Reader Response: Association of Position Played and Career Duration and Chronic Traumatic Encephalopathy at Autopsy in Elite Football and Hockey Players

Schwab et al.1 rigorously describe postmortem neuropathology in 35 elite athletes. Brain tissue from well-characterized cases remains scarce, demanding creative approaches to data collection. The inadequacy of web-based methods alone is evident in the authors’ inability to define their primary exposure, career duration, as well as incomplete characterization of isolated traumatic brain injury (TBI). Open-ended questions yielded 0% prevalence of more severe TBI—a stark contrast to population-based studies that report >20% prevalence of TBI with loss of consciousness.2 The authors assumed, but did not quantify mild TBI exposure, suggesting an accommodation of rigor to data available. That lifetime head trauma exposure is so poorly enumerated obscures investigation into the contributions of isolated TBI to the neuropathology of repetitive trauma and the exposure thresholds that confer elevated neurodegenerative disease risk. The value of a structured TBI screening tool cannot be understated,3 particularly for identification of remote events. Retrospective family interview is sometimes the best, and often the only method for postmortem characterization, and has contributed greatly to our understanding of clinical dementia and cerebrovascular disease.4,5 Common Data Elements for postmortem characterization of TBI exposure are now under development; their adoption will invite replication of this study’s results with more complete data and an even greater scientific impact.

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