Inappropriate diagnoses

April 22, 2020

At a glance: A postmortem exam of the brain remains the gold standard for diagnosing chronic traumatic encephalopathy, or CTE, the neurodegenerative brain disease believed to arise from repeated hits to the head.

Yet a small but by no means trivial number of former professional football players say they have received a diagnosis of CTE, according to a new study from Harvard Medical School and the Harvard T.H. Chan School of Public Health published April 13 in Annals of Neurology.

The research--based on a survey of nearly 4,000 former NFL players, ages 24 to 89--was conducted as part of the ongoing Football Players Health Study at Harvard University, a research initiative that encompasses a constellation of studies designed to evaluate various aspects of players' health across the lifespan.

Even though the results are based on player self-reports rather than on documented clinical diagnoses, the researchers say their findings are alarming for a number of reasons.

First, CTE is a post-mortem diagnosis and cannot be diagnosed definitively in living individuals. Second, an erroneous, or clinically unverifiable, diagnosis of CTE could obscure the role of other treatable conditions common among former football players that could cause a cluster of cognitive and behavioral symptoms mimicking CTE. Third, delivering a verdict of an untreatable disease could render patients hopeless, discouraging them from pursuing healthy behaviors and focusing on modifiable risk factors and conditions that may give rise to symptoms attributed to CTE.

Researchers emphasize that any cognitive and behavioral symptoms should be investigated thoroughly, and CTE concerns should never be dismissed.

"Former football players are rightfully worried about brain health and CTE concerns should not be overlooked, yet in the absence of validated clinical criteria and diagnostic methods for CTE, the fact that former players report being told they have the disease is highly concerning," said study lead author Rachel Grashow, a researcher at the Harvard T.H. Chan School of Public Health. "A diagnosis of CTE could downplay the effects of other conditions and discourage the pursuit of alternative explanations, while creating a sense of despair among those who believe they might have an untreatable brain condition."

Nearly 3 percent of the players in the current study (108 out of 3,913) reported they had received a diagnosis of CTE from a physician or another clinician. Those older than 60 were more likely to report a CTE diagnosis than younger players (3.7 percent, compared with 2.3 percent).

Symptoms of cognitive impairment--difficulty concentrating, forgetfulness, mood changes--were notably more common among former players who reported CTE diagnoses, regardless of age. Those who reported a CTE diagnosis were also more likely to report sleep apnea, heart disease, hypertension, stroke, depression, high cholesterol, obesity, use of prescription pain medication and low testosterone.

All of these are relatively common in former football players and can cause certain cognitive symptoms, which could be fueling clinical suspicion for CTE among some physicians, the researchers said. Given that safe and effective interventions exist for many of these conditions, it is critical that these patients are evaluated and treated before cognitive problems are prematurely or wrongly attributed to CTE.

Former players who self-identified as Black had higher percentages of CTE diagnoses, the study found. Researchers said the higher prevalence of conditions such as high blood pressure, diabetes and cardiovascular disease among Black men may explain the higher rate of CTE diagnoses in this group.

The current study was not designed to determine why or how the CTE diagnoses were made. The researchers, however, say a number of factors could be at play.

For example, some clinicians may suspect the presence of CTE because past studies have identified a link between neuropsychiatric symptoms in the decade preceding an athlete's death and subsequent postmortem CTE diagnosis. Also, clinicians may be seeing certain behavioral and cognitive changes as markers of brain degeneration, propelling them to consider a CTE diagnosis, while downplaying or not fully exploring alternative explanations for the symptoms, such as sleep apnea, heart disease or depression. Clinicians may also be more likely to consider--and suggest--CTE to players who spent their careers in more high impact positions, the researchers said.

Lack of clarity about symptoms and possible causes might leave patients prone to over-interpretation and set the stage for misunderstanding, the researchers said.

"Given the high visibility and intense media coverage of CTE, former football players may be highly sensitive to any hints or suggestions of CTE and assume a connection between their symptoms and this rather high-profile, but not necessarily accurate or appropriate, diagnosis," Grashow said. "Either way, it is incumbent upon the physicians who care for former athletes to ensure that such clarity is achieved."

None of this is to say that some former players may not, in fact, have CTE.

"CTE is real, and it probably plays a role in the cognitive or behavioral symptoms experienced by some former players, yet many of these symptoms could also arise from a number of other, more treatable, conditions," said study senior author Ross Zafonte, head of the Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation Hospital and Harvard Medical School.

Zafonte cautioned that a grim diagnosis like CTE could magnify symptoms, a psychological phenomenon known as the nocebo effect. It could also discourage people from engaging in healthy behaviors and pursuing critical treatments for other conditions responsible for the symptoms, added Zafonte, who is also principal investigator of the Football Players Health Study.

First described in the 1920s as boxers' dementia or "punch-drunk syndrome," CTE gained public attention over the last 20 years after a series of reports identified the hallmarks of the disease--abnormal protein clumps in certain parts of the brain--in postmortem exams of former football players, many of whom had shown cognitive, emotional and behavioral symptoms for more than a decade prior to their postmortem exams. CTE develops predominantly in people who sustain repeated blows to the head, including athletes in contact sports such as boxing, football, hockey and rugby, in military personnel who sustain head trauma and in victims of domestic violence.
-end-
The research was funded by the National Football League Players Association (NFLPA).

Other investigators involved in the study include Marc Weisskopf, Aaron Baggish, Frank Speizer, Alicia Whittington, Lee Nadler, Ann Connor, Robyn Keske, Herman Taylor and Alvaro Pascual-Leone.

Relevant disclosures:

The authors of the study are or were either partly or fully supported by the Football Players Health Study at Harvard University, which is in turn sponsored by the NFL Players Association. The NFLPA had no role in the design and conduct of the study; in the collection, management, analysis and interpretation of the data; in the preparation, review or approval of the manuscript or in the decision to submit the manuscript for publication.

About the Football Players Health Study at Harvard University

Launched in 2014, the Football Players Health Study at Harvard University is composed of select studies and research initiatives addressing the whole player over the course of his entire life. The study is funded pursuant to an agreement with the NFLPA, utilizing shared resources across supporting institutions at Harvard University. With more than 4,100 participants, it is the largest study of living former players. Several smaller studies supporting novel research and promising treatments are currently underway across the University. The research is independent and not directed by the NFL, NFLPA, or any other stakeholder. These organizations exercise no control over the findings or recommendations.

Harvard Medical School

Related Heart Disease Articles from Brightsurf:

Cellular pathway of genetic heart disease similar to neurodegenerative disease
Research on a genetic heart disease has uncovered a new and unexpected mechanism for heart failure.

Mechanism linking gum disease to heart disease, other inflammatory conditions discovered
The link between periodontal (gum) disease and other inflammatory conditions such as heart disease and diabetes has long been established, but the mechanism behind that association has, until now, remained a mystery.

New 'atlas' of human heart cells first step toward precision treatments for heart disease
Scientists have for the first time documented all of the different cell types and genes expressed in the healthy human heart, in research published in the journal Nature.

With a heavy heart: How men and women develop heart disease differently
A new study by researchers from McGill University has uncovered that minerals causing aortic heart valve blockage in men and women are different, a discovery that could change how heart disease is diagnosed and treated.

Heart-healthy diets are naturally low in dietary cholesterol and can help to reduce the risk of heart disease and stroke
Eating a heart-healthy dietary pattern rich in vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, vegetable oils and nuts, which is also limits salt, red and processed meats, refined-carbohydrates and added sugars, is relatively low in dietary cholesterol and supports healthy levels of artery-clogging LDL cholesterol.

Pacemakers can improve heart function in patients with chemotherapy-induced heart disease
Research has shown that treating chemotherapy-induced cardiomyopathy with commercially available cardiac resynchronization therapy (CRT) delivered through a surgically implanted defibrillator or pacemaker can significantly improve patient outcomes.

Arsenic in drinking water may change heart structure raising risk of heart disease
Drinking water that is contaminated with arsenic may lead to thickening of the heart's main pumping chamber in young adults, according to a new study by researchers at Columbia University Mailman School of Public Health.

New health calculator can help predict heart disease risk, estimate heart age
A new online health calculator can help people determine their risk of heart disease, as well as their heart age, accounting for sociodemographic factors such as ethnicity, sense of belonging and education, as well as health status and lifestyle behaviors.

Wide variation in rate of death between VA hospitals for patients with heart disease, heart failure
Death rates for veterans with ischemic heart disease and chronic heart failure varied widely across the Veterans Affairs (VA) health care system from 2010 to 2014, which could suggest differences in the quality of cardiovascular health care provided by VA medical centers.

Heart failure: The Alzheimer's disease of the heart?
Similar to how protein clumps build up in the brain in people with some neurodegenerative diseases such as Alzheimer's and Parkinson's diseases, protein clumps appear to accumulate in the diseased hearts of mice and people with heart failure, according to a team led by Johns Hopkins University researchers.

Read More: Heart Disease News and Heart Disease Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.