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Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football
Open accessAbstract
Importance: Players of American football may be at increased risk of long-term neurological conditions, particularly chronic traumatic encephalopathy (CTE). Objective: To determine the neuropathological and clinical features of deceased football players with CTE. Design, Setting, and Participants: Case series of 202 football players whose brains were donated for research. Neuropathological evaluations and retrospective telephone clinical assessments (including head trauma history) with informants were performed blinded. Online questionnaires ascertained athletic and military history. Exposures: Participation in American football at any level of play. Main Outcomes and Measures: Neuropathological diagnoses of neurodegenerative diseases, including CTE, based on defined diagnostic criteria; CTE neuropathological severity (stages I to IV or dichotomized into mild [stages I and II] and severe [stages III and IV]); informant-reported athletic history and, for players who died in 2014 or later, clinical presentation, including behavior, mood, and cognitive symptoms and dementia. Results: Among 202 deceased former football players (median age at death, 66 years [interquartile range, 47-76 years]), CTE was neuropathologically diagnosed in 177 players (87%; median age at death, 67 years [interquartile range, 52-77 years]; mean years of football participation, 15.1 [SD, 5.2]), including 0 of 2 pre-high school, 3 of 14 high school (21%), 48 of 53 college (91%), 9 of 14 semiprofessional (64%), 7 of 8 Canadian Football League (88%), and 110 of 111 National Football League (99%) players. Neuropathological severity of CTE was distributed across the highest level of play, with all 3 former high school players having mild pathology and the majority of former college (27 [56%]), semiprofessional (5 [56%]), and professional (101 [86%]) players having severe pathology. Among 27 participants with mild CTE pathology, 26 (96%) had behavioral or mood symptoms or both, 23 (85%) had cognitive symptoms, and 9 (33%) had signs of dementia. Among 84 participants with severe CTE pathology, 75 (89%) had behavioral or mood symptoms or both, 80 (95%) had cognitive symptoms, and 71 (85%) had signs of dementia. Conclusions and Relevance: In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football.
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“The presence of comorbid ALSþCTE in an ALS cohort parallel similar findings of CTE in neurodegenerative cohorts, e.g.6% in an multiple system atrophy (MSA) cohort as reported by Koga et al (46), 6% in an American football CTE group (47) and 11.9%-32% in a group of various diseases reported by Ling et al (48).”
From Chronic Traumatic Encephalopathy Within an Amyotrophic Lateral Sclerosis Brain Bank Cohort (2018) · cites this paper as [47]
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Chapter 22. Neurocognitive Disorders
Merideth, F. L., Vahia, I. V., & Jeste, D. V. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg22
Chapter 2. The Neurological Examination for Neuropsychiatric Assessment
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Chapter 25. Somatic Symptom and Related Disorders
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Chapter 1. An Internist’s Approach to the Neuropsychiatric Patient
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Chapter 4. Neuroimaging, Electroencephalography, and Lumbar Puncture in Medical Psychiatry
Talmasov, D., & Klein, J. P. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg04
Chapter 6. Cardiovascular Disease
Shapiro, P. A. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg06
Chapter 7. Endocrine Disorders and Their Psychiatric Manifestations
Gagliardi, J. P. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg07
Doghramji, K. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg24
McCarron, R. M., Sheth, S. J., Mesa, C. D., & Parish, M. B. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg23
Chapter 3. The Bedside Cognitive Examination in Medical Psychiatry
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Chapter 17. Psychotic Disorders Due to Medical Illnesses
Brown, H. E., Mukerji, S., & Freudenreich, O. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg17
Chapter 10. Gastroenterological Disease in Patients With Psychiatric Disorders
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(2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.index
Chapter 16. Neurodevelopmental Disorders
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Chapter 18. Catatonia in the Medically Ill Patient
Beach, S. R., & Fricchione, G. L. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg18
Chapter 12. Neurological Conditions and Their Psychiatric Manifestations
Fogel, B. S., Baslet, G. C., Safar, L. T., Raynor, G., & Silbersweig, D. (2020) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615378869.lg12
Metadata
- Authors
- Mez, J., Daneshvar, D. H., Kiernan, P. T., Abdolmohammadi, B., Alvarez, V. E., Huber, B. R., Alosco, M. L., Solomon, T. M., Nowinski, C. J., McHale, L., Cormier, K. A., Kubilus, C. A., Martin, B. M., Murphy, L., Baugh, C. M., Montenigro, P. H., Chaisson, C. E., Tripodis, Y., Kowall, N. W., Weuve, J., McClean, M. D., Cantu, R. C., Goldstein, L. E., Katz, D. I., Stern, R. A., Stein, T. D., & McKee, A. C.
- Affiliations
- Boston University (US)
- Concussion & CTE Foundation (US)
- Boston Children's Hospital (US)
- Corresponding author
- McKee, Ann C.
- ORCID
- Mez, Jesse
- Daneshvar, Daniel H.
- Kiernan, Patrick T.
- Abdolmohammadi, Bobak
- Huber, Bertrand R.
- Alosco, Michael L.
- Solomon, Todd M.
- Nowinski, Christopher J.
- Martin, Brett M.
- Baugh, Christine M.
- Chaisson, Christine E.
- Tripodis, Yorghos
- Kowall, Neil W.
- Weuve, Jennifer
- McClean, Michael D.
- Cantu, Robert C.
- Goldstein, Lee E.
- Katz, Douglas I.
- Stern, Robert A.
- Stein, Thor D.
- McKee, Ann C.
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2017-07-25
- Volume
- 318
- Issue
- 4
- Pages
- 360
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC5807097
- OpenAlex
- W2750121529
- Cited by
- 1,098
- References
- 41
- Citations by year
- 2026: 60 · 2025: 78 · 2024: 75 · 2023: 116 · 2022: 137 · 2021: 146 · 2020: 165 · 2019: 139 · 2018: 142 · 2017: 33
- FWCI
- 102.62
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- other-oa
- Locations
- JAMA (publishedVersion, other-oa)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- OpenBU (Boston University) (submittedVersion)
- Funders
- U.S. Department of Veterans Affairs
- Alzheimer's Association (NIRG-15-362697)
- National Operating Committee on Standards for Athletic Equipment
- National Institute on Aging (K23AG046377, P30AG013846, RF1AG057902)
- National Institute of Neurological Disorders and Stroke (U01NS086659)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
- Health Sciences › Medicine › Clinical Neurology › Long-Term Effects of COVID-19
- Physical Sciences › Engineering › Biomedical Engineering › Automotive and Human Injury Biomechanics
- Keywords
- chronic traumatic encephalopathy, American football, neuropathology, neurodegenerative diseases, cognitive symptoms, dementia, head trauma, former athletes, military veterans, concussion
- MeSH terms
- Chronic Traumatic Encephalopathy, Adult, Aged, Athletic Injuries, Mental Disorders, Brain, Brain Concussion, Cause of Death, Cognition Disorders, Football, Humans, Male, Middle Aged, Severity of Illness Index, United States, tau Proteins, Substance-Related Disorders, Athletes
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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