CTE Must read

[WisNeuro]

For everyone in clinical practice who sees patients with TBI's and concussions (I'm looking at you VA psychologists) this is a must read. Especially with all the garbage out there in mainstream media.


Neuropsychol Rev. 2013 Dec;23(4):350-60. doi: 10.1007/s11065-013-9243-4. Epub 2013 Nov 22.
Modern Chronic Traumatic Encephalopathy in Retired Athletes: What is the Evidence?
Karantzoulis S, Randolph C.
Author information
Abstract
It has been theorized that a career in contact sports may be associated with long-term neurodegenerative changes. This idea dates as far back as the 1920s, was initially reported in boxers, colloquially termed 'punch drunk,' later more formally termed dementia pugilistica (DP), and now coined chronic traumatic encephalopathy (CTE). Despite considerable ongoing interest on this topic, there is so far only limited evidence showing an association between sport-related concussion (SRC) and increased risk for late-life cognitive and neuropsychiatric impairment, with no causality or risk factors yet determined. The modern CTE description is nevertheless proposed as a unique tauopathy with characteristic pathological stages occurring in retired athletes who have experienced previous repetitive brain trauma. This review highlights the principal issues that so far preclude firm conclusions about the association of athletic head trauma and neurodegenerative diseases of any type. We consider alternative interpretations that may contribute to the clinical progressive neurological findings in some athletes and recommend carefully-controlled epidemiological work to overcome current limitations in this area of research and stimulate future research.

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[erg923]

For everyone in clinical practice who sees patients with TBI's and concussions (I'm looking at you VA psychologists) this is a must read. Especially with all the garbage out there in mainstream media.


Neuropsychol Rev. 2013 Dec;23(4):350-60. doi: 10.1007/s11065-013-9243-4. Epub 2013 Nov 22.
Modern Chronic Traumatic Encephalopathy in Retired Athletes: What is the Evidence?
Karantzoulis S, Randolph C.
Author information
Abstract
It has been theorized that a career in contact sports may be associated with long-term neurodegenerative changes. This idea dates as far back as the 1920s, was initially reported in boxers, colloquially termed 'punch drunk,' later more formally termed dementia pugilistica (DP), and now coined chronic traumatic encephalopathy (CTE). Despite considerable ongoing interest on this topic, there is so far only limited evidence showing an association between sport-related concussion (SRC) and increased risk for late-life cognitive and neuropsychiatric impairment, with no causality or risk factors yet determined. The modern CTE description is nevertheless proposed as a unique tauopathy with characteristic pathological stages occurring in retired athletes who have experienced previous repetitive brain trauma. This review highlights the principal issues that so far preclude firm conclusions about the association of athletic head trauma and neurodegenerative diseases of any type. We consider alternative interpretations that may contribute to the clinical progressive neurological findings in some athletes and recommend carefully-controlled epidemiological work to overcome current limitations in this area of research and stimulate future research.

Its a shame that Frontline subtley framed that champions for well controlled scienntific research as some sort of money hungry NFL guard dog....

 

[WisNeuro]

People will follow the money. Frontline knows how to drive viewership. Just how some ethically bankrupt scientists know how to get grant money and media attention.

 

[Therapist4Chnge]

Great thread.

This topic is only going to grow, which may or may not be good for those of us who work in this area. I'd guess 40-50% of my current out-pt practice involves concussion & PCS....and the invention...errr....emergence of CTE is further muddying the waters.

 

[WisNeuro]

Yeah, the emergence of PCS borne from methodologically flawed data was not a good day for the clinical neurosciences. This is why people need a good understanding of research and stats in the clinical world, otherwise they buy into the PCS and CTE swill.

 

[Therapist4Chnge]

Yeah, the emergence of PCS borne from methodologically flawed data was not a good day for the clinical neurosciences. This is why people need a good understanding of research and stats in the clinical world, otherwise they buy into the PCS and CTE swill.

You can guess the number of actual PCS cases I diagnose....

 

[WisNeuro]

You can guess the number of actual PCS cases I diagnose....

Is it a nice round #?

 

[Rivi]

Thanks for posting this article. Here is what I gather on the limitations of the research on CTE:

1. There are too few cases, too many extraneous variables (i.e., dementia, substance abuse, depression) and too much variability amongst existing cases to establish a reliable diagnostic category and profile of CTE.
2. Inconsistent symptoms and neuropathology amongst "pure" CTE cases
3. No controls used with a lot of the CTE studies; Tau protein can be found in a variety of other conditions, including normal aging (according to the article), and shouldn't necessarily be considered a telltale sign of CTE.
4. No clear link between the accumulation of Tau protein and the severity of symptoms that people are describing, although this is consistent with other types of dementia (i.e., Lewy Bodies).

My concerns:

I get that the media has run away with this one. I still think the preliminary data is concerning. CTE may not be a unique neurodegenerative disease, but it seems plausible that the repeated concussions may put you at a higher risk for dementia, mild cognitive decline, etc.

 

[WisNeuro]

I get that the media has run away with this one. I still think the preliminary data is concerning. CTE may not be a unique neurodegenerative disease, but it seems plausible that the repeated concussions may put you at a higher risk for dementia, mild cognitive decline, etc.

What preliminary data though? There's not much out there with good methodology to support that view. If anything, epidemiological studies show that NFL retirees live longer, are healthier, and have lower rates of suicide when compared to the general population. Seems to argue against this notion that a few concussions will lead you down a drug addles path and early death by suicide that some would like you to believe.

Now, I'm all for examining the consequences of concussions further by all means. Let's just do it with good science and realistic interpretations of the data. We don't need an epidemic of iatrogenesis here.

 

[IT514]

I think we're close to an epidemic of iatrogenesis, if not already there given what I see from PCPs, neurologists, OT/PT/SLPs, etc, and even some neuropsychologists who clearly dont have a good scientist background or have a clue about somatization in clinical practice. The media ecology around this stuff is interesting and no doubt plays a part, but what I see from the professional side looks like a systematic misunderstanding. If I could, I would give a copy of McCrea's book on mTBI to every person on this planet.

 

[WisNeuro]

I think we're close to an epidemic of iatrogenesis, if not already there given what I see from PCPs, neurologists, OT/PT/SLPs, etc, and even some neuropsychologists who clearly dont have a good scientist background or have a clue about somatization in clinical practice. The media ecology around this stuff is interesting and no doubt plays a part, but what I see from the professional side looks like a systematic misunderstanding. If I could, I would give a copy of McCrea's book on mTBI to every person on this planet.

I would agree. I've seen the "CTE" phrase in some medical charts by providers in ludicrous circumstances. For example, after a minor incident in which there was no LOC, no PTA, reported disorientation for ~5 minutes, an MD was saying that CTE explained the subjective cognitive complaints in a 40-ish year old patient. Absolutely ridiculous. Oh yeah, we tested them and they were below chance on the WMT, but average on CVLT LD.

 

[erg923]

Do you guys have reviews of the frontline episode from a couple months back?

 

[WisNeuro]

Do you guys have reviews of the frontline episode from a couple months back?

League of Denial? Haven't personally seen it. But colleagues of mine say that it does a poor job of looking at both sides of the issue, instead playing up the prevailing media sensationalism.

 

[IT514]

Do you guys have reviews of the frontline episode from a couple months back?

No, but it sure made vacation with my family interesting when it was brought up and I was looked to for an opinion. I should have kept quiet, because based on my response, I was placed in in one of two categories: stupid ignorance or evil empire. I went on to remind them that I've had at least five concussions, two with LOC (one football, one karate), and they better treat me nice before I come down with the old CTE bug.

 

[AcronymAllergy]

I think we're close to an epidemic of iatrogenesis, if not already there given what I see from PCPs, neurologists, OT/PT/SLPs, etc, and even some neuropsychologists who clearly dont have a good scientist background or have a clue about somatization in clinical practice. The media ecology around this stuff is interesting and no doubt plays a part, but what I see from the professional side looks like a systematic misunderstanding. If I could, I would give a copy of McCrea's book on mTBI to every person on this planet.

McCrea's book was pretty darn good, yep. Should be required reading for anyone working in mild TBI.

 

[researchgirl]

I want to preface this by saying I have very little background on this topic. However, I'm in a neuropsychology practicum right now and my supervisor and I were talking about this recently. Have researchers considered that, although they may be unwilling to admit to it, it is likely that most of these former pro athletes also took some sort of PEDs or had other lifestyle abnormalities that may explain differences in their brain structure or the way they age in general?

 

[WisNeuro]

I want to preface this by saying I have very little background on this topic. However, I'm in a neuropsychology practicum right now and my supervisor and I were talking about this recently. Have researchers considered that, although they may be unwilling to admit to it, it is likely that most of these former pro athletes also took some sort of PEDs or had other lifestyle abnormalities that may explain differences in their brain structure or the way they age in general?

I'm not aware of common PED's causing significant neural damage. As for lifestyle abnormalities, many of the suicides being touted as CTE cases had long-standing histories of alcohol and drug abuse. You always have to consider the mechanism of action in any explanation.

 

[AcronymAllergy]

I'm not aware of common PED's causing significant neural damage. As for lifestyle abnormalities, many of the suicides being touted as CTE cases had long-standing histories of alcohol and drug abuse. You always have to consider the mechanism of action in any explanation.

Yep. Athletes of course aren't immune to psychological distress/disorder. Quite the contrary, given the life and work circumstances many of those folks are exposed to and grow up with.

 

[WisNeuro]

Pretty good recent article sent through the Npsych listerv today

http://www.research.va.gov/currents...m_source=HP&utm_medium=EB&utm_campaign=June15

 

[Therapist4Chnge]

Is it a nice round #?

Why yes...it is a nice round number.

 

[PsyDr]

I've been banging my head against my desk when these cases come by: do I have cte? Since I am self employed can I sue myself ?

 

[WisNeuro]

CTE is the biggest fraud of the oughts by far at the moment.

 

[AcronymAllergy]

I've been banging my head against my desk when these cases come by: do I have cte? Since I am self employed can I sue myself ?

Agreed. Although honestly, I can't blame a lot of the folks I see who're worried about CTE. Sure, a chunk who come in may just be full of it, but for the rest, when you've had even PCPs and neurologists tell you in the past that "you're never going to be the same" after a mild concussion, and Googling "head injury" pulls up a million "references" talking about how just a fall is supposedly linked to everything from Alzheimer's disease to genetic diseases in your children, the iatrogenic effects are huge.

This is also why I hate, hate, hate seeing "neuropsychologists" without proper training conducting evals in this context. Just the other day, I read a report from an outside provider that linked a person's recent-onset potential cognitive "decline" (which by itself was debatable) and possible "early-onset dementia" to PTSD, a remote (i.e., 20+ years ago) history of a handful of possible concussions, and "toxin exposure" (again, debatable). The poor patient had been getting progressively more anxious over the 3 or 4 years since that eval because he was worried that he was developing brain damage-induced dementia, and has subsequently become increasingly hypervigilant about every single little cognitive slip. Which also caused him to likely discount possible effects from obesity, diabetes, HTN, HLD, etc., until very recently because hey, "you can't cure brain damage."

Arrrrggggh.

 

[WisNeuro]

There's a lot to be said about iatrogenesis. We have great data available about expectations after concussions and head injuries. Outcomes will tend towards how providers tell them they will be. Doesn't help with the media hysteria and misinformation. Take this little snippet from the Brain Injury Association of America on the recent NFL ruling

"A single concussion, whether diagnosed or not, is capable of generating debilitating physical, cognitive and behavioral impairments that interfere with the activities of
daily living and require treatment throughout the lifespan."

Honestly, someone should bring a class action against the BIAA and other organizations that spout this nonsense for the iatrogenic damage they are perpetrating. It's disgusting.

 

[PsyDr]

I think there's a lot of people trying to avoid dealing with the fallout from a narcissistic injury by "biologizing" one's short comings. You are not the worlds best professional/student/etc because you had a concussion. Instead of: you are of average intelligence, have self induced risk factors for dementia/impaired cognition, you need some therapy for anxiety, you didn't plan your career or retirement well, you are just getting older, etc.

 

[AcronymAllergy]

I think there's a lot of people trying to avoid dealing with the fallout from a narcissistic injury by "biologizing" one's short comings. You are not the worlds best professional/student/etc because you had a concussion. Instead of: you are of average intelligence, have self induced risk factors for dementia/impaired cognition, you need some therapy for anxiety, you didn't plan your career or retirement well, you are just getting older, etc.

Agreed; I was actually just talking to a psychiatrist colleague about this a few days ago. When "it's the brain injury's fault" is the automatic response, it basically absolves one of all responsibility both for the consequences of actions and for needing to take any steps to change (because, again, "you can't cure a brain injury").

This is one reason why in my feedback for any assessment, after discussing the results and expected course (e.g., full recovery in mTBI), I focus almost exclusively on "what you can do to get better," or to at least improve QoL and, possibly, functioning (even in the presence of likely permanent or degenerative impairments).

 

[Chalupacabra]

I think a lot of the problem with public perception is that CTE is an idea that has a lot of face validity to laypeople, particularly those who don't understand the whole bit about correlation not equaling causation and the importance of recognizing confounding variables - getting hit in the head is bad, and if it happens a lot it make sense it would have serious long-term consequences, right? And of course there's the problem of journalists who try to dabble and consider themselves an expert in everything from psychology to statistics to the law to geological science - hence why yesterday I saw reports drawing diametrically opposed conclusions about the EPA report on fracking, and there were similar outcomes when the supreme court ruled on the ACA a few years ago. Mainstream journalism seems to have some sort of allergy to nuanced reporting a lot of the time, an allergic reaction that seems to increase in severity relative to how complex of an issue is being covered.

 

[psych844]

s - getting hit in the head is bad, and if it happens a lot it make sense it would have serious long-term consequences, right?

"Makes sense" is also a problem. I'm not talking about psychology specifically, but in a lot of science, especially physics, a lot of the findings are totally counter-intuitive and they are not "logical". Maybe we just give the benefit of the doubt too often, or use "common sense" too often, when we should just let the facts speak.

 

[AcronymAllergy]

"Makes sense" is also a problem. I'm not talking about psychology specifically, but in a lot of science, especially physics, a lot of the findings are totally counter-intuitive and they are not "logical". Maybe we just give the benefit of the doubt too often, or use "common sense" too often, when we should just let the facts speak.

I don't think the poster was speaking to psychologists' views (although I've certainly spoken with my fair share of psychologists who think that CTE = universally agreed-upon and well-defined diagnosis, and that one concussion = definite CTE = likelihood of permanent disability), but rather that the concept seems to inherently "make sense" to the lay public. Thus why it's so pernicious and misunderstood.

 

[Therapist4Chnge]

This is one reason why in my feedback for any assessment, after discussing the results and expected course (e.g., full recovery in mTBI), I focus almost exclusively on "what you can do to get better," or to at least improve QoL and, possibly, functioning (even in the presence of likely permanent or degenerative impairments).

This is where rehab psych training/model works great. I teach my residents and fellows to "focus on function" when the pt is defensive about the psych stuff. After more of a rapport is established (w their therapists and psychologist), then the psych stuff can be broached in terms of "stress" and "worry" instead of depression and anxiety.

I'd rather get some positive momentum and build trust (through my recs) than have the pt. get stuck in a rut and dig in even more. The results have been very positive, as I return nearly 3x as many of my (workers' compensation) pts to work than the state average.

 

[Chalupacabra]

I don't think the poster was speaking to psychologists' views (although I've certainly spoken with my fair share of psychologists who think that CTE = universally agreed-upon and well-defined diagnosis, and that one concussion = definite CTE = likelihood of permanent disability), but rather that the concept seems to inherently "make sense" to the lay public. Thus why it's so pernicious and misunderstood.

Precisely.

 

[Justanothergrad]

I don't think the poster was speaking to psychologists' views (although I've certainly spoken with my fair share of psychologists who think that CTE = universally agreed-upon and well-defined diagnosis, and that one concussion = definite CTE = likelihood of permanent disability), but rather that the concept seems to inherently "make sense" to the lay public. Thus why it's so pernicious and misunderstood.

I imagine there is a trend towards evaluation of athletic head injuries much as there is for PTSD/TBI evaluations at the VA. We assume and look for excuses to list them even when no experience justifies the conclusion. I've seen primary support for traumatic head injuries listed as things like "was hit in the head during a fight as a kid" on so many evaluations that it hurts- even when there is no problem with function. It more than baffles me because its not merely the lay public that tends to rely on the 'makes sense' approach to diagnosis.

 

[smalltownpsych]

I was going to be a psychologist, but my high school football career ended that dream. Too many knocks on the head.
Seriously though, I always get frustrated when they interview lay people or even medical people without any specific knowledge of a topic and they begin spouting "science" in the mass media. It is especially bad when I see this done by fellow psychologists. I, for one, have always doubted the popular inferential link between degenerative brain injuries and history of concussions. The most famous would be Ali and Parkinsons. It is not my area of expertise so I actually have no idea if there is or is not any type of link, but I always question "common sense" and n=1 extrapolations. That's why I am a psychologist despite my sports career. Well, career might be a tiny bit of an exaggeration, although I did get woozy a few times from some head-ons with fullbacks and I did date a few cheerleaders.