Limitations of Diagnostic Tools for Chronic Traumatic Encephalopathy (CTE)

By Frederick Schenk, CaseyGerry – As Published in Living Safer Magazine

A high stakes class action lawsuit  filed on behalf of thousands of former players against the National Football League has raised awareness about the dangers associated with multiple concussions, including the potential for Chronic Traumatic Encephalopathy (CTE), a degenerative brain disease.

As a result, public concern about CTE, which can cause depression, erratic behavior, memory loss, impaired judgment, aggression and, eventually, progressive dementia has mounted, especially following the suicides of several former professional athletes, among them former Pittsburg Steelers lineman Terry Long, New England Patriots player Aaron Hernandez, San Diego Chargers linebacker Junior Seau, Steelers linebacker Adrian Robinson, Jr. and Chicago Bears safety Dave Duerson – all of whom were found to have CTE.

According to researchers from the Center for the Study of Traumatic Encephalopathy at Boston University, CTE is a progressive disease found in those with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic sub concussive hits to the head. Originally diagnosed as dementia pugilistica or “punch-drunk syndrome,” CTE is often found in athletes and military veterans and has been known to affect boxers since the 1920s.

Recent reports have been published of neuropathologically confirmed CTE in retired professional football players and other individuals who have a history of repetitive brain trauma. In a recent BU study, researchers studied the brains of men who played football at all levels and found evidence of CTE in 177 of 20, or 87 percent of them. The disease prevailed across all levels of play, but the highest percentage was found among those who reached the NFL — 110 of 111 brains examined.

According to Boston University researchers, repeated head trauma triggers progressive degeneration of the brain tissue, including the buildup of an abnormal protein called tau, which kills brain cells. These changes in the brain can begin months, years or even decades after the last brain trauma or end of active athletic involvement. Currently, CTE can only be officially diagnosed through autopsies, but researchers are working toward a breakthrough and have used a PET scan — an imaging test that uses radioactive tracer dye to show how organs and tissues are working in order to identify abnormal tau proteins in living football players. There is still much work to be done on that front.

Other than repeated brain trauma, the causes of CTE remain unknown, but research studies are looking into possible genetic, exposure level and other risk factors. When CTE is suspected, a thorough medical history, mental status testing, neurological exams, brain imaging and further diagnostic tests may be used to rule out other possible causes.

In the meantime, CTE is exceptionally hard to diagnose. In fact, the only accurate way to currently detect CTE is through a brain study done during an autopsy.

As a result, there is a fundamental problem with the diagnostic  tools –  which entail neuropsychological testing along with neurologic medical evaluation – utilized by the NFL to diagnose and classify the levels of the disease.

While a $1 billion concussion settlement was reached with the NFL, under the settlement, many retired players will receive a diagnosis that is not a true medical diagnosis with minimal follow up or treatment. //practicalneurology.com/2018/10/a-neurologists-perspective-on-the-national-football-league-and-retired-players-settlement/

What does BAP entail?

To qualify for any recovery, players must be preapproved with a brain injury diagnosis mostly through a Baseline Assessment Program (BAP) – a neuropsychological testing program that screens for signs of cognitive impairment. Sadly, this system has been beset with problems, with seventy percent of claims denied or sent back with requests for more information.

BAP is the key mechanism by which a player’s claim is handled. Under the BAP, every retired NFL player who has earned at least a half of an eligible season can be seen by an independent board-certified neuropsychologist or board-certified neurologist to receive a cognitive assessment to determine if he is suffering from neurocognitive impairment.

The medical evaluations available to retired players include the baseline level examination, the identification of any symptoms of cognitive decline and a diagnosis of a qualifying condition if one exists.

Even if the player is found to be free from impairment, the results of the examination can be used as a baseline for any similar evaluations in the future.

The BAP Dilemma  

The problem with the BAP exam is that brain injury, especially CTE, is highly complicated and exceptionally difficult to diagnose. Currently, a completely accurate diagnosis of CTE requires a brain study during autopsy to detect the existence of tau, the abnormal proteins that kill brain cells.

BAP exams entail a battery of neuropsychological tests performed by trained psychologists but do not require a thorough medical evaluation. Again, as of now, unless the player is dead, there is no way to accurately diagnose CTE short of pathologic confirmation.

For those who suffer from CTE and the emotional instability, depression and memory loss that it so often triggers, a reliable medical breakthrough cannot come soon enough.

Longtime CaseyGerry partner Frederick Schenk concentrates his practice on products/premises liability, catastrophic injury and asbestos litigation and represented his firm on the Plaintiffs Steering Committee which oversaw the national multi-district litigation against the National Football League.