Monthly Archives: February 2013

Serious Questions Raised about the Management and Prevention of CTE in Sports

(The Editor’s Note: The following excerpt comes from an article written by Michael J. Perrotti, Ph.D., a concussion expert and frequent contributor to Concussion Litigation Reporter. The full article, as well as several other relevant articles (,  appears in the February issue of the Reporter.)

Recently the examination of the brain of Junior Seau revealed the diagnosis of chronic traumatic encephalopathy, or CTE. This diagnosis underlines the seriousness not only of repetitive brain trauma in professional sports and in military populations, but also raises continuing serious questions about the management and prevention of CTE in sports.

Introduction to Concepts: CTE, originally termed dementia pugilistica, is associated with memory disturbance, neurobehavioral disturbance, parkinsonism, and motor and speech abnormalities.

There has been increasing attention to neurological sequelae of concussive injuries in sports. While one has heard frequently of individuals having a “concussion” and then returning to play after the “concussion,” what is not realized is that players, as McKee et al. (2009) note, may experience thousands of subconcussive hits over the course of a single season. These are cumulative, and repetitive head trauma is applicable to athletes and military veterans.

Clinical Pathology: CTE was first introduced by Martland in 1928, who introduced the term “punch drunk” to a symptom complex related to repeated blows to the head. Symptoms of CTE are firstly deteriorations in functions of attention, concentration, and mnemic functions as well as disorientation and confusion occasionally accompanied by dizziness and headaches. Junior Seau frequently complained of headaches to peers. With progressive deterioration, additional symptoms, such as lack of insight, poor judgment, and dementia, become manifest. Severe cases are related to progressive slowing of muscular movements, gait disturbance, and speech disturbance. Corsellis et al. describe three stages of clinical deterioration. The first stage is characterized by affective disturbance and psychotic symptoms. Social instability, erratic behavior, memory loss, and initial symptoms of Parkinson’s appear during the second stage. The third stage consists of general cognitive dysfunction progressing to dementia and often accompanied by full-blown parkinsonism as well as speech and gait abnormalities.

Incidence: It is estimated that, in cases of repetitive concussion, there is mild traumatic brain injury (MTBI). At least 17% of these individuals develop CTE. Moreover, 1.6 to 3.8 million sports-related concussions occur annually in the U.S.

Prevention and Treatment: Of course, the most direct way to manage CTE and decrease incidents is to decrease the number of concussions or mild traumatic brain injuries by limiting exposure to trauma. The NFL is making some attempts at this, such as a second look at run backs after kickoffs as well as prescriptions against, or mandates against, helmet-to-helmet contact. However, from the players’ point of view, they are vocal in asking for independent medical personnel or independent health-care providers on the sidelines to make decisions about “concussions.”

Asymptomatic individuals have been shown to have persistent decreases in P300 amplitudes in response to an auditory stimulus at least five weeks after a concussion thereby casting doubt on the validity of the absence of symptoms as a guidepost. Neuropsychological tests have also helped provide estimates as to the appropriate time for athletes to return to play.

McKee et al. (2009) note that PET (positron emission tomography),,DTI (diffusion tensor imaging), and MRI (magnetic resonance imaging) studies have all shown abnormalities in concussed athletes or non-athletes with TBI lasting for two to four weeks. Thus, these studies indicate safe return-to-play guidelines might require at least four to six weeks to facilitate more complex recovery and protect from reinjury as a second concussion occurs much more frequently in the immediate period after a concussion. Animal studies note that there is expansion of brain injury and inhibition of functional recovery if the animal is subjected to overactivity within the first week.

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NATA Zeros in on Concussions with National Action Plan for Sports Safety

The National Athletic Trainers’ Association (NATA) made concussions a primary focus at the 4th annual Youth Sports Safety Summit in Washington, DC earlier this week

NATA, which organized the event, worked with other entities to prepare the first-ever “National Action Plan for Sports Safety,” which touches on four major areas—Cardiac Events, Neurologic Injuries, Environmental/Exertional Conditions, and Dietary/Substance-Induced Conditions.

NATA President Jim Thornton, MA, ATC, CES, suggested that events in the aforementioned areas “can be largely prevented, managed and treated if the right protocols are in place, and properly trained medical personnel including athletic trainers are available to provide immediate care. Only 42 percent of U.S. secondary schools have access to athletic trainers.”

The recommendations pertaining to each of those areas can be viewed here:

The emphasis on concussions was evident on the roster of speakers. Among those in the field were: Charles Gfeller, Esq. who addressed risk management for schools and recommended sports safety protocols; Kevin Guskiewicz, PhD, ATC, of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, University of North Carolina, Chapel Hill, who addressed the changing culture of play; and Chris Nowinski, Sports Legacy Institute, who talked about his experience with and perspective on concussions.

NATA has been active in other ways on the concussion front as well. In December, the association and the NATA Research & Education Foundation announced their participation and partial funding of the Consensus Study of Sports-related Concussions in Youth, which is being conducted by the Institute of Medicine.

The 15-member IOM Committee on Sports-Related Concussion in Youth was recently formed to study concussions in youth, from elementary school through young adulthood, including military personnel and their dependents. The final statement is expected to be issued in December 2013.

“There has been continued public awareness, media attention and medical research dedicated to head-related injuries and the acute and chronic effects from concussion,” says NATA Foundation President Mark Hoffman, PhD, ATC. “NATA and the NATA Foundation are honored to be a part of this esteemed team of experts through our $50,000 sponsorship and our submission of names of secondary school colleagues and researchers who will serve as resources to the working group.” The NATA Foundation is the only non-governmental sponsor of the consensus study.

Tracey Covassin, PhD, ATC, associate professor at Michigan State University and a leading concussion researcher, will serve on the committee and as the voice of the athletic training profession.

The committee will review current literature on concussions, their causes and the relationship of hits to the head during sport, effectiveness of protective devices and equipment, screening and diagnosis, prevention, management and treatment. Specific topics of interest include:

  • The short and longer-term effects of single and repetitive concussive and non-concussive head impacts on the brain.
  • Risk factors for sports concussion, post-concussive syndrome and chronic traumatic encephalopathy.
  • The spectrum of cognitive, affective and behavioral changes that can occur as a result of head injuries.
  • Physical and biological triggers and threshold for injury.
  • Hospital and non-hospital diagnostic tools.
  • Biomechanics of head injury and the effects of selected helmet designs.
  • The work of public health agencies, professional sports associations and state legislatures to promote awareness of the risks and consequences of concussive injury, return to play decisions and the increased use of neurological tests for diagnostic purposes.

Dates and agendas for future open sessions of the committee will be posted online at Visitors to the site are encouraged to click the “Sign Up Now” button on the right hand side of the page to join the project list serv.

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Experts See NCAA as Vulnerable to Concussion Litigation

In an article that appeared in the Washington Times earlier this week, two experts (one in the field of concussions and another in the area of sports law) expressed the opinion that the NCAA may be vulnerable to lawsuits from former student athletes.

The article touched on the Arrington lawsuit against the NCAA, written about extensively in Concussion Litigation Reporter and the steps, or lack of steps being taken by the NCAA to address the concussion issue, according to Chris Nowinski, a former Harvard football player and executive director of the Sports Legacy Institute, which studies head injuries in athletes

“I think the gap is widening between what the NFL is doing and what the NCAA is doing,” he said. “There is money being made and the players have no voice in protecting themselves.”

Later in the Article, Marc Edelman, a sports law professor at Barry University School of Law, shared his thoughts about whether the NCAA litigation has a greater possibility of success in comparison with the NFL litigation.

“In time, all of this is going to change,” he said. “The case against the NCAA, given the organization’s unique position created to protect student athletes from head injuries, is going to make the case against the NCAA far stronger than the case against the NFL.”

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