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Concussions, CTE and Confusion Among Experts

The Internet makes everybody an instant expert.

For most of us, if we're curious about a topic, we plug it into Google, read the Wikipedia article and maybe a few of the citations and boom, knowledge. The more research-inclined might go seek out articles from reputable journals if they're available for free. But we can form a pretty reasonable knowledge base with just a few hours of getting lost on our keyboards.

Unfortunately, real research isn't nearly so cut-and-dried, and it's an incredibly lengthy. complicated process that's as likely to give a murky answer as a definitive one.And when it comes to newly discovered, controversial issues like the tie between contact sports, concussions and degenerative brain diseases, it's often hard to separate the known truth from unproven hypothesis or simple overstatement.

Nicholas J. Cotsonika of Yahoo Sports had a pair of wonderful articles on a condition called "chronic traumatic encephalopathy" that's been all the rage in sports medicine circles for the past few years, and Puck Daddy followed up with a longer excerpt of the interview with Toronto Maple Leafs general manager Brian Burke, who is featured heavily.

I don't want to repeat any of his great reporting, but I do think all Dallas Stars fans who want to learn more about the topic, whether out of concern for the own hockey players in their family or simple curiosity, could use a little more knowledge about exactly where the Boston University team is in the research process and why there is a very legitimate case to be made that they don't know nearly as much as they say they do, at least yet.

After the jump, a brief primer on CTE and the words you'll see thrown around when discussing it, an overview of the research process and where this study is in that journey and what, exactly, is it studying and the politics of research, publicity and grant money.

CTE is a little bit of a confusing term because people can use it to mean one of two things. One is a physical condition, where "abnormal tau protiens" are found in the brain in excess amounts and a likely cause is repeated head trauma, whether that's a concussion or a milder blow. The other is a set of symptoms that are progressive and degenerative, including depression and dementia, that some researchers believe are directly related to (and possibly caused by) the tau proteins.

The acronym CTE can be used to describe either or both of these things, and because the level of that protein cannot be measured while a person is alive, it is impossible to make a diagnoses before a brain autopsy. It's also not known if these abnormal proteins are a cause or effect of the symptoms of many major brain diseases or if they occur at the same time but are not related to the symptoms at all. What is known is they show up in the brains of patients with diseases like Alzheimer's and dementia, though again, their relationship to how those diseases work is not clear.

In the early 2000s, researchers began finding those proteins in the brains of former NFL players in large amounts, much larger than they would expect for a middle aged adult who had not been diagnosed with a degenerative condition. Several, though notably not all, of those players suffered from neurological symptoms like depression and decreased mental function. After autopsies of several players, a hypothesis about those proteins causing the symptoms was born, and because many of the athletes played a sport with a much higher risk of concussion or other head trauma, a further hypothesis was drawn about those sports putting athletes at risk for the physical condition (and therefore, the symptomatic condition) later in life.

Research is ongoing, but as this is a condition that can only be diagnosed after death, there are very few samples so far. My mother, a professor who has taught graduate-level courses about research at major universities and who I drew on heavily for this story, refers to the number of samples as N. From my understanding of the stories, the N of the largest CTE study is around 96, a very small number in the scheme of research.

That process is the next source of confusion in reporting about CTE. The CTE studies are very, very early in their lifespans. What they seem to be looking at now is the prevalence of these tau proteins in the brains of deceased athletes of contact sports, regardless of whether or not those athletes were symptomatic at the time of their deaths. The prevalence seems to be about 74 percent, which is very high and suggests (though does not prove) some sort of tie between contact sports and a large amount of this abnormal protein.

But remember, this research is not studying a tie between that protein and presence of symptoms, nor is it comparing the former athletes to a control group to find out things like "Are some people born with more abnormal tau proteins?" or "Do people who play contact sports only as children also have similar brains at X age?"

What they seem to have discovered so far is a correlation, but correlation is nowhere near the same thing as causation. They need a much larger-scale study to be able to prove that. When other doctors or researches criticize some of the publicity, this is the hole they're usually pointing at. One of the linked articles gives a very good parallel when it comes to plaque in the arteries as to what they believe these tau proteins might be equivalent too. And to be fair to this group, none of them discourage further research - they are simply against the current results being taken as proof that contact sports cause a dementia-like disease later in life.

The counterpoint from the researchers is a public-health type rationale. They sincerely believe repeated head trauma causes a chronic, degenerative brain disease even if their research hasn't proved it quite yet. They believe they see enough smoke that they are compelled to warn people about the oncoming fire even if they can't see it over the ridge. It's an understandable argument, but one that's rooted in the assumption that their multiple hypotheses are correct.

You can fall on either side, but the truth is, at this point of the research process, no one really knows what the truth is. That's why they do research.

Finally, a fairly cynical point about what I think is really driving some of this publicity - money. Just like everyone else, research universities need funding, and lots of it. And as Boston University has established a specific institution for the study of CTE, I suspect on some level they are always on the look-out to get their name, and their center's name, associated as the leading institute for research into this topic the world. In their perfect world, this gets them more grant money, which in turn allows them to further their research, attract better scientists and raise their profile, which then gets them even more money and the cycle continues.

It's an ugly side of academia and research, but it's also real. Studies and institutes don't pay for themselves.

I hope you came out of this article with a clearer take on a very complex process that can't be condensed into a 500-word newspaper article (or even a 1,300-word blog post - that's why I needed so many links). It's going to be a hot topic among hockey circles for the foreseeable future with no real clear answer emerging for some time, I expect.