Study Tracks Early Symptoms of Traumatic Brain Disease

August 22, 2013

News Review From Harvard Medical School -- Study Tracks Early Symptoms of Traumatic Brain Disease

A new study offers clues to early symptoms of a brain disease linked with head trauma that has affected football players and other athletes. The study focused on chronic traumatic encephalopathy (CTE). This disease causes brain damage that gets worse over time. People with CTE often are depressed and may show impulsive or erratic behavior. The new study included 36 male athletes who had been diagnosed with CTE after death. Their ages when they died ranged from 17 to 98. Most of them had played football as professionals or amateurs. The rest had been involved in hockey, wrestling or boxing. Researchers interviewed their relatives and asked about early symptoms related to thinking or behavior. They found that 22 of the athletes had behavior or mood problems as their first symptoms of CTE. Eleven had memory or thinking problems first. Three had no symptoms up to their time of death. Behavior and mood problems tended to occur at earlier ages, about 35 on average. Memory and thinking problems started around age 59. The journal Neurology published the study online. HealthDay News wrote about it August 21.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

The risks of chronic brain injury during athletic competition have been in the news a lot lately -- for good reason.

Last year's suicide of Junior Seau, a popular former member of the New England Patriots, was big news here in Boston. The tragedy was made even worse by the discovery that he had a preventable brain disease related to his years of playing football.  His depression and eventual suicide were linked to chronic traumatic encephalopathy, or CTE. This is a brain injury caused by repeated head trauma.  Seau was just the latest case that has come to light in recent years.

The most common cause of CTE is the repeated concussions endured by some elite athletes, especially in football and boxing. Increasingly, though, CTE has been recognized to occur after injuries less severe than concussions. Perhaps the most worrisome discovery is that CTE may not be limited to elite athletes. High school and college players may be at risk as well.

What are the first signs of CTE? That's the subject of a study in the latest issue of the medical journal Neurology. Researchers interviewed the families of male athletes who were diagnosed with CTE after death. The diagnosis was made by examining their brains at the time of autopsy. Their ages ranged from 17 to 98. Most played football. Others played ice hockey, wrestled or boxed.

Of the 36 athletes, 3 had no symptoms. For the others, the first sign of CTE was:

• Behavior and mood problems -- This occurred in 22, or 60%, of the former athletes. They tended to be younger than the others, with an average age of 35. Examples of their symptoms included physical or verbal violence, depression or being "out of control."
• Memory and difficulty with thinking -- This was described for 11 study subjects, or about 30%. They tended to be older than the others, with an average age of 59. Symptoms included word-finding problems and loss of memory.

Almost all of those with mood or behavior problems eventually had trouble with memory and thinking. Those with memory and thinking problems at the start developed behavior or mood problems only about 50% to 60% of the time.

This study provides important insights into the symptoms a person with CTE may have. It also points out how easily doctors could make a mistake in diagnosis. For the oldest people in this study who had memory problems, many doctors could have diagnosed Alzheimer's disease or another form of dementia. This study shows that prior head trauma may cause similar symptoms regardless of age.

This study, of course, won't be the last word on the subject. The study was small and subjects were highly selected. The families who decided to take part may have noticed more severe symptoms than families who did not participate. These limitations could have affected what researchers found.

What Changes Can I Make Now? 

Even before the first practice or scrimmage, coaches, athletes and parents need to share information about CTE. These steps are crucial to protect players:

• Know how to identify a concussion. (For more detailed information, see this government website.)
• Make sure safety equipment fits properly and is used in the correct way.
• Emphasize that everyone should protect athletes -- both teammates and opponents -- from serious injury.
• Understand the rules of the sport, especially ones that are intended to protect athletes.
• Limit the number of games and practices for sports in which head injury is most common (such as ice hockey and football).
• If head trauma is common in your sport, have  trained personnel available at athletic events, including practices. It is essential to have on-site, real-time screening for concussion after head trauma.
• Promote laws that require athletes who suffer concussions to be removed from action and not play again until they are cleared by a trained health care professional. Most states already have such laws.

The symptoms of CTE can mimic other common conditions, such as Alzheimer's disease. CTE can only be diagnosed for certain after death, and treatment options are limited. But other conditions, such as an underactive thyroid, can also mimic CTE. So it's important to be evaluated if you have symptoms that suggest CTE, especially if they are new.

Symptoms of CTE include:

• Poor memory
• Poor judgment
• A lack of impulse control
• Aggression
• Depression

What Can I Expect Looking to the Future? 

I think you will see a major effort in the near future to make contact sports safer.  This is already happening.  But some basic questions need to be answered:

• How can safety equipment be improved?
• Who is most at risk for CTE? 
• Can CTE be diagnosed before death?  If so, can treatments be developed that slow or even reverse the brain damage?

Until we have the answers to these questions, more scrutiny will be applied to sports in which head injury is common.  And that will raise the ultimate question for anyone concerned about CTE:  Is playing worth it?