If you want journalists to mock you, say aloud that chronic traumatic encephalopathy (CTE) has “an unknown incidence” among football players and that “a cause and effect relationship has not yet been demonstrated between CTE and concussions or exposure to contact sports.” That’s just what many of the sports world’s best brain scientists did in a consensus statement at the 4th International Conference on Concussion in Sport held in Zurich in November 2012.
To some writers, it was as if a group of physicists had repealed Newton’s law of gravity. The Newark Star-Ledger‘s Dave D’Alessandro, for instance, accused the doctors of telling a “whopper” and wondered “whether they are losing their minds.”
If you have been immersed in the wall-to-wall coverage of football and CTE, you may be more ignorant than the people completely ignorant of the coverage. In the wake of suicides by Junior Seau, Dave Duerson, Andre Waters, and other retired NFL players, and the post-mortem investigations that discovered CTE in their brains, a popular impression has formed that football causes CTE, that CTE causes suicide, and that the prevalence of CTE among contact-sports enthusiasts dwarfs its prevalence among their peers watching from the sidelines.These suppositions have become articles of faith; the fallen players, martyrs.
Like adherents of other belief systems, the CTE faithful treat heretics accordingly. The staid doctors in Zurich finding their sanity and ethics questioned by a sports columnist could tell you that. How dare neurologists presume to lecture a journalist on the workings of the brain?
The speculation linking CTE with suicide and CTE with sports isn’t science. Such generalizations aren’t supported by any longitudinal or cross-sectional study. The beliefs, nevertheless, find many passionate adherents.
For players once worshipped as gods, the cruel demise through cognitive decline naturally seems unfitting to fans who once held them up as immortals.The nature of the condition can’t help but appeal to our hearts more than our minds. The degenerative brain disease has been associated with memory loss, reduced impulse control, and premature senility. It sadly reduces athletes who once heard crowds chant their names to shells of their glorious selves who no longer even know their own names. Any fan glimpsing footage of Hall of Famer John Mackey in his waning days, and remembering how vigorous and vital the Baltimore Colts tight end looked in his heyday, has felt CTE’s tug on the heartstrings.
The coverage of the disease naturally plays on this emotional element.Scientists do the intellect. The emotions? Not so much.
Journalists Ahead of the Scientists
The detached science on CTE and football is actually rather primitive, excusably so given that the first instance linking the disease with a player occurred about a decade ago. Not a single study has attempted to demonstrate, let alone succeeded in establishing, a causal link between contact sports and CTE. This hasn’t stopped writers from pretending that science has indicted football as the source of the neurodegenerative disease. The sensationalistic coverage has decimated the ranks of youth football teams. Parents who once hoped their boy would become the next Junior Seau now worry that their boy will become the next Junior Seau.
Admissions by neurologists of what they don’t know contrast with boasts by public intellectuals of what they do know. The Atlantic‘s Ta-Nehisi Coates declares that “it is the repeated ‘minor’ hits that cause CTE. The enemy is the game itself. And it is killing men.” The Frontline documentary based on the Mark Fainaru-Wada and Steve Fainaru League of Denial book speculated that every football player may develop the debilitating brain disease. The New Yorker‘s Malcolm Gladwell, somewhat more restrained in his forecast, told an audience of Ivy League students that whenever they watch a football game “chances are that someone on that field is going to die a horrible death well before their time because of playing football.”
Who needs to be right when serving a cause so righteous?
The CTE meme advanced by such armchair scientists has met with severe resistance by actual scientists as of late. In the months since the Zurich statement, four important articles have appeared in academic journals noting that at this point even the people who know the most about CTE have more queries than conclusions. Notably, each of the four articles cautions against embracing conventional wisdom as established science. To their popularizers, the scientists offer a message in their articles at once implied and obvious: stop putting words in our mouths.
Finding CTE Under the Bed, Behind the Door, in the Glove Compartment
Perhaps the most important of the recently published articles is authored by Loyola Medical Center’s Christopher Randolph, MacArthur Foundation “genius” grant recipient Kevin Guskiewicz, and NYU Medical Center’s Stella Karantzoulis. “The media attention to this issue continues to far outweigh any meaningful results from sound experimental science, and a definitive epidemiological study still has yet to be done,” the trio points out regarding CTE in the Journal of the International Neuropsychological Society.
The few dozen autopsies conducted with a selection bias on brains presupposed to be damaged doesn’t amount to a randomized, unbiased study, the likes of which has been done to prove, for instance, the causal link between smoking and cancer. No such CTE study exists, despite the Boston Globe editorializing in September, “The link between football and CTE is about as clear as that of smoking and lung cancer in the ’60s.” But by 1960, the world was four years removed from the British Doctors Study that demonstrated the relationship of smoking to lung cancer. As the Randolph-Guskiewicz-Karantzoulis study shows, researchers are nowhere near the stage of scientifically determining the causes of CTE.
The doctors point out that “there remains substantial pathological overlap” between CTE and Alzheimer’s disease. They note that the theory that CTE instigates suicide runs up against the happy reality, proved in a 2012 National Institute for Occupational Safety and Health study, that NFL retirees kill themselves at reduced rates compared to their peers in the broader population. Why are player suicides so few in number, even though so massive in public awareness, if football causes CTE and CTE really increases the likelihood of suicide?
Perhaps the most troubling issue spotlighted regards the Center for the Study of Chronic Encephalopathy, whose researchers, in contrast to other neuroscientists, have remarkably found CTE in nearly every brain from deceased football players that they have inspected. The Boston University group’s threshold for what constitutes CTE includes the presence of neurofibrillary tangles (NFTs), which appear in the brains of almost every older American. The trio writes that “the only requirement for satisfying a neuropathological diagnosis of CTE was the presence of tau-positive astrocytic tangles and NFTs. Because NFTs are present in a variety of neurodegenerative disorders and are also evident in most normal older individuals, this classification criterion deserves further scrutiny.” The article cites a study that found NFTs in 97 percent of older people.
If BU’s CTE criteria prove so elastic to include most senior citizens, then suspicions naturally arise as to whether the BU group helps ensure that its scientists looking for CTE will find it. That reputation surely inspired Loyola’s Christopher Randolph, when asked by Breitbart Sports about the possibility of finding CTE in long-dead linebacker Jovan Belcher’s exhumed brain, to respond: “If the brain is sent to Boston, CTE will be identified regardless of what shape it is in:).”
‘No Published Epidemiological, Crosssectional, or Prospective Studies’
The scholars raise questions in search of answers, not questions answering themselves. But for those emotionally invested in the emotional issue, merely raising questions–a necessary component of the knowledge-gathering process–strangely indicates an anti-scientific bent. Apostates feel the wrath of true believers. Concussion blogger Irv Muchnick has started ridiculing Dr. Guskiewicz as “Dr. No Jr.”–a nickname referencing a former co-chairman of the NFL’s committee on mild traumatic brain injury who repeatedly offered “no” to questions about links between football and brain damage. Others ominously point out that Guskiewicz’s sons play football.
But numerous academics, whose sons don’t play youth football, have raised similar questions.
Five scientists, including University of Michigan NeuroSport program director Jeffrey Kutcher, point out in an April number of the British Journal of Sports Medicine that the science on CTE is sparse. “At present, there are no published epidemiological, crosssectional or prospective studies relating to modern CTE,” the doctors note. “Owing to the nature of the published studies, being case reports or pathological case series, it is not possible to determine the causality or risk factors with any certainty. As such, the speculation that repeated concussion or subconcussive impacts cause CTE remains unproven.” In other words, a few dozen autopsies finding CTE in players in large part presumed brain-damaged doesn’t condemn a sport annually played by about four million people.
The University of Colorado School of Medicine’s Hal Wortzel, Lisa Brenner, and David Arciniegas warn of “media sensationalism,” a “state of alarm,” “public hyperawareness,” and “hyperbolic” reports surrounding CTE in a September article that reads almost as a response in kind to the Fourth Estate attacks on brain scientists. The hysteria has led many parents to imagine a concussion resulting in a brain-damaged future for their children, despite, the authors point out, no scientific evidence that single concussion events lead to neurodegenerative disease. Significantly, the authors note that the Brain Injury Research Institute and the Center for the Study of Chronic Encephalopathy, the two main groups researching the malady, each use a different “case definition and neuropathological criteria” to describe CTE.
The people researching the disease most intensely don’t precisely agree about what CTE is. “Traumatic Brain Injury and Chronic Traumatic Encephalopathy: A Forensic Neuropsychiatric Perspective,” like so much of the recent scholarship in the field, spotlights the lack of actual scientific evidence linking CTE with contact sports, advising clinicians “to avoid embracing preliminary results derived from relatively small case numbers and methodologically problematic studies as undisputed medical fact.”
The declaration from Switzerland, and the articles in UK and US journals, found affirmation north of the border. “Further research is needed to establish the relationship between multiple concussions and the development of CTE,” nine Canadian scholars write in May’s edition of Frontiers in Human Neuroscience, “and to examine the prevalence and the risk factors that mediate the relationship between multiple concussions and development of CTE.” After discovering CTE in three of six brains from deceased professional football players who had suffered from neurological disorders in their final years, the group offered that “our findings advocate caution in the clinical diagnosis of CTE in patients with histories of contact sports and neurocognitive decline” given that a certain number of athletes, like a certain number of couch potatoes, develop brain diseases unrelated to CTE.
The case studies, ranging in age from 61 to 87 years of age, included victims of Alzheimer’s, Parkinson’s, and Lou Gehrig’s Disease whose brains exhibited no signs of CTE postmortem even if they exhibited symptoms consistent with the disease during their finals years. The authors of the study explicitly warn, particularly given the history of their subjects playing in the Canadian Football League, that clinical diagnoses of CTE would more resemble guesswork than medicine. Implicitly and perhaps unwittingly, in finding CTE in just half of the brains from a pool of damaged brains, the Canadians raise red flags about the methodology of the BU group that has close to a 100 percent rate in finding CTE in deceased football players.
More Questions Than Answers
So why did some of the CFL players suffer from CTE and others escape it? One possible answer suggested in an earlier paper by the BU group involves genetics. While about a quarter of the population inherits a specific genetic marker believed to predispose individuals to Alzheimer’s, the majority of CTE victims studied possessed the unfortunate gene. BU’s Brandon Gavett, Robert Stern, and Ann McKee wrote in an article published in 2011 that “individuals carrying the APOE e4 allele may be more likely to have a poor outcome” after a traumatic brain injury.
Does biology predispose us to develop or avoid CTE? Might behavioral factors, such as steroid or alcohol use, increase risk? How prevalent is the disease among people who have never laced up a cleat, a skate, or a boxing glove? When will medicine advance to diagnosing the condition in the living? What set of behavioral symptoms, and postmortem evidence of brain damage, should constitute a standard definition of CTE? Why do some athletes who endure repetitive, heavy trauma over decades never develop CTE but other athletes exposed to less intense trauma over shorter periods develop CTE? How substantial are the differences in the criteria among the various groups autopsying brains to determine CTE? Why don’t NFL linemen exhibit elevated mortality rates from the neurodegenerative diseases that CTE seemingly mimics when they endure the bulk of the subconcussive blows that some theorize unleash the condition? What, precisely, is the difference between CTE and Alzheimer’s?
Any mildly curious person investigating the issue can’t help but ask such questions. The scientists admit that they don’t yet know all the answers. But their counterparts in the media exude more certainty than curiosity, a phenomenon noticed by those studying the issue.
Peter Brukner, a professor at the University of Melbourne who attended the Zurich conference, called the link between football and CTE “dangerously premature” and “absolutely unproven.” He blogged, “If [CTE] is somehow related to playing [in the] NFL there are a number of possible causative factors which require thorough investigation including multiple concussions, the amount of minor hits to the head (‘sub concussive’) episodes, drugs and alcohol intake etc, so while this is an interesting area it is far too early to draw any of these conclusions. Unfortunately the media has got hold of this issue.”
Science in Front of TV Cameras v. Science Behind Microscopes
Science playing out on televisions instead of in laboratories has instigated much mischief. A lucrative industry, reminiscent of 19th-century salesmen with buckboard wagons in tow, exploit ginned up fears by hawking anti-concussion mouthpieces, sports-drink brain elixirs, and snake-oil pills all promising to protect athletes for a price. Many parents have begun to view football as organized, ritualistic child abuse. The most recent statistics show a decline in participation in both high school and youth football, the latter lopping off seven percent of its player population during the 2012 season. Pop Warner football is dying a slow, CTE-induced death.
The recently settled retired players’ lawsuit against the NFL leaned heavily on media-hyped connections between CTE and contact sports. The master suit cited as one of the NFL’s “material misrepresentations” the league’s position that “no scientifically valid link between repetitive traumatic head impacts” and CTE existed–the consensus position of scientists studying concussions–and further claimed that CTE is “associated with an increased risk of suicide,” despite decreased suicide among NFL retirees.
The scarce findings on CTE may serve the future as valuable building blocks for research. To the present they appear as junk science, useless in telling us anything beyond the individual case studies. We can’t project the discoveries in John Mackey’s brain upon his fellow NFL competitors, let alone upon the millions of players who will never go beyond youth or high school football. Nevertheless, reckless writers do just that, imagining one athlete’s downfall as the justification for an entire sport’s.
Junk science has consequences–$765 million of them for the NFL, quack cure-alls in health food stores, and playing fields resembling ghost towns. In a Massachusetts courtroom, a high school football player charged with murdering his girlfriend even employed CTE as a defense in his trial earlier this year. The court rejected his not-guilty-by-reason-of-football defense. But journalists writing about another Massachusetts murder case involving a football player have already named CTE as an unindicted co-conspirator. Philadelphia magazine’s Joel Mathis asks, “Did football drive Aaron Hernandez to murder?” Comparing football hits to cigarette smoking, Mathis wonders whether CTE-caused violence might be the sport’s equivalent of second-hand smoke. But with no existing science demonstrating that football causes CTE, what causes the leap in logic that being a member of the New England Patriots, rather than the Bristol Bloods, nudges a man towards murder?
Beginning with Certainties
Scientists don’t follow their gut. They use their brains to follow the facts. The assertions tossed about regarding CTE and football don’t follow the known facts, which are unfortunately few. Future studies may prove that trauma of the kind endured in contact sports not only plays a role in fostering CTE, but serves as the primary causal agent. But just as declaring the victor in a game before the kickoff requires a leap of faith, drawing conclusions before scientists conduct an actual study is more Jimmy the Greek than Francis Bacon.
And in science–even sports science–it makes more sense to imitate a geek than the Greek. “If a man will begin with certainties, he shall end in doubts,” Francis Bacon informed. “But if he will be content to begin with doubts, he shall end in certainties.”
Predictions, whether taking the Dolphins getting six points or banking on future studies to vindicate one’s current intuition, often seem a lock upon their issuance. But they don’t provide the certitude of the scientific method.
Daniel J. Flynn, the author of The War on Football: Saving America’s Game (Regnery, 2013), edits Breitbart Sports. Check back tomorrow for part two in this series on CTE and football.