SPORTS CONCUSSIONS AND THE BRAIN

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Introduction They just didn’t believe it. When The Times published its first major story regarding football concussions in January 2007, on the emotional decline and suicide of the former Philadelphia Eagle Andre Waters, most fans and media outlets said, “Tragic, but how can that be related to football?” When The Times profiled how retirees like John Mackey (a Hall of Fame tight end) and Ralph Wenzel (an anonymous lineman) had degenerated to the point of fullblown dementia in their early 60s, the league insisted that such isolated anecdotes held no significance. And when the paper showed how high school boys and girls — for whom concussions can be far more serious, even deadly — were having their futures endangered, many onlookers just wouldn’t believe that football could involve this level of danger. Broken bones, yes. Torn shoulders, sure. But permanent brain damage? Through the full articles as they appeared in The Times, this e-book captures how long it took for people — particularly, of course, the N.F.L. itself — to appreciate how real this truly was. Some stories deal with professionals, others children. There are whistleblowers and deniers, Congressional hearings and faulty helmets. Then comes the February 2011 suicide of the former Chicago Bears star Dave Duerson, whose bullet blew through football’s heart as much as his own. The results of The Times’s four-year series of more than 100 articles were staggering. The N.F.L. revamped its rules regarding concussions; states across the nation passed laws mandating appropriate concussion care for children; and most professional and college sports, from baseball to hockey and more, followed suit with rules designed for their specific arenas. By 2014, it was virtually impossible to watch a game or read a sports section without some mention of concussions. Sports can be fantasy — which isn’t necessarily a bad thing. It’s an escape to a land of heroes and warriors, of vigor and valor. For football and its fans, the ugly reality of brain damage hit them as hard as players hit each other, and left them just as dazed. —Alan Schwarz

Expert Ties Ex-Player’s Suicide to Brain Damage By ALAN SCHWARZ January 18, 2007

Since the former National Football League player Andre Waters killed himself in November, an explanation for his suicide has remained a mystery. But after examining remains of Mr. Waters’s brain, a neuropathologist in Pittsburgh is claiming that Mr. Waters had sustained brain damage from playing football and he says that led to his depression and ultimate death. The neuropathologist, Dr. Bennet Omalu of the University of Pittsburgh, a leading expert in forensic pathology, determined that Mr. Waters’s brain tissue had degenerated into that of an 85-year-old man with similar characteristics as those of early-stage Alzheimer’s victims. Dr. Omalu said he believed that the damage was either caused or drastically expedited by successive concussions Mr. Waters, 44, had sustained playing football. In a telephone interview, Dr. Omalu said that brain trauma “is the significant contributory factor” to Mr. Waters’s brain damage, “no matter how you look at it, distort it, bend it. It’s the significant forensic factor given the global scenario.” He added that although he planned further investigation, the depression that family members recalled Mr. Waters exhibiting in his final years was almost certainly exacerbated, if not caused, by the state of his brain — and that if he had lived, within 10 or 15 years “Andre Waters would have been fully incapacitated.” Dr. Omalu’s claims of Mr. Waters’s brain deterioration — which have not been corroborated or reviewed —add to the mounting scientific debate over whether victims of multiple concussions, and specifically longtime N.F.L. players who may or may not know their full history of brain trauma, are at heightened risk of depression, dementia and suicide as early as midlife. The N.F.L. declined to comment on Mr. Waters’s case specifically. A member of the league’s mild traumatic brain injury committee, Dr. Andrew Tucker, said that the N.F.L. was beginning a study of retired players later this year to examine the more general issue of football concussions and subsequent depression.

“The picture is not really complete until we have the opportunity to look at the same group of people over time,” said Dr. Tucker, also team physician of the Baltimore Ravens. The Waters discovery began solely on the hunch of Chris Nowinski, a former Harvard football player and professional wrestler whose repeated concussions ended his career, left him with severe migraines and depression, and compelled him to expose the effects of contact-sport brain trauma. After hearing of the suicide, Mr. Nowinski phoned Mr. Waters’s sister Sandra Pinkney with a ghoulish request: to borrow the remains of her brother’s brain. The condition that Mr. Nowinski suspected might be found in Mr. Waters’s brain cannot be revealed by scan of a living person; brain tissue must be examined under a microscope. “You don’t usually get brains to examine of 44-year-old ex-football players who likely had depression and who have committed suicide,” Mr.Nowinski said. “It’s extremely rare.” As Ms. Pinkney listened to Mr. Nowinski explain his rationale, she realized that the request was less creepy than credible. Her family wondered why Mr. Waters, a hardhitting N.F.L. safety from 1984 to 1995 known as a generally gregarious and giving man, spiraled down to the point of killing himself. Ms. Pinkney signed the release forms in mid-December, allowing Mr. Nowinski to have four pieces of Mr. Waters’s brain shipped overnight in formaldehyde from the Hillsborough County, Fla., medical examiner’s office to Dr. Omalu in Pittsburgh for examination. He chose Dr. Omalu both for his expertise in the field of neuropathology and for his rare experience in the football industry. Because he was coincidentally situated in Pittsburgh, he had examined the brains of two former Pittsburgh Steelers players who were discovered to have had postconcussive brain dysfunction: MikeWebster, who became homeless and cognitively impaired before dying of heart failure in 2002; and Terry Long, who committed suicide in 2005. Mr. Nowinski, a former World Wrestling Entertainment star working in Boston as a pharmaceutical consultant, and the Waters family have spent the last six weeks becoming unlikely friends and allies. Each wants to sound an alarm to athletes and their families that repeated concussions can, some 20 years after the fact, have devastating

consequences if left unrecognized and untreated — a stance already taken in some scientific journals. “The young kids need to understand; the parents need to be taught,” said Kwana Pittman, 31, Mr. Waters’s niece and an administrator at the water company near her home in Pahokee, Fla. “I just want there to be more teaching and for them to take the proper steps as far as treating them. “Don’t send them back out on these fields. They boost it up in their heads that, you know, ‘You tough, you tough.’ “ Mr. Nowinski was one of those tough kids. As an all-Ivy League defensive tackle at Harvard in the late 1990s, he sustained two concussions, though like many athletes he did not report them to his coaches because he neither understood their severity nor wanted to appear weak. As a professional wrestler he sustained four more, forcing him to retire in 2004. After he developed severe migraines and depression, he wanted to learn more about concussions and their effects. That research resulted in a book published last year, “Head Games: Football’s Concussion Crisis,” in which he detailed both public misunderstanding of concussions as well as what he called “the N.F.L.’s tobacco-industry-like refusal to acknowledge the depths of the problem.” Football’s machismo has long euphemized concussions as bell-ringers or dings, but what also alarmed Mr. Nowinski, 28, was that studies conducted by the N.F.L. on the effects of concussions in players “went against just about every study on sports concussions published in the last 20 years.” Studies of more than 2,500 former N.F.L. players by the Center for the Study of Retired Athletes, based at the University of North Carolina, found that cognitive impairment, Alzheimer’s-like symptoms and depression rose proportionately with the number of concussions they had sustained. That information, combined with the revelations that Mr. Webster and Mr. Long suffered from mental impairment before their deaths, compelled Mr. Nowinski to promote awareness of brain trauma’s latent effects. Then, while at work on Nov. 20, he read on Sports Illustrated’s Web site, si.com, that Mr. Waters had shot himself in the head in his home in Tampa, Fla., early that morning. He read appraisals that Mr. Waters, who retired in 1995 and had spent many years as an assistant coach at several small colleges — including Fort Valley (Ga.) State

last fall — had been an outwardly happy person despite his disappointment at not landing a coaching job in the N.F.L. Remembering Mr. Waters’s reputation as one of football’s hardest-hitting defensive players while with the Philadelphia Eagles, and knowing what he did about the psychological effects of concussions, Mr. Nowinski searched the Internet for any such history Mr. Waters might have had. It was striking, Mr. Nowinski said. Asked in 1994 by The Philadelphia Inquirer to count his career concussions, Mr. Waters replied, “I think I lost count at 15.” He later added: “I just wouldn’t say anything. I’d sniff some smelling salts, then go back in there.” Mr. Nowinski also found a note in the Inquirer in 1991 about how Mr. Waters had been hospitalized after sustaining a concussion in a game against Tampa Bay and experiencing a seizure-like episode on the team plane that was later diagnosed as body cramps; Mr. Waters played the next week. Because of Dr. Omalu’s experience on the Webster and Long cases, Mr. Nowinski wanted him to examine the remaining pieces of Mr. Waters’s brain — each about the size of a small plum — for signs of chronic traumatic encephalopathy, the tangled threads of abnormal proteins that have been found to cause cognitive and intellectual dysfunction, including major depression. Mr. Nowinski tracked down the local medical examiner responsible for Mr. Waters’s body, Dr. Leszek Chrostowski, who via e-mail initially doubted that concussions and suicide could be related. Mr. Nowinski forwarded the Center for the Study of Retired Athletes’ studies and other materials, and after several weeks of back-and-forth was told that the few remains of Mr. Waters’s brain — which because Waters had committed suicide had been preserved for procedural forensic purposes before the burial — would be released only with his family’s permission. Mr. Nowinski said his call to Mr. Waters’s mother, Willie Ola Perry, was “the most difficult cold-call I’ve ever been a part of.” When Mr. Waters’s sister Tracy Lane returned Mr. Nowinski’s message, he told her, “I think there’s an outside chance that there might be more to the story.” “I explained who I was, what I’ve been doing, and told her about Terry Long — and said there’s a long shot that this is a similar case,” Mr. Nowinski said.

Ms. Lane and another sister, Sandra Pinkney, researched Mr. Nowinski’s background, his expertise and experience with concussions, and decided to trust his desire to help other players. “I said, ‘You know what, the only reason I’m doing this is because you were a victim,’ “ said Ms. Pittman, Mr.Waters’s niece. “I feel like when people have been through things that similar or same as another person, they can relate and their heart is in it more. Because they can feel what this other person is going through.” Three weeks later, on Jan. 4, Dr. Omalu’s tests revealed that Mr. Waters’s brain resembled that of an octogenarian Alzheimer’s patient. Nowinski said he felt a dual rush — of sadness and success. “Certainly a very large part of me was saddened,” he said. “I can only imagine with that much physical damage in your brain, what that must have felt like for him.” Then again, Mr. Nowinski does have an inkling. “I have maybe a small window of understanding that other people don’t, just because I have certain bad days that when I know my brain doesn’t work as well as it does on other days — and I can tell,” he said. “But I know and I understand, and that helps me deal with it because I know it’ll probably be fine tomorrow. I don’t know what I would do if I didn’t know.” When informed of the Waters findings, Dr. Julian Bailes, medical director for the Center for the Study of Retired Athletes and the chairman of the department of neurosurgery at West Virginia University, said, “Unfortunately, I’m not shocked.” In a survey of more than 2,500 former players, the Center for the Study of Retired Athletes found that those who had sustained three or more concussions were three times more likely to experience “significant memory problems” and five times more likely to develop earlier onset of Alzheimer’s disease. A new study, to be published later this year, finds a similar relationship between sustaining three or more concussions and clinical depression. Dr. Bailes and other experts have claimed the N.F.L. has minimized the risks of brain trauma at all levels of football by allowing players who sustain a concussion in games — like Jets wide receiver Laveranues Coles last month — to return to play the same day if they appear to have recovered. The N.F.L.’s mild traumatic brain injury committee has published several papers in the journal Neurosurgery defending that

practice and unveiling its research that players from 1996 through 2001 who sustained three or more concussions “did not demonstrate evidence of neurocognitive decline.” A primary criticism of these papers has been that the N.F.L. studied only active players, not retirees who had reached middle age. Dr. Mark Lovell, another member of the league’s committee, responded that a study using long-term testing and monitoring of the same players from relative youth to adulthood was necessary to properly assess the issue. “We want to apply scientific rigor to this issue to make sure that we’re really getting at the underlying cause of what’s happening,” Dr. Lovell said. “You cannot tell that from a survey.” Dr. Kevin Guskiewicz is the director of the Center for the Study of Retired Athletes and a member of U.N.C.’s department of exercise and sport science. He defended his organization’s research: “I think that some of the folks within the N.F.L. have chosen to ignore some of these earlier findings, and I question how many more, be it a large study like ours, or single-case studies like Terry Long, Mike Webster, whomever it may be, it will take for them to wake up.” The N.F.L. players’ association, which helps finance the Center for the Study of Retired Athletes, did not return a phone call seeking comment on the Waters findings. But Merril Hoge, a former Pittsburgh Steelers running back and current ESPN analyst whose career was ended by severe concussions, said that all players — from retirees to active players to those in youth leagues — need better education about the risks of brain trauma. “We understand, as players, the ramifications and dangers of paralysis for one reason — we see a person in a wheelchair and can identify with that visually,” said Mr. Hoge, 41, who played on the Steelers with Mr. Webster and Mr. Long. “When somebody has had brain trauma to a level that they do not function normally, we don’t see that. We don’t witness a person walking around lost or drooling or confused, because they can’t be out in society.” Clearly, not all players with long concussion histories have met gruesome ends — the star quarterbacks Steve Young and Troy Aikman, for example, were forced to retire early after successive brain trauma and have not publicly acknowledged any problems. But the experiences of Mr. Hoge, Al Toon (the former Jets receiver who considered suicide after repeated concussions) and the unnamed retired players interviewed by the

Center for the Study of Retired Athletes suggest that others have not sidestepped a collision with football’s less glorified legacy. “We always had the question of why — why did my uncle do this?” said Ms. Pittman, Mr. Waters’s niece. “Chris told me to trust him with all these tests on the brain, that we could find out more and help other people. And he kept his word.”

Dark Days Follow Hard-Hitting Career in N.F.L. By ALAN SCHWARZ February 2, 2007

Ted Johnson helped the New England Patriots win three of the past five Super Bowls before retiring in 2005. Now, he says, he forgets people’s names, misses appointments and, because of an addiction to amphetamines, can become so terrified of the outside world that he locks himself alone inside his Boston apartment in bed with the blinds drawn for days at a time. “There’s something wrong with me,” said Mr. Johnson, 34, who spent 10 years in the National Football League as the Patriots’ middle linebacker. “There’s something wrong with my brain. And I know when it started.” Mr. Johnson’s decline began, he said, in August 2002, with a concussion he sustained in a preseason game against the New York Giants. He sustained another four days later during a practice, after Patriots Coach Bill Belichick went against the recommendation of the team’s trainer, Johnson said, and submitted him to regular onfield contact. Mr. Belichick and the Patriots’ head trainer at the time, Jim Whalen — each of whom remain in those positions — declined to comment on Mr. Johnson’s medical experience with the team or his allegations regarding their actions. Following his two concussions in August 2002, Mr. Johnson sat out the next two preseason games on the recommendation of a neurologist. After returning to play, Mr. Johnson sustained more concussions of varying severity over the next three seasons, each of them exacerbating the next, according to Mr. Johnson’s current neurologist, Dr. Robert Cantu. Dr. Cantu said that he was convinced Mr. Johnson’s cognitive impairment and depression “are related to his previous head injuries, as they are all rather classic postconcussion symptoms.” He added, “They are most likely permanent.” Asked for a prognosis of Mr. Johnson’s future, Dr. Cantu, the chief of neurosurgery and director of sports medicine at Emerson Hospital in Concord, Mass., said: “Ted

already shows the mild cognitive impairment that is characteristic of early Alzheimer’s disease. The majority of those symptoms relentlessly progress over time. It could be that at the time he’s in his 50s, he could have severe Alzheimer’s symptoms.” Mr. Johnson is among a growing number of former players and their relatives who are questioning whether their serious health issues are related to injuries they sustained and the treatment they received as players. Mr. Johnson said he decided to go public with his story after reading in The New York Times two weeks ago about Andre Waters, the former Philadelphia Eagles player who committed suicide last November and was later determined to have had significant brain damage caused by football-related concussions. Mr. Johnson said he was not suicidal, but that the depression and cognitive problems he had developed since 2002 had worsened to the point that he now takes Adderall, a prescription amphetamine, at two to three times the dosage authorized by his doctors, who have been unaware of this abuse. When he runs out of these pills, Mr. Johnson said, he shuts himself inside his downtown apartment for days and communicates with no one until a new prescription becomes available. He said he was coming forward with his story so that his friends and family might better understand his situation, and also so that the National Football League might improve its handling of concussions. While the league’s guidelines regarding head injuries have been strengthened over the past decade, the N.F.L.’s record of allowing half of players who sustain concussions to return to the same game remains a subject of medical debate. “I am afraid of somebody else being the next Andre Waters,” said Mr. Johnson, who spent two weeks in February at a psychiatric hospital outside Boston with, he said, no appreciable results. “People are going to question me: ‘Are you a whistleblower, what are you doing this for?’ You can call it whatever you want about what happened to me. I didn’t know the long-term ramifications. You can say that my coach didn’t know the long-term, or else he wouldn’t have done it. It is going to be hard for me to believe that my trainer didn’t know the long-term ramifications, but I am doing this to protect the players from themselves.” The N.F.L. spokesman Greg Aiello said that the league had no knowledge of Johnson’s specific situation. Regarding the subject of player concussions in general, he said, “We are very concerned about the issue of concussions, and we are going to continue to look hard at it and do everything possible to protect the health of our players.”

At a news conference yesterday in Miami, where the Super Bowl will be held Sunday, Gene Upshaw, the executive director of the National Football League Players Association, spoke in general terms about concussions in the N.F.L. “If a coach or anyone else is saying, ‘You don’t have a concussion, you get back in there,’ you don’t have to go, and you shouldn’t go,” Upshaw said, not speaking about the Johnson case specifically. “You know how you feel. That’s what we tried to do throughout the years, is take the coach out of the decision-making. It’s the medical people that have to decide.” Mr. Johnson, who has a 2-year-old daughter and a 1-year-old son, is currently in divorce proceedings with his wife, Jackie, a situation that he admitted was compounding his depression. He was arrested in July on domestic assault-and-battery charges, which were later dropped because his wife declined to testify. Mr. Johnson said that his concussive symptoms and drug addiction not only precipitated his marriage’s decline but began several years before it, specifically that preseason of 2002. According to Patriots medical records that Mr. Johnson shared with The Times, the only notable concussion in his career to that point happened when he played at the University of Colorado in 1993. Against the Giants on Aug. 10, 2002, those records indicate, he sustained a “head injury” — the word concussion was not used — and despite the clearing of symptoms after several minutes on the sideline, he did not return to the game. Mr. Johnson said that four days later, when full-contact practice resumed, Mr. Whalen issued him a red jersey, the standard signal to all other players that he was not supposed to be hit in any way. About an hour into the practice, Mr. Johnson said, before a set of high-impact running drills, an assistant trainer came out on the field with a standard blue jersey. When he asked for an explanation, Mr. Johnson said, the assistant told him that he was following Mr. Whalen’s instructions. Mr. Johnson, whose relationship with Mr. Belichick had already been strained by a contract dispute, said he interpreted the scene as Mr. Belichick’s testing his desire to play, and that he might be cut and lose his $1.1 million salary — N.F.L. contracts are not guaranteed — if he did not follow orders. “I’m sitting there going, ‘God, do I put this thing on?’ “ Mr. Johnson said. “I put the blue on. I was scared for my job.”

Regarding the intimidation he felt at that moment, Mr. Johnson added, “This kind of thing happens all the time in football. That day it was Bill Belichick and Ted Johnson. But it happens all the time.” Several Patriots teammates said they did not recall this incident but invariably testified to the believability of Mr. Johnson, the team captain in 1998 and 2003. Said one former teammate, who insisted on anonymity because he still plays with the Patriots under Mr. Belichick, “If Ted tells you something’s going on, something’s going on.” Mr. Johnson said that the first play called after he put the blue jersey on, known as “ace-ice,” called for one act from him, the middle linebacker: to sprint four yards headlong into the onrushing blocking back. After that collision, Mr. Johnson said, a warm sensation overtook his body, he saw stars, and he felt disoriented as the other players appeared to be moving in slow motion. He never lost consciousness, though, and after several seconds regained his composure and continued to practice “in a bit of a fog” while trying to avoid contact. He said he did not mention anything to anyone until after practice, when he angrily approached Mr. Whalen, the head trainer. “I said, ‘Just so you know, I got another concussion,’ “ Johnson said. “You could see the blood, like, leave his face. And he was like, ‘All right, all right, well, we’re going to get you in to see a neurologist.’ “ Dr. Lee H. Schwamm, the neurologist at Massachusetts General Hospital who examined Mr. Johnson, concluded in a memo on Aug. 19, 2002, that Mr. Johnson had sustained a second concussion in that practice. Dr. Schwamm also wrote that, after speaking with Mr. Whalen, that Mr. Whalen “was on the sidelines when he sustained the concussion during the game and assessed him frequently at the sideline,” and that “he has kept Mr. Johnson out of contact since that time.” Mr. Johnson said that the next day he spoke with Mr. Belichick about the incident but that they only glossed over it. “He was vaguely acknowledging that he was aware of what happened,” Mr. Johnson said, “and he wanted to just kind of let me know that he knew.” Mr. Johnson missed the next two preseason games, played in the final one, and then, believing he was still going to be left off the active roster for the opening game against Pittsburgh, angrily left camp for two days before returning and meeting with Mr. Belichick and confronting him privately about the blue-jersey incident.

“It’s as clear as a bell — ‘I had to see if you could play,’ “ Mr. Johnson recalled Mr. Belichick saying. Minutes later, Mr. Johnson said, Mr. Belichick admitted he had made a mistake by making him wear the blue jersey. “It was a real kind of admittance, but it was only him and I in the room,” Mr. Johnson said. Mr. Johnson sat out the season opener but played the following Sunday against the New York Jets, a game in which Mr. Johnson said he could not remember line formations and was caught out of position because he could not concentrate. After sitting out the next game against Kansas City, Mr. Johnson played against San Diego and had the same problem. He learned how to manage the disorientation and played the rest of the season but said that, “from that point on, I was getting a lot of these, what I call mini-concussions.” Mr. Johnson added that he did not report these to his trainer or coaches for fear he would be seen as weak. This continued through the 2003 season, Mr. Johnson said, as he noticed himself feeling increasingly more unfocused, irritable and depressed. Teammates noticed as well, said Willie McGinest, a fellow linebacker who now plays for the Cleveland Browns. “He was always an upbeat, positive guy,” Mr. McGinest said. “After the last few concussions, you could tell he was off at times.” Playing poorly, Mr. Johnson lost his starting job. In the week before the 2004 Super Bowl, Mr. Johnson said, a friend who supplied amphetamines to several major league baseball pitchers gave him some Adderall pills to cure his lethargy and increase his concentration. “It was the best I had felt in the longest time,” Mr. Johnson said. “The old Ted was back.” After playing only sparingly in that Super Bowl, Mr. Johnson began taking larger and larger doses before and throughout the 2004 season, when he regained his starting position at middle linebacker and helped the Patriots win their second consecutive Super Bowl. The better mood did not last long, he said. The minor concussions — euphemized as “dings” in N.F.L. lingo — that he regularly sustained in practice and in games hurt more than the Adderall could help. The thought of violently tackling a player, he said, “made me physically ill.”

“For the first time in my life,” he said, “I was scared of going out there and putting my head in there.” Mr. Johnson retired before the 2005 season and briefly worked as a football analyst for WBZ-TV in Boston. But he said his malaise and cognitive problems were only getting worse, and in his attempt to regain some sort of balance, he wound up taking large amounts of antidepressants along with increasing amounts of Adderall, creating a dangerous up-and-down cycle that he realized required professional attention. Last February, he spent two weeks at McLean Hospital, a psychiatric institution in suburban Belmont, Mass. Mr. Johnson said he felt no better after that experience, and he quickly resumed the Adderall abuse that continues today. He has moved out of his former house during his divorce proceedings and lives in a two-bedroom apartment downtown, which after three months contains dozens of half-open moving boxes. “Welcome to the glamorous life of a former N.F.L. player,” he said. A half-hour later, he stepped into his Range Rover and drove to his local CVS to pick up another bottle of Adderall. The 72 pills of 30 milligrams each are supposed to last nine days, but he knows he will blow through them in four or five. One of his most maddening frustrations, Mr. Johnson said, is that no tests — from M.R.I.’s to other scans of his brain — have confirmed his condition, causing some people in his life to suspect that he is wallowing in retirement blues. “That’s ridiculous,” he said, “because I always treated football as a steppingstone for the rest of my life. I used to have incredible drive and ambition. I want to get my M.B.A. But I can’t even let myself have a job right now. I don’t trust myself.” Dr. Cantu, his neurosurgeon, said he was convinced that Mr. Johnson’s condition was primarily caused by successive concussions sustained over short periods of time. He said that M.R.I.’s of Mr. Johnson’s brain were clear, but that “the vast majority of individuals with postconcussion syndrome, including depression, cognitive impairment, all the symptoms that Ted has, have normal M.R.I.’s.” The most conclusive method to assess this type of brain damage, Dr. Cantu said, was to examine parts of the brain microscopically for tears and tangles, but such a test is done almost exclusively post-mortem. It was this type of examination that was conducted by a neuropathologist at the University of Pittsburgh, Dr. Bennet Omalu, on the brain of Mr.

Waters after his suicide, revealing a condition that Dr. Omalu described as that of an 85year-old with Alzheimer’s disease. “The type of changes that Andre Waters reportedly had most likely Ted has as well,” Dr. Cantu said. Experts in the field of athletic head trauma have grown increasingly confident through studies and anecdotal evidence that repeated concussions, particularly those sustained only days apart, are particularly dangerous. Dr. David Hovda, a professor of neurosurgery and director of the Brain Injury Research Center at U.C.L.A., said, “Repeated concussions — it doesn’t matter the severity — have affects that are more than additive, and that last longer.” Sitting in his apartment this week, Mr. Johnson said that he had not considered a lawsuit against Mr. Belichick, any Patriots personnel or the N.F.L. He said that his sole motivation was to raise awareness of the dangers that football players can face regarding concussions. Asked who was to blame for his condition — Mr. Belichick, Mr. Whalen, himself or the entire culture of the N.F.L. — Mr. Johnson thought for 30 seconds and said he could not decide. Several hours later, he was riding in an elevator up to a consultation with Dr. Cantu. As the door opened on the seventh floor, a middle-aged man walked out and smiled warmly at Mr. Johnson. “We missed you this year,” he said. “Thanks, man,” Mr. Johnson said with a grin and a nod. Later, Mr. Johnson said something else went through his troubled mind at that moment. “I miss me, too,” he said. Clifton Brown contributed reporting from Miami.

Wives United by Husbands’ Post-N.F.L. Trauma By ALAN SCHWARZ March 14, 2007

ANNAPOLIS, Md., March 9 — The night that Sylvia Mackey and Eleanor Perfetto first met, back in October at a Baltimore Ravens reception for former National Football League players and their families, their connection was immediate. As she sat on a couch with her husband, Mrs. Mackey watched Dr. Perfetto cradle the hand of her husband as he blankly shuffled across the floor toward the Mackeys. “Your husband has dementia,” Mrs. Mackey said. “Yours does, too,” Dr. Perfetto replied. “We both just knew,” Dr. Perfetto recalled on Friday, when the two visited the assisted-living facility where Dr. Perfetto’s husband, Ralph Wenzel, resides. Mrs. Mackey quickly added, “You can see it in the wives’ faces just like the husbands’.” On that evening last October, Mrs. Mackey added another N.F.L. wife to her growing network of women who seek her guidance and support as their husbands deteriorate mentally. Her husband, John, was a Hall of Fame tight end for the Baltimore Colts in the late 1960s and early ’70s, and is probably the most notable victim of dementia among former football players. Mrs. Mackey said that she regularly communicates with about 10 women like Dr. Perfetto as they learn to handle their husbands’ dementia, which often begins as early as their 50s. “I know about 20 in all,” Mrs. Mackey said. “And if I know 20, there are probably 60 or 80 out there.” Last May, Mrs. Mackey wrote a three-page letter to Paul Tagliabue, the N.F.L. commissioner at the time, detailing John Mackey’s decline, the financial ruin it would soon cause her, and how the Mackeys were not the only couple facing such a crisis at a time when the league’s coffers are bursting. She wrote that dementia “is a slow, deteriorating, ugly, caregiver-killing, degenerative, brain-destroying tragic horror,” and appealed to Mr. Tagliabue to help.

The result was the formation of the 88 Plan, a joint effort between the league and the N.F.L. Players Association named after John Mackey’s jersey number. Under the plan, families of former players who have various forms of dementia can receive money for their care and treatment — up to $88,000 a year if the player must live in an outside facility, and up to $50,000 a year if the player is cared for at home. The first applications were mailed in late February to families of 22 former players who are already known to have dementia, including Mr. Mackey, 65, and Mr. Wenzel, 64. No family has received any money yet. The N.F.L. spokesman Greg Aiello said the league would be aggressive in informing other families about the plan. Although both the league and the players union are quick to deny any connection between someone’s having played football and later cognitive failure — in an e-mail message, Mr. Aiello described dementia as a condition “that affects many elderly people” — the 88 Plan has been created at a time of heightened scrutiny of the effects of brain injuries among football players. In January, a neuropathologist who examined the brain of Andre Waters, the former Philadelphia Eagles player who committed suicide last fall at 44, said that repeated concussions had led to Mr. Waters’s brain tissue resembling that of an 80-year-old with Alzheimer’s disease. And last month, the doctors of the former New England Patriots linebacker Ted Johnson, 34, said he was exhibiting the depression and memory lapses associated with oncoming Alzheimer’s. Coming Up With a Plan Former players who have dementia do not qualify for the N.F.L.’s disability insurance program, because neither the league nor the union consider their conditions football-related, a stance that has been cast in doubt by several scientific studies. Dr. Perfetto said that Mr. Wenzel’s neurologist had determined that on-field brain trauma was the probable cause of his Alzheimer’s-type dementia. In more lucid times Mr. Wenzel estimated his number of concussions as “more than I can count.” Sylvia Mackey said that the cause of her husband’s frontal temporal dementia was less clear, but that his football collisions — including one headfirst impact with a goal post at full speed — were the likely culprit. “I have been approached many times by lawyers who wanted to use me in a lawsuit — I turned them all down, and I’m glad I did,” Sylvia Mackey said, turning back to the

88 Plan. “This is better, because everyone who is affected will benefit, whether they were stars or Hall of Famers or just regular players like Ralph.” John Mackey and Ralph Wenzel will almost certainly qualify for aid, as they appear to be textbook cases of dementia among N.F.L. veterans. Mr. Mackey is a sturdy 6-foot-3 and 240 pounds underneath his trademark black cowboy hat. He’s convivial with fans who remember him, but soon into any interaction quickly demonstrates his mental decline. During lunch on Friday, he used a spoon to drink his coffee, thinking it was soup, and uttered non sequiturs to almost any question, including several repetitions of “I want a cookie” and “I got in the end zone.” His most prized possessions are two rings, which he repeatedly proffered on his fists. “I got this one for winning Super Bowl V, and this one when they put me in the Hall of Fame,” he said several times. The rings are so precious to him that last year, when airport security screeners asked him to remove them, he grew enraged, ran toward the gate and had to be wrestled to the ground, screaming, by armed officials. “I was afraid they might shoot him dead,” Sylvia Mackey said. She no longer lets him fly; when the two traveled from Baltimore to Miami for this year’s Super Bowl, they rode Amtrak for 28 hours. When they are home in Baltimore, John regularly attends an adult day-care facility that costs $76 a day, with 24-hour care on the near horizon. Mr. Wenzel’s dementia is far more apparent than Mr. Mackey’s. Mr. Wenzel walks gingerly, rarely mumbles more than a few nonsensical syllables before growing tired or tongue-tied, and cannot feed himself. He can offer no memories of his N.F.L. career, whether they are about the position he played (offensive line), his seasons (1966-73), his teams (the Pittsburgh Steelers and San Diego Chargers) or his teammates. “Do you remember playing with Lloyd Voss?” his wife asked, trying to give his memory some traction. “No,” he said. “Your best friend?” “Nah,” Mr. Wenzel said as his head drooped further. Dr. Perfetto, Mr. Wenzel’s second wife, found she could no longer care for her husband in their home in Stevensville, Md. In February she moved him to the Annapolitan Assisted Living Community at the cost of about $65,000 a year. His building’s doors are locked and guarded so the residents do not wander away.

Families Facing Bankruptcy A senior director in health policy for Pfizer, Dr. Perfetto, 48, said that caring for her husband would eventually bankrupt her retirement accounts. (Mr. Wenzel receives a monthly N.F.L. pension of $925.) Sylvia Mackey, 65, returned to work as a flight attendant for United Air Lines several years ago solely because her husband’s pension, now $2,450 a month, fell well below their living costs. She said that if it were not for the funds from the 88 Plan, she would have to sell her home, particularly when her husband needs institutionalization. The paradox of veterans of the N.F.L., a $6 billion-a-year business, struggling to pay medical bills is compounded by another, far less obvious fact. Dr. Perfetto said that she had trouble finding a home that would accept Mr. Wenzel because victims of Alzheimer’s-type diseases occasionally become violent, and former football players of his size (6 feet 2 and 215 pounds) are difficult for staff members to subdue. “These facilities are used to older people who are fairly decrepit — who have strokes or blindness or use a walker, that sort of thing,” Dr. Perfetto said. Dr. Perfetto said that while she hoped to receive assistance from the 88 Plan, she remained cautious. Many former N.F.L. players and their families have complained that the league’s disability insurance system is far too strict, with thresholds too high and hurdles too numerous for the deserving to get help. This skepticism is shared by Sharon Hawkins, who will be applying for 88 Plan assistance on behalf of her husband, Wayne, a former offensive lineman for the Oakland Raiders from 1960-69 who receives at-home care for his increasing dementia. “I’m full of hope that we’ll be able to get it,” Mrs. Hawkins, who lives in Reno, Nev., said in a telephone interview. “Until something has really happened the way they say it will, I’m reserving judgment.” Gene Upshaw, executive director of the N.F.L. Players Association and the target of many veterans’ dissatisfaction with the disability system, said in a telephone interview that he understood Mrs. Hawkins’s doubt and agreed that there was too much red tape. He said that even though 88 Plan awards would be determined by the same sixmember panel (split evenly among appointees of the league and the union) as the league’s existing disability plan, he pledged that the 88 Plan would be handled differently.

“There will not be any red tape,” Upshaw said. “There will not be any hurdles to overcome.” No Memories at All Meeting up with old teammates is supposed to ease the pain among hurting N.F.L. veterans, but that was not the case with Mr. Mackey and Mr. Wenzel. They played together on the 1972 Chargers, even blocking on the same offensive line, but neither has any memory of it. Neither remembers playing for the Chargers at all. Even after spending two hours together, and being reintroduced several times, neither man knew the other’s name. “Do you remember playing with Ralph at all, John?” Mr. Mackey was asked. “Who’s Ralph?” Mr. Mackey replied. “The guy sitting to your left.” “You’re Ralph?” he asked Mr. Wenzel. “Yes.” “I’m John Mackey,” he declared, staring blankly ahead. Sylvia Mackey and Eleanor Perfetto looked on, hoping to see some glint of recognition in their husbands’ eyes. But the only sign of recognition in the room was between the two women when they turned to look at each other and smiled sadly, their connection only growing as their husbands’ disappeared.

Silence on Concussions Raises Risks of Injury

Kelby Jasmon, left, like many high school teammates, said he would not tell his coach if he thought he had a concussion. (Todd Heisler/The New York Times)

By ALAN SCHWARZ September 15, 2007

To Kelby Jasmon, there was only one answer. The question: If he received yet another concussion this football season, while playing offensive and defensive line for his high school in Springfield, Ill., would he tell a coach or trainer? Jasmon, with his battering-ram, freshly buzz-cut head and eyes that danced with impending glory, immediately answered: “No chance. It’s not dangerous to play with a concussion. You’ve got to sacrifice for the sake of the team. The only way I come out is on a stretcher.” Jasmon, a senior with three concussions on his résumé, looked at two teammates for support and unity. They said the same thing with the same certainty: They did not quite know what a concussion was, and would never tell their coaches if they believed they had sustained one.

Matt Selvaggio, who plays with Jasmon on both lines, said: “Our coaches would take us out in a second. So why would we tell them?” Many of the 1.2 million teenagers who play high school football are chanting similar war whoops as they strap on their helmets. They either do not know what a concussion is or they simply do not care. Their code of silence, bred by football’s gladiator culture, allows them to play on and sometimes be hurt much worse — sometimes fatally. The National Football League has recently faced questions about its handling of concussions after four former players were found to have significant brain damage as early as their mid-30s. But teenagers are more susceptible to immediate harm from such injuries because, studies show, their brain tissue is less developed than adults’ and more easily damaged. High school players also typically receive less capable medical care, or none at all. At least 50 high school or younger football players in more than 20 states since 1997 have been killed or have sustained serious head injuries on the field, according to research by The New York Times. Experts say many of these accidents could have been prevented by simple awareness of and respect for their gravity. Poor management of high school players’ concussions “isn’t just a football issue,” said Robert Sallis, president of the American College of Sports Medicine. “It’s a matter of public health.” Interviews with players indicate that even those aware of the dangers of concussions ignore them. Coaches, trainers and parents can detect a gimpy knee or a separated shoulder, and act. But a concussion is often the player’s secret. It is the one injury no one sees — until a case like Will Benson’s, which no one forgets. Benson carried himself with a verticality that captivated teachers, classmates and coaches. A handsome, straight-A student headed for the Ivy League, he was the star quarterback for St. Stephen’s Episcopal School in Austin, Tex. “He loved the idea of playing for his teammates and his brothers on that battlefield of the gridiron,” recalled his good friend and classmate Kashif Sweet, now a senior at Columbia. “He was a naturally tough kid with a high threshold for pain. He liked to endure things, to conquer things, and have people follow him.”

On a play during St. Stephen’s first game of 2002, as a pile of bodies grew too dense to see through, a crack was heard throughout the stadium: the sound of helmet meeting helmet, two shells of polycarbonate alloy crashing together. Watching from the stands, Judy Ryser, Benson’s mother, heard the sound — everyone did — and turned to a friend next to her. “Oh, my goodness,” she said. “I hope that wasn’t Will.” • In the stifling heat of July in Alabama, hundreds of high school players from across the United States gathered at Hoover High School outside Birmingham, preparing to compete in a preseason tournament. They ambled about the field in baggy polyester shorts, helmets dangling from their fingers. Give them each five years and 50 pounds, and it could be an N.F.L. rookie camp. Some sat on the grandstand’s metal benches, waiting for their games to begin. They were asked about concussions. Garrick Jones, a senior quarterback at Whitehaven High School in Memphis, said he sustained one last year: He was briefly knocked unconscious when a linebacker picked him up and threw him to the ground on his head. No flag was thrown. He said he wobbled to the huddle, took the next snap and dropped back to pass before his vision blurred completely. “I couldn’t come out — my team needed me,” Jones said. “You have to keep playing — until you can’t.” Some players airily guessed at describing a concussion: “You feel dizzy and stuff”; “when you’re cross-eyed”; “when you feel real sleepy”; “it’s like when you turn into someone else.” Only a few of more than 50 players interviewed at the tournament came close to defining the injury: a blow to the head that causes the brain to crash into the skull. Concussion — the word derives from the Latin concutere, meaning shake violently — is typically followed by dizziness, headache, nausea, lethargy, impaired vision or other disruptions in brain function. Studies show that concussions are drastically underreported in high school football in part because many youngsters — even adults — still mistakenly think the injury requires the player to have been knocked unconscious. Athletic trainers report about 5

percent of high school players as having had a concussion each season, studies show, but formal widespread surveys of players strongly suggest the number is much higher. Anonymous questionnaires that ask specifically about concussions have reported rates among high school football players at about 15 percent each season; when the word concussion is omitted and a description of symptoms is provided instead, close to 50 percent of players say they had one, with 35 percent reporting two or more. Although concussions remain one of the more imprecise diagnoses in sports medicine — magnetic resonance imaging exams and CAT scans cannot detect them — the players’ testimony has been taken by experts to indicate that a vast majority of concussions are not treated. Asked to define a concussion, Josh Bailey, a senior safety at Patterson High in Louisiana, could not. After being told, he said he definitely had one last year, when his head slammed against another player’s knee. He said no one noticed, and he never considered leaving the game. “Football, it’s all about contact — you kind of have to suck it up,” Bailey said. “Because you’re going to feel pain. That’s what the game is about. If you don’t put yourself through that, you don’t really love the game.” • The crack on the St. Stephen’s field five years ago was indeed the sound of Will Benson’s helmet slamming into another. He played the rest of the game, which his team lost. Admitting to headaches several days later, Benson sat out the next game — and St. Stephen’s lost again. “He felt a lot of responsibility,” recalled Jay Lamy, a volunteer coach that season. “He didn’t want to let his teammates down. He knew the impact that he had.” That influence was felt the next Friday night. Filling his No. 7 uniform as only a star quarterback can, Benson ran for a touchdown in the first quarter. But later in the half, with seemingly no provocation, he took off his helmet and walked off the field. Benson told his coach he felt weird and had “big blobs” in his vision. He sat on the bench and put a towel over his head. Then a golf cart took him to the trainer’s room. A few minutes later, Benson was screaming in a way that no one present will ever forget. “Mom!” he shrieked before he lost consciousness. “Mom!”

“Mom!” • Doctors call it second-impact syndrome. Almost solely among teenagers, sustaining another blow to the head — even a seemingly benign one — before a first has healed can set off a devastating chain of metabolic events: Cerebral blood flow increases, arteries swell past capacity, and pressure builds inside the brain, often leading to coma and death. Helmets can do only so much to keep youngsters’ brains from sloshing inside their skulls, like the yolk inside an egg. A recent study in The American Journal of Sports Medicine led by Barry P. Boden of the Orthopaedic Center in Rockville, Md., found that catastrophic football head injuries were three times as prevalent among high school players as college players — and that “an unacceptably high percentage of high school players were playing with residual symptoms from a prior head injury.” For many victims, staying alive is only the first challenge. Kort Breckenridge of Tetonia, Idaho, has trouble holding down a job because of short-term memory problems stemming from a football brain injury two years ago. Brady Beran of Lincoln, Neb., emerged from a coma reading at a kindergarten level; he remains in physical therapy with hopes of running again. Second-impact syndrome is relatively rare, however. Experts said that for every such case there can be hundreds of victims of postconcussion syndrome, leaving youngsters depressed, irritable and unable to concentrate, and they sometimes miss school for weeks or perform poorly on tests. Ben Mangan of Lewisburg, Ohio, still has mood swings and cognitive problems deriving from at least one major concussion in 2002. “It definitely has held me back in progressing through school,” said Mangan, now 20 and attending a small Ohio college. “I was a B student in math before, but now I sit there and I’m like, Why can’t I get this? I’ll do the same problem five times and keep getting different answers. It’s really frustrating.” With no limp or wince to advertise most concussions, coaches and sideline medical staff must be keenly aware of their signs; waiting for gross disorientation or nausea invites disaster. Diagnostic methods vary in science and scope, but most involve asking questions to gauge a player’s awareness, testing short-term memory by repeating strings of words and numbers backward and forward, and administering short pencil-and-paper tests. Players

are encouraged to be re-examined after physical exertion to see if headache or cognitive problems return. Many school districts require an ambulance and paramedics to be on-site in case of emergencies, but a sideline physician is often a luxury. Only 42 percent of high schools in the United States have access to a certified athletic trainer, according to the National Athletic Trainers’ Association. “Budgets are tight,” said Bob Colgate, the assistant director of the National Federation of State High School Associations. “You hate to say that, but it’s a reality.” Howells High School is among the 77 percent of Nebraska schools without an athletic trainer. The football coach, Mike Spiers, said that he cannot monitor the health of every player, many of whom he speaks with only a few times a game. “I have a tremendous fear of all injuries that could permanently damage a kid,” Spiers said. “It’s something that may convince me not to do this anymore.” At midweek practices, which often feature even more banging and tackling than games, volunteer coaches with little training typically evaluate injuries while the head coach calls plays. Sallis, of the American College of Sports Medicine, joined many experts in saying he was not trying to discourage the playing of football, only the widespread acceptance of playing it unsafely. “It’s crazy,” he said. “High schools hire a zillion coaches before they wonder about hiring a trainer. If you hire a head football coach, that next hire should be an athletic trainer.” • As Will Benson wailed, vomited, had a seizure and lost consciousness, the ambulance dispatched for him could not find the entrance to the St. Stephen’s campus. According to records released by the local emergency medical services unit, it spent 13 minutes trying to find the trainer’s room. A helicopter whisked Benson to a hospital as the game continued. Coaches were confused: He had not been involved in any notable hits or tackles in the game. Bleeding in his brain, Benson slipped into a coma that night and never regained consciousness. A neurosurgeon operated to relieve pressure inside the skull but could not

revive him. Five days later, Benson was declared brain dead. He was kept alive overnight so his organs could be harvested for donation. There is no shortage of unenlightened coaches. Scott Robertson, a volunteer team physician for Nipomo High in Southern California, said he had seen coaches at other schools “berate and ostracize” players who complained of concussion symptoms. Jerry Bornstein, another team physician for several Los Angeles-area schools, said a coach once yelled at him for refusing to let a concussed player return to a game. His response: “I’ll be happy to, Coach, as long as you accept the responsibility for this kid waking up dead tomorrow morning.” Ellen Marmer, the team physician for Rockville High School in Vernon, Conn., said that after she determined an offensive player from the opposing team was unfit to play after a concussion, his coach had him switch uniforms to try to play defense. Parents lose perspective as well. Garrick Jones, a quarterback from Memphis, said that the week after his concussion, his father pleaded with the coach to let him play. (The coach won.) Vito Perriello, the team doctor for St. Anne’s-Belfield School in Charlottesville, Va., said, “I have had parents tear up the form that I’ve filled out strongly recommending their child not play, and shop a doc to get their kid O.K.’d.” Yet many experts say that as poorly as adults can behave, it is the football bravado they instill in children, the thirst for competition and the blind eye to pain, that keeps players in the game. More than a dozen high school players at the Alabama tournament said they had hidden concussions from their coaches and medical personnel to stay on the field. “If the coach knew about it, he’d take us out,” said Matt Arent, a quarterback in Nashville. “They treat us like we’re their own kids. It comes down to the player not telling the coach that something’s wrong.” Players will hide from trainers and try to sneak back into huddles. They will rehearse answers to impress the trainer, so they won’t forget to use magic phrases like “I don’t have any headache at all” when asked. One maneuver involves the preseason memory and cognitive tests many schools administer as a baseline for comparison should a player sustain a concussion. Several doctors and trainers said they have heard players boast of purposely doing poorly on the preseason tests so they will be more readily found fit to play.

A paradox has developed in high school football: The more strict the rules, the more likely they are to be evaded by the players they aim to protect. Many doctors support a rule whereby any player sustaining a concussion cannot return to play that day. But Sallis supported a more realistic approach, in which a player may return to the game if doctors are convinced the symptoms have cleared. If not, Sallis said: “Players are all going to stop telling the team physician that they have any symptoms — they’re going to hide them. Which we know they already do, but I think it’s going to get even worse. It’s putting them at more risk.” • Dick Benson spent five years trying to wring something positive out of his son Will’s death. In June, Will’s Bill, legislation he crusaded for, was signed into law. It requires every Texas high school coach and official involved in every sport to be trained in basic safety and emergency procedures. Beyond neck injuries and heart attacks, special attention will be afforded to the symptoms of concussion and roots of secondimpact syndrome. Benson said: “We’re not teaching people the principles of neurology. This is fundamental, basic stuff.” The law does not apply to Will’s old high school, however. It originally covered parochial and private schools, but the primary sponsor of the bill, State Senator Leticia Van de Putte, said it became entangled in “a raging school-voucher argument.” The legislation had to be scaled back “over politics,” she said. Benson said that he hoped that the steps taken in his son’s name would reach other states, but added that the process would be slow at best. “It usually takes something like Will to get people to take this kind of thing seriously,” he said. “People like learning things the hard way.” Particularly adolescents. Playing linebacker two years ago, Riley Haynes of Ponte Vedra Beach, Fla., tackled a running back with such force that he found himself on the ground, all but unconscious, not remembering his name. His head throbbed, and he had no idea where he was. A teammate reminded him. He jumped on top of Haynes and screamed through his face mask: “That’s football, baby! That’s football, baby!” Haynes gathered himself, stumbled back to his position and took his stance for the next snap.

Concussion Studies Show Girls Are More Vulnerable By ALAN SCHWARZ October 2, 2007

Hannah Stohler sat beside the piano she could no longer play, in the living room that spun like a carousel, in the chair in which she tried to read but could not remember a word. Ten months after her third concussion while playing high school soccer knocked her into a winter-long haze of headaches and dizziness and depression that few around her could comprehend, Stohler recalled how she once viewed concussions. “I thought they were a football injury — a boy thing,” said Stohler, a junior at Conard High School in West Hartford, Conn. “Those guys are taught to hit hard and knock people to the ground. But anyone can get a concussion, and I don’t think a lot of girls recognize that. They have no idea how awful the effects can be — it changes your life.” Stohler, 16, has more company than most people know. While football does have the most concussions (and controversy over their treatment) in high school athletics, girls competing in sports like soccer and basketball are more susceptible to concussions than boys are in the same sports, studies show. According to a study to be published in the Journal of Athletic Training, in high school soccer, girls sustained concussions 68 percent more often than boys did. Female concussion rates in high school basketball were almost three times higher than among boys. Girls also consistently took longer for their symptoms to resolve and to return to play. The study, conducted by researchers at Ohio State University and Nationwide Children’s Hospital, examined data submitted by 425 certified athletic trainers across the United States during the 2005-6 academic year. According to the National Federation of High School Sports Associations, a million youngsters play high school basketball and 700,000 play high school soccer each year; male participation is only slightly higher than among girls. Fatal brain injuries in high school sports outside football are exceedingly rare, but post-concussion syndrome — in which dizziness, lethargy and the inability to concentrate

can cost teenagers weeks or months of school — is a growing concern, doctors said. They added that it was just as common among girls as boys and even more misunderstood. “Generally speaking, the medical profession does not do a very good job in recognizing that female athletes sustain concussions at an equal or even higher rate as males,” said Dr. Robert Cantu of Brigham and Women’s Hospital in Boston, one of the nation’s leading experts in concussion management. “It’s flying under the radar. And as a result, looking for concussions in women is not pursued with the same diligence, and it’s setting girls up for a worse result.” Hannah Stohler twice slammed her head against the turf while playing soccer last fall, both times experiencing the disorientation, blurred vision and nausea that are telltale signs of concussion. She said her neurologist at the time told her that when her headaches subsided, she could play again. “I really didn’t think it was a big deal,” she recalled, adding that she returned a few weeks later before her other symptoms had cleared. “Soccer is everything to me. I identify myself as an athlete.” In November, Stohler collided with another player, could not get up for 10 minutes, and left the field with her vision totally black. Her eyesight returned, but she experienced headaches and disorientation for three months, could barely read and was forbidden to exercise for fear of causing further damage. “I was the freak at school who could only do half days and had to go home all the time,” said Stohler, whose reading comprehension and memory remain slightly impaired. “I didn’t feel like myself — ever. I was miserable. It takes the life out of you.” Another young female victim of post-concussion syndrome lives just 20 miles up the road from Stohler. Kate Pellin, a standout basketball player in Suffield, Conn., has sustained at least four concussions, three times being knocked unconscious while diving for balls or being slammed to the hardwood by other players. “I get offended when people say girls don’t play sports as hard as boys,” she said. Pellin’s last concussion, in April, caused such lingering headaches, sensitivity to light and noise and constant dizziness that she ultimately missed the rest of her junior school year. “My teachers couldn’t understand why I couldn’t do my homework,” Pellin said. “I didn’t have crutches, where everyone can see you’re hurt. It’s a hidden injury. Boys

would tell me, ‘You should wear a head brace!’ like ha-ha, and I was like, ‘Maybe that’s what I should do for you to take me seriously.’” According to the study to be published in the Journal of Athletic Training, football has the highest rate of concussions in high school sports, with 47 such injuries per 100,000 player games or practices. Girls soccer was second highest with 36 per 100,000, followed by boys soccer (22) and girls basketball (21). Most soccer concussions are caused by hard falls to the ground or collisions with other players. Heading the ball is not a primary cause, studies have determined, because the impact is not of sufficient force to send the brain crashing into the skull. Attempts at heading do engender many concussions, however, as players’ heads collide in battles for the ball. This has led to the increased use of padded headbands designed to lessen the forces of many blows, but their effectiveness remains the subject of debate. One study published this summer said that such headgear appeared to reduce concussions among soccer players, but some coaches and doctors fear that their use could foster more aggressive play. Hannah Stohler said she wore one only temporarily. “It was really distracting,” she said, “and I didn’t feel it was going to make much difference.” Doctors are also uncertain as to why documented rates of concussion among high school girls are consistently higher than among boys in the same sports. The primary theory is that girls might be more honest in reporting injuries — though experts are confident that many girls, just like boys, hide injuries either because they are not aware of the risks or because they simply do not want to miss playing time. Other rationales include the fact that girls’ neck muscles are less developed than boys’, providing less shock absorption during impact. After sustaining her second concussion playing high school basketball in Ohio, Sarah Ingles kept playing the rest of the game because, she said, “I didn’t really realize it had happened.” On the bus ride home she began asking friends, “Where are we? What’s going on?” She did not know she had played basketball two hours before, let alone been knocked hard to the floor on a layup. Ingles missed six weeks of school. Now at Ohio Wesleyan University, she found her dizziness and nausea return two weeks ago by merely bumping her head on a bed frame. She is sitting out her freshman field hockey and basketball seasons on the advice of a neurologist.

“Girls are just as competitive as boys, and they’ll push through concussions just like boys would,” Ingles said. “For every one of me, who ends up getting treated, there are maybe four or five who keep playing because they don’t want to admit they’re hurt. It’s easier not to do anything. It’s really going to mess them up further.” The decision over whether to stop playing competitive sports can be agonizing for high school girls and their families. Kate Pellin planned to serve as basketball captain this winter, in part because several colleges her parents could not otherwise afford — Colgate, Iona, Lehigh — were considering her for a full basketball scholarship. But her headaches have persisted for five months. She still has trouble reading and transposes numbers in math, signs that her brain has not yet recovered and remains susceptible to greater injury. Pellin decided only recently not to risk playing basketball anymore, in large part because of news media coverage of concussions’ role in long-term brain damage among professional football players. She sat on her living room couch, a seemingly healthy teenager, and broke into tears. “I don’t want to have Alzheimer’s when I’m 40,” Pellin said. “I want to know who my husband is. Who my children are. I never knew this was such a concern. In the long run, I’ll be glad I stopped now.” The decision was less clear-cut with the Stohlers. Sherry Stohler said that she and her husband spent many hours talking with Hannah about whether her soccer career should end. Half-seriously, she said, “It’s like she can have depression when she’s older because of the concussions, or be in therapy now because she hates her parents.” Sitting beside Hannah, she said: “It’s a nerve-racking decision when your child’s identity is so wrapped up in something she’s played since she was 5 or 6. To snatch that dream of playing high school sports away is a pretty large burden to carry. It’s very hard to take away something they treasure.” Hannah looked at her mother and said defiantly: “There was no way I wouldn’t play. I know I’m not going to be a professional soccer player, but I’m good at it, and the team atmosphere is something I love. It’s not something I’m willing to give up easily.” She did not. The next evening, having convinced her neurologist and her parents that her remaining symptoms were minimal, Hannah Stohler wore No. 22 and played defensive midfield as Conard High played rival Windsor High.

As Sherry Stohler watched from the stands, leaning forward slightly every time No. 22 hit the turf during a slide tackle or rough play, old images of her daughter lying motionless were superimposed over the new. “As long as she gets up and keeps playing,” the mother said with a sigh, “it’s a good night.”

Dementia Risk Seen in Players in N.F.L. Study By ALAN SCHWARZ September 30, 2009

A study commissioned by the National Football League reports that Alzheimer’s disease or similar memory- related diseases appear to have been diagnosed in the league’s former players vastly more often than in the national population — including a rate of 19 times the normal rate for men ages 30 through 49. The N.F.L. has long denied the existence of reliable data about cognitive decline among its players. These numbers would become the league’s first public affirmation of any connection, though the league pointed to limitations of this study. The findings could ring loud at the youth and college levels, which often take cues from the N.F.L. on safety policies and whose players emulate the pros. Hundreds of onfield concussions are sustained at every level each week, with many going undiagnosed and untreated. A detailed summary of the N.F.L. study, which was conducted by the University of Michigan’s Institute for Social Research, was distributed to league officials this month. The study has not been peer-reviewed, but the findings fall into step with several recent independent studies regarding N.F.L. players and the effects of their occupational head injuries. “This is a game-changer — the whole debate, the ball’s now in the N.F.L.’s court,” said Dr. Julian Bailes, the chairman of the department of neurosurgery at the West Virginia University School of Medicine, and a former team physician for the Pittsburgh Steelers whose research found similar links four years ago. “They always say, ‘We’re going to do our own studies.’ And now they have.” Sean Morey, an Arizona Cardinals player who has been vocal in supporting research in this area, said: “This is about more than us — it’s about the high school kid in 2011 who might not die on the field because he ignored the risks of concussions.” An N.F.L. spokesman, Greg Aiello, said in an e-mail message that the study did not formally diagnose dementia, that it was subject to shortcomings of telephone surveys and

that “there are thousands of retired players who do not have memory problems.” “Memory disorders affect many people who never played football or other sports,” Mr. Aiello said. “We are trying to understand it as it relates to our retired players.” As scrutiny of brain injuries in football players has escalated the past three years, with prominent professionals reporting cognitive problems and academic studies supporting a link more generally, the N.F.L. and its medical committee on concussions have steadfastly denied the existence of reliable data on the issue. The league pledged to pursue its own studies, including the one at the University of Michigan. Dr. Ira Casson, a co-chairman of the concussions committee who has been the league’s primary voice denying any evidence connecting N.F.L. football and dementia, said: “What I take from this report is there’s a need for further studies to see whether or not this finding is going to pan out, if it’s really there or not. I can see that the respondents believe they have been diagnosed. But the next step is to determine whether that is so.” The N.F.L. is conducting its own rigorous study of 120 retired players, with results expected within a few years. All neurological examinations are being conducted by Dr. Casson. According to a 37-page synopsis of the study furnished to the league, the Michigan researchers conducted a phone survey in late 2008 in which 1,063 retired players — those who participated from an original random list of 1,625 — were asked questions on a variety of health topics. Players had to have played at least three or four seasons to qualify. Questions were derived from the standard National Health Interview Survey so rates could be compared with those previously collected from the general population, the report said. Some health issues were reported by N.F.L. retirees at normal rates (kidney and prostate problems), while others were higher (sleep apnea and elevated cholesterol) and others lower (heart attacks and ulcers), the summary said. The researchers also asked players — or a caregiver for those who could not answer — if they had ever been diagnosed with “dementia, Alzheimer’s disease, or other memory-related disease.” The Michigan researchers found that 6.1 percent of players age 50 and above reported that they had received a dementia-related diagnosis, five times higher than the

cited national average, 1.2 percent. Players ages 30 through 49 showed a rate of 1.9 percent, or 19 times that of the national average, 0.1 percent. The paper itself questioned the reliability of using phone surveys to assess prevalence rates of diagnosed dementia, as did several experts in telephone interviews. For example, some of those affected may not be reachable; then again, N.F.L. players may have greater access to doctors to make the diagnosis. The lead researcher, David R. Weir, said in an interview that proxies might have been handled differently in past studies. “This suggests something suspicious,” said Dr. Amy Borenstein, professor of epidemiology at the University of South Florida. “But it’s something that must be looked at with a more rigorous study.” Dr. Daniel P. Perl, the director of neuropathology at the Mount Sinai School of Medicine in New York, agreed with Dr. Borenstein but described the Michigan work as significant. “I think this complements what others have found — there appears to be a problem with cognition in a group of N.F.L. football players at a relatively young age,” he said. All rates appear small. But if they are accurate, they would have arresting real-life effects when applied across a population as large as living N.F.L. retirees. A normal rate of cognitive disease among N.F.L. retirees age 50 and above (of whom there are about 4,000) would result in 48 of them having the condition; the rate in the Michigan study would lead to 244. Among retirees ages 30 through 49 (of whom there are about 3,000), the normal rate cited by the Michigan researchers would yield about 3 men experiencing problems; the rate reported among N.F.L. retirees leads to an estimate of 57. So the Michigan findings suggest that although 50 N.F.L. retirees would be expected to have dementia or memory-related disease, the actual number could be more like 300. This would not prove causation in any individual case, but it would support a connection between pro football careers and heightened prevalence of later-life cognitive decline that the league has long disputed. After the University of North Carolina’s Center for the Study of Retired Athletes published survey-based papers in 2005 through 2007 that found a correlation between N.F.L. football and depression, dementia and other cognitive impairment, a member of the N.F.L. concussion committee called the findings “virtually worthless.”

After initiating a fund in 2007 that provides financial assistance to retirees receiving care for dementia, the league insisted that it was doing so only because the disease “affects many elderly people” well beyond N.F.L. players. And a pamphlet that the league gives every player about concussion risks states, “Research is currently under way to determine if there are any long-term effects of concussion in N.F.L. athletes.” “It’s time to edit that brochure,” said Kevin Mawae of the Tennessee Titans, the president of the N.F.L. Players Association. “Now it’s in their words and not just other people’s.”

Ex-N.F.L. Executive Sounds Alarm on Head Injury By ALAN SCHWARZ October 28, 2009

TAMPA, Fla. — As the president of the Tampa Bay Buccaneers and the daughter of their owner, Gay Culverhouse was the woman in the men’s locker room. Twenty years later, she is trying to keep her former players out of the emergency room. Sitting at a restaurant here Friday, she reconnected with a few Buccaneers retirees. There was Richard Wood, the fearsome linebacker known as Batman whose searing migraines and tendency to get lost while driving near his home leave him scared for his future. Across the table was Scot Brantley, an even harder hitter through the 1980s whose short-term memory is gone. Then there was Brandi Winans, former wife of Buccaneers lineman Jeff Winans, who slipped into such inexplicable depression, fogginess and fury several years ago that their marriage splintered. Culverhouse looked at disability forms, listened to stories, offered counsel and expressed regret. She has done the same via telephone for another half-dozen former Buccaneers in their 40s or 50s who have increasing cognitive problems. Having followed story after story detailing how National Football League retirees are experiencing various forms of dementia at several times the national rate, and listening to the league and its doctors cast doubt that football played any role in their problems, she has emerged after 15 years to reconnect with players and sound an alarm. She will testify before the House Judiciary Committee at its hearing on football brain injuries on Wednesday to, as she put it, “tell the truth about what’s going on while I still have the chance.” Culverhouse has blood cancer and renal failure and has been told she has six months to live. “I’ve got to see that someone stops this debacle before it gets any worse,” said Culverhouse, 62, the daughter of the former owner Hugh Culverhouse who held various executive positions from 1985 to 1994. “I watched our team do anything it could to get players back on the field. We have to make that right.”

The N.F.L. and the players union have added programs to aid former players since their pension and disability plans came under public fire two years ago. One helps with joint-replacement surgeries, another with cardiovascular health screenings. The most prominent is the 88 Plan, which helps pay expenses for players with dementia. But for the hundreds of those whose cognitive decline falls short of dementia, the industry’s disability plan has little to offer. A recent New York Times analysis of the plan’s 73 current members suggested that N.F.L. retirees ages 60 to 89 are experiencing moderate to severe dementia at several times the national rate. A recent telephone survey sponsored by the N.F.L. had similar results, corroborating findings from several independent studies, but the league and its doctors continue to discredit all evidence of such a link. “Telling the players that football has nothing to do with it is literally adding insult to injury,” Culverhouse said. “It’s a joke. It’s unconscionable.” Culverhouse read about the controversy, heard about how her former lineman Tom McHale had died at 45 with brain damage associated with boxers, and began calling her former players. She had always been an N.F.L. misfit. An alumna of Columbia University with a master’s degree in mental retardation and a doctorate in special education, she later became the Buccaneers’ vice president for community relations and eventually president in 1991, always amid whispers that she was just the owner’s daughter. But she relished a good fight; she caused a local uproar by threatening to sue the Palma Ceia Golf and Country Club because as a woman she was barred from using the team’s corporate membership. Every former player Culverhouse called had debilitating physical problems, she said. A stunning portion had cognitive ones, even in their mid-40s, and most of them lacked the short-term memory or concentration required to seek medical assistance or slog through the disability paperwork. One player told her, “I’m headed for the 88 Plan.” “The thing that I always admired about Gay is that she’s a rebel with a cause,” said Brantley, 51. “Football was a man’s world. Still is. I’ve always said, if you want something done and done right, get a woman involved. No one else has shown any interest in us for a second. We might as well have the plague.” At a Lee Roy Selmon’s restaurant in Tampa — Selmon is a former Buccaneers defensive lineman — Culverhouse spoke with her former players about others who might

need her help, including a former Buccaneers fullback. “I’ve got to get to” him, Culverhouse said. “He’s not good, no,” replied Wood, 56. “It’s tough to understand him because his speech is so slurred.” “I’ll fly to Little Rock and fill out the paperwork for him and drive him to the doctors,” Culverhouse said. “You get so far gone that you can’t deal. It’s easier to go home, pop a few pills for the pain and forget about it.” “Tell me about it,” Brandi Winans said. After learning how cumulative brain trauma can contribute to serious emotional and substance-abuse problems 20 years after retirement, she said while breaking down, “I felt that I had deserted him.” Brandi and Jeff Winans now reconnect on the phone twice a week. He lives in Northern California, and has said he is pursuing medical assistance for his cognitive issues. All four at the table — the executive, the players and the spouse — insisted that they loved football and hoped it would continue. But they said that discussing the consequences of professional football in the 1970s and 1980s, when players routinely played through concussions with no idea of the risks, was important to comfort the retirees and, more important, to emphasize the seriousness of brain injuries to today’s amateur athletes. Dr. William Carson, the Buccaneers’ team orthopedist from 1987 to 1997, said in a telephone interview that during his time and certainly before it, most players with “dings” — now understood as mild concussions — would be returned to games. And the players who never came out also played through those dings, and worse, risking cumulative damage only now understood. Just the other day, Culverhouse called another one of her former players, Randy Grimes, who told her about his addiction to painkillers and his dwindling short-term memory. She helped explain his disability-plan options, how he was not alone. She did not tell him that she was dying, and that she would soon be in Washington sharing her experience with Congress. Before they hung up, Culverhouse said that Grimes remarked: “I think I’m fighting this real good, Gay. Your father would be proud of me.” Culverhouse replied: “That’s just amazing to me. Because what you did for Dad, playing so hard for us and not knowing the risks, that’s what got you into this mess.”

New N.F.L. Culture May Filter Down Slowly By ALAN SCHWARZ December 4, 2009

TUSTIN, Calif. — For years, as the National Football League steadfastly defended its policy of letting some players return to the field after concussions, independent medical experts warned that the league’s policy influenced the college and youth levels, which often take their cues from the professional ranks. So when the N.F.L. reversed course Wednesday and said that players who show anything more than the most fleeting and minor concussion symptoms must come off the field for the day, it seemed likely that high schools would take notice. Or not. If the attitudes of several Tustin High School players in Southern California are any indication, the culture the N.F.L. helped build will not be reformed overnight. Sitting outside their locker room Thursday, linebacker-fullback Wade Minshew and defensive end Kuresa Moaliitele both said they would not tell anyone if they sustained a concussion during Friday’s big state playoff game. They heard about the N.F.L.’s new rule. They have watched stars like Ben Roethlisberger, Kurt Warner and Brian Westbrook struggle with concussions in recent weeks, and have been taught by their athletic trainers that playing through a concussion, when you are a teenager, can be highly dangerous and even deadly. “It’s our mentality toward football — you put the team first,” Minshew said. Moaliitele added: “I’d keep playing. It’s the dedication I have to the team.” Just then their coach, Myron Miller, walked in. Informed of his players’ comments, he calmly explained that he would do the same if he was 16. “That doesn’t surprise me,” Miller said. “They shouldn’t do it, I’ve told them not to do it, but it takes a lot of maturity to put your health ahead of the team. If I was playing in the game tomorrow night and got a concussion, I don’t think I’d tell anyone either. I’m not a hypocrite.”

The Tustin players’ candor indicates that the N.F.L.’s new commitment to better concussion management will take some time to filter down to lower levels of the sport. Colleges and high schools cannot be directed to handle concussions the way the N.F.L. now does. High schools generally answer to their state legislatures and athletic associations, and the N.C.A.A. has said it leaves medical protocol up to individual colleges. A prominent college-level physician, Dr. Peter Indelicato of the University of Florida, heard about the N.F.L. rule in a telephone interview Thursday and said he would support making it applicable across the N.C.A.A. “It takes away the gray zone and removes me from inadvertently or unwittingly making a poor decision,” he said, “and it protects kids at other schools who might not have the best medical care.” Dr. Robert Cantu, director of the Neurological Sports Injury Center at Brigham and Women’s Hospital in Boston, predicted that colleges and high schools would eventually decide or be coerced to follow an N.F.L.-like rule. The N.F.L. still allows independent experts to return concussed players to a game or practice if his headache or dizziness was both mild and transitory. Cantu said that amateur levels will almost certainly adopt tighter recommendations made by a worldwide panel of experts in Zurich earlier this year, which said that concussed teenagers should never be returned the same day because their underdeveloped brains are in greater danger. “This should be the standard at all levels, and I think it will be in time,” Cantu said of the N.F.L.’s rule with the Zurich addition. “Schools will put themselves at risk if they don’t follow this policy. I think when the next kid gets concussed, the media and maybe even lawyers are going to be on the medical teams for allowing the kid to go back in. Everyone knows about this now.” Particularly the athletes themselves, according to Brian Murphy, a senior defensive end for the New Jersey powerhouse Don Bosco Prep. He praised the N.F.L.’s tightened rules and said it would affect young players. “It’s the N.F.L. — everyone looks up to them, and we follow,” he said. John Papas, football coach at Buckingham Browne & Nichols School in Cambridge, Mass., said that players cannot help but hear announcers and N.F.L. players talking about the foolishness of playing through concussions. High school players will keep hiding symptoms, Papas said, but it seems certain that those numbers will dwindle.

“High-school-age players look up to the N.F.L. players — they all want to be tough guys,” Papas said. “The message the N.F.L. is sending now is the right message: If you think you suffered a concussion, there’s no way you’re going to get better without resting.” Some lawmakers have attempted to improve conditions since football brain injuries became a hot-button topic several years ago. Legislatures in Washington, Oregon and Texas passed laws that require certain medical personnel on sidelines, mandatory concussion training for players and staff, and baseline neuropsychological testing for players. A bill sponsored by Representative Bill Pascrell, Democrat of New Jersey, aims to give the secretary of Health and Human Services the power to establish concussion management guidelines, “including standards for student-athletes to return to play after a concussion.” That bill awaits discussion in committee. Messages left at several high school athletic associations on Thursday did not receive responses. A request to the N.C.A.A. to interview its director of health and safety, Dr. David Klossner, about the possibility of N.C.A.A.-mandated reform was not answered. Nationwide, 58 percent of high schools do not have a certified athletic trainer available for players, according to the National Athletic Trainers’ Association. Many sideline physicians have little experience in the subtleties of concussion management. College programs also have wide variations in care. On Monday, La Salle University paid $7.5 million to settle a lawsuit involving a player who was seriously injured after improper management of his concussion. “I think most schools are already not returning players with concussions to games; I know that’s what we do,” said Paul Berkner, team physician for Colby College, which plays in Division III. “But it’s inconsistent across the country. For those who don’t, the N.F.L. rule will empower the rest of the Division III schools to do the same.” Starting next week, the N.F.L., following a strong recommendation by members of the House Judiciary Committee during an Oct. 28 hearing on football brain injuries, will broadcast a public-service announcement on the seriousness of concussion. The league is working with USA Football and the Centers for Disease Control and Prevention to improve concussion awareness nationwide.

Player education is vital, experts say, because athletes must be convinced that playing through concussions is too dangerous, even for fleeting glory. Otherwise a familiar paradox that has held back concussion reform will continue: that as strong as rules get, they are no match for the strength of players’ resolve to skirt them. “I just had a high school kid who told me he didn’t tell his coach when he couldn’t see for a few plays, and you hear those stories all the time,” said Gillian Hotz, the director of the concussion program at the University of Miami School of Medicine. “If there’s going to be a rule where they’re going to be pulled, they’re not going to say anything and then these kids will be at higher risk.” Indelicato admitted he has returned concussed players to games if their symptoms had subsided — a practice that an N.F.L.-like rule would not allow. He said he believed the practice was safe, but given recent reports of heightened rates of dementia and other cognitive decline in retired professional players, he also said he would give up some personal discretion for the possibility of greater safety. “We have cleared some because we think we know what we’re doing — I don’t mean to be glib, but that’s the truth,” Indelicato said. “If in fact, years from now, we learn that putting players back in that situation over time causes long-term damage that could have been avoided, then it’s worth it. There are too many smoke signals out there regarding repetitive brain trauma in sports.”

N.F.L. Acknowledges Long-Term Concussion Effects By ALAN SCHWARZ December 21, 2009

After weeks of transforming its approach to concussions and its research into their longterm effects among players, the N.F.L. not only announced Sunday that it would support research by its most vocal critics but also conceded publicly for the first time that concussions can have lasting consequences. “It’s quite obvious from the medical research that’s been done that concussions can lead to long-term problems,” the league spokesman Greg Aiello said in a telephone interview. He was discussing how the league could donate $1 million or more to the Center for the Study of Traumatic Encephalopathy at Boston University, whose discoveries of brain damage commonly associated with boxers in the brains of deceased football players were regularly discredited by the N.F.L. Told that his statement was the first time any league official had publicly acknowledged any long-term effects of concussions, and that it contradicted past statements made by the league, its doctors and literature currently given to players, Aiello said: “We all share the same interest. That’s as much as I’m going to say.” Since an Oct. 28 hearing before the House Judiciary Committee, when the league’s approach to science was compared to that of the tobacco industry, the N.F.L. has accepted the resignations of the co-chairmen of its concussion committee and overhauled its policies toward concussion management. Players now must be cleared by brain-injury experts unaffiliated with the team, and cannot return to a game or practice in which they have shown any significant sign of concussion. The second rule has since been recommended by an N.C.A.A. committee as standard policy for athletes in all sports, and will be considered by several state legislatures that have bills governing high school athletics before them. The recent changes by the N.F.L. had amounted to tacit acknowledgments that it was no longer able to defend a position that conflicted with nearly all scientific understanding of head trauma.

Until recently, the league and its committee on concussions had consistently minimized evidence testifying to the risks of repeated brain trauma in N.F.L. players — from researchers like those at Boston University, to phone surveys the league itself commissioned, to demographic analysis of players known to have early-onset dementia. While discrediting such evidence, a pamphlet on concussions currently given to players states, “Research is currently underway to determine if there are any long-term effects of concussion in N.F.L. athletes.” That research study, conducted by the N.F.L.’s committee on concussions, was recently suspended amid strong criticism of its design and execution by outside experts, players and members of Congress. “Mr. Aiello’s statement is long overdue — it’s a clear sign of how the culture of football has changed in recent months,” Dr. Robert Stern, a co-director of the Boston University center and its Alzheimer’s Disease Clinical and Research Program, said in a telephone interview. “There is no doubt that repetitive blows to the head result in long-term problems in the brain, including progressive dementia. With the N.F.L. taking these recent actions, we are finally at a point to move forward in our research and ultimately solve this important problem — for professional athletes and collegiate and youth players.” Aiello said that the amount of the league’s donation to the center had yet to be determined with Boston University officials. Dr. Robert Cantu, a co-director of the center with Stern, met with N.F.L. Commissioner Roger Goodell and the league lawyer Jeff Pash in October to discuss nonfinancial support for the center. “No money was ever requested when I met with them, and I went into considerable detail on why we couldn’t accept any money without consideration of conflicts of interest,” said Cantu, the director of the Neurological Sports Injury Center at Brigham and Women’s Hospital in Boston. “We can’t receive any money until you know what the strings are and the strings aren’t. I’m not saying it couldn’t happen, but it has not been broached.” The Boston University group’s work centers on receiving commitments from current and former athletes in various sports to donate their brains for examination after their deaths. (The disease primarily found in retired football players’ brain tissue, chronic traumatic encephalopathy, can be diagnosed only through special staining techniques.)

More than 110 athletes have registered to donate in little over a year — about 50 of them current and ex-N.F.L. players. Discussing his participation in the program last year, Ted Johnson, a former New England Patriots linebacker who sustained multiple concussions that have caused significant memory and emotional problems through his 30s, indicated his frustration at the league’s stance on the matter. “I shouldn’t have to prove to anybody that there’s something wrong with me,” he said. “I’m not being vindictive. I’m not trying to reach up from the grave and get the N.F.L. But any doctor who doesn’t connect concussions with long-term effects should be ashamed of themselves.” Aiello said that regardless of any financial support, the league would encourage current and former players to donate their brains to the Boston University research. He added that the roughly 85 retired players and families receiving aid from the 88 Plan — a fund jointly administered by the league and the union to help pay the costs of retirees with dementia — would be singled out to participate. The players union has said it supports the program as well. The work of the Boston University group has already provided some of the most compelling evidence of football’s long-term effects on the brain. All 11 retired players examined for chronic traumatic encephalopathy — an exceedingly rare disorder caused by concussive and subconcussive blows to the head — have been found to have the disease, which is associated with early-onset dementia, emotional disturbances and drug abuse. Studies at the University of North Carolina and the University of Michigan have found heightened rates of dementia and other cognitive decline, results corroborated by a New York Times demographic analysis of members of the league’s 88 Plan. After every finding, the league and its committee doctors have faulted the methods of the studies, and suggested that other causes were responsible and that the question remained open. When the league- sponsored Michigan study reported this September that retirees were reporting rates of Alzheimer’s and other memory-related diseases at five times or more the national rate, Aiello said, “There are thousands of retired players who do not have memory problems,” and, “Memory disorders affect many people who never played football or other sports.”

Asked about those remarks Sunday, Aiello said: “We didn’t say it doesn’t deserve further study and attention, which is what we’re trying to do. The only statement we’re making is that we’re doing this.” Stern said that the Boston University group had raised $450,000 in grant support, and that he was preparing a proposal to the National Institutes of Health. “This type of research is extremely expensive,” Stern said. “And time is very much of the essence.”

In N.F.L. Fight, Women Lead the Way By ALAN SCHWARZ April 10, 2010

Those who have followed the debate over the risks of sports concussions nodded knowingly Monday when its most significant legal action to date was brought by a woman. Eleanor Perfetto’s worker’s compensation claim on behalf of her husband, Ralph Wenzel, asserted that his early-onset dementia was an occupational hazard of his seven seasons as a lineman in the N.F.L. Having heard league officials say for years that high rates of dementia in former players either did not exist or could not be ascribed to football, Perfetto, who has a Ph.D. in public health, said she wanted to end all doubt in the courts. Perfetto, who declared herself “one very pushy broad” while testifying before the House Judiciary Committee last October, is one of six women from diverse backgrounds who have redirected the discussion of brain trauma. They range from players’ family members to a former team president, from a congresswoman to a leading neuropathologist. “There is a sense of: ‘What is she doing here? She doesn’t belong,’ “ said Representative Linda T. Sanchez, Democrat of California, whose blunt criticism of the N.F.L.’s concussion policies during last fall’s Congressional hearing led to changes in league protocol. “People underestimate you, and it makes you very powerful. “That’s something that’s afoot here with these women. The N.F.L. is so male and macho and testosterone-dominated, I don’t think they figured that women were going to be a force to be reckoned with in this thing, and they’re finding out the hard way.” Dr. Ann McKee, a leading neuropathologist at Boston University School of Medicine, has been the primary doctor to identify trauma-induced damage in the brains of former players, and to dispassionately connect that damage to football. Gay Culverhouse, the former president of the Tampa Bay Buccaneers, not only blistered the league’s playing down those findings before Congress, but also began a foundation to assist players in need.

The eloquent personal appeals of Sylvia Mackey, the wife of the former N.F.L. tight end John Mackey, who was almost bankrupted by his early-onset dementia, persuaded the league and the union to start an assistance plan for families like theirs. And much of the recent reform to concussion management — which extends to state legislatures covering high school sports — might never have been made without the efforts of Kwana Pittman, a niece of Andre Waters, the former N.F.L. safety who killed himself in 2006. Pittman persuaded reluctant relatives to allow an analysis of Waters’s brain tissue, and the finding of rampant damage made football’s concussion problem national news. In recent interviews about their roles in the evolving discussion of football brain trauma, none of the six women condemned the sport, and most called themselves fans — just with a dash of compassion and clarity. As Culverhouse put it: “Men look at the violence and they say, ‘Oh, yeah!’ When someone gets hurt, women say, ‘Oh, no!’ “ A Search for Responsibility Women have long shuddered at football’s inherent brutality. In November 1909, a New Jersey football game between Montclair Military Academy and Montclair High School was canceled just before kickoff. The New York Times later wrote, “The mother of nearly every one of the high school’s team had visited Principal H. W. Dutsch and informed him that if he permitted the game to be played and their sons were injured, they should hold him personally responsible.” Responsibility is what Pittman also sought after her uncle’s suicide. She had watched Waters, her mother’s brother, transform from upbeat and playful to profoundly depressed in only a few years before he shot himself in the head in November 2006. Grieving, she received a startling call a few weeks later from Chris Nowinski, a former Harvard football player and professional wrestler looking into the effects of concussions. Nowinski asked her if researchers could examine pieces of Waters’s brain. “I took some biology courses and I was interested in anatomy, so that helped, I think,” said Pittman, a middle school teacher in West Palm Beach, Fla. “My family and I, we couldn’t understand why Uncle Andre did this. We wanted some answers, and Chris promised that it would help people. I wanted to keep this from happening to other families.”

Nowinski said: “She could have hung up the phone. She could have not followed through by convincing her family to sign off on it. But Kwana really came through, and it changed everything.” Waters was the third former N.F.L. player to have his brain identified with chronic traumatic encephalopathy, a degenerative disease whose only known cause is repetitive trauma. But it was his death, and the subsequent finding of trauma, that produced headlines and catalyzed debate. McKee was not involved in the Waters case but was immediately drawn to the study of football brain trauma. She grew up a rabid Green Bay Packers fan in Appleton, Wis., idolizing the star safety Willie Wood, who now has dementia. With two older brothers who were star football players, she recalled: “I used to play football in the summers. I used to run the tires with the guys during practice. I remember being told I should have been a boy.” Now one of the nation’s leading neuropathologists, McKee was approached by Nowinski’s group to examine football players’ brains. One pleasure of the otherwise ghoulish process, she said, was speaking to the players’ widows and helping them understand better what had happened to their husbands. “The tissue teaches us,” McKee said. “The men are not alive, but there’s a sense of existence. I do feel like John McHale, John Grimsley, Wally Hilgenberg, these men are still speaking to us. I help them explain things to their wives.” Culverhouse is speaking to her father, in a way, by criticizing how the N.F.L. has handled the concussion debate. She described her father, Hugh, as the typical N.F.L. owner of his era — in football for glory and money and male fraternity, she said, “with no regard for the players’ health.” Culverhouse said she saw players shot with cortisone on the sideline and routinely sent back on the field after serious concussions. “I think my father made some very poor choices — I’m embarrassed for the choices he made,” Culverhouse said. Asked if she felt guilty, she said: “None of us knew what was going on, really. Now I’ll stand in front of a truck to make things right.” Her foundation, the Gay Culverhouse Players’ Outreach Program, has identified two dozen former players whom she is helping to fill out disability paperwork. One of those players, the former tight end Jimmie Giles, said with a laugh, “Her daddy would slap her.”

While Culverhouse and Perfetto have been vocal from the outside, Sylvia Mackey has taken a more conciliatory tone from inside the N.F.L.’s innermost circles. Partly because John Mackey was a union leader, she has always known management well; today she considers herself friends with Commissioner Roger Goodell and his wife, Jane. She sat with them and Gen. David H. Petraeus at the Super Bowl in 2009. The 88 Plan, the N.F.L.’s dementia assistance program begun in February 2007 and named after John Mackey’s uniform number, derived from Sylvia Mackey’s letter to the former commissioner Paul Tagliabue in which she pleaded for help with her husband’s “slow, deteriorating, ugly, caregiver-killing, degenerative, brain-destroying tragic horror.” In dozens of interviews, she has always expressed gratitude for the plan without criticizing the N.F.L., complementing Perfetto’s more pointed activism. “I love Eleanor — it fits her personality, not mine,” said Mackey, who considered filing a worker’s compensation claim for her husband a few years ago. She said the papers remained in a desk drawer, blank. “When you’re fighting a fight, or you’re trying to win fair benefits and recognition, you need different types of people on different roads going for the same thing,” Mackey said. “I feel I get more with sugar than with vinegar. But we need her personality on our side.” Perfetto’s personality is summed up in one statement: “I don’t care if the commissioner of the N.F.L. is mad at me.” She has watched men defer to the N.F.L.’s power structure from their own playing days and dreams. But the wives of players with dementia regard their relationship with football as personal. After husbands live the dreams, the wives live the nightmares. It’s Up to the Women But what if men were to find that a woman’s product — cosmetics, for example — were dangerous? Would the husbands fight for change as passionately? “I don’t think so,” said Perfetto, a senior policy director at Pfizer. “I think it’s the way women handle health issues. If it were all women who were sick, it would probably be a lot of women taking care of them. That’s kind of how health issues are handled in our society.” In a Congressional hearing regarding football head injuries last October, McKee, Culverhouse and Perfetto provided some of the most compelling testimony, and Sanchez

made many of the most damning remarks toward the N.F.L. Meanwhile, Representative Lamar S. Smith, Republican of Texas, played down the scientific findings that led to the hearing; Representative Ted Poe, another Texas Republican, rued “the end of football as we know it.” Sitting in her Congressional office months later, after the N.F.L. and many state legislatures had adopted rules to make football safer, Sanchez smiled. “In some instances, you have to be the outsider to be the person who advocates for change — the person who’s not part of the status quo,” Sanchez said. “That’s something the women in this share in common. We’re this outside element, and we’re tough. And we’re not going to be pushed around.”

As Injuries Rise, Scant Oversight of Helmet Safety

Used helmets worn by the vast majority of young players encountered stark lapses in the industry’s few safety procedures. (James Estrin/The New York Times)

By ALAN SCHWARZ October 20, 2010

NORMAN, Okla. — Moments after her son finished practicing with his fifth-grade tackle football team, Beth Sparks examined his scuffed and battered helmet for what she admitted was the first time. She looked at the polycarbonate shell and felt the foam inside before noticing a small emblem on the back that read, “MEETS NOCSAE STANDARD.” “I would think that means it meets the national guidelines — you know, for head injuries, concussions, that sort of thing,” she said. “That’s what it would mean to me.” That assumption, made by countless parents, coaches, administrators and even doctors involved with the 4.4 million children who play tackle football, is just one of many false beliefs in the largely unmonitored world of football helmets.

Helmets both new and used are not — and have never been — formally tested against the forces believed to cause concussions. The industry, which receives no governmental or other independent oversight, requires helmets for players of all ages to withstand only the extremely high-level force that would otherwise fracture skulls. The standard has not changed meaningfully since it was written in 1973, despite rising concussion rates in youth football and the growing awareness of how the injury can cause significant short- and long-term problems with memory, depression and other cognitive functions, especially in children. Moreover, used helmets worn by the vast majority of young players encountered stark lapses in the industry’s few safety procedures. Some of the businesses that recondition helmets ignored testing rules, performed the tests incorrectly or returned helmets that were still in poor condition. More than 100,000 children are wearing helmets too old to provide adequate protection — and perhaps half a million more are wearing potentially unsafe helmets that require critical examination, according to interviews with experts and industry data. Awareness of head injuries in football was heightened last weekend when helmetfirst collisions caused the paralysis of a Rutgers University player, a concussion to Philadelphia Eagles receiver DeSean Jackson and injuries to three other N.F.L. players. Although some injuries are unavoidable results of football physics, helmet standards have not kept up with modern football, industry insiders said. The one helmet standard was written by the National Operating Committee on Standards for Athletic Equipment, or Nocsae, a volunteer consortium that includes, and is largely financed by, the helmet makers themselves. Nocsae accepts no role in ensuring that helmets, either new or old, meet even its limited requirement. One frustrated vice president of Nocsae, Dr. Robert Cantu of the Boston University School of Medicine, said the organization has been “asleep at the switch” for five years. Cantu joined other prominent voices involved in youth sports concussions in calling for stronger standards. Recent engineering advances made by Riddell, Schutt, Adams and other manufacturers have undoubtedly improved the performance of the football helmet, which from its leather roots has always symbolized football’s duality of valor and violence. But helmets communicate a level of protection that they do not provide, experts said, in part because of lax industry standards and practices.

As she looked again at the helmet of her 11-year-old son, Hunt, Ms. Sparks said: “You just trust. You care so much about your kid, and then you just trust.” One Limited Standard After more than 100 high school and college football players in the 1960s were killed by skull fractures and acute brain bleeding, Nocsae was formed to protect players against the extreme forces that caused those injuries. The resulting standard, phased in by all levels of football through the 1970s, requires helmets to withstand a 60-inch free fall without allowing too much force to reach the skull. This standard has accomplished its intent: skull fractures in football have essentially disappeared, and the three or four football-related deaths each year among players under 18 are caused by hits following a concussion that has not healed (known as secondimpact syndrome) rather than by a single fatal blow. As the size and speed of players have increased since the full adoption of the Nocsae standard in 1980, concussion rates have as well. An estimated 100,000 concussions are reported each season among high school players alone, according to Nationwide Children’s Hospital in Columbus, Ohio, but many times that figure are believed to go unreported or unrecognized. Preventing concussions — which are typically marked by confusion, disorientation, nausea and other symptoms following a blow to the head — is trickier than preventing skull fractures. The brain can crash into the inside of the skull through a wide range of forces, some arriving straight to the head and others suddenly rotating it. Scientists have yet to isolate where thresholds are in different players at different positions and at different ages. While bicycle helmets are designed to withstand only one large impact before being replaced, football helmets can encounter potentially concussive forces hundreds of times a season. Helmets cannot get too large or heavy, so helmet designers say they face a trade-off: make helmets stiff enough to withstand high impacts and allow less violent forces to cause concussions, or more softly cushion against concussive-type forces while allowing large impacts to crack the skull. The helmet industry has essentially chosen the former. With some differences among brands, helmets are generally made of polycarbonate plastic shells cushioned inside with foams of various stiffnesses and some air-pocket cushioning. Headgear worn

by pee-wees to professionals differs primarily by size; Nocsae’s standard makes no distinctions for the wearer’s age. Because of the uncertainty of how concussions occur in football, experts said there was no way to cite real-life examples of players whose injuries might have been avoided by a stronger helmet testing standard. But requiring headgear to perform across a spectrum of impacts would undoubtedly decrease the total number of injuries, they said. Nocsae’s standard for lacrosse and hockey helmets includes tests for concussivetype forces. But because football helmets have already prevented deaths so effectively for decades, and because football’s faster and more violent environment leaves biomechanists unsure of how to prevent concussions in the sport, Nocsae has not asked helmets makers to even try. “When you have something that has worked well for a lot of years, you have to be pretty cautious,” said Mike Oliver, Nocsae’s executive director and general counsel since 1995. “If we save 15,000 concussions with a new standard but allow one skull fracture, if we save 5,000 concussions and allow one subdural hematoma, is it worth it? I can’t tell you that would be the trade-off, but you’ve got to basically be really sure that change wouldn’t adversely affect something else.” Some experts, both within and outside Nocsae, question why helmets still are not required to handle the less violent impacts believed — although not scientifically proven — to cause concussions. Blaine Hoshizaki, director of human kinetics at the Neurotrauma Impact Research Lab at the University of Ottawa, said he lobbied Nocsae to strengthen its standard five or six years ago but, “It was like punching a balloon; they, yeah, understand, and then do nothing.” “They say they don’t know what the thresholds are; O.K., but I can tell you that less angular acceleration is better than more,” said Mr. Hoshizaki, referring to the forces that cause the head to rotate suddenly. “To suggest we have no idea so we’ll do nothing is not an excuse to me. This has become a serious impediment to making a safer football environment.” Helmet companies say they are making inroads on their own, pursuing improvements that they say decrease the number of concussions that players receive. Riddell has gained the largest share of the overall helmet market in part because of the 2002 introduction of its Revolution model, which the company markets aggressively as having features, like thicker jaw padding, that reduce concussion risk by 31 percent

compared with previous helmets. Riddell’s president, Dan Arment, said: “We think we’ve taken great strides to improve the protective features of our helmets, and we’re not done. We see it as an open frontier.” Outside experts have criticized Riddell for overselling the protective properties of the Revolution and its successors. Dr. Cantu noted that the 31 percent figure — derived from a study conducted by researchers at the University of Pittsburgh Medical Center and a Riddell vice president — resulted from reports of concussions among high school players, which are notoriously inaccurate, and compared new Revolution helmets with old helmets of unknown age and condition. Dave Halstead, the technical director of Nocsae, said: “It’s a good helmet. But I don’t believe that 31 percent for a Yankee minute.” Schutt, which runs a close second to Riddell in market share, has unveiled helmets with plastic- based cushioning that its Web site says are “designed with the intent to reduce the risk of concussions” and feature “breakthrough technology providing maximum protection to athletes.” No scientific information is provided, although Schutt’s YouTube channel has a video demonstration in which a head-sized watermelon bearing the plastic does not break when struck by a 15-pound bowling ball. “That was meant to be a parody,” Robert Erb, Schutt’s chief executive, said. “I don’t believe that there’s any single one test that will tell you whether a helmet can stop a concussion. We communicate with coaches, equipment managers and other people in the football community. We have years of experience, test different conditions, temperatures, putting the helmets through a variety of contexts to see if it has superior dampening ability for a range of impacts.” Helmets produced by Adams U.S.A., worn by about 650,000 high school and younger players, are focused on meeting the Nocsae skull-fracture standard, David Wright, the chief executive of Adams, said. “Once we see evidence that says we can reduce these types of injuries,” he said, referring to concussions, “then we’ll do it. We haven’t seen that.” Art Chou, vice president of Rawlings, agreed: “We’re not in the standards-making business. We make equipment focused on standards given to us.” Chou also serves on the Nocsae board. Along with Riddell, the company most emphasizing concussion safety is Xenith, whose X1 model is making inroads among high schools, colleges and the N.F.L. The X1

features a radical new design: air-filled shock absorbers that attempt to withstand a wider range of forces than traditional foam. Xenith’s founder and president, the former Harvard quarterback Vin Ferrara, said the Nocsae standard had discouraged innovation among other companies and was “wholly inadequate” for modern football. “The fact that there’s only one standard for everything, designed 30 years ago for a different problem, indicates how far off the industry is right now from having an acceptable standard,” Mr. Ferrara said. Dangerous Misconceptions The fact that helmets are held to no standard regarding concussions surprised almost every one of dozens of people interviewed for this article, from coaches and parents to doctors and league officials. Even one member of the Nocsae board, Grant Teaff — who represents the American Football Coaches Association — said he was unaware of it. “Obviously if you’re protecting against skull fracture, you’re protecting against any type of concussion,” Teaff said, incorrectly. Nocsae receives no oversight from any independent agency, such as the Consumer Product Safety Commission or the Occupational Safety and Health Administration. Its 16-member board features five representatives of the helmet industry, six volunteer doctors, two athletic trainers, two equipment managers and one coach. Nocsae’s annual budget of about $1.7 million is funded mostly by sporting-goods manufacturers whose products bear the Nocsae seal of approval. The largest share of that comes from football helmet makers and reconditioners. “That’s pretty scary,” said Dr. David Price, who is heavily involved with youth football as a sports medicine physician for Carolinas Medical Center in Charlotte, N.C. “You would think there would be some sort of third-party oversight.” Mr. Oliver, Nocsae’s longtime president, said that helmet companies do not unduly influence the organization’s policies. Dr. Cantu agreed, but said that the board has become as concerned about legal liability as about child safety. If Nocsae were to supplement its helmet standard in an attempt to address concussions, it could open itself to lawsuits brought by players saying that their helmet did not prevent the injury. “I have been calling for a new standard to be written for football helmets for years, and Nocsae has been sitting on their duffs,” Dr. Cantu said. “Everyone’s afraid of being

sued, because if you say that certain helmets are better, you’re saying that millions of them out there now aren’t safe.” Nocsae officials insisted that the organization does not mandate adherence to its standard; it is merely used, voluntarily, by every level of football from Pop Warner to the N.F.L. Nocsae goes so far as to state in its testing instructions that its standard “does not purport to address all of the safety problems, if any, associated with its use.” One use of the standard often emerges after a young player sustains a head injury and sues a school district or helmet manufacturer. In the 42 lawsuits in which he has testified as an expert, Mr. Halstead of Nocsae said, the primary (and usually successful) defense is that the helmet met the Nocsae standard. “Manufacturers and schools, equipment managers and the coaches — the whole football industry — don’t want to go after or even criticize the security blanket of Nocsae,” said Sander Reynolds, Xenith’s vice president for product development. “If there’s a lawsuit, they all look to Nocsae to say, ‘Hey, see, the product met the set standards.’ They’re all ultimately on the same side when it comes to liability. Nocsae exists for two reasons — to avoid skull fractures, and to avoid liability.” USA Football, which oversees tackle football among players ages 6 to 14, requires only that helmets have a Nocsae seal of approval. In the slightly more explicit rule book of the National Federation of High Schools, before several paragraphs that regulate the size of uniform numbers, decorative stripes and the like, helmets are required only to have “met the Nocsae test standard at the time of manufacture.” This has allowed thousands of older youth helmets to be re-used — particularly in poorer, rural communities — that would not even meet the Nocsae standard if they were examined critically through an industry procedure called reconditioning. To the extent that 1.7 million helmets do undergo reconditioning each year, they encounter procedures and practices that industry experts described as laughable if they didn’t compromise the safety of children’s brains. Borrower Beware Everyone with experience in youth football has his favorite horror story. The helmet with socks inserted where the padding should have been. The helmet with a nail holding parts together. Hundreds of cracked helmets with detached foam that had no business being worn at all.

At Stadium System, a family-operated business in northern Connecticut that for decades has been the primary helmet reconditioner for New England schools and youth leagues, the owners Mike and Ken Schopp shook their heads last August at one typical rack of helmets awaiting work. One youth helmet had torn ear padding that compromised safety for who knew how many games or seasons. Another’s inflatable air liner was ripped and useless. Another high school helmet, covered with skull-and-crossbones stickers, had padding that was switched from front to back and placed upside down, probably because it was itching the player’s neck. “That’s a fairly common thing for kids to do — and the kid’s wondering why he has a bloody forehead,” Mike Schopp said. Ken, his brother, added, “And it would probably pass the Nocsae test no problem.” Only about 10 to 20 percent of football players of high school age or younger wear a new helmet, which can cost from $150 to $300. The vast majority of headgear is handed down for years and at various points undergoes a reconditioning process that costs about $25 to $45. Most get reconditioned every one or two seasons, which most experts recommend. But data closely held by the National Athletic Equipment Reconditioners Association, Naera, indicated that about 500,000 young players this fall were wearing helmets that had not undergone this basic safety check, which encounters glaring failures of its own. About 25 facilities are authorized by Nocsae to recondition helmets and recertify them as meeting the original testing standard. The dozen-step process involves removing and washing all padding, inspecting parts for cracks and other deformities, washing and repainting the shell, and reassembling the helmet with either used or new parts. About 15 percent of helmets are deemed unfixable and discarded. Nocsae’s sole means of quality control is to require each reconditioning facility to perform the Nocsae drop test — in which a helmet is placed on a fluid-filled polyurethane head-form and dropped along wires from a height of 60 inches — on a random sample of about 3 percent of their helmets to see if they still absorb enough force to protect against skull fracture. The test is designed to help identify the rare helmet model that requires recall, not to pinpoint individual helmets that need replacement. The test is failed by about 1 in 300 reconditioned helmets, according to Naera reports. All of the passing helmets — along with the vast majority that undergo no testing at all, just a visual assembly-line inspection — receive a sticker that indicates they continue to meet Nocsae standards, and are returned to the league or school.

This largely faith-based process allows for significant errors. Hundreds if not thousands of supposedly reconditioned helmets emerge still unfit for use, according to interviews with coaches, parents and helmet-industry principals. This summer two reconditioners, Clean Gear in New Jersey and Maxletics in Hawaii, skipped the drop testing altogether and sent back all its helmets to schools, said Ed Fisher, Naera’s executive director and a longtime high school football coach in Washington state. He added that he discovered this only because an athletic trainer happened to complain about the condition of the helmets at a trade show. The helmets were recovered by Nocsae, which terminated the companies’ licenses to recertify helmets. During a tour of Stadium System in Connecticut, Fisher walked into the drop-testing room and found the technician testing helmets that were far too loose on the head-form to be measured correctly. The Schopps said that they were following Nocsae instructions — although those instructions require a “reasonable fit” — and that they had been testing helmets like that for the entire summer, or longer. “I need to have a critical eye,” Fisher said. “And to the people that say they’re doing it correctly, I need to have some procedures that will allow me to walk in and be able to say, show me and prove it. We’re working on that.” Some helmets are returned to teams with obvious defects. This summer, high schools in California, Wisconsin and several other states received reconditioned helmets (all bearing the Nocsae seal) that had missing harness cables, improperly attached face masks, incorrect padding and other problems that would almost certainly pose a danger to a young player. One of them was received by Jim Rudloff, the coach of Marblehead High School near Boston. “We’re rolling the dice and trusting that these things are done right,” Mr. Rudloff said. “There is that blind faith in a lot of towns that you put on whatever they give you.” Mr. Halstead, the technical director of Nocsae, added: “School districts are so strapped that they just go to the cheapest place and hope. They’ll always want to fix an old bus rather than find the money to buy a new one. That means they keep using old helmets, and sometimes not recondition them for way too long. For example, I would never let my kid wear a helmet that is more than 10 years old.” Mr. Fisher of Naera and most everyone involved in the helmet industry agreed that helmets older than about 10 years present an unacceptable safety risk. Riddell and Adams

both strongly recommend that their helmets be discarded after 10 years. Schutt sets no such limit. Naera data indicated that more than 100,000 helmets more than 10 years old were worn by players in the 2009 season, thousands were close to 20 years old. Helmets made before 1997 could pose an additional safety risk of which few people outside of Nocsae are aware. The standard to which helmets are now held — a drop-test score of less than 1,200 in a measure of force called severity index — had been 1,500 until 1998, when Nocsae lowered it. (This was done because new helmets were easily passing the 1,500 test and would easily pass the new figure, Nocsae officials said.) But helmets produced before 1997 were grandfathered in. So any one of the 70,000 pre-1997 helmets currently in use can test above 1,200 but below 1,500 — a range now agreed by most to be unsafe — and still be certified as meeting the Nocsae standard. “There’s no scientific evidence that a helmet has to be pulled after 7, 10, 12 years, that there’s some line in the sand,” Schutt’s Erb said. “There are helmets that are out there that are performing fine. Do you want your car manufacturer to tell you that your car, at the end of 10 years, you have to destroy it? That’s a decision for the user.” Some players at Cooperstown Central High School in New York are wearing helmets made in 1991, the school’s athletic coordinator, Jay Baldo, said. They were Schutt helmets reconditioned this summer by Stadium System. “Our plan is to replace them next year,” Mr. Baldo said. “The money’s going to have to come from somewhere else. Our whole budget is about $300 for football.” Only two people have access to the test logs that would determine just how many non-Schutt helmets more than 10 years old are being recertified and used in which areas of the country: Naera’s Mr. Fisher and Nocsae’s Mr. Halstead. They provided data to The New York Times that indicated that the number is minuscule. Mr. Oliver, Nocsae’s executive director, said he does not receive or consult reconditioning data. Asked if helmets more than 10 years old should be worn by a child, he said: “I can’t say it should or shouldn’t be. All I can go on is how it tests on the standard.” The Future Most experts agree that regarding concussions and growing evidence of their health risks — particularly among young athletes — the first order of business is to get players,

coaches and parents to recognize the injury and then keep the player away from sports for as long as it takes to heal. Others added that football leagues and referees must more vigilantly penalize players who lead with their head while tackling. This dangerous maneuver received heightened news media coverage this week given several high-profile injuries, but it occurs in almost every game at every level. The Wild West culture regarding helmets must also change, they said. Some call for Nocsae and Naera to set stronger standards and more proactively enforce their rules, but that would almost certainly require greater legal protection, said Dr. Cantu, the Nocsae vice president. Mr. Ferrara, the president of Xenith, called for the industry to receive governmental oversight. “I want to answer to a higher authority than Nocsae,” Mr. Ferrara said. “I want to answer to the F.D.A.” After four years of national debate over sport-related concussions as a public-health concern, and after several officials were interviewed for this article, Nocsae decided earlier this month to consider moving on the matter of a concussion-related helmet standard. Strongly pressured by Dr. Cantu, Mr. Oliver scheduled a meeting for Saturday to have experts in the field discuss possible adjustments — specifically a test for the less violent forces believed to raise concussion risks. Even if adjustments begin that day, the process will take at least three or four years. Meanwhile, and pending more effective industry oversight, young football players will continue to wear helmets whose limitations are obscured by their communities’ love for football. Nowhere was this more clear than here in Norman last August, when fifthgraders lined up to receive their headgear for the season. No one thought to question what helmets are designed to do, how old the helmets were, if and when they had been reconditioned, or whether their sweat- stained and dirty padding retained its safety properties. One of them, Joseph Kirk, stood at attention as his team, the Punishers, received their primary brain protection for the season. A league volunteer reached into a rack of helmets and chose No. 5045 — a worn white Riddell Little Pro with no known age, no known history and one Nocsae sticker. “That good, big man?” the volunteer asked as Joseph peered unblinkingly from behind the face mask. The man fiddled with the fit, handed Joseph a leather chin strap and said, “Put this on when you get home.” The entire process took nine seconds.

Joseph shuffled to the next station to get his shoulder pads as the volunteer beckoned, “Next!”

Teaching Young Players a Safer Way to Tackle

Players at Bobby Hosea’s camps are taught to tackle with knees bent, backside out and chests up, bending the spine and forcing the chin and eyes up. (Kevin Terrell for The New York Times)

By ALAN SCHWARZ December 25, 2010

CARSON, Calif. — They walked through dawn’s thick fog to the practice turf — two dozen boys as old as 17 and as young as 9, giving up a Saturday morning to the coach in the Panama hat. “Dip ’n’ rip, baby! Dip ’n’ rip!” the coach said as players ducked under five-foot limbo sticks and exploded out the other side. “Head up! No! Head up!”

“Not chest up, chest out! Yeah!” Bobby Hosea, a 55-year-old former defensive back and longtime bit actor, has a singular passion: teaching young football players how to protect their heads while tackling. He has watched too many end up in wheelchairs, even coffins. He sees N.F.L. defenders recklessly diving helmet-first and claiming it is too late to change. He hears youth coaches exhorting tacklers to “lay a hat on him,” a maneuver so neck-crushingly dangerous it could well be called Rushing Roulette. So Hosea runs camps that focus on one skill — tackling with your head up instead of down, and away from contact — and gives individual instruction to players in and around Los Angeles. As football careens through its dark cloud of head injuries, Hosea sees himself as saving more than the players’ ability to walk and think. He sees it as saving the sport, one youngster at a time. USA Football, the governing body of Pop Warner and other leagues for players ages 6 to 14, recently hired Hosea as its tackling consultant and placed videos of his technique on its Web site. “When a kid gets paralyzed or dies, it’s not an accident — the injuries happen because people never teach kids how to tackle the right way,” Hosea told about 20 rapt campers before a session this month. “Everyone’s talking about head injury awareness, awareness, awareness. What are you going to do about it? It drives me absolutely crazy. It’s time for this to stop!” To lighten things up, Hosea could have amused the youngsters by reading the official definition of tackling, codified at Rule 3, Section 34 of the N.F.L. Rulebook: “The use of hands or arms by a defensive player in his attempt to hold a runner or throw him to the ground.” This quaint approach has evolved into the more gratifying and theatrical act of launching headfirst into a ball carrier’s gut, chest or helmet. A result has been a steady rise in concussions — estimated at more than 500,000 each season among the 4.4 million children who play tackle football — as well as more rare but catastrophic injuries where vertebrae are crushed or fractured, leaving the player paralyzed. “A lot of youth coaches have no idea how to teach tackling — they say to just put a helmet in the numbers or light the other guy up,” said Jeff Leets, whose seventh-grade son, Zack, is a defensive end and devoted Hosea pupil from nearby Torrance. “They have

the caveman element and don’t want to be told their way is wrong or that their way is unsafe. Or they simply don’t know. It’s sad — you’ve got babies in your hands, man.” On this Saturday, those babies ranged from a 9-year-old who weighed 70 pounds to a beefy high school senior eyeing junior-college ball. The players did not know Hosea from his playing days at U.C.L.A., in the Canadian Football League or in the United States Football League, nor did they recognize him from recent parts on “24” or “Bones.” To them, he is the tackling guy — equal parts coach, pal and drill sergeant. Hosea takes a tackler’s most instinctual act — to dive toward a runner, head down and arms extended — and rebuilds it from the turf up. He keeps knees bent, backside out and chest up, bending the spine and forcing the chin and eyes up. Arms remain at the side until just before impact, when the hips and shoulders thrust up into the opponent, only then swinging forward to wrap up the runner and wrestle him down. Hosea ran drills as unconventional as his method. The players lined up on their knees 10 at a time and flopped forward onto pads with their arms clasped behind their backs, looking like flying fish. In midair, they must call out the number of fingers a coach raises — to prove that their chins are up and eyes are alert. Elsewhere, they must run full speed under horizontal bars only 52 and 60 inches off the ground — Hosea’s so-called Dip-’n’-Rip sticks — before hitting tackling dummies to ensure that they stay low enough with proper form. Any dropping of the head resulted not just in dozens of push-ups, but also in spirited hooting from fellow students. “It gives me more confidence on the field — I feel like I’m not going to hurt myself,” said Michael Wilson, an eighth grader from Long Beach. “Before, I didn’t know what I was doing. When I was first taught, all the coach said was to put my head on the ball and knock it out.” Hosea is barely known outside Southern California, where he still collides with traditionalist resistance; several parents at the recent camp said their local coaches disapproved of an outsider teaching their children how to tackle. One mother said she pleaded with local school district officials to use Hosea for their peewee programs but got no response. One of Hosea’s first campers, almost 15 years ago, was a fifth grader named Dashon Goldson. He now plays defensive back for the San Francisco 49ers.

“Bobby’s definitely the real deal — he’s a genius when it comes to this tackling stuff,” said Goldson, noting that teammates occasionally ask him to share the finer points of his tackling style. “If it wasn’t for him, I don’t know how many concussions I’d have.” Hosea’s current prodigy is Eric Capacchione, a senior at Torrance South High. Five years ago, Eric said to his father, “Dad, is it normal to see white lights when I tackle?” Bill Capacchione, who played college football and now cannot twist his neck more than a few degrees, knew that those white lights were not good. They were probably concussions. Bill Capacchione — proudly noting that his surname in Italian means hard head — came upon Hosea’s tackling camps and became a quick convert. Eric has gone to about 100 three-hour sessions over five years, at the standard $40 a session, and this season was Torrance South’s most valuable player, leading the team to the district championship game. His 193 tackles were the second most in the state, according to MaxPreps.com. “I don’t see the white lights anymore — mainly because I don’t hit my head in there,” said Eric, who will probably receive an N.C.A.A. Division I scholarship. “I don’t have to play afraid.” This month’s campers certainly let loose. They shuffled and cut, imitated pterodactyls and pummeled foam dummies with a manic verve. At the end, Hosea gathered the group, seated them under a canopy and delivered his strident crescendo. “Who breaks your neck and damages your brain?” Hosea said, yelling. “Me,” the youngsters groaned. Dissatisfied, Hosea barked the question to each youngster individually and demanded the same answer. “Me!” “Are you ever going to put your head down on a tackle?” “No, sir.” Not loud enough. “No, sir!” When the grilling ended, Hosea exhaled. His final words came through a smile warm and hopeful: “You’re the new generation, guys. You’re empowered. You, my friends, are going to change the football world.” The youngsters rose wearily, gathered their gear and trudged back to the parking lot under what had become a searing California sun. Their heads were up. The fog had lifted.

A Suicide, a Last Request, a Family’s Questions By ALAN SCHWARZ February 22, 2011

SUNNY ISLES BEACH, Fla. — The words came up on Alicia Duerson’s cellphone as blithely as text messages typically do, but this one was different: her former husband, the former Chicago Bears star Dave Duerson, asked her to donate his brain for research. She texted back and heard nothing, then called their son, Tregg, who was just ending his workday as a bank analyst in Chicago. They called again and got voice mail. The next and last message they received from Dave Duerson was meant for them, their family and perhaps all of professional football. It was written in his hurried hand, repeating his text message in case it had not been received, and found in the South Florida condominium where he placed a gun to his chest and shot himself to death last Thursday. “Please, see that my brain is given to the N.F.L.’s brain bank.” Alicia and Tregg Duerson cannot know and do not care to guess what his intentions were in this final request. What they do know is that, they said, it brings them some solace in a sad and confusing time. “I think it’s just an example of the type of person he is,” Alicia Duerson said. “In his time, he put the future in front of him — future generations of football players in front of him. I’m just so proud of him at this moment.” His family said that Duerson, the 50-year-old former Bears safety who graduated from Notre Dame, had been finding it hard to remember names and to put words together. They described a devoted father of four who had spent countless hours with the football players union, where he became familiar with the plight of retired players dealing with physical decline and dementia. Sitting with his mother on the deck of his father’s building Monday night, Tregg Duerson sobbed. “He was looking for an answer,” Tregg said. “And he was hoping to be a part of an answer.”

The pertinent question is whether Duerson had chronic traumatic encephalopathy, the degenerative brain disease recently found posthumously in about 20 retired players, a disease that has been linked to depression, cognitive impairment and occasionally suicide. That determination will be made over the next several months by doctors at the Boston University Center for the Study of Traumatic Encephalopathy, who recently began receiving financial support from the N.F.L. The broader issue, given the growing number of football players developing dementia or other cognitive problems, is what the cost of football will eventually be for generations of retired players, and how the game might be made safer for active players, from professionals to children’s leagues. Duerson’s final letter, consisting mostly of personal comments that relatives declined to make public, did describe blurred vision and pain, Alicia Duerson said, “on the left side of his brain.” The implication, by pledging his brain to research, was that his problems, and perhaps his suicide as well, stemmed from his football career. “I would have to guess it was a statement about football and its impact on the brain,” said Robert Smith, a former N.F.L. running back, who served with Duerson on the panel that considers former players’ disability claims. “It had to be. And, his belief that it contributed to his final despair.” A hard-hitting but nimble defensive back from Muncie, Ind., Duerson was an allAmerican at Notre Dame and a two-time Super Bowl champion, first as part of the 1985 Bears’ famed 46 defense, then five years later with the Giants. He met Alicia during his freshman year at Notre Dame; they divorced last year. “He was hitting so strong and hard, and he was so aggressive as a defensive back that after the game I was really afraid to go up to him,” she said of their first meeting, after a Notre Dame football game. “He was like: ‘What’s wrong with you? Come over here, let me give you a hug.’ He was so sweet and kind. He could leave the game on the field and go back to being Dave.” When Duerson left the field for good after the 1993 season with the Arizona Cardinals, he was succeeding in the food service business. He also stayed active in players union affairs. Duerson eventually joined the six-man volunteer panel that considered retired players’ claims under the N.F.L.’s disability plan, in addition to the 88 Plan, a fund that has assisted more than 150 families caring for retired players with dementia since its

inception in 2007. Duerson read applications, testimonies and detailed doctors’ reports for hundreds of players with multiple injuries, including those to the brain that in some cases left players requiring full-time care. He had to vote on whether these people received financial assistance. In 2007, two Congressional committees held hearings into whether the disability board was unfairly denying benefits. Duerson testified before the Senate Commerce Committee alongside Brent Boyd, a former Minnesota Vikings lineman whose depression and cognitive impairment had been ruled unrelated to his playing career, therefore warranting significantly lower benefits. It is unknown how Duerson voted on Boyd’s case. He did get into a testy exchange when Boyd, then 50, asserted that his condition — and that of other players with dementia — was caused by football. “In regards to the issue of Alzheimer’s, my father’s 84, and, as I had mentioned earlier, Senator, spent 30 years at General Motors,” Duerson said, according to the hearing transcript. “He also has — he also has Alzheimer’s and brain damage, but never played a professional sport. So, the challenge, you know, in terms of where the damage comes from, is a fair question.” Around this time, Duerson’s life began changing course. His company, Duerson Foods, was forced into receivership. His 17-room home in Highland Park, Ill. — the one with “NFL22” carved on a driveway pillar — went into foreclosure. He pleaded guilty to a misdemeanor domestic-battery charge after pushing Alicia during an argument, leading him to resign from Notre Dame’s board. Duerson filed for personal bankruptcy last September. Few close to Duerson appear to have noticed anything wrong with him. Miki-Yaras Davis, the union’s director of player benefits, said that at a disability board meeting last November, Duerson was his usual joyous, cigar-smoking self. Other union officials said they did not see any signs of cognitive impairment, although one, who spoke on condition of anonymity, said Duerson once spoke plaintively that he might someday develop chronic traumatic encephalopathy. Alicia Duerson, who kept in touch with him, said that he developed a hesitancy in putting words together on paper and in conversation. He also had short-term memory loss that, she said, “got worse as time went on.” “I think David knew that inside of him there was something wrong,” she said. As much as Duerson loved football, she said, his final gestures were his way of saying: “I’m

a veteran of the game. Something is wrong. Somebody has to step up and acknowledge that.” Duerson asked that his brain go to “the N.F.L. brain bank,” an indication that he recognized the league’s support of the Boston University research. After denying and discrediting evidence of football’s long-term impact on the brain for several years, the N.F.L. has increased its efforts to make the game less dangerous through concussiontreatment protocols and rule changes. “It is a tragic situation that has everyone in the football community feeling both saddened and concerned,” the N.F.L. spokesman Greg Aiello wrote Tuesday in an e-mail. “Dave Duerson was a leader, a doer and a giver. He made great contributions to the N.F.L. and to many others. The human tragedy is gut-wrenching, and Dave’s family and friends have been in our thoughts. On the medical side, we will stay in close contact with our medical advisers and the B.U. research group to understand the facts and their significance.” Smith said that after joining the disability board last year, he never sensed skepticism from Duerson that players’ cognitive problems were related to football. He acknowledged Duerson’s personal and financial problems must have contributed to his final act, and that his brain might in fact not show the protein deposits and damaged neurons indicative of C.T.E. “He devoted so much to retired players and their problems,” Smith said, “you wish that the information that he had received from all those other cases would have led him to seek the help that could have saved him. That’s what I will have to deal with as my time on the board continues — to do what I can to help get his message across.” Alicia said that some of Duerson’s ashes, per his longtime wishes, would be spread at Notre Dame and Soldier Field, the sites of his finest days. A public memorial service is scheduled for Saturday in Chicago. Tregg Duerson also played football at Notre Dame, until he decided after one year to concentrate on earning his management degree. “I just wish he had played baseball,” Tregg blurted angrily at one point during the interview. But a few minutes later, asked if his father might have had the same second thoughts, he broke into a knowing smile and actually laughed. “My dad’s not a second-guess type of guy,” he said. “If he makes up his mind, it’s on, baby. There’s no looking back.”

Duerson’s Brain Trauma Diagnosed By ALAN SCHWARZ May 2, 2011

BOSTON — The suicide of the former Chicago Bears star Dave Duerson became more alarming Monday, when Boston University researchers announced that his brain had developed the same trauma-induced disease recently found in more than 20 deceased players. The diagnosis adds a new and perhaps pivotal chapter to football’s still-unfolding narrative surrounding concussions. Duerson shot himself Feb. 17 in the chest rather than the head, presumably so that his brain could be examined by Boston University’s Center for the Study of Traumatic Encephalopathy, which announced its diagnosis. About two dozen retired N.F.L. players have been found to have the disease, known as chronic traumatic encephalopathy, but none acted upon his suspicion of it like Duerson, 50, who complained to family of his deteriorating mental state during his final months. His death reminded the football community that for all the reform in the management of concussions and other on-field brain trauma in recent years, the damage to past players remains a vestige of the game’s more brutal times. “It’s tragic that Dave Duerson took his own life, but it’s very meaningful that he recognized the symptoms of the disorder — it validates this condition,” said Dr. Ann McKee, the neuropathologist who examined Duerson’s brain. She said she found indisputable evidence of C.T.E. in the tissue samples, with “no evidence of any other disorder.” Although the precise motivations behind Duerson’s suicide remain unknown, he had complained of headaches, blurred vision and a deteriorating memory in the months before his death. His final note to his family finished with a handwritten request: “Please, see that my brain is given to the N.F.L.’s brain bank.” The N.F.L. does not run the Boston University research group but did donate $1 million to its financing last year, after the league acknowledged long-term effects of football brain trauma.

C.T.E., a condition previously associated mostly with boxers and manifested in behavior more commonly known as dementia pugilistica, is a degenerative and incurable disease that compromises neural activity and is linked to memory loss, depression and dementia. Although groups at Boston University and elsewhere are pursuing tests for living patients, the condition can currently be detected only after death, by brain autopsy. “We hope these findings will contribute more to the understanding of C.T.E.,” the N.F.L. said in a statement. “Our Head, Neck and Spine Medical Committee will study today’s findings, and as a league, we will continue to support the work of the scientists at the Boston University Center and elsewhere to address this issue in a forthright and effective way.” DeMaurice Smith, the executive director of the players association, said in a telephone interview that Duerson’s having C.T.E. “makes it abundantly clear what the cost of football is for the men who played and the families.” He added: “It seems to me that any decision or course of action that doesn’t recognize that as the truth is not only perpetuating a lie, but doing a disservice to what Dave feared and what he wanted to result from the donation of his brain to science.” Duerson s death rattled players both active and retired, who after years of news media coverage are more aware that the damage done to their brains could be permanent. Pete Kendall, a recently retired offensive lineman, said, “The whole issue of C.T.E. is something that players young and old have no choice but to think about.” Duerson’s former wife, Alicia, attended the Boston news conference with their four children. Their son Tregg, 25, made a brief statement, saying, “It is our hope that through this research questions that go beyond our interest may be answered — questions that lead to a safer game of football from professionals to Pop Warner.” He added with regard to his father, “It is my greatest hope that his death will not be in vain and that through this research, his legacy will live on and others won’t have to suffer in the same manner.” Duerson was an all-American defensive back at Notre Dame before spending most of his 11 N.F.L. seasons with the Bears. He played safety on the famed 46 defense that fueled their Super Bowl championship in the 1985 season, and he won the 1991 Super Bowl with the Giants. Duerson retired after the 1993 season and became successful in the food-services industry before his businesses collapsed, his marriage failed and he went bankrupt. He

began showing symptoms of repetitive brain trauma, including memory loss, poor impulse control and abusive behavior toward loved ones. Another son, Brock, 22, said that the diagnosis of C.T.E. provided an explanation for his father’s decline and final act. “I don’t want people to think just because he was in debt and broke he wanted to end it,” he said. “C.T.E. took his life. He changed dramatically, but it was eating at his brain. He didn’t know how to fight it.” Duerson’s case is unique beyond the circumstances of his suicide. Since 2006, he had served on the six-member panel that considered claims for disability benefits filed by former N.F.L. players. Although individual votes are kept confidential, that board has been sparing in awarding benefits, including those for neurological damage. Duerson himself told a Senate subcommittee in 2007 that he questioned whether players’ cognitive and emotional struggles were related to football. However, Duerson’s legacy will almost certainly be how he apparently came to believe he had C.T.E., acted upon it and requested that his brain tissue be examined for confirmation and contribution to science. Dr. Robert Stern, along with McKee a co-director of the Boston University research group, cautioned that C.T.E. could not explain all of a player’s actions. “When it comes to suicide and chronic traumatic encephalopathy, it is possible that in some individuals the combination of C.T.E.-related symptoms of poor impulse control, depression and cognitive impairment may indeed lead to suicide,” Stern said. “However, we can never clearly point to any cause-and-effect relationship in any one case.”

Obama to Host Concussions Meeting By MICHAEL D. SHEAR and KEN BELSON May 28, 2014

WASHINGTON — President Obama on Thursday will seek to elevate a national conversation about the dangers of sports-related concussions, especially among children and other young athletes, by pushing for more medical research and more money spent on public awareness campaigns. The president will host a daylong summit at the White House that will include researchers, professional athletes, parents, coaches, league officials and sportscasters. Officials said the goal was to use the power of the presidency to accelerate progress on one of the most serious health issues to confront sports in a decade. “Our focus here is on giving parents information that they need to help make judgments about how their kids can be safe,” Jennifer Palmieri, the White House communications director, said. Obama is “a big believer in sports,” but as a parent, he is “concerned about the safety of his own daughters,” Palmieri said. Obama’s daughters, Malia and Sasha, play sports, Palmieri said, although she declined to say whether either had sustained a concussion or other head injury. The president will announce a series of initiatives, financed by the government, nonprofit groups and major sports leagues, that will aim to promote awareness and increase the amount of data that researchers can use to better understand the consequences of strong blows to the heads of young athletes. Obama will not, however, call for new regulations or legislation aimed at requiring the use of specific helmets or restricting certain sports for young children. Such efforts would probably create controversy in the same way that Michael R. Bloomberg, the former mayor of New York, met resistance to his efforts to ban large sodas. The president’s aides said there was not scientific consensus on what such regulations or restrictions might look like. They said that helping to start the research might someday lead to a better understanding of the medical issues and perhaps new regulations. The relatively modest financial commitments to be announced Thursday are evidence that the push to make concussions a top-tier health concern is at an early stage

— even with the backing of the president. The N.F.L., which has set a goal of earning $25 billion in annual revenue by 2027, will agree to spend $25 million over the next three years to promote youth sports safety. That is in addition to other commitments, including a pledge to spend $45 million to promote safer tackling techniques and coaching certification. The N.C.A.A., which oversees college sports, and the Defense Department will together spend $30 million on a study of the risks and treatment of concussions. Those amounts pale in comparison with the billions of dollars spent annually on other health concerns like heart disease, cancer, smoking and diabetes. Research into what doctors call traumatic brain injuries, or T.B.I., has received much less support and can be costly. White House officials said the money would make a big difference in a field that had had few major investments to date. “We’ve been talking for a number of years about the importance of T.B.I. and concussions, and the funding has lagged,” said Dr. Christopher Giza, the founder and director of the U.C.L.A. Steve Tisch BrainSPORT Program, which will be announced at the White House event Thursday. The U.C.L.A. program will initially receive $10 million from Steve Tisch, an owner of the Giants. Giza said more research was needed to prove to athletes of all ages that there were significant dangers to staying in a game after a head injury. White House officials said that nearly 250,000 young people went to emergency rooms each year with sports- or recreation-related brain injuries. Jay Carney, the White House press secretary, said he and the president had talked frequently about their concerns for their own children. “I know parents across the country are making decisions about whether they want their kids to play football or soccer,” he said, putting himself in that category. “This is a perfect opportunity for the White House and the president to bring people together, convene people and focus a spotlight.”

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