PBS last night aired Frontline: League of Denial, an in-depth look at the NFL's history of concussion and other brain-related injuries (and its seemingly lackluster response to those issues). The hour-plus episode is the result of over 17 months of investigative work, though it's based on a book by ESPN reporters Mark Fainaru-Wada and Steve Fainaru. PBS and ESPN had originally agreed to collaborate on the project, but ESPN abruptly dropped out back in August. The sports network asked that PBS not use its logos or give ESPN any collaborative credit on the program. PBS carried on undeterred with the help of both reporters, finally airing the eye-opening special last night. Frontline paints a troubling portrait of a league that has long been aware of the threat concussions pose to its players, but one that has been relatively slow in addressing the safety crisis.

For their part, Frontline's producers don't seem to be finished with the issue just yet; they've set up a Concussion Watch tracker that's been aggregating head injuries throughout the 2013 NFL season. Safety aside, it's also proven to be an expensive problem for the NFL; earlier this year the league reached a $765 million settlement with 4,500 players who accused the NFL both of not doing enough to protect them, and underplaying the threat of concussions to players and the public at large. Today at 1PM ET, viewers can join a live chat with Frontline producer Mike Wiser, reporters Steve Fainaru and Mark Fainaru-Wada, and Richard Deitsch of Sports Illustrated.

Chronic traumatic encephalopathy (CTE) is a form of encephalopathy that is a progressive degenerative disease, which can only be definitively diagnosed postmortem in individuals with a history of multiple concussions and other forms of head injury. The disease was previously called dementia pugilistica (DP), as it was initially found in those with a history of boxing. CTE has been most commonly found in professional athletes participating in American football, ice hockey, professional wrestling and other contact sports who have experienced repetitive brain trauma. It has also been found in soldiers exposed to a blast or a concussive injury,[1] in both cases resulting in characteristic degeneration of brain tissue and the accumulation of tau protein. Individuals with CTE may show symptoms of dementia, such as memory loss, aggression, confusion and depression, which generally appear years or many decades after the trauma.
Repeated concussions and injuries less serious than concussions ("sub-concussions") incurred during the play of contact sports over a long period can result in CTE. In the case of blast injury, a single exposure to a blast and the subsequent violent movement of the head in the blast wind can cause the condition.

So far, the long-term effects of repeated head injuries in professional football have been hard to pin down. There are a whole host of economic and social reasons for this, but the simple truth is that the scientific research itself just isn’t clear-cut. While some studies have found decreased cognitive function and an increased risk of Alzheimer’s disease in NFL players, others haven’t found strong evidence linking careers in professional football to long-lasting cognitive decline.

The problem, researchers argue, may be “ecological validity.” In other words, the skills and competencies that scientists test may not accurately represent those required in real life. The psychological tests used in laboratory settings are highly controlled and standardized, while real-world situations are much messier. Players with brain injuries might retain enough cognitive control mechanisms to pass lab-based tests yet fail miserably at the complex scenarios they face in everyday life.

A new study in Scientific Reports clears up some of this confusion, using a combination of cognitive tests and neuroimaging to get a better picture of what happens to football players’ brains as a result of repetitive traumatic brain injuries (TBIs).

The study included 13 retired NFL players with no history of psychological problems (two other ex-players also volunteered for the study, but had to be nixed since they couldn’t fit in the fMRI scanner). During their careers, each of these players had been pulled from a game at least once due to a head injury. From a control group of 60 college graduates, 20 were chosen as an age-matched control for these experiments.

First, each participant in the study performed a spatial planning task in which they were shown two different arrangements of colored balls in tubes; their goal was to figure out how many moves it would take to turn the first arrangement into the second one. Essentially, this task tests a person’s working memory and their ability to plan ahead.

As in many previous lab-based tests, the NFL group didn’t perform significantly worse than the control group did. Only in the very hardest problems—those that required four moves—was there a small decrease in the football players’ performance compared to the other participants. But overall, only two out of the 13 ex-NFL players ranked at or below the bottom tenth percentile compared to controls. Clearly, a career in football didn’t necessarily result in failure—or even underperformance—on this task.

However, when the researchers examined fMRI data showing what happened in the participants’ brains as they worked out the solution, they saw stark differences between the two groups. Compared to the control group, the ex-NFL players had decreased functional connectivity between various brain regions. In other words, different parts of the football players’ brains didn’t interact as much as they did in the other participants’ brains. This effect was particularly strong in the frontal lobe, a region involved in planning, organization, and attention. In a measure of frontal lobe connectivity, all but one of the retired players were in the bottom tenth percentile compared to the control group; that’s a much larger effect than what the researchers saw when they simply looked at performance on the task.

So why was there such a discrepancy? How could the players perform decently on the test despite the reduced connectivity?

It turns out that there was another major difference in how the two groups’ brains functioned. Two parts of the football players’ brains were surprisingly active: the dorsolateral prefrontal cortex and the frontopolar cortex, two areas in the frontal lobe. And the harder the problems got, the more active these regions became. In terms of overall activation in the dorsolateral prefrontal cortex, more than half of the players were in the top tenth percentile compared to the control group.

High activity in these areas suggests that the retired football players were devoting extra brain resources to solving the problems, possibly to overcome the effect of decreased connectivity. The control participants, on the other hand, didn’t need to compensate in this way.

Perhaps the most disturbing evidence in this study was the link between the frequency of head injuries and the extent of the player’s brain changes. As a player’s number of career TBIs went up, brain connectivity fell precipitously and frontal lobe activity increased sharply.

Up to a certain point, people with these sorts of injuries may be able to overcome brain injuries and function relatively normally by allowing regions of the frontal lobe to go into overdrive. But as tasks get increasingly complex—or the brain suffers enough damage—this compensation might not be enough to mask cognitive problems.

There are definite drawbacks to the study; the sample size is small, and we’re talking correlation, not causation. Additionally, the researchers didn’t compare activity in TBI-riddled brains with those of NFL players without repeated head injuries. But, as the study says, “NFL alumni are a particularly difficult population to recruit for research studies.”

Although this study doesn’t close the book on the relationship between TBIs, brain damage, and cognition, it suggests a very plausible explanation for the inconsistencies and conflicts in research on football players’ cognition. In the long run, this type of analysis could potentially serve as an early warning sign for players that are on the road to serious cognitive problems. These applications likely extend well beyond the NFL, as well. Soccer players, military veterans, and Parkinson’s patients could also benefit from research that helps us understand how brain abnormalities affect the way we think, act, and perform.

I am seriously torn on letting my son play football ever, and I think pee-wee football is a grossly irresponsible act as a society.

The brain of former Kansas City Chiefs linebacker Jovan Belcher -- the 25-year-old player who shot and killed his girlfriend in 2012 before committing suicide -- showed signs of pervasive brain damage like that found in other deceased NFL players, according to a neuropathologist.

In a report obtained by "Outside the Lines," Dr. Piotr Kozlowski writes that he detected neurofibrillary tangles of tau protein, which is identified with chronic traumatic encephalopathy. The tangles were distributed throughout Belcher's hippocampus, an area of the brain involved with memory, learning and emotion.


Jovan Belcher fatally shot his girlfriend, Kasandra Perkins, multiple times before killing himself at Arrowhead Stadium on Dec. 1, 2012.

Dozens of former NFL players have been diagnosed posthumously with CTE, a neurodegenerative disease linked to dementia, memory loss and depression. The disease, researchers say, is triggered by repeated head trauma.

On Dec. 1, 2012, Belcher shot and killed girlfriend Kasandra Perkins, the mother of his then-3-month-old daughter. Belcher then drove to the Chiefs' practice facility, where he shot himself in front of team officials in the parking lot. While the murder-suicide reignited the debate over athletes and guns, it also increased the focus on a frequently overlooked issue at the time: the NFL's domestic violence problem.

Belcher's body was exhumed one year after his death, and his brain was examined two weeks later. Kozlowski was hired to diagnose the brain by court-appointed Kansas City attorneys who represent the interests of Belcher's daughter. Belcher's mother, Cheryl Shepherd, initiated the process of exhuming her son's body to have his brain studied, attorney Dirk Vandever said.

Vandever declined to comment about why his law firm released Kozlowski's findings now, almost nine months after the diagnosis. "Outside the Lines" requested copies of images of Belcher's brain to send to another neuropathologist for independent analysis, but that request was denied.

Neurosurgeon Dr. Julian Bailes, chairman of the department of neurosurgery and co-director of the NorthShore Neurological Institute in Chicago, did not study Belcher's brain but said of the possible findings: "It is of great interest. Violence against others is not typically part of the CTE picture. But it was in the case of [former professional] wrestler Chris Benoit. It would be nice to have these findings corroborated.

"If correct, they're very compelling."

If it can be shown that Belcher did have CTE, Belcher's daughter and mother, together, would be eligible for up to $4 million under the proposed concussion settlement between the NFL and former players. Furthermore, the lawyers representing Belcher's daughter have filed a wrongful-death lawsuit against the Chiefs on her behalf. Belcher's mother, with different attorneys, filed an almost identical suit.

Among the allegations contained in the lawsuits is that Belcher was knocked unconscious during a game against the Jacksonville Jaguars in 2009 and did not receive adequate treatment. The lawsuits also refer to a November 2012 game against the Cincinnati Bengals when, the lawsuits allege, Belcher "suffered what should have been recognized as an acute concussion." However, one lawsuit continues, "despite exhibiting obvious symptoms, Decedent was never removed from play for evaluation and recovery." The lawsuits also claim Belcher exhibited signs of CTE, including changes in his mood and behavior.

"The NFL has a long history of a changing the rules of the game to make it safer on the field, providing players the best medical care, and updating protocols on diagnosing concussions, treating concussions, and returning to play after a concussion," the league said in a statement.

The NFL said it has funded $161 million in CTE and related research projects, including a $30 million grant to the National Institutes of Health in 2012.

The Chiefs declined to comment.

Kozlowski, through Vandever, was not made available for comment. According to the American Board of Pathology, he is certified in anatomic pathology and neuropathology. He was formerly a program director at the National Institutes of Health Institute for Neurological Disorders and Stroke in Maryland. Kozlowski serves as the dean of research and pathology professor at the Touro College of Osteopathic Medicine in New York City.

Vandever said Belcher's mother had the idea of having her son's brain studied after reading multiple reports about football players and CTE. He declined to discuss why Kozlowski was chosen as opposed to researchers who are more experienced in the study of CTE and football players -- those from Boston University and the NIH, for example.

As for Belcher's brain being examined slightly more than a year after his death, Kozlowski's report refers to some brain decomposition, with certain parts better preserved than others. Bailes said it is possible to find evidence of tau protein and CTE-like changes a year after a death.

Bailes, who has studied the connection between football players and head injuries, worked on the case of Andre Waters, a former Philadelphia Eagles safety who committed suicide by shooting himself in the head. "Even in this case of a gunshot wound to his brain, it was possible to diagnose him with CTE," Bailes said of Waters.

A total of 87 out of 91 former NFL players have tested positive for the brain disease at the center of the debate over concussions in football, according to new figures from the nation’s largest brain bank focused on the study of traumatic head injury.

Researchers with the Department of Veterans Affairs and Boston University have now identified the degenerative disease known as chronic traumatic encephalopathy, or CTE, in 96 percent of NFL players that they’ve examined and in 79 percent of all football players. The disease is widely believed to stem from repetitive trauma to the head, and can lead to conditions such as memory loss, depression and dementia.

In total, the lab has found CTE in the brain tissue in 131 out of 165 individuals who, before their deaths, played football either professionally, semi-professionally, in college or in high school.

Forty percent of those who tested positive were the offensive and defensive linemen who come into contact with one another on every play of a game, according to numbers shared by the brain bank with FRONTLINE. That finding supports past research suggesting that it’s the repeat, more minor head trauma that occurs regularly in football that may pose the greatest risk to players, as opposed to just the sometimes violent collisions that cause concussions.

But the figures come with several important caveats, as testing for the disease can be an imperfect process. Brain scans have been used to identify signs of CTE in living players, but the disease can only be definitively identified posthumously. As such, many of the players who have donated their brains for testing suspected that they had the disease while still alive, leaving researchers with a skewed population to work with.

Even with those caveats, the latest numbers are “remarkably consistent” with past research from the center suggesting a link between football and long-term brain disease, said Dr. Ann McKee, the facility’s director and chief of neuropathology at the VA Boston Healthcare System.

“People think that we’re blowing this out of proportion, that this is a very rare disease and that we’re sensationalizing it,” said McKee, who runs the lab as part of a collaboration between the VA and BU. “My response is that where I sit, this is a very real disease. We have had no problem identifying it in hundreds of players.”

In a statement, a spokesman for the NFL said, “We are dedicated to making football safer and continue to take steps to protect players, including rule changes, advanced sideline technology, and expanded medical resources. We continue to make significant investments in independent research through our gifts to Boston University, the [National Institutes of Health] and other efforts to accelerate the science and understanding of these issues.”

The latest update from the brain bank, which in 2010 received a $1 million research grant from the NFL, comes at a time when the league is able to boast measurable progress in reducing head injuries. In its 2015 Health & Safety Report, the NFL said that concussions in regular season games fell 35 percent over the past two seasons, from 173 in 2012 to 112 last season. A separate analysis by FRONTLINE that factors in concussions reported by teams during the preseason and the playoffs shows a smaller decrease of 28 percent.

Off the field, the league has revised safety rules to minimize head-to-head hits, and invested millions into research. In April, it also won final approval for a potential $1 billion settlement with roughly 5,000 former players who have sued it over past head injuries.

Still, at the start of a new season of play, the NFL once again finds itself grappling to turn the page on the central argument in the class-action lawsuit: that for years it sought to conceal a link between football and long-term brain disease.

The latest challenge to that effort came two weeks ago with the trailer for a forthcoming Hollywood film about the neuropathologist who first discovered CTE. When the trailer was released, it quickly went viral, leaving the NFL bracing for a new round of scrutiny over past efforts to deny any such connection.

The film, Concussion, starring Will Smith, traces the story of Bennet Omalu, who in 2005 shocked the football establishment with an article in the journal Neurosurgery detailing his discovery of CTE in the brain of former Pittsburgh Steelers center Mike Webster. At the VA lab and elsewhere, CTE has since been found in players such as Hall of Famer Junior Seau, former NFL Man of the Year Dave Duerson, and Colts tight end John Mackey, a past head of the player’s union.

While the story is not a new one, for the NFL, it represents a high-profile and potentially embarrassing cinematic interpretation of a period in which the league sought to refute research suggesting football may contribute to brain disease.

From 2003 to 2009, for example, the NFL’s now disbanded Mild Traumatic Brain Injury Committee concluded in a series of scientific papers that “no NFL player” had experienced chronic brain damage from repeat concussions, and that “Professional football players do not sustain frequent repetitive blows to the brain on a regular basis.”

In the case of Omalu, league doctors publicly assailed his research, and in a rare move, demanded a retraction of his study. When Omalu spoke to FRONTLINE about the incident for the 2013 documentary, League of Denial: The NFL’s Concussion Crisis, he said, “You can’t go against the NFL. They’ll squash you.”

In a conversation with FRONTLINE, McKee said that her biggest challenge remains “convincing people this is an actual disease.” Whatever pockets of resistance still exist, she said, have primarily come from those with a “vested interest” in football.

“People want to make this just Alzheimer’s disease or aging and not really a disease,” according to McKee. “I think there’s fewer of those people, but that’s still one of our major hurdles.”

For the last 13 years, the N.F.L. has stood by the research, which, the papers stated, was based on a full accounting of all concussions diagnosed by team physicians from 1996 through 2001. But confidential data obtained by The Times shows that more than 100 diagnosed concussions were omitted from the studies — including some severe injuries to stars like quarterbacks Steve Young and Troy Aikman. The committee then calculated the rates of concussions using the incomplete data, making them appear less frequent than they actually were.

...

These discoveries raise new questions about the validity of the committee’s findings, published in 13 peer-reviewed articles and held up by the league as scientific evidence that brain injuries did not cause long-term harm to its players.

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Some retired players have likened the N.F.L.’s handling of its health crisis to that of the tobacco industry, which was notorious for using questionable science to play down the dangers of cigarettes.

Concussions can hardly be equated with smoking, which kills 1,300 people a day in the United States, and The Times has found no direct evidence that the league took its strategy from Big Tobacco. But records show a long relationship between two businesses with little in common beyond the health risks associated with their products.

In a letter to The Times, a lawyer for the league said, “The N.F.L. is not the tobacco industry; it had no connection to the tobacco industry,” which he called “perhaps the most odious industry in American history.”

Still, the records show that the two businesses shared lobbyists, lawyers and consultants. Personal correspondence underscored their friendships, including dinner invitations and a request for lobbying advice.

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“One of the rules of science is that you need to have impeccable data collection procedures,” said Bill Barr, a neuropsychologist who once worked for the Jets and who has in the past criticized the committee’s work.

By excluding so many concussions, Mr. Barr said, “You’re not doing science here; you are putting forth some idea that you already have.”

AROUND THE WEB:

-- Roger Goodell was at the Jets facility on Monday and answered questions from fans at a forumwith the team’s rookie safety Jamal Adams.

While talking about improvements to player safety, the NFL commissioner downplayed the link between football and degenerative brain disease from concussions.

“The average NFL player lives five years longer than you,” Goodell said. “So their lifespan is actually longer and healthier. And I think because of all the advancements, including the medical care, that number is going to even increase for them.”

A recent study revealed 110 of 111 brains donated by NFL players showed signs of CTE.

“I think the one thing everyone agrees on is there’s an awful lot more questions than there are answers at this point,” Goodell said.

Adams sat right beside Goodell during the forum and said he is willing to lose his life on the football field.

“Literally, I would — if I had a perfect place to die, I would die on the field,” Adams said. “And that’s not a lie. There’s so much sacrifice that we go through as a team, and just connecting as one and winning ballgames. There’s nothing like playing the game of football. But again, I’m all about making the game safer, that’s all I can say.
Goodell showed no emotion as Adams said this, but addressed the comments with the media after the forum.

“What he was really making the point of is how much he loves the game and how passionate he is of the game — that he loves playing it, and it’s just something that means a great deal to him,” Goodell said. “I think the fans understood the emotion of what he was saying.”

This comes just days after the NFL and National Institute of Health decided to end their brain research partnership.