How Will Junior Seau's CTE Diagnosis Affect The Next Generation?
January 14, 2013 1:26 p.m.
Dr. Alexander Khalessi, Director of Neurovascular Surgery, UC San Diego
MAUREEN CAVANAUGH: The National Football League is still reeling from the swastika San Diego charger Junior Seau who took his own life last may suffer from chronic brain disease. Doctors say the disease CTE can cause a host of mental problems including mental loss, irritability and depression. It's caused by brain injury due to concussion, contact sports or blast trauma. And it's not only professional athletes who may be a risk of sustaining these injuries college high school and youth football programs are also learning about CTE and trying to lessen the danger to players. I'd like to introduce my guests. Dr. Alexander Khalessi is codirector of vascular surgery at UC San Diego and Dr. Khalessi, welcome to the program.
DR. ALEXANDER KHALESSI: Good afternoon Maureen thanks for having me.
MAUREEN CAVANAUGH: Coach Phil Lomax is commissioner of San Diego youth football and cheer and is coach at Mira Mesa High. Coach Lomax thanks for coming in.
PHIL LOMAX: It's my pleasure thanks for having me.
MAUREEN CAVANAUGH: Dr. Khalessi, chronic traumatic encephalopathy is what they found when they examine Junior sales. Tell us what does that do to the brink?
DR. ALEXANDER KHALESSI: What chronic traumatic encephalopathy refers to is essentially damage to some of the deep structures at the base of the brain, the areas involved typically of the hippocampus which is responsible for memory and impulse control and the base of the frontal lobes which is responsible for executive function. What the doctors at the NIH found is if you look at the cellular level of some of the cells many of the cells of those regions of the brain were making proteins that they shouldn't in a way that is similar for example to Alzheimer's, some forms of Parkinson's and other neurodegenerative disorders that we are familiar with and backing up and taking a look at the cause and clinical symptoms associated with CTE is obviously much larger question.
MAUREEN CAVANAUGH: How much do we know about this particular brain injury? Do we know how head trauma actually creates this change in the proteins in the brain?
DR. ALEXANDER KHALESSI: Yes I think what's important for your listeners to realize is unfortunately as things stand now no matter how sophisticated the neuroimaging is this is still an autopsy diagnoses in other words you can't say someone has suffered from chronic traumatic and simple be until the autopsy when you're looking at sections of the brain. In terms of the clinical systems symptoms that we think they got the disease said it really divides into four stages and it's been demonstrated that it's not necessarily having an initial concussive effect it's having multiple concussions in a row without interruption actually make it more likely that you're going to develop this concussion down the line, this condition.
MAUREEN CAVANAUGH: Just to be clear concussion can cause other brain injuries as well
DR. ALEXANDER KHALESSI: No question. Concussion by definition is when you had a disturbance of how neurons talk to each other within the brain and that's a little different more severe injury so that the brain where you can see on images for example bruising of the brain or bleeds within the brain and other diagnoses actually mean by imaging obviously involving a neurosurgeon at that point.
MAUREEN CAVANAUGH: The NFL hosted a conference last November on health and safety for youth football players. I believe did you take part in an event, coach Lomax?
PHIL LOMAX: Yes I did
MAUREEN CAVANAUGH: What happened?
PHIL LOMAX: One of the things the (inaudible) during in the NFL in the partnership with youth football gear exposing youth coaches and high school coaches in the area ways to help reduce the amount of concussions and how to protect the players from recurring concussion type injuries and symptoms and then we also got information on proper equipment fitting, which is also a key component for my youth coaches is to be able to understand how to properly fit equipment
MAUREEN CAVANAUGH: Especially helmets, and Dr. Khalessi, I know that you are on the board of the Pop Warner medical advisory committee, dealing with football you are at the event as well. What impressed you about it?
DR. ALEXANDER KHALESSI: I think that Coach Lomax hit the nail on the head in terms of the three major stretchers we have for protecting the user on understanding CTE the first is actually is Coach Lomax mentioned appropriate equipment fitting especially if you are dealing with kids that actually can change very dramatically and players of different size the second and equally important is tackling technique in the sense of not leading with ahead and learning how to wrap up the players appropriately and I know coach Lennox has been very involved in educating the coaches that way and that there is changing the culture of the sport and also have people available both in practice and games that essentially can recognize the signs and symptoms of a concussion. One of the greatest challenges of any form of neurologic diseases that the player themselves or the patient themselves doesn't necessarily have insight into their own limitations it is very important for third-party observer to recognize the person may be vulnerable and to pull them out of the game and obviously coming up with more rigorous standards of play tonight but summoned back in play until the systems, symptoms have completely resolved so we are lowering the threshold for taking kids out at the national level one pump water hazard and is essentially reduce the amount of content that you people can practice we found there are other ways to get players ready for games the lesson less than 30% of practices are actually content-based and I think that with a lot of a lot of teams using the kickoff, there's a lot of special-teams injury they've been alerted the NFL level in terms of analyzing its to the outside we are seeing a sea change in the sport to make sure that all the positive things from a health point standpoint being involved in a team sport population Corporation cardiovascular fitness that we can enjoy all the other benefits but at the same time have a real sensitivity to the fact that neurological injury can take place if not recognized properly.
MAUREEN CAVANAUGH: Coach Lomax, let me get your information is much speculation at the time of Junior Seau's suicide that he took his life because he was suffering from a brain illness when asked was confirmed that the diagnosis was CTE, what was your reaction?
PHIL LOMAX: Initially my reaction was was saddened to hear that that type of injury impacted Junior's life and when that possible cause for why it impacted his life but also important I have to understand from a parent's perspective, the youth in our organization are impacted by the type of information and they want to know instantly what we do to prevent those things from happening, how do I know that's not going to happen to my child as they continue to play and even for myself as a. As my son goes on to play at the next level how important is that, and are the universities taking the same measures that the NFL is taking in order to ensure the safety of the players.
MAUREEN CAVANAUGH: Would you recommend that parents find out about the particular organization their songs are playing and when it comes to youth football. I mean, what do they need to know, what are the safety recommendations that you have for young players.
PHIL LOMAX: I think as Pop Warner is doing and we are doing in American youth football as well as the organization taking measures to reduce the amount of hitting that goes on during the week for youth players they are much more susceptible to concussion injuries in practice as opposed to games which changes as they get older in high school and on into the next level. So that's been a project of the culture youth football in the amount of hitting that was taking place about corners taking measures, we are taking measures one used USA football to make sure there's less heading that goes on in practice we want to find out about that as an organization you also want to find out are they teaching proper tackling techniques. The NFL's partner with USA football to teach that same tackling program which is kind of an all-encompassing concussion awareness and tackling improvement program. Here in San Diego, youth football we've partnered with USA football to ensure all the coaches get the training. They are all certified in that, they'll get the concussion certification training and you want to find out have they been trained by the local distributor for helmets whether it is shared or Riddell or CNET whoever is making the elements in the proper fitting and care of the elements to make sure the kids are getting the equipment fitted properly for them. Those three components I think our what parent should be looking to find out about what their youth organization.
MAUREEN CAVANAUGH: Have you had any reaction from parents that have their kids taken out because of this?
PHIL LOMAX: We've actually seen a reduction. Averaged we were just under last year 5000 we did well under 5000 participants for a while. About 10 to 12% reduction last year. I would expect a reduction again this year. And, awareness of the injuries and awareness of the things we are doing to help ensure the safety of the children is a key component in ensuring that parents are comfortable bringing kids up regardless of that we will still see a small reduction in the amount of kids participating in football a young age.
MAUREEN CAVANAUGH: Dr. Khalessi, I just pulled this little statistic out of the 50 postmortem diagnoses of CTE for the players, six of those diagnoses were from-high school football players what does that tell you?
DR. ALEXANDER KHALESSI: It's difficult for me to comment about those particular cases. I think that that bears out what I commented on earlier in the sense that what is more important than essentially accumulative impact that you've had over time is essentially having multiple hits in very close proximity to one another so obviously if you are playing in an environment where the hits are not appropriately recognized you potentially be at risk, but I do think it's important to kind of take a step back because from my perspective earlier when we were talking about how we've come to understand CTE it was based on looking at our physicians experience and other neurodegenerative diseases and the treatment of stroke for example and I think we are reaching a tipping point as well in our understanding of multiple hits to the head both in our veterans returning, and in youth football. So the irony of this conversation to me is that we are now in a situation where in youth football we are very sensitized to the risks, so in a way it's a much more supervised environment, is a much safer game and unfortunately confession is not something that is just limited to youth football. In fact if you look at statistics and other youth sports for example women's soccer, that the concussion risks and those ports are actually also very very real. So if I were a parent looking at the risk of concussion for my child I would want them to participate in any sport where there's actually an appropriate consideration of the neurologic outside of able today to make sure that it's recognized and they can return to play until the systems have completely resolved.
MAUREEN CAVANAUGH: When the shocking things about the CTE finding a membrane of Junior Seau is the fact that he did not suffer concussion while he was playing in the NFC this is multiple sub concussions was what they found that has just head hits, multiple hits. So how do you protect against head hitting when that is so much a part of the game?
DR. ALEXANDER KHALESSI: It's a great question but I would submit that in a strict sense almost certainly over the course of Junior's career he did indeed suffer a concussion and I think he maybe played in a time when there was a lot less refinement in the immediate kind of sideline diagnosis of those concussive events. As I mentioned one of the really tough things about concussion for participants is that short of losing consciousness they don't necessarily have insight into the limitations. There's a whole host of kind of common parlance of he cutting, or he's a little woozy, but he is right back out there then explain. And I think right now there's a much greater cost taken to take a dutiful neurocognitive assessment and bring out subtle or cognitive deficits that you would see five or 10 years ago because I wasn't someone doing an independent assessment in real-time.
MAUREEN CAVANAUGH: Coach Lomax this is not go to high school or used for football coaches but Pro coaches are known to have told players who are getting many there's a lot riding on the play that day to lead with their heads, to hit harder, and harder. Do you expect that to change?
PHIL LOMAX: I think you can start changing already, as Dr. Khalessi mentioned earlier it's a cultural shift in the NFL is taking it. Practically and you can see now there are players that are reluctant to return and are not as quick to return from head injuries and concussions. I think you see the impact being felt all the way down a flight level site exactly 10, 15 years ago with the way the culture of football existed or suffered a mild concussion type symptom would be good to return to the game. But, the culture has changed dramatically and I think players are much more conscious of their own safety and health than they were during that time.
MAUREEN CAVANAUGH: How do you think this is actually going to change the way football is played? Because it may be, players may be taking more time to return to the game, but the ultimate goal might be that players to not get concussive injuries to begin with. So I'm wondering what you see in the future of football, either youth football or Pro football that changes the game so that the injuries do not occur as often as they do now.
PHIL LOMAX: All the steps I think are already in place and as equipment improves and as tackling and the way people approach the game becomes a free think you will see a reduction and I think one of the key components one of the things I learned at the symposium was that allowing the brain time to recover, be sure that the player has been off the field and away from content for a long enough period of time that the next time he goes out there he's not going to reenter or combat the symptoms that he may already have. You can sustain a concussion following in your living room or playing another sport. It is not something that is specific to football but what is specific to football is the toughness that players are portrayed in the past that have caused them to go back probably sooner than they should have. And you can see the culture of that changing now.
MAUREEN CAVANAUGH: Dr. Khalessi, as a medical professional how safe do you feel that youth football is?
DR. ALEXANDER KHALESSI: I think youth football is safe as long as the appropriate safeguards are taken, as long as the participant involved is aware that if they do see symptoms may need to inform a coach or supervisory person and if they have any symptoms they need to stay out. I think it is important to have context and that we live in a society now where we are dealing with epidemics in childhood obesity, diabetes, and other problems so if I had to choose between a child being outside playing youth football getting fresh air as opposed to sitting on the couch playing video games I am much more worried about the health risks of the letter that I am with them being involved in youth football.
MAUREEN CAVANAUGH: If you had something you would like to see changed about right now what would it be?
DR. ALEXANDER KHALESSI: I actually think reducing contact in practice is the number one thing we can do to prevent these kind of injuries. As I mentioned because those are less supervised activities and also as the coach mentioned we are actually doing a better job of reducing those kind of nonessential hits. I should mention that the earlier question you asked about what's being done at the professional level has actually already bored not really significant success. So, simple things like putting up the kickoff point is actually reduce injuries 45% in the NFL in the two years since the rule change so I think people are asking questions of how do we reduce the high velocity is and I think we are making huge gains in the first characteristic problem and obviously coming up with interventions that actually lower the rate overall.
MAUREEN CAVANAUGH: Dr. Alexander Khalessi with UC San Diego and coach Phil Lomax Commissioner of San Diego youth football and cheer thank you both very much.
BOTH: Thank you.