Subscribe
Share
Share
Embed
Whether amateur or pro, the international Concussion in Sport Group (CISG) consensus statement impacts the care received by players if hit in the head during a game. Steven Broglio, PhD. is the director of the Michigan Concussion Center, the Neurotrauma Research Laboratory, and co-author of the CISG consensus statement. He is also a professor of athletic training, neurology and physical medicine and rehabilitation at the University of Michigan.
As part of the international team of researchers playing an important role in shaping the consensus on recognizing and treating concussion in sport, Dr. Broglio joined writer, journalist, and traumatic brain injury survivor Christina Brown Fisher to discuss current scientific knowledge, research findings, and clinical experience. Plus, he explains why banning football is not the answer to eliminating head injury in sports.
This podcast discusses scientific research findings and is not intended to diagnose or provide personal or individual medical advice. If you have an existing health condition, always consult your healthcare practitioner.
This podcast discusses scientific research findings and is not intended to diagnose or provide personal or individual medical advice. If you have an existing health condition, always consult your healthcare practitioner.
Creators & Guests
Host
Guest
Steven Broglio, PhD.
Steven Broglio, PhD. is associate dean for graduate student affairs, a professor of Athletic Training, and adjunct professor of Neurology and Physical Medicine and Rehabilitation at the University of Michigan. Dr. Broglio is the director of the U-M Concussion Center and the NeuroTrauma Research Laboratory, where he oversees clinical care, educational outreach, and multi-disciplinary research aimed at fundamental questions on concussion prevention, identification, diagnosis, management, and outcomes.
What is Me, Myself & TBI: Facing Traumatic Brain Injury Head On ?
Me, Myself & TBI: Facing Traumatic Brain Injury Head On provides information and inspiration for people affected by brain injury. Each episode, journalist and TBI survivor Christina Brown Fisher speaks with people affected by brain injury. Listen to dive deep into their stories and lessons learned.
Christina Brown Fisher:
Hi, and welcome to me, myself and TVI. I'm your host, Christina Brown Fisher. I am a writer, journalist, and traumatic brain injury survivor.
There is little doubt concussion has become the most troubling injury in sports today. How to best detect, assess, treat, and prevent concussions are the questions concerning everyone from parents to players, coaches and clinicians. This episode features an eye-opening conversation with one of the world's top experts when it comes to sports related concussion.
Dr. Stephen Broglio is a professor of athletic training, neurology and physical medicine and rehabilitation at the University of Michigan. He is the director of the Michigan Concussion Center and the Neurotrauma Research Laboratory, where he oversees clinical care, educational outreach and multidisciplinary research focused on questions surrounding concussion prevention, identification, diagnosis management, as well as outcomes.
He is also part of an international team of researchers playing a critical role in shaping the consensus on recognizing and treating concussion in sport. Their document, the Concussion in Sport Group consensus statement, was published in the British Journal of Sports Medicine. These statements are published once every four years, and basically, they're the foundation for concussion management worldwide. This year marks the sixth statement the group has published since 2001. Dr. Steven Broglio breaks down the team's findings and sheds light on why he believes right now one sport in particular, football, is the safest it's ever been in the history of the game. He joined me from his office at the University of Michigan.
Steven Broglio, PhD.:
Thank you for the invitation. I'm excited for the conversation we're going to have.
Christina Brown Fisher:
I was talking to someone about how excited I was about speaking with you, trying to explain to them your role in what we know about concussions, how they're diagnosed, managed in the sports world, and not just at the professional level, but also collegiate, high school, and elementary school. Is that fair?
Steven Broglio, PhD.:
That is fair. Absolutely.
Christina Brown Fisher:
Okay. So, in other words, you're a big deal.
Steven Broglio, PhD.:
I don't know about that, but maybe, maybe just to my mom, but that's another story, I think.
Christina Brown Fisher:
Explain to me how the document, this framework actually works. You are the coauthor of this Concussion in Sport Group consensus statement. And it seems as though the document serves as a sort of guidepost. Basically, it distills current scientific knowledge and research findings and helps create the standard for how athletic trainers and others who support athletes identify whether a player has suffered a concussion and then determine next steps.
Steven Broglio, PhD.:
Yeah, so, thank you for the kind intro and everything else. The international document, which you correctly identified, is something that happens about every four years. This most recent one was delayed a little bit because of COVID. So, it was actually a six-year interval. But it's really, it's a, it's a labor of love from I'm trying to remember how many people are involved. I want to say 125 or maybe 130 scientists and clinicians from around the world that collectively work on 12-systematic reviews. So pooling literature from, I think 2002 up to I think we stopped in spring of 2022, and we look at all this literature and then perform these 12_systematic reviews that are related to, you know, injury prevention, to identification to management, to exercise on and on. Those 12-documents are then kind of consolidated and summarized in the consensus document which you mentioned, which seems to over the years gained more and more prestige not only in the medical field, but just sort of in the general public around kind of guidance of injury identification and management, you know, for the next four years. And so, it's really designed for the health care provider. So, you mentioned an athletic trainer, or it could be a physician or maybe a physio, if we're overseas. We do give some guidance to kind of more lay individuals that are kind of around sports. So the coach, maybe a parent, and I'm distinguishing between the two because, you know, the coach and the parent typically are not medical professionals. You know, obviously in some cases they can be, but often not. And, you know, kind of giving different guidance, more conservative guidance to those individuals than we can to a trained health care provider who can really make a nuanced decision just because they have the background and the experience to be able to do so. But I've been involved with the consensus process, I think this is my third one. And it's, it's really just been amazing the amount of work people put in, the commitment to trying to find the right answer and to seeing it grow over the last ten or 15-years. It's just been a lot of fun to watch and be a part of.
Christina Brown Fisher:
I want to dig in a little bit more about that, but I think before we go any further, what we need to do is kind of level set. And so, let's first just talk about what is concussion because there are varying degrees of what, of how concussion has been defined over the years. So, let's level set in first. Okay. What is concussion? And then I'd like to talk about what is TBI and just kind of the spectrum there just so that we're all on the same page.
Steven Broglio, PhD.:
TBI is traumatic brain injury, and it occurs along a spectrum. And just kind of three big buckets in that spectrum are mild, moderate, and severe. When we talk about moderate and severe TBI, typically there is some sort of structural damage that has happened to the brain, right? So we can image, we can put something in a CT scanner or an MRI and we can see a bleed or we can see focal injuries that have occurred because of the blunt force trauma that's happened. On the mild end of the scale, when you put somebody in the imaging device, at least on standard imaging, nothing shows up. The brain looks exactly like it should, perfectly healthy. We kind of colloquially refer to mild TBI as concussion, and there's a bit of debate as to what whether concussion is its own entity. It's the mildest of the mild or whether kind of mild TBI and concussion can go interchangeably. But I think for our conversation today, I think we can use those two interchangeably. Asking about the definition of, okay, so what is a concussion? The last it's been a long time, but at one point we looked at I think there's over 100 definitions in the medical literature for concussion, and that's over probably 100-years, all right? So it's it has changed and evolved. But I think right now what we think about is concussion, is it when someone gets hit, whether it's a direct force to the head, so you can think about helmet to helmet or head-to-head collision or a somebody gets hit in the chest and there's kind of this whiplash mechanism. The brain shifts inside of the skull and the tissue stretches. And because of that stretch, we get a shifting of the ions across the cell membrane and in the brain, and that causes that area of the brain to not function appropriately. And so, what that then presents as on a clinical level is that's the slowed reaction time, or the difficulty remembering words, or maybe somebody complains of headache or other symptoms that are related to the injury. So, the challenge is there is no gold standard to diagnose the injury. It is a clinical diagnosis. And what I mean by that is, like I said previously, you can't put somebody in a scanner and say, “oh, here is the injury,” like a like an x-ray for a broken bone. You can see the break. You can't do that with concussion. There is no blood test to say, “oh, this marker shows up in the blood, therefore you have a concussion.” So, it is up to the health care provider to ask the questions of the athlete and say, you know, “how do you feel you have a headache, Do you feel fatigue? Do you feel nauseous,” or do some of these tests that people have probably heard or seen, whether it's reaction time or memory or, or like a connect the dots type of test or balance testing. And then based on that information, the provider has to make a decision, yes, no, the athlete has a concussion or not. So it can be very challenging because symptoms don't always immediately show up. They can sometimes be delayed by 30 or 60 or 30 or 60 minutes or longer, or the athlete may be motivated to go back into the game and not tell you that they have any symptoms. So, it can be quite challenging at times, but that is the state of the science and medical care where we are today.
Christina Brown Fisher: And one of the things that you said that really stands out to me and it's something that I often hear from people, which is, you know, “I had some sort of head injury, head impact, went to the doctor, went to the E.R., they did a CT, they did an MRI, and it came back,” The phrase that I often hear is “unremarkable.” You know, nothing showed up, and so they take that information thinking they're okay. But what you're saying is that a concussion will not show up on an MRI or a CT, correct?
Steven Broglio, PhD.:
Absolutely. So, I mean, there are some very advanced, highly sophisticated imaging tests that we're using in the research space, but they are not clinically ready to go. And we can see some things, but it's not consistent. And so five or ten years from now, we may have you know, you can put somebody in the scanner and you can see something. But you're absolutely correct that under today's kind of common standard imaging techniques, we cannot see it. And so there are certainly cases and I've heard of them, where somebody goes in and exactly what you're describing, they have this image. The imaging is done and it's normal. And the physician's like “everything is good here.” But the patient is saying like, yeah, but, you know, I can't sleep and have a headache and I can't focus. And all the common things that we would associate with concussion.
Christina Brown Fisher:
As part of the concussion and support group consensus statement, there is discussion surrounding imaging and what's actually available in clinical environments. But I want to go back a little bit and talk about just how this came to be in the first place. My understanding is that this started around 2000, 2001. Can you explain how it's evolved? I mean, we're now more than 20 years later since its initial release. We have very different standards in place now
.
Steven Broglio, PhD.:
It is hard to imagine going back 20, 25-years. Concussion care at that point really was the Wild, Wild West. Like everybody, every individual provider was doing their own thing based on their experience with the injury. And I mean, there was there was a period kind of in that area where people thought you could only have a concussion if you've lost consciousness. And we there was a great study that came out of University of Pittsburgh that showed really only 10% of concussions involve loss of consciousness. And now some of the data that we have internally is showing it's closer to 5%. So but people were really just sort of like, “oh, I had this experience and I'm going to manage it this way.” And then maybe, you know, the next university over somebody is managing it differently. And so a number of people from around the world kind of recognized that, you know, there was no standard protocol. And they got together, they formed the Concussion Support Group. And then out of that came the first consensus statement. I think they met in the fall of ‘01, and it was published in the spring or summer of ‘02. And then in that at the tail end of that document, they had agreed that they would meet again in four years and revisit the literature and kind of make modifications as needed. And then the second reading happened, or the second document was published in ‘06. And then obviously you kind of went on from there. Concussion at the time, the Concussion in Sport group was founded in ’01 really nobody, I don't say nobody, but very few people were paying attention to it. And it wasn't until January of 2007 when concussion and really CTE, which I'm sure we'll get into later on, hit the front page of The New York Times. And it really was kind of thrust into the public consciousness and it became front page news, not only because of kind of the first couple autopsy cases that were coming out of football, but we were also engaged in two wars overseas, Iraq and Afghanistan. And TBI became the signature injury of those wars. So you had this kind of general public sport interest in concussion and then you also had military interest in concussion. And so with that came research dollars, which then allows, you know, more interest. You know, people follow the dollars and researchers do the work. And then so you see this giant uptick really starting in 2010, because it takes time to get the dollars and do the work and publish and etc.. But it really to me, I mark January of 2007 as kind of the tipping point of the modern concussion era. That's kind of where it began. And since then, I mean, it's hundreds of thousands of papers have been published on kind of this work and trying to understand acute effects and long-term effects and what test do we use when and where and how and how we manage and how to recover. So, and the I think this Concussion in Sport Group has gained notoriety and recognition because it filled a void that just there was nothing there. There was no standardized protocols. And now, you know, pretty much every sporting organization in the world has something, whether it mimics the Concussion in Support Group or not, they have something in place to manage the athletes that are injured.
Christina Brown Fisher:
The last statement was in 2016, that one was released at the Berlin Conference and then I mentioned this most recent one published the summer. What are the most significant changes? What was added or taken away?
Steven Broglio, PhD.:
The single biggest addition was the inclusion or the recommendation for exercise, early exercise after injury. So going back…
Christina Brown Fisher:
So no more dark room?
Steven Broglio, PhD.:
Nobody knows exactly what happened. So going back ten years, it was sort of this cocoon therapy rest, shut somebody down, put them in a dark room, no TV, no books, no cell phones, no nothing. And really what we found is that that psychological isolation actually spins up all sorts of symptoms that are unrelated to the injury. So then as concussion symptoms are resolving over the initial days of injury, the psychological symptoms are spinning up and then disentangling the two becomes very common.
Christina Brown Fisher:
Can you explain that difference? Because there is overlap between the TBI injury and the psychological injury.
Steven Broglio, PhD.:
Maybe depression and anxiety is a super easy one that people can relate to. It is clear that some people, after a concussion experience a bout of depression and maybe some anxiety because, you know, they're injured, they don't they don't know kind of what the outcome is going to be. They may be a highly anxious person to start with. And so the injury can kind of increase some of the symptoms. And those do typically resolve, you know, in the weeks, week or weeks after injury. But then if you take somebody and you isolate them from the rest of the world, social isolation, isolation, we are humans, as you know, as animals, basically, we are social creatures. And if you remove that from them, some of these, that isolation can increase symptoms. So as the body is healing from injury and the depression, anxiety or in theory going down, they may be going back up because they're not interacting with their friends, their peers, particularly a high school or college student, that that social aspect is quite important at that stage in life. So these things can go up. Athletes that don't exercise actually start to feel worse because they're just used to exercising a lot. And that may increase fatigue or just general kind of lackadaisical emotions. And so those things go up because they're not engaged in their daily routines. So now the new guidelines, the ones that came out earlier this year, it is, you know, not shut somebody down, but reduced their activity for the first 24 to 48 hours. So whatever it is that they're doing, so long as it doesn't increase symptoms. So you can do you know, you can leave your room, you can make, you know, breakfast, lunch and dinner. You can do some chores around the house, so long as it's not making symptoms worse. And then after that, we're recommending some light exercise to start reengaging with with the things that you normally do. So that may be go, and when I say a light exercise, that's not, you know, go for 5K run, if you're a cross-country runner, that's like go for a walk or maybe sit on a stationary bike and just be very easy, turn the pedals over type of thing. And then as you feel better, you can increase the intensity and the duration of that, and really using exercise as a form of medicine to help the recovery process. And then as you know, as symptoms resolve and you're cleared by your health care provider, you can start reengaging in your sport. And that's going to look different for every athlete and every sport. So, reengaging in your sport as a football athlete is a much more conservative process than reengaging in your sport as a golfer. So, you know, there's still a lot of individual tailoring that has to happen with the athlete, but it is I don't want to call it more aggressive, but we're definitely not as conservative as we had been in the past.
Christina Brown Fisher:
And is there a distinction in these protocols in terms of whether or not you are playing at the professional level, the collegiate level, high school in elementary school?
Steven Broglio, PhD.:
Yeah, that's a I'm glad you said that. So some of the older documents made to, distinguish, they distinguished between the professional athlete or the elite athlete and then kind of the amateur athlete. And that's no longer the case. This is, that it's the same protocol for everybody, which I think is absolutely the right thing to do. And I think the scientific literature supports that approach.
Christina Brown Fisher:
Okay. So that right there is kind of mind boggling for me because that is not something that I would have thought. And I know you and I have talked about a little bit about the difference between the public perception surrounding concussion, and diagnosis, recovery, approach versus what the science is, what the data says. And you're saying that the science says that the protocols should be the same, whether you're operating at the elite athlete level, amateur and children?
Steven Broglio, PhD.:
Yeah. I mean, you may end up being a little more concerned that the health care provider may be a little more conservative with, let's say, a child or a high school athlete. Um, just kind of based on circumstances, there's some informed decision making going on. You know, careers aren’t on the line. But in general, the protocols are all the same at this point. And at least in the document, there is no longer a distinction between some of the I think one of the older documents said, you know, “there's more resources at the elite professional level and you can manage them differently” or something like that, and that that has been removed. So the protocols are all largely the same. How people move through those protocols is probably going to vary a little bit, because we do have data that say that children and high school athletes take longer to recover than the professional athlete. That doesn't mean they're being managed differently, it's just that they're moving through the protocol at a faster pace.
Christina Brown Fisher:
I see, and what about recovery time? And in defining what is considered normal recovery. I feel like you hear different things depending on with whom you're speaking. How does the statement address that?
Steven Broglio, PhD.:
Yeah, this was actually a key point that I was I homed in on while we were at the meeting, and I was I was pretty aggressive in getting it added to the document, and I'm glad it made it in the final version. So historically, we defined concussion recovery as normal concussion recovery within two weeks, 14 days. And what has sort of happened with that is as the athlete gets in today, 15, 16, 17, they start getting labeled as an abnormal recovery or poor recovery or a bad injury, and then so this is again, kind of where the psychology of the injury can start playing a role is, you know, that that athlete is like, oh, some athletes, I shouldn't say all of them, but some athletes are like, “Oh, it's hopeless. I have a bad injury. I'm going to be out, you know, forever or whatever.” But if you go back and look at the scientific literature, that 14-day recovery is the average recovery time. So, it's 50% of people recover in 14-days. That means another 50% are going to go longer than 14-days. So, I was very adamant about we need to extend what we call normal recovery as up to one month. And the data we have, it's something like 90 or 95% of people recover within a one-month interval. And so, it's certainly half of people will recover by 14-days. But just because somebody takes three weeks or four weeks, it doesn't mean it's an abnormal or a prolonged recovery, they just needed more time. So, it's some of the phrasing around the injury, I think that is pretty important for people to realize that, “hey, I'm a day 21, that's okay. It's just taking me a little bit longer,” and in a way, you know, one of the analogies I give to people is, you know, if you have a cold, you know, average recovery from a cold is seven days. But if somebody took ten days, you would be like, “oh, that was a really bad cold. That's an abnormal recovery.” You would you say, “they had a bad cold and it took them three more days.” So that I'm glad that that language is in there and there's additional language in there about getting additional resources. If people are not recovering at the rate that we think they should, whether that's some vestibular rehab or cervical spinal rehab, whatever the case may be, it's all obviously very dependent on the individual.
Christina Brown Fisher:
And when you talk about normal recovery, as an example, are you saying that this is for someone who has sustained and been diagnosed with one concussion, or is there a distinction between, say, someone who has had one diagnosed concussion versus, say, someone who has had repeated head impacts that haven't necessarily resulted in a concussion diagnosis? So, I'm just trying to figure out the distinction here in terms of what is considered the normal recovery time.
Steven Broglio, PhD.:
So, yeah, it's somebody with a diagnosed concussion. I don't, I don't know of anybody that has scientifically, specifically looked at I'll just take a football player that had a lot of head impacts without concussion, and then has their first injury. And whether or not that recovery period is longer than, let's say, a swimmer, that they are now getting their very first concussion but have never been hit in the head otherwise. What I can tell you is when we look across all NCAA sports, our football athletes are actually recovering, they kind of have an average recovery time of around two weeks. And there's about 50% of the sports that are faster recovery times and 50% of the sports that are longer recovery times. And they don't, that kind of time scale does not seem to break out around contact and non-contact sports, which I'm using, as kind of a little bit of a marker for like repeated head impact exposure. So, I don't have data to support this, but my gut tells me that head impacts without concussion are not influencing concussion recovery time.
Christina Brown Fisher:
I see, and then what comes out of the statement, with regards to the suggestions around preventing injuries. I think we can all be realistic about the fact that it's likely impossible to prevent concussion in sport. But what are some of the guidelines that you and the team are suggesting around preventing the injuries?
Steven Broglio, PhD.:
Yeah, so, I'm glad you raised the issue. We will never get to a point where all concussions are eliminated in all sports. I think we can continually improve to reduce risk and some sports will carry a higher risk than others. And, you know, we talk about football a lot, but ice hockey, women's soccer, men's soccer, men's lacrosse in particular, these are just higher risk sports for concussion. I think around the prevention space new to this document that just because there is new data to support this is the use of mouth guards to reduce concussion risk, which up till this point had not been supported by the literature. So that was a bit of a change that we had not seen in the past. Now, in a sport like football, you have to wear a mouth guard, ice hockey, you have to wear a mouthguard. But there are other sports where you don't, or maybe, you know, some people will want to consider that.
Christina Brown Fisher:
So mouth guards? That seems like a very simple fix, mouth guard.
Steven Broglio, PhD.:
I agree, and it and I can even in my head, I don't quite understand kind of biomechanically like how this would work. But, you know, sometimes the data shows something that you don't expect, and, you know, you go in a direction you have to, you have to follow the data. So, I think the other there's some really nice work out of Carolyn Emery's group at the University of Calgary. She has done ten-years worth of work at looking at checking in ice hockey, and I don't think this comes as a surprise, but if you eliminate checking from ice hockey, then concussion risk plummets. I'm not going to say it goes to zero because there's incidental things that happen, but the risk for injury goes really low, and then when you if you do that at the youth level and then introduce it later on, there's actually no increased risk for concussion for people that hadn't checked when they were younger. So, she's done a really nice series of papers on this, so that's one thing that we can think about, is maybe eliminating some, some contact while children or people are learning to play the game, and you can teach fundamentals and skills and then introduce the contact portion later on. And then there was some language around some warmup procedures that was a smaller study done in, I think, a rugby cohort. I think that one in my mind needs a little bit more, a little bit more investigation before I would wholesale implement it as a concussion prevention tool, but I don't think it's going to hurt anything if people are doing it now. So those are some of the big ones. But I think it's, you know, we're trending in the right direction. Better equipment, you know helmets have improved dramatically over the last 15-years, and those things will continue to evolve and get better, and we'll just kind of keep chipping away at the problem as we go.
Christina Brown Fisher:
You mentioned rugby. Are you talking about reducing contact practice?
Steven Broglio, PhD.:
The Ivy League eliminated contact practices, I think maybe seven or eight years ago, and I don't have data on whether or not their concussion rates have dropped. But what I can tell you is about half of all concussions happen, in football, half of all concussions happen during practices. So, if you, if you're, if you're not hitting each other, you're not hitting your teammates during the week, then you're less likely to have injuries and then you can actually field a better team on the weekend and increase your odds of winning. So, there's some work that we've done, myself and some colleagues have done around preseason football. And when you reduce the number of contact practices, then the number of concussions go down. So, I think there is this you know, you have to hit a little bit because you have to learn how to tackle and tackle appropriately. But I think the idea of some of these drills of, like Oklahoma Drill, and Bull in the ring.
Christina Brown Fisher:
I was just thinking the Oklahoma drill. I was actually just going to ask you that. Yeah.
Steven Broglio, PhD.:
Yeah, so I think two years ago was the first time the Oklahoma drill was not done at Oklahoma.
Christina Brown Fisher:
The Oklahoma drill originated in the 1940s with the college football team, the Oklahoma Sooners. It is a contact drill, pinning an offensive player directly against a defensive player. Basically, the offensive player is trying to get past the defensive player while the defensive player tries to stop them with a tackle.
Steven Broglio, PhD.:
It is, you know, eliminating like just blatant hitting for no real reason. I think a lot of coaches are moving into that space because they know that it's, they're injuring their own team and then those guys can't play on the weekend.
Christina Brown Fisher:
The priority for coaches is to win. How does the Concussion in Sport Group consensus statement help athletic trainers make a case to coaches and managers that may result in ultimately pulling a top player out of the lineup?
Steven Broglio, PhD.:
Yeah, I think you're raising a good point. I think. You know, when I started with this, you know, some, some coaches, I don't want to say all but some coaches were very apprehensive about, you know, you just want to take my players off the field, and hold them and, and that sort of thing. And I think I go back to we were talking about exercise as a, as a treatment. Those protocols actually allow the recovery process to it's a little bit faster. People that exercise early actually have a little bit quicker recovery periods than those that don't. And so I think a document like this gives some power to the athletic trainer to implement those things in the clinical space and to get players back on the field when injuries do happen. I think the other thing this document does, you know, talking about prevention is it allows them then to say, “hey, maybe we should think about,” you know, not football, but a sport that doesn't have mouth guards, “maybe we think about mouth guards for our athletes. Maybe we think about reducing the number of contact practices so we're not injuring our own teammates, and then we can field a better team tomorrow or the next day or whatever.” So it gives them some power. I think what I would, I would tell the athletic trainer is, you know, if you have data drives everything, if you can go to your coach and say, like, “hey, coach, you know, the bulk of our concussions in practice are happening when we do drill X, maybe we need to take a look at drill X and adjust accordingly.” And so that takes a little bit of more, more work from the athletic trainers on the prevention side. But it's going to save them a lot of work on an identification and management side, you know, because you're stopping injuries from happening.
Christina Brown Fisher:
A parent or grandparent, for example, has a youngster in sports. Pediatric athletes are going to be less likely to have the trained medical personnel, the athletic trainer available on the sideline. What advice do you give them the caregivers about the concerns that they may have about concussion, and the conversations that they should potentially be having with coaches?
Steven Broglio, PhD.:
Yeah, I think at the at the pediatric level, you know, the parents, the grandparents are you know, they know their child. And so if they if they feel that, you know, my kid or my grandkid came back from practice and they're just acting funny, you know, there's no harm in taking them into whether it's the pediatrician or if there's a specialty clinic in their area and having them checked out, I think that's totally appropriate. I think I think even before that happens, I would I would tell the parents they need to figure out if that sport that the child wants to play is appropriate for the child. And I'll give the example of my nephew when he was, I think, 13 or 14 years old, he wanted to play football. And my sister-in-law was like, “what do you think?” And I said, “to be quite honest, I don't think he should do it because he's like four foot eight and 95-pounds.” He's just going to get hurt and not even concussion, but just orthopedic injury. I mean, he was very tiny for his age. So that's one thing that they need to, I would tell parents to think about. And then if they're if the child wants to play a contact and collision, sport is how does the coach teach the sport? And the example I've used publicly in the past is we were working with a high school at one point and they went through the first two or three days of preseason practice, which were kind of heat acclimatization days. And then on the first day they were allowed to hit by state regulations. The coach literally says, “line up from the man across from you, on the whistle, hit them.” And I turned to the student that was with me, I was like…
Christina Brown Fisher:
What age were these, what age were these kids?
Steven Broglio, PhD.:
This was this was high school. And I turned to the student, I said, “dial 9-1-1 and get ready,” and thankfully, nothing happened, but that's an example where just they, you know, you have to teach to tackle. That's fine, but you need to do that appropriately, and there was there was no instruction given. So I would have as a parent, I would have a conversation with the coach of, you know, “how do you do this?” Like, “what is your training in this? How are you going to teach my child? How are you going to teach them safely to do this?” And if as a parent you get that pit in your stomach, it may not be the right sport for your kid, and you might need to hold on that a little bit.
Christina Brown Fisher:
So, we're talking about football and we're talking about youth football. Player safety in football obviously has been a topic of debate for years. High school participation, though, in the 11-player tackle football was trending upward in the 21st century until the 2009-2010 academic year. That's when we see enrollment begin to wane, according to data from the National Federation of State High School Associations, High School Athletics Participation Survey. The latest survey, released the first since 2018-2019, shows that the 2021-2022 school year was the first on record, with fewer than a million players participating in the 11-player high school football in America since the turn of the century. How much of that, Dr. Broglio, do you believe is connected to, as we discussed earlier, the widely known narrative or accepted narrative, that football is dangerous? You know, it's a threat, it's a public health threat, if you will. Is there a disconnect between what people think, believe about football and then what the data is actually showing about football?
Steven Broglio, PhD.:
Now is probably the safest time to play football in the era, in all the time that football has existed. Certainly, there is risk to playing. There's a risk of playing every sport and football has a very high concussion rate.
Christina Brown Fisher:
You said now is the safest time to play football in the history of any sport.
Steven Broglio, PhD.:
In the history of the sport.
Christina Brown Fisher:
Wow, that’s big.
Steven Broglio, PhD.:
That's right, and I would say that because medical care is a lot better, our awareness around concussion is a lot better, equipment is a lot better. And so, you know, all of these things are you know, we are in a better spot today than we were yesterday. And, you know, football, if you go back to the beginning of American football at the early 1900s, the sport was on the verge of being banned because of deaths on the field at the college level, like literal deaths on the field from severe TBI and brain bleeds, and Teddy Roosevelt basically called the college presidents together and said, fix it or I'm banning it. And there were some rule changes and some other things that came into place after that. So, we're a long way from that, thankfully, and that's not to say that we are done. I think, you know, there's a lot of people around the world that are trying to understand concussion and other injuries related to sport and how to eliminate them, or at least reduce and then manage when they do happen. But I do think this is probably the one of the better times to be playing it, if that's the sport you choose to play.
Christina Brown Fisher:
We've briefly touched on CTE, chronic traumatic encephalopathy. Let's first talk about what that is. And I keep coming back to this narrative, right, because I, and I I've read just in statements that I've seen from you in different reports in which you've said, you know, “I think that the media has, you know, basically gotten it wrong,” right? In terms of how football, CTE, concussion, danger -- so, I really want to dig into that. First, let's talk about what CTE is and why we see it associated with football athletes and what in your mind is, is wrong in the discussion around it?
Steven Broglio, PhD.:
So, I'll start off with what it is, so CTE, as you said, is chronic traumatic encephalopathy. It has been in the medical literature since I think the 1940s, but it was first identified in a modern football player in 2005. I think most people, it's Mike Webster, or Bennet Omalu was the pathologist in Pittsburgh, the Will Smith movie that that was based on that story.
Christina Brown Fisher:
“Concussion,” yeah.
Steven Broglio, PhD.:
A few years ago, yup, and so what, what the disease is we all have tau proteins in our brain. It's a naturally occurring protein. It's a support structure kind of to the neurons that are in our brain. And what we believe happens is when the brain is hit and we’ve talked about this stretching is this tau kind of breaks loose and then it clumps at various points in the brain, kind of within the folds of our brain. It's not clear if that clumping is the problem or the clumping is a marker of other damage that has happened. And that's a little bit of nuanced response, but that's kind of what it is. It has been tied to a number of things that nobody really knows, to be quite honest, and I think this is where my views and my current views, my past views, that I think it's really been oversimplified.
Christina Brown Fisher:
What do you mean by that?
Steven Broglio, PhD.:
Yeah, I'm not denying it exist, CTE is definitely a thing, but I think the idea of saying, “you know, here is this one brown spot in your brain, you now are destined for like clinical depression and suicidality and irrational behavior,” that link has not been made yet in the literature. But what it does appear is that, you know, there is, there's probably a tipping point where if you have enough of this, whether it's the tau itself or, you know, the tau is just a marker, that you're probably going to have some sort of problems. So let me let me kind of give some explanation to this. There is no way in my mind that if you had one concussion that you're going to be destined to have these problems, because if that were the case, then we as a human species never would have survived. It just wouldn't happen. That being said, I'm not recommending you go get a concussion. And what, what we sort of think, or at least the way I think about it is as we get older, we're all going to decline. Right? We've seen this in our parents, we see it in our grandparents. And it's a sad thing that happens, but it just it happens. It's just life, and these repeated head impacts or maybe repeated head impacts in combination with concussion, accelerate that decline. Now, that doesn't mean that, you know, I played a season of football as, as a high school student and now at 55 I'm going to have dementia. Everybody's curve is going to be a little bit different, and probably the more you play, the more likely it is that that curve is going to get steeper in the downward direction. What the literature is showing is that if you played high school football, you probably are not going to see, there's, it is very unlikely you're going to have any long-term effects of it. There are a percentage of former professional athletes that have problems, but not all of them. So, this idea of 100% of NFL athletes have CTE is highly unlikely. And then if you're kind of in the middle, you're at the kind of college level, it's a little bit up in the air. And so the best analogy I can give is, is probably smoking where, you know, if you're trying to be the cool kid in high school and you put in, you smoked a couple packs of cigarettes probably not going to worry about lung cancer in 30 or 40 years. If you're a lifelong smoker, two, three or four packs a day for 30 years, your odds of cancer are going up. But the odds of lung cancer in lifelong smokers is only like 25 or 30%. So even the people on the most extremes, it's not a guarantee that you're going to have a bad outcome. Again, I'm not recommending any of this. I'm just saying if we look at the data, it is not as simple as “I played football in high school, therefore I have this problem.” And that's what I mean by I think it's oversimplified, is I think the media has largely portrayed it, it is like “if you play football, you're in trouble.” And that is clearly not the case because there are far too many former high school college and professional athletes that are doing just fine in life, and they have no symptoms of anything other than just, you know, they're 90-years-old and they are they're old, to be quite honest.
Christina Brown Fisher:
Do you think that this perception, and for a lot of people, perception is reality. Do you think that this perception is drawn just largely from the fact that football is just such a popular sport, when you have other sports that, like you're saying, are potentially just as dangerous. Yet football seems to be the one that gets the attention.
Steven Broglio, PhD.:
Yeah, I'm getting the feeling that you, like, live inside of my brain. So, these are, you're absolutely correct. So, you know, I liken this to like the fast-food industry. You know, fast food taste good. We know we probably shouldn't eat it, and McDonald's gets all the, all the flak because they're the biggest and the baddest. Right? And Wendy's and Arby's and all those other places aren't getting the attention just because they're smaller. And you're exactly right about football, in my mind, at least it is, it's the biggest kid on the block and everybody's going after it. But, you know, ice hockey and soccer and a number of other sports have similar concussion rates, maybe a little bit less of head impact exposure. But they are also, you know, everybody who plays a sport is at risk for concussion. It's just reality. Even the swimmers, even the track athletes, because accidents happen. But football gets the most in my mind. They get the most attention because they're the biggest kid on the block. I will also say that football and in particular NFL, they had a pretty dark period from, I would say like early 2000s up until maybe five or six years ago where they largely just denied concussion and any sort of problems with it. However, I honestly believe that since they admitted the potential link between concussion and CTE, they've probably done more than any other sport to try to reverse it. And they have, they have a standardized protocol now, they were the first to put a spotter in the box to try to stop the game. Officials can stop the game for, for potential injuries. The blue tent, there are a number of things that they have done to try to advance medical care in this space that other sports are sort of you know, maybe not as aggressive with.
Christina Brown Fisher:
I want to talk about, what are the big offenders, number one, risk of concussion?
Steven Broglio, PhD.:
I know rugby was number one and then it was football, and then I think it was women's ice hockey after that. I can tell you broadly, ice hockey, men's and women's ice hockey, lacrosse, soccer, wrestling, those are kind of the big offenders, if you will. And I think it's important that as we talk about football, participation in football is going down, and some of the narrative that we hear is, “I'm taking my kid out of football. It's too dangerous, but I'm going to put them into soccer.” I'm like, concussion risk in soccer is not much lower than football, and not that I'm advocating they don't play soccer. I absolutely think every kid should play a sport, but just sort of, you know, do your, do your homework. If you're doing it just because of concussion risk, then just make sure you understand kind of what you're walking into.
Christina Brown Fisher:
Can you, Dr. Broglio, talk about the distinction between concussions, between men and women, boys and girls at the athletic level? I know that in some of your reports you've talked about women being more susceptible for additional concussions once they've suffered one in particular. Can you explain why?
Steven Broglio, PhD.:
So, if we look at sex comparable sports and soccer's an easy one, it's the male game and the female game is virtually identical. We do see higher concussion rates in women than we do in men, all right. So, soccer, softball, baseball, the sports of that nature, and we don't entirely know why that is. I can kind of give you some theory here. So, some is women have smaller neck musculature relative to head mass. So, when they get hit, they're not able to stabilize the head quite as well as men can. Women there's some theory that at various points in the menstrual cycle, women are more susceptible to injury where men don't have the same hormonal fluctuations. The one to me that I think probably is the standout is I think women, if you look across all medical literature, women are more likely to tell someone that they're injured because they're more concerned about their long-term health than men.
Christina Brown Fisher:
So, they're going to report? They're not going to mask their injury.
Steven Broglio, PhD.:
Exactly. So, you know, the 16, 17, 18-year-old boy that's, you know, trying to be macho and suck it up and get out there, and, you know, “I don't want to let my teammates down.” And I'm not saying women aren't tough, like, I've been around enough high-level female athletes that, it's incredible what they can do. But they are historically or, on a, on a broad scale, they are, they're more likely to report an injury than, than a man is. So, I doubt it's one of those three things I just said. It's probably a combination of all three. But what we do see where the literature is pointing us now, is that the recovery rates between men and women are nearly identical. Maybe a day or two difference, but not enough, that would really shift how we manage the female, the injured female athlete relative to the male athlete.
Christina Brown Fisher:
When you talk about the recovery rates being identical between male and female, are you talking about short term? You're talking about that 28-day period now, or are we talking three, five, ten years out.
Steven Broglio, PhD.:
In the short term? So, the time from injury until we can get them asymptomatic and then get them back on the field. So, in that kind of 14-to-28-day window.
Christina Brown Fisher:
What kind of distinctions are you seeing in terms of long-term recovery or long term impact.
Steven Broglio, PhD.:
Great, yeah, great question. I don't have the answer to that one. I've been involved in the co-lead on a project called the Care Consortium for the last almost ten years now with a couple other colleagues across the country where we enrolled 55,000 varsity athletes and military service academy members while they're in college, typically as they entering their institutions, track them through college. And then now we're in the first phase of tracking them after graduation. So it's up to ten years after graduation is the point. So, the idea being is, you know, we know what you look like when you were a first-year student at your institution and we want to track you for the next 40 or 50 years. So, we just started this kind of first post-graduation phase two years ago. So, we have data, but we haven't really looked at it yet in a way that I can give you any sort of useful information. But we are we are looking down the line and tracking these individuals for a number of years to really drill down into the question that you're asking, amongst other things, of course.
Christina Brown Fisher:
What do we know about the subtle years long effects of repeated head impact? What's readily available now in terms of what the data reveals?
Steven Broglio, PhD.:
Yeah, I think, you know, it is it's clear that some people have problems, and but it is not clear why some people have problems and why other people don't. And I think that's part of the narrative that's kind of been really blurred. You know, the narrative is largely if you played a contact collision sport, if you had a concussion, you're going to have problems, and it's just clear that that's not the case. But we don't understand why, you know, conceivably two players from the same that played the same position for the same number of years with the same number of everything else. And one has a problem, and one doesn’t. And that's the thing that we're trying to understand. So, I think what I would it's going to take time. I mean, we the people we're tracking are 30ish years old. And to track them until they're 50 or 60 years old is it's going to take a long time. Now, we're going to answer questions along the way, of course, but I don't think we're gonna have a definitive answer for some time. I think what is encouraging is some of the work being done to be able to diagnose some of these like CTE as these other things in the living, and then as soon as we can do that, then we can start developing treatments.
Christina Brown Fisher:
Right, because CTE is diagnosed postmortem?
Steven Broglio, PhD.:
Exactly, exactly, so, but what I can tell you is, you know, whether you're an athlete or not, things like depression and anxiety and, you know, some of these other things are very treatable. And so if you're a former athlete and you think, you know, you have CTE, and you're depressed and irritable and all those other things, I would really encourage you to go to your primary care, and talk to them about it and start addressing some treatments. Because, you know, depression, you know, with some cognitive behavioral therapy and maybe some medication is very treatable and it can be managed very well.
Christina Brown Fisher:
I want to talk a little bit about the technology and in terms of what is out there and what's available. We've talked a bit about helmets. I know from your research, I know from other research, not all helmets are created equal. So, can you talk to me about what technology is out there that can help us better identify and figure out the tools that are going to also assist in preventing injury?
Steven Broglio, PhD.:
So, I think just on helmets specifically, I would direct people to the Virginia Tech Star rating system. And if you just Google Virginia Tech Star, it should show up top of the list. And they I think starting around 2008, started basically doing impact testing on football helmets first and they've gone out to another a number of other sports and, and rating them relative to their ability to reduce concussion risk. And I think what people need to realize is up until that point, helmets. Which were designed to prevent moderate and severe brain injury there. They were designed to prevent skull fracture. They were designed to prevent severe brain bleeds and they were really good.
Christina Brown Fisher:
That’s very important distinction because at the beginning of this, we talked about there's a spectrum when it comes to traumatic brain injury. There's mild, there's moderate, there's severe traumatic brain injury. I cannot just emphasize that enough. So, you're saying that the helmets that are out there are really focused on moderate to severe? So, the technology isn't designed to prevent…
Steven Broglio, PhD.:
Well, the helmet up until about 2008 was designed specifically for that. And then when this team came out with this rating system that was specific to concussion, then the manufacturers started to shift. They started to iterate and improve design, and that because everybody wants the five-star rating, everybody wants to be the top of the list. This is public, this is publicly available data like anybody can go to their website and pull it down. It's a very easy system to understand. It's five stars just like car crash, five stars.
Christina Brown Fisher:
Okay, I'll make that available in the show notes.
Steven Broglio, PhD.:
Yeah, and you can see as a parent, you can go in and you're like, “oh, this helmet is the highest rating.” And, you know, maybe you can ask your school to buy it for your kid. Or if you have the resources personally, you can buy it. The other thing I would tell you is, you know, you can get a very good helmet and it doesn't have to you don't have to drop $300 on it, like some very good helmets that are you know, that are cheaper than that. But because of that rating system, you know, helmet companies have started to iterate on this, and the technology has gotten better and there's data to back up that concussion risk is reduced with kind of these modern helmets versus some of the older helmets that, you know, from 15 or 20 years ago. And now we're even seeing position specific helmets are coming out. I think I saw something Aaron Rodgers is wearing a quarterback specific helmet and that's based on some sensor data showing kind of where various players on the field get hit in the head and then they, add, or they'll make adjustments to the helmet accordingly. So, we're starting to see this kind of more individualized approach to the helmet design. And then there's other sports that have been evaluated as well. I think they’ve done baseball and ice hockey. Equestrian I know was a big one, they just released, I think, earlier this year. So, it's not just a football rating system they've done a number of different sports.
Christina Brown Fisher: And of course, we're obviously talking about helmets, sports only. But we did discuss earlier that there are other recommendations and suggestions, for example, using the mouthguard. What about soccer?
Steven Broglio, PhD.:
Soccer's a great one. So there are some companies that make some headbands or maybe some full head kind of padding systems, but I have not seen any data from soccer, or at least none that I'm aware of that suggest that they help reduce concussion risk. So, I don't, I don't think it's going to hurt somebody to wear them, but I'm not convinced yet that it is going to do anything to help either.
Christina Brown Fisher:
When it comes to soccer. Is the concussion risk primarily from heading the ball, or is it from some other impact on the field?
Steven Broglio, PhD.:
Yeah, great question. So, I think it's about 90 or 95% of concussions in soccer come from head-to-head contact. So, it's two athletes going up for the same ball and then they collide. And then we see, you know, there is a small percentage of concussions that happen from, you know, somebody trying to head a ball that the goalkeeper kicked, you know, and it's coming from an odd angle, really high. They just hit it kind of awkwardly and they have an injury. We see injuries from contact with a goalpost or some other piece of equipment. So those things happen. But the bulk of it is this head-to-head contact from two athletes going together at the same time.
Christina Brown Fisher:
Does an athlete have to have a concussion in order for there to be changes in brain function?
Steven Broglio, PhD.:
There was some data done out of Purdue where they looked at high school football players. They had equipped them with some head and sensors and then they did imaging fMRI imaging, which is functional magnetic resonance imaging, which sort of looks like how the brain is processing information. And they actually they reported changes in this kind of brain functioning across the season with no reported concussion, which is sort of a kind of eyebrow raising finding. There was a similar study done at Dartmouth on ice hockey players, and they found similar things during the season. But everybody had kind of gone back to kind of this normal or preseason level of functioning the next year. So, we're not really sure what to make of this. You know, the brain is highly plastic, meaning it can morph and change over time. And when you're talking about high school kids there’s all sorts of brain, just normal growth that happens. So we're just not quite sure if this is an early marker of things to come or if it's just part of, you know, regular brain growth and just things that happen over time. So we've done work here at the University of Michigan Concussion Center, where we looked at high school football players. We did clinical testing before, during and after the season, and we didn't see any changes kind of on a clinical level. But these other studies that I mentioned, they're looking at kind of brain function on a subclinical level, if you will. So there might you know, we're we're kind of measuring two different things. But I think what I would say is, you know, a subclinical finding may mean nothing, and it may have may be of no concern at all.
Christina Brown Fisher: Millions of American kids are suiting up to play contact sports right now. At least two million of them are playing tackle football despite calls by some to ban the sport.
Steven Broglio, PhD.:
We have a very clear understanding of the benefits to physical activity and sport participation. And that's, you know, the physical side of that. It is the confidence building. There's a very clear link between physical activity and positive brain function and people doing better in school, who are more physically active. All of that is very clear in the medical literature, but there's also risk that comes with sport participation. In my mind, in broad strokes, the benefits of sport outweigh the risks. But that's an individual, it’s an individual choice by parents and kids and the sport that they're choosing to play. So, I absolutely disagree with comments about we need to ban certain sports and distracting the other. But what I do think we need to do is take a hard look at how some of these sports are played and make adjustments where we can. No sport is the same today as it was 100 years ago. Like all sport evolves kind of with the times and with our understanding, and I think sport will continue to evolve to be healthy, to keep our athletes and health and safety in mind.
Christina Brown Fisher:
My guest, Dr. Steven Broglio, athletic trainer and neuroscientist from the University of Michigan. He is one of the nation's leading experts on sports related concussion and director of the Michigan Concussion Center and the Neurotrauma Research Laboratory. To check out the work Broglio and his team are doing, please follow them at X, the site formerly known as Twitter at "U. Mich Concussion." That's U-M-I-C-H Concussion. Thank you for listening to Me, Myself and TBI. I'm your host, Christina Brown Fisher.
Virginia Tech Helmet Ratings: https://www.helmet.beam.vt.edu