Chronic Traumatic Encephalopathy and the NFL

Daniel Te’o-Nesheim, a former University of Washington football player who played for both the Philadelphia Eagles and Tampa Bay Buccaneers, was only thirty years old when he was found dead at a friend’s house in in October 2017 of an apparent overdose. He was later posthumously diagnosed with chronic traumatic encephalopathy, or CTE, a degenerative brain disease linked to repetitive cranial trauma. Prior to his death, Te’o-Nesheim was suffering extensive pain from the injuries caused by half a lifetime of tackle football, including bone spurs, ankle and shoulder surgery, and chronic headaches. As his doctors prescribed ever-increasing amounts of painkillers, he became paranoid and withdrawn – a complete transformation from his friendly, family-oriented personality. He forgot purchases he had made on his credit cards, insisted he was being followed, and made worrisome phone calls to his family from unknown numbers. His sister, Marie, remembers him as distracted, overwhelmed, and dismissive. “It was scary and we tried to reach out, but could not get him to open up,” she confided in a New York Times article in May of this year. Eric Kaufman, Te’o-Nesheim’s former agent, was also among those close to the football player and privy to the direct effect of his downward mental spiral on his career. “Without a doubt in my mind, all of these were early signs of CTE,” says Kaufman.

Te’o-Nesheim did apply for “line of duty” benefits given to football players suffering extensive physical injuries early in 2017; however, his request was turned down because his injuries were not considered severe enough. Less than a month later, he spent the evening at a friend’s house drinking vodka and talking. After going to sleep in one of the bedrooms for the night, he was found the next morning unresponsive and declared dead of overdose. Te’o-Nesheim had made arrangements to donate his brain to science right before his death; therefore, a subsequent microscopic examination of his frontal lobe revealed a “surprising and disturbing” amount of lesions for “a guy who was just 30,” according to Ann McKee, neuropathologist and expert in degenerative neurological disease at Boston University.

Though Te’o-Nesheim’s tragic case was not the most severe manifestation of CTE, it nonetheless was an all-too-common hallmark of one of the most acute yet widely disregarded problems in professional football. CTE is defined by the Concussion Legacy Foundation as “a degenerative brain disease found in athletes, military veterans, and others with a history of repetitive brain trauma.” Football players are particularly affected: in fact, according to a 2018 study from the VA-BU-CLF Brain Bank at Boston University, 94% of college and/or professional football players have been diagnosed with CTE. Its molecular basis is characterized by a protein called tau, which helps to support microtubule networks in neurons in a healthy brain. However, when microtubules break down due to repeated trauma, these tau proteins break free and form clumps in the brain. Eventually, these clumps begin to grow independently in a process called prion spread, at which point they can damage and interfere with regular brain function. Since CTE requires a sample of brain tissue to be conclusively diagnosed, it can only be identified postmortem, making it difficult to recognize and seek treatment. However, those suffering mood changes, severe headaches, and memory problems can target these symptoms through treatments such as behavioral therapy and medication. Nevertheless, CTE currently has no permanent cure.

During advanced phases of CTE, prion spread causes severe brain atrophy.

A large part of CTE’s notoriety is its connection to the world of professional football. Research by Dr. Ann McKee in 2017 found that 110 out of 111 former NFL players’ brains tested positive for the disease, including such Pro Football Hall of Fame names as Oakland Raiders quarterback Ken Stabler and Pittsburgh Steelers center Mike Webster. This study places the rate of CTE in professional football players at a shocking 99%. Despite such overwhelming evidence, the NFL itself has historically been reluctant to acknowledge a link between CTE and professional football, citing a lack of evidence as a chief reason. However, Jeff Miller, the NFL’s senior vice president of health and safety police, publicly acknowledged for the first time the connection between football and CTE in March of 2016. This groundbreaking announcement raised hope both within and outside the football industry for an increased focus on player safety and potential financial compensation for affected players.

For a while, it appeared the NFL finally began treating CTE and concussions in football with the gravity they deserved. In fact, in 2016, it launched its $100 million “Play Smart Play Safe” initiative with the goal of funding “independent medical research and engineering advancements,” with an emphasis on concussion research. However, the first study funded by the grant in 2017 involved the research of CTE in horse jockeys, not football players. Given the remarkably different physical natures of these professions, one concussion expert noted that comparing the two would be like “comparing apples and pears.” Similarly, Joel Sitzel of the Wake Forest Baptist Medical Center, a biomedical engineering expert consulting for the NFL, was told when he suggested looking into the long-term effects of subconcussive impacts that this was not the scope the NFL was trying to evaluate.

Additionally, in June 2015, a judge approved a class-action lawsuit settlement filed against the NFL by thousands of retired players and their families. This settlement allocated up to $5 million per player for complications resulting from repeated head trauma during the player’s career, including ALS, Parkinson’s, and Alzheimer’s disease. The NFL Concussion Settlement website states that as of November 5, 2018, 675 monetary awards have been issued to former players for a total amount of just under $600 million. However, the settlement provides mainly for the families of deceased CTE sufferers, and since the disease can only be diagnosed posthumously, any living players with possible CTE symptoms would find it difficult to take advantage of the claims. Moreover, the settlement only covers players who retired in or before June 2014, meaning any current players who are beginning to experience symptoms are also disadvantaged.

Despite the contentious legal atmosphere surrounding the relationship between CTE and football that pits players against the NFL, not all voices in both the football and medical communities are united on a single front. Former NFL running back and ESPN sports analyst Merril Hoge has published a book in the last couple months with the incisive title “Brainwashed: The Bad Science Behind CTE and the Plot to Destroy Football”. Coauthored by Peter Cummings, assistant professor of neurobiology at the Boston University School of Medicine, this work aims to debunk the connections made between CTE and professional football through the work of Dr. Ann McKee. Hoge points to the aforementioned 2016 study that found CTE in 110 or 111 NFL brains as flawed due to its lack of control group; however, he neglects to mention an associated 2015 study with the Mayo Clinic that was akin to a control group in testing 198 brains of non-players and finding all free of CTE. Though the blurb of Hoge’s book asserts he writes with the intention of supporting the “survival of our nation’s most beloved game,” Chris Nowinski, CEO of the Concussion Legacy Foundation, has his apprehensions. “Every time a football industry person belittles the issue of CTE within their sport, they are not just hurting football families, they also are hurting military families who need the science community to continue working together to find a cure for CTE,” asserts Nowinski.

So what does the future hold regarding CTE in the world of professional football? Though the debate about its impact rages on, the NFL’s statement affirming the connection between CTE and football was a step forward in the fight for the safety of its players, both past and present. The NFL’s efforts are also not intangible – its settlement and research funding may need to be revisited, but they nevertheless represent steps toward change. Indeed, research done at Boston University into the underlying genetic factors behind the disease has this past month has identified two categories of TMEM106B genetic variations that were present in almost 100% of CTE brains tested. "Understanding the genetic risk factors might allow us to predict who will be most at risk for disease and therefore who to follow more closely clinically and get treatment when possible," says the study’s author Thor Stein. "Genetic risk factors can also provide clues for possible mechanisms that lead to disease and help guide how we might eventually target treatments for CTE.”

In the meantime, many in the football community are calling for the NFL to reform the game itself to make it safer for all players. Some progress has been made on this front – this past March, the NFL moved to ban a dangerous technique that allowed players to lower their heads and use their helmets as weapons during a tackle. Several states are also considering a ban on youth tackle football. Since CTE is noticeably more present in players who began tackle football before the age of 12, such a decision may ultimately prove effective in the prevention of the disease in future generations.

Many apprehensions about such measures ultimately come down to concern for the preservation of this all-American game. “There are risks in contact sports. There's risk in football to injury,” says NFL commissioner and high school player Roger Goodell. “You have to do what you can to manage that. That's a personal decision ultimately. But I believe the game of football has taught me values and lessons. I would not give back a single moment of playing football because it taught me about teamwork, it taught me about perseverance, it taught me about myself.”

This rosy image is a sharp contrast to NFL player Daniel Te’o-Nesheim’s slow surrender to his disease. “He would talk and would make you feel sore just listening to him,” says Kaluka Maiava, Te’o-Nesheim’s close friend. “Just seeing him, he looked like he never slept, exhausted all the time. He’d be up all night in the dark staring at the walls dealing with the stuff in his head.”

In order for the NFL and society as a whole to truly offer past CTE victims the care and respect they deserve, as well as to advocate for its prevention in current and future players, even the most hardpressed football fanatic among us must realize that tradition is not worth the ultimate price of human lives. Football viewership in America is higher than ever – with the whole country watching, now is the time for the football industry to champion lasting reform.