a meat supply company to $63.5 million.
The glory and fortune disappeared in the last decade. An onset of memory loss, hammering headaches, spelling problems, blurred vision, and hot temper led to spousal abuse, divorce, bankruptcy and finally, suicide in February at the age of 50. In the most eerie recognition yet by an ex-football player as to why he was losing his mind, Duerson presumably shot himself in the chest to preserve his head for research. He left behind the now-famous note, “Please, see that my brain is given to the NFL’s brain bank.”
That brain was sliced open by McKee, a co-director of Boston University’s Center for the Study of Traumatic Encephalopathy (CSTE). The “brown things” were nerve cells filled with tau protein, prevalent in degenerating brains like those in Alzheimer’s disease. There were so many brown spots, with tails curling off them, the slide looked like a muddy negative of spinning galaxies.
In that microscopic universe, we were looking into the black hole of contact sports: Chronic Traumatic Encephalopathy (CTE). This was the hole likely blown into Duerson’s head in a career of at least 10 recognized concussions and countless subconcussive hits. This is the void we still let our gladiators and kids fall into, cheering them all the way.
“If it were a normal person, you would see absolutely none of that,” she said in her lab at the Bedford Veterans Administration Medical Center, where she also runs brain banks for research on military injuries, Alzheimer’s and heart disease. She pointed out how the tails of the tau-infested cells made long projections to make contact with other cells, causing short circuits and disordered thoughts.
“Totally chaos,” McKee said of the slide. “To imagine that a guy was 50 when he had this,” she said. “I deal with neurodegenerative disease all the time, but you don’t see it in 50 year olds even if you had a gene for the disease.”
McKee then showed me a recently-made slide of another well-known NFL player who died in his late 70s or early 80s. The constellations of tau were overwhelming. “He’s got disease everywhere,” McKee said. “There is no place I can go in this brain that’s just not incredibly diseased. I’ve never seen anything like this. This is the worst case I’ve seen. This guy’s brain is 800 grams, half the size of most players brains.”
A slide from a healthy brain would have had a far more clear background with blue spots. The difference from a CTE brain is so dramatic, the comparisons should be required viewing for parents and youth contemplating high-contact sports and the coaches, athletic directors and school principals in charge of them. These images should be pinned on the wall with those of blackened lungs we’ve long used to scare teens from smoking. They just might scare parents and officials into making these sports as safe as possible.
The urgency grows with each new brain analyzed by McKee. In an interview with her and CSTE co-directors Robert Cantu and Robert Stern, all three and other researchers around the country fear that today’s hard-earned concussion awareness, won only in the last couple of years against the prior denial of the NFL, is already being outstripped by new scientific findings.
Chief among them is that the biggest culprit for CTE for many athletes may not be the massive blows that cause concussions but the thousands of lesser ones that do not.
“It gets very scary,” McKee said. “In fact, it’s gotten to the point where I don’t even think about the future. I just report what I see. I think its going to change things, but I really don’t know how its going to change. I think we have some very concerning information.”
It is scary enough that Cantu, who has a book coming out next year on concussions and children, believes that youth under 14 should not play collision sports like football, ice hockey, soccer and lacrosse until they are modified to eliminate head blows in routine play. “It doesn’t make sense to me,” Cantu said, speaking for himself and not for the center, “to be subjecting young individuals to traumatic head injury. There’s no head injury that’s a good one and you can’t play collision sports without accumulating head injuries.”
The information from CSTE over the last decade was concerning enough. The CSTE has now analyzed the brains of more than 75 deceased athletes. It has found CTE, originally diagnosed in 1928 in “punch drunk” boxers, in more than 50 of them, including at least 14 of 15 NFL players, and four of six hockey players. Evidence of early CTE has now been found in former high school and college football players who died when they were 17, 18 and 21.
The 21-year-old with CTE was Owen Thomas, a popular captain of the University of Pennsylvania football team and a junior in the school’s Wharton business program. He committed suicide last year after what friends said was a sudden plunge into depression. He had no history of it, nor had a diagnosed concussion on the football field. But he was a lineman who was known as a hard hitter from the moment he started playing at the age of nine. He likely took thousands of head blows.
Those circumstances, beyond even the findings in professional athletes, made McKee realize on the day she analyzed Thomas’ brain that CTE “wasn’t a fluke. This wasn’t just a series of horrible coincidences, this was real, this was shockingly common - and it was affecting our kids. I drove home that night and couldn’t think about anything else all through the evening and night. All I could think of was Owen Thomas, what was going through his mind, was it possible that these changes somehow influenced his decision to take his life?”
The evidence to date has forced significant recent changes in contact sports. The NFL, colleges and state high school athletic associations, including Massachusetts, have revised or instituted new protocols to taking concussed players off the field for the rest of a game and not returning them to play until medically cleared. The NFL recently handed down its first one-game suspension for the recent, vicious helmet-to-helmet hit by Pittsburgh Steelers linebacker James Harrison on Cleveland Browns quarterback Colt McCoy.
The NHL has also improved its treatment protocol and now penalizes deliberate hits to the head during play. Hockey Canada now penalizes all hits to the head during play, even accidental ones, in the minors (13-17 years old) and for females. The Ivy League this season slashed the number of football practices with contact in full pads.
But while reporting of concussions is way up, there is yet no proof that blows to the head are dramatically down. The NFL and the National Collegiate Athletic Association face multiple lawsuits from former players _ including those in their 20s, 30s and 40s who claim to be suffering from all the hits _ who say the organizations were negligent in addressing brain trauma. The NFL last year gave CSTE an unrestricted $1 million to further its research but the league also continued to rack up concussions, 260 last year compared to 200 in 2008 according to the Associated Press.
After the Browns became the latest team to botch a concussion diagnosis _ with team medical staff saying it missed McCoy being flattened by Harrison _ the league this month decided to put an independent trainer up in the press box to survey the action. But that change falls short of the critics’ call for an independent neurologist on the sidelines. For a $9 billion enterprise, that would seem to be a small price to pay for medical credibility.
Play remains so violent in the NHL that at one point in mid-December, 23 players, including many stars, were out with concussions. This month, Rajendra Kale, the interim editor-in-chief of the Canadian Medical Association Journal, called for the banning of fighting in hockey, citing BU’s research that repetitive head trauma of any kind may contribute to CTE. Three of the four deceased hockey players found to have CTE were frequently-fighting “enforcers,” including 28-year-old Derek Boogaard.
The CMAJ editorial came two weeks after NHL commissioner Gary Bettman this month dismissed connections to hockey’s style of play and CTE calls to further reduce regulate play or ban fighting, saying, “our fans tell us they like the level of physicality in our game.” But calls to end fighting are growing from within. David Branch, the president of the Canadian Hockey League, the prime feeder league for the NHL and which has much tougher penalties against fighting, this month told the National Post that, “The time will come where it will be deemed to be totally unacceptable.”
Hall of fame goaltender Ken Dryden highly criticized Bettman’s level of denial in a December essay in the Toronto Globe and Mail, saying, “that’s how thousands of asbestos workers and millions of smokers died.”
This barely begins to address where brain trauma may actually start in many cases: youth sports. A Centers for Disease Control and Prevention report in October found that virtually the same number of youth aged-10-to-14 (60,272) annually go to to emergency rooms for nonfatal traumatic brain injuries (TBI) as youth 15-to-19 (61,851).
For boys, the top cause in both age groups was football. For girls, the top cause at 10-to-14 was bicycling. By 15-to-19, it was soccer. Other significant causes for girls 10-to-19 were basketball and gymnastics.
Emergency room visits for youth sports-related traumatic brain injuries (TBI) went up 62 percent from 2001 to 2009. Much of that rise likely represents much better concussion awareness. But researchers also believe it represents athletes continuing to get bigger, faster and stronger and sports officials not adjusting their rules fast enough to mitigate the damage. This makes no sense when according to the CDC, “younger persons are at increased risk for TBIs with increased severity and prolonged recovery.”
Those ER visits scream for us to hear the silent story. A Purdue University engineering team, using accelerometers in football helmets and before-and-after brain scans, last year found “previously undiscovered” levels of cognitive impairment in high school players who suffered no concussions. Researchers Eric Nauman, Thomas Talavage and Larry Leverenz recorded up to 1,800 hits in a season, primarily among linemen and linebackers. G forces of the hits ranged from four times to more than 20 times that of a roller coaster. There were four recorded hits of nearly 300 G.
The number of hits correlates with the working assumption by BU researchers that linemen likely absorb between 1,000 and 1,500 subconcussive head blows a season.
“We can see what parts of the brain shuts down or works twice as hard to complete a task,” Nauman said in an interview. “As these hits accumulate, different parts of the brain stop working and other parts are being recruited to cover up for the damage. Even though they may not show symptoms, the brain has changed. We scratch our heads, both at what the brain can take and the damage the brain can hide.”
Last month, an Albert Einstein medical school study also found subconcussive trauma among adult men and women amateur soccer players who frequently headed the ball. In an amazing parallel to the presumed number of head hits to football linemen, significant trauma was seen in soccer players who headed the ball 1,000-to-1,500 times a season.
“It only amounts to a few times a day for a regular player,” said Einstein researcher Michael Lipton in a press release. “Heading a soccer ball is not an impact of a magnitude that will lacerate nerve fibers in the brain. But repetitive heading may set off a cascade of responses that can lead to degeneration of brain cells.”
It is a cascade that, despite the publicity given to the NFL and the NHL, knows no gender. Purdue’s Nauman said heading in girls has a G force four to eight times that of a roller coaster, and can also cause cognitive impairment without an actual concussion. In a sports medicine journal review article this year, the BU researchers noted that the rate of concussion for collegiate women’s soccer players is slightly higher than for football players, the rate for women’s hockey players is more than twice that of male hockey players and the rate of women’s lacrosse players is equal to the men.
With scientific restraint, McKee, Cantu and Stern cautioned against panic. As sports fans, they are not at all interested in banning contact sports. They just want to get the head out of the way. Another co-director, Chris Nowinski, is a former Harvard football player and professional wrestler. McKee is a Wisconsin native whose office is adorned with Green Bay Packer’s memorabilia down to a ticket she was given from the 1967 NFL championship game in Green Bay nicknamed the “Ice Bowl” because it was won by the Packers in temperatures 13 below zero.
“The flip side, when you say ‘ban this and ban that,’ is what’s the kid going to be doing?” Cantu asked. “Is he going to be out on his motorcycle or in a car with another teen driving? There are many things more dangerous in terms of catastrophic injury than playing football. Those numbers pale to the numbers of kids who die in car accidents, motorcycle accidents.”
Yet they all are troubled by the slowness of society to protect the noggin on the field _ and off. Despite the media spotlight on concussions, brain safety is so lightly regarded in daily life that 85 percent of high school youth told federal researchers in 2009 that they rarely or never wore a helmet while bicycle riding, a percentage unchanged from 10 years ago. That is surely why bicycling is the second leading cause behind football for emergency brain injury treatment for boys and girls of all ages.
Stern has coached Little League baseball, holding a clicker to know when to pull a pitcher off the mound for reaching a throwing limit meant to avoid arm surgery. “The number was based on absolutely no science,” Stern said. “It was an arbitrary number that is now followed universally and it’s the law, based on the minuscule possibility that these kids are going to develop these potential orthopedic injuries. . .Then we drop our kids off at Pop Warner football and let them hit each other in the head over and over and over again and no one is counting _ and that damage may not be correctable.”
It all adds up to a major course correction for collision sports. I would not only ban collision sports for youth under 14 as Cantu suggests, but I would also have a federal commission work with researchers to take head trauma out of normal high school play. State-by-state changes will be too slow, too confusing and resistance to change would likely be heightened for sports particularly ingrained into regional culture.
In football, that means new stances for linemen so they do not launch into each other and clunk helmets on virtually every play. Given the up to 1,800 hits and the cautionary story of Owen Thomas, high school and youth football linemen should be held to a strict play count. It would mean re-teaching the techniques of tackling to end any leading with the head, launching off the feet and penalizing every last helmet-to-helmet hit, even accidental ones. If a player has to leave a game because he was knocked out of it by a helmet-to-helmet injury, so does the offending player.
In soccer, that means eliminating heading from high school on down and a maximum number of times a college player can head the ball in practice and in games. In hockey, that means banning all fighting and penalizing even accidental hits to the head. It means ending body checks that crush and rattle players against the boards.
The head is so precious, and the effects of repetitive trauma on the young head are still so unknown, if we’re going to keep high school and youth collision sports in our culture, it also means having a neutral neurologist at every game, everywhere in America. That person would have the authority to take any player off the field at anytime brain trauma is suspected. Expensive? Yes. But nothing like brain surgery, years of therapy or a lawsuit.
It means the NFL, NHL and Major League Soccer, whose stars youth emulate, to lead by example that the brain comes before brutality. The NFL must end all launching of players, penalize all helmet-to-helmet hits. The NHL must ban fighting and slamming against the boards. The MLS must have practice and game limits for heading.
They must at least start with that, because there is a good chance science will ultimately declare this to be the bare minimum of what should have been done. The BU CSTE has received a multitude of brains from families who suspected something was wrong with their spouse or father, but those brains now need to be rigorously compared with donated brains of athletes who played through the same violence but lived long and seemingly lucid lives.
Stern is often asked by the media and other scientists about NFL hall of fame quarterbacks Steve Young, 50 and Troy Aikman, 45, each of whom suffered many concussions, but currently are both successful television football analysts.
“I’ve been on discussions with media and scientists who pick specifically those two and say, ‘Well if they’re OK, then how can you say there’s a problem with playing football and later life difficulties?’” Stern said. “That’s like saying, ‘Here’s a 60-year-old woman who doesn’t have breast cancer, so how can you say that there’s a risk of getting breast cancer?’ It’s really a ridiculous argument.”
Cantu said Young and Aikman may end up as examples of the risk at different positions, taking “spectacular” hits in games, but too valuable to be touched in practice, “Unlike a lineman who’s getting his cage rattled every single play.”
Yet to be done is research that better identifies concussions. Cantu said that for every recognized one, seven or eight are probably missed. Yet to solved are the mysteries of why some people, like hockey star Sidney Crosby, are knocked off the ice for months with prolonged concussive syndrome and why others, like quarterback Aaron Rodgers of the Packers, missed one week with a late-season concussion but came back razor sharp to march his team toward the Super Bowl crown.
To get at the even more mysterious CTE, an especially urgent quest now that it has been found in teenagers, the BU team has begun to interview 100 living former NFL players to work toward possible treatment when athletes are alive. “We don’t yet have therapies that get at the root of the underlying problem, because we don’t really yet understand the problem,” Cantu said. “. . .We know it occurs, but we don’t know how much impact is necessary, what are the genetic factors or the environmental factors such as how many blows close together or far apart does it take. What we do know scares us.”
Besides Duerson, McKee said many of the other analyzed brains belonged to well-known football players who were “heroes” in their prime. While the identity of many of them remain anonymous, the center announced in November that Cookie Gilchrist, an all-pro running back in the early 1960s with the Buffalo Bills in the American Football League, had severe CTE. Gilchrist lived to 75, but his family said he exhibited many of the problems Duerson had, as well as paranoia for the last 40 years.
This month, the center announced that Lew Carpenter, an all-purpose runner and receiver of the late 1950s and early 60s who was on three NFL title teams in Detroit and Green Bay, had advanced CTE. He died this year at 78. Despite no official history of concussions, his family cited significant memory loss in recent years.
“To know this is what was in store for them. . .when you see this disease it gets so overwhelming,” McKee said. “I think the data is only going to get stronger. It’s not going to get weaker. There’s a huge sense of responsibility that we really need to figure this out. so that we can help these guys. There are so many worried people out there now that have played professional sports or even just amateur sports.
“But it is not just owing it to them. Military injuries can lead to this and it’s affecting military servicepeople. This is a huge problem for our future generations and for the future of really, our country.”
The future begins with looking at those slides from McKee, before another generation of pee-wee football, soccer and hockey players slide into the same void, from which there is no known return.