Thinking clearly. New attention focusing on athletics and brain concussions, principally in football. We're seeking insight from University of Iowa Sports Concussion Program Director Andy Peterson and two high school football coaches with varied backgrounds, Regina's Marv Cook, a former NFL player and Dowling's Tom Wilson on this special edition of Iowa Press.
Borg: This special edition of Iowa Press follows the PBS Frontline presentation that most of you have probably been watching for the past couple of hours. We're further illuminating a subject that is receiving increasing attention in most contact sports and in the courts. We're seeking an Iowa perspective -- the incidence of athletic brain concussions, what is being done and what is left to do and who is doing it. Pediatrician Dr. Any Peterson directs the University of Iowa Sports Concussion Program. Andy is a Hawkeye team physician. Former Hawkeye football player Marv Cook played in 7 NFL seasons wearing helmets for the New England Patriots, Chicago Bears and St. Louis Rams and he now coaches Iowa City-Regina's football team. Tom Wilson coaches football and directs athletics at Des Moines Dowling Catholic High School. Gentlemen, welcome to this special edition of Iowa Press. Nice to have you here.
Nice to be here.
Borg: Thanks for making time. And across the table, James Lynch from the Gazette in Cedar Rapids and Des Moines Register Sports Columnist Bryce Miller.
Miller: Marv, kicking it off, how much of a problem and concern are concussions?
Cook: It's a concern and it's obviously something we've got to pay very close attention to and I think there is obviously and rightfully so more awareness to the topic. You know, our youth are the most important asset we have going forward in the state of Iowa and across the country and anything we can do to make it safer for them, we're never going to make it completely safe, but anything we can do to make it safer for them playing all the different sports we need to always take a look at and always continue to try to upgrade.
Miller: Dr. Peterson, what do you think? How concerning are concussions and the discussion and safety related to those?
Peterson: Yeah, I think it is concerning. Clearly there are people that are having long-term effects from having multiple head injuries. It's happening primarily at the upper levels and less so at the lower levels as we've just seen in the Frontline special. But, you know, football is also as safe as it has ever been. I think people lose track of this. There's about 4 million football players in the United States at all levels and there are only 2 deaths, 2 traumatic deaths in all of football last year. That compares back to the 1930s, 40s and 50s when there were maybe 100 deaths a year. Football has become dramatically safer over the past decade.
Miller: Tom, are you more or less concerned about safety related to concussions now as a coach, maybe through your journey as a football player leading into your coaching duties now?
Wilson: Well, I would say more and I think some of that is because of education. I think we know more now and back when I was a player and just starting out in coaching we had very little knowledge of concussions and like most people it was getting your bell rung and you wipe yourself off and get ready to go again. And now we know that that's not the best thing to do.
Borg: Let me just interrupt here just for a second, Jim. You mentioned that we've just been watching the Frontline special. I'm interested in asking all three of you, did you think that special was illuminating enough? And did you have any special problems with it or wish it had done more?
Peterson: Yeah, I think it's a tough, from a scientific standpoint I think the issue of whether or not concussions lead to chronic traumatic encephalopathy is still a little bit difficult. I think everyone who does concussion work thinks that it does. It is intuitive, we're just getting a lot of anecdotal data that people who have had a lot of concussion exposures are at high risk as they move forward. But it's not the same type of level of science that we're used to seeing in most medical fields. I think there's still a lot more that needs to be done to make sure that the causative relationship between head trauma and the long-term effects that football players are seeing is real and that we know the mitigating factors, we know what genetic factors play a role, what types of things we can do to protect people while they're playing and what types of follow up might make a difference in people's long-term recovery.
Cook: Well, I guess an old coach used to say you're either getting better or you're getting worse and if you're staying the same then you're getting worse. And ultimately in everything we do we need to get better. And I think programs like this bring more awareness. Obviously you can look at any scenario and paint two sides of the picture of the outcome. But ultimately I think the awareness is the greatest aspect that we're getting out of this and we're just going to get better because of it. I mean, our safety, the technology is going to get better with equipment, obviously we're getting better as coaches as far as recognizing the symptoms and erring on the side of caution first and foremost. As coach said, the old way was you got your bell rung, when you can get back in there, get back in there. And as a player you want to get back in there. I think now the awareness is that we need to fully recover, rest and make sure that we get the doctors to sign off on us returning to play.
Borg: Tom, alarmist in this Frontline program? Not enough said or what?
Wilson: Well, I wouldn't say not enough. I think that we have to get the subject and the topic out there. And like Marv said, something like this and that program is just great for the overall recognition of what we have to do to move forward. And I think that's what we're doing. And, like Marv said, we're going to get better because of it and I think the more we educate people whether it's parents, whether it's we as coaches or the players themselves the better off we're going to be.
Lynch: Following up on that, Tom, you say the awareness has grown, the knowledge has grown, but has protection grown and increased and kept up with high school athletes who are bigger, stronger, faster than they were probably when you played and certainly when I played? Is the safety equipment keeping up?
Wilson: Technology changes all the time and really football equipment is nothing different. And there are always things that are better. Each year it seems like technology helps us with some facet of our football equipment. Now, nothing is going to prevent it but we feel like we get a chance to put our kids in some of the best equipment that money can buy and I feel very good about that and I think it has changed a lot and it is going to continue to change and part of it is because of the topic we're talking about.
Peterson: I kind of want to interrupt here because there's this common fallacy that concussion, that equipment can prevent concussions in some way and it doesn't. There has never been any evidence that a better helmet, a cap that you add to the helmet, any additional padding, any other piece of equipment really makes any difference. In fact, a very elegant study was just done out of the University of Wisconsin that demonstrated that. Football players didn't have any change in their concussion risk based on the age of their helmet, the quality of the helmet, the price of the helmet, the brand of the helmet, any additives to the helmet, type of mouth guard they're wearing whether it is a custom one or a non-custom one or just a cheap one that is a boil and bite. It doesn't matter. These equipments can help diffuse the impacts but they don't absorb those impacts. The impacts are still going to be transmitted to the brain and there is no piece of equipment that is going to be able to absorb that type of force.
Miller: So you're honestly saying that a better cushioned helmet doesn't provide more realistic protection against concussions?
Peterson: Correct. That is absolutely true. It is well established at this point. More cushioning does not prevent concussions because it's not the direct blow to the brain that causes the damage, it's the more transmitted or sheer force type of injury. And so you get these sheer forces that changes the axons, they have kind of tearing forces through the axons. It's not the type of blunt trauma that we see in things like motor vehicle accidents, motorcycle accidents, other types of traumatic brain injury. These types of forces are different. They can be transmitted blows. In fact, it's very common to see people who are hit in the chest or hit in other parts of their body or have a rotational type of injury where they're not hit in the head at all but develop concussions --
Borg: Just to be clear -- just to be clear -- are you contrasting that all the way from leather helmets up to what we have today and say no difference?
Peterson: Correct. Absolutely true. So you go back and look at leather helmets and they did a terrible job of preventing skull fractures, subdural hematomas, other types of bleeding into the brain that lead to death. But there's really no difference in your risk of concussion from a helmet that doesn't provide that type of impact resistance to something that does.
Miller: Now, as coaches, what Dr. Peterson just said, are you surprised by that, that better equipment and better helmets, or as former players, would that surprise you at all that there aren't technology advances that potentially could provide better protection?
Cook: Well, I've seen a few things just in the last couple of years, I think football is starting to work with NASCAR a little bit, we're seeing a little bit more protection down in the jaw area, also seeing face masks that maybe absorb some of the collision but as doc mentioned, obviously this is doc's expertise, but we're fixing face masks a lot more than we used to. They used to be really rigid and structured and it would take that blow and then it would force the brain to move and now some of our face masks are bending and absorbing some of that pressure. But the thing is these kids are getting bigger, faster and stronger and I can attest to that. I've seen these kids grow up from when I was playing to now and they hit, they run faster, they hit harder and a lot of it has got to be in the way we coach the game. I'm an ambassador with Heads Up USA Football with the NFL and there's new ways to teach to tackle to try to keep the head out of the tackle and I think that is the direction that the league is going to be going and high school and college football as well.
Miller: Tom, would parents be surprised to hear that equipment can't protect their son better in a high school football game?
Wilson: Well, I certainly think so and I think it is good for them to hear, I think it's good for us to hear. You know, there's an awful lot of money that goes into that. And as Marv said, the way we coach, the way we teach certainly is important with us moving forward in the game and we can sit here and talk about equipment, which I think is important obviously, but I think the way we teach the game is also very important.
Lynch: Dr. Peterson, just to be clear, you're saying that the helmet isn't going to prevent a concussion. But it does serve some other purposes, it prevents other injuries.
Peterson: Like death, right, it does a great job of preventing skull fractures and death.
Lynch: Broken jaws.
Peterson: Broken jaws, broken heads, those sorts of things. But if you're talking about risk of concussion none of these helmets make really any difference in terms of reducing concussion risk. In fact, all these companies that have come out with a bunch of products that could be added to helmets like these guardian caps and such, the helmet manufacturers have taken the step this year to adding language to their warranties saying that if you add something to the helmet it voids their warranty. And these companies that are marketing their products to try to prevent concussions don't actually do that, there's no evidence that they do anything. And the Federal Trade Commission has started to crack down on that.
Lynch: So, is there sort of a false sense of security for parents and players that we got new helmets this year so we're safer, we're more protected?
Peterson: Yeah, I think so. We worry obviously about people changing the way they play because they think that they're more protected, going back to using the head as a weapon because they feel like they're in a safer helmet. Thankfully we haven't seen that bear out in the data. But there is also no evidence that these helmets do anything to protect people.
Lynch: Would it be better off if we didn't wear helmets and people had to protect --
Peterson: No, no, I'm not saying that at all. People die if they don't wear helmets playing football, right. You go back to the early parts of the game and hundreds of people died every year playing football. And now across four million football players at all levels in the United States there were only two traumatic deaths in all of football last year. So they do their job.
Miller: Moving along, Marv, talking about dovetailing with the discussion of safeguards about decision making protections, coaches and medical professionals who have the best interests of players in mind, do you think those decision making protections exist equally at all levels based on your experience, high school, college, NFL?
Cook: No. Obviously the NFL have staff, fully funded staff on the sideline and colleges as well and high school levels don't have that as much as the college and the pro ranks. And I think that's the greatest thing about where we're at right now, the Iowa High School Athletic Association Roger Barr, Todd Tharp and those guys are really pushing the safety agenda. You know, and it is recognizing it, removing the player, rest, recovery and then getting authorization to go back in and I think that is the most, that is the greatest thing that has come out of this whole concussion deal is let's bring them out, get them evaluated, we have this baseline testing now they can do and they won't send them back in until they achieve the level they were before and that's the way to do it. I mean, these kids are 16, 17 years old and we need to make sure that they're going to be great when they're 55 and 60 years old.
Miller: Generally, culturally did you feel people had your best interest, your safety in mind at a particular level?
Cook: You know, culturally I was a football player and I did not want my backup playing the snaps and I was sitting on the sideline. Ankle injuries, broken fingers, I was going to find a way to get back in that game as quick as possible and the doctor had to hold me out sometimes because I wanted to play.
Miller: Isn't that a danger?
Cook: It is, it is.
Miller: Players partially making that decision?
Cook: You know, Mark Schlereth, an ESPN analyst, you know, his resume, every time they introduced him he talks about his 14 knee surgeries. It's part of, it's a band of --
Miller: It's his resume.
Cook: Exactly. And there's a warrior mentality to the game unfortunately and we've got to, like I said, we've got to try to reel that back in and understand that it is a game and you play for the fun of it, the enjoyment and all the great things you get out of teamwork, participation, being a good friend, commitment, all that stuff. There's so many great lessons that we need to continue to emphasize that part of the game. But ultimately keep the kids safe. And you’re never going to make it completely safe. I think doctor is exactly right on that.
Borg: But, Tom, it's often not you that recognizes that a player is in trouble. If I'm diagnosing concussions correctly it's self-diagnosis, isn't it Dr. Peterson?
Peterson: Well, often times coaching staff and other people on the sidelines, especially position coaches at the higher levels, notice that someone is not playing at the level they should be playing at. So coaches will commonly notice that someone isn't quite right and pull people out of the game.
Wilson: Or their teammates to be honest with you because we have that all the time is one of our kids will come over and say hey coach, you may want to look at so-and-so, I don't think they're quite right. And really our kids do a good job of policing each other if they think something is wrong and then that could alert us or position coaches, as the doctor said, that there may be something wrong and we have to give them attention.
Miller: Marv, there was a USA Today story I think it was a year ago, the NFL star Junior Seau eventually committed suicide. A teammate was quoted as saying, he estimated Junior had 1,500 grade 1 concussions during his career. Those are defined as a moment where you see stars, because he said that happened all the time. If that definition and that measure is correct, how many concussions do you think you had in your career? Have you ever measured that? And how concerned are you later in life about the potential damage there?
Cook: You know, there's a couple of times I can recall where I couldn't process information, went to the wrong huddle for a second and then went to the huddle and tried to process the next play call and then my teammates got me out, as Coach Wilson pointed out, my teammates are the ones that knew something was wrong with me and they got me out of the play and I think I sat out two or three series and maybe got back in later in the game. But I was processing things better at that point. But probably two or three times in my career of seven years, five and all through junior high and high school, I can recall two or three. But, you know, that's the hard part, for a layman to try to justify what is a tier 1, tier 2 or whatever, and then to look in a 17 year old kid's eyes on a Friday night and they're kind of flighty anyway sometimes. So it is good to have buddies. We have heat buddies in the summertime when it's hot, they've always got to check in every break to see how their buddies are doing and we probably need to be doing that with just the concussion element as well, just have them every time there's a break in the play just go chat with their buddy and see how he's doing.
Peterson: It's gotten easier for laypeople though in terms of recognizing a concussion because these grading scales that both of you mentioned have gone away. We haven't graded concussions for nearly a decade now. A concussion is a concussion is a concussion. There's no more prospective grading scales where you try to predict how long someone is going to be out or make changes prospectively on their care based on what the initial injury looked like.
Miller: But even if it's not medically defined that way just the experience level of I saw stars versus I am blacked out --
Peterson: Loss of consciousness does not predict long-term outcome from concussions. So having a concussion where you lose consciousness is not going to be any worse than a concussion where you don't lose consciousness.
Borg: Coach Wilson, you wanted to say something --
Wilson: Well, and I think diagnosing those concussions or recognizing the symptoms of a concussion are one thing and the process that you take for return to play is another because I think that is a place where we've gotten so much better is that Marv said, you know, he felt a certain way and then he felt better later and got back in. Well that's not going to happen today most of the time because there's return to play protocol and the doctors need to clear those kids and I think that ends up helping us make sure that something worse or more doesn't happen later on.
Miller: But how realistically do you think coaches, I know it's hard to admit that this is a reality potentially in football, but where wins and losses mean so much at the high school level or in college or the pros it could mean millions of dollars in contracts or a number of incentives, how difficult is it for a coach to say, it's a borderline case, this kid maybe shouldn't go back in, should go back in but we really need to win the game and this is our best wide receiver?
Wilson: In my case, in the situation I'm in now it's really out of my hands because we have doctors on our sidelines. When I was at Dike-New Hartford that wasn't the case. A lot of times you're the trainer, you're the doctor, you're also the head coach and calling the offense, which at the smaller schools it gets a little bit more difficult. Right now, and I would think it's similar or better at the college level, it's in the doctor's hands, it's in the trainer's hands, it's not in the head coach's hands.
Cook: Here's, I mean, you go to a high school football game, you see big hits all the time and technically, see, you don't know what level because a kid could come off fine but I guarantee you there was some element of pressure and trauma on the brain to some extent and whether that created stars or created nausea or whatever and that is the hard part that it's hard to diagnose so we're fortunate enough that we have a doctor that is on the sideline as well and thank goodness it's in their hands and not in our hands.
Lynch: Marv, what does a concussion feel like? And do you know you've had a concussion? When you talked about going to the wrong huddle --
Cook: Yeah, my recollection is, and I saw Saving Private Ryan where Tom Hanks at the end of the movie he gets, like there's a big blast near him and his ears are kind of ringing and he can't hear and he can't, he sees people talking to him but he can't process that information and it's kind of a buzzing kind of noise. That is what I experienced and that is what my reaction to it was. And like I said, I just wasn't able to think and process the play call in the huddle and when I broke the huddle I didn't know where to line up and so then that's when we kind of knew something --
Lynch: Did you know you had a concussion or was it up to your teammates?
Cook: Honestly I thought my bell was rung. I mean, that's the old --
Borg: Yeah, that's the old way of describing it. Andy, is there a difference in age in the ability to withstand a hit?
Peterson: Yeah, so this is a very complicated question. So if you look at the risk of injury it increases nearly linearly as you get older in football. But that's not because you become less resilient as you get older, it's because the collisions become much bigger. The types of collisions you see in fourth, fifth, sixth grade football are smaller than what you see at the junior high level are smaller than what you see at the high school level are smaller than what you see at the college level and on and on. But we do think that younger brains are a little more susceptible, they tend to have symptoms that last a little bit longer, they're more likely to have long-term effects from injuries. But the types of exposures that they see are very, very different than what is seen at the higher levels.
Lynch: So is there sort of an age appropriate guideline of Pop Warner or Pee Wee league football sort of level what would be appropriate, what would be appropriate at the junior high, high school levels?
Peterson: There's a lot of opinions. I wouldn't say there's good science on this. My personal opinion, and I want to be clear here this is personal opinion, is that at the younger levels time is spent better acquiring skills than it is on hitting. So if you're looking at younger kids maybe before junior high age, hitting doesn't need to be a part of that game. They need to learn how to run and catch and throw and do the real basics of the game.
Lynch: But everybody wants to hit.
Peterson: Everybody wants to hit, right, because that's what you see on TV on Saturday and Sunday. Yeah, but I think if you talk about the development of a football player early time should be spent on working on skills, later time should be spent on developing proper tackling and blocking technique.
Miller: And Tom, talk about that exact point. When is too young to start playing football in a coach's mind? And philosophically or in real terms when do your youth programs, how young are those kids when they start playing football that eventually are in the feeder system that might play at Dowling?
Wilson: I completely agree with the doctor. We start flag football in the first grade within our feeder program and our kids will start playing tackle football in the third grade. And to be honest with you I think it's entirely too young. Part of it is, is where our society is, is that if they're not going to play in our league they're going to go somewhere else in Des Moines or West Des Moines and go play because a lot of the parents they think their kid is different, you know, all they want to do is hit somebody. Well, we've heard that for a long time. I don't feel that the younger they start the better football player they're going to be once they get older. I don't know what the hurry is to be honest with you. I would love to have it that every kid starts in junior high with the tackling part of it and I'd be perfectly pleased with that.
Miller: How do you address that pressure competitively if you're not starting in third grade in the Dowling program, you're starting in third grade at those teams that you're going to face down the road? How do you deal with that pressure?
Wilson: Oh, it's tough because those kids may be growing up in our parochial system and then they go over there to play and then they decide to go to school over there and that’s a factor. And I think it is, you know, we're kind of at their mercy and that's part of the problem that we have. It's within the youth programs and what parents and people want and all the participation in our youth sports and then everything starts sooner and I think that is wrong.
Cook: I've got a better answer for that, nothing personal. My wife is going to listen to doc and we're going through that process right now, we actually transitioned our third and fourth grade which was pad back to flag. We're considering going back to fifth and sixth as well and really working the skills and drills and the fun part of football. I mean, all the kids tell you they want to hit and they want to do that stuff but third and fourth and fifth grade when a kid is 40, 50 pounds bigger than you it's not as fun as they thought it was. And so ultimately we want to make the game fun. Our numbers have been going down, participation in the high school level and I think a lot of it is because of the youth padded stuff and kids aren't having a good experience and they can go play soccer or something else and have a lot of fun, play fall baseball. So we've got to make it fun for the kids, make them enjoy the game and really do the skills and drills part. And one of the interesting things is, this is football, you go helmets for three days, you put on full pads and you start going after it. That's what the old way of football was. And we need to really develop the technique of tackling and do it every single time until they get it right and then let them go tackle, not put a helmet on three days later and then let them go tackle or try to learn to tackle that way. So I like the way that it's moving. It's education. The way we converted our third and fourth grade back to flag was through an educational program sitting down with the parents and a doctor and kind of going over this stuff and having just a dialogue with the parents as well as the coaches and then making a collective decision.
Lynch: Dr. Peterson, there's an Iowa law that says if a player is showing signs of a concussion they have to be taken out of the game and they can't return to play until they have been evaluated and I think actually written authority from a medical personnel -- is that state law working? And would you recommend any changes?
Peterson: Yeah, so we think it's working. There are laws like this all over the country now. The first one is in Washington state, the Lystedt Law and ours is essentially a mirror copy of that Lystedt Law. There were a lot of concerns initially with these laws that it would be an incentive for people to hide their concussion symptoms, so people knew that they wouldn't return to a game so they wouldn't tell people that they were concussed and I think those fears have largely borne to be untrue, although there is not good research to support that at this point.
Miller: Marv, as we're wrapping up in just the final minutes, in just 30 seconds can you talk about, you mentioned NASCAR, can it be NASCAR without the crashes? Can it be safe and still be football?
Cook: No, that's one of the things we had in our parent meeting, it's a collision sport and we've got to try to get our kids in the best physical shape to be able to take on those collisions and if it's concussions, knee injuries, ankles, we're never going to make football a completely safe game, we just need to make it as safe as possible by better techniques, better teaching, better coaching and better recognition.
Borg: Dr. Peterson, how do you advise parents? He just said it's a collision sport, there are going to be hard hits. What do you advise parents?
Peterson: Let their kids play football. I think people are surprised to have the concussion doctor say that I think it's okay for kids to play football but I do. I think that the risk at the lower levels is fairly low. I think there's a handful of people that are going to end up with long-term problems but it's not nearly the risk of sitting on the couch and eating chips and getting out of shape and being obese and having cardiovascular disease later in life. I think that the benefits of playing sports clearly outweigh the risks of playing sports.
Borg: But what do you advise about the culture within the home? The pressures to --
Peterson: Oh sure, right, so this is a problem not just with football but it's a problem with lots of sports. I always advise people against early specialization, to try to do things that are going to improve overall fitness, improve skill acquisition, especially at lower levels and that usually involves playing a lot of different sports rather than just focusing on tackle football early on.
Borg: Gentlemen, thank you very much. It's been an interesting, very interesting discussion. Thanks for making time for us. Well, this coming Friday evening on Iowa Press we're discussing water quality and the latest efforts by the Environmental Protection Agency and cattle producers throughout Iowa. That's Iowa Press, 7:30 Friday night, noon on Sunday. Thanks for joining us for this special edition of Iowa Press.