Premortem Chronic Traumatic Encephalopathy Diagnoses in Professional Football
Grashow R, Weisskopf MG, Baggish A, Speizer FE, Whittington AJ, Nadler L, Connor A, Keske R, Taylor H, Zafonte R, Pascual-Leone A. Ann Neurol. 2020 Apr 13. doi:10.1002/ana.25747. Online ahead of print.
Take-Home Message
Clinicians should screen patients with suspected chronic traumatic encephalopathy (CTE)-like symptoms for treatable comorbidities that may contribute to similar symptoms.
Summary
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that lacks diagnostic criteria, except after death. However, some clinicians may diagnose former football players with CTE even though other comorbidities may cause similar symptoms (cognitive impairment, depression). Hence, the authors enrolled 3,913 (27%) former National Football League players that participated in the league between 1960-2014 to determine the prevalence of clinician-diagnosed CTE and comorbidities that are related to cognition. Participants completed a survey regarding demographics (e.g., race, age, position), years of play (1-4 seasons, 5-9 season, or 10+ season), diagnosed health conditions (e.g., heart attack, sleep apnea, stroke, dementia, depression), and medications. The authors also asked if a health care provider diagnosed them with CTE. Lastly, the participants completed the Patient Health Questionnaire (PHQ-4) and the Quality of Life in Neurological Disorders to assess depression and cognitive symptoms, respectively. The authors found that almost 3% (108 players) of the participants reported a CTE diagnosis. A diagnosis of CTE was more common than peers among black former players, lineman, and people playing 5-9 years. Further, CTE diagnosis was more likely to be diagnosed along with obesity, sleep apnea, depression, stroke, hypertension, use of prescription pain medication, low testosterone, hypercholesterolemia, dementia, or cognitive impairment.
Viewpoints
The authors found that despite CTE being a postmortem diagnosis, some athletes reported that clinicians diagnosed them with CTE. Furthermore, former athletes who reported a diagnosis of CTE often had other comorbidities that may explain symptoms such as impaired cognition. This is concerning because it suggests that many treatable comorbidities may be overlooked. For example, many comorbidities are known to affect cognition and impact the black population to a greater extent (hypertension, diabetes). However, we should be cautious because the authors relied on self-reported data, which could lead to a misreporting of diagnoses (e.g., under or over-reporting of comorbidities, players confusing clinician diagnosis of CTE rather than self-diagnosis). Furthermore, it is unclear if the clinicians were addressing the treatable comorbidities (e.g., obesity, prescription pain medication, sleep apnea) despite a CTE diagnosis. Currently, since medical professionals cannot diagnosis CTE in a patient nor offer a disease-modifying treatment, there is a need to evaluate former athletes for treatable conditions that demonstrate CTE-linked clinical symptoms to improve their health and wellness.
Questions for Discussion
Have you heard of someone being diagnosed with CTE? Do you think treating these comorbidities could help if someone was suffering from CTE? What do you want to know about CTE diagnosis?
Written by: Jane McDevitt
Reviewed by: Jeffrey Driban
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I haven’t heard of someone being diagnosed with CTE apart from media coverage on post-mortem diagnoses. But it is really interesting to me that this study highlights an increased trend in living patients being diagnosed with CTE. This is concerning for a couple of reasons. First, that there are premortem diagnoses being given even without proper diagnostic criteria to do so. And also that there are several other comorbidities that have similar neurocognitive effects. Do you think CTE is being used like a blanket diagnosis? And do you think it is hindering holistic care of the symptoms that could alleviate some of these problems? I have seen so many concussion diagnoses and a handful of post-concussion syndrome diagnoses as well and some of those long-lasting symptoms associated with post-concussion syndrome mirror those of CTE. This to me means that we should also focus on treating the comorbidities of that as well.
Personally I have not seen anyone diagnosed with CTE besides on media as well. If CTE can’t be diagnosed until after death, then why are former athletes being diagnosed with it? Cognitive impairment and depression are symptoms of other diseases as well. There really isn’t a way to prevent CTE other than terminating contact. I found it interesting that a diagnosis was more likely to happen with obesity, sleep apnea, depression and stroke. I’d be interested to see how the athlete’s position whether football or hockey effects CTE.
I have only heard of one being diagnosed with CTE once they are deceased. Never have I heard of CTE being diagnosed in a patient prior to the testing done during an autopsy. However, if someone is suffering from CTE, I feel as though treating these comorbidities would be a great start to a treatment plan. Since this article describes how the other comorbidities that were reported along with CTE had similar symptoms to CTE, such as impaired cognition. This could possible mean that these symptoms were due to their pre-exisiting illness opposed to CTE. I personal feel that increase testing and studies must be done prior to diagnosing CTE as a premortem diagnosis. CTE is a very interesting topic of discussion and I would like to know more about how this postmortem diagnosis has now been a premortem diagnosis? How can a clinicians confidently diagnosis CTE while there are multiple other illnesses the symptoms could be due to? Could they do this study in other sports with high amounts of head trauma? What treatments are being put in place to help treat not only CTE but this multiple other comorbidities?
I personally have only heard of CTE diagnosis in postmortem populations. And even then, I only have knowledge of a small amount of diagnoses due to the suggested growing prevalence in American football. I think that it is very interesting to me that these researchers uncovered that people are being diagnosed with CTE when it is only truly diagnosed after the patient has deceased. I think this shows the need for greater education to clinicians on this subject, as well as to these retired athletes. I believe that treating these comorbidities will not only help someone if they are possibly suffering from CTE, but may also treat other conditions that coincide with these comorbidities. I am interested to see future directions of this subject and see if a way to diagnose CTE prior to death is discovered. I am curious to know if athletes from other high-impact sports backgrounds are also being diagnosed similarly by clinicians? Overall, I agree that the findings of this study highlight how important it is for clinicians to assess these comorbidities and other various causes of cognitive decline, instead of assuming CTE.
I personally have only heard of CTE diagnosis in postmortem populations. And even then, I only have knowledge of a small amount of diagnoses due to the suggested growing prevalence in American football. I think that it is very interesting to me that these researchers uncovered that people are being diagnosed with CTE when it is only truly diagnosed after the patient has deceased. I think this shows the need for greater education to clinicians on this subject, as well as to these retired athletes. I believe that treating these comorbidities will not only help someone if they are possibly suffering from CTE, but may also treat other conditions that coincide with these comorbidities. I am interested to see future directions of this subject and see if a way to diagnose CTE prior to death is discovered. I am curious to know if athletes from other high-impact sports backgrounds are also being diagnosed similarly by clinicians? Overall, I agree that the findings of this study show how important it is for clinicians to assess these comorbidities and other various causes of cognitive decline, instead of assuming this condition and forgetting other possible pathologies.
I think that this a great stepping stone in regards to CTE research. I have not heard of anyone being diagnosed with CTE while still alive. I think if anything, this study shows the importance of knowledge about CTE for clinicians. If we can identify certain conditions that can be linked to CTE such as obesity, sleep apnea, hypertension, etc we can have a better understanding on how to treat and possibly diagnose CTE while someone is still alive. I think would be interesting to see if treating these comorbidities has any sort of effect on the diagnosis of CTE, obviously there is major limitations being that we have only been able to diagnose CTE in deceased patients, but it is an interesting topic for future research.
CTE has definitely been one of the most eye opening diseases within the athletic population, in my opinion, even though it has been seen more prevalently in contact sports where contact to the head is pretty prevalent. After reading this article, I agree that, for right now, the best thing that healthcare professionals can do with these athletes is to sit down and go over the importance of taking care of themselves once they walk away from their sport. When it is time for an athlete to walk away from a sport that they have played for so long, their way of life can take a complete 360 degree turn, when this happens, I believe, much of these comorbidities of CTE can occur if they were not already present. In preparation for that next chapter within the individual’s life, I think that is when the healthcare professionals should do their best to provide as many resources and as much support as they can in order to help improve that individuals well-being and treatment of any comorbidities of CTE that may appear or are present during this transition within their lives. This could be a small but helpful option that medical professionals could provide to individuals even if CTE is not able to be diagnosed while the individual is still alive for years to come.
Thank you for you comments. It is very important to note that at this point CTE can only be diagnosed until post mortem. I think this study really highlights the importance of identifying co-morbidities that may be the underlying reason behind mild cognitive impairment instead of jumping into CTE.
Much of the research behind CTE utilize brain samples that come from the same 2 brain banks. Therefore, there is a limited and somewhat biased (there was probably some problem that made them think the brain should be donated) sample bank to perform CTE research on in the first place. However, I agree it would be interesting to note how much post mortem diagnosed CTE patients 1. had these comorbidities and 2. if they received treatment did they live longer or report better patient outcomes compared to those that did not receive treatment for comobrioddiites. Again, this may be tough to do depending on the clinical records that correspond to the samples.
I really haven’t heard much about CTE other than on media and the growing issues in football. CTE definitely needs to be a more common discussion with athletes, with how serious it can be. As well as bringing more attention to this area it could help in brining more research and resources. If we are able to start diagnosing it would hugely impact treating comorbidities. CTE will never be easy but if we can start helping educate and improve the lives of individuals with CTE would be beneficial as well as a huge life change.