Mind And Body: Head Injuries And What New Research Means For Football

MS. DIANE REHM

11:06:56
Thanks for joining us. I'm Diane Rehm. Today for our ongoing series "Mind and Body," we'll look at new research showing a clearer link between repeated head trauma and long term brain disease. There are now questions about the safety of contact sports like football.

MS. DIANE REHM

11:07:17
Here to discuss the science and the reaction from the sports community, Dr. Gerard Gioia of Children's National Medical Center here in Washington D.C. Mark Meana of the Fairfax County Youth Football League in northern Virginia, Stefan Fatsis, sports journalist and joining us from his office in Concord, Mass. Dr. Robert Cantu. He's a neurosurgeon and author of the book titled, "Concussions and Our Kids."

MS. DIANE REHM

11:07:52
Throughout the hour, I'll look forward to hearing from you. Join us on 800-433-8850, send us an email to drshow@wamu.org, feel free to follow us on Facebook or Twitter. Good morning to all of you.

MR. MARK MEANA

11:08:12
Good morning.

MR. STEFAN FATSIS

11:08:12
Good morning.

DR. GERARD GIOIA

11:08:13
Good morning.

DR. ROBERT CANTU

11:08:13
Glad to be here.

REHM

11:08:14
Dr. Cantu, I'll start with you. You're the co-author of the new study, describe your findings. Dr. Cantu, are you there? Let's see if we have him. Dr. Cantu? No, he's not there. All right, I'm going to go to you, Dr. Gioia. Tell us about CTE and symptoms?

GIOIA

11:08:46
Well, chronic traumatic encephalopathy is something obviously that Dr. Cantu and his group, Dr. Stern, Dr. McKee have been studying closely for the last several years. It is not my area of specialty, quite honestly with children, but certainly in their work they are finding that there seem to be some indications in a variety of athletes where there are deposits in the brain of certain proteins, some abnormal amounts.

GIOIA

11:09:20
And with that seem to be associated with a number of cognitive, behavioral, emotional kinds of changes in those individuals that have been found to have that and some pretty devastating kinds of life circumstances, particularly in midlife to older adults.

REHM

11:09:41
All right, and I think now Dr. Cantu is back with us. Good morning, sir.

CANTU

11:09:47
Good morning, Diane. I was never not with you, but you weren't with me, I guess.

REHM

11:09:52
Okay. Well, there we are. Tell us about the findings of your new study?

CANTU

11:10:00
Well, Dr. Ann McKee's the leader author on this study and what it really is, is the largest series of cases of chronic traumatic encephalopathy in the world's literature. It more than doubles the cases, these are 68 new cases out of the 85 individuals that were studied and the sheer volume of it is very impressive but the other parts of the study that I think are very useful is a grading system for CTE in terms of severity and it also, I think at least in my mind, is very worrisome in the sense that six of the cases, six of the 68, were in high school. So this disease can be seen as early as one in their teens.

REHM

11:10:54
And tell me how many of those, not just the ones in high school, but the 68 men, how many of those happened to be football players?

CANTU

11:11:13
Thirty-three played in the National Football League of them and approximately another 15 were in college and then the six in high school.

REHM

11:11:26
So tell me how the symptoms present themselves and how people are diagnosed with CTE?

CANTU

11:11:40
The symptoms are primarily are cognitive symptoms, difficulties early on with attention and focus and also insight in judgment issues and also emotional issues, the hallmark of them being difficulty with handling frustrating circumstances so that both physical and verbal abusive behavior is very common with these individuals. Other symptoms that are very common in the emotional category are depression, anxiety and sometimes paranoid behavior.

REHM

11:12:18
Stefan Fatsis, you've been following sports of all kinds for a long time but you just heard Dr. Cantu say that about 50 of the people in his study had played football and about 30 had played professional football. How prevalent do you believe this to be in football generally?

FATSIS

11:12:50
I think it's unpredictable and that's part of the issue here. The science is going to catch up to the behavior. We have tens of thousands people play football, millions play if you include youth players. At the NFL level these are athletes that have been sustaining hits regularly in the sport for 10, 20 years on average, most for upwards of 20 years. Most athletes in the NFL started playing football when they were very young.

FATSIS

11:13:20
There is a tremendous concern in the NFL among players, there's a much greater awareness thanks to the kinds of work that Dr. Cantu has done, thanks to reporters like Allen Schwartz of "The New York Times," who over the last three or four years really brought this issue into light and the gaining publicity, the growing publicity that this issue has gotten.

FATSIS

11:13:41
Has that tempered behavior among players? No, and I think that's one of the critical issues here to think about. NFL players are grown adults, they understand what they're getting into, they are highly aware of the dangers that they put their bodies at risk of during their careers.

REHM

11:13:58
Actually, some have been given bonuses to make harder hits.

FATSIS

11:14:06
The, well there's some, there was a report issued yesterday by the former commissioner of the NFL, Paul Tagliabue, who exonerated some of the players in this case, involving the New Orleans Saints. But yes, there is a cultural violence and we have to appreciate that the NFL is a culture of violence.

FATSIS

11:14:22
Players understand that, but they also are growingly concerned about what it's doing to their bodies. Is that going to stop them from playing? No. I spent a summer with the Denver Broncos to write a book about life in the NFL. I was on the team as a place kicker, I never got hit because I would've died if they had hit me because I'm not...

REHM

11:14:41
They're bigger than you are.

FATSIS

11:14:43
They're substantially bigger than I am. But I talked to the players about this fear and most of them simply operate under the code of, I can't think about it. It's too traumatic for me to think about what this might be doing to me in 10 or 20 years.

REHM

11:14:56
Dr. Cantu, you're quick to point out that one concussion does not necessarily lead to CTE?

CANTU

11:15:08
No, not at all, Diane. And in fact, I kind of like to say if you've seen one concussion, you've seen one concussion. All concussions are unique. They, some of them are severe, those that are severe have greater implications than those that aren't. And by severe, I mean, duration of symptoms last many months, sometimes even years.

CANTU

11:15:28
That's a totally different injury than somebody who just has symptoms for a few hours or day. so I don't think we can think about concussions just by the number and certainly our experience is when we're thinking about CTE we need to think about total brain trauma, it's not just at the concussion level. We have cases in the brain bank that did not have any recognized concussions.

CANTU

11:15:54
So it's total brain trauma, all those, over the course of an NFL player's career would be tens of thousands of sub-concussive blows count. I do want to slightly disagree in the sense of the players not being concerned about this. I agree with everything that's been said, most of them try to block it out and some do a very good job of that.

CANTU

11:16:16
But if we think back to the most recent collective bargaining agreement, which was hammered out between the NFL and the Player's Association, the Player's Association argued long and hard to reduce the number of full contact practices and they'd done it so well that they can actually have less than one week.

CANTU

11:16:36
It's 14 full contact practices over the 18 weeks of the season and that was done primarily with the recognition that they did not want to subject themselves to the head trauma that was taking place in those practices.

REHM

11:16:50
Dr. Robert Cantu, he's co-director of the Center for the Study of Traumatic Encephalopathy and author of "Concussion and Our Kids." Turning to you, Dr. Gioia, what do you think parents should make of this study?

GIOIA

11:17:13
Well, you know I think, first of all, the issue of concussion and its, you know, greater awareness in our society and in all sports not just football, obviously, You know, should have parents sitting up and being alert and being, you know, appropriately educated and good consumers of their kids' sports. It's really important that a parent not go into, you know, bringing their kid into sport without any knowledge of how that sport is being coached, how it's being officiated, who is actually aware of recognizing these injuries, what they do about it, what are the policies.

GIOIA

11:17:52
So parents have to become good consumers of this. they also themselves need to be educated about the injury itself because we know that injuries occur that escape the coach on the field and they need to know that if their son or daughter comes home from an activity, sporting activity, they can recognize that something may not be right and find the proper medical personnel. So I think that the key really for parents is to be good consumers but also be educated themselves.

REHM

11:18:22
And when we come back after a short break, we'll talk with Mark Meana. He's chair of the Fairfax County Youth Football League in northern Virginia. One of the other sports I find myself wondering about is soccer when the hit is used to bounce that ball. Short break here, stay with us.

REHM

11:20:06
And in this hour of our ongoing series Mind and Body we're talking about head injuries and the frequency of their leading to concussions which can eventually lead to serious brain damage. Mark Meana, you're chair of the Fairfax County Youth Football League in northern Virginia. You work directly with parents and kids. How concerned are parents and young people about playing football these days?

MEANA

11:20:45
Well, certainly the parents have a very big concern. It's what you see in the newspapers. It's what you hear on the radio and what you certainly see on the TV. Again it's probably the lack of knowledge all the way around is what we're finding more and more, certainly in my career in operating a youth football league. Lately more and more people are hungry for information. Certainly the doctors, Dr. Cantu, Dr. Gioia, the information put out supported by the medical experts around the world is really, I think, the key to one of the solutions in player safety, in youth football especially.

MEANA

11:21:27
Not only the signs and symptoms, equipment fitting, coaches education, all of this goes in, which is a greater concern than I saw ten years ago, fifteen years ago.

REHM

11:21:39
All right. Dr. Cantu, I gather you're calling for the elimination of tackle football for kids under the age of 14. Tell me why.

CANTU

11:21:54
Well, the main reasons that we believe tackle football should be eliminated for kids under the age of 14 is that the youth brain is more vulnerable to injury than is the adult brain. The youth brain does not have a full coating of myelin on the nerve fibers, that's the protection. It's kind of like coating on the telephone wire. It helps transmission, but it also gives strength.

CANTU

11:22:16
Youth brains are also more susceptible to the excitotoxic shock injury, the metabolic injury of concussion. Youth brains are housed in disproportionately large heads. Kids by the age of four have received about 90 percent of the head circumference growth that they will have as an adult. And yet those very large heads are on very weak necks and that bobble-head-doll effect puts them at greater risk. And our youth are usually with the oldest equipment, usually with the least experienced coaches, usually with no medical personnel on the sideline.

CANTU

11:22:57
And they've not really received informed consent in most instances in terms of the possible damage they're doing to their brains. That coupled with what I see across my desk every week that we see patients. And coupled with our experiences with the center for the study of traumatic encephalopathy where we're seeing early CTE in teenage kids that took the trauma that produced it in early years in life. It's just led me to believe that we don't want to see tackle football played the way it's currently played.

CANTU

11:23:31
I certainly want football to be played. I want all sports to be played. We have recommendations for other sports as well, how they can be played more safely. We want to see more people playing them. And I think more people would at the youth level play football if it were flag football and the tackle was deferred.

REHM

11:23:52
All right. Dr. Gioia, I gather you disagree with calling for the elimination of tackle football for kids under 14.

GIOIA

11:24:05
You know, I disagree with its elimination, but I certainly fully agree that we need to continue to improve the game and its safety.

REHM

11:24:15
How?

GIOIA

11:24:15
And I'll get to that in a minute. I just want to say that as we're better understanding what we can do more effectively, you know, one of the key things is going to be understanding what are those key ages that we really should be introducing this. And when should we not? And so we really need to be looking at that.

GIOIA

11:24:36
I think, you know, one of the things that's been called for is certainly the reduction of forces that kids take. In other words, can we modify practices and the number of times that kids are exposed to contact while still teaching more effective techniques? I go back to my own personal history of both playing football and playing rugby. And thinking that you would never do in rugby what you do in football with a helmet.

GIOIA

11:25:07
And getting away, I think, maybe over the decades from when I played, which was about 40 years ago, you know, in these games from learning how to tackle in different ways. We know that tackling is really one of the major parts of the game where the injury is sustained. But again I think that we need to understand what are the ages -- and as Dr. Cantu was saying, you know, those necks are weaker -- is there a certain age at which it is more effective to control the head and teach these kinds of techniques?

GIOIA

11:25:42
You know, we certainly see now some of the objections of, even at the professional level, being penalized for certain kinds of things. And quite honestly, these are folks that have learned, you know, frankly to use the wrong technique for 20, 30 years. And it's hard for them to change. I really think that we need to be starting early to be teaching the proper technique.

REHM

11:26:04
Stefan Fatsis, is it possible to make football safer for kids?

FATSIS

11:26:11
I don't think so given its current configuration. And I think part of the problem is simply who children are. You can teach all the technique you want, but children don't have the cognitive or physical ability very often, as five minutes on the sideline of any sports game, youth sports event will show you, to implement and control their bodies when they want to or when they should.

FATSIS

11:26:33
So I'm very skeptical that it can change and I think coaches, for all their well meaning-ness, youth coaches are mostly parents. They are not particularly well educated, with all due respect to Mark. There is a lack of sophistication and there are conflicting motives when parents are coaching. They don't understand children very often and they don't understand the sport at a very nuance level. I think there are ways to ease children into tackle football when they go through puberty, as Dr. Cantu has indicated, without sapping their love or their interest in this sport.

FATSIS

11:27:08
Playing flag football would be one way. Gradually padding them up and playing flag football while teaching different techniques would be another way. But I think to subject children to repeated sub-concussive blows from the ages of five, which is where Pop Warner football can begin, five years old and 35 pounds I think is -- just common sense is telling us this is no longer smart.

REHM

11:27:34
And joining us now by phone from Richmond, Va. Mary Ann Easterling. Mary Ann's husband Ray Easterling played safety in the NFL for the Atlanta Falcons from 1972 to 1979. Good morning, Mary Ann.

MS. MARY ANN EASTERLING

11:27:57
Good morning, Diane.

REHM

11:27:59
I know your husband Ray retired in '79. When did he begin to decline? What were his symptoms?

EASTERLING

11:28:10
About 1989, I noticed that he was having trouble sleeping, staying asleep and falling asleep. And he developed depression.

REHM

11:28:24
And what else?

EASTERLING

11:28:27
At the time, those were the kind of symptoms. And progressively he would make impulsive decisions, would not think through important things in our lives. He would say things that didn't make sense in the context of the conversation, couldn't get along with figures of authority very well.

REHM

11:29:01
You said at one point he would show up dressed inappropriately. What do you mean?

EASTERLING

11:29:10
Well, we would have family gatherings for Thanksgiving or Christmas and he would come in very late, 30 minutes, an hour late, still dressed in his running clothes.

REHM

11:29:23
And what did you think was going on? Did you know then about CTE?

EASTERLING

11:29:31
Oh no, I had no idea. I really had no clue what was going on.

REHM

11:29:37
So did you think it had any connection whatsoever to his playing football?

EASTERLING

11:29:46
I did not.

REHM

11:29:48
And so you, I gather, began talking to other players' wives.

EASTERLING

11:29:55
No. Actually what happened was I was online in December of 2010 and that's how late and how long the NFL buried the information, although they purport to want the best for the players and for their health. I found a connection to the Boston study that gave case studies of former players who had died either of suicide or accidental death. The description of their symptoms, particularly their cognitive behavior, were eerily similar to what I had been experiencing for 20 years with Ray.

REHM

11:30:47
And sadly, I'm so sorry to note that your husband Ray committed suicide last April. What were his behaviors like just before he took his own life?

EASTERLING

11:31:07
He was argumentative, difficult to follow any kind of information given him. He would forget where his keys were, his glasses, his wallet. But just before he died, he was beginning to be unable to drive in the daylight and know where he was.

REHM

11:31:38
And then following his death, he was diagnosed with CTE?

EASTERLING

11:31:48
Well, prior to his death, about a year and two months, we had gone to a neuropsychiatrist here in Richmond, an excellent gentleman, Gregory O'Shanick, who diagnosed dementia due to concussions he sustained while playing football. But the CTE can't be -- at the -- well, even now it cannot be diagnosed until an autopsy is done on the brain. And that was conducted at University of Virginia by a neuropathologist there. And she did verify that there was CTE in his brain.

REHM

11:32:30
So I gather you are now involved in a lawsuit against the NFL.

EASTERLING

11:32:37
Yes, ma'am.

REHM

11:32:38
What do you hope comes from it?

EASTERLING

11:32:42
My hope is that the NFL will recognize this body of people that are suffering and could potentially suffer due to the negligence of not revealing information that they have perpetuated. Recently they've -- Commissioner Goodell has turned that around somewhat. But prior to 2009 there was just -- there was nothing. And we have lots of players and families who are suffering due to the symptoms that I've described. And they need to be diagnosed, they need to get on medicine.

EASTERLING

11:33:32
All these things are difficult for a player that has no health insurance, which was true in our case. Diagnoses and tests are very expensive. So that's my hope that they will be able to provide that kind of funding for the players and the potential sufferers.

REHM

11:33:53
Mary Ann, how old was your husband when he took his own life?

EASTERLING

11:33:59
Sixty-two.

REHM

11:34:00
And for how many years, seven years, he played for the Atlanta Falcons.

EASTERLING

11:34:08
He did. He sustained a lot of damage, though, I believe during the training camp of 1980.

REHM

11:34:16
Mary Ann Easterling. I'm so sorry for your loss. Thank you for joining us.

EASTERLING

11:34:23
You're welcome, Diane.

REHM

11:34:26
And you're listening to "The Diane Rehm Show." Stefan Fatsis, up to now we've been talking about children. Mary Ann Easterling's husband, an adult, playing for the NFL. What is going on?

FATSIS

11:34:46
Just a growing, I think, awareness of -- as the doctors have talked about, of the risks of playing this sport. And I think the connection that we need to make between youth football and adult football -- we don't want to go too far. Tens of thousands of people, hundreds of thousands of children play football and don't develop symptoms into adulthood. But the distinction that I think needs to be made is that on the sides for defending youth football will tell you, well there are dangers in soccer. Yes, there are from heading the ball. There are dangers in ice hockey. There are dangers in lacrosse.

FATSIS

11:35:16
There are dangers in all sports but those sports the primary function of those sports is not to run into each other. In football it is part of the game. It is the central part of the game. Tackling and blocking and colliding are the central part of the game. And I think that's what sets this sport apart from others. There are risks in everything that we play. that's what competitive sports involved. But football is distinct and I don't want to get dragged into making a false comparison between the risks in other sports and the risks in football.

REHM

11:35:51
Mark, I know that the NFL Commissioner Roger Goodell came to answer questions from parents during your season. What did he say?

MEANA

11:36:05
Well, what's important in his visit was he actually got a good hands-on look at the Heads Up football pilot program that we have in place in the three areas of the country. Talked to the coaches, talked to the players, saw it, witnessed it. And saw the organized approach to trying to make it a better and safer game. You got to start somewhere. And then probably the most popular piece of it is when he addressed the parents in the stands. Certainly that was right on the heels of closing the officiating agreement that he had. So a lot of us were thinking a lot of questions were going to come from that.

MEANA

11:36:42
But every single question focused on safety, concussion awareness. I didn't know this, I didn't know that. Certainly Dr. Gioia was there to fill in some of the details there. But they were genuinely concerned. They know the game from a spectator point of view but they don't know what goes on on the field, knowing how a helmet and shoulder pads are supposed to fit. What are some of the signs and symptoms? They're with them 99 percent of the time. They're in a better position than anybody.

MEANA

11:37:14
So the commissioner opened it up to everyone and fielded all the questions. But the sincerity was there. And one of the mothers raised her hands and said, well my son is playing youth, now he's going to high school. What about that? And we were fortunate we had the head coach there and they had a director of student activities for Fairfax County to say we're going through.

REHM

11:37:33
Mark Meana, chair of the Fairfax County Youth Football League in northern Virginia. Your calls when we come back.

REHM

11:40:03
And welcome back. We're talking about head injuries from sports, leading to concussions, leading to even more serious problems. I'm going to open the phones now, 800-433-8850. First to Jacksonville, Fla. Good morning, Ann, you're on the air.

ANN

11:40:29
Good morning, Diane. And I truly appreciate this topic. And I want to sort of do a little meta analysis, everything I've heard. Ultimately I've been a psychiatric family, pediatric, neurologic nurse practitioner and so I've kind of developed a practice where, because of my own head injuries as a child and my own psychological traumas as a child, I always was trauma informed. And what I see in the field of behavioral health now, consumers need to be informed right up front to tell providers about minor head traumas they might've blown off along the way and/or the psychological traumas.

ANN

11:41:12
Based on the fact of not getting these screenings done, the psychiatry field has ignored the history of the brain and only looked at the history, the behaviors or the thoughts or the disorder. WE need to improve the treatment model, other than diagnosing children with ADHD, bipolar, all forms of other illnesses and treating them with medicines that actually increase the symptoms by decreasing their seizure thresholds. When brains have been injured, they're more sensitive. And the medications that are usually used actually provide greater side effect profiles to an individual who's had chronic, traumatic injuries of that brain that could be from child abuse, homelessness, being in prison. The rates of those individuals...

REHM

11:42:02
Okay. And I don't want to get too far off the subject, but I appreciate your call. Dr. Gioia.

GIOIA

11:42:10
Well, I think the issue here is that we need a lot more information...

REHM

11:42:14
Yeah.

GIOIA

11:42:14
...we need a lot more research to understand really the, you know, the nature of this injury to the brain and to the developing brain. We need to understand if you take that trauma to the head, you know, what is that recovery period that is necessary? Are there some individuals that seem to rebound more quickly and others more slowly and others possibly with, again, some lasting effect. You know, I think we know that at least, you know, my Boston colleagues, Dr. Cantu, Dr. Stern, Dr. McKee, you know, believe that there are some other factors that seem to be together with those blows to the head creating the chronic, traumatic encephalopathy.

REHM

11:42:53
Such as?

GIOIA

11:42:55
Well, possibly a genetic predisposition, you know, possibly other biologic factors that mix.

REHM

11:43:01
But isn't that sort of looking in another direction when a head has been hit repeatedly? I mean, don't you look primarily there?

GIOIA

11:43:16
Well, you really look at both factors. So again I'm not suggesting one more than the other, but we need to understand what are the factors because that may help us to guide ultimately down the road this individual, you know, with one injury toward a different activity or different sport. The point is that we really need more research on this issue, again, in all sports, but certainly as it relates to head trauma more generally.

REHM

11:43:40
All right.

GIOIA

11:43:40
We actually have -- we're pretty under-funded in those areas, and that's an area we really need to increase our funding toward.

CANTU

11:43:47
Diane, I couldn't agree more with Gerry that we do need more research in this area, more funding for the research. And fortunately both I think are coming and a very large amount of it's coming from the National Football League who recently gave a $30 million grant to the NIH Foundation and has committed $100 million over a ten year period to jointly fund studies in this area. In the book we cover all sports because concussions happen in all sports. And certainly soccer is right up there at the top of the list for girls. And we monitor them in soccer to swimming, and discuss ways of making different sports safer.

CANTU

11:44:34
But I think it's very important that when we talk about the sport of football, which we are today, and we talk about it in terms of youth, that we also reflect on the fact that catastrophic football injuries in this country account for 97 percent of the catastrophic injuries we monitor at the National Center for Catastrophic Sports Injury Research at Chapel Hill.

REHM

11:44:57
I see. All right.

CANTU

11:44:58
It's a huge proportion.

REHM

11:45:00
Okay. Let's take a caller in Greensboro, N.C. Good morning, Julie.

JULIE

11:45:07
Good morning. Thanks for taking my call.

REHM

11:45:09
Sure.

JULIE

11:45:09
I was hoping your guest could just speak to the fact that recently there's been news about a higher incidence of ALS among NFL players and those suffering concussions and head injuries at some point in their life. My mother died two years ago of ALS at age 61. And she suffered a concussion several -- well, many years earlier from a ski accident. I'm wondering if more research is being done. And as a mother of a young lacrosse player, I constantly worry about hear injuries and because I don't want to see the same thing for my kids.

REHM

11:45:47
Of course. Dr. Cantu.

CANTU

11:45:50
Yes, Diane, there have been now two publications, both with Ann McKee as the lead author from the work at Boston University. We have found a subset of individuals with chronic traumatic encephalopathy that also have a motor neuron disease. And their brains look like CTE, classical tau depositions at the depths of the sulci and the various locations, medial temporal lobe where it's most profound with CTE. But if you look at their spinal cords, they have tau deposition in the anterior horn cells and another kind of protein, TDP43, as well that's seen with ALS. So it looks like there is a variant of chronic traumatic encephalopathy that manifests as a motor neuron disease. And tragically these people die of the ALS aspects of it.

REHM

11:46:41
So where does that leave you, Dr. Cantu? Are you saying that you believe that the risks of these concussions are worth what could develop later on in terms of not only children below the age of 14, but as you, Dr. Gioia, mentioned high school kids and they're the ones who are playing as hard as they can?

CANTU

11:47:24
Well, I think what we -- the dots we've connected so far -- and there is so much yet to learn, but the dots we've connected so far is that the risk for CTE is related to total brain trauma, not just concussions. But those sub-concussive blows count as well. We don't know how many of those have to equal a concussion, but we know that you can wind up with CTE without any recognized concussions.

CANTU

11:47:51
Personally I think it's hugely important that we get out youngsters active in sports. I think sports are very vital. I think physical activity is very, very important and sports is just one part of it. But I think at some point given the proper, informed consent and proper technique, scaling way back the contact and practices, I think sports like football can continue to be played, as long as people understand the risks involved.

REHM

11:48:21
All right. Mark Meana, we have lots of questions about helmets. And from Facebook, Football promotes head to head contact through the advances in, quote, "protective helmets." There are fewer traumatic head injuries in a sport like rugby because there is no helmet so the head is not used as a weapon. How do we demote the use of the head as a weapon when these heavy helmets become weapons themselves?

MEANA

11:49:05
Well, I think I take a little bit different position. Of conquering this through education, helmets are there to prevent skull fractures, have certainly...

REHM

11:49:13
But do they?

MEANA

11:49:14
Pardon me?

REHM

11:49:15
Do they?

CANTU

11:49:15
Yeah.

REHM

11:49:16
Do they prevent?

MEANA

11:49:17
They certainly I think statistically. I'll defer to the medical community on that, that the reductions have been tremendous. Technology has come a long way as well from leather to where we are now. But I think what's more important is the education of all the volunteers that coach, administer, the parents, how they fit, what to do when it appears contact has happened on the field.

REHM

11:49:43
Okay. What do you do? What would you do as a coach if it appeared somebody had a concussion on the field?

MEANA

11:49:53
Well, I don't believe anybody can determine if they have a concussion on the field. If they exhibit signs and symptoms...

REHM

11:49:58
Okay.

MEANA

11:49:59
...any of those...

REHM

11:49:59
Yeah.

MEANA

11:50:00
...disorientation, can't remember a play.

REHM

11:50:01
So what do you do? What do you do?

MEANA

11:50:03
Pull them out and sit them out until...

REHM

11:50:05
Just sit them out is...

MEANA

11:50:07
Sit them out from the contest and defer them to the parent if they -- or a qualified medical professional if they are available. But more importantly to make sure that somebody with the education and expertise can follow-up on that incident. And, you know, USA Football's Heads Up program is targeting that, not just the players, not just the coaches, everyone involved from the ground up. It's a comprehensive effort of education. I go back to seatbelts. It took a long time to prevent -- to get people to wear seatbelts and in 25 years it's saved approximately 147,000 lives.

REHM

11:50:48
Stefan, is that enough?

FATSIS

11:50:51
No, I don't think it is, and here's why. USA Football which is the governing body for youth football has been promoting this Heads Up program to try to retrain athletes how to tackle and how to hit. Again, I think it's very difficult to control those behaviors once you're on the field. The impulse and making split second decisions in football often override the training that you have received. Ask any NFL player. The instinct is to use your head. And very often using your head -- not using your head is impossible. There was a study that I read about from Stanford University just this week that also indicated that hitting with the chest, not directly with the head, can also lead to some sort of brain injury through whiplashing of the head.

FATSIS

11:51:37
Second, getting coaches on board is a Herculean task. Every sport tries to do it. I sat on a panel discussion here in Washington a few weeks ago. The head of USA Football talked about training 100,000 coaches, coming up with a program where they would have to pass 15 tests, and then there would be a monitor on the sidelines at every game to make sure that coaches were coaching properly. Also heard from someone promoting the use of neurotransmitters inside helmets. These are $1,000 helmets that you can buy.

FATSIS

11:52:11
And I left thinking we're doing all of this to help preserve a sport. A journalist colleague, a friend of mine, said afterward we're burning down the village in order to save it. What do we have to do to try to make this sport palatable? And Mark can answer some of those things.

MEANA

11:52:27
Yeah, I respectfully disagree with his approach. The -- you have to start somewhere and we're taking small steps. And concentration on anything is going to make it get better, a better, safer game. And in the case of Heads Up Football program, we are starting. It's part of drills. Why are the drills there? Are they scaled back? You know, what is the design of the drill? What is it supposed to accomplish? Eliminating contacting drills from so far apart.

MEANA

11:52:58
Organizing verbiage so everybody, all the wonderful teachers of the game, and not only this game, but other game, are all talking on the same page. And when you start doing all of this and you get an education from an accredited program, you've really taken giant steps toward a comprehensive solution.

REHM

11:53:16
And you're listening to "The Diane Rehm Show." Stefan Fatsis, there's a lawsuit by former player who's against the NFL. You heard the wife of one of the players involved earlier. Tell me about this suit.

FATSIS

11:53:34
Well, there are more than 3,000 former NFL players that are participants in what is now a consolidated lawsuit in Philadelphia, class action against the NFL.

REHM

11:53:43
What's the charge?

FATSIS

11:53:44
The charge is that the NFL knew and didn't inform, as Mary Ann Easterling described, players about the risks of head injuries. Up until very recently in the early 2000's, the NFL continued to say that there was no link between football and head injuries. So this case was going to determine whether -- what the NFL knew and when they knew it, and whether it is liable for what could be billions of dollars in damages, and vast changes in how the NFL and its teams insure themselves, the league and players.

REHM

11:54:16
How strong a case do you think the players and their spouses have?

FATSIS

11:54:21
I'm not a lawyer, but if you look at past cases, I think the comparisons have been made to asbestos and to tobacco. And, you know, while this is not going to be on that scale, we're going to see in discovery what kinds of documents the plaintiffs surface and what kind of a defense the NFL's able to mount.

REHM

11:54:39
Could we be seeing a winding down of professional football?

FATSIS

11:54:47
I don't think so. I think football is culturally embedded in this country. And I think with good reason. It's a fantastic game. I love to watch it. I watch it very differently than I watched it ten years ago. Having been around NFL players, I'm much more aware of what they're suffering through. Not only in terms of the physicality of the sport, but the mental pressure that they are placed under being on an NFL team. But it's a beautiful game. I mean, it really is. It's fun to play and that's why so many parents want to play it.

FATSIS

11:55:15
The question is what can we do to ensure its safety. And I'm not sure how possible that is at the younger levels, but I think that Mark's right, they have to do whatever they can do to try to make the game safer if that's possible. But on a larger scale, I think just being aware of what these guys are going through creates, as fans and observers of the game, I think a more -- a smarter and a more sensitive public. And I think fans could do that.

REHM

11:55:39
If you had a child up to high school age, would you allow or want that son to play football?

FATSIS

11:55:52
No, I probably would not. Not probably, I would not. Knowing what I know and seeing what I've seen at the adult level and what athletes go through, and also being cognizant of sort of how youth football in some places, not everywhere, operates, I wouldn't do it. If they wanted to be a kicker though, you know, that'd be okay.

REHM

11:56:09
Dr. Gioia.

GIOIA

11:56:11
You know, again, I take a moderated approach here and I would say that, again, as a good consumer, I would be examining the team and the league and being sure that they're using the most up to date methods that we know, that they are, you know, have safety measures in place, they're recognizing and they're responding appropriately, then I would allow my son to play.

REHM

11:56:29
And, Dr. Cantu, what about you very quickly, please?

CANTU

11:56:33
Well, very quickly, Tom Brady, Senior did not let Tom, Junior play until he was in high school. And John Madden has endorsed no playing under the age -- that is tackle football, under the age of 14. And certainly I go there too.

REHM

11:56:46
All right. And Mark Meana.

MEANA

11:56:48
I disagree with some of the points made here. I believe that you need to play. You need to get to used to it. We need to make it better and safer. You can find a lot of people that'll say yes or no. We don't want to get into that.

REHM

11:57:02
Mark Meana, Dr. Robert Cantu, Stefan Fatsis, Dr. Gerard Gioia, the jury is out, but the cautionary comments, be careful. Thanks for listening. I'm Diane Rehm.

ANNOUNCER

11:57:23
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