Head Injuries in Anime Part 4- CTE- Chronic Traumatic Encephalopathy

Head Injuries in Anime Part 4- Chronic Traumatic Encephalopathy

 

Chronic Traumatic Encephalopathy, or CTE, has been in the news a lot recently with the concussion crisis that the NFL and American football in general has been dealing with.  Now you are probably expecting me to be looking at Eyeshield 21, an American football anime.  Sadly, I will not, and it’s not because I have no knowledge of the sport (I played for 8 years little league through high school), it’s because I only discovered the anime while working on the head injuries in anime series of posts I have been doing.  Also, judging by the brief plot summaries I was able to find, I don’t think concussions are a major part of the story, if at all.  If I ever get the time, I would love to give you my perspective on how accurately Eyeshield 21 portrays American football.  However, what really inspired the head injury in anime series is Hajime No Ippo, because I read that in the more recent chapters of this long running manga Ippo the main character, has become punch drunk for a period of time.  Punch drunk, also known as pugilistica dementia is what caused Mohamed Ali problems later in life, and is what chronic traumatic encephalopathy used to be called.

 

What is chronic traumatic encephalopathy?

Chronic traumatic encephalopathy, unlike the other conditions I’ve covered in this series on head injuries in anime, is not the result of a single blow to the head, but rather the consequence of many blows to the head, most often concussions.  The repeated head trauma has a collective effect on the brain over time and will usually manifest 8 to 10 years after repeated trauma has occurred.  Typically, the more frequent and severe the head trauma, (concussions), the faster and more severe the onset of chronic traumatic encephalopathy.

 

The early symptoms of chronic traumatic encephalopathy  can mimic the symptoms of different neurological disorders including Alzheimer’s disease and Parkinson’s disease.

Cognitive impairment

Depression or apathy

Short-term memory loss

Difficulty planning and carrying out tasks

Substance abuse

Suicidal thoughts or behavior

Motor impairment

 

However, there are some symptoms that are coming to be seen as being distinctive to chronic traumatic encephalopathy , when the afflicted individual is known to have had repeated head trauma.  Those symptoms are emotional instability, impulsive behavior, and aggression.  Also, CTE does not immediately cause the death of the individual, but the mental impairment and changes caused by CTE, can drive individuals to suicide, as seen with pro bowl linebacker Junior Seau in 2012, when he took his own life.

 

How do concussions cause chronic traumatic encephalopathy?

The exact nature of how repeated head trauma does this is not entirely clear at the present time, but the damage caused by repeated concussions builds up overtime.  This damage causes the brain to actually shrink and get significantly smaller as seen below as brain cells are killed with each impact.

CTE

 

On a microscopic level damaged proteins build up inside of neurons of the brain, impairing the cell’s ability to function.  Think of it like the milk beginning to curdle inside of the container, spoiling the milk, only this time it is the cells of your brain.

CTE

The brown is the plaque damage caused by repeated concussions resulting in CTE.

 

Can we diagnose chronic traumatic encephalopathy?

Right now, the only way to definitively diagnose CTE is by autopsying the brain after death.  There has been some interesting work coming out of Mount Sinai hospital in New York City recently that might allow medical professionals to diagnose CTE in the future using positron emission tomography (PET scan).

https://www.theatlantic.com/health/archive/2017/09/football-brain-injury-chronic-traumatic-encephalopathy/540459/

 

Is there a cure for chronic traumatic encephalopathy?

Sadly, despite all of the advances that modern medicine has made since CTE was first described in 1920, there is no cure or treatment for CTE.  The best defense against CTE is prevention.

 

How to prevent chronic traumatic encephalopathy

The most obvious protection against CTE is to not get a concussion in the first place, and if you get a concussion, give your brain enough time to heal before entering a situation where you might get hit in the head again.  Clearly this has affected American football the most, as youth participation has plummeted in the last few years, and changes are being made to protect the players at all levels more.  Perhaps the biggest change is how coaches deal with concussions.

 

Warning: Personal Experience Segment

The only sport I really played over a long period of time in a competitive manner that involved the potential for head trauma was American football 1991-1999.  I don’t remember anyone on my team ever getting a type 3 concussion, but I did see people get type 1 concussions.  We used to call it getting your bell rung, and the player had to sit out until he was back to normal and then it was right back into the game or practice.  Thankfully this never happened to me, but proper recovery time for concussions wasn’t really a concern back then.

 

While I have yet to coach football, I have coached crew (rowing) for eight years in NJ, and during that time I had to attend a seminar on how to deal handle concussions.  This seminar was mandatory for all high school coaches in the state of NJ.  The focus was on what concussions are, why they are serious injuries, how to identify concussions, and the proper procedure for dealing with them.  Given my background (science teacher and former med student) I didn’t learn much additional information, but it is a huge step forward in an attempt to stop the “play through” it mentality that is pervasive in some sports.  At least in NJ there are penalties for coaches who do not deal with concussions properly.  There was actually a recent incident in the NFL where a player was allowed to play after having a concussion.

http://abcnews.go.com/Sports/wireStory/nfl-concussion-protocol-savage-incident-52047061

Personal Experience Over

 

American football is not the only sport facing changes due to the dangers of concussions and chronic traumatic encephalopathy.  Boxing, professional wrestling and MMA should come as no surprise, neither should sports like rugby, ice hockey, but football (soccer to us Americans) and baseball are also included as sports putting people at risk for CTE.  It is the headers in football that are proving to be problematic as several professional football players have been diagnosed with CTE.  In fact, US soccer has banned headers for individuals under the age of 11.

http://www.baltimoresun.com/sports/soccer/bs-bz-youth-soccer-headers-20170506-story.html

            As it is right now, the best way to prevent chronic traumatic encephalopathy is to reduce the number and severity of concussions people have.  The only way for that to happen is to tweak how the sports are played and improve the protective equipment.

 

Chronic traumatic encephalopathy in anime

Warning there will be spoilers

 

Hajime no Ippo

Ippo

 

As you can probably expect, I’ve only found one anime that has mentioned chronic traumatic encephalopathy via the term punch drunk, and that is Hajime no Ippo, where we follow the story of Ippo Makunouchi as he becomes a world class boxer.  The term punch drunk dates back to around 100 years ago, and referred specifically to the problems boxers developed over time.  These problems included problems with balance, motor skills, memory, and behavioral changes, all hallmarks of CTE.  There is some debate as to why George Morikawa is having Ippo develop punch drunk syndrome in the more recent chapters of the manga.  Punch drunk or dementia pugilistica or a subset of CTE specific to boxers has been known for a long time, with Muhamed Ali being one of the most famous examples.  While all of his neurological problems were exacerbated by his repeated concussions, he was diagnosed with Parkinson’s disease.

 

This could have been planned since he started the manga in 1989, or it could have been a more recent change, given the amount of press concussions and CTE have received as a result of the NFL.  I will say that he first mentioned concussions in an early chapter of the manga.  Either way Ippo is suffering the after-effects of a type 3 concussion (probably a type 3b) as of chapter 1073, as he was knocked out in his last fight and is dizzy the next day during a run (a symptom of a severe concussion).  This is exactly the wrong thing to do after a concussion and the manga lampshades this by having Ippo mention that he should actually be resting.  In chapter 1076 we see that he is having trouble drawing straight lines which implies some motor incoordination, which is a symptom of CTE.  In chapter 1077 we learn that he is cleared by the doctors to box, which doesn’t mean much since it is impossible to diagnose CTE at the present time.

 

Things begin to become clear in chapter 1153, where it is directly stated that Ippo is punch drunk, and that even though the doctors clear him one of his coaches states that there is a lot we still don’t know about how repeated blows to the head damage a person’s brain.  The manga even goes so far as to mention how different people will progress at different rates.  Honestly, I was surprised by how well the topic was handled.  In the same chapter we see that Ippo still can’t draw a straight line and begins to realize something is wrong with him.  Ippo’s coach goes on to give him a series of questions on memory, hand eye coordination, and balance in an effort to determine if he really is punch drunk.

CTE

 

Spoiler alert: Ippo lies and fakes his way through a final test, drawing a straight line to test his fine motor skills to see if there is any damage from multiple concussions (CTE).  That is to be expected, given Ippo’s character and how the storyline is progressing.  However, his coaches aren’t buying it and make him take time off (1month) to completely recover to reduce his risk of becoming punch drunk.  Given my limited knowledge on the subject, I have to think that a 1 month break probably isn’t enough, since even getting knocked out once would require a 6 month break and Ippo’s taken more damage than that.

 

If I have one real complaint with Hajime no Ippo, it is in chapter 1156 where two elderly boxers are talking about the one of them being punch drunk back in the day.  This conversation makes it seem like being punch drunk (CTE) is a temporary thing, when it really isn’t.  Sure, some initial problems might subside, but other problems can crop up later years after you are done boxing.  This is what happens at the end of chapter 1164 as he passes his coach’s test and finally draws a straight line, but chapter 1165 is more interesting.  Here we find out Ippo doesn’t even know just how many concussions he has had, when talking to a friend about the possibility of being punch drunk.  It even goes so far as to sneak in a reference to the fact that having one concussion makes it more likely for you to have a concussion in the future.  This is done by mentioning that boxers who have heard the count, meaning the count that the referee starts to end the match, are more likely to hear it in the future.  I don’t know if this is true to boxing, but it makes sense since boxers who are knocked out would clearly have concussions.  Chapter 1166 shows Ippo getting what looks like a CT scan, which is all clear.

CTE

 

I wonder what a PET scan would show, however, and even his coaches know that a clean CT scan doesn’t remove Ippo’s risk.  Everything looks fine as Ippo goes into his comeback match against Antonio Guevarra, but it becomes clear early on that something is wrong.  It’s also pretty clear that Ippo gets a concussion during the match as he doesn’t remember being knocked down and a count starting (raising his already high risk for CTE).  This is probably the result of the head shots he is taking as the fourth round of the match begins.  The match ends and it’s pretty clear to everyone including, Ippo, that he is punch drunk and that his career as a boxer is over.  All that remains is seeing what, if any, permanent damage Ippo will have.  Having read chapters 1055 to 1203, I am now very curious to see how George Morikawa will wrap things up.  All in all, though, I will say that Hajime no Ippo did an excellent job in handling CTE, and if the manga didn’t go into all of the side characters so much, I would assign it as reading for a unit on CTE.

 

Cyborgs and chronic traumatic encephalopathy

As I was working through all of these posts on head injuries, it hit me that there is another subgenre of anime that is getting it wrong, and that is sci-fi/ cyberpunk anime.

 

“But Mr. Meharg, aren’t cyborgs supposed to be super strong and built to withstand more damage?”

Yes, but a titanium skull like the one that encases Mokoto Kusanagi’s brain in Ghost in the Shell still won’t protect you from concussions.

Titanium skull

 

Yes, I know that it is titanium, but if modern NFL football helmets still aren’t preventing concussions, then a futuristic metal skull won’t either.  Despite having a skull that is pretty much impossible to break, the brain is still going to bounce around inside of the skull, giving the major a concussion as we see in Episode 21.

 

You can clearly see that the major is stunned during the battle, and before you say that it’s from the pain and other injuries she had sustained, remember that we know that the major is able to turn off various sensors around her body.  Given that her arm is blown off by this point, she has probably turned off the pain sensors in her body, and her stunned look is from a concussion.  Thus, it’s not a big leap to think that she could develop CTE later in life with all of the combat she sees over the course of the series.  Her only hope at this point is that futuristic medicine has developed a cure for CTE.

 

Another example is Angelica from Gunslinger Girl.  While she lacks the major’s titanium skull, she is still a highly durable cyborg who survives a close encounter with a truck bomb.

cyborg

 

While I know that the drugs she takes to make her cybernetics work are damaging her brain, being at ground zero of an explosion does not help either.  This probably didn’t help her failing health at the time, but the explosion and subsequent brain damage probably scrambled her brain enough to allow her to remember things that the drugs were blocking.  Either way, when it comes to head injuries with cyborgs, I have to call them busted due to a super strong body being unable to stop the brain from rattling around during head trauma.

Thanks for reading and please leave any comments or questions below.

 

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945234/

https://www.bu.edu/cte/about/frequently-asked-questions/

https://www.mayoclinic.org/diseases-conditions/chronic-traumatic-encephalopathy/symptoms-causes/syc-20370921