Talks@12: Tackling Football Injuries

[email protected]: Tackling Football Injuries


I’m Gina Vild. I’m Associate Dean for
Communications and External Relations. Welcome to today’s [email protected] With the Super Bowl
only days away, the topic of tackling
football injuries could not be more timely. So thank you for being
with us today, and also a warm welcome to all of you
who are joining us through live streaming and those
who are joining through our first ever Periscope
broadcast through Twitter. Thank you for being with us. It’s been said that baseball
is America’s pastime, but football is
America’s passion. This has never been more
clear as the game attracts fans representing every
demographic across the country. In the United States, the six
most watched television shows of all times are the Super Bowl. And yes, it was a disappointment
that our New England Patriots won’t be playing this Sunday. But still, Super
Bowl 50 is expected to exceed 114 million viewers. It’s because of
audiences like this that the football championship
is easily the most watched show in America’s history. But increasingly, the topic
of football-related injuries is flooding the news. Only last Friday,
the New York Times published an article citing that
concussion diagnosis increased by nearly one-third over
the last year due new health and safety measures
that aid detection that the NFL has put in place. And for those who
follow this game, it’s been a season of
some notable injuries. Some of Harvard’s
leading researchers, working in collaboration
with physician scientists from our Harvard Medical
School teaching hospitals, are trying to better understand
and address the complex issues players face through the
Football Players Health Study at Harvard University. Here’s a brief video that
highlights this effort. [VIDEO PLAYBACK] -Each individual former
player has a chance to be involved with the
Players Health Study here at Harvard University
that directly relates to them. -It’s not concussions
only or joints only. It really is looking
at the whole player. And we’re concerned
about the whole life. -What’s different
about this study is that it’s a partnership
with the players. It’s not Harvard studying them. It’s a we. -That’s the incentive
right there, because this is coming from the
players to study themselves, to study us. That’s groundbreaking. -We’re by the players
and for the players. And no study is like that. No study really talks to their
subject population and says, what is important to you? -There’s that respect
level across the board, from the researchers
to the doctors to the players and vice versa. -And then you get to see some of
the leading guys who are doing their thing behind the group. They’re like, who’s
this guy right here? He’s the Tom Brady of what? That guy is the
Barry Sanders of who? When I see that excellence,
I am so familiar with it that I naturally
try to do– and this is about being a
part of a team, how can I fit to make it better? -We’re committed to help
the former players today, while we engage them to
learn for the benefit of the next generations
of former players and of the population at large. -This is a landmark study. This can literally
change the way people think about their health. -Implications for college. It’s implications for
high school players. Implications, as we said, for
kids who are making decisions about– and their families. Should they play, or
should they not be given the opportunity to play? -This is going to reach so
much further than pro football. [END PLAYBACK] I’m pleased to introduce two of
the studies co-directors, who together with Lee Nadler
of HMS and Dana Farber and Bill Meehan of Boston
Children’s Hospital are leading the study. Alvaro Pascual-Leone is
a professor of neurology. I’m sorry. Alvaro Pascual-Leone is
a professor of neurology and an Associate Dean for
Clinical and Translational Research at Harvard
Medical School. He serves as the chief for the
Division of Cognitive Neurology and the director of the
Berenson-Allen Center for Noninvasive Brain
Stimulation at Beth Israel Deaconess Medical Center. He is a world leader in
research and development, clinical application, and
teaching of noninvasive brain stimulation. Ross Zafonte is the Earle P
and Ida S Charlton Chairman of the Department of
Physical Medicine and Rehab at Harvard Medical School. He’s is the Vice President
of Medical Affairs at Spaulding Rehab Hospital
and Chief of Physical Medicine and Rehab at Massachusetts
General Hospital. He is a world-renowned expert
on traumatic brain injury. Please join me in welcoming
our guest speakers. [APPLAUSE] So, I get to go first. And the first thing I
would say is thank you. Thank you to our collaborators. Gina listed a few of them. And thank you all
for being here. We are only able to
do this because we’ve set up an extraordinary team. And that’s people throughout
Harvard, and people external, and the former players who we’re
getting tremendous input back from, and our PI,
Dr. Lee Nadler. So, why is everybody
so interested in this? Why is this so important? Gina touched on just a
couple of the issues of why. It’s the most watched
thing in America, and frankly, all over the
place– North America. The worldwide viewing
keeps going up. The ratings this year, despite
all the notoriety of injury, are higher than
they were last year. And we have a compelling
reason to want to know. We have 53 active
players every week, almost 1,700 players throughout
the league who are ongoing. And we have millions involved
in youth-related sport and in collegiate sport
that are not only football but are other contact
sport, from which this study will help inform. It’s not a parallel population,
but it will help inform. Football was under
threat in the 1900s when Teddy Roosevelt
intervened because of the number of injuries. What we want to do,
what we seek to do, is really go back and
understand what is going on. What, in these unique
group of people, is forming the changes
that they experience throughout their life? And I’ll talk more about that. Why this is
important– I’m going to touch for a second
on my own experience. I’ve had the privilege of
treating former players in the past. And one of the things you
notice about them is they are more than just bigger
than a lot of other people and stronger. They’re uniquely
driven individuals. You don’t get there
without being driven. You don’t get there
without being focused. You don’t get there without
being the 1% of the 1%. And within that, uniquely being
able to teach in visual stimuli quickly and react to it. Otherwise, wouldn’t
be employed very long. Now, one of the critical
issues is what we are not. What we are not, as
was said in the video, is we’re not just
a concussion study. No way. Because even if we were to
elucidate that issue alone– it’s one of the
many things we’re tackling– we’re going to
leave a lot of former players still with significant issues. So it’s part of the study. It’s not the whole study. And that’s part of what
makes us different. This is a unique, comprehensive
look at player health from beginning to end. And Alvaro will detail
a piece of that. So, what has been our treatise? Our treatise has been,
hey, the primary focus is on player health. And we need a collaboration
on player health. So, you heard in the
video a bit about that. And where we came
to look at this is something in my area of
work, almost participatory kind of research. We’re interested in the
affected population. What do they really see as
the most important issues in their life impacting
function, impacting their quality of life,
impacting what happens to them on a daily basis? And then, how do we develop
ways to diagnose, mitigate, and maybe transform
some of those injuries? And we need to understand who
these people uniquely are. And I’ll touch on
that in a minute. We also focused, with
our collaborators at Harvard Law
School, on the issue of confidential and
secure information. This is a very tenuous
time for former players, a time associated
with legal action, a time associated with rampant
media, a time associated with concern and threat
related to information they receive almost
on a daily basis. How do we assure that
the information they get is correct? One of our big things was if
you’re going to participate, we’re going to do
whatever we humanly can to respect your
confidentiality. Because these unique
people are identifiable. And so we fought very
hard with our colleagues at Harvard Law
School to make sure we got an NIH Certificate
of Confidentiality to protect our data as
much as is possible, to do what we can do
to assure that we build that relationship of trust. I’ll tell a story in just a
second about a former player who I know very well, who’s,
in the last several weeks, received a 11 letters
on 11 different studies. Everybody is in this game. What we’re interested
in is, how do we transform the lives
of former players and use that information
to impact the future? We need to understand
more about diversity. Diversity is more than
just racial diversity, although that’s
incredibly important because likely over
65% of present day NFL players are
African-American. But there’s more
to it than that. There’s diversity about
where you grew up. Over 60% are from the South. What are your belief systems? How were you raised? What would be epigenetic issues
that influenced your life? And we’re managing this,
thanks to Lee’s input, with innovative teams in
focused interest areas. So we can deliver
things now, and then refine them in the future. So it’s not a study
based on you’re isolated. We give you this
little bit of money. You’re isolated. We give you this
little bit of money. It is consistently
managed and focused on outcome and deliverables. And as I said before,
knowledge translation is really important. A common complaint of
really a lot of research for participants, especially
former players, is, hey, I didn’t get any feedback. i didn’t get any feedback. So we’re dedicated
to giving feedback as we can, as is appropriate, to
former players regarding, hey, we noticed this
instance of sleep apnea among offensive linemen. If you meet these criteria, this
maybe a thing to do to address. So, to go back to that
idea about participatory and research, we wanted
players’ engagements. And so we went out on
quite a little effort to get to former
players and say, hey, what are the most
important issues to you? Now, one of the most
important issues that came up is really one that was
also in USA Today survey several years ago, knee injury,
and knee osteoarthritis, and degenerative
issues of the knee, and associated functional
impairments from that. Chronic pain is a constant
complaint of former players, but they may manifest
it differently. And let me tell you
what I mean by that. When we talk with
former players, one of the things
we notice is these are gentlemen who
are selected out to be able to tolerate pain,
to play their career from pain. And if you couldn’t, you
don’t last very long again. So they’re not used
to, A, accommodating related to the pain. If we asked them, can
you get something done? Can you get through your home? Can you go do an errand? Yes, I can. I do it. It hurts, but I do it. What is the impact of that pain? And what’s the impact
of all the medicines they took to mitigate that
pain during their career and afterwards? No issue over the
past decade, perhaps, has ramped up in the
American consciousness from a health perspective
like concussion. Concussion has really hit the
headlines, almost every day sometimes. And it really was driven by
a sentinel series of reports that came out in 2005 and
2006 linking concussion to long-term
neurodegenerative risk. But there are so many
issues that we do not understand with that. We don’t understand who’s going
to get into long-term problems. We don’t understand what
the genetic risks are. What are the
manifestations of that? How are other
things interrelated, as we’ll talk about And so we’re making
this clarion call that things shouldn’t be
looked at in isolation, but in an integrative manner. If you look at
cardiovascular health, one of the things that
Alvaro will touch briefly on is the role that some
of our colleagues have had in trying to determine
the fact that whether the way players train, specifically
strength trained athletes, in and of itself results in
a thickening of their heart walls, a risk for hypertension,
and a form of cardiomyopathy. Remember– I think we
have a distinguished former player in the audience–
but few plays go on more five, six seconds. And so it’s really full out
force multiple, multiple times. What does that mean long-term
for cardiovascular risk? Now, to get this done,
it’s really important that we think about more
than just ourselves. When Dr. Nadler brought
everyone together, and certainly Alvaro,
Bill, and I helped, we thought of this as a broad,
one Harvard kind of effort. So we see this as an
important broad collaboration to solve the myriad of issues. And we feel those
myriad of issues will have a benefit, not only to
former players and present day players, but to others and
other unique populations. So we brought together the
Harvard hospitals– all of them are affiliate here– a broad
element of Harvard itself, the law school, our
academic collaborators throughout Harvard, and external
for some of our projects out of the country. We’re interested in who
the best experts are, and how do we solve the
problem, and even collaborating with some of our
federal agencies. Remember, some of
the lessons we’ve learned in this population can
be garnered from the military or from others. Now, to take a page from Dr.
Nadler, one of the things that we have to think about
is really catalyzing health. How do we ask the right
translational questions? How do we put right
investigators together, forming right communities? How do we do right
tools and technologies? One of the things about most
all of the studies in the past regarding former
players is they’ve been important contributions. Nobody would say otherwise. But they’ve been limited by
rather small populations, limited data, death
certificate studies. Those are important, but we’re
interested in what’s going on in the people who are alive. And they’ve led to associations
that we don’t know are true. So if we put two
things together, first the comorbidity might
be unidirectional, in that one condition causes another. That’s possible. Second, there might be
a bidirectional causal relationship between
the two conditions. That’s possible. Third, the two
conditions might be comorbid due to some shared
underlying risk factor– the environment, genetics,
exposure, or both. Finally, genetic risk factors,
or environmental risk factors, or exposure might produce
a state of neurobiology that underlies many
of these conditions, or biomechanical biology. So what’s important is
we need a paradigm shift, that working in isolation
regarding this problem is not going to do it. And we need to understand
this is an integrated disease, to bring the bench
to the bedside and the bedside to the bench. So we’ve been
collaborating and crossing between fundamental scientists,
and patients, and individuals at risk. And we’ve look to develop
products, biomarkers, therapeutics and prevention, via
selecting the important problem and putting these two together
in a managed grouping. Alvaro will talk a little bit
about some of our projects that already have
produced some success. For example, can
we target a therapy for so-called chronic
traumatic encephalopathy? Can we look for a biomarker
and identify a mechanism? Can we prevent long-term
degenerative arthritis after an ACL repair? And we know that this year,
the number of ACL injuries actually went up in the NFL. So, one way to think of this
is as the integrated player, that biological processes
are likely related. An example can be inflammation. Inflammation at times to be
a good thing in the healing process. But clearly, it can also
have some negative dilatory consequences in the
neurocognitive systems, in the joint
systems, and others? Couldn’t these be
multi-factorial? What are the psychosocial
risk factors– ADHD, learning disability, or others? And how does that
play into this? What about lifestyle? What happens to
people after football? You know, as I mentioned,
this is the 1% of the 1%. Most really have been recognized
since they were 12, 13, 14, as unique individuals. You go from that level
of acknowledgement to [SNAPS FINGERS] next
day, hey, nobody knows me. That’s a real impact on
your psychosocial well-being and how you feel yourself in
this very, very complicated world and environment. And all of these systems
maybe interlinked to impact clinical
function of other systems. Now, this is a slide
I love to show, because we think about it in
some ways as an integrated player. There are pre-injury factors. There are injury exposure
and post-injury factors They lead to
cognitive disturbance, emotional disturbance,
and physical disturbances. And what we believe is true
is not necessarily true. For example, if you have
someone who’s an offensive lineman, and they’ve
been playing at 310. And now they’re 420. And they have sleep apnea. And they have hypertension. And they have heart disease. And they’re depressed,
what is the source of their cognitive deficit? What is the source
of their disturbance? So many of these things need
to be parsed out importantly, because they produce the
symptoms that I have for you on the end of the
slide that include chronic pain, joint pain,
headaches, behavior. How someone approached
their training in a biomechanical manner, what
their initial treatments were like, or lack thereof, produce
this integrated picture. And we need to
parse some of that out and understand the
biology associated with it. So we’ve really thought about
this as the whole player, the whole life. And we don’t think
that these are distinctly separate
groups of things but really linked
and integrated. Our population studies,
as Alvaro will talk about, will tell us more about health
status and quality of life. And this will inform our pilot
studies, which are already ongoing and successful, that
are dedicated to developing new preventative strategies,
diagnostics, and treatment. In words, these things
aren’t separate. They’re all integrated. And our law and
ethics team has done an extraordinary job looking
at the structural issues related to player health
and how that might impact their long-term well-being. So, one of the critical issues
that I talked about earlier is that participation in
these kinds of studies is really problematic
and important. Former players are always asked
to give back to something. And as I said, there’s a
myriad of studies going on. But this is different. This is focused. This isn’t in isolation. And so we’ve spent
a lot of time– Alex has really led that–
going out, explaining the differences, dealing with
direct mail, going to events, using former players
as ambassadors to explain the situation. So this is very much, in
some ways, like the isolated military populations or
others, in which really there needs to be an outreach
call for this group. And then, I think we view this
all is that we’re different. We’re player-driven, i.e. as I said on the primary goals. We have a focus on
the whole player over the player’s entire life. And we’re focused on addressing
biological, individual, and structural
factors of health, and then making a meaningful
difference within them. It’s no good if these
differences simply are noted without transferring
that knowledge back and doing something for former players. So I will introduce my
colleague, Dr. Pascual-Leone. [APPLAUSE] Thank you. I have it on, yeah. So, thank you, Ross. Maybe I’ll start
re-emphasizing the pointed that Ross was sharing. You know, as a clinician,
as a physician, we generally remember, at
least good clinicians do, that it is about the person
we have in front of us. It’s not about the walking
cancer, or the brain stroke, or the whatever, stomach ulcer. But it’s about Mrs.
Jones and Mr. Robinson. And good clinicians know that. That doesn’t mean
we need to not know about the biology
of the disease, but we understand
that that disease doesn’t exist in isolation. In research, we sometimes,
I fear, forget that. We forget that what we’re
really interested in when doing human research
for human health still needs to be anchored
in the individual. We need to extract the
knowledge about the biology, about the fundamental aspects
of the risk factors for health. But we need to relate it
back to the individual that is suffering that illness,
because the illness may manifest one way or another. And that individual, again,
doesn’t exist in isolation, but rather exists in a
very specific surrounding that may have structural
conditions that determine health. Arguably, that is
never more clear than in professional football. And we think we have a real
opportunity, a real challenge, but a real opportunity
in addressing the health and well-being of former
football players to learn, not only something that makes
a difference for their lives, and their families, and their
kids, but for athletes at large and for all of us and other
cohorts of individuals. Because the challenge of
structural, biological, individual might be
different, but they always exist, even if we
don’t identify them. Because of that, because of the
desire to get to that level, we need everyone. We need everyone, because
when we focus on responders in any one epidemiologic effort,
we risk having it by a sample. We risk having a selected
sample– and again, never more clear than in football. The truths that we’re all
hearing about in the press and otherwise are based on
studies that, at the largest, encompass short of 2,500
living players, former players, or 3,000 deceased players. Deceased players, as Ross
was saying, can inform a lot. But we care about
those that are living. And those that
are living, 2,500, is a very small sample of the
actual n football players. And of course, those
that actually get engaged are either those that have a
problem, schematically here with the heart, or the
brains, or the knees, or those that don’t
have a problem at all and are just sort of
researchers, professionals themselves. We want to start with
to get a sense of what the prevalence of the problems
are in the population. And simple as that
may sound, that’s something that we don’t know
for the many problems that are being talked about
for football players. So we need everyone. We need everyone to
extract information about the population. What is the number? The number of former players
if you go from 1960 to today. Why 1960? Because it was the introduction
of the hard shell helmet. To today, would be
somewhere around 15,000. Now, this means accepting
as a former player anybody that has been paid a
paycheck as a player for NFL team. Doesn’t mean that
they played ever on the big stage of
televised football games. That’s a very small group of
former players comparatively. But the others still
have the lifestyle in many ways with differences,
with different stressors. They’re important to capture. So we want those 15,000. But we want to remember
that those 15,000 are 15,000 specific individuals. We don’t want to blur their
individual differences. We want to highlight and
identify those differences. Because as Ross was saying,
these are some of our advisers. Each one of them has
a very different life, a very different upbringing,
a very different biology, a very different
position they played, a very different number
of years they played, a very different transition
to the rest of their life. So we think of this cohort
of unique individuals that then have a
rather unique life with a degree of physical
effort that I can’t even begin to imagine, leave alone do. And they do it continuously for
many years with the stressors of will you be selected? Will you make it? Will you not– With the
drive for achievement and the challenges
that come with that, with the social
recognition, and oftentimes their sometimes not quite
true social support, and in some instances,
real social support that can be quite labile and be gone
from one moment to the next. When they are cut, there
are big transitions. Will they make it to the game? Do they leave the
big transitions? The impact of
transitions themselves becomes a key determinant
of unique lives. But we want to remember that
that unique population, which like Ross was saying,
may lay way out here in terms of the uniqueness
of the individuals from the very beginning,
has in itself a distribution of population that different
individuals in the population are different. And so our goal has
been to understand the meaning of health and
affliction for the NFL players. And for that, we have benefited
enormously from their guidance. So I want to share
the perspective of one of our other advisers that
made it particularly clear, at least to me. This is a slide from
Damien Richardson. Damien Richardson is
one of our advisers. He’s also an orthopedic
surgery resident who had been having a
hard time communicating, because he was on
call last week. And I said, oh, I know a
little bit more about that than I know about football. So the point was that he
was picked in 2002, drafted by the Carolina Panthers. He describes himself as a quote,
“typical professional player.” He was in the league
for six years. Some have a much longer career. Some have a shorter career. He was a reserve safety,
a special teams player. He was on minimal
salary at the NFL. Didn’t mean he didn’t work hard. Didn’t mean he
didn’t get injured. In fact, he got injured,
needed knee reconstruction twice, fractured
several vertebrae, was two years on
injured reserve. Then he was told,
thank you very much. Actually, probably wasn’t
told, thank you very much. Was told, please
clear your locker. And that was that. And then he’s trying to build
a career outside of football. But his point was, you know, you
can’t focus on this or of this. Because this doesn’t
exist in vacuum. I’m this kid. I’m this kid who in
1980 was so excited about my gift of a
football, because I wanted to be a football star. Because I knew I can
be a football star. And that kid
convinced his parents to let him play Pop Warner. And some of you may not
know, but last year, there were 150,000 football
injuries in kids playing Pop Warner, treated in the
emergency room, ages six to 17, 25 of those injuries
in kids 10 years or younger, 100 plus
hospitalizations because of those injuries. He had his share. He recovered from
it with enough drive to make it to high school. And he is this kid in
high school, superstar of the high school team. I don’t know if you know, but
10% of high school players suffer injuries that render
them unable to complete the year in high school. I’m not talking the season. I’m talking the
year in high school. You know, he had one of those
injuries, not season ending. He was blessed with health
and made it to college. And then in college, we
know that about 7% to 10% have concussions. About 5% have
significant fractures. Ankles and knees are the
main target of fractures. And he accumulated all this
by the time he got drafted. He was carrying this baggage. What does this baggage
do to your health? That needs to be
part of what we ask. Because unless we us
that, we will never understand what the health of
the former football players is and how to best help it. So we need the whole life. And we need the whole payer. We need the whole player,
because yes, there is genetics. But there is very different
development and upbringing. Some of you will have heard or
read the comparison of Manning and our own Brady and the
very different upbringing, very different backgrounds,
very different stories. What impact does that
have on overall health? Well, we know that in
extreme cases studied by Harvard faculty
and many others, there is an impact
of development on brain organization,
on brain connectivity. So we know that
environmental influences are going to have an effect. We know that these stories
off accumulating injuries will have an effect. We know they a brain
is not detached from the stomach, and the
heart, and the joints, there are going to be
multi-organ interactions. If we want to really address
health and well-being, rather than understand
the pathology of CTE, we’re going to have to go
beyond any one organ system. But in addition to that,
part of health and well-being needs to address the
system’s structural factors that condition the
individual player’s health. These are players that
have a health provision system in the
setting of clubs that have specific doctors, that
have specific structures, that look out for their
well-being in that setting. Is that the best or is that not? Are there risks with
that or are there not? These are issues that
are important for health and well-being, just like
the biological factors are important. And that’s a commitment of our
study, to address all those. So how do we do that? Well, we start with the players. And of course, we start
with the literature. I told you already, the
literature is sort of limited. What we have is what we have. There are descriptions of it. But there are huge
knowledge gaps that we want to
capture and address. But with the help of the players
and informed by the literature, we can set up an
initial effort to try to characterize
what is the health and wellness a
former players today? And that is the process that
we embarked in about a year and a half ago, a year ago. With that, we’re
going to gather data. And we’ll look at the data,
not as the end all, be all. We want an epidemiologic
effort that is on steroids and that is guided by the likes
of Frank Spicer and Jim Weir, but that we want to
get to a point where, rather than just simply
characterize a population, we used it as ways to identify
additional issues that are important to address,
that we identify deficits in knowledge that we need
to think about how to fill, and that we generate
hypotheses that we can test. And we try to go about
testing those hypotheses or filling those knowledge
gaps in what I think are rather innovative and different ways. Rather than looking
for proposals alone– that is
part of what we do, open our phase, where we try
to identify the best ideas that may have meaning and
essentially provide ground support for that work. And I’ll tell you a little
bit about those time studies. But beyond that, we want
to do case control studies. We want to not say,
you know, Rodney Peete should be compared
with myself, because I wish I was that accomplished,
that athletic, and that big. It would be great. How do you find the
appropriate control group? Well, the best control group is
to find all those players that played a given position, that
had a given exposure that had a given role,
and compare them against those that match
the same experience but didn’t have the
problems and do case control studies that way. In order to do that, we
need a large population. Because we want to have those
that have heart problems and knee problems but
have different cognitive manifestations, for example,
and compare it that way. So case control studies
is one set of studies. Another approach
is rather than say, tell me your best idea
for an imaging of tau or for an imaging
of brain damage, is bring together all experts
that think they have something that can provide insight
and say, you know, if you guys are willing
to work together, and only if you’re
willing to work together, we’ll support you. If you think you know so much
that you can go at it alone, all the power to you. Good luck. It’s a very different
way of doing sort of good collaboration
science here. It’s truly team science. It’s a team science of
rivals coming together. And as Americans, we
know the enormous power of rivals coming together. We are hoping to
catalyze on that. And for imaging,
for neuroimaging, Mike Fox and Georges El Fakhri
are developing a protocol with many experts to test
comprehensively and come up with the best way to
characterize in vivo the potential
consequences to the brain. This is just one
example– similarly, for heart and for
joint biomechanics, but also for translatable
models, for our animal models. Some questions we should
be testing in animal models to be able to
translate it to humans. What is the best animal model? Well, we can find a few. Or we can bring those
few to work together to develop the
best set of models. And that’s the approach
we’ve been taking. These are the type of pilots
that, in addition, we’re funding. Studies led by different
teams, specifically aimed at developing new
diagnostics, new preventive instruments or strategies,
or new therapeutics for specific problems. And they range from
a very novel way to repair the ACL that
Martha Murray is developing and was able to do the
first studies in humans, thanks to the support of
Football Players Health Study, instead of doing surgery
to replace the ACL, actually providing a
scaffolding within the joint to allow it to heal
the subject’s own ACL. Two animal models
looking at what protein changes take place after
repeated traumatic brain injury, and how that
conformational change in the tile protein
can be prevented by an antibody that
could potentially then be translated in not only a
diagnostic, but a therapeutic after the trauma to
prevent the damage. We can tell you more about this. But just so we get
to questions, let me finish coming back to Damien. So when Damien
presented recently to the Society for
Neuroscience and Neuroethics, made the point, you know, what
do former NFL players want? He said, it’s simple. Just want the truth. We want the truth. That’s the same thing
we want as scientists. We want the truth. We don’t want the
reported story. We want to know what
really are the facts. The decisions as to what to do
with the facts are not ours. They are ultimately individual
players’ in the context of their lives. We need to deliver that truth. In fact, we need to
deliver that truth and explain it in such
a way that the players and their families can
understand it and make the appropriate decisions. But we want to do more. We want to do that in order
to translate those truths into new diagnostics, new
preventative interventions, new therapeutic
interventions, to promote the health of football players. And ultimately, we
believe that if we do that, we will learn from this
particular series of studies, initiative, lessons that
apply to all athletes, and frankly all populations. So that’s the ambitious goal
of this multi-year effort. And I think we are well on the
way with a spectacular team of people. So thank you. And we’ll hopefully
take your questions. [APPLAUSE] Question? Questions. So, my impression is that the
folks that are playing football are bigger, faster, and stronger
as we go through each decade. Is that true or is not true? And if it is true,
is there a limit to which one’s
structure, such as bones, tendons, cartilage, can really
withstand the kind of force that is applied to them? And that same goes
for concussion, but speaking more about
musculoskeletal injuries. So, it’s probably pretty
clear, although we haven’t done a separate
analysis of it yet, that if you look at
people who were playing on the line, offensive line
in the 1970s or early ’60s, the present day
players are bigger. There’s no doubt about it,
and that the speed that they can produce from various
forms of training is really quite remarkable. The questions would be,
has that led directly to altered biomechanics, a
precedence for further injury, altered collision dynamics? And that’s one of the
questions in the future we will be asking. Is there a limitation
to what the body can tolerate from a force
and speed perspective? And in some ways, are
there ways that people can de-train or mitigate
some of those things? So just to expand on that,
also, it is not just the size. It’s also the way
that practice takes place, the amount of
practice, the number of games. A lot of things have changed. And with that, the
potential impact of deconditioning when they stop
playing becomes very different. We know from, example,
from animal models, that if you over-train– to stay
in the brain for a second– you over-train a given animal,
there is, [INAUDIBLE] mediated expression of
a change in plasticity with improved plasticity
driven by that exercise. That’s a good thing. But those animals that do a
lot of that exercise, when they stop, not only do they
lose that benefit, but actually reverse
paradoxically to a loss. So what does that
mean if that were to be the case in humans also? It probably means that you need
to do plan a deconditioning, decrease in exercise activity
that some of the players do, because they figure
it out themselves. Others just continued to
exercise because they like it. But we should be
able to prescribe it and to make recommendations
that are guided by data. And one things that’s distinct
about the 1960s and ’70s is that people trained,
but they didn’t really train all year long. You see present
day professionals and immediate former
professionals taking very, very short, if any, breaks off. So to Alvaro’s point, this
is continuous training for years and years and
years and suddenly drops off. In your beautiful and
comprehensive presentation, there’s one group that
you didn’t mention. And I wonder if you feel that
the coaches, and the teams, and leagues are
partners or adversaries? Well, so thanks there
for the easy question. [LAUGHTER] So are they partners
or adversaries? You know, I don’t
think that they are partners or adversaries. I think they are part of the
structural factors that I think are important to consider. I think if they become potential
important positive or negative factors for the health and
well-being of the players, depending on how that structure
of reporting is set up. And part of the
commitment that we’ve had is to make those kind of
factors a specific focus on the analysis that we’re doing
for their health and well-being and recommendations. It wasn’t an attempt
to leave them out. They are very
important components. And of course, in
the news, we often hear about one
aspect or another. But it’s all aspects
of the club structure, from physicians to
coaches to trainers, that are part of the structural
system of health and provision for the players
that are important, including their agents. Some are less obvious, right? But their agents, for example,
are important factors as well. So there are broad
groups of people. It’s not only the
coaches and the players, but it’s even those
who have businesses, who have contracts or other
relationships and agents. All of these folks
have some influence on the health paradigm. The variation in
coaches and other teams may be an important variable. So someone with an
offensive philosophy that is running many,
many, many, many, many more plays or a situation where
games are stacked very together maybe an important variable
for us to find out about. So as a former
player, this is great. And I know you mentioned about
this ideal of not doing work in isolation. But as a researcher, how do
you balance the almost infinite life variables that
exist in this work and being able to convey some
tangible, practical things to players in real time,
if that makes sense? Yeah, that makes sense. And that is a
challenge, of course. And I think that what we don’t
want this to be telling people, look, let’s engage
you, get data, and all this kind of stuff. And five generations from now,
that’s not what we want to do. And so we want to make sure that
we extract knowledge that we can convey to people right now. So let me give you one example,
because Ross mentioned. And so one of the pilot
studies that is supported is from Aaron Baggish. It’s a study on cardiology. He’s a cardiologist at MGH. And initialling college
students, Harvard athletes, he showed that depending
on the type of training, even within the
preseason period, they develop a cardiac
enlargement, a heart enlargement, that could take
one of two different forms, depending on the training. If there was mostly aerobic,
long-distance for rowers, and runners, and so forth,
they develop a dilated, more cardiac capacity,
more ejection fraction, no cortical wall
thickness with it. Whereas the strength
training alone would develop, again, a
cardiac enlargement, but mostly with wall thickness,
enlargement, concentric cardiomyopathy, with
a risk, potentially, of not only arrhythmias, but
also ischemia, and ultimately a losing of ejection
fraction with hypertension. What he’s gone on to
show is that, depending on the retraining
and the practice schedule that you can
do, you can in part compensate for that. And that treating hypertension,
for example, if it develops, prevents damage long-term and
doesn’t change performance. Now, those are
recommendations that should be implemented right now. Whether they’re
implemented or not may depend on structural aspects
of their health care provision, but at least make the
players aware of those things we should be doing. And many of those things, as
Alvaro said, are integrated. So sometimes players
don’t want to take antihypertensives
because of they fear the impact on
their performance. But they need to
understand and we need to translate the knowledge
regarding the long-term impact. One of the key things
that I tried to show is that we’re dedicated to
early knowledge translation now. For example, I tried to use a
little bit of that soliloquy related to the fact that if we
have a lot of offensive lineman who have sleep apnea, we
know the deleterious effects of that on the neural system,
the cardiac system, and others, well, we really need to make
that a part of early screening for people, or how
we approach things, or it may play
into your question. Is getting so big part
of that risk factor? And do we need to
deal with it up front? As you guys talked about the
players being bigger, stronger, and faster, for lack of a better
term, another thing you see is the violence in the
game with the helmet. And over the past
20 or so years, the evolution in the technology
of the helmets has improved. But at the same time,
it sort of seems like they’re being
more used as a weapon now, as opposed to
a form protection. Do you guys address that and
other issues of equipment in your studies? Well, I mean, I think
as a first step, equipment issues are not
yet one of the primary aims of the study. But it is one of the
things that we’re going to account for and deal
with as to how it affects injury and how we can
try to prevent injury. One of the things
that you see now, and Rodney Pearl probably knows
this a million times better than me, is this
attempt to get away from this launching phenomena. Because we have really
created a weapon. And some people are launching
at high speed with that, and really try to teach
almost a rugby-style tackling, not that that’s
completely safe, either. But it has less of that
helmet-to-helmet contact. Of the most recent reported
concussions this year, a fairly high number of them
are actually helmet-to-helmet. Another question, please. What is your association with
both the NFL owners and the NFL Players Association? And I ask that question. Let’s say you identify
something of concern early on in your research. Is there the opportunity,
either through one or the other, to make an intervention
now, so that you can be looking at whether
that’s making an ongoing change? Yeah, It’s a very good. Easy question. It’s a very good question,
another easy one, like Ross said,
but a critical one. So we feel, and we
have gone a long way, to make sure we should
stay truly independent, that if we’re going to
deliver on the commitment to the players of
providing the truth, that truth should go to the
players through the literature. And the NFLPA, the
NFL, can learn from it, and hopefully take
the appropriate action based on that. But it shouldn’t be going
through them for them to decide what to do with that. So that’s the commitment,
is to make sure that whatever we learn, we
actually, if it’s important, make it public knowledge
fast and broadly. And the independence
in that regard, of academic freedom,
academic search, and of Harvard’s independence,
of any funding agencies, is obviously critical
in that regard. Sorry. I was going to say, that
said, we look forward to the opportunity to work
with the many stakeholders and to learn from them and
to exchange information and so forth, but not to let
any of that exchange influence whatever we find. To go to Alvaro’s
point, I mean, I think we went to real
extremes to make sure that we are independent, that we
are scientifically independent, and that our interest
is reporting the truth. And that truth can be we find
something as deleterious, or perhaps maybe
there’s a lower risk of one disease or another in
a group that trains this hard. It is possible. So we want to expose
the entire truth, and when it really
impacts people’s health, get that out there
as soon as possible. Hi. You both alluded to the complex
legal and ethical issues that are swirling
around these topics. And I’m from an
education project here in the Department
of Genetics, where we think a lot about those issues. And I’m wondering as some
of the genetic risk factors are identified in
these studies, how does that feed back into the
NFL and the current players? Of course, that’s a
very complicated topic, a series of issues. Yeah, so, I mean, it
is a complicated issue. And it’s going to be looked at. And you know,
probably, that there is a number of different
measures that– quote, “scientific measures,”
evaluation ways, that play into decisions of
drafting a player or not. It’s all over the news,
and exactly what those are, how validated those are. That’s something that is
not always very clear. So if you have, in that setting,
genetic markers and so forth, would there be the
temptation to do so? Presumably so. I think that we are not
in the business of doing the regulations for the
game or assessments of how a given business is conducted. What we should be
in the business of is to make sure that
would convey information to the players, so that they can
make the appropriate decision as to what the implications
are of what they’re doing. And I think that’s the
commitment that we have. And if we identify
genetic markers of a given risk or another, or
phenotypic characteristics, then I think that would
be part of the truth to convey properly. And that’s why
we’ve been working with the Center for Bioethics,
the Petrie-Flom Center, because I think all of
these are broad issues. You’d hate to see
a scenario where a team is doing a
genetic test on somebody and ruling necessarily
somebody out, unless, you know, they understand way ahead of
time all the associated issues. Alvaro, thank you. That was really a
great presentation. This has come a long way
since when you started. It struck me when hearing Damien
Richardson’s story and a point that you made that 150,000
Pop Warner children end up in the ER every year. Is there any way
to sort of, I don’t know– when you sit down with
Rodney Peete and you say, OK, you had three concussions
when you play professional. You got hit a lot
when you were USC. In high school, you had
the following things. Are you able to link back
to early life exposures? Because the more we know
about chronic disease, the more we know the importance
of what happened between ages 10 and 17, such
that what you find could actually be advice
for Pop Warner leagues, and not just NFL players,
retired NFL players? Yeah, so I thank you. I think that’s exactly the
reason why both Ross and I were emphasizing the whole live
perspective, the whole player perspective. I don’t think that we
can look at just one snippet of the time on the field
or the years of the NFL career and pretend that we now
understand the issues. It’s going to depend a lot
on what happened before. [INAUDIBLE] self-reported
by the players, or do you link back to college
records and Pop Warner records? So right now, what we’re
doing is a questionnaire that is self-report. And obviously, with appropriate
IRB approval and so forth, we’re looking to
get increasingly records as appropriate and
with appropriate protection. And there should be
records from trainers, and so forth, that
hopefully we’ll be able to look at as well,
to have more objective measures of the degree
of injury might happen, what evaluations happen,
and so forth, including what repairs are not happening. I mean, as you know, those
early life issues are critical. So as we bring people
here for further imaging, for further
laboratory tests, for further biomechanical
assessment, drilling down on those issues, as
Alvaro said, is critical. I wonder if we have–
like, are we out of time? We’re over. If people want to
stay, feel welcome. I was just wondering
whether we should introduce Rodney Peete and
Holly Robinson Peete, who are part of the
advisers for this study. And maybe you want to
share some thoughts. Sure. This way? Actually, we’ll get
out of your way. We’ll get out of your way. We’ll give you space. Maybe I should give
my wife the mic. She does all the
talking in the family. [LAUGHTER] As it should be. As it should be. I guess I should stand. I’m excited about this. And there were some
great questions, I think. The presentation was fantastic. And all of the questions
were great as well. The reason I’m excited about
it is for the simple fact that, as it was
mentioned, they’re treating the whole player. It is about going
back in history, about your family history. And it’s about when
you started playing. I started playing football
when I was eight years old. And obviously, there
were certain traumas that happened at that point when
my body was still developing. I was lucky enough to play
in the NFL for 16 years. And through that time,
I played with guys from different generations. We were just talking earlier
that I came into the National Football League in 1989. And me being a guy that played
16 years, there were guys that, when I was a rookie, that we’re
in the league for 10, 15 years. So they were
playing in the ’70s, at a time where there are
a lot of things going on that you wouldn’t even
dream of happening now. I can remember as a rookie
coming into the locker room after practice and about
15 guys smoking cigarettes in the locker room,
just lighting up like it was nothing. Fast forward to when
I retired in 2005. You couldn’t even dream of
something like that happening. But I’ve had my
share of injuries. I went through times where
I got hit in the head. And it was a concussion. And they said, how many
fingers am I holding up? And I said, two. And they said, OK. You’re good. Go back in the game. But knowing what we know
now, and understanding what we know now, and
having a real partnership, and I think the most important
thing that was mentioned, an independent partnership
that’s not influenced by the NFL or the league. And the studies
are confidential. And so it’s vital for players
like me and other players to share this information, so we
can understand the human body, so we can understand
life after football. There are a lot of things
that are unknown to us. I mean, it’s a scary time. I turned 50 in March. And look, I’ve had torn
both my Achilles tendons. I tore my patellar tendon. I’ve had– who knows– just
off the top of my head, I’ve had about 10 concussions. And when you look at the
concussion protocols now, you’re not allowed
to play the next week after you’ve been diagnosed
with having a concussion. For us, when I played it was,
you’re good enough to play. Your eyes look good. You know how many
fingers I’m holding up. You can play next week. And who knows what kind of
lingering effects that has. So it’s scary. So it’s vital not only for me,
but for the future players, for the kids playing
today, the young kids that are playing football. You just mentioned the 150,000
kids that are in the ER. It’s important. It’s my duty to give all
the knowledge to these guys as I can, so we can
help those players, so we can help the
players of my generation that are struggling right now. In particular, a
guy that played here for a couple years, who is
a very close friend of mine. I went to school with him,
played with him, Junior Seau. And you know, junior was a
guy that you would never known he was going through what
he was going through. And I was his close friend. And I had no idea. And so to be able to
understand what’s going on and be able to provide these
guys with the knowledge, so they can understand
the symptoms, and understand the triggers,
and really see the signs, and help me see the signs
in friends that I know. It’s vital. It’s vital. So I appreciate
what you’re doing. And I appreciate the opportunity
to work with you guys. Because this is something
that’s long, long overdue. Thank you very much. Thank you. [APPLAUSE] Thank you so much, [INAUDIBLE]. And that’s it.

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