Have concussion fears doomed youth football participation in Western Pa.?

Matt Moret: Welcome to Field Study, a podcast about sports and science from the Pittsburgh Post-Gazette. I’m your host, and producer, Matt Moret.

If you’re even remotely tuned into the world of football, you’re probably aware that head injuries and concussions have dominated player safety debates.

But researchers are still working to fully understand the long term consequences of these injuries. Meanwhile, parents are debating whether kids should be allowed to take the field at all.

Some observers have even argued that the uncertainty surrounding head injuries could doom America’s most viewed sport.

The problem is, many people don’t understand the true causes of a condition called CTE. Even fewer understand how to properly treat head injuries once they occur.

And that’s what brings us to the topic of this episode. Post-Gazette sports reporter Bill Brink set out to investigate how head trauma may be changing the future of football in Western Pennsylvania. Here’s what he learned.

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Bill Brink: You won’t find this on Pittsburgh’s tourism website, but the city has played an important role in the world’s understanding of head trauma. It was here that an Allegheny County neuropathologist named Bennett Omalu discovered a condition previously seen only in boxers in the brain of former Steelers center Mike Webster.

You might not know Omalu, but you might know Will Smith, who played Omalu in the movie “Concussion.”

Remember the Browns-Steelers game at Heinz Field in 2010, when James Harrison knocked both Mohamed Massaquoi and Josh Cribbs out of the game? Remember when, on the same day, Brandon Meriweather and Dunta Robinson also delivered vicious hits to the head? That Sunday pushed the NFL to crack down on dangerous hits, but the hits remain. Just ask Mason Rudolph, who was knocked unconscious by Earl Thomas earlier this season.

The University of Pittsburgh Medical Center has one of the nation’s best concussion programs. Mickey Collins, the director of the program, is a leading authority on the matter.

Mickey Collins: There’s concern about this injury, and rightfully so, but I really do feel that we've made a tremendous amount of progress in terms of how we can look at this injury and come up with the right approach to getting them healthy and asymptomatic from the injury.

Brink: When I began reporting this podcast, I intended to explore declining participation in youth football in the era of increased knowledge of concussions and chronic traumatic encephalopathy, or CTE. The rough hypothesis was, as more parents understood the real risks, fewer kids would play.

The numbers are down nationwide for five consecutive years — nearly 31,000 fewer high-school boys played 11-player tackle football last year than in 2018, according to the National Federation of State High School Associations, and the total number of slightly more than 1 million was the lowest since 1999.

In Pennsylvania, 25,515 high school students played 11-player tackle football last year, down from 26,910 a decade ago. It has decreased for 10 consecutive years. Here’s Tim O’Malley, the executive director of the Western Pennsylvania Interscholastic Athletic League, or WPIAL, with some anecdotal evidence.

Tim O’Malley: There’s a concern in regard to the fact that we have had over the last two or three years a few small school teams who have elected to have to forfeit because of their inability to safely, if you will, put enough kids on the field to compete. So therein lies a concern.

Brink: It turns out it’s impossible to definitively link something as hypothetical as knowledge about head trauma to declining football participation, especially with so many other factors at play: one-sport specialization, cuts in funding, closing or merging of schools, etc. Head trauma does appear to be a factor, according to Dr. Jesse Mez, an assistant professor of neurology at Boston University medical school.

Dr. Jesse Mez: I think that fewer people are choosing to play because they're linking play with concussions. I think as we link it to the sub-concussive injury and this understanding that playing safely might not be possible or might not absolutely reduce risk, I think probably fewer people will play.

Brink: It also turns out it’s very possible that just as identification and treatment of concussions has improved, more knowledge of CTE has revealed both increased risk and a Catch-22 when it comes to prevention. Here’s Dr. Mez:

Dr. Mez: We look at sports like football where the very nature of the sport is to hit, and the very reason why I think it’s so popular is because of how violent it is. So it really gets at the very nature of the sport and that short of playing flag football, or short of not playing, I’m not sure we can really reduce risk without stopping play or reducing the amount of play.

Brink: Concussion risks aren’t limited to football. Soccer players receive impact on every header. Hockey players deal with body checks. Wrestlers aren’t exempt from head trauma. But in football, the players’ helmets collide with something — the ground, another helmet, another player — on nearly every play.

The skull does an excellent job of protecting the brain from exterior trauma, but a poor job of protecting the brain from itself. A blow to the head can cause the brain to bounce around or twist inside the skull, causing chemical changes, which sometimes include the stretching or damaging of brain cells. Collins referred to a concussion as “an energy crisis to the cells and neurons in the brain.”

We don’t sit in dark rooms anymore to treat them. Doctors have identified six different types of concussion: Cognitive, vestibular, ocular, migraine, neck or cervical, and anxiety or mood-related. Each requires a different form of treatment.

Collins: Some of this information may surprise a lot of listeners here in that rest does not treat any of those problems. We actually need active and targeted treatments. So for example, for a vestibular problem, the way we treat that is actually by retraining it.

Brink: With the correct treatment, players who receive concussions can usually return to play. Identifying that a concussion has actually occurred is crucial. Collins conducted a study, published in the Journal of Pediatrics, that showed players who got a concussion and were knocked unconscious returned quicker than those who were concussed, but did not lose consciousness, and continued to play for an average of 15 minutes.

Counterintuitive, no? You get knocked out, you come back quicker? Well, those knocked unconscious left the field immediately, so the recovery process began sooner. The biggest factor in length of recovery was how soon after the incident the player came to see Collins. And while you can usually recover from one concussion, getting a second one before the first one heals — known as second-impact syndrome — can be deadly.

OK. So be alert for concussion symptoms; leave play quickly if you suspect one; seek treatment immediately; don’t return until you’ve recovered. Got it. What about CTE?

Chronic Traumatic Encephalopathy is particularly insidious because rather than resulting from the blows to the head that play on a loop on ESPN, it stems from the thousands of sub-concussive impacts that football players accumulate. It’s a degenerative brain disease that develops slowly as a protein called tau forms clumps and disrupts brain function, strangling and killing cells along the way.

Dr. Mez: CTE has long been known about. Since the 1930s it's been described in boxers. Back then it was called punch-drunk. When I was in medical school, it was largely called dementia pugilistica. It was considered an extremely rare entity. You learned about it in your pathology class. When I was training in aging and dementia, I didn’t really think I’d ever seen a case, and if I did, I didn’t realize it.

Brink: Back to Mike Webster. He dealt with amnesia, depression and dementia before dying of a heart attack in 2002 at age 50. Omalu discovered signs of CTE during Webster’s autopsy — the first such discovery in a former football player — and published his findings three years later. The NFL, you’ll be shocked to hear, pushed back hard.

Since then, Dr. Ann McKee, Dr. Mez and the Boston University CTE center have led the way in researching the condition. But here’s the catch: Doctors still can’t diagnose CTE in a living person.

What they are finding is a sharp correlation between years of football played and the likelihood of developing CTE. Here’s Dr. Mez on a study he conducted, published in October in the Annals of Neurology, the official journal of the American Neurological Association:

Dr. Mez: In this study we looked at just individuals from both brain banks who had played American football, at any level of play and any number of years of play, so anywhere from one or two years to as many as 30 years. We examined each of the brains for evidence of CTE, and then we looked at the relationship between years of play and risk of disease and severity of disease.

Brink: The brains, all 266 of them, came from the Veterans Affairs-Boston University-Concussion Legacy Foundation and Framingham Heart Study brain banks, so you can imagine a touch of selection bias, so the researchers used a process called inverse probability weighting simulation, a complicated technique that I don’t understand, to remove that selection bias.

The study found the odds of having CTE increased 30% per year played, and the chance of CTE doubled for every 2.6 years played.

Coaches, trainers and governing bodies are doing what they can. USA Football began the Heads Up Football program, which teaches kids to tackle with their shoulders while stressing the recognition of concussions, in 2012. Dartmouth's football team eliminated tackling in practice; instead, their players hit 190-pound robotic dummies that move like players do. Every state has limits on hitting in preseason and in practice. And beginning in 2022, Canada will ban 12-on-12 tackle football (their regulation version of the sport) for kids younger than 13.

O’Malley: I picked up a helmet the other day for the first time in a long time and the improvements made to the headgear, phenomenal. The padding that the kids wear. So the evolution of rules, the increase in the technological development of the equipment provided, I think all speak to the fact that safety is paramount, and everybody’s involved in the promotion of safety.

Brink: Locally, players and parents must fill out a Pennsylvania Interscholastic Athletic Association form called the Comprehensive Initial Pre-Participation Physical Evaluation — they call it CIPPE for short. Page three describes concussions and their symptoms, advising players and parents on what to do if they suspect a concussion has occurred. Both parties sign the form below this statement:

“I hereby acknowledge that I am familiar with the nature and risk of concussion and traumatic brain injury while participating in interscholastic athletics, including the risks associated with continuing to compete after a concussion or traumatic brain injury.”

O’Malley: Back in the day, there was a two-sided card, a white card with blue printing. That’s all it took. The doctor checked that you were ok, you signed it, your parents signed it, bingo. The CIPPE form now is seven pages long and it is an extremely detailed view of every individual’s health and well-being.

You are required as a parent and as a payer to sign and individual that you are aware of the potential for injury, specifically as it relates to the potential for concussion. So, you know. And you do it willingly.

Brink: CTE is trickier. The only way to prevent it is to reduce contact and there is no treatment yet. Hits taken in high school might not manifest themselves until decades later. At least six states have tried, thus far unsuccessfully, to pass legislation creating age limits on tackle football.

Recently, an alternative has emerged.

Here’s Gary Roney, the athletic director for the Catholic Diocese of Pittsburgh. He has seen a decrease in football participation during his tenure.

Gary Roney: One of my only concerns with this flag football movement or staying away from football is if you introduce tackle football in ninth grade they might not have the skill and the technique to do it safely from the get-go. So I think there could be a both/and kind of approach. We teach the technique at a young age, even if that’s slowly introducing physical contact in tackle, but we still need to teach that technique and then carry it on.

Brink: Roney has a point. He also off-handedly mentioned the alternative.

In 2017, according to the Aspen Institute, the number of students playing high school football fell, for the fourth year in a row, to 1.07 million. Between ages 6 and 12, participation has decreased 17.4 percent over the past five years. Also in 2017, the percentage of kids between 6 and 12 playing flag football passed, for the first time, those playing tackle.

Rashad Colvin has been the vice president of league operations for the Pittsburgh NFL flag football league for 15 years. He’s played and coached football all his life, including on flag football teams in Iraq and Kuwait while serving 20 years in the Army. When he began working with the flag football league, he had maybe 30 kids. Now he’s got 100.

Rashad Colvin: We teach, like, the basic, same fundamentals. Trying to make sure your head is on the right side, making sure you wrap your arms, you want to be able to see the target, you want to get that butt down low. So we teach the same exact fundamentals, but instead you wrapping and trying to get the person on the ground, you're wrapping and trying to pull the flag. So the fundamentals and the basics are still there.

Brink: The NFL doesn’t look like it’s going anywhere. Neither is college football, as long as there are scholarships on the line. Even Division III schools, which don’t offer athletic scholarships, have seen an increase in football roster sizes and total participation.

Collins remains enthusiastic about getting kids back on the field.

Collins: I’ve been doing this for 20 years. I started at UPMC in 2000. Here's what’s happened. When I started here in 2000, we had to argue and do everything possible to keep kids out of play because of their injury. Now, I have to argue to put kids back to play.

The pendulum has swung so much. The truth is in between. It's worse than what we thought, because we learned so much more and we understand that there’s real morbidity and real problems with this injury, but it’s nowhere near the level of what it's being made out to be in the media. The great, great majority of kids will get better from this and get back to the sports that they love, and the advancements in the treatment are real and the knowledge is real.

Brink: Dr. Mez is aware of the risks, but he isn't trying to sway the argument.

Dr. Mez: I really view myself as a researcher and a clinician, and that my job is to understand these relationships as well as possible and to convey that information to patients and the public, and then let them make informed decisions about what they want to do. There are risks and benefits to everything we do. I don't want to be the advocate who says hard and fast, you should not be playing. But I do want them to understand the risk.

Brink: O’Malley remains optimistic.

O’Malley: It's much safer than it's ever been before, and I hope it continues to get safe. Whether or not you choose to play, that’s a choice that you make, and the hope is that it'll continue. I guarantee you here in Western Pa., they’ll still play football. However many kids choose to play it, though, that remains to be seen.