Big Hits

There aren’t many sports articles in the journal Science, so it was with great interest that I read “A Late Hit for Pro-Football Players” by Greg Miller (www.sciencemag.org).³ This article is a very interesting compilation of recent research and developments in the area of sports-related concussion. The article highlights the efforts of Chris Nowinski, a former Harvard football standout who reached stardom as a professional wrestler. His fame and fortune were cut short by a series of concussions which forced him into early retirement. Disturbed by the chronic symptoms related to his head trauma and the lack of medical research in the area, Nowinski co-founded The Sports Legacy Institute (www.sportslegacy.org), a nonprofit dedicated to research of sports-related head injuries. A partner in the effort is Ann McKee, a neuropathologist at Boston University, who has researched the processes of neurodegeneration in diseases such as Alzheimer’s. The institute’s goal is to understand the relationship between contact sports and the disturbing pathology found to date in some former athletes.

Obviously, there are thousands of former athletes who played contact sports who are not walking around “punch drunk” and do not appear to have suffered any ill effects from their athletic endeavors. In fact, knowing the profiles of many of the stars on today’s sports pages, some may say that the games they played actually knocked some sense into them. All kidding aside, even if the feared degeneration is not detectable in most players, the preliminary evidence is serious enough that all involved should take a hard look at these findings. Considering the fact that there are over 300 000 sports-related concussions annually in the United States,¹ even if only a small percentage develops long term problems, this could represent a major challenge for our health care system.

The relationship between sports head trauma and neurodegeneration is strongest in boxing. In 1928, Harrison Martland, a pathologist, wrote of his studies of battered boxers and their subsequent brain damage. The syndrome “Dementia Pugilistica” evolved which demonstrated Chronic Traumatic Encephalopathy (CTE) at autopsy. Fast forward to 2005, when Bennet Omalu reports the first case of neurodegeneration in a young National Football League (NFL) player.⁵ Omalu, the Chief Medical Examiner for San Joaquin County, California, examined the brain of Michael Webster (Iron Mike), a veteran Pittsburgh Steeler star of 17 NFL seasons, who died at age 50. A second report by Omalu⁴ documents the CTE findings in another Steeler, Terry Long, who died after drinking antifreeze in a suicide attempt. In all, Omalu reports that he has found CTE in 8 of the 9 NFL players that he has examined postmortem.³ While these numbers must still be considered preliminary, the implications are worrisome.

While Omalu’s work is not universally accepted and is subject to criticism, others are reporting similar findings. Ann McKee, cofounder of the Institute at Boston University, examined the brain of John Grimsley, a retired NFL linebacker who died of an accidentally inflicted gunshot wound to the chest in February 2008. His autopsy revealed CTE and is highlighted in a report in the July 2009 issue of the Journal of Neuropathology and Experimental Neurology.² With disturbing reports now from several investigators, sports medicine clinicians must view these potential problems quite seriously.

Long before the recent reports of CTE began to surface, the NFL formed the Mild Traumatic Brain Injury (MTBI) Committee in response to safety concerns regarding head injuries. This committee of medical science experts has worked diligently for the past 15 years trying to address several key questions. Working from the mechanisms of injury and protective equipment to prospective epidemiological outcome studies, this committee has addressed multiple facets of this problem and produced no less than 22 publications on its research. Despite their excellent efforts, there remain troublesome findings and unanswered questions. No doubt, the research work on MTBI needs to continue keeping in mind the comorbidities that many players are faced with, including performance enhancing drugs. Outcome studies sponsored by the NFL of retired players now underway featuring sophisticated neuropsychological testing and imaging should help answer questions. As for the Sports Legacy Institute, they have already secured agreements with 134 former NFL players for postmortem exams of their brains. Eventually, we will know more about the relationship between contact sports and the brain. Let’s hope for the best!

—Edward M. Wojtys, MD
Editor-in-Chief