In Wake of Duerson Case, 5 Questions About Football and Brain Injury

Former Chicago Bears safety Dave Duerson, number 22, hits a receiver during a game at Chicago’s Soldier Field on Sept. 2, 1984.

Just before he took his life this winter, former football great David Duerson sent a text message to his ex-wife — and wrote a suicide note as well — that would call attention once again to some big questions surrounding football and the possibility of permanent brain injury among some players.

“Please see that my brain is given to the NFL’s brain bank,” it read.

Duerson’s suicide note. Photo by Marc Serota/The New York Times/Redux

The full reasons for Duerson’s suicide will always be unknown. But the connection between hard hits in football and brain trauma returned to the spotlight last week after doctors confirmed that Duerson was indeed suffering from chronic traumatic encephalopathy, or C.T.E., at the time of his death.

Dave Duerson and his ex-wife, Alicia

Duerson killed himself in February, opting for a gunshot to his chest rather than his head so as to preserve his brain for future research on the neurological disease. His tragic death makes him probably the most well-known former player to date to be diagnosed with C.T.E. posthumously.

It also prompted us to take a moment to update what’s understood about the illness and how the sport itself is responding to a problem that has gained greater recognition since Ray Suarez first reported on it for us in 2009.

To do that, we checked in with a few prominent voices in this story including: Dr. Ann McKee, a neuropathologist who diagnosed Duerson and other players and is the co-director of the Boston University Center for the Study of Traumatic Encephalopathy; Alan Schwarz of the New York Times, who was nominated for a Pulitzer Prize for his persistent and dogged work on the subject; and Greg Aiello, a spokesman for the NFL.

We asked them to weigh in on five questions:

1) WHY IS THE DAVE DUERSON CASE RESONATING?

In some ways, Duerson’s story parallels that of other former players who grappled with C.T.E., particularly with some of the symptoms. But his story has become an especially notable one because he may be the most high-profile player for a recent generation of fans: He was a four-time Pro Bowl safety who played for 11 seasons in the NFL. And he was a well-liked player on two Super Bowl-winning teams: the 1986 Chicago Bears and the 1990 New York Giants.

Shown at right with his father when he was a younger man, Duerson was just 50 years old when he died.

“He never said to anyone, I think I have C.T.E. But the fact that he self-referred himself (to have his brain examined after his death) is very significant,” McKee told us. “He had read the reports about C.T.E. and he was concerned. He was more volatile, he was having memory problems, also some visual problems.”

“Presumably, he suspected that he had the disease,” Schwarz said. “He’s the first player to kill himself with those suspicions. That’s very alarming.”

“It seems likely that the symptoms he was experiencing prior to death could be explained by lesions of his brain,” said McKee, who runs the center’s brain bank, located at the Veterans Affairs Medical Center in Bedford, Mass. “He showed advanced pathology in the structures of the brain that influence mood, memory, impulse control, inhibition.”

2) WHAT DO SCIENTISTS UNDERSTAND ABOUT WHAT C.T.E. IS — AND WHAT IT’S DOING TO PLAYERS’ BRAINS?

Doctors point out that C.T.E. is by no means limited to the sport of football. It’s been found in hockey players, boxers and military veterans. And one doesn’t have to suffer a knockout to be afflicted with the disease. Researchers say C.T.E. can be triggered by other hard hits to the head that do not necessarily cause someone to lose consciousness.

In fact, C.T.E. is actually a new name for a disease that was once referred to as dementia pugilistica, or more commonly called “punch-drunk syndrome” because it was found among boxers.

Researchers now say it’s a progressive neurological illness that can be caused by repeated blows to the head, including hits that impact at the so-called sub-concussive level.

“After an injury, the nervous system in the brain is affected,” says McKee. “So if you have a player who had stopped playing because of a concussion or a very hard hit to the head that was sub-concussive and then this player gets a second brain injury on top of that, it can be very dangerous to the nervous system if the brain has not really had adequate time to recover.

“We know athletes who have had a second concussion say that it only takes a milder hit for them to have to deal with the concussive symptoms all over again,” she says.

The brain, says McKee, is floating in fluid and when the head is jarred, those forces knocking the brain forwards and backwards can lead to damage.

The damage from C.T.E. is caused by a buildup of toxic proteins called tau that are found in deposits in the frontal lobe of the cerebral cortex as well as the hippocampus and the temporal lobe of the brain. The more those proteins build up, the more damaging they are — leading to so-called neurofibrillary tangles throughout the brain that kill brain cells and cause memory loss, erratic behavior, mood and control issues, and other neurological problems.

In fact, scientists can clearly see how tau builds up when they look at tissue of the brain once someone has died. That was the case with Duerson.

As the picture of Duerson’s brain shows, there’s a buildup of tau in his hippocampus and temporal lobe seen in brown-stained deposits near the bottom of the larger images. The smaller images reveal the concentration of tau at a microscopic level.

“As you can see in the picture, he had very high density of this,” says McKee. “It sort of filled up the cell with a mess. He has classic pathology.”

3) HOW PREVALENT IS THE ILLNESS AMONG FOOTBALL PLAYERS OR OTHER ATHLETES?

For one thing, a person can not be accurately diagnosed with it until after the individual has died since researchers look at the brain posthumously.

Duerson was the 14th of 15 retired players to be diagnosed with C.T.E. whose brains were examined by researchers at the BU center, according to McKee. The center also has found it in more than 50 former military veterans and retired boxers.

“I think it’s more common than previously suspected” among players, McKee says.

But she and others acknowledge that they still don’t know just how prevalent it is and says you can’t make any real estimates about thousands of former players based on the small sample of individuals whose brains have been studied. In the case of many of those players, their families suspected they might have been afflicted by C.T.E., making it a type of self-selected group. (Dozens of retired and current players who are still alive have pledged to donate their brains to the center for study after their deaths.)

As Schwarz put it in a piece in Sunday’s Times about the 14 men who tested positive:

“Although 93 percent of players tested so far have had C.T.E., that does not mean 93 percent of today’s players have it. “The rate of brain diseases among retired players may wind up stunningly high — particularly among linemen,” he writes. “But that 93 percent figure will assuredly be be diluted by the slower inclusion of healthy brains. Then again, to suggest that the only 14 players with C.T.E. have been found and that the 0ther 14,986 men will be unaffected is absurd.”

Increasingly, researchers also think there is a genetic component that may put someone at a higher risk for C.T.E. But that’s a question and a theory they don’t fully understand yet.

“We have had three players from the same family and only one of them has it,” says McKee. “Yet his brothers who seemed to play even more football than he did are well. We think there are some genetic risk factors involved.”

4) HOW IS THE NFL ADDRESSING THE PROBLEM?

The league maintains that it has always taken the risk of brain injury seriously. But some observers say the NFL is now focusing on the problem more seriously than in the past – though still not seriously enough for many.

“There has been a significant culture change throughout sports concerning concussions and the NFL has led the way, going back to 1994 when (former commissioner) Paul Tagliabue appointed a medical committee on concussions,” NFL spokesman Greg Aiello wrote in an email to the NewsHour.

But the league has been criticized for not acting tough enough or quickly enough, especially when a player — or his coach — is determined to get back into the game.

For years, the league has had rules prohibiting certain kinds of hits to the neck and head. But amid growing criticism that those rules were not tough enough, and dangerous hits were still taking place, the NFL changed its rules last season to crack down on hits to the head and the neck with greater financial penalties and new suspensions for helmet-to-helmet contact.

This year, says Aiello, the NFL is implementing even more new rules and guidelines, requiring each team to have an independent neurologist to evaluate a player closely before he can return to the field after an especially serious hit. Too often, some players — and their coaches — are eager to return to the game before they are really ready.

Schwarz says that’s part of the reason these changes will be important.

“There’s not a whole lot that can be done to prevent these injuries from happening,” says Schwarz. “But they are trying to minimize the outcome when they do happen, and that’s a great development.”

Specifically, team doctors will administer a standard exam to a player before he can re-enter the game. That can include a set of questions, hands-on physical examinations, balance tests and a screening of the player’s eye movements.

5) WHAT ELSE IS BEING DONE?

Many observers say it’s important to focus more on minimizing concussions and trauma among kids and students. Roughly 135,000 children between the ages of 5 and 18 are treated in emergency rooms each year for sports or recreation-related concussions or head injuries. (Betty Ann Bowser looked at concussions among high school athletes back in 2007.)

As attention about professional football has increased, it has drawn the spotlight to dangers for younger athletes. An autopsy of a University of Pennsylvania football player who killed himself last year also found that he had mild stages of the same illness found in retired players.

That in turn, is leading to calls for new laws, safer equipment and changing people’s mindsets about delaying a kids’ re-entry into the game after a concussion.

On that front, the popular video game, Madden NFL 12, will now include information about concussions as part of what gamers see and hear. For example, gamers will see a player suffering a concussion on the field and will learn that he is being sidelined for the rest of that game. The announcers will now say the player was removed because of a head injury.

Given that more than 90 million copies of Madden NFL have been sold over two decades, the warnings about concussions in Madden NFL 12 is seen as an important cultural recognition and a possible teaching tool.

“It has to be a big thing in the video game,” Hall of Fame Coach and former broadcaster John Madden told Schwarz in the Times. “It starts young kids – they start in video games. I think the osmosis is, If you get a concussion, that’s a serious thing and you shouldn’t play.”

For its part, the NFL is pressing states to pass the Lystedt law – first passed in Washington state – to protect young athletes by requiring he or she be removed from a game after a concussion. The student would only be able to re-enter the game after being cleared by a health care professional.

Aiello says 16 states have a version of the law already, three other states are expected to join soon.

The helmet industry is also under pressure to make changes for high school and youth football.

The voluntary trade group that oversees refurbishing of helmets used by young players announced this spring that it would no longer refurbish helmets that are more than 10 years old. Currently, more than 100,000 kids and students wear those kinds of helmets now. But even that program raises questions.

Schwarz, who has chronicled the helmet issue closely and the dangers of older helmets, writes that “underfinanced schools and youth organizations that might have reconditioned their old helmets — at a cost of about $30 apiece — could balk at the idea of spending $150 to $200 for each new helmet and choose to use the old ones for another year.”

McKee says improving helmets only has limited use if a player is put back into a game too soon after an initial injury.

“I don’t think this is going to be a problem solved by a better helmet,” she told us. “The brain is a semi-gelatinous material. Increasing protection over the skull is going to have limited use on these inertial forces that are moving back and forth.”

Still, the changes afoot in 2011 suggest some greater recognition of the problem –and further attempts to deal with it.

“For the last year or so, the league has stepped up, made changes to its rules,” says McKee, whose center is receiving $1 million from the NFL for further research. “I think we’re going to see incremental changes in the way the game is played so we protect the health of these players. That seems to be the direction they’re moving.”

You can learn more about the BU center at its website and in this YouTube video.