Jay Ruderman: As a parent of four kids, I want to know will them playing youth football or other contact sports lead to a disability?

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Jay Ruderman: Joining me today to discuss this extremely interesting topic of football and disability is assistant professor of neurology at the Boston University School of Medicine, who works at the Boston University CTE Research Center and is the coauthor of multiple papers on this topic. Dr. Michael Alosco, welcome to the show.

Michael Alosco: Thank you for having me.

Jay Ruderman: So let’s start off by telling our listeners what is CTE.

Michael Alosco: Sure, so CTE stands for chronic traumatic encephalopathy. It’s actually a progressive brain disease that’s associated with repeated hits to the head. These repeated hits to the head are such as those that you see in American football or other contact sports. But it’s a disease that’s similar to Alzheimer’s disease, but distinct in many ways.

Jay Ruderman: At what age do people develop this disease?

Michael Alosco: That’s a great question. The disease really develops across a wide range of ages. We’ve seen it as young as in 20s and going all the way up to the lifespan.

Jay Ruderman: What are the symptoms or what are the implications on their daily lives?

Michael Alosco: It’s very similar to these other neurodegenerative disease where you get these progressively worsening symptoms of memory problems, forgetfulness, problems with executive function or these higher-order problems like multitasking, problem solving, as well as disturbances in behavior and mood. So often, what we see is kind of the short fuse or aggressive, explosive behaviors, depression. These are some of the symptoms that we’ve been seeing in CTE. They seem to worsen and worsen over time, worsen with age, and eventually reach to the point where they lead to dementia. Dementia is a … It’s a clinical syndrome where these cognitive and these behavior and these mood problems reach the point where it starts to interfere with a person’s life. So it starts to interfere with their ability to drive, pay bills, take care of themselves.

Jay Ruderman: Okay, and how was the connection between contact sports and CTE first discovered?

Michael Alosco: Actually, despite what it may seem, it’s not actually a new disease. Really, it can actually be dated back to 1928 when Dr. Harrison Martland described this syndrome of clinical symptoms in boxers or fighters. And really, from 1928 and on, there’s other terms like dementia pugilistica. That’s really describing these progressively worsening, thinking memory motor problems that were found in boxers. And actually, the neuropathology of CTE was observed in the 1940s in boxers.

Michael Alosco: But really when this issue came to the forefront of society, scientific attention, and so forth, was in 2005 when pathological changes of CTE were first described in a former NFL player. Since then it’s really taken off in terms of coming to everyone’s attention.

Jay Ruderman: For all those parents out there, does playing youth contact sports mean that your child will inevitably develop CTE?

Michael Alosco: No. Playing youth contact sports on its own, we do not think will lead to this progressive brain disease. We’ve done some research on looking at the association between when you start to play tackle football, playing at a youth levels before the age of 12. These have all been in people who have gone on to play football to a much greater level, so people have gone on to play high school, college and mostly professional football as well.

Michael Alosco: We see an association where the younger you start to play, it seems to increase your vulnerability to later life symptoms and cognitive and behavior, mood problems. But playing youth football or playing youth contact sports on its own is unlikely to be sufficient to result in CTE.

Jay Ruderman: Let’s talk a little bit about, since this is your field of study, the diverging opinions. I’m sure you have colleagues who are like, “Absolutely not. This is a danger to our youth and others who are like, ‘It’s fine.’” So can you talk about the debate within your science?

Michael Alosco: One of the issues is that … I described being around since 1928. But really, we are in the beginning stages of characterizing and defining the long-term consequences participating in contact sport. So it’s a relatively emerging field. As a result, I think we don’t yet fully know. Does contact sports directly lead to these long-term problems? That’s something we’re still trying to figure out through longitudinal studies.

Michael Alosco: Right now, there are some people who are not sure yet about the association between contact sports and long-term consequences. However, our data does really raise the possibility and really suggest that there is a link, and this is something that we’re going to further explore in the future.

Jay Ruderman: Okay, so since research on CTE has become more public, what shifts have you seen in the decisions of parents to let their children play football and other contact sports? And what changes have you seen in these sports themselves and the people that are running them?

Michael Alosco: In terms of the first part of the question, I think we do know that there’s a decline in participation rates and in things like youth football or even high school football. I think that the research on CTE, the research on the long-term consequence of contact sports has led to quite a bit of awareness to the potential risk associated with participating in contact sports. But at the same time, we also … This goes back to your question on diverging opinions.

Michael Alosco: At the same time, we also like to advocate that there’s a lot of benefits associated with playing sports. You know, leadership, psychosocial, psychological benefits, and it’s kind of bringing that risk benefit relationship. So that’s something that’s always important to keep in mind. In terms of your other question about what have we seen at the organizational level, so again, there’s been a ton of awareness. There certainly have adopted protocols to better improve detection and management of concussion.

Michael Alosco: But perhaps this disease isn’t really about concussion, and that’s one of the things we’re always trying to educate the public on is that CTE is associated with repeated head trauma. So these are subconcussive hits. When I say subconcussive, those are the tiny hits to the head that don’t result in immediate symptoms we think result in some type of injury to the brain. So if you think about linemen on every down and every play, they’re hitting their head. No symptoms right away, but we think that there is some type of injury going on to the brain.

Michael Alosco: Those are the types of hits that football players can have hundreds, if not thousands per season. So really, how you prevent those types of hits in the game of football is a complicated question, and I don’t know if they can be prevented. They can certainly be limited. Other contact sports like soccer and so on could certainly be modified because the repetitive hits aren’t as inherent to the game.

Jay Ruderman: So is there a number associated, like a certain number of hits means that you’re all that more likely to develop CTE in your life?

Michael Alosco: Yes, so that’s what we’re looking at. Is there a threshold in terms of years of play or in terms of number of hits you hit your head? I don’t think we know that answer yet, but I think that has very important public health implications by getting at that exact question.

Jay Ruderman: So football is a huge part of the American culture. The NFL owns a day of the week. College football is the biggest thing in many communities and states around the country. You as a scientist, and in the field of medicine, what’s the pushback? I mean, it must be tremendous when it’s such an ingrained part of our culture.

Michael Alosco: That’s a good point, especially when you’re trying to adopt change in a game like football. It can be really hard because it is so part of our culture. So the more research that has come out I think has really started to resonate with a lot of people in the country. But it is a difficult thing. I think change in any type of behavior is hard, and at the end of the day, people are always going to engage in risky behaviors. How long have we known about the long-term consequences of smoking? People still smoke.

Michael Alosco: Certainly, there’s a lot of awareness to that, and I think we’ve gotten better, but people still smoke. We’re also not advocating for things like removing contact sports or removing tackle football. I think that’s ridiculous. I think what we’re trying to do is conduct science and conduct research to look at the long-term effects or look at the risk and then figure out a way is how can we minimize that risk? How can we benefit from all these benefits that team sports have but at the same time minimize someone’s risk?

Jay Ruderman: So our professional sports, college sports, even youth sport, are they in contact with you and others in your field to take your research seriously and try to think about modifications to the sport?

Michael Alosco: One of the organizations, Concussion Legacy Foundation is a non-profit who works with a lot of these organizations to figure out a way to minimize this risk. In fact, one of the things that CLF or Concussion Legacy Foundation has done is they recently got heading in soccer to not be allowed until after the age of 10, I believe. They’re right now running a campaign where they’re looking at flag football under the age of 14, so not playing tackle football until high school.

Michael Alosco: So yeah, we work closely with them through outreach, but they’re interacting with the different leagues, kind of push this change along.

Jay Ruderman: Some of the high-profile suicides and deaths of football players, how does that impact what you’re doing or the public discussion?

Michael Alosco: I think it raises awareness, certainly. I think suicide in particular is very complicated though. I think sometimes in the setting when a suicide happens, and there’s evidence of CTE, people are quick to link the two, but it should be noted that suicide is a very complicated construct that’s never caused by one thing. So we really don’t know the relationship between suicide and CTE.

Jay Ruderman: Okay, let’s talk a little bit about your research. Where are you at this point? If you can divulge, what are some of your main findings and which direction are you heading?

Michael Alosco: I mean, most relevant to what we’ve been talking to today is about youth football. We’ve had a series of papers come out. One in 2017 looked at the relationship between the age you start to play football and long-term cognitive behavior and mood consequences in 214 former, amateur and professional football players. We found that the younger you started to play, the more problems with things like depression, apathy, reported executive function emerged later in life.

Michael Alosco: Then most recently, we also looked at the relationship between when you start to play and the onset of symptoms and CTE in deceased football players who were diagnosed with CTE after death. So CTE right now can only be diagnosed through an evaluation of the brain after death. So, post-mortem examination. It included 246 deceased football players. 211 had CTE. We actually did not find a relationship between when you start to play football and disease severity. But the younger you started to play did in fact correlate with earlier onset of cognitive and behavioral symptoms, and that’s a really complicated set of findings.

Michael Alosco: But it suggests to us that in the context of individuals who play football for a long time, the younger you start may increase your vulnerability to the symptoms. But it could also extend to Alzheimer’s disease. It might be a modifying variable where your vulnerability becomes increased. So in the research that we’ve done, we’ve actually found that the younger you start to play football has been associated with earlier onset of cognitive behavior and mood symptoms in diseased football players diagnosed with CTE.

Michael Alosco: In fact, those who started playing before the age of 12 on average had onset of symptoms 13 years earlier than those who started playing football after the age of 12.

Jay Ruderman: So is that the cutoff? Is that a recommendation? You know, don’t let your kids play before 12? Or is it a moving target?

Michael Alosco: Almost all of our studies have focused on the age of 12, and the reason being is that before the age of 12 is a time of really peak neurodevelopment, so peak brain development where the brain is really rapidly growing and might be most vulnerable to injury. We focused on age 12. Is it the magic number? If you start playing at 13, is it going to make a difference or 11? We don’t think that. But it’s a number that we focused on, and we found some pretty powerful findings across several of our studies.

Jay Ruderman: Just out of curiosity, the helmet. Have you looked into the redesign of the helmet? I know there are several different new helmets that are coming out. Are they going to potentially impact this? Or is it a non-issue?

Michael Alosco: Helmets do a great job of preventing skull fractures. A concussion or even a subconcussion occurs when there’s an impact or a force applied to the head, and it causes the brain to move around within the skull and rotate and bounce around. So it’s unclear how a helmet can actually prevent the brain from stopping to move within the skull. It can definitely prevent you from getting skull fracture, but we’re not sure, and hopefully the technology will exist and will develop to do so. But it’s unclear how it can actually prevent a concussion or a subconcussive trauma.

Jay Ruderman: Can you talk about the scope of your study? How many people, former football players or current football players you worked with? And, what was the willingness of people who’ve devoted their lives to football to work with you on this issue?

Michael Alosco: Sure, so I described two studies to you, both of those looking at age of first exposure, youth football. But we have a lot of the larger ongoing studies. At the CTE Center, we have the VA-BU-CLF Brain Bank. That’s directed by Dr. Ann McKee, and that brain bank includes individuals who donated their brains either before they passed or after they passed by family members to better understand chronic traumatic encephalopathy. So everyone who donates their brain has a history of repeated head trauma. That can be from football, other contact sports, military service, domestic violence, and so on.

Michael Alosco: In that brain bank, there’s over 600 cases, and we’ve reported in the literature on … In 2017, there’s a JAMA paper that identified CTE in 177 out of 202 former football players. So that’s a very large study looking at the neuropathology of CTE. We also have studies looking at living subjects, and these are mostly former football players. These are being led by Dr. Robert Stern. There is one study that’s now concluded. It was funded by the NIH. It’s known as the detect study and that looked at about 100 former National Football League players and about 30 controls.

Michael Alosco: There’s an ongoing study right now also funded by the National Institutes of Health. It’s a seven-year multi-site study, and that’s looking at over 100 former NFL players. It’s also looking at college football players and controls. We’re looking at it both in life and also after death, and we have quite a bit of people who are participating. To get at your second question, the willingness is actually very high. A lot of these people who are participating in research, they are individuals who are eager to participate, to learn and to understand what are the long-term consequences of playing football.

Michael Alosco: Some of them are concerned on their own, and because no treatments, or you can’t diagnose this disease during life, this is one of the only ways that they can get involved and potentially try to get some answers.

Jay Ruderman: We talked a little bit about coming up against the culture. You’re also coming up against a huge industry that’s worth billions of dollars. Do you feel that pressure in terms of continuing your research?

Michael Alosco: I don’t think so. I think there’s certainly … The industry and financial side of things in our research. But I think our research is really focused on the science and really figuring out what are the risks, what are the long-term consequences of playing contact sports. We work through peer review and rigorous scientific process to conduct our studies. So in that sense, I don’t think we feel any pressure. Our primary pressure is addressing this public health issue. From that standpoint, we want to be able to figure out this disease. We want to be able to diagnose it during life and eventually get to treatment and prevention.

Jay Ruderman: If one of my young children wanted to play football or another contact sport, and I asked your opinion. What would you say to me and other parents who are in a similar position to myself?

Michael Alosco: We do get that question a lot, particularly about youth sports. From my perspective, I would not allow my child to play football. I think it’s hard to modify that game, especially at a young age. But that said, we are very aware of the benefits. We first like to educate. We want to make you aware and make everyone aware of the risks or the potential risks and what it could potentially be associated with. So I think it’s important to know those risk. Then as a parent, you make an informed decision. I think all parents try to do what’s best for their children.

Michael Alosco: So then I think they have to ask themselves. I think we have to ask ourselves, “Does it make sense to bring your kid to play football where they’re repeat hitting their head over and over again? Does that intuitive intuitively makes sense?” I think those are the questions we have to ask, and I think conducting more research will help raise awareness to that.

Jay Ruderman: If you remember the history of prevention of smoking, first, people were made aware of the risks and the potential consequences, and then it began to be legislated in terms of high taxation and restrictions. So juxtaposing that to football, what do you see looking into the crystal ball about the landscape of football changing over the next, let’s say, 10 years?

Michael Alosco: So I’m going to get to your question, but one point I do want to make though is that we’re talking about the CTE. We’re talking about its association with contact sports. Not everyone who plays contact sports or expose repeated head trauma goes on to develop problems. There’s plenty of people, millions of people who are very successful and are doing just fine, and it’s what we’re doing now too is to look at the risk factors that interact with this head trauma to get you to the point of CTE.

Michael Alosco: But bringing it back a little bit to your question, I think you’re right. I think at some point there’s going to need to be a legislative effort in terms of, “Should there be no tackle football as a youth?” I’m doubtful that will happen without legislation, and I’m not sure because one of the reasons being is that there’s been studies that show just socioeconomic status. So that will influence whether or not flag football can be an alternative method.

Michael Alosco: Some people might not have access to such programs. To really get changed broadly across the board, I think you’re right in that it might have to go through legislation. I think you’re going to see a lot more changes. You’ve seen a lot of changes already to the game of football. But I think there’s going to be more changes to make it safer, hopefully. So I think with more research, there’s going to be more awareness, and there’s going to be more changes to the game. Potentially, some of those changes through legislation.

Jay Ruderman: Is there anything that we haven’t covered that you really want the public to understand about this issue that’s really maybe not well understood?

Michael Alosco: I think the most important piece of information that we’re always trying to advocate and that’s not always clear is that we don’t think that CTE is a consequence of a single or even multiple concussions or traumatic brain injuries. We really think it’s related to years and years of exposure to this repeated head trauma. The type of head trauma where you can have hundreds of thousands of hits per season every year for 20 years or more. I think that’s really important because I think there’s concerns that if I have a concussion, “I hit my head today, or I had a concussion yesterday, and then am I going to get CTE?” We don’t think that’s the case, and we want to make sure people are aware of that.

Michael Alosco: The other thing too is that just because you play contact sports or just because you play football doesn’t mean you are going to get CTE. We think that this is a disease that might start with some exposure to these repeated hits to the head and then interact with a bunch of different other risk factors, genetics, lifestyle, a host of different risk factors that interact to lead to this disease. So it’s just not one pathway or one thing.

Jay Ruderman: Well, I want to thank you, Dr. Alosco for joining me today. This was a fascinating discussion, and I think it’s food for thought for millions of people across America and in other parts of the world, and we look forward to following your research.

Michael Alosco: Thank you for having me.