Chris Nowinski, Ph.D. the Sports Concussion

THE SPORTS CONCUSSION & CTE CRISIS: HOW NEW RESEARCH IS CHANGING HOW WE VIEW HEAD IMPACTS CHRIS NOWINSKI, PH.D.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF MY HISTORY

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CHRIS HARVARD IN IOWA

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DR. CANTU CHANGES MY LIFE

Dr. Robert Cantu 4 in wrestling >2 in football

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DR. CANTU’S 3 LESSONS

1. Dings are concussions

2. Immediate remove from play is essential, and no return until symptoms clear (and cleared by a doctor)

3. There may be long-term effects

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF NEW REVELATIONS?

“During the past 7 years the practice has been too prevalent of allowing players to continue playing after a concussion. Again this year this is true. Sports demanding personal contact should be avoided after a concussion.”

1937 – Proceedings of the 17th annual American Football Coaches Association meeting

I should write a book!

Advance:

$4,000

Insurance:

$21,000

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF HEAD GAMES

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ANDRE WATERS COMMITS SUICIDE • November 20, 2006

• “I think I lost count at 15.” He later added: “I just wouldn’t say anything. I’d sniff some smelling salts, then go back in there.”

12 ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation.org ConcussionFoundation ConcussionFoundation.org @ConcussionLF 13 @ChrisNowinski1 CONCUSSION LEGACY FOUNDATION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CONNOR MARTIN, OREGON

Oregon high school football player sues for $38 million after suffering concussion.

Suffered a concussion, cleared 4 days later, suffered another, symptoms may be permanent.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 15 RASHAUN COUNCIL AWARDED $7M Instead of calling 911, the coach called Rashaun’s mother, the lawsuit states. The boy’s father, Terry Council, arrived to find Rashaun on the ground, slumped over with his head between his legs, covered in his own vomit. His father took him to an emergency room, and Rashaun was diagnosed with a concussion and a subdural hematoma, a collection of blood between the brain and its outer covering.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 16 COMPLICATIONS – SHORT AND LONG TERM

Weeks Months Years

Second Impact Syndrome

Delayed Return to Play

Post Concussion Syndrome

CTE?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF SECOND IMPACT SYNDROME

• Second Impact Syndrome occurs when an athlete, who has already sustained a head injury, sustains a second head injury before symptoms have cleared from the first injury

• This second blow to the head, sometimes minor, can result in a loss of auto-regulation of the brain's blood supply, leading to rapid brain swelling.

• 50% of SIS sufferers die, and the survivors rarely recover fully. It usually occurs to athletes <21 years old, although it can happen to older athletes

Source: NY Times, Cantu, R. C. (1996). Head injuries in sport. British Journal of Sports Medicine, 30, 289-296. ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CONCUSSION RATES BY SPORT Volleyball Baseball Softball Basketball (M) Fake News Basketball (W) Field Hockey Wrestling Soccer (M) Soccer (W) Lacrosse (M) Lacrosse (W) Ice Hockey (W) Ice Hockey (M) Football

0 2 4 6 8 10 12

College High School Source – Institute of Medicine

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CONCUSSION EPIDEMIOLOGY

• 730 Division I FCS football players • Questions: – How many concussions did you have last season? – How many additional concussions did you think you had but did not report? – How many dings or bell-ringers did you have? 1 6 21

Source: Baugh et al (2014) ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DELAYED SYMPTOMS, DELAYED DIAGNOSIS • 3 Division FBS Football Programs

Timing of Diagnosis Percent Immediately or within minutes 17% Later the same day 41% Next day 22% 2-4 days later 20%

• Average diagnosis was 17 hours later

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF PATRICK CHUNG

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CHUNG KO’D

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF LONG-TERM EFFECTS

• One concussion = Parkinson’s 56% – Gardner RC et al. Mild TBI and risk of Parkinson disease: A Chronic Effects of Neurotrauma Consortium Study. Neurology 2018.

• One concussion (no LOC) = Dementia 136% – Barnes DE et al. Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in US Military Veterans. JAMA Neurology 2018.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CHRONIC TRAUMATIC ENCEPHALOPATHY

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF VA-BU-CLF BRAIN BANK

• Founded in September 2008, the first center in the world dedicated to CTE research

• Pathological, clinical, and basic science research

• The world’s largest CTE brain bank now contains 630 brains and nearly 400 new cases of CTE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF THE RESEARCH TEAM

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• First named in 1928 by Dr. Harrison Martland

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF A NEGLECTED DISEASE?

• Prior to 2005, there were only 45 cases of CTE in the medical literature!

Primary Trauma Source 45 Boxing 39 Soccer 1 Battered spouse 1 Head banging behavior 2 Circus clown 1 Epilepsy 1

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 29 * Source: McKeet et al. 2009 © 2011 SLI Sign up at: ConcussionFoundation.org/Pledge

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 2015 NINDS CTE CRITERIA

• In CTE, the tau lesion considered pathognomonic is an abnormal perivascular accumulation of tau in neurons, astrocytes, and cell processes in an irregular pattern at the depths of the cortical sulci.

Tau antibody staining of neurons and Lower field photo illustrating the neurites in perivascular pattern (arrow focal nature of the tau staining at pointing to blood vessel). depth of sulci (asterisk at bottom of sulcus).

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Videos courtesy of Dr. Joel Stitzel, Wake Forest University - [email protected] ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Walter J. Koroshetz, M.D. National Institutes of Health Director, National Institute of Neurological Disorders and Stroke

“I don't think there's any wiggle room. It's pretty clear this is due to head injury. Whether there are other things involved, and when it starts, that's hard to know, but I don't think there's any question that it's related to head injury.”

March 6, 2014. ESPN

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Daniel Perl, M.D. Professor Director of CTE Research Department of Defense Uniformed Services University

“CTE is only seen in the setting of repeated head trauma. At the end of the day, this is produced by head trauma. I'm sorry, that's what all the research says.”

March 6, 2014. ESPN

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DAVE DUERSON

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF PATRICK AT AGE 29

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF PATRICK GRANGE’S BRAIN

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CTE in an Active College Football Player

• Co-Captain of 2010 Penn Football Team • Began playing football at 9 years old

• Committed suicide April 26, 2010, at the age of 21

• No history of concussion • No history of mental illness • Mentioned doing poorly in two classes to his parents the day before hanging himself in his off-campus apartment

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 41 Owen Thomas had CTE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 42 Eric Pelly, 18 Years-Old

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF © 2011 SLI 43 ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF MILD CTE

Reported symptoms:

Stage I: (mean age 28) Headaches and issues related to attention and concentration

Stage II: (age 44) Symptoms expand to include depression, explosivity and short-term memory impairment

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF SEVERE CTE

Stage III: (age 56) Cognitive impairment and problems with executive functions, specifically planning, organization, multitasking and judgment

Stage IV: (age 77) Full-blown dementia (i.e., memory and cognitive impairments severe enough to impact daily living) in 90%

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF JAMA JULY 2018

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF NEW YORK TIMES

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF NFL LEGEND NICK BUONICONTI • Nick, age 76 and in a wheelchair, has probable CTE

• @ChrisNowinski1

• @ChristopherNowinski

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF HOW SHOULD WE RESPOND TO THIS DATA?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Individuals may have a higher risk of developing CTE in the future if they engage in activities that increase their chances of having repetitive hits to the head.

Researchers currently do not know the incidence and prevalence of CTE, but they do know that CTE does not occur only in athletes. The greatest risk factor for CTE is the number of years of exposure to repeated head or brain injuries (subconcussions in particular).

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF RISK FACTORS – ENVIRONMENTAL EXPOSURE

Smoking CTE 1 Packs per Day Hits per Season 2 Age at First Exposure Age of First Exposure 3 Years of Smoking Years of Brain Trauma

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF RISK FACTORS – ENVIRONMENTAL EXPOSURE

Smoking CTE 1 Packs per Day Hits per Season 2 Age at First Exposure Age of First Exposure 3 Years of Smoking Years of Brain Trauma

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WHAT IS THE EFFECT OF AGE?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF • Men who started smoking before 20 had are 2x as likely to get lung cancer as those starting later

Gender OR <20 OR ≥ 20 Men 12.7 6.0

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF AGE OF FIRST EXPOSURE ASSOCIATED WITH COGNITIVE IMPAIRMENT

• 246 American football players – 211 CTE (126 CTE-only) – 35 without CTE (26 with progressive pathologies, 34 with symptoms)

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF AGE OF FIRST EXPOSURE TO TACKLE FOOTBALL AND CHRONIC TRAUMATIC ENCEPHALOPATHY • Each additional year of youth tackle football was associated with earlier cognitive sx by 2.4 years & behavioral/mood sx of 2.5. • Starting before age 12 was associated with an onset of symptoms 13 years earlier.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF RISK FACTORS – ENVIRONMENTAL EXPOSURE

Smoking CTE 1 Packs per Day Hits per Season 2 Age at First Exposure Age of First Exposure 3 Years of Smoking Years of Brain Trauma

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF LEGEND STUDY – BEHAVIORAL DYSREG • Cumulative Head Impact Exposure Predicts Later-Life Depression, Apathy, Executive Dysfunction, and Cognitive Impairment in Former High School and College Football Players. Montenigro PH, Alosco ML, Martin B, Daneshvar DH, Mez J, Chaisson C, Nowinski CJ, Au R, McKee AC, Cantu RC, McClean MD, Stern RA, Tripodis Y. J Neurotrauma. 2016 Mar 30.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF META-COGNITION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF EXECUTIVE DYSFUNCTION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DEPRESSION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF APATHY

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF COGNITIVE IMPAIRMENT

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF FLAG FOOTBALL UNDER 14

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF BIANJ VISION STATEMENT

Our vision is a world where all individuals with brain injury and their caregivers maximize their quality of life, the consequences of all unavoidable brain injuries are minimized and all preventable brain injuries are prevented.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF FlagFootballu14.org ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF BENEFITS UNIQUE TO TACKLE FOOTBALL?

The consensus top 5 NFL players all-time did not play football until high school

1. Jerry Rice 2. Jim Brown 3. Tom Brady 4. Lawrence Taylor 5. Walter Payton

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF EXPERTS DISCOURAGE YOUTH TACKLE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF FACT VS FICTION

• A law has been proposed in New Jersey to ban tackle football before 12.

• What are the arguments against flag football under 14/tackle football bans?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF “The pathology and link between head impacts and long-term neurological conditions such as CTE is still unclear, with questions of causation yet to be settled.”

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF • >1,700 brains, CTE in 21/66 contact sport CTE CTE athletes (32%) Exposure Total Present Absent • 0/165 with CTE in controls without brain Contact Sports 21 45 66 trauma or contact sports No Contact Sports 0 198 198 • 0/33 brains with CTE with a single TBI Total 21 243 264 • Strong evidence linking contact sports to CTE p = 1.44 x 10-14

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF “CTE pathology in the brain has been shown by British pathologists to be present in approximately 12 percent of normal healthy aged people who died at an average age of 81 years (Ling et al. Acta Neuropathologica)…. To be clear, CTE pathology could be present in a normal person.”

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DO 13% OF CONTROLS HAVE CTE?

13% of normal individuals have CTE pathology?

Ling, H., J. L. Holton, K. Shaw, K. Davey, T. Lashley and T. Revesz (2015). "Histological evidence of chronic traumatic encephalopathy in a large series of neurodegenerative diseases." Acta Neuropathol 2015. 130(6): 891-893.

Slide courtesy of John Crary ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CTE IS STILL CONFUSED WITH ARTAG & PART

Brain atrophy in CTE Microscopic – neurofibrillary tangles Diagnostic CTE injury Age-related changes

PART

ARTAG

Slide courtesy of John Crary ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF FACT VS FICTION

• What are the arguments against flag football under 14/tackle football bans?

• Kids don’t hit hard enough.

• “The science, in fact, concludes that it is the continuation of playing that could contribute to the risk of developing CTE or other problems. That continual playing is specifically at the highest energy levels found in college and professional football, most certainly not at the lowest energy levels of youth football.” – President of the largest youth tackle football program in Illinois

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF PUSHBACK BASED ON FICTIONS • Kids don’t hit hard enough to hurt each other. FICTION • Mean impact of a 7 year-old is ~80% as hard as college football players

1. Daniel RW, Rowson S, Duma SM. Head impact exposure in youth football: middle school ages Munce TA, 12-14 years. J Biomech Eng. 2014;136(9):094501. PubMed PMID: 24950298 2. Daniel RW, Rowson S, Duma SM. Head acceleration measurements in middle school football. Biomed Sci Instrum. 2014;50:291-6. PubMed PMID: 25405436 3. Dorman JC, Thompson PA, Valentine VD, Bergeron MF. Head Impact Exposure and Neurologic Function of Youth Football Players. Med Sci Sports Exerc. 2015;47(8):1567-76. PubMed PMID: 25437194

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WHEN HUMAN BOBBLEHEADS COLLIDE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF “The scientific evidence linking youth casual sports play to brain injury, brain injury to CTE, and CTE to dementia is not strong.”

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DOES WAITING PUT THEM AT RISK? • If we pass such a bill and tackling begins at age 12, might we be increasing the injury risk?

• Is it better to start teaching such skills when children are less strong, lighter, and more equal in size?

FICTION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF LET’S USE COMMON SENSE

1. Do I really have to convince you that hitting a child in the head hundreds of times is a bad idea?

2. Audience survey 1. Does anyone hit their own kids in the head? 2. How about yourself?

3. Of course we don’t get hit in the head voluntarily! We know it is a terrible idea. 1. 17% of adults smoke, but ~0% expose themselves to repetitive head impacts!

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WOULD YOU SIGN UP FOR THIS?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF THANK YOU Books available: To reach me: [email protected]

• @ChrisNowinski1

• @ChristopherNowinski

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WHAT IS THE PREVALENCE?

• CTE cannot be diagnosed with any established accuracy in a living person • How do we interpret this data? • Controls

Data Percent NFL 110 of 111 99% College 48 of 53 91% HS 3 of 14 21%

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF • The Mayo Clinic reviewed 4,711 cases collected over 18 years

• CTE cannot be diagnosed with any established accuracy in a living person • How do we interpret this data? • Controls • Diagnostic accuracy of similar diseases • ~9% of former NFL players who died during the study period

Data Percent NFL 110 of 111 99% College 48 of 53 91% HS 3 of 14 21%

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF IRRELEVANT POINTS

• Not all athletes with multiple brain traumas develop CTE. • There are cases of CTE in non-athletes with no history of brain trauma. • The suicide rate in retired professional NFL players is less than that of men in the general population. • Playing competitive professional football, with repeated subconcussive head blows, is a much different scenario than that of a youth in community or school sports. • Many factors can be associated with CTE beside multiple head injuries, such as genetic, physical health, mental health, behavior, risky health behaviors and habits.