For a critical analysis of the Boston University study mentioned below and an explanation of why its findings need to be taken with a grain of salt, check out How one flawed study and irresponsible reporting launched a wave of CTE hysteria.
Note that the information in this article has not been evaluated or approved by the FDA. The products mentioned in this article are intended to support general wellbeing and are not intended to treat, diagnose, mitigate, prevent, or cure any condition or disease. Please seek advice from your medical doctor. The sports world is buzzing since last week’s publication of a report which revealed that 110 out of the 111 brains of former NFL players were afflicted with the degenerative condition chronic traumatic encephalopathy (CTE). As the mother of a high school football player and a healthcare professional, the news struck close to home for me. I have several goals in this article:
- To unpack some of the relevant detail from the Boston University study
- To highlight the fact that the problem is not just concussions — we need to be just as concerned about the cumulative impact of the hundreds of sub-concussive head blows that the average high school football player experiences each season
- To explain why — despite the risks — football occupies center stage in our family each fall
- To summarize what I — as a mother, nutritionist, exercise physiologist, and board-certified herbalist — am doing to safeguard my son’s current and future physical and mental health
87% of deceased football players’ brains showed evidence of degenerationIn the article published last week (the New York Times published a summary of the article the same day) researchers at Boston University reported the results of their examination of the brains of 202 deceased former football players. The bottom line? 87% of the brains examined showed evidence of CTE, a condition linked to repeated blows to the head. CTE causes a variety of symptoms, including apathy, hopelessness, impulsivity, anxiety, memory loss, attention problems, confusion, explosivity, and dementia. The lives of individuals afflicted by this devastating condition are often marked by failed marriages, failed businesses, substance addiction, criminal behavior, and suicide.
High school to the NFL, punter to lineman — no one is immuneThe brains examined belonged to individuals as young as 23 and as old as 89. They belonged to individuals who played every position on the field, from lineman to punter. The brains of unknown former high school football players were examined, as well as those of members of the NFL Hall of Fame. The brains belonged to individuals who played the game at a variety of levels:
- High school football players: 14 brains examined, 21% showed evidence of CTE
- College football players: 53 brains examined, 91% showed evidence of CTE
- Semi-professional football players: 14 brains examined, 53% showed evidence of CTE
- Canadian league football players: 8 brains examined, 88% showed evidence of CTE
- NFL football players: 111 brains examined, 99% showed evidence of CTE
Before we hit the panic button — these findings have to be interpreted with cautionFrom the outset it is important to emphasize that this study most definitely DOES NOT mean that 21% of former high school football players and 99% of former NFL players have or will develop CTE. Since the publication of the Boston University study last week, many have been quick (and correct) to point out that the brains examined by the researchers were definitely not randomly selected — in many cases family members donated the brains of deceased football players specifically because the individuals showed signs of the condition prior to their death, making it impossible to generalize the findings of this study to all football players. The sample size of this study is also very small. But, as pointed out in the New York Times article:
About 1,300 former [NFL] players have died since the Boston University group began examining brains. So even if every one of the other 1,200 players had tested negative — which even the heartiest skeptics would agree could not possibly be the case — the minimum C.T.E. prevalence would be close to 9 percent, vastly higher than in the general population.The question of just how prevalent CTE actually is remains to be determined. The problem is that, at this time, CTE can only be diagnosed with certainty at autopsy. Researchers are working toward developing technology that will allow for diagnosis of CTE in living brains, but that technology will likely not be available right away.
But the problem isn’t just concussions!In recent years, much attention in the sport of football has been paid to concussions. Helmet technology has improved dramatically, tackling techniques have changed, and policies from the high school to professional levels of the game have been altered to require players who are suspected of having been concussed to be removed from the field of play until they have had adequate time to recover and have been cleared by a physician. Heck, even the video games have changed — the Madden football game that my son and his friends love used to allow players with concussions to return to play in the same game, now that is no longer the case. But CTE experts agree that it may be the cumulative effect of many seemingly minor, non-violent, “sub-concussive” blows to the head that sets into motion the degenerative changes to the brain that eventually result in CTE. Depending on position, some high school players may experience as many as 60 of these sub-concussive blows in a single game and hundreds of such blows over the course of a season’s worth of games and practices. Research on high school football players shows that individual players experience an average of 652 head hits over the course of a 14 week season. Another study showed that line players experience more hits, but players at skill positions are more likely to encounter harder blows to the head. Although children and teenagers recover from most injuries more quickly than adults, research makes it clear that that is not true when it comes to concussion and animal research suggests that juveniles may be more vulnerable than adults to cumulative damage from sub-consussive head blows . In one study researchers found that former NFL players who started playing football prior to age 12 had significantly poorer cognitive function and memory and lower IQ than those who started playing football after age 12. Having spoken to a number of football coaches, athletic trainers, players, and parents of players (all at the high school level) about CTE, I find that almost none of them are aware of this. Almost all of them believe that if players are protected from concussions and/or receive appropriate medical evaluation and time to recover when concussions occur, that the risk for CTE vanishes. Unfortunately this does not seem to be the case. Helmet technology has improved dramatically in recent years and, as a result, the incidence of skull fracture, brain contusion, and catastrophic head injury in football is relatively low. But even the best helmet cannot mitigate the acceleration-deceleration forces that affect the brains of all involved players every time offensive and defensive linemen slam into one another from a three point stance, a receiver is taken out by a defensive back, or a quarterback is sacked into the turf. These impacts cause the brains of players to slosh inside their skulls, placing shearing forces on neurons and other cells in the brain. When this occurs over and over and over again, the potential for damage begins to accumulate.
Despite all this, my son plays footballDespite all of this, high school football occupies center stage in our family each fall. In just over a week, my oldest son Luke will start two-a-day practice for his fourth season of tackle football and we can’t wait. At first I strenuously opposed my him playing the sport. Risk for head injury and CTE aside, as a licensed acupuncturist I’ve cared for scores of middle-aged and older men who trace their chronic knee, back, shoulder, and neck pain back to their high school football careers. Many of them express regret at having played — in retrospect they would have foregone a few years of glory if they could have avoided the decades of suffering that has followed. But we live in Texas, a place where high school football isn’t just a sport, it’s a culture. Years of pleading on Luke’s part caused me to tentatively relent on my hard and fast “no football” policy when he was in seventh grade. I consulted the Virginia Tech ratings, bought him a $400 helmet, and entrusted him to the care of his coaches and his guardian angel. To be honest, I was hoping that he would lose interest after a season of running stadium stairs and suicides in 105-degree heat and sitting the bench while the boys who had been playing since they were Pee Wee age started every game, but that is not what happened. Instead his interest in the game grew into a passion. Within days of the start of his first season, I noticed that he was carrying himself with a confidence I had never seen in him before — he was walking taller and standing with his shoulders square and straight. Rather than sitting on the couch playing video games in his spare time, he was in his bedroom doing pull-ups and pushups or outside running, doing agility drills, and throwing the football any time he could talk someone into catching for him. His football team is a racially diverse band of brothers in a school that is otherwise mostly self-segregated. His teammates are a group of boys that I welcome into my home any time they want to come because I have found them to be respectful of adults, honorable in their treatment of their opponents, and supportive of one another through thick and thin. Because of football, Luke has worked tirelessly to get strong, lean, and fast and he cares for his body as diligently as even the most health-conscious adults I know, ordering broccoli instead of French fries and water instead of Coke every time we eat out. Although drugs, alcohol, and tobacco are readily available at his school, he can’t imagine taking the risk of failing a random urine test and so it’s easy for him to say “no thanks”. Last August he earned his Eagle Scout rank, but to be honest with you, I believe that playing football has done at least as much as Boy Scouting to make him the trustworthy, loyal, and brave young man he is today. These benefits are impossible to measure or quantify, but, at least in my son’s case, they weigh heavy against the risks associated with the game.
Can anything be done to reduce the risk to my son’s brain and the brains of his teammates?But as last week’s publications reminded everyone — clearly the risks are real. So what can be done to minimize the risk of future brain degeneration as a result of high school football? Many people would say that the obvious answer is “don’t let your son play” and that’s the reaction I hear from many of my colleagues from other parts of the country when this topic of conversation arises. But, as I’ve explained above, my son’s life has changed in many profoundly positive ways as a direct result of his participation in tackle football. I feel certain that he would be far less physically or emotionally healthy today if I had stuck to my guns back in seventh grade and refused to let him play. At least in his case, these benefits cause me to be willing to tolerate some degree of risk. As the mother of three sons, I am learning that you cannot raise a confident man by locking a boy in a padded room and shielding him from all risk. By the same token, however, I take my responsibility to make good choices on my son’s behalf very seriously. At age 16, my son’s sights are set on a starting position on the varsity team, risk to his future health be damned. It’s my job to have my sights set on safeguarding his long-term physical and mental health. To that end, I have spent the past three years learning as much as I could about CTE.
How does CTE develop? No one knows for sureIt is clear that no one knows exactly how and why CTE develops. Researchers know that, by a mechanism that is not yet understood, repeated trauma causes normal structures in the brain to be replaced with a build up of a protein called tau. It is the accumulation of tau protein in various regions on the brain that results in the changes in cognition, mood, and movement that are characteristic of CTE. For example, CTE in the frontal cortex causes changes in memory, planning, and abstract reasoning, CTE in the insula (an area of the brain that is important in emotion) affects social perception and self-awareness, CTE in the amygdala (an area of the brain involved in assessing risk) affects emotional control, aggression, and anxiety, and CTE in the mammillary bodies affects memory.
Could CTE be an autoimmune disease?According to one emerging theory, sub concussive head blows cause injury to the blood brain barrier (as opposed to the brain itself) and set off a chain reaction that eventually results in degenerative changes to the brain. According to this theory, even relatively minor head blows disrupt the integrity of the BBB and make it temporarily leaky, allowing brain proteins to pass into the peripheral blood circulation. Because these brain proteins are not normally present in the bloodstream, the immune system treats them as if they are dangerous foreign invaders and produces antibodies against them. Then, the next time the BBB opens up (which, according to research, occurs in some players after every game), these antibodies gain access to the brain and set into motion an attack by the immune system on normal brain tissues. Damage then accumulates over time as the BBB becomes leakier and the immune produces more anti-brain antibodies. Perhaps this mechanism explains why the signs of CTE typically do not show up for years or even decades after athletes play their last game. The video below explains this emerging theory in greater depth.
What I am doing to protect my son’s brainThe protocol that I’ve put together for my son is based on my background as a nutritionist, exercise physiologist, and board-certified herbalist. Much of what’s described below comes from a protocol developed and tested by Dr. Daniel Amen, internationally renown psychiatrist, brain imaging expert, and author of the 2011 scientific paper Reversing Brain Damage in Former NFL Players: Implications for Traumatic Brain Injury and Substance Abuse Rehabilitation. In the paper Dr. Amen describes a protocol of dietary supplements and lifestyle changes that were implemented by 30 retired NFL players for six months under his supervision. At the end of the six months, the players showed a significant increase in blood flow to their brains and improvements in attention, memory, reasoning, mood, sleep, and information processing.
“We demonstrated that even if you have been bad to your brain, on the right program you can often reverse the damage and improve your life. It’s one of the most exciting discoveries in medicine today. I hope this message finds anyone who played contact sports like football, hockey, soccer, or boxing so they can find help because their degenerative conditions can be reversed.” – Dr. Daniel AmenIn addition to Dr. Amen’s recommendations, I’ve consulted the detailed chapter on natural neuroprotective approaches to concussion in The Handbook of Neurological Sports Medicine.
Preseason baseline testingThis past weekend I administered baseline testing to Luke and my 12 year old son Sam (who is an All Star cheerleader). This will give me a point of comparison in case either of them has a head injury in the upcoming season. I had them complete sections 4, 6, 7, and 8 of the Sport Concussion Assessment Tool 3 (SCAT3) and recorded their results. Luke scored significantly higher than Sam on the immediate memory and concentration sections of section 4 and Sam scored much better than Luke on section 6 (balance examination). Having a baseline is important because it will enable me to confidently recognize even small deviations from normal if either of them have a head blow so that I can take appropriate action (removal from play, medical attention, etc). Now I know that if Sam scores anything less than perfect on the balance examination that it will be cause for concern, whereas a few errors on the memory section would be considered normal for him. On the other hand, I know that a perfect score on the immediate memory and concentration section comes easily to Luke, whereas a few errors on the balance test won’t be anything to worry about.
Adequate SleepThere is no question that adequate quantities of deep sleep are critical for brain health. Deep sleep has been shown to slow cognitive decline, reduce cortisol levels, promote regeneration of myelin (the fatty substance that insulates nerves), increase the growth of new brain cells, and support the integrity of the blood-brain barrier. As any parent of a teenager knows, however, making sure that your son gets enough sleep can be a challenge. Between late night football games, early morning practice, and the demands of homework (along with a constant stream of Snapchat notifications) it is hard for kids these days to get the 8-10 hours of sleep that their brains really need. As far as I’m concerned, one of the benefits of my son being an athlete is that he is forced to learn to manage his time effectively in order to keep up with his responsibilities, including the responsibility to get the sleep that his body and brain needs. In our house we treat bedtime as if it is as hard and fast a commitment as practice time or game time. This often means that he doesn’t have as much time as he’d like to for social media or Netflix, but that is the cost of playing the game he loves. For us the key to adequate sleep is getting screens out of his room – the cell phone and iPad get charged overnight in the kitchen and there is no TV or computer in his bedroom.
Fish OilIt appears that high dose fish oil was instrumental in several high profile cases in which patients experienced virtually miraculous recovery from brain damage after a mine accident, a car accident, and after having been hit by a car. Although no one knows for sure how fish oil works to assist in brain recovery after these severe injuries, it may help prevent cell death, may help reconnect neurons, and may help activate genes in the brain that work to limit inflammation. In research that is probably more relevant to the type of repeated mild head trauma experienced by football players, one study showed that pre-injury supplementation with fish oil makes the brain more resistant to the cascade of reactions that occur following mild traumatic brain injury and counteracts learning disability associated with such injuries, while another study showed that pre injury supplementation makes the brain more capable of recovering homeostasis post injury.
CurcuminCurcumin is a compound found in the Indian spice tumeric and has been a staple medicinal used by practitioners of traditional Chinese and Indian medicine for thousands of years. Some researchers speculate that widespread dietary consumption of curcumin may be responsible for the relatively low incidence of Alzheimer’s disease observed in India. Modern research suggests that curcumin is a potent antioxidant and has strong anti-inflammatory properties. It is capable of crossing the blood brain barrier, enabling it to exert a multitude of brain-protective effects. Curcumin has many of the same benefits in the brain as fish oil; additionally it protects the blood brain barrier and decreases brain swelling following injury. Research suggests that curcumin is most effective in providing brain protection when it is administered prior to head trauma.
CreatineStudies have suggested that creatine supplementation may provide neuroprotection against chronic neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, and amyotrophic lateral sclerosis (ALS). When creatine is administered prior to head trauma, the magnitude of tissue damage and the concentration of markers of cellular injury is significantly decreased.
MagnesiumMost American diets (especially the diets of teenagers) are very low in magnesium. When magnesium levels are low, brain cells are less capable of generating sufficient energy to repair themselves after injury. In a low magnesium state, the cascade of reactions that occur after a head injury, including inflammation, excitotoxicity, mitochondrial dysfunction, energy failure, edema formation, free radical production, and apoptosis (cell death) is magnified. Two additional benefits of magnesium are that it helps prevent muscle cramps and it is calming to the nervous system and can serve as a gentle sleep aid.
B-vitamins, Vitamin C, and Vitamin DAnimal studies have shown that B-vitamins, vitamin C, and vitamin D may help support normal synthesis of neurotransmitters and reduce damage, inflammation, and behavioral changes following brain injury. Vitamin C is important for reducing the oxidative stress that occurs after brain injury. Vitamin D deficiency is extremely common and is now being recognized as a risk factor for inflammatory, autoimmune, and neurodegenerative diseases (including dementia, Parkinson’s disease, and Alzheimer’s disease). As an added benefit, together vitamin C and vitamin D support immune function and increase resistance to respiratory viruses.
Ginkgo & VinpocetineThe Amen protocol focuses on increasing blood flow to the brain. Ginkgo biloba and vinpocetine (a substance derived from the periwinkle plant) are two key components in the program that were included because they do just that. Ginkgo has been used in China for thousands of years to treat a number of health problems. It’s one of the top-selling herbal supplements in the world and is treated as a prescription medication in Germany. Ginkgo has been shown to improve cognitive function, memory, and attention. It reduces the risk of dementia and Alzheimer’s disease and improves mood and mental energy.
Acetyl-L-Carnitine & Huperzine AThe Amen protocol also includes Acetyl-L-Carnitine and Huperzine A, two supplements that work together to increase the levels of acetylcholine (considered the “learning neurotransmitter”) in the brain.
PhosphatidylserineThe Amen protocol also includes Phosphatidylserine, a fat soluble amino acid that supports cognitive function and may reduce risk for dementia. It has also been shown to reduce cortisol, a stress hormone that can contribute to brain degeneration if it remains at chronically high levels.
Brain ProtomorphogenRemember the video above about the theory that CTE may be an autoimmune disease? Although conventional medicine considers this theory to be new, when I came across it it rang a bell for me. It took me a few days to figure out why, but then I remembered: years ago I had listened to a recording of a lecture given by nutrition genius Dr. Royal Lee over sixty years ago. In the lecture Dr. Lee explained how head injuries, even minor ones, can set into motion a progressive decline of memory, cognition, and emotional regulation. The really amazing thing about the lecture is that Dr. Lee proposed that the mechanism behind the decline in mental function after head blow(s) is the development of what he called “natural tissue antibodies” (meaning antibodies to the body’s own tissues — what doctors today would call autoantibodies) in response to the damage caused by the initial injury. This is pretty remarkable because the lecture was given back in the early 1950’s, before the discovery of autoimmune disease. What Dr. Lee described in that lecture over sixty years ago is essentially what Dr. Bazarian describes in the video above. According to Dr. Lee, progressive decline of brain function can be halted and even reversed by giving dietary supplements called tissue protomorphogens (PMGs), which are purified extracts of nucleic acids from the nucleus of specific types of cells. A PMG essentially is like a blueprint that reminds a particular type of cell of how it should operate. The video below explains how ingesting PMGs may help to retrain the immune system in autoimmune disease.
The video above describes the microscopic injury and resultant inflammation that occurs with a concussion. Research in rats suggests that acupuncture reduces the production of toxic substances that result in cell death and increases the production of substances that promote brain healing following concussion. Although there is not direct scientific evidence to suggest that acupuncture is beneficial following subconcussive blows, one study found that it protects the blood brain barrier. For that reason acupuncture is part of our regular routine.
Side benefits of this protocolIn addition to supporting healthy brain function, this protocol has many other benefits, including:
- Enhancing cognitive function, memory, and focus.
- Supporting energy production and fat burning.
- Enhancing athletic performance.
- Facilitating recovery from intense workouts and decreasing muscle soreness.
Keeping track of all those pillsEven though I’ve done my best to choose products that cover as many bases as possible, this protocol still amounts of a lot of pills — 17 per day, to be exact. We have found that a pill organizer is key for keeping everything straight. A few other advantages of a pill organizer include:
- We only have to get out the supplement bottles once a week when Luke fills his organizer
- A day’s pod can be tossed into his backpack in the morning, allowing him to take his morning supplements with breakfast after morning practice
- At the end of the week he is kept accountable — an empty organizer means that he’s held up his end of our bargain
These are the products that we use
- Vital Nutrients Ultra Pure Fish Oil 700
- Designs for Health Mitochondrial NRG
- Designs for Health Magnesium Malate
- Pure Encapsulations O.N.E. Multivitamin
- Nature Health Vibrant Mind
- Standard Process Neurotrophin PMG