As a sports medicine physician I have been fortunate to cover a lot of exciting sporting events and I have seen a lot of interesting cases. I have taken care of a wrestler who had a stroke. I have rushed an NFL player to the hospital with a pneumothorax. I have stitched up my share of hockey players bleeding all over the ice and I’ve evaluated countless unconscious athletes on the field. I have been a ringside fight doc and I have even been at the bottom of the X-games mega ramp to evaluate a skateboarder who fell 50 feet in the air and landed on his head. These have all been unforgettable and sometimes frightening experiences. But no matter how big the athletes or how extreme the sports, nothing really scares me anymore as a sports medicine doctor… That is, except for one. There is still one sports medicine nightmare.

Being a sideline team physician can be a little scary at first because you never know what kind of trauma to expect. Sometimes it is the subtlety of a concussion and sometimes it is the obvious fracture/dislocation. But ultimately all trauma, no matter how scary, can be simplified to stabilizing the patient and calling for paramedics. But sports medicine is more than just trauma. Of course it also includes all of the less acute overuse injuries but these are hardly scary either. But there is so much more than musculoskeletal injuries. What if any acute medical emergency could happen? What is most scary is knowing that ANYTHING could happen during a sporting event and that you need to be prepared for it ALL. There is only one event that could provide anything and everything all on the same day and that is why its what scares me the most. Its the Ironman triathlon.

The day starts early in the morning with the largest mass of swimmers you could imagine. There is trauma and pulmonary edema and near drowning and even hypothermia. After the transition to the bike comes the more significant trauma from the bike crashes that often occur many miles and sometimes hours from the nearest trauma center. For those that make it to the run the dehydration starts to set in. Then all of the electrolyte abnormalities and the mental status changes and the hyperthermia threaten to stop the athletes. And these elite athletes are hard to stop. Some have been training their entire lives for this event and convincing them to stop, receive medical treatment and be disqualified can sometimes be a battle. But surprisingly they aren’t all elite athletes either. I am always surprised by how many older or overweight athletes compete in these events. Cardiac issues, stroke and sudden death are always threatening. Finally the sheer number of participants in mass events like these make a football game seem like a walk in the park. Especially when the mass event is a high profile one, and no Ironman is more high profile than the Kona World Championships.

I am now amongst the thousands who have come here to Kona for this spectacle and tomorrow I will be an Irondoc. This will be my third time being an ironman physician traveling up and down the course in a mobile van unit searching for athletes in trouble. I have no idea what I will encounter tomorrow and that is the scariest thing for a physician. But I love doing this and I am only one of many who volunteer their time and efforts for these events. And no matter how scary it gets, I am just glad that I am not the medical director responsible for coordinating all medical care for an event like this. That truly is a sports medicine nightmare and I have the utmost respect for those willing to take on that challenge. As for me, it is nightmare enough just driving in the van.

Many treatments in the world of orthopedics involve removing or replacing damaged or injured tissue.  We might “trim out” cartilage tears or perhaps “reconstruct” ACL tears by using other tissue,  or we may even “replace” joints with artificial parts.  However, in the world of Regenerative Medicine we try to augment the body’s own natural healing abilities to truly repair and heal the damaged tissue itself.  We aim to actually cure the problem instead of just trying to come up with a second best solution. Utilizing the patient’s own stem cells is one of the most powerful tools that we have to achieve this.

Mesenchymal stem cells are produced in our bone marrow and they are responsible for healing connective tissues such as injured bone, ligaments, tendons and cartilage. As we get older or injured, we sometimes cannot get enough of these cells into the area in need of repair. This is especially true in and around joints and tendons where blood flow is poor or even non-existent. Since there is poor blood supply to these tissues, the stem cells have no way of reaching these tissues as they try to travel from the bone marrow to the site of injury. This is why injuries such as meniscal tears, labral tears, articular cartilage injuries, rotator cuff tears, ACL tears and many other orthopedic injuries fail to heal on their own. Stem cell procedures help solve this problem by precisely delivering a high concentration of stem cells into the injured area and aid your body’s ability to heal naturally. Patients experience very little down time and they typically avoid the long, painful rehabilitation periods that often follow surgery.

Let’s look at precisely how this is done. The first step is to harvest the bone marrow. This is usually performed through a needle aspiration from the pelvis. Typically anywhere from 1 to 6 needle aspirations are performed under local anesthesia yielding anywhere from 15cc to 120cc of a bone marrow aspirate. This bone marrow aspirate has the appearance of thick blood and is full of many different types of cells, the majority of which are NOT stem cells. Therefore, this bone marrow aspirate must be prepared in order to isolate and concentrate the stem cells. This process usually involves several steps of centrifuging, separating, purifying and reconstituting a mixture resulting in only a few milliliters of fluid containing millions of stem cells. Patients should be aware that there are many different systems available to do this and therefore all stem cell preparations are not the same. A final stem cell concentrate preparation may range anywhere from 5 million to 200 million stem cells. Ultimately the final concentration of the stem cells will depend on the type of system used as well as the age and health of the patient. Our stem cells are most robust prior to age 50 and will decline as we age. Therefore, the younger and healthier the patient, the better the stem cell sample we will end up with. Although there are many other factors, we do believe that ultimately the more stem cells we are able to concentrate and inject, the better the outcome will be.

Once the sample is prepared, we must then precisely inject it into the target tissue at the site of injury. Therefore it is crucial that this injection be performed under some type of guidance either using ultrasound or x-ray. It is also important for the stem cells to stay in the area of injury in order for them to do their job. Therefore often times the stem cell preparation may be combined with thrombin or another agent to make it into a sticky “paste” so that it can attach to the target tissue. After the procedure the target tissue may also have to be protected for a short amount of time and the patient may require a short duration of bracing or crutches so as not to disturb the stem cells.

We are still learning more and more about how exactly it is that the stem cells do their job of healing in the first place. We initially believed that the stem cells actually become or “grow into” the new tissue itself (cartilage, tendon, etc). However, this may not actually be the case. It may be that the stem cells somehow communicate and interact with the damaged tissue to induce those cells to heal themselves. Therefore, we are learning that it is the communication between the stem cells and the surrounding injured tissue that is most important and creating the right environment for them to do their job is essential. That is why often times platelet rich plasma or other biologic solutions may be injected in conjunction with the stem cells in order to provide growth factors and other cellular communicating functions to continue to instruct the stem cells how to heal the damaged tissue.

The take home message is that all stem cell treatments are not the same. The method of collection, preparation, delivery and providing the right environment for the stem cells can all have significant influence on the success or failure of the procedure. Patients should be educated and ask insightful questions from their healthcare providers in order to ensure that they are receiving the best possible treatment for their injury.

The use of stem cells in the world of orthopedics is an evolving science which is still in its infancy. It holds tremendous potential to naturally heal many injuries which may otherwise require more invasive surgeries with long recoveries. However, there are still many unanswered questions regarding this science and since these procedures are often expensive and are still regarded as experimental by most insurance carriers, they typically require large out of pocket costs to the patient and it is therefore important for the patient to be well educated in choosing a procedure that is right for them.

by Don Brady, PhD, PsyD, NCSP, LMFT
www.donbrady.com
Excerpts From:
“A Preliminary Investigation of Active and Retired NFL Players’ Knowledge of Concussions”
August 14, 2004

After examining the concussion literature and present research findings, it becomes apparent that varying degrees of concussion-related knowledge and differing theoretical orientations exist among health care professionals and athletes. These varying and sometimes opposing theoretical perceptions regarding aspects of a concussion directly influence the assessment, management, and return-to-play decisions made after an athlete sustains a concussion. Despite the different perspectives and resultant controversy, Putukian (1998) pointed out that the athlete’s health should remain the first priority when making return-to-play decisions.
Additional brain injury along with other injuries may occur as a result of returning to play too early in the functional recovery process. An athlete may be at risk for experiencing further physical injury after sustaining a concussion since an individual may manifest diminished cognitive abilities and corresponding physical reaction time while participating in a game or practice (Lovell, 1998; McSherry, 1989). Furthermore, an adequate time-lapse may not have occurred for possible secondary effects of the initial brain injury to have overtly revealed themselves and thus be adequately evaluated. Permitting a player to return prematurely to competition before an appropriate and thorough evaluation has occurred may also place the athlete at risk for permanent disability or death (Kelly & Rosenberg, 1998). Given these potential significant risks, pressure to allow the athlete to prematurely return to competition, especially in the “big game,” must be ignored (Asthagiri, Dumont, & Sheehan, 2003; Genurdi, & King, 1995; Roberts, 1992). Health care providers need to be not only vigilant of athletes underreporting the presenting symptomatology of their concussion (Echemendia & Julian, 2001; Kelly & O’Shanick, 2002; 2003; Lovell, 1998; Lovell & Collins, 1998; & Wills & Leathem, 2001), but must also rule in or out the presence of numerous possible symptoms.

Sports team health care personnel also need to focus primarily on the athlete’s health and well being, and not minimize an injury (Huizenga, 1994) or primarily focus on the player’s capacity to perform (Matheson, 2001; Pipe, 1998). This is necessary in order to avoid any real or perceived conflicts of interests emerging in the return-to-play decision-making process (Pipe, 1998; Matheson, 2001).

This particular concern has long been raised within the sports field and in particular by the National Football League Players Association (NFLPA) (Moore, 1982). In a 1982 article, the sports medicine coordinator for the NFLPA advocated for “improved medical care that he thinks is lacking in the injury world of professional football” (p.162). Moore (1982) also pointed out the existence of apparent COIs existing for team physicians and athletic trainers via conflicts in their dual roles of “allegiance to their team owners and the best interests of their patients”(p.162). Huizenga (1994), a former team physician for the Oakland Raiders, voiced similar perspectives pertaining to these two medically related concerns.

Several months ago, when football player, Terrell Owens, returned to the competition after sustaining a concussion earlier in the game, former All Pro NFL player and current Fox TV sports announcer and attorney, Cris Collinsworth, created controversy when he declaimed: “team doctors and players have a messy, triangular relationship. It’s not a one-on-one situation where my doctor tells me what he thinks is best for me. With a “team doctor,” by definition you’re dealing with someone who has been hired by the club, so there are conflicts of interest…I would have a “players” doctor on the sidelines, someone hired by the players (Orlando Sentinel, Sept 15, 2003). ”

It should be noted that the NFLPA advocated for a players’ physician over 20 years ago (Moore, 1982). Further input on this topic was provided by another player who responded to this writer’s survey. The athlete offered his unbridled perspective pertaining to COIs and some NFL team physicians when he opined that “they are soulless gatekeepers protecting the money, that’s why they are there” (anonymous NFL player, personal communication, September 16, 2003).

Perhaps football could take guidance from boxing, another sport in which concussions are a concern. Certain state boxing laws mandate the removal from the ring, for a significant period of time, of a boxer who has been knocked out. Rhode Island boxing statutes forbid a knocked out boxer from resuming participation for 70 days (Title 41 Sports, Racing & Athletes, 2004). Oregon boxing statutes require that a boxer who sustained a knockout be made medically ineligible to return to the ring for 60 days (Oregon Boxing & Wrestling commission, 2004). It appears ironic that two athletes, participating in their respective sports within the same state, have significantly differing criteria for returning to competition: An NFL player who loses and regains consciousness during a game may subsequently return to the field to play, while a boxer who loses and regains consciousness has a mandated removal from participation for an extended period of time.

Acknowledged pressure exists to minimize sports injuries and “play through the pain” (Huizenga, 1994; Moore, 1982; personal communication, anonymous NFL football player, September 16, 2003). Therefore, it seems plausible and logical to assume that similar research and clinician biases related to adverse pressure to minimize concussion injuries may also be present in the concussion field. Statements such as “just a ding” and “had his bell rung” serve to verify this perspective as these phrases minimize, discount, or invalidate the adverse implications of sustaining a concussion. Recent support for the existence of sports-related clinician bias may be found in Kelly and O’Shanick’s (2003) discussion of the formulation of the 1997 AAN concussion management guidelines. The presenters shared that the Quality Standards Subcommittee of the American Academy of Neurology–which devised these concussion management guidelines–included NFL team physicians. These team physicians reportedly influenced the committee’s decision that determined that a timeframe of 15 minutes was ample time for an athlete to “sit out” after sustaining an initial concussion. This recommended timeframe was reportedly not based on empirical evidence but was arbitrarily and directly related to the 15 minute quarter of a football game, so that an athlete would be able to return to play in the same game he sustained the initial concussion, if the symptoms resolved” (Kelly & O ‘Shanick, 2003).

Excerpts From:

Research-Based Practice
Sport-Related Concussions
By Don Brady and Flo Brady

NASP Communiqué (CQ) Volume 39, Issue 8 June 2011

www.nasponline.org/publications/cq/39/8/sport-related-concussions.aspx
• Although athletes may appear to have fully recovered from concussion, their brain may require more effort or energy to complete a task than was required prior to sustaining a concussion (Gronwall, 1989). Because the brain has been injured, the use of the concept of “functionally recovered” is encouraged over “recovered.”
• Individuals recovering from concussions may typically display fatigue along with difficulty with concentration, memory, new learning, organization, insight, irritability, and emotional self-control (Wrightson & Gronwall, 1999).
• The developing brain of a child or adolescent appears to take a longer period of time to functionally recover from sustaining a concussion than does the brain of an adult.
• Unfortunately, at the present time, functional recovery from a concussion typically focuses on when an athlete is resuming participation in sports, ignoring how well the student part of the student-athlete is able to adequately function within the classroom, home, or social setting.

A statement written approximately 35 years ago, advocating for both the exercise of reasonable concussion healthcare delivery and reasonable caution, remains pertinent to the management of SRCs:

“Doctors [and other health-care providers] do have a duty to convince controlling bodies and participants in sports where concussion is frequent that the effects are cumulative and that the acceptance of concussion injury, though gallant, may be very dangerous. (Gronwall & Wrightson, 1975, p. 997)”

Sports team healthcare personnel need to focus primarily on the athletes’ health and well-being, and not minimize an injury or primarily concentrate on the players’ capacity to perform on the field.

Don Brady (2014):

“While narrow and so-called screenings and their corresponding screening results have been interpreted as being asymptomatic…

Various studies have revealed the presence of other brain injury symptoms when other instrumentation is used to assess the same concussion / brain injury….

Thus the absence of evidence is not necessarily the evidence of absence…

Sadly some of the COI pseudo screeners desire the public to accept these false negative findings as accurate. “

Editorial by Andrew Blecher MD:

It is important to understand the differences between “functionally recovered” and “recovered”. Currently our management of sports-related concussion focuses around the “functionally recovered” athlete. This is due to several factors. First and foremost it is easier, cheaper and quicker for us to measure functional recovery than it is to measure actual recovery. We have developed many tools (such as computerized neuropsych testing and sideline assessment tools) to do this. There is tremendous pressure to use these tools and rely on them to determine management and return to play decisions. These pressures have developed due to the conflict of interest concerns of both the doctors utilizing the tools as well as those who developed the tools themselves. We all want to see the “functional recovery” of the athlete so that they may return to their athletic pursuits. Unfortunately, the true brain recovery timeline from concussion remains unknown to the practitioner who is making the management decisions. The long -term pathologic recovery from concussion will not always remain unknown however. With new forms of imaging and blood testing that are rapidly being developed this unknown world will soon become more visible to us all. What is now believed to be the truth by some and critically panned as junk science by others may someday become a well-accepted standard by all. But until we can completely and accurately measure true brain recovery from sport-related concussion, it will continue to remain a potentially dangerous unknown that if ignored in our management of the athlete may end up coming back to haunt us as the long-term affects continue to be discovered. The possible relationship between CTE and the “mismanagement” of the unknown true concussion recovery timeline will someday be confirmed or denied. In the meantime healthcare personnel must make their own management decisions knowing that someday those decisions may have serious long-term consequences. Hopefully those decisions were, are and will continue to be made in the best interest of the long-term health of the athlete, free from bias and conflict of interest. Unfortunately, in the real world, this is often not the case. It certainly hasn’t been in the past. But we can be hopeful for the future.

The Reclassification of Football Part III: The Collegiate Game

In Part I of this series we described the NFL as bloodsport. It is an unsafe sport and profession with tremendous injury risk. Its players are adults who acknowledge and accept this risk and participate in it because they believe that their personal rewards (money, fame, love of the game, etc) outweigh their risks. In Part II we discussed how high school and youth athletes are underage and unable to adequately consent to this brutal sport. Furthermore, we are still unable to fully quantify just how dangerous this sport is to developing brains in the long term. Until we know these answers or until the sport can be made safer, it is inappropriate to subject our children to this experiment in brain trauma. Therefore, the game of football that is played at the underage level needs to rapidly evolve into a safer version of the sport. So what will develop is two different classifications of tackle football (just like there are two different versions of boxing, martial arts, wrestling, etc). On the one hand is the dangerous NFL professional version, and on the other is the safer underage non-professional version. So now that leaves us with the collegiate game which is stuck somewhere in the middle. On the one hand the collegiate game is played by adults over age 18 who are able to consent to the risks, but on the other hand they don’t receive the level of reward that the NFL players do. So what happens to collegiate football? Does it need to undergo reclassification as well?

Let’s start with the risk side of the equation. Currently the risks of trauma (brain trauma included) are likely about the same at the NCAA Div 1 level as they are in the NFL. NFL players may have a higher overall rate of injury over the course of their careers, but their careers are longer than the 1-3 years of playing time in the NCAA. On the reward side, the NCAA Div 1 players don’t have any salaries or marketing deals but they do have scholarships and they also have a somewhat legitimate hope of obtaining fame and fortune if they can make it to the NFL. Therefore these collegiate players may also accept the risks associated with playing “NFL- style football” and make the decision that they still want to play. Since football is big business to these top schools just as it is in the NFL, the schools themselves are likely to accept the risks of continuing to offer “NFL-style” football at their institutions and afford the liability and other expenses involved in maintaining their football programs. How will these risks be managed? We will have to wait and see the outcome of all of the NCAA concussion litigation before we can be sure, but just as with the NFL, it is safe to say that at this point both the players and the institutions should realize that PLAYING PROFESSIONAL-STYLE FOOTBALL CARRIES AN INCREASED RISK OF HEAD INJURY WHICH MAY HAVE LONG-TERM EFFECTS AND HELMETS DO NOT PREVENT THIS.

Since both the Div I NCAA football players and their institutions now fully realize and accept these risks of head trauma, it is likely that “NFL-style” football will continue to exist at this level even if it is completely different than the high school version. This may be concerning and intimidating to incoming freshman who have not been exposed to this type of football and some experts believe that this quick transition from one type of football to another puts the athletes at even greater risk since they are not familiar with this style of tackling. So how do athletes make the leap from playing the high school version as 17 year olds to the “NFL-style” as 18 year old collegiate athletes? Well that is what redshirting as a freshman in college is all about, isn’t it? They spend the entire year learning how to play this new style of tackle football with full head contact. The majority of these Div I athletes are scholarship athletes who are essentially being “paid” to learn how to play this game that is generating money for their school. They can then more safely make the transition to the new game at the Div I level without officially being exposed to it.

But what of all the other schools … the Div II and III schools and all of the junior colleges and community colleges where football is not a money maker, there are no scholarships, no chance of fame and fortune and no big budget athletic department to afford the liability? I believe that both the players and the institutions would not believe that the risks vs. reward equation benefits either of them. Therefore here too tackle football is going to evolve into the safer non-professional version that we will see at the high school level. We might find that tackle football takes on an intramural form or becomes a “club sport” at these schools much like rugby. Thus, when all is said and done I believe that we will see a two class system of tackle football in the United States (just as we do with wrestling, boxing and martial arts). On the one hand, we will see the brutal bloodsport version that will be played at the professional level as well as the NCAA Div I level (which as we all know is essentially the minor leagues of professional football anyway – but that is another discussion). On the other hand will be another “non-professional” version of tackle football that will be played throughout the remainder of collegiate, intramural, interscholastic and youth leagues. This version will still be tackle football but will carry less risk of trauma, specifically head trauma. In these leagues, the head trauma will be reduced to an “acceptable level” by eliminating all purposeful head contact from the game. Determining what that “acceptable level” actually is, will be our greatest challenge in the field of sports medicine head trauma research. But until we know those answers, I believe we need to err on the side of caution and protect the brains of our children.

In summary, American tackle football is being reclassified. It is not just a collision sport. It is a brutal sport. With the high injury rates and the long term risks of head trauma we can no longer consider it safe. With every passing year more of the players themselves begin to acknowledge this and refuse to let their own sons play the very game they love. In spite of this, I have no doubt that football will continue to persist as a brutal sport at both the NFL and NCAA Div 1 levels. It is too much engrained into American culture. It is too big to fail. But the NFL and Div I NCAA is such a small percentage of football that is being played in America and at all other levels it must evolve into a safer sport. As described in Part II, this evolution into a non-brutal sport can only occur by eliminating all purposeful head contact by changing the rules, changing the equipment and most importantly, changing the culture. It is a lot to ask for and it won’t be easy, but now that football has been reclassified, this country has an ethical, social, moral and possibly even legal obligation to do so. Keeping our heads in the sand is no longer an option.

The Reclassification of Football Part II: The High School and Youth Game of Football

In Part I we recognized that professional tackle football is a truly unsafe sport. Even though we enjoy it, in our hearts and minds we know that the NFL is just as brutal as boxing and MMA. It’s bloodsport. But if grown men want to risk bodily harm for money, fame, the love of the game or whatever other reason they choose, then so be it. Adults choose lots of risky or unhealthy behavior all of the time. But these are adults. Now let’s talk about kids. I remember trying tackle football for the first time when I was eight years old and I remember trying it again when I was eighteen. What a tremendous difference. The eight year old thinks the game is fun and occasionally you might get hurt. The eight year old also has no clue what the words “possibility of permanent long-term cognitive dysfunction” even mean. The eighteen year old on the other hand knows that the game is fun and also knows that you are likely to get hurt. The eighteen year old does know the terms “permanent long-term cognitive dysfunction”, but he also thinks he is invincible so it won’t happen to him. But in the end, the eighteen year old is making a choice to play football. Is the eight year old also making a choice?

In the medical world a child cannot consent to being a participant in a research study. Why? According to the National Institutes of Health Protecting Human Research Participants:

Children may not have full capacity to make decisions in their own best interests; and therefore:

• Children are considered a vulnerable population, and
• Children are unable to provide “legally effective informed consent

Because children cannot provide informed consent, children provide assent to participate in research, to the extent that they are able, and parents/guardians give permission for a child to participate in research.

So can a child consent to playing tackle football? Well maybe they can in their backyard but not in any sanctioned league. A parent or legal guardian must sign a release form to allow them to play. But this is true of any interscholastic or organized youth sport. So why am I making a big deal out of this? Because parents can feel confident that participating in interscholastic or youth sports are likely to be beneficial for their children and have an extremely low likelihood of posing any long-term health risks to their child. But is this true about tackle football as well? Honestly, I believe the medical and scientific community is starting to question it. We hear about the unfortunate second impact syndromes in high school football players that result in death or permanent disability. This year already there have been five fatalities of high school football players due to trauma and the season has just barely begun. We also worry that all of the concussions and repetitive sub-concussive blows at such an early age may contribute to developing CTE later in life. So the truth is that we really can’t yet quantify how tackle football poses health risks to our children and we are still doing research to figure it out. So essentially, playing youth tackle football is research.

Let’s design a research study that recruits adult males to undergo baseline testing to evaluate their cognitive brain function. Let’s divide them into two groups. One group will have to go out into their driveway naked and run full speed into their garage doors. They will have to lower their heads just before impact so that they hit the door head first at full speed. We won’t re-evaluate them after the impact. Instead we will give them about 24 seconds to recover but then they will have to run into their garage door again. They will have to repeat this about one hundred times before they can call it a day. We won’t re-evaluate them at the end of the day either, but we will have them repeat this once a week for 16 weeks. Then they will have to repeat this every year for about 10 years. Then the subjects will be re-evaluated. Their scores will be compared to the other group that never had to run into their garage doors. The study will be designed to see if repetitive running into your garage door causes any long term brain damage. How many volunteers are we going to get for this study? It sounds ridiculous, right? We could never perform a study like this. It would never pass a review board. Well now let’s repeat the study but give them pads and a helmet. Does that change anything? We already know that the helmet doesn’t protect the brain inside.

This would still never pass a review board. But instead of a study let’s call it a game and pay the volunteers a lot of money. Ok I admit I might sound a little cynical here but is it really that far off? Football is research. We don’t have the answers. As unethical as the above study might sound, it’s even worse if it were conducted in children. Not only are they a vulnerable population that cannot provide informed consent to a study, but they may even be more at risk in the study itself. We know that the human brain continues to develop until at least age 18 so a child’s developing brain may be more susceptible to trauma than an adult’s. Perhaps that is why second impact syndrome almost always occurs in teenagers. Perhaps that is also why the incidence of concussion is almost twice as high in high school as it is in college. Whether we blame the smaller relative neck sizes or the poor tackling technique or whatever other reason you choose, it certainly seems that children are not only a vulnerable population by study standards, but their brains are more vulnerable by any standard.

So if children are by definition a vulnerable population that are unable to consent to a sport that has a higher incidence of brain injury and a potentially worse outcome than their adult counterparts, should they really be participating in it? Is the risk vs. reward balance still in their favor especially since there is no fame and fortune to be had in youth football? Should they be playing tackle football at all? Some say no. Some say tackle football should be eliminated for kids under the age of 14 or maybe even age 18. I don’t know that it necessarily needs to be eliminated, but it does certainly need to evolve. Let’s look at boxing and martial arts again. These sports do exist on the youth level, but the youth versions are far safer than the adult professional versions of the sport. We don’t see the professional versions in our schools because there is too much liability and it is generally considered unsafe. Every parent knows this at a gut level. So why can’t we see a safer and more diluted version of tackle football in our schools? The NFL talks about evolution but it is evolving at a glacier’s pace. Youth football on the other hand needs a major evolution. It needs to separate itself from the professional game. After all, we have reclassified professional football as a brutal sport.

We cannot let our children play a brutal sport. The youth and high school version of football also needs to be “reclassified” and become significantly different from that of the NFL. Of course the NFL will resist this change because they don’t want to lose their “feeder system”. But one of the NFL’s defenses in the lawsuit against them is that any causal link between football and CTE might be due to the thousands of hits and head trauma that occurred in youth, high school and collegiate football while the brain was still developing. Therefore how can the NFL be held responsible if the damage was already done even before the players entered the NFL. Well, NFL, you can’t have it both ways. If the NFL is not to be blamed and youth football is, then it is youth football that must be changed. Now that doesn’t mean that I’m in favor of reducing the game to two-hand touch or flag football. It does however, mean that youth football can evolve into a less brutal contact or even collision sport. It must be a sport that has absolutely no repetitive or purposeful head contact at all. Sure we can’t completely eliminate head injury from any contact sport but we can significantly reduce it. Tackling and collisions can continue to exist, but any head contact or leading with the head on any play, be it tackling or blocking, offense or defense, must be completely eliminated from the game.

We will need to have major changes in football rules, equipment, education and culture in order to get this done. The way the game is played, coached and taught will need to evolve. Intentional head contact of any kind must lead to immediate ejection. Tackling and blocking techniques must be completely changed to eliminate all head contact. The helmet must be redesigned so that it cannot be used as a weapon. The helmet’s sole purpose is to prevent skull fractures. Unfortunately its design has developed such that it is now the players hardest shell on his body and thus his best tool to tackle or block another player. It is used as a weapon because of its design. This is simple instinct. This must be eliminated. It cannot be simply “coached away” with a heads up tackling campaign. Helmet redesign must go along with the rule and coaching changes. The facemask must also be redesigned so as not to encourage leading or blocking with the face. The athlete must have absolutely no incentive to use the head to initiate contact. In fact, the helmet /facemask unit must be redesigned to create a disincentive to use it to initiate contact. Instead of making helmets that are “more comfortable to hit with”, we need to do the opposite. These changes may be costly and they may be unpopular but this evolution needs to happen until such time that we can prove that tackle football is safe and is no longer a research study on long term head trauma.

Because these changes will be unpopular, they will certainly be resisted by players, coaches, parents and fans. So how can we enforce these unpopular changes? As suggested in part I, if one were so inclined, we could force the changes in the NOCSAE standards so that their football helmet certification matches what the helmets are truly being tested for. Football helmets would therefore only be certified for a single day of use. Without any certified helmets for repetitive use beyond one day, tackle football would only be able to continue if new helmets were issued for every single day of practice and for every single game. This would become so cost prohibitive that schools and youth programs would be forced to make a choice to either abandon tackle football, or to accept a change in the rules and a change in the equipment. In addition, if a sport is going to be played with such a high risk of head injury, then it should be mandated that a representative with experience in diagnosing and managing head injuries (such as a certified athletic trainer) would need to be in attendance for every practice and every game, just like the coaching staff.

This needs to be the case not only for varsity football, but for every single level of tackle football in every single school and every single youth program. In order to play organized tackle football there must be equipment, coaches AND an athletic trainer. If the program cannot afford an athletic trainer, then it cannot afford tackle football. Period. This may mean that due to economic constraints, not every child may have an opportunity to participate in tackle football. Some may argue that it will not be fair to inner city children. Well not every child has the opportunity to participate in boxing or karate either. Not every child has the opportunity to participate in skiing, or skating, or fencing, or horseback riding or many other sports for that matter. But either we need to make every effort for our children to participate in these sports safely, or they should not be participating in them at all. I think tackle football is a great sport and I have decided that I want my child to be able to participate in it. But I also don’t want to regret that decision forty years from now. Only time will tell just how dangerous tackle football really is to the developing human brain. But when it comes to a generation of our children, can we really afford to be on the wrong side of history on this one? The only solution is that tackle football for minors must evolve and it must evolve now. There is no time to wait.

Collision sports are full-contact sports with a greater than average risk of injury. They include sports such as football, rugby, ice-hockey, mixed-martial arts and boxing. But there is something different about the last two. In the professional sports of MMA and boxing the intent is to hurt your opponent. In fact the best outcome would be to knock-out your opponent. Since a knockout is a concussion, the intent of the sport is therefore to cause brain injury to your opponent. How can this be right? In fact, for decades the American Medical Association has called for banning professional boxing for this very reason. From the Summaries and Recommendations of Council on Scientific Affairs Reports 1999 AMA Annual Meeting:

“Until such time as boxing is banned in this country, the following preventive strategies should be pursued to reduce brain and eye injuries in boxers: (a) Ideally, head blows should be prohibited…The World Boxing Council, World Boxing Association, and other regulatory bodies should develop and enforce objective brain injury risk assessment tools to exclude individual boxers from sparring or fighting including APOE e4 screening, neuroimaging, clinical neurological assessment, neurophysiological assessment, and indices of cumulative brain injury… [They] should develop and enforce standard criteria for referees, ringside officials, and ringside physicians to halt sparring or boxing bouts when a boxer has experienced concussive or subconcussive blows that place him or her at imminent risk of more serious injury…The AMA will: Promote the concept that the professional responsibility of the physician who serves in a medical capacity at a boxing contest is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even injured athletes that they not be removed from the contest should not be controlling. The physician’s judgment should be governed only by medical considerations.”

Now wait a second. This sounds very familiar. This was over a decade ago, but if you re-read this and replace “boxing” with “football” and replace “World Boxing Council” with “NFL”…. suddenly it perfectly describes today’s current events. Football is an inherently dangerous sport. We know this. It has an injury rate of over 100%. With an injury rate that high, there must be something within the sport that includes intent to cause harm. Do 100% of NFL players get injured and they are all just “work-related accidents”? Or does the “Bounty” scandal illustrate that there may be something else going on? NFL players have a higher rate of injury than any other profession according to the National Worker’s Compensation Board. But just being a dangerous sport isn’t the problem. It is specifically the specter of traumatic brain injury and its long term affects that defines football’s current crisis.

The problem with boxing is that the cumulative concussive and subconcussive blows (especially those that are not medically managed correctly) are risks for developing long term brain injury. That brain injury has a name. It’s called Dementia Pugilistica, also known as chronic boxer’s encephalopathy, traumatic boxer’s encephalopathy, boxer’s dementia, chronic traumatic brain injury associated with boxing (CTBI-B), and punch-drunk syndrome. This is not something new. It was first described in the 1920’s. But the injury that is new is CTE or Chronic Traumatic Encephalopathy. What’s the difference? Well nothing really, other than the fact that it’s what we use to describe the exact same condition but in non-boxers… namely, Football Players.

The evidence might not yet be as clear-cut in football as it is in boxing and some will say that we shouldn’t jump to conclusions, but we are starting to connect the dots and medical research is catching up. As the brain bank full of ex-football players with CTE continues to grow we must acknowledge that although the object of football might not be to cause brain injury, as it is in boxing, there does seem to be a growing preponderance of evidence that the game of football is not good for brains. But what about the helmets, you ask? There are no helmets in boxing but we have the best helmets that money can buy in the NFL. Surely that must make a difference. Unfortunately it doesn’t. There has never been a single medical study to show that helmets reduce the incidence of concussion or long term brain injury. Do they reduce the incidence of skull fracture and death due to acute brain trauma? Absolutely. But that’s not what we are discussing here. We are concerned with long-term cumulative brain injury.

Let’s take a quick look at how helmets are tested. The majority of helmets that are used for recreational activities such as biking and skiing and skateboarding are designed to withstand a single impact. This means that the helmet absorbs impact by deforming and is therefore intended to be replaced after a single impact. However, in contact sports, helmets are certified by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) to withstand multiple impacts. How does NOCSAE test these helmets? Approximately 27 different impacts are created at different locations on the helmet with different velocities and under different temperature conditions. “A passing helmet model is able to withstand all impacts.” This means that the helmet survived the impacts. It says nothing about the forces that occurred inside of the helmet and whether the accelerating/decelerating brain inside of the skull that is inside of the helmet can survive those impacts. Furthermore, 27 impacts occur in 1 single days worth of a football game or practice. So these tests do not measure whether the helmet can survive an entire season of impacts.

So the majority of helmets are indicated for single use only. But some, such as football are indicated for repetitive use. Does this mean that they prevent the effects of repetitive or cumulative brain injury? No. It just means that with repetitive use the helmet (or your skull for that matter) won’t break down. But even still, the helmet needs to be refurbished or replaced after a certain amount of use. But what about your brain? Does it get to be refurbished or replaced after a certain amount of use? Isn’t it time that the helmet companies and NOCSAE start calling the football helmet what it really is? It’s a device that will protect your skull up to a certain amount of wear and tear but has no claims whatsoever for protecting your brain against long term brain damage. In fact, it’s really a device that is only certified to withstand 27 impacts. So therefore it should only be used for one day of playing football. So either NOCSAE has to develop more rigorous testing, or the certification should only be good for one day of use and football players should only be allowed to wear a helmet for one day until it needs to be replaced. Otherwise it violates NOCSAE standards.

Since the NFL, NCAA and National Federation of State High School Associations all require the use of NOCSAE approved helmets, one could therefore say that in order to be in compliance, each of these organizations would need to supply its players with new football helmets for every single day of use. While the NFL might be able to afford this, surely most colleges and high schools could not. So if someone were so inclined to “legislate the banning of football” all they would have to do would be to deny government funding (high school and collegiate) to schools that weren’t following these standards. I am not going so far as to say that this is what needs to be done, however, it is important that we all understand what is currently occurring with football helmet use and certification. I can guarantee that these are facts that the majority of past and present football players are unaware of. Once we have all completely digested and understood these facts, can we then make well-educated decisions about whether or not we want to play football. And if we as a society (or the AMA as a medical society) decide that playing this dangerous game of football should not be allowed to continue in its current form until a helmet can be designed to prevent the long term brain damage… Well, then we may in fact be seeing the beginning of the end of football as we know it.

Ultimately isn’t that what today’s crisis is all about? We already know what the potential effects of football related concussions and head injuries are. The cat is out of the bag. The question is whether or not the NFL has understood this and made sure that its players were fully informed about the risks. How the NFL chooses to handle its past is up to them. But going forward let’s make no mistake… EVERY NFL PLAYER SHOULD BE FULLY INFORMED THAT PLAYING PROFESSIONAL FOOTBALL CARRIES AN INCREASED RISK OF HEAD INJURY WHICH MAY HAVE LONG-TERM EFFECTS AND HELMETS DO NOT PREVENT THIS. Does this mean that professional football needs to be banned or changed? No, I don’t believe that it does. But we do need to be aware of what it is. Let’s call a spade a spade. Let’s not gloss over the issue by having a safety first campaign, or throwing millions of dollars towards helmet research or touting an independent neurologist on the sidelines and that concussions are finally going to be managed correctly. These things are great and long overdue, but they ultimately don’t negate the fact that unless repetitive head contact is taken out of the game of football, (let’s say it again): EVERY NFL PLAYER SHOULD BE FULLY INFORMED THAT PLAYING PROFESSIONAL FOOTBALL CARRIES AN INCREASED RISK OF HEAD INJURY WHICH MAY HAVE LONG-TERM EFFECTS AND HELMETS DO NOT PREVENT THIS.

I don’t know whether or not that means that every player needs to sign something that clearly illustrates this understanding before they play in the NFL. I will leave these issues up to the lawyers. Whether or not the NFL recognizes itself for what it truly is will be something that may ultimately end up being determined in a court of law. But what I do know is that sooner or later the public will realize what the NFL truly is. It’s bloodsport. It’s still a great sport. It’s entertaining and love it or leave it, it’s part of our culture. But let’s not call it safe anymore. It’s a very unsafe sport and it’s a very unsafe profession. If players fully understand their risks and agree to play, and spectators understand the risks and agree to watch, then the NFL will continue to exist, just as it has… just as boxing has. And I will continue to watch.

Comprehensive concussion education event for athletic directors, coaches and athletic trainers

VAN NUYS, Calif. (May 2013) – The second annual SCORE Concussion Program educational conference
for athletic directors, coaches and athletic trainers will be held Thursday, May 23, 2013, at the Odyssey
Restaurant in Granada Hills. Call (818) 909-5054 to register.
Hosted by the doctors of Southern California Orthopedic Institute, through the nonprofit Southern California
Orthopedic Research & Education Center (SCORE), and in conjunction with the Wells Fargo Play It Safe
Concussion Program, the educational conference will include presentations from the Southern California
Orthopedic Institute sports medicine experts, a representative from the Play It Safe Concussion Program and
featured guest speaker Reggie Berry, former NFL defensive back for the San Diego Chargers.

“It is imperative that athletic directors, coaches and athletic trainers understand the symptoms and warning
signs of a concussion,” says Dr. Andrew M. Blecher, SCORE director and sports medicine doctor at
Southern California Orthopedic Institute. “We are honored to be able to continue to provide this muchneeded
comprehensive treatment and prevention education to help our local athletes stay safe.”
In addition to the presentations, students and faculty from the University of Southern California will discuss
their involvement in the Sports Legacy Institute Community Educators (SLICE) program, which provides
free, interactive concussion education to schools and youth organizations in Los Angeles and six other cities
across the country.
Working with the Wells Fargo Play It Safe Concussion Program, SCORE provides concussion insurance,
including baseline concussion testing and concussion management coverage, for all varsity football players
for the 2013-2014 school year, at no cost to schools. The details of the insurance program may be viewed at
www.wellsfargo.com/com/insurance/concussioncare.
For more information regarding the SCORE Concussion Program or the upcoming concussion education
conference, please contact Southern California Orthopedic Institute by calling (818) 909-5054.
Southern California Orthopedic Institute is one of the largest private orthopedic practices on the West Coast.
Along with its main headquarters in Van Nuys, the practice also has five satellite offices in the Los Angeles
area, as well as an office in Bakersfield. Over 30 orthopedic specialists provide care in the following areas:
shoulder, elbow, foot and ankle, spine, hand and wrist, hip, knee, physical medicine and rehabilitation, sports
medicine, orthopedic trauma and pediatric orthopedics. For more information on Southern California
Orthopedic Institute and its specialists, visit www.SCOI.com.

It was just over a year ago that with great trepidation I dipped a toe into the world of social media by opening a twitter account. I was delighted to quickly realize that it was a fantastic avenue to meet new people, reconnect with old friends and hear people’s thoughts on current events in real time. After a year of tweeting on sports medicine topics and sharing other people’s opinions, I have learned two things

• People also seem to genuinely care about MY opinion
• 140 characters is not enough for my opinion

So now it’s time to really jump into social media with my new blog! I hope that it can serve as an extension of my twitter account so we can more thoroughly talk about current issues in the world of sports medicine. I will try to get on here whenever there is a sports medicine happening that needs to be discussed. In the meantime, please contact me if you have a hot topic with some burning questions and I will try to give you an in depth analysis as eruditely as I can. Lol! Or more likely I will at least give you my two cents.