Nfl players with cte

Brain condition CTE seen in H.S. football players: study

(HealthDay)—Crippling brain injury from football can start early, even among high school players, a new study suggests.

And its effects can last over time, even without additional head impacts, researchers report.

Football players can develop chronic traumatic encephalopathy (CTE) after playing high school football, although higher rates of CTE are tied to college and pro football, the researchers said.

“Unfortunately, we found CTE in people who only played high school football and passed away at a very young age,” said lead author Dr. Daniel Daneshvar, from Boston University’s School of Medicine CTE Center.

CTE is a devastating degenerative brain disease found in athletes, military veterans and others with a history of repetitive brain trauma, according to the Concussion Legacy Foundation.

It is most prominently found among football players: 110 of 111 deceased NFL players were found to have some form of CTE in a study released in 2017. Among them were Junior Seau, Ken Stabler and Frank Gifford.

“We still don’t understand a lot about the disease and what causes it,” Daneshvar said.

But, he added, the findings suggest that CTE is progressive and worsens with age even in the absence of additional head trauma.

CTE can only be diagnosed after death by examining brain tissue.

For the study, Daneshvar and his colleagues looked at the brains of football players who had died. The study included more than half of the diagnosed CTE cases worldwide.

The brains were donated between February 2008 and May 2016. The researchers also surveyed people who had known these men.

Autopsies of the brains found signs of CTE in 177, or 87 percent of all the football players in the study. Specifically, it was found in 29 percent of high school players, 87 percent of college players, 71 percent of semi-pro players, 88 percent of Canadian Football League players and 99 percent of National Football League players.

The researchers found CTE followed an age-dependent evolution, from small lesions in teenagers and young adults to severe brain damage in middle age.

Based on their interviews and surveys, the players also often had cognitive, behavior, mood and motor symptoms during their life, the researchers said.

Pro players suffered from CTE at greater rates and died with advanced CTE. They were also more likely to have been diagnosed with dementia, compared with college players.

Daneshvar hopes that a way to diagnose the disease can be found while players are alive and can lead to a treatment.

What can be said is that CTE occurs in a high percentage of individuals who play contact sports, Daneshvar said.

“The brain doesn’t care what hits it. We’ve see CTE in victims of domestic violence, in hockey players, boxers and military veterans. So if you end up getting hit in the head a lot, you’re at risk for CTE,” he added.

One expert not involved with the study said parents of kids who play football should be aware that there may be potential long-term harm.

“I tell parents that we don’t know what’s going to happen,” said Dr. John Kuluz, director of traumatic brain injury and neurorehabilitation at Nicklaus Children’s Hospital in Miami.

“We don’t know what effects concussions are going to have on their child, but we should be concerned about it,” he said.

“We should also keep an open mind, because this study is not definitive,” Kuluz added.

The results of the study were scheduled to be presented Feb. 21 at the annual meeting of the Association of Academic Physiatrists, in Puerto Rico. Findings presented at meetings are typically viewed as preliminary until they’re published in a peer-reviewed journal.

Explore further

New research offers insights into football-related concussions More information: Daniel Daneshvar, M.D., Ph.D., Boston University School of Medicine CTE Center; John Kuluz, M.D., director, traumatic brain injury and neurorehabilitation, Nicklaus Children’s Hospital, Miami; Feb. 21, 2019, presentation, Association of Academic Physiatrists, annual meeting, Puerto Rico
The Concussion Legacy Foundation offers more on CTE.

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Awareness about concussions has never been greater among high school athletes and coaches, thanks to the spotlight shone on some former NFL players who’ve experienced problems later in life. But a downside to this heightened awareness is the fear it has sown among parents that their children who play sports like football, soccer, or hockey may end up the same way.

As a parent, I understand that fear. My son played soccer throughout high school and college and sustained several concussions. While I was obviously concerned at the time, he recovered quickly after each with proper rest, and, as with most people, shows no lingering effects.

As a neuropsychologist, I applaud the increased attention that has led to improved protocols for diagnosing sports-related concussions and removing athletes from play until they have fully recovered. But I worry that the pendulum has swung too far. The reality is that we still don’t know who is most likely to suffer a concussion, who will take longer to recover, how anatomic or genetic differences influence concussions, and who may be at risk of prolonged symptoms or developing cognitive problems later in life.


Scientists have made great strides in unlocking the mysteries of the brain in recent years, but much remains unknown, including the long-term effects of head trauma. And while a number of studies have examined various aspects of sports concussions, the sample sizes have tended to be small and the findings disparate.

Some parents who decide that their kids shouldn’t play football or other contact sports out of fear that they may suffer life-changing brain trauma may have been influenced by media coverage of former professional football players who died after developing chronic traumatic encephalopathy (CTE).

One of the studies that generated the most headlines — and misperceptions, I contend — was a 2017 report in JAMA that showed CTE in the brains of 110 of 111 deceased former NFL players that had been donated for analysis. (So far, CTE can be diagnosed only after death.) While the study more broadly found CTE in 177 of 202 brains donated from people who had played football at some level, the NFL findings came from a highly select group — namely players who had reportedly shown signs of mental decline before their deaths. Even the authors cautioned that the study was limited by ascertainment bias and lacked a comparison group representative of all individuals who played football.

In contrast, a report published just days later in JAMA Neurology made a very different point. In this long-term follow-up study of 3,904 men who graduated from high school in Wisconsin in the 1950s, there was no difference in cognitive function or decline between those who played football and those who didn’t. In fact, the football players were actually less likely to have developed depression by their 60s and 70s.

My colleagues and I at UT Southwestern Medical Center in Dallas recently completed a study of 35 former NFL players age 50 and older who had sustained multiple concussions throughout their careers. Our findings showed no significant association between the length of the individuals’ careers, the number of concussions, and their cognitive function later in life.

How to account for these differences? Why does one former pro football player develop cognitive problems while another doesn’t? We simply don’t know.

Although many factors must be considered, I think it is premature to discourage teenagers from playing contact sports. What is needed now is more research to gain a deeper understanding of how concussions and hits to the head affect the brain. To facilitate this work, all states should follow the lead of Texas, Michigan, and others that have instituted registries to gather data on concussions sustained by high school athletes. Data from these registries can help us define the number of concussions that occur in every sport and learn how they occur, how long it takes to recover from them, and how they affect boys and girls differently.

Our team at UT Southwestern joined with the governing body for high school sports in Texas to launch the ConTex concussion registry in 2017. Although it began as a voluntary reporting program, beginning this fall the state’s largest school districts are now required to provide concussion data. We plan to use the data to begin examining how often concussions occur in high school athletic activities, examine regional and longitudinal trends, and investigate whether the steps being taken to make sports safer are actually reducing injuries.

Football and other sports are an integral part of American society and teach millions of kids invaluable lessons about teamwork and physical fitness. While every head injury must be taken seriously, most concussions result in short-term symptoms that typically go away in days to weeks with proper identification and treatment.

Rather than allowing fear to deprive children of the benefits of sports participation, let’s allow science to define the risks and help us make informed decisions.

Munro Cullum, Ph.D., is a neuropsychologist at UT Southwestern Medical Center’s Peter O’Donnell Jr. Brain Institute in Dallas.

According to the Boston University CTE Center, Chronic Traumatic Encephalopathy (CTE) is a degenerative brain disease found in athletes, military veterans, and others with a history of repetitive brain trauma. Most of what we have learned about CTE has come from the research of Dr. Ann McKee, director of the VA-BU-CLF Brain Bank, who has revolutionized our understanding of CTE. In CTE, a protein called Tau forms clumps that slowly spread throughout the brain, killing brain cells. CTE has been seen in people as young as 17, but symptoms do not generally begin appearing until years after the onset of head impacts.

CTE At a Glance: Click to View Infographic.
Photo credit: Ann McKee, MD, Boston University, VA Boston Healthcare. Support Dr. McKee’s research by clicking here.

Early symptoms of CTE usually appear in a patient’s late 20s or 30s, and affect a patient’s mood and behavior. Some common changes seen include impulse control problems, aggression, depression, and paranoia.

As the disease progresses, some patients may experience problems with thinking and memory, including memory loss, confusion, impaired judgment, and eventually progressive dementia. Cognitive symptoms tend to appear later than mood and behavioral symptoms, and generally first appear in a patient’s 40s or 50s. Patients may exhibit one or both symptom clusters. In some cases, symptoms worsen with time (even if the patient suffers no additional head impacts). In other cases, symptoms may be stable for years before worsening.

Learn more about CTE from Dr. Ann McKee, director of the VA-BU-CLF Brain Bank, by watching the video below. You can support her research by clicking here.

A brief history of CTE

CTE was first described in 1928, when Dr. Harrison Martland described a group of boxers as having “punch drunk syndrome.” Over the next 75 years, several researchers reported similar findings in boxers and victims of brain trauma, but fewer than 50 cases were confirmed. In 2005, a pathologist named Bennet Omalu published the first evidence of CTE in an American football player: former Pittsburgh Steeler Mike Webster. Shortly thereafter, the Concussion Legacy Foundation partnered with Boston University and the U.S. Department of Veterans Affairs to form the VA-BU-CLF Brain Bank, led by Dr. Ann McKee. The Brain Bank has revolutionized how we understand the disease, with more than 600 brains donated, over 360 of which have been found to have CTE.

Learn more about the symptoms of CTE from Dr. Robert Stern, director of clinical research at the Boston University CTE Center:

What causes CTE?

The best available evidence tells us that CTE is caused by repetitive hits to the head sustained over a period of years. This doesn’t mean a handful of concussions: most people diagnosed with CTE suffered hundreds or thousands of head impacts over the course of many years playing contact sports or serving in the military. And it’s not just concussions: the best available evidence points towards sub-concussive impacts, or hits to the head that don’t cause full-blown concussions, as the biggest factor.

Learn More: What is a subconcussive impact?

Who is most at risk for CTE?

Every person diagnosed with CTE has one thing in common: a history of repetitive hits to the head.1 CTE is most often found in contact sport athletes and military veterans, likely because these are some of the only roles in modern life that involve purposeful, repetitive hits to the head. CTE has been found in individuals whose primary exposure to head impacts was through tackle football (200+ cases confirmed at the VA-BU-CLF Brain Bank), the military (25+ cases), hockey (20+ cases), boxing (15+ cases, 50+ globally), rugby (5+ cases), soccer (5+ cases, 10+ globally), pro wrestling (5+ cases), and, in fewer than three cases each, baseball, basketball, intimate partner violence, and individuals with developmental disorders who engaged in head banging behaviors.

CTE has been found in… Source of head impacts
Boxers Punches to the head
Tackle football players Hits to the helmet
Soccer players Headers and collisions
Ice hockey players Fighting, checking
Military veterans Blast injuries, combat
Victims of domestic abuse Repeated violence

Related: I think I have CTE. What do I do?

Importantly, not everyone who has suffered repetitive hits to the head will develop CTE. There are several risk factors at play that make some people more prone to develop CTE than others, including:

Length of exposure to head impacts

Athletes with longer careers playing contact sports are at greater risk for CTE than athletes with shorter careers. A 2019 study on deceased football players led by Boston University researchers and published in the Annals of Neurology medical journal found that the risk and severity of developing CTE among football players is not correlated to number of concussions, but is instead correlated to the number of years playing tackle football.

The study analyzed 266 deceased football players, 223 of whom had CTE and 43 of whom did not. The researchers found that the risk of CTE increases by 30 percent every year of tackle football, and doubles every 2.6 additional years. (We don’t know the risk of developing CTE after one year of playing tackle football, but it’s likely very low.) This shockingly strong relationship between years of tackle and risk of CTE may be even stronger than the link between years of smoking and risk of lung cancer.

The link is so profound that a high school football player who starts tackle football at age 5, instead of age 14, has an incredible 10 times the risk of developing the brain disease CTE.

The discovery that risk of CTE is correlated with length of career – or, years of exposure to repetitive head impacts – has remained true with other contact sports and head impact exposure groups. Researchers have also found that among those diagnosed with CTE, athletes with longer careers are more likely to have more severe pathology than those with shorter careers.

There are very likely other risk factors that have yet to be discovered, including possible genetic differences that make some people more prone to develop CTE than others. More research will help scientists determine what those factors might be, and could help us understand how to prevent and treat the disease.

Age of first exposure to head impacts
Athletes who begin playing contact sports at younger ages are at greater risk for CTE. Several published studies show that exposure to head impacts before age 12 is associated with worse outcomes than starting after age 12.

How is CTE diagnosed?

Currently, CTE can only be diagnosed after death through brain tissue analysis. Doctors with a specialty in brain diseases slice brain tissue and use special chemicals to make the Tau clumps visible. They then systematically search areas of the brain for Tau clumps with a unique pattern specific to CTE. The process can take several months to complete, and the analysis is not typically performed as a part of a normal autopsy. In fact, until recently there were relatively few doctors who knew how to diagnose CTE.

In 2015, researchers from the VA-BU-CLF Brain Bank, led by Dr. Ann McKee, collaborated with the National Institutes of Health to develop diagnostic criteria for CTE, so that any neuropathologist familiar with brain diseases can accurately diagnose CTE. This important work has made it possible for more and more scientists to be on the lookout for CTE, helping accelerate progress.

I suffered a concussion. Is that going to give me CTE?

One concussion in the absence of other brain trauma has never been seen to cause CTE.

The best evidence available today suggests that CTE is not caused by any single injury, but rather it is caused by years of regular, repetitive brain trauma. There are also many individuals who suffer years of head impacts, but do not develop CTE. More research will help us understand these factors in the future.

What treatments exist for CTE?

Treating a disease that can’t be officially diagnosed until after death is difficult. Luckily there are lots of things that patients worried they have CTE can do to address their symptoms and find relief. Most treatments for CTE involve identifying the symptoms that are causing patients the most difficulty, and treating those symptoms with targeted therapies.

Mood changes
Mood changes, including depression, irritability, and anxiety, may be treated with cognitive behavioral therapy. Working with a cognitive behavioral therapist can help patients develop strategies that help them manage the particular mood symptoms that are causing the greatest problems.

A variety of treatment options exist for headache, including craniosacral therapy, massage, acupuncture, or medications. Working with a doctor to determine the type of headache is helpful for determining the best treatment options.

Memory problems
Memory training exercises, including consistent note-taking strategies, can be helpful for continuing a patient’s activities of daily living, despite increasing difficulty with memory.

If you think you or a loved one has CTE, read more of our recommendations on living with CTE and check out the CLF HelpLine, where we support patients and families struggling with the outcomes of brain injury.

If you are interested in contributing to research, consider pledging your brain to CTE research or reviewing other opportunities to participate in research.

1. A single case report claims a Stage 2 CTE case in a 45-year-old male. However, as the authors state, “lack of a trauma history comes only from the recollection of the patient’s wife,” so until other cases are reported with better exposure histories, we do not consider this isolated report meaningful, although we will continue to monitor the literature closely for other possible causes of CTE.

The grim list of football players with CTE continues to grow | The Kansas City Star

Former Oakland Raiders quarterback Ken Stabler has been added to the growing list of NFL players afflicted by the brain disease chronic traumatic encephalopathy, or CTE. Ben Margot Associated Press

The days leading up to Sunday’s Super Bowl 50 have been the usual spectacle of festive interviews, parties and celebrities. But now those three letters that have been haunting the NFL have popped up again.


Former Oakland Raiders quarterback Ken Stabler, who died in July, was added this week to the growing lineup of NFL players afflicted by the brain disease chronic traumatic encephalopathy, thought to be caused by repeated blows to the head.

Denver Broncos linebacker Brandon Marshall was bothered when he heard the news during his Super Bowl preparations.


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“You’ve got to look after yourself because, really, nobody else will,” Marshall told The Associated Press, adding that he has heard about players walking away from football.

“The game is so much a part of who I am, so I can’t give up a big part of me. I just hope the game doesn’t one day take away a big part of me.”

In a study released in October, 87 of 91 former NFL players who donated their brains to science tested positive for the disease. Researchers have so far found CTE in men who played every position except kicker.

“While we know on average that certain positions experience more repetitive head impacts and are more likely at greater risk for CTE, no position is immune,” said Ann McKee, a neurology professor at Boston University who studied Stabler’s brain.

The death in 2013 of football player Michael Keck, a former star at Harrisonville High, threw a new spin on the increasingly loud CTE discussion — he was only 25 when he died and never played pro football. (Read Sam Mellinger’s story here.)

Here are just a few of the NFL players affected by CTE:

▪ A postmortem analysis of the brain of Jovan Belcher, the Chiefs linebacker who killed his girlfriend in December 2012 in a murder-suicide, found that the 25-year-old linebacker probably was suffering from CTE. He is among the youngest known players to have the disease. (Read more here.)

▪ New York Giants safety Tyler Sash, 27, died of an accidental overdose of medications in September. His mother, who had seen his irregular behavior and periods of confusion and memory loss, said her son knew something was wrong. It was CTE, which had advanced to a stage rarely seen in someone his age.

▪ Former New York Giants running back and broadcaster Frank Gifford, who died last August, had CTE, as his family had suspected.

▪ Ray Easterling, a former safety for the Atlanta Falcons, was depressed and suffering from apparent dementia when he shot himself in 2012. An autopsy found CTE in his brain. “It amazed me to think about what he dealt with every day inside his head,” said his widow, Mary Ann.

▪ San Diego Chargers linebacker Junior Seau, who suffered from CTE, shot himself in 2012 at the age of 43.

This week, Bennet Omalu, the doctor played by Will Smith in the movie “Concussion,” said he believes that O.J. Simpson suffers from the disease. Simpson’s “trial of the century” for murder is playing out over the next few weeks in the FX miniseries “The People v. O.J. Simpson: American Crime Story.”

Omalu pointed to Simpson’s “irrationality, his impulsivity … his sexual improprieties, his violent tendencies, domestic violence history” as signs of the disease.

Omalu has estimated that more than 90 percent of all NFL players have CTE. The disease, however, can only be diagnosed after death.

It’s not clear yet why the disease hits some players and not others. In the study released last fall by the U.S. Department of Veterans Affairs and Boston University, researchers said their results didn’t necessarily mean that 96 percent of all NFL players are at risk.

The brains studied came from players who had concerns about CTE when they were alive.

After Stabler’s diagnosis was revealed on Wednesday, reporters at the Super Bowl asked former San Francisco 49ers legend Ronnie Lott whether he worried that he might have CTE.

“Everyone should think they have it and then work to slow it down by working to have a better life,” Lott said. “As far as symptoms, I don’t have anything.”

Scientists use words like “magnificent” to describe the human brain, a 3-pound motherboard floating in your skull that controls your emotions, your breathing, your movements and records every minute of every day of your life when it’s working well.

Like a computer, the brain doesn’t take kindly to hitting, dropping, slamming, banging, pounding or whacking, especially when it happens over and over and over again.

CTE, believed to be linked to repeated head trauma and concussions, makes the brain go haywire.

In a person with CTE, the brain gradually deteriorates. It loses mass. Parts of it atrophy, while other areas become enlarged, according to the Brain Injury Research Institute.

It was once called dementia pugilistica because it was thought to primarily affect boxers. But it’s now found in people involved in contact sports and members of the military who have suffered concussions and traumatic brain injuries.

Stabler’s family donated his brain to researchers at Boston University who spent months dissecting it and studying it, according to The New York Times.

His brain weighed just under three pounds. CTE was widespread throughout. Researchers said that the damage to the areas of Stabler’s brain that affected his memory and regulation of his emotions was “quite severe.”

Stabler reportedly told his family that he wanted his own brain studied after learning that Junior Seau had been diagnosed with CTE.

Reporters have noted that the Stabler diagnosis creates a sobering counterpoint to the festive run-up to Sunday’s game, especially since both the Carolina Panthers and Denver Broncos are known for hard-hitting, aggressive defenses.

“Stabler might be inducted posthumously into the Hall of Fame on Saturday,” wrote ESPN senior writer Ian O’Connor. “And if his legacy makes the journey to Canton, it will do so with the letters CTE attached.”

One of the biggest clouds hanging over the NFL in recent years has been the growing specter of head injuries, concussions, and CTE. As more and more former players reveal they are living with dementia and other degenerative brain diseases, the game of football has had to face some tough questions about player safety and what is being done to prevent this terrible illness.

Right now, it is impossible to know how many NFL players have CTE (chronic traumatic encephalopathy) because the diagnosis can only be confirmed after death. But increasingly, players are leaving their brains to science to study the disease, making the connection between CTE and football clearer by the day.

The 52 NFL players on this list were all confirmed to have been suffering from CTE. Some of them died of natural causes but debilitated by disease, while others like Junior Seau and Adrian Robinson have been added to the growing list of NFL players with CTE who killed themselves.

As the years go on and this list grows, the NFL will be forced to reckon with the years of trauma players have suffered while playing a game, many since before even high school. There has been a CTE settlement with some families, but there will likely be many more before the issue is put to bed.

WASHINGTON — Former football players who had experienced more severe concussions were more likely to report erectile dysfunction and low testosterone than other players, according to a team of Harvard researchers.

Former athletes were more likely to report that doctors had recommended or prescribed treatments for the sexual health conditions if they had a higher “concussion symptom score,” a measure derived from self-reported head injury symptoms like dizziness and nausea, or if they reported more frequently losing consciousness playing football.

“We found a very strong association between number of concussion symptoms and the likelihood that a former football player reported erectile dysfunction, or reported low testosterone,” Rachel Grashow, a research scientist at Harvard’s T.H. Chan School of Public Health and the study’s lead author, said in an interview. “As you increase the number of reported concussion symptoms, you see a subsequent increase in likelihood of ED or low T.”


It is the latest study to shed light on the long-term effects of playing football. Most research into football’s health impacts, however, has focused on future cognitive health problems, such as dementia and depression. It is the first study, the researchers said, to examine sexual health in a non-clinical setting in a large population of football players who suffered repeated brain injuries.

In the investigation, published Monday in JAMA Neurology, researchers used self-reported data about treatment for ED and low testosterone in 3,409 former players. More than 18% of the players reported low testosterone levels, 22.7% reported erectile dysfunction, and both rates rose in association with head trauma. Fewer than 10% reported undergoing treatment for both symptoms.

While the investigators did not directly attribute the association to a specific physical injury, the paper cited damage to the pituitary gland often sustained during major injuries as a likely culprit for the linked sexual health problems.

The association between overall concussion severity and loss of consciousness events remained strong even when researchers adjusted for external factors, including the players’ specific football position, body mass index, age, race, and self-reported use of prescription or performance-enhancing drugs.

Numerous past studies have shown a link between brain trauma and sexual dysfunction. Those studies, however, were often tied to a single, severe incident such as a car crash or battlefield injury — not football injuries that were comparatively less life-threatening. Researchers also observed an association with sexual dysfunction regardless of how often a football player had experienced brain trauma.

“We saw a statistically significant increase in risk of low testosterone even at relatively low numbers of reported concussion symptoms,” Grashow said, “which suggests that there may be no safe number of head hits.”

Measuring the impact of comparatively more mild concussions is also instructive in the context of past research, said Dr. Daniel Daneshvar, a researcher who works at Boston University’s Chronic Traumatic Encephalopathy Center, which conducted the first large-scale brain health study in former NFL players. Daneshvar was not involved in the Harvard research.

“We’re increasingly finding that the repetitive number of impacts are a better predictor of whether someone develops as opposed to a limited number of more severe injuries,” Daneshvar said. CTE, a neurodegenerative condition that can impact mood and behavior, is among the most studied health effects of football-related brain injuries.

The study also could also influence societal beliefs regarding football’s health impacts. The results of sustained brain damage are normally thought of as relating to depression, suicidality, and dementia. The Harvard investigation could expand society’s views of football-related brain injuries as causing not just cognitive health problems but physical health ones as well, Daneshvar said.

“When we talk about CTE, we’ve largely been talking about problems related to behavior, to mood, to cognition,” he said. “But we know that traumatic brain injury has associations with issues throughout your entire body. We’ve found in multiple studies that there’s a relationship between pituitary problems and major traumatic brain injury.”

The study authors cited numerous factors, including a reliance on self-reported health data instead of clinical assessments and potential recall bias, in acknowledging the paper’s limitations.

Both Grashow and Danesvhar, however, said they viewed the correlation as stronger and more likely to be borne of a causal link because it remained consistent both when measuring overall concussion severity and reporting blackout incidents. Self-reported loss of consciousness events, Grashow said, were likely distinct and memorable, and therefore less subject to recall bias.

Overall, Grashow called the findings “the strongest statistical relationship I’ll ever find in my career.”

The finding, she said, could have sweeping real-world implications, given the broader implications sexual health holds for quality of life and the fact that they often portend broader health issues.

“If you’re a former player who had a head injury and you have ED, speak to your doctor,” Grashow said. “The hope is that we can undo some of the stigma associated with ED, that it’s a personal failure or failure of masculinity — there’s a real biological reason you’re experiencing this.”

“There’s just not amazing science in the field in general,” says Torres. “So you have to decide which not-so-great science are you going to follow.” Those are not exactly the sorts of words you want to hear at a doctor’s office.

Getting our legs under us

Ghajar, at Stanford, thinks he’s developed a device that can both better diagnose, more effectively monitor, and could possibly help prevent, concussions. His device is based on the idea that our eyes provide insight into how our brains orient and coordinate our bodies in time.

“Our brains are actually two and a half seconds in the future,” says Ghajar. “By the time you sense something, it’s already happened. We anticipate the future, interact in the present, and are aware of the past.” To hit a tennis ball screaming down the line, a person’s brain has to anticipate where that ball will be, and react before it gets there.

Everyone’s life is lived on a slight time delay. But when someone has a concussion, that whole system gets out of whack. It makes people feel literally “out-of-sync”—symptoms sometimes described as “brain fog” or being “dazed,” says Ghajar. He built a system to measure that disconnect with eye-trackers and a Samsung Gear VR headset.

“EYE-SYNC Technology,” as he calls it, measures a person’s ability to maintain what’s called smooth pursuit with their eyes. Basically, it analyzes how the eyes perform when tracking words across a page or an object in motion. There’s a diagnostic standard called the King-Devick test that measures this ability, but it requires that someone observe and interpret eye movements as the patient reads numbers off a card. Ghajar’s EYE-SYNC can do the same, but in much less time, and without all that pesky human error.

The subject is fitted with a modified Samsung VR headset equipped with the latest eye-tracking technology, and told to follow a virtual dot as it traces a circle across the screen.

At a recent conference, Ghajar showed two videos demonstrating the technology in action. The first showed a normal, predictive brain state: the subjects’ eyes always tracked slightly ahead of the dot they were told to follow, leading smoothly and anticipating the predictable pattern of the circle. The second was of a concussed brain. Here, the eye-dot was shockingly sporadic, jumping in front of and falling behind its intended target, with no clear system or pattern. It was pretty clear all systems were not go.

Ghajar says the technology can also also pinpoint attention deficiencies in a person’s visual field, and improve them. He has been working closely with Stanford athletes, all of whom are required to undergo baseline tests with the EYE-SYNC device. Results from some athletes’ tests suggested they might not notice things coming from the lower left as well as from other angles. When the trainers found this out, they worked with the athletes to train away those weaknesses.

This sort of approach could prevent concussions, Ghajar says because more often than not, it’s the hit you don’t see coming that knocks you out.

The road to recovery

W.H. Earles, writing in the Journal of the American Medical Association, said that, “Every case of recent head injury, however trivial it may appear, should, we believe, be treated with the greatest consideration, lest damage to hidden and important structures escape our attention, thus leaving a foundation for future trouble which too often is irreparable.”

Earles wrote that in 1903. Football has always had a problem with concussions, but without visible damage to assess and the fact people walked away soon after the injury, it was hard to make the case that it was a big deal. And that attitude stuck around for almost a century.

In speaking with Mara Sproul, a program manager at the Concussion Center, I recalled watching NFL games in the 1990s, and seeing players get the sense knocked out of them on first down, and go back in for third. She told me she remembered when people thought it wasn’t a concussion unless someone lost consciousness.

“People laughed at 20 years ago,” says Broglio, “it’s only been in the last 10 years that the money, resources, and attention have been there to push the field forward.”

According to the US Centers for Disease Control, from 2001 to 2010, the rate of American emergency room visits for traumatic brain injury nearly doubled (from just over 400 to more than 700 per 100,000). Though this sounds like grim news, it actually may represent a sobering sign of progress.

The increase in concussion cases doesn’t mean people hit harder now, or that there are more horses to fall off of—one study found that horse accidents accounted for 42.5% of all adult TBI events between 2001 and 2012—or even that we now are more diligent in spotting them. What the numbers are most likely showing is that more and more people are becoming aware of the dangers and are motivated to seek help. As a result, during that same decade-long period that saw US emergency room visits double, the number of deaths due to TBI saw a steady decline.

Hopefully these positive trends are a direct result of the public coming to grips with the true nature of these injuries. Even if a person is able to walk away from an accident, a pile-on, or a vicious hit that makes a stadium wince in unison, that does not mean they escaped unharmed. Though we are only starting to learn what’s going on behind a sufferer’s eyes, what we now know for sure is that telling anyone to walk it off, to get back in there, is not, and has never been, enough.

Correction: This article has been updated to more accurately describe the role of the NOCSAE.

One of the dumbest storylines of the NFL preseason was Antonio Brown and his banned helmet. The whole saga stunk of a marketing ploy, a soap opera built for the Instagram age. Yet beneath all that fluff, there was a topic worthy of discussion. If the league is serious about reducing traumatic brain injuries, should players wear helmets at all?

The biggest misconception about football helmets is that they prevent concussions. They don’t. Helmets protect the skull from fractures. Concussions are caused when the brain moves inside the skull; helmets do little if anything to prevent the brain from rattling inside the skull. Helmets are part of the problem, not part of the solution.

Modern NFL players are not built like normal people: they range in size somewhere between Captain American and The Hulk. When they put on a helmet, athletes gain a false sense of security. Since they believe helmets are there to protect them, they hit more often – and with reckless abandon. There’s a psychological term for this: risk compensation. Studies of cycling and snowboarding found that athletes wearing helmets are more likely to take dangerous risks than those without. They know there’s danger in plummeting down a mountain with a helmet on. Without one, they feel that danger and are more cautious.

Then there is the facemask problem. Although NFL facemasks offer some protection, they also make opponents appear less human. One of the most impactful psychological studies of the modern age was Stanley Milgram’s authority-obedience test. A significant part of Milgram’s work was evidence that people are more likely to inflict pain and harm to people they cannot see. It’s no stretch to believe the same is true in sports with facemasks and visors. The cycle continues: Hit more. Hit harder.

Facemasks carry a more significant risk, too. There are two different forces that can cause concussions: linear and angular. Linear involves a direct, head-to-head blow. Angular is an offset blow – basically any contact that isn’t forehead-to-forehead – to the head. According to a report published in the Clinics in Sports Medical Journal, with angular force, the brain cells not only stretch but they twist around themselves causing either damage or death to the cells. Though they don’t always inspire the same kind of gasps or shock, angular forces are more detrimental than linear ones. Additionally, the facemask also gives the otherwise spherical helmet a “nose” increasing torque, therefore amplifying any hit that isn’t head-to-head.

Modern plastic, shelled helmets were not introduced to football until the end of the 1940s. Facemasks did not become commonplace until the 1960s. Prior to that, players tackled in a “rugby style”: with the initial point of contact being the shoulder (in the very early days of football, spear tackles were allowed but this dangerous practice was eventually outlawed). Once the plastic helmet was introduced, however, athletes felt safer and began to tackle headfirst. Fatalities spiked.

Authorities took the same approach then as they do now. They added more equipment and more rules. In the past 10 years, the NFL has altered the physics of the game: the way people tackle; kick-offs; new rules on punts; who can be tackled, and when.

Last year’s so-called “bodyweight” rule broke the dam for even the most ardent of player-health-above-all supporters. It was met with universal contempt. This wasn’t football, the cynics scoffed. This was softer, more millennial. The goal was to keep quarterbacks on the field so the league’s owners could pen large TV deals, not preserve the brain cells of their stars. It was a step too far. The league was breaking the basic fabric of the game.

Taking the helmets off would change that dynamic. Players would naturally alter their style, but the general aesthetics of the game would be preserved. NFL coaches have preached about rugby-style tackling for years. In a helmet-free world that wouldn’t be a fun niche, it would be a necessity.

Studies are currently underway into knock-on effects of such a drastic move, headed by the University of New Hampshire. In one season, head impacts decreased 30% by the end of the season in training groups that performed tackling drills without a helmet compared to those who completed the drills with a helmet. Learning how to tackle and take a hit is changing, too. Schools still use dummy bags, but they also use tackling robots and other innovative measures to cut-down on player-on-player hits. Most youth camps remove helmets altogether and use skull caps.

Pro football has finally moved in line with college football – it has become quicker, more finesse based, built around athletes in space, not power up the middle. That’s meant fewer destructive hits to players who play on the perimeter. But the risks remain the same for the big guys inside. Offensive and defensive linemen woodpecker away all game banging heads on somewhere between 70-80 plays in an average game. That’s about a 25 play-per-game increase in little over two decades. That’s 25 more times a pair of linemen’s helmets ricochet off one another and create a subconcussive effect, the phenomenon in which the brain hits the inside of the skull causing trauma but without players showing the obvious symptoms of concussion. New, innovative helmets do nothing to stop that; they exacerbate the problem. Removing helmets would force linemen to move their heads away from each other rather than risk bumping foreheads up to 80 times in a three-hour span.

The league has been focused on the dramatic hits that cause concussions, turn off TV viewers and scare parents away from feeding their children into the league’s pipeline. But it’s the subconcussive hits that have the most damaging effects long-term. If there is a concussion crisis in football, it is a subconcussive one.

Removing helmets is not about ruining the game fans love. It’s about preserving the game and the players who play it. The current changes have been small potatoes, nice things to stick in a social media campaign or spin to TV executives or parents. Concussions and brain trauma will never be entirely removed from football – or any contact sport – but there is a radical idea sitting under the league’s nose. And it’s time to start taking it seriously.

NFL players with brain trauma receive notice of settlements stripped to nothing

For debilitated and often-broke former football players and their families, the National Football League’s agreement to pay more than $1 billion in a settlement for victims of chronic brain trauma appeared to be the end of the battle that had consumed them for years.

The money was supposed to provide a measure of peace and stability for the wives, widows and children of tormented players who had died young or are fading away in nursing homes. Not disclosed, however, is the significant portion of the fund that is being withheld from those it was promised.

As the award notifications begin to trickle out, some of the recipients have been stunned to find they may receive just pennies on the dollar of what they’re owed, likely setting off another spate of frustrating court battles.

Some have even received notices that show pending payments in the negative.

Sarah Goldston, the 90-year-old widow of Ralph Goldston – who was one of the first black players on the Philadelphia Eagles in 1952 before Alzheimer’s set in during his retirement – learned this month that their family had been awarded $160,000 from the settlement. But that preliminary award dwindled to negative $740 after deductions and “holdbacks,” including thousands the court has kept in case the family owes money for Ralph’s medical bills.

“I thought they made a mistake,” Ralph’s daughter, Ursula Goldston, said after seeing the family might receive nothing because of the pending liens, which email correspondences show might have been withheld in error. “I just cannot believe these people did that.”

USA TODAY reviewed documents or interviewed families in a dozen cases of former players whose settlement projections have been similarly reduced. Money that the former players or their family members had counted on will instead, for now, remain in the NFL’s settlement fund or will be redirected to insurance companies, lawyers, credit card companies or others who have placed a lien on the awards in an effort to secure a piece of the payout.

More:NFL had ‘intervention’ with seven teams on concussion rates

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More:Family of Junior Seau settles concussion lawsuit against NFL

The payout determinations are not final. Court officials and lawyers are sorting through the lienholders’ claims, while players can also appeal their deductions for an additional cost of $1,000. Out of 20,000 players involved in the suit, less than 700 have been approved for payment so far.

Some of the former players, as well as outside observers, blame in part lawyers who have filed liens seeking a large percentage of the awards even though they did minimal work on the case or recruited players with false promises after the settlement was reached.

USA TODAY reviewed letters in which former attorneys, who were fired before the case settled, demanded as much as 25 percent of a player’s award for as little as 15 months of work. The firms indicated in the letters that their work product amounted to “considerable time and effort.” They say they deserve fair compensation for helping qualify players to receive a settlement and that the lien is largely a fight with the new lawyer over fees.

John C. Coffee Jr., a professor at Columbia Law School, reviewed a sample of the settlement payout notices obtained by USA TODAY. He said if attorneys who did little work are demanding large chunks of a player’s award, that amounts to “unjust enrichment.”

“That’s where you should be outraged,” he said.

‘Patently unfair’

It’s now on those players to dispute the work their old lawyers put in, and a magistrate judge will ultimately decide if and how much of a cut they will get.

The settlement terms created a formula for each player’s specific case and then a court administrator decides how much of the settlement fund to disperse, while holding back any money contested in a lien.

As of this month, payouts in the settlement total almost $570 million, according to a claims administrator. Though it includes claims the NFL has appealed, the high dollar figure has been touted by both sides as evidence that the settlement is already compensating players.

But until now, the specific dollar amounts withheld from players had not been reported. Those involved will not release what share of the total payouts are actually deductions and disputed liens.

Jim Acho, a Michigan attorney who has represented roughly three dozen retired players, said that his clients have said they are stunned by the holdbacks. He called some of the deductions “patently unfair” and said they “eviscerate a big chunk of the payment,” leaving his clients with a fraction of what they expected.

“When it really hits home for them is when your are sent the breakdown of the payout by the claims administrator,”Acho said. He added that his clients have likened the reduced payouts to being “punched in the gut.”

Craig Mitnick, a lawyer whose firm co-represents more than 1,000 players in the class-action, said he now regrets publicly championing the agreement when it was first announced. Clients who fought for years to get a piece of the settlement have seen their potential payouts reduced to the low thousands, or even to nothing, by the holdbacks, he said.

“These players didn’t know what they were getting into,” Mitnick said. “The settlement is not what we thought it was.”

Players and their families who spoke with USA TODAY said the withheld payouts are the latest insult in a years-long battle to hold the NFL, the world’s highest-earning sports league, accountable for brain injuries incurred during playing careers. The league long denied connections between the sport and lasting brain injury and, the suit claimed, failed to warn players or do what it could to protect them from head trauma caused by hard hits, leading to a condition now known as chronic traumatic encephalopathy, or CTE.

Plaintiffs have complained in the past that the legal battle against the NFL has been full of trapdoors and fine print that has tested resolve and stretched bank accounts, all while dealing with the devastating long-term impact of careers spent in football. Some had to unearth decades-old proof of their playing days and medical history before fighting through audits, appeals and narrow diagnosis criteria to show the court they deserved part of the settlement.

“A lot of people would have given up by now,” Ursula Goldston said. She and her family corralled decades-old paperwork documenting her father’s illness from past doctors. They got letters from neighbors who witnessed Ralph declining. One saw him standing by himself outside in the Ohio winter, freezing and confused, years ago. He stopped bathing and caring for himself. He lashed out at his wife in fits of rage.

“I’m not giving up,” Goldston said, “because my mother deserves this money.”

Different from other settlements

The terms of the class-action settlement are a result of negotiations between lawyers representing the players as a whole and those for the NFL. In interviews, many of those on the players’ side faulted Chris Seeger, co-lead counsel for the plaintiffs, for negotiating settlement terms that they said opened the door for holdbacks without safeguards to ensure players don’t leave empty-handed.

In a letter sent to USA TODAY, Seeger wrote that the court accepted the terms and payout structure. He pointed to the hundreds of millions in approved payouts as evidence that the settlement was “working effectively.”

“It is required by law” to hold back funds until medical liens are resolved, Seeger wrote. He added that no players whose medical liens had been finalized had received a negative payout.

In a statement from Seeger after the story was published online, he wrote, in part, that “the majority had $0 deducted from their awards for medical liens or lien-related fees. For the minority that did pay medical liens and related fees, their average deduction has been 2.2%.”

In other high-profile class-action cases with large settlements, the parties negotiated the ability to increase award amounts to make sure deserving victims did not see their payouts diminished, said Kenneth Feinberg, an attorney who has administered class-action settlements, including one stemming from the September 11 attacks.

“We had broad discretion to prevent the injustice of an eligible member getting nothing due to the cold calculation of a formula,” Feinberg said.

Similar steps were not taken to ensure NFL players won’t walk away with very low or no awards.

“I’m afraid that wasn’t part of the negotiating,” said Larry Coben, a lawyer for the plaintiffs involved in reaching the terms of the settlement.

The NFL declined to make a league official available for an interview. In a statement, the league did not address the issue of depleted awards but said, “The settlement program is working as intended, and we will continue to work in good faith to pay all approved claims under this settlement, which has been thoughtfully and thoroughly negotiated by the parties and approved by multiple courts.”

Coben defended the broader terms of this deal – which has been criticized by debilitated former players as too full of exclusions and provisions – as “not a one-time shot.”

“Ten to 15 years from now, if their condition worsens, they could apply again and potentially get a benefit,” Coben said.

Echoing an opinion of the federal judge overseeing the settlement, Coben justified the holdbacks as a measure to negotiate down liens and prevent players from later getting sued by medical providers or other entities. It’s not uncommon for large, public settlements like this to open the door for third parties who think they are due a cut. Health care plans with hospitals, insurance providers and Medicare often specify some sort of repayment should a patient ever win a windfall settlement meant to help cover the cost of care.

Some of the payout notices reviewed by USA TODAY show initial awards calculated by the administrator reduced to nothing after all the pending lien holdbacks.

After Gordon Smith – a Minnesota Vikings tight end who played in the 1960s – went through a formula that calculated his age at the time of his Alzheimer’s diagnosis, degree of illness, years in the league and medical history, the courts administrator awarded him $183,000 for his brain trauma.

But because private insurance had covered some of the costs related to his care, the courts administrator held back all but $4,600.

Smith’s wife, Maetha, who spoke on Gordon’s behalf, said she was shocked at the amount after seeing the public statements about large payouts from the NFL and lawyers who negotiated the settlement.

“We were hearing hundreds of thousands,” she said. “This settlement is minuscule.”

The administrator awarded Barbara Stark $100,000 in a settlement for her husband, Ed Cooke, a defensive end on five teams in the 1960s who later developed Alzheimer’s. After holdbacks for pending liens, the final figure showed Cooke is slated to receive negative $200.

Andrew Stewart, a 52-year-old former linebacker who has Parkinson’s disease, said that angry phone calls and messages are circulating among retired players and their wives after receiving notices detailing their settlement payouts.

“It’s shocking what the offsets are,” said Stewart, who was on the Cleveland Browns, Cincinnati Bengals and San Francisco 49ers from 1989 through 1993. He saw his own potential award drop from $3 million to $750,000 after the administrator reduced the amount of seasons he was credited for because he missed time with injuries. He has not yet received his claim determination because his case is tied up in appeals, he said.

“I’ve heard of guys receiving a tenth of what they were going to get,” Stewart said. “Nobody’s getting what they thought they were getting.”

Officials working on the claim distribution said many of the liens placed on players’ payouts are from former lawyers, some of whom were fired before the class-action litigation even began.

Sandra Irvin, speaking on behalf of her husband, Darrell, a defensive lineman for the Buffalo Bills and Seattle Seahawks in the early 1980s who was diagnosed with Alzheimer’s, called her fired attorney’s $200,000 lien an affront.

“I think we got a total of three phone calls from them,” Irvin said. “What a joke.”

Contributing: A.J. Perez

‘They’re in the violence business’: The Aaron Hernandez documentary highlights how the brain disease CTE has affected the entire NFL

  • Netflix released “Killer Inside: The Mind of Aaron Hernandez,” a documentary looking into the rise, fall, and death of Aaron Hernandez, on Wednesday.
  • The documentary chronicles the story of Hernandez, a former New England Patriots player who died by suicide while serving a life sentence for killing Odin Lloyd, the boyfriend of his fiancée’s sister.
  • After his death, researchers found that he had severe chronic traumatic encephalopathy (CTE), a brain disease caused by repetitive brain trauma.
  • “Killer Inside” features long segments on the brain disease, including interviews from other football players. It does not tie Hernandez’s crimes specifically to the disease.
  • Visit Business Insider’s homepage for more stories.

A new Netflix documentary about former New England Patriots tight end Aaron Hernandez highlights how brain trauma is affecting the NFL’s players.

While “Killer Inside: The Mind of Aaron Hernandez” does not blame chronic traumatic encephalopathy (CTE) for Hernandez’s criminal behavior — or the murder of Odin Lloyd, which Hernandez was sentenced to life in prison for — the documentary does give insight into how the untreatable disease affects NFL players for the rest of their lives.

Through interviews with lawyers, Hernandez’s friends, and former NFL players, the documentary tells stories of CTE, which can only be diagnosed after death.

Chris Borland, a former 49ers linebacker who retired after just one year in the league over fears of the longterm effects of head injuries, said in an interview that he was experiencing symptoms of concussions — including ringing in the ears and imbalance — every day.

“In my minimal interactions with folks high in the NFL, I think there’s a certain degree of hubris. You know, they own a day of the week,” he told “Killer Inside” filmmakers. “Football’s a religion.”

“No matter whether or not they’re throwing a flag, or claiming concussions are down, or taking players into the blue tent, the reason football is the most popular sport is because it’s violent,” he added, referencing penalty flags for helmet hits, and the blue medical evaluation tents on the sidelines of NFL games. “They’re not in the health business. They’re in the violence business.”

The documentary covers the CTE diagnoses of Mike Webster and Junior Seau

Pittsburgh Steelers center Mike Webster pictured in the 1988 season. AP Photo/Gene J. Puskar, File

Before delving into Hernandez’s own CTE diagnosis, the documentary highlights the diagnoses of Mike Webster, who was the first former NFL player to be diagnosed with the disease after he died of a heart attack in 2002, and Junior Seau, who was diagnosed after he died by shooting himself in the chest in 2012.

Retired Patriots cornerback Leigh Bodden told filmmakers he wasn’t shocked at Hernandez’s CTE diagnosis because he had already known what happened to Seau, another Patriots teammate.

“Having CTE be the kind of thing they both shared is eye-opening to athletes and to everybody in the football world,” he said.

As more people learn about the problems CTE can cause, more players are retiring from the NFL early.

Researchers have shown that head hits in youth sports increase the risk of developing CTE. Another study has shown that players are at a higher risk if they play longer.

Carolina Panthers linebacker Luke Kuechly announced his retirement on Wednesday at just 28, saying it was the “right thing to do.”

New England Patriots Junior Seau speaks to reporters before training at the Oval Cricket Ground ahead of their NFL game against Tampa Bay Buccaneers in London October October 23, 2009 REUTERS/Luke MacGregor

The NFL says it supports scientific research into CTE, pledging $100 million into independent studies in 2016. After Boston University’s CTE Center released a study in 2017, which found evidence of the disease in 110 out of 111 former players, the NFL issued a statement saying the research added value “in the ongoing quest for a better understanding of CTE” but said there are “unanswered questions relating to the cause, incidence, and prevalence of long-term effects of head trauma such as CTE.”

Hernandez had ‘advanced’ CTE when he died by suicide in 2017

When Hernandez’s brain was examined after his death in 2017, Ann McKee, a neuropathologist and expert in neurodegenerative disease at Boston University’s CTE center, said his diagnosis was advanced.

“He had a very advanced disease. And not only was it advanced microscopically, especially in the frontal lobes, which are very important for decision making, judgment, and cognition,” she said in “Killer Inside.”

Patrick Haggan, the prosecutor on Hernandez’s second trial told interviewers in “Killer Inside” that he researched CTE after hearing about Hernandez’s diagnosis.

“I started to look at the signs of CTE — impulsiveness, rash decisions, sometimes propensity to be violent. It was Aaron Hernandez,” he said in the documentary. “And if you look at everything that this young man had going on — not only physically, but mentally, emotionally, from what had happened when he was a child, and what had happened in his own life, then on top of it you add the CTE — it all made sense that this tragedy had probably begun, or the seeds of this tragedy had started many, many years earlier.”

Former NFL player Aaron Hernandez and defense attorney Charles Rankin wait in the courtroom during the jury deliberation in his murder trial at the Bristol County Superior Court in Fall River, Massachusetts, April 10, 2015. REUTERS/CJ Gunther/Pool

Jermaine Wiggins, a former New England Patriots tight end, believes there was something worse going on with Hernandez, and that CTE wasn’t to blame for his crimes.

In the “Killer Inside” segment on CTE, filmmakers included an old local TV interview of Patriots owner Robert Kraft where he encourages people to still play football.

“My sons and grandson played, I played, and I’d recommend to every other mother out there who wants their son to grow up special that they should play too,” he said.

  • Aaron Hernandez’s casual prison behavior ‘chilled’ guards, according to a new Netflix documentary showing how he lived a double life of NFL stardom and murderer
  • Aaron Hernandez had a severe form of the brain disease that impacts a wide swath of NFL players — here’s what it does
  • The rise and fall of Aaron Hernandez: How he went from a rising star to a convicted murderer and the newest face of football’s concussion crisis
  • Aaron Hernandez had CTE, the brain disease associated with repeated concussions

A Tribute to the NFL Players Who Suffered CTE Brain Injury

Linebacker Junior Seau spent nearly 20 years in the NFL, earning many honors before his retirement after the 2009 season. His high-energy performances earned him the nickname “The Tasmanian Devil.” He was voted to the Pro Bowl 12 times.

Three years after he retired, Seau died by suicide in 2012, a tragic end to an extraordinary life and career. An examination of his body revealed brain damage caused by chronic traumatic encephalopathy, known as CTE: a degenerative brain disease found in people who have suffered repetitive head trauma.

In a study published in the medical journal JAMA in July 2017, CTE was found in 99 percent of deceased NFL players’ brains that were donated to scientific research. Doctors believe CTE contributed to Seau’s suicide and to other behavioral and medical issues players have suffered after experiencing repeated head trauma while playing football.

Begin the slideshow of player photos and obituaries

Last April, ex-New England Patriots tight end Aaron Hernandez was serving a life sentence in jail for first degree murder when he was found dead in his cell by hanging. Afterwards, he was diagnosed with severe CTE damage for someone his age. CTE can cause aggressive, impulsive behavior. His fiancee and daughter have sued the NFL in a wrongful death lawsuit based on the CTE diagnosis.

In November, news broke that researchers had finally identified CTE in the brain scan of a then-living patient. Dr. Bennet Omalu confirmed that ex-NFL linebacker Fred McNeill was the subject of that research. McNeill had been examined at UCLA before he passed away in 2015 after showing signs of the disease. Dr. Julien Bailes, who participated in the study, told ABC News, “The importance of this one today is that this is the first time to have a scan which shows brain degeneration of CTE in a living person and then to have that person die and it correlates with the autopsy.”

The list of former NFL players with CTE is long, and many former professional football players have announced their plans to donate their brains to science after they die. Hall of Famer Warren Sapp announced in June 2017 that, when he dies, he will donate his brain to the Concussion Legacy Foundation—because “I wanted this game to be better when I left than when I got into it.”

Click through the photos below to view the stories and obituaries of 20 former pro football players, including Hall of Fame members Junior Seau, Ollie Matson, Tommy Nobis, Frank Gifford, and Ken Stabler, who were found after their deaths to have been suffering from CTE.

What a lifetime of playing football can do to the human brain

Football isn’t just a contact sport — it’s a dangerous game of massive bodies colliding into one another. And while it may seem obvious that this sport can do extraordinary damage to brains and bodies, it’s taken far too long for the NFL, the medical community, and football fans to fully reckon with this.

Doctors have learned a tremendous amount about concussions and chronic traumatic encephalopathy, or CTE, a degenerative brain condition believed to be caused by repeated hits to the head, since the first former NFL player was diagnosed with CTE in the early 2000s. Concern around the issue has only grown now that more than 100 former NFL players have received a postmortem diagnosis of CTE, and new research is finding that youth football may be a risk factor for CTE down the line.

Football is still an immensely popular sport in the United States, and this weekend, millions will watch and enjoy the Super Bowl. But all the evidence we now have about the very serious risk of brain injuries casts a dim light on the future of the sport. Here’s what you need to know.

1) Concussions are incredibly commonplace in professional football

The human brain — the most complicated and powerful organ on planet Earth — is squishy. And when a person hits their head hard, the brain can bounce around and twist in the skull. It’s this rapid motion of the brain inside the skull that creates the traumatic brain injury known as a concussion.

During impact, individual neurons can be stretched and damaged. Brain chemistry gets out of whack. Concussions make people “see stars,” become disoriented, lose consciousness, become sensitive to light and sound, get headaches, and have sluggish or confused thoughts for weeks and even months.

Heads and bodies get smashed and shuddered every week during the football season. And despite changing the rules to allow for more severe penalties and fines for flagrant helmet-to-helmet hits, the NFL has not succeeded so far in preventing concussions.

The number of concussions sustained during practice and gameplay in 2018 fell somewhat, from a total of 281 in 2017 to a total of 214 in 2018, according to the NFL’s injury data. And then increased again to a total of 224 in 2019.

Javier Zarracina/Vox

This data doesn’t cover the countless additional blows to the head that don’t reach the level of concussion but still may pose a risk for the brain.

2) Chronic traumatic encephalopathy is a degenerative brain disease caused by repetitive hits

CTE is not about single concussions. It’s the result of repeated concussions — and even head impacts that are not quite as severe — which can result in lasting structural changes in the brain. “The pain you feel is not necessarily an indicator of the damage that does to your head,” Philip Bayly, an engineering professor at Washington University in Saint Louis, who has been studying the mechanics of brain movement inside the head, said in a 2019 interview.

Specifically, brains with CTE accumulate a protein called tau (which is believed to be dislodged from brain fibers during an injury). Tau clumps together in the tissues of the brain, interrupting critical information flow.

The mechanisms of how this all happens still aren’t well understood. “The challenge is nobody sees what happens to the brain when someone gets a concussion,” Bayly said. One hypothesis is that the sulci — the grooves on the surface of the brain — experience high mechanical stress during an injury and burst open pockets of tau. (In autopsies, these clumps of tau are often found near the blood vessels at the bottom of sulci.)

The disease isn’t exactly new. A form of it was originally discovered among boxers in the 1920 (who, like football players, sustain regular hits to the head). Then, it was called dementia pugilistica, or punch-drunk syndrome. Currently the only way to definitively diagnose CTE is through an autopsy. In 2005, researchers published the first confirmed case of CTE in an NFL player. The results of that report contained ominous statistics to suggest CTE might be frighteningly prevalent among players:

There are approximately 0.41 concussions per NFL game of American football: 67.7% of concussions involve impact by another player’s helmet, 20.9% involve impact by other body regions (e.g., a knee), and 11.4% involve impact on the ground (29, 31, 32, 40). It has been reported that 9.3% of the concussions involved loss of consciousness and 2.4% of the concussions resulted in hospitalization. Most (92%) of the players who sustain a concussion return to practice in less than 7 days; fewer (69%) of the players who experience loss of consciousness return to practice in less than 7 days.

And since then, evidence has only mounted that the repeated head blows in the NFL contribute to the disease.

In 2017, Aaron Hernandez, a former player for the New England Patriots, hanged himself in prison while serving time for a violent murder. Upon an autopsy, doctors diagnosed him with CTE. It was the most severe case ever seen in a person his age (27 years old).

3) There’s a range of CTE symptoms, from forgetfulness to violent behavior

The symptoms of CTE creep slowly, taking 8 to 10 years to manifest after initial repeated brain traumas, and can grow worse over decades. Here’s a diagram of what’s happening inside the brain as CTE grows more and more severe.


These images are from a 2013 study in the journal Brain, which assessed 85 brains donated from former athletes, veterans, and people with a history of brain injury. The brown stains represent the dangerous tau proteins. What starts off as areas of the brain pockmarked with tau spreads to surround whole brain structures.

In stage I, symptoms are subtle: headaches, short-term memory loss, and loss of attention. By stage IV, “most subjects also showed profound loss of attention and concentration, executive dysfunction, language difficulties, explosively, aggressive tendencies, paranoia, depression, gait and visuospatial difficulties,” the paper explains.

4) It’s unclear how many former NFL players have CTE

Getty Images/Collection Mix: Subjects RM

CTE can only be conclusively diagnosed in autopsy (though progress is being made in diagnosing via MRI). So it’s hard to say how many current and former football players have the condition. What we do know is that there are dozens of cases of confirmed CTE — enough to be alarming.

In 2017, JAMA published a major and disturbing finding. Researchers had collected the autopsied brains of 202 former football players who had donated their brains to science, or had them donated via their next of kin. The players included those who had played in the NFL, but also those who only played through college, and a few who had only played in high school.

Of the 202 brains, 177, or nearly 90 percent, were diagnosed with CTE. And there was a pattern: Those who had played football longer were more likely to have worse brain damage. Among the former NFL players in the sample, 99 percent had CTE. This suggests the effects of brain trauma on CTE are cumulative. The more trauma over a longer period, the worse the symptoms.

This is not to say that 99 percent of NFL players will develop CTE (the brains were donated and are not a representative sample). But it does show that football players are, indeed, at risk.

As Ann McKee, the Boston University neuropathologist who is the leading expert in CTE, told PBS Frontline in 2013, “People think that we’re blowing this out of proportion, that this is a very rare disease and that we’re sensationalizing it. My response is that where I sit, this is a very real disease. We have had no problem identifying it in hundreds of players.”

And to note: Football is not the only sport that poses the risk of head injury. There’s growing concern about CTE in hockey players, as well as abroad; players of Australian rules football have also complained about cognitive problems after retirement.

5) Even high school and college-level play poses a risk

One of the biggest consequences of the concussion research is that fewer young people are participating in the sport. In a 2018 documentary, retired star quarterback Brett Favre said he’d prefer that his grandsons play golf over football. Celebrities like former President Barack Obama have said they wouldn’t let their sons play football.

National trends reflect the unease. The number of high school students playing football dropped by 30,829 between the 2017-2018 and the 2018-2019 school years, continuing a downward trend. In 2008, 1.11 million high school students played football. Now, it’s 1.006 million — the lowest number since the 1999-2000 school year, the National Federation of High Schools reports. That said, football is still the most popular sport for high school males.

(There’s some data to suggest that drop in participation is led by white students. “Black kids in lower-income communities without a lot of other sports available are still flocking to football,” the Atlantic’s Alana Semuels reports.)

Parents have reason to be concerned about young kids playing the sport.

A 2015 study found that former NFL players who began football before age 12 fared worse on cognitive assessments than those who started later in their teens. And this held true even controlling for number of years played.

It suggests (though not conclusively) that playing football at ages younger than 12 is more dangerous for long-term cognitive decline than starting at an older age. “The results of this study suggest that sustaining repeated head injuries during critical periods of brain maturation could alter neurodevelopmental trajectories, leading to later-life cognitive impairment,” the study concluded.

More recently, a study on the brains of deceased football players also found a link between early play and CTE. Athletes who began playing tackle football before age 12 developed the cognitive and behavior symptoms of CTE 13 years earlier on average than those who started playing later in their teenage years.

“Every one year younger that participants began to play football resulted in earlier reported onset of cognitive and behavioral mood symptoms by approximately 2.5 years,” the study concluded. However, the study did not find an increased amount of physical abnormalities in the brains of athletes who began playing earlier than age 12. Scientists are still working to figure out the exact relationship between physical brain damage and the start of symptoms — and are recognizing that behavior symptoms can occur without detectable physical changes.

Regardless, brain changes are a concern for younger football players. Yet another study found evidence to suggest that college football experience can lead to a decrease in the volume of the hippocampus — a critical region for memory — compared to people who never played college football.

There are many uncertainties left in the research. Another study recently found that participation in tackle football before 12 years of age did not result in any cognitive deficits while in college. So it’s not the case that playing football early will necessarily lead to impairments in early adulthood. And a study of 3,000-plus Wisconsin men who had played high school football in the 1950s found no elevated rates of cognitive impairment. This shows not everyone who plays football as a teen suffers consequences, and researchers still need to better understand how much exposure to football tackles is too much.

6) The NFL has made the game somewhat safer. But it’s still dangerous.

Doug Pensinger/Getty Images

The NFL didn’t acknowledge the concussion problem until 2009; for years, the NFL had downplayed and denied the links between concussions and cognitive decline. (Frontline has a fantastic documentary about how the league turned a blind eye to the problem for years.) And these days, the league is donating millions to concussion-related research.

But there has been significant friction with the scientific community over the issue. In July 2018, the NFL and the National Institutes of Health ended a $30 million partnership with half the money left unspent. According to ESPN, “the NFL backed out of a major study that had been awarded to a researcher who had been critical of the league,” which precipitated the ending of the partnership.

The league has also made some steps to make the game a bit safer. (Read SB Nation for a full explainer on the NFL’s concussion protocols.) Players are immediately removed from the field when there’s a potential concussion. If diagnosed, they can only return to play after completing a five-step protocol, which includes an unspecified period of rest, followed up by supervised exercise, and then examinations not just with the team doctor but also with an independent neurological consultant. Critics, however, have charged that these protocols have been enforced unevenly across teams and players.

Furthermore, the NFL has banned helmet-to-helmet hits, made kickoff plays slightly safer, and limited the amount of contact allowed in practices. It’s also looking into artificial playing surfaces to soften the blow of impacts.

There’s still a lot of research to be done. Scientists are trying to better model what happens inside the brain when the skull is hit. Just “providing good data” is a research priority, Bayly says. “So people can build better simulations, and if people can build better simulations, they can design better helmets.”

But even with better helmets, football might not ever be a perfectly safe sport for brain health. As long as football is a sport where human-to-human collisions are fundamental to play, it’s going to be a dangerous game.

After the scans were complete, the players began playing. During all subsequent practices and games, they wore helmets containing specialized accelerometers that tracked the number and intensity of every head impact and how the athletes’ heads moved when they were hit.

At the end of the season, the researchers gathered the helmet data and re-scanned players’ midbrains. Two of the athletes had sustained concussions; their information was removed.

The other 38 players had not been concussed but had whacked their heads with regularity, their helmets recording a total of 19,128 impacts, some slight and others packing a wallop.

When the researchers next compared the scans and the helmet data, they saw a disconcerting pattern. Most of the players’ midbrains were subtly different. The area’s white matter, which is the tissue that connects neurons, was slightly less healthy now, the scans showed.

“There was a kind of fraying” of the tissue, Dr. Hirad says.

And the players whose heads had absorbed the most hits, especially if those hits involved slightly off-center impacts and head rotations, showed the greatest disruption inside their midbrain’s white matter.

For all of them, Dr. Mahon says, these brain injuries “were clinically silent,” causing no symptoms.

The researchers next scanned the brains of 28 athletes who had been diagnosed with a recent concussion, to check whether the subconcussive brain changes mimicked those seen in these players and found the same pattern of slight disintegration in their midbrains’ white matter.

The finding also underscores the limits of current helmet technology. Football helmets were originally created to reduce skull fractures, and they do a pretty good job at that, says Hirad. But the brute forces that cause a skull fracture are different from the rotational ones that seem to lead to concussions. “Helmets do little to nothing to prevent those sorts of forces,” Hirad says.

A 2013 report released by the Institute of Medicine and National Research Council backs up that claim. It concluded there was “little evidence that current sports helmet designs reduce the risk of concussions,” and that seems unlikely to change. Protective cushioning can help dissipate some of the force, but it can’t eliminate the forces of the impact, Broglio says. “Helmets will be part of the solution, but they will not be the solution.”

Even when technologies sound promising, they often fail to live up to the hype. A device called the Q-Collar applies pressure to the jugular vein with the idea that this will slow blood flow out of the head and increase the blood pressure in head. It’s like “bubble wrap” for your brain, according to the manufacturer. A high school in Moose Jaw, Canada, just mandated that its football players wear the collar.

The product is based on the notion that woodpeckers are able to bang their heads without injury because they have a tongue that wraps around the jugular to increase blood volume in the skull, providing extra cushioning. The collar’s inventor, David Smith, has published research suggesting that concussions are less common at altitude because blood volume in the brain is higher, adding to the idea that more blood in the head means more protection for the brain.

But Smoliga, a physiologist and biomechanist at High Point University, has looked into the claims and found them to be nonsense. Woodpeckers have multiple adaptations for protecting their brains from injury, but occluding their jugular veins is not one of them. Smoliga tried, and failed, to replicate the study of concussions and altitude for more recent football seasons. But using the same methodology he showed that concussion risk was about 30 percent lower in teams with animal mascots versus non-animal mascots. “If you look hard enough for an effect, you’ll find it,” Smoliga says, noting that the original study considered high altitude to begin at 600 feet, a trivial elevation.

Gregory Myer, director of the Human Performance Laboratory at Cincinnati Children’s Hospital Medical Center, has researched the Q-Collar as well. He acknowledges that “we’re still in the early stages of discovery, but I’m excited for the potential paradigm shift of protecting the brain from the inside.” When asked whether he had qualms about marketing an unproven product to kids, he asked, “How many helmets are studied like this before they’re allowed to be worn in play?” (Although his institution gets money from Q-Collar’s maker to fund his research on the device, Myer says he has “no skin in the game.”)

The only surefire way to eliminate concussions from football is to stop bashing players’ heads, and the sport has made some changes to that end. The NFL and USA Football have promoted a program targeted at youth called Heads Up Football, which teaches players to practice tackling by leading with their shoulders and keeping their heads upright. It sounds like a start, but Bachynski says it won’t do much to prevent concussions, because it’s accelerations and decelerations that cause injury, no direct hit required. Critics, like former Denver Broncos player Nate Jackson, have called the Heads Up program a marketing ploy.

The NFL has also banned helmet-to-helmet hits, but Hirad says such hits are only one source of concussions, and not the most common ones. Players can just as easily get a concussion from hitting their heads on another player’s body or on the ground. Will the sport ban those kinds of contacts too? “How many things can you remove from football before you don’t have football?” Hirad says. “I don’t know the answer to that.”

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