CTE and its violent underpining

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Google images – CTE
WESTBOROUGH, MA January 20, 2018 More is becoming known about Chronic Traumatic Encephalopathy or CTE.  It is now able to be diagnosed prior to the death of the patient by identifying unique protein markers in the blood of those who have sustained multiple brain injuries.  Former professional wrestler Chris Benoit was found to have CTE after killing his wife and son before killing himself in 2007. But murder or other violence against others has not typically been associated with CTE until recently.  As recently as summer, 2017, the brain of former N.E. Patriots star Aaron Hernandez was also found to have signs of severe CTE raising the specter of its possible impact on his violent life and eventual death by suicide. I have posted post-mortem photos of his brain first published on the Boston University site in a prior blog on my Concussion site (Sefton, 2017).  See that post by clicking here.  It is now understood that an athlete need not have sustained numerous concussions in his career to be found to have CTE at time of death.  More so, the accumulation of repeated blows to the head – subconcussive force – is being implicated in the etiology of this complex disease process. So contact sports like football, rugby and ice hockey are being closely scrutinized by experts in concussion, athletic training and sports medicine.  Researchers at BU School of Medicine have reported that a protein known as CLL11 may be elevated in the brain and spinal fluid of athletes with a history of brain injury.  It holds some promise of being able to diagnose athletes before death.  This protein leads to elevate Tau protein a known cause of progressive brain damage associated with dementia.
In 2014, The K.C. Star reported that analysis of Belcher’s brain after he’d been exhumed revealed a key signature of chronic traumatic encephalopathy, best known as CTE, a degenerative brain disease found to cause dementia, confusion, depression and aggression). “Belcher’s murder-suicide is the worst possible example of domestic violence, and these findings come as the NFL is under attack for its handling of domestic violence.” (Mellinger, 2014 Kansas City Star). 
“CTE has been found to cause erratic and sometimes tragic behavior by some NFL players, perhaps most notably Hall of Fame linebacker Junior Seau, who killed himself last year. The disease, only recently diagnosable before death, has often been found in former and longtime football players.” Mellinger, 2014 K.C. Star
 Riding a bicycle is a leading cause of brain injury in childhood. Recently, CTE has not been diagnosable before death. It has been found over and over in former and longtime football players. Domestic violence behaviors cut across all socioeconomic strata.  They germinate in an environment of secrecy often early in courtship.  During this time abusive spouse slowly isolates his intimate partner from her support – family, friends, finances.  “In doing so there is a subtle but undeniable manipulation of control – usually coupled with threats and intimidation.  There is growing awareness that red flag behaviors precede DV and domestic violence homicide.  Things like pathological jealousy, forced sexual contact, manipulating friendships, detachment from members of immediate family and others are the early signs of domestic violence.” (Sefton, 2012)  Some believe that the most significant pre-incident red flag is whether or not the victim truly believes she is going to be killed by her intimate partner one day and that these victims are at most risk of death.

Sefton, M (2012) Athletes and Celebrities Not Immuned: Kansas City Chief’s player kills wife and self in act of DVH, Blog post December 1, 2014, taken December 28, 2017. 
Sefton, M. (2017). Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE. Blog post, Nov 19, 2017 Taken December 28, 2017
Read more here: http://www.kansascity.com/sports/nfl/kansas-city-chiefs/article2296030.html#storylink=cpy
Read more here: http://www.kansascity.com/sports/spt-columns-blogs/vahe-gregorian/article187534063.html#storylink=cpy
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Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE

Westborough, MA November 18, 2017 The NFL has some explaining to do. Why are former athletes killing themselves and in some cases other people? As students studying the brain it was something special when you could make a correlation between an identified brain lesion and the behavior you are seeing.  I was in China in early November 2017 at a conference on RNA targeted therapy for cancer.  As the non-scientist in the group I was referred to as the clinician who saw the phenotype rather than the genotype – referring to the innumerable genetic underpinnings of cellular biology and changing science of modified nucleotides.  I understood this to have some meaningful interest to the faculty that consisted of 3 prior Nobel laureates and leading scientists in RNA targeted therapy.  So after sitting through hours of presentations I realize the importance of not making a rush to judgment about the cause of some predicted outcome. As a neuropsychologist we are asked to make assumptions about brain integrity after CNS infarcts and make educated predictions about the functional implication of focal lesions in brain.
Recently the scientists at Boston University announced the results of the post-mortem analysis of the brain of Aaron Hernandez, former N.E. Patriots receiver and convicted murderer.  Hernandez had his conviction expunged after he died while his case was on appeal. The 27-year old brain was highly suggestive of having the tell tale signs of chronic traumatic encephalopathy or CTE thought to be the result of repeated concussions and now realized as the result of hundreds – perhaps thousands of sub-concussive blows to the head that accumulate over time.  Hernandez’s brain was the youngest of the donated brains to be identified with advanced CTE. Hernandez played football for 17 years starting when he was a young boy. The question remains did the brain damage that was identified in the post-mortem analysis cause behavior change in Hernandez and could the murder of Odin Lloyd be attributed to the build up of dangerous tau protein in his brain?
“While no one can prove a causal link between Hernandez’s brain damage and his actions, there is little dispute that he displayed CTE symptoms associated with behavioral problems, such as aggressiveness, explosiveness, impulsivity, and suicide.”
Boston Globe Bob Hohler November 9, 2017
By history Aaron Hernandez was an angry, impulsive and violent teenager that his mother reported began when his father died suddenly. Coupled with this was a biological proclivity toward degenerative brain disorders such as Alzheimer’s Disease and CTE.  Both are diagnosed only after the death of the victim. We know that brain-behavior relationships exist from research in stroke and traumatic brain injury where focal injuries result in specific and expected changes in behavior.  These often result from a disconnection between functional centers of the brain including limbic structures that link centers for emotional regulation and the frontal system that exerts inhibitory control over those emotions. The athlete’s who have donated their brain’s upon their death have almost universally exhibited changes in behavior including poor impulse control, depression, and anger.

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BU Medical School and WCVB images 2017

The results of postmortem examination of over 100 brains of NFL athletes are in

WESTBOROUGH,MA July 25, 2017 The laboratory at the Boston University School of Medicine has recently completed its initial examination of over 100 brains donated by the family members of those athletes who have died because of marked behavior and personality changes attributed to playing football.  The results confirm the presence of destructive proteins that have come to be known as chronic traumatic encephalopathy.  This was first reported over 10 years ago and was featured in the movie Concussion released in 2015 starring Will Smith as Bennet Omalu, M.D. who first reported on the syndrome.

NCAA student athletes: should there be a concussion registry?

“The NCAA said it doesn’t keep track of medical disqualifications or how many sidelined players have transferred to play football elsewhere. Most of the schools that make up the lucrative, upper echelon of college football refused to release even basic information about disqualifications.”  

David Robinson – Boston Globe January 8, 2015


WESTBOROUGH, MA January 10, 2016 Can prior history of concussion be provided to the medical staff of a prospective team? Should an athlete be responsible in reporting the true incidence of concussion? At what point does healthcare privacy protect the student athlete from needing to report the history of brain trauma?  What will the longterm implication be of repeated concussion in young athletes?

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Concussion is a common injury among LAX players

The fact is that student athletes who become disqualified due to concussion often make themselves available to other NCAA Division I schools. It seems impossible to believe that any medical staff of the highly regarded football program (or any contact sport) would disregard the pertinent facts of the athlete’s physical health and permit them to compete in football or any contact sport.  This is as despicable as the NFL’s failure to speak out against concussion in defiance of those players who were badly damaged by the game – many who have died. Improved healthcare for student athletes and an NCAA concussion registry may reduce the chance of an athlete returning to football when medical opinion has removed them from competition because of the risk associated with repeat concussion. This is especially true when common sense fails and young players become enticed by the promise of fame and fortune.

The literature has now revealed the devastating impact of concussion and even the sub concussive head bumps on long term health and well-being of student athletes.  Contact the Whittier Rehabilitation Hospital 508-871-2077 or Dr. Michael Sefton 508-579-0417 for pre-injury baseline testing or post-injury care.

 

NFL yields to pressure acknowledging link to CTE

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Bennet Omalu, M.D. a pathologist who is given credit for first identifying the signs of CTE in brain of NFL player  (PHOTO Google images)

WESTBOROUGH, MA March 15, 2016 In a published article headlining the BBC web pages the NFL has acknowledged that a link exists between repeated concussion and chronic traumatic encephalopathy – a deadly brain disease resulting in depression, memory loss, and erratic behavior. Only 50 days ago the NFL’s hired “expert” Mitch Berger, M.D., a neurosurgeon claimed that no link had been established between hits in football and the chronic brain disease leading to death.

This is the first time the NFL has acknowledged that such a link exists. Why are they now acknowledging what science has accepted years ago?

In Boston, neuropathologist Dr. Ann McKee unequivocally states that a correlation between concussive and subconcussive blows to the head has resulted in CTE in 90 of 94 brains she has examined – all from NFL players who have died and donated their brains to the Boston University Brain Bank. “The Boston Globe features this story as well today” according to Michael Sefton, Ph.D. “I have heard Dr. McKee and her colleagues report these findings since they examined the first series of brains including the brain of former N.E. Patriot Junior Seau who committed suicide shortly after his retirement from football.” The link has been well established for over 5 years but denied by NFL medical experts and league president Roger Goodell.  The NFL Player’s Association sued Goodell and the NFL for hiding the dangers associated with concussion in 2014.  The major motion picture Concussion starring Will Smith as real life physician Bennet Omalu was overlooked for an Oscar nomination in 2015.  Nevertheless, the movie brought many of the NFL’s secrets about concussion out for all to see.


This link will take the reader to the BBC report.

Concussion night 2016 at Bruin’s game

206982_1037539872681_50_nThe Children’s Hospital of Boston is participating in the special night at the Boston Bruin’s game on March 10, 2016.  The Bruins welcome Rebekah Mannix, M.D. a physician spokesperson at Children’s Hospital.  She acknowledge that brain injury is a silent injury often overlooked.  She described the importance of brain injury awareness including concussion prevention. Dr. Mannix talked about the silent injury that is concussion.  As an emergency room physician she noted that most injuries do not show up in the computerized tomography (C-T scan).  Athletes should rest following injury but recovery is different with all athletes – especially the younger players. Treatment options were discussed with Dale Arnold – NESN Sport Bruins Face-Off Live host.

Concussion – Physicians once espoused a link to unresolved litigation

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Bennet Omalu, M.D. was first to recognize the impact of repetitive trauma and concussion PHOTO – The Trent
I am reading Concussion – the novel by Jeanne Marie Laskas upon which the film starring Will Smith is based – released on Christmas day 2015.  Smith portrays Dr. Bennet Omalu – forensic pathologist who first published the startling details of changes in the brains of those who suffer repeat head trauma. I am struck by the David and Goliath nature of the task – bringing medical discovery to the mainstream marketplace and the adversarial response of the medical establishment and the corporate giant National Football League.
There are still people in the brain injury field who attempt to discredit Dr. Omalu and the discovery of chronic traumatic encephalopathy.  Indeed, the affliction did not begin with NFL football.  I am sure over the years people with repeated concussions and subclinical injuries exhibited similar pathology when their autopsied brains were studied.  Aging boxers have been known to exhibit soft neurological signs even Parkinson’s disease.  An early study may have chronicled their symptoms as a common sequelae of boxers who experienced a career of getting blows to the head.  Dr. Omalu implored the medical establishment to take notice of the incidence of depression, substance abuse and suicide among retired NFL players that may be correlated with the findings from autopsy studies of players who died as middle-aged men.
I have observed first hand just how difficult it has been selling concussion management to schools, coaches, and athletic directors for over 15 years. In 1993, my interest in mild traumatic brain injury was first set in motion by a series of cases that were referred to me by a group of physicians with whom I was associated. I collected data for several months using emergency department statistics to come up with numbers of persons who were treated for mild traumatic brain injury. I was interested in pediatric patients. What I found in review of months of emergency department visits was that many cases were not coded for ‘brain injury’ because of other afflictions like lacerations, fractures, and more.
What’s more unless someone were brought into the emergency department with altered mental status or unconscious from head trauma the true incidence of injuries to the brain were not carefully recorded. Arguably, the reason for this was a tendency to wrongly believe that in the absence of a documented loss of consciousness there was no reason to think brain injury nor was there any real concern for those few cases who were seen for concussion – as long as there was no loss of consciousness. Yet I was seeing cases from car crashes, falls, and football injuries that were having prolonged recovery times who were never diagnosed with mild TBI.
The squeaky wheel – gets a referral
For those patients who managed to get referred to the neurologist or neuropsychologist the symptoms they experienced were debilitating and often quite severe. It was not always linked back to their concussion – sometimes addressed as psychological or even psychosomatic in etiology.  We began to see that a subset of concussion or Mild TBI cases went on to have a very unexpected set of symptoms including headaches, sound/light sensitivity, poor concentration, mood changes, and more that lasted for weeks and months. 5-10 % of cases of concussion remain symptomatic 8 weeks after first becoming injured and require supportive therapy.
What is now diagnosed post-concussion syndrome or PCS was frankly dismissed as a psychiatric illness like depression or anxiety or even an attempt at malingering as an intentional attempt to gain compensation years ago.  PCS has no visual markers on computer brain scans or currently available lab tests.  Like concussion it is an invisible injury that renders many people unable to work. Headaches, neck pain, fatigue, visual changes, irritability, sensitivity to sound and light, depression, and poor sleep hygiene were common.
Some physicians even stated “the symptoms would likely get better once the law suits were settled” when making a referral to me.  Over 20 years later, I sometimes meet with same misattribution but in general there is greater understanding of the potential long-term effects of concussion. Omalu warns us that repeated injuries have a cumulative impact on aging brains. His serendipitous findings has raised awareness of the neurologic malfunctioning that may take place when athletes are exposed to repeated blows to the head while playing football.  Many have gone on to commit suicide.
I was fortunate enough to be invited to the prescreening debut of the film Concussion a few days before it opened in Boston.  It was sponsored by MomsTEAM.  I was introduced to Brooke de Lench, Executive Director of MomsTEAM, Institute of Youth Sports Safety. He blog post was published in the Huffington Post the week before the film’s release. I enjoyed the film and found it a compelling caveat to my current knowledge and what I know to be true.
Sefton, M. (2014). Postconcusive Symptoms: Lingering symptoms following concussion. Blog post: https://concussionassessment.wordpress.com/consultation/post-concussion-syndrome-pcs/. Taken December 26, 2015.
de Lench, B. (2015) Why I’m not a football apologist. Blog post: http://www.huffingtonpost.com/brooke-de-lench/why-im-not-a-football-apo_b_8855362.html. Taken 12-26-2015