1. School Tackle Football: Time out. Steven Miles MD Department of Medicine Center for Bioethics University of Minnesota 8/20/16

2. Objectives: Participants will Understand the relevance of the organization of pre-college football to reforms to reduce brain trauma. Be able to apply current science on brain trauma on the effects of pre-college football. Be able to design a better informed consent for school football. Be able to evaluate proposals for reforms to reduce brain trauma in school football.

3. INSERT TITLE TEXT HERE Scope of Presentation This presentation focuses Only on football On studies of tackle football before college. Does not discuss acute catastrophic brain injuries (e.g. hemorrhages), neck, spine, orthopedic or visceral injuries, heat stroke or sudden death. I have no actual or potential conflict of interest in relation to this program.

4. 4.1 Million Students Play League Football

5. INSERT TITLE TEXT HERE The Science of Repetitive Brain Trauma

6. Definition: Collision Sport Athletes purposely and frequently hit or collide with each other or inanimate objects with great force. American football, rugby, boxing, hockey, mixed martial arts.

7. J Athl Train. 20047;42: 495–503. Note: Concussions are undercounted. Subconcussive Repetitive Brain Trauma not counted. Concussion rates / 1000 Practice and Competition Games 50x as many boys play football as hockey.

8. FIRST CONTACT WITH health care system. JAMA Pediatr. 2016;170(7):e160294. 1 o Clinic ED Spec MD Hosp

9. Concussion [ A subset of Traumatic Brain Injury.] Low velocity blow to the head or "impulsive" force transmitted to the head. shaking brain to cause symptoms. Typically, rapid-onset, short-lived impairment resolving spontaneously or evolving over minutes to hours to longer. May involve loss of consciousness. May cause neuropathology but is largely a functional disturbance rather than structural injury. (This view is changing with neuroimaging.) Traumatic Brain Injury A jolt to head or a penetrating head injury disrupting brain function. Symptoms: mild to severe. Mild TBI may result in brief altered mental status/unconsciousness. Severe TBI may result in extended periods of unconsciousness, coma or death. – 4th Internat Conf on Concussion in Sport. Zurich, 2012.

10. Chronic Traumatic Encephalopathy A neurodegenerative disease. Preceded by repeated brain trauma. Wide deposition of hyperphosphorylated tau (P-tau). Some correlation with APO ε3. Neurology 2013;81;1122-1129 Young onset Initial behavioral/ mood disturbance Minimal motor cognitive disturbance Young onset Initial behavioral/ mood disturbance Minimal motor cognitive disturbance Older onset Cognitive and motor impairments Older onset Cognitive and motor impairments

11. Players receive 200 to 1,850 hits to the head / season. 20 to 100+ Gs! Max was 280Gs. [Headkick in soccer is ~20 Gs.] 3x as many players showed brain changes as experienced concussion. BasePre-seasSeas 1 Post J Biomech 2012;30;45:1265-72. 2 yr study of high school football players. Helmet Accelerometers. fMRI. Develop Neuropsych 2015;40(2):92-7. “change in the fMRI signal is significantly correlated to the number and distribution of hits that a player takes. … Brain activity changes, showing that certain areas are no longer being recruited to perform a task.” HIGH SCHOOL fMRI measures white matter injury.

12. NFL players: Age of beginning tackle football and late-life corpus callosum MRI imaging changes showing white matter damage. 40 retired age-matched NFL players, age 40-65, divided into two groups by age when began to play tackle football (before / after Age 12) Former NFL players in the under 12 first exposure group had more corpus callosum white matter damage (fractional Anisotropy and higher radial diffusivity) those starting after 12 years old. – J Neurotrauma 2015;32:1768-76. – Develop Neuropsych 2015;40:92-7. – J Neurotrauma 2014;31:1617-24.

13. Repetitive Head Impact (RHI) and Long Term Cognition Cumulative Head Impact Index CHII quantifies RHI by combining self-reported history (i.e., # of seasons, position(s), etc,) and impact data from helmet accelerometers. A threshold dose-response relationship between CHII and later-life cognitive impairment (p<0.0019), self-reported executive dysfunction (p<0.0003), depression (p<0.0009), apathy (p<0.0040), behavioral dysregulation (p<.0001) J Neurotrauma. 2016. doi:10.1089/neu.2016.4413. 93 former high school and collegiate football players that completed objective cognitive & self-reported behavioral/mood tests as part of a larger longitudinal study.

14. One season of High School Football. # impacts and exposure to linear, rotational and combined impacts. Strong linear relationship between impacts and anisotropic inflammatory changes in white matter. Strong correlation between white matter changes and Verbal Memory subscores. J Neurotrauma 2014;31:1617-24. 24 high school football players, one season, no experience of clinical concussion with Head Impact Telemetry System (HITS™) during all practices and games. Pre- and postseason MRI with diffusion tensor imaging (DTI).

15. Athletes with recent concussions performed had worse attention and concentration. Symptom-free athletes with two or more concussions performed like youth with a recent concussion. Cumulative GPAs were lower for athletes with two or more previous concussion groups and for those with recent concussions. – Neurosurg 2015;57:300-6. 223 boarding high school athletes. – J Neurotrauma 2014;31:327-38. Number of Concussions.006.012

16. CTE in young people “there's a link between playing football and CTE,... [in five years] we've found it in [autopsies of] 45 of 55 college players and 6 of 26 high school players.” “It cannot be rare.” Its not about limiting concussions; its about limiting head injuries. – Dr. Ann McKee, professor of neurology and pathology at Boston University. Testimony. House Energy Committee Hearing 3/14/16. https://energycommerce.house.gov/hearings-and- votes/event/broad-review-concussions-initial-roundtable

17. Joseph Chernach played football grades 5-12 and stopped. 2009-2012: His mood and academic performance steadily deteriorated in college. 2012: Suicide by hanging at age 25. 2016 Pop Warner paid “less than $2 million” to family. “Very severe changes in the brainstem, with numerous tau neuro- fibrillary tangles in the locus coeruleus... These findings indicate Stage II, possibly Stage III CTE.”

18. INSERT TITLE TEXT HERE Game Modification?

19. Do helmets differ? Concussed football players (ie, mean # of symptoms, kinds of concussion symptoms, duration of symptoms, etc) were similar among players wearing new helmets when compared with reconditioned helmets. The mean number and kind of concussion symptoms, symptom resolution time, and time until return to play were similar for concussions sustained by football players wearing the most common helmet manufacturers and models. Am J Sports Med 2016;44:1382-90. 2012-2013. National High School Sports-Related Injury Surveillance Study. 3,528,790 practices and games.

20. Heads-Up tackling Recommended by CDC, NFL, schools. No difference in concussion rate detected by trained sideline coaches between Heads Up Tackling and conventional play. Orthopaedic J Sports Med 2015;3(7):1-8. – Control: 2108 youth players, 2014 season. – Head Up group: 1404 players. J Law Med. & Ethics 2014;42:323-9 N Engl J Med 2016; 374:405-7. Amer J Sports Med 2014;42:2470-8.

22. Mission: “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.” 1957: “football has no place” for children under 12. 1968: “Unless a school or community can provide exemplary supervision medical and educational it should not undertake a program of competitive sports, especially collision sports, at the pre-adolescent level.”

23. 2010: “Young athletes pose a unique challenge, because their brains are still developing and may be more susceptible to the effects of a concussion.” – Sport-Related Concussion in Children and Adolescents http://pediatrics.aappublications.org/content/126/3/597 2015: “Removing tackling from football altogether would likely lead to a decrease in the incidence of overall injuries, severe injuries, catastrophic injuries, and concussions.... [however, removing] tackling from football would lead to a fundamental change in the way the game is played. Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling.” - Tackling in Youth Football http://pediatrics.aappublications.org/content/136/5/e1419

24. Lead authors had conflicts of interest. Passing reference to effects of concussion on academic performance. No template for informed consent for “participants.” Non evidence based speculations (e.g. proposing neck strengthening might decrease the catastrophic neck injuries or cautions that that raising the age at which tackling is allowed might increase injuries.)

25. INSERT TITLE TEXT HERE Informed Consent

26. Standard Consent Doesn’t disclose risks. Misleading context (e.g., “There is a degree of risk in all daily activities.”) Doesn’t rebut ungrounded hope of 26% of parents, that their child will turn school participation into a professional athletic career. Mainly liability waivers. – Amer J Bioeth 2016;16:6-10.

27. Parents and students should be aware of preliminary evidence that suggests repeat concussions, and even hits that do not cause a symptomatic concussion, may lead to abnormal brain changes which can only be seen on autopsy (known as Chronic Traumatic Encephalopathy (CTE)). There have been case reports suggesting the development of Parkinson’s-like symptoms, Amyotrophic Lateral Sclerosis (ALS), severe traumatic brain injury, depression and long term memory issues that may be related to concussion history. Further research on this topic is needed before any conclusions can be drawn. http://www.fhsaa.org/sites/default/files/orig_uploads/gov/sportsmed/minutes/160308.pdf Florida High School Athletic Association- 2016

28. Additional elements for Informed Consent Repetitive head trauma from tackle football is likely to adversely affect attention, memory, and school performance for weeks and possibly long term. Coaches cannot detect most brain injuries. Brain damaging injuries often do not have the symptoms of a concussion. School football is an unlikely path to a college scholarships or pro sports careers. 1 /16 high school football players will play on a college team. 1 / 1,200 high school football players will play on a pro team. The average pro career is 3.3 years. The school does not provide health, rehabilitation, or long term care insurance or pay for adaptive aids (e.g., crutches, wheelchairs). It does not cover future lost income or vocational retraining. Amer J Bioeth 2016;16:6-10. Amer J Sports Med 2015;43:1260-4.

29. INSERT TITLE TEXT HERE Social Trends

30. Tackle programs ending YMCAs, cities, schools are ending tackle and shifting to flag for middle school. Kick off return rules are changing. Practices with tackle are shifting to 2/week or 25-35% of practice time. Stronger rules for taking kids out of play or returning. More medical training at games (often not practices.) Lawsuits NCAA 60+ plus suits. School lawsuits including a suit against a district for claiming it could reduce concussions by a third. Pop Warner paid a suit on a suicide at 25 of a child who started playing at 11. Insurers are backing away. CDC is preparing new school guidelines.

31. Parents care. 65% say that sports concussions are a major problem; 6% not much of a problem. 78% believe that tackling should not be be introduced until age 14 or older. Women oppose tackle football (94% before age 10; 84% before age 14. Men (72%) and sports fans (74%), oppose tackle football before age 14. – National survey. U Mass. =/- 4% https://www.uml.edu/docs/CPOR-Concussion-HIGHLIGHTS_tcm18-248453.pdf

32. A Proposal

33. Close School Football Programs It would decrease incentives to play ‘for the school’ or to reap academic rewards (excused time, leniency in academic performance). It would focus school physical education programs and resources to broad participation, lifetime fitness sports (e.g., gyms, jogging, tennis, bicycling, swimming) rather than spectator sports for a few. – http://www.physicalactivitycouncil.com/pdfs/current.pdf It would not end the ‘right’ to play football but it would reduce public expenditures for football.

34. Game Over Steven Miles MD miles001@umn.edu Slides available at my faculty website