Chronic traumatic encephalopathy – commonly referred to as CTE – is a progressive neurodegenerative disease with associated clinical, behavioral and neuropathological findings.

The upcoming “Concussion” movie, which is based on the first documented case of CTE found in a professional football player, has prompted discussion about this seemingly rare but tragic disorder that results in mood, behavior, cognitive and movement problems associated with deposits of certain proteins in particular parts of the brains of some individuals, including athletes.

CTE is an important finding and deserves further study. Currently, there are fewer than 200 documented cases of modern-day CTE dating back to 1954. Controversies exist about CTE partly because it is a diagnosis that currently can only be made after death. Scientists and clinicians involved in neurodegenerative research note that the lack of prospective data and properly controlled research studies limit current understanding.(1) It is unclear whether the findings noted at autopsy actually cause the clinical symptoms of CTE or what the root causes are.

Multiple blows to the head are a presumed risk factor, but it is unknown whether there are others. Some athletes who show mood, behavior, thinking and movement disorders do not reveal autopsy findings described to CTE, while others who have autopsy-related findings of CTE did not show any clinical manifestations of the disease.

To complicate the situation further, the brains of some deceased athletes who have findings of CTE also show findings of other diseases – including Alzheimer’s – that can cause similar symptoms to those of CTE. Finally, some of the changes in brain tissue that occur naturally within aging are very similar to what is seen in CTE. All of these factors make diagnosis elusive.

As our colleagues who are active CTE researches have noted, it is not currently possible to determine the risk and incidence of CTE in professional athletes.(2) Also, in pediatric populations, the effect of blows to the head – including single or repetitive concussions – on the risk of developing later life neurodegenerative disease remains unknown.(3) However, while there is still much work to do, those involved in CTE research have made significant discoveries and raised important hypotheses which deserve further study. They should be commended for their work.

Even in the absence of understanding what specifically triggers the development of CTE, there is benefit in removing unnecessary head contact from sports. As more research is conducted – and more is needed – experts across medicine and sport are proactively and progressively establishing programs and interventions to make sports safer.

The American Academy of Pediatrics (AAP) represents more than 64,000 primary care physicians and other professionals dedicated to the health, safety and well-being of children. In October, this group recommended standards for youth tackle football that include enforcing the rules of proper tackling – including zero tolerance for illegal, head-first hits, expanding non-tackling leagues and having skilled athletic trainers available on the sidelines – but did not include a minimum age for participation.

The national governing body of the sport, USA Football, supports the AAP’s proposals, many of which are within USA Football’s medically supported Heads Up Football program. Organizations including the American College of Sports Medicine, the National Athletic Trainers’ Association and the American Medical Society for Sports Medicine back Heads Up Football for all youth and high school programs.

No one is more concerned about youth and high school football player safety than USA Football, which continues to lead by establishing standards rooted in the best available science. USA Football’s Heads Up Football program, which more than 6,500 youth football organizations and 1,100 high schools registered for in 2015, includes blocking and tackling techniques that limit helmet contact. USA Football also provides practice guidelines and tools for coaches to teach these techniques in a progressive manner, making sure young athletes take the proper steps and learn the fundamentals before advancing to full contact.

Heads Up Football combined with practice guidelines limiting player-to-player contact is producing encouraging results. According to an independent 2014 study by the Datalys Center for Sports Injury Prevention and Research(4), a comprehensive coaching education program combined with practice guidelines limiting player-to-player contact may help lower injury rates. In addition, in lieu of practice guidelines, coaching education alone may also be effective at lowering injury rates.

In a study published in the Orthopaedic Journal of Sports Medicine, a global, peer-reviewed journal, youth football players in leagues that registered for Heads Up Football showed:

• *-87 percent lower injury rates during practice in organizations with Heads Up Football coach education plus Pop Warner practice guidelines that limit contact
• *-63 percent lower injury rates during practice with Heads Up Football coach education only compared to those with no coach education or practice guidelines
• *-82 percent lower concussion rate during practice with Heads Up Football coach education and Pop Warner practice guidelines among 11- to 15-year-old athletes

We need more studies to understand the relationship between cumulative effects of subconcussive blows – blows to the head that do not cause a concussion – and the subsequent development of CTE. More also needs to be known about other potential contributing factors, including substance use or abuse, genetics, aging and the type, location and number of impacts. While repetitive trauma may trigger later development of CTE, not all individuals who suffer repetitive head trauma develop CTE, and the research to understand which subsets may be at greater risk needs to be undertaken.

The great majority of athletes, especially youth athletes, appear to show no long-term symptoms in regard to brain health. In fact, sports participation is associated not only with better physical fitness levels and therefore overall health but also improved academic performance and psychological well-being.

Those health benefits can be obtained while simultaneously advocating for ongoing head injury education for athletes, parents, coaches, administrators, healthcare providers and others combined with application of recommendations of concussion legislation now present in all 50 states and the District of Columbia.

As researchers continue their important work, parents and coaches can lead the way through proper training, conditioning, enforcement of rules, better blocking and tackling techniques, fair play and modified practice  – all ways to help take unnecessary head contact out of sport. 

Dr. Gerard A. Gioia is a pediatric neuropsychologist and the chief of the division of pediatric neuropsychology at Children’s National Medical Center in Washington, D.C., where he directs the Safe Concussion Outcome Recovery & Education Program. He is a professor of pediatrics and psychiatry at the George Washington University School of Medicine and works closely with the Centers for Disease Control and Prevention on concussion education programs. Gioia is the team neuropsychologist for the NHL’s Washington Capitals and the NFL’s Baltimore Ravens. He also serves on the National Advisory Board of the Positive Coaching Alliance and the Sports Medicine Advisory Committee for the Maryland Public Secondary School Athletic Association.

Dr. Andrew Gregory is a physician in the sports medicine division of the Department of Orthopedics at Vanderbilt University Medical Center. He is a team physician for Nashville Christian School as well as Vanderbilt and Belmont universities, the Nashville Sounds and USA Volleyball. He serves as director of the Primary Care Sports Medicine Fellowship and is a fellow of both the American Academy of Pediatrics and the American College of Sports Medicine. He is also a former board member of the American Medical Society for Sports Medicine.

Dr. Tamarah Hunt is a certified athletic trainer and the director of the Athletic Training Graduate Program at Georgia Southern University. Prior to Georgia Southern, she was the director of research for the Ohio State University Sports Concussion Program. As a researcher, Hunt focuses on youth concussion assessment and has worked with high schools in several states examining high school recovery patterns, effort on concussion assessments, co-morbidities and possible educational intervention in at-risk populations.

Dr. Patrick Kersey is a member of the NFL Physician Society, the Governor’s Council for Fitness and Sports, the American Medical Society for Sports Medicine and the American College of Sports Medicine. He also served as a team physician for the NFL’s Indianapolis Colts from 1999-2012. As USA Football’s medical director, he directs the independent nonprofit organization in prioritizing and addressing health and safety matters for its members and America’s football community.

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1. Meehan W et al. Chronic Traumatic Encephalopathy and Athletes. Neurology 2015; 851-858

2. Jha NK et al. Solving The Concussion Crisis: Practical Solutions (Consensus 2015) http://www.quanterix.com/files/0915_KonkussionWhitePaperEditorial.pdf

3. Carman AJ et al. Short Term and Lon Term Neuropsychological Outcomes of Youth Sports-Related Concussions. Nat. Rev. Neurol. advance online publication 17 March 2015; doi:10.1038/nrneurol.2015.30

4. Kerr et al. Comprehensive coach education and practice restriction guidelines result in lower injury rates in youth American football. The Orthopaedic Journal of Sports Medicine online publication. July 2015; http://ojs.sagepub.com/content/3/7/2325967115594578.full.pdf?ijkey=RTefNhMrw9p4pJ4&keytype=finite

*-This blog has been updated with the most recent Heads Up Football efficacy data as published in The Orthopaedic Journal of Sports Medicine (July 2015).