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NFL: 2019 Player Health and Safety End of Season Briefing

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NFL: 2019 Player Health and Safety End of Season Briefing

2020-01-27 19:25:541 Oct 2018 01:53 AM EST

 

-by Daniel Mogollon, Staff Writer; Image: The Kansas City Chiefs versus the San Francisco 49ers. (Image Source: Michael Zagaris/Getty Images)

The NFL held a media briefing to recap the 2019 season in NFL player health and safety, including sharing injury data from the 2019 season, on January 23, 2020. The injury data is compiled and analyzed by IQVIA (formerly Quintiles), an independent third-party company retained by the NFL.

The following is a transcript of the briefing with reporters.

SPEAKERS:

  • Jeff Miller, Executive Vice President, NFL Health and Safety Innovation
  • Dr. Allen Sills, Chief Medical Officer, NFL
  • Dr. Christina Mack, Vice President, Epidemiology, IQVIA
  • Jennifer Langton, Senior Vice President, NFL Player Health Innovation
  • Dr. Nyaka NiiLampti, Vice President, NFL Wellness and Clinical Services
  • Leigh Weiss, Chairman of the NFL-NFLPA Joint Lower Extremity Soft Tissue Injury Task Force; Physical Therapist; New York Giants Director of Rehabilitation
  • Dr. Leigh Ann Curl, President, NFL Physicians Society; Head Team Orthopedic Surgeon, Baltimore Ravens

QUESTION: For Dr. Sills or Dr. Mack, you mentioned that the number of concussions recorded has gone down over last two years.  Do you have any reason to think that the change in the protocol, adding this new approach over the last couple years, has made players more reluctant to report concussions? 

DR. ALLEN SILLS:  No, in fact, our data would suggest the opposite.  We actually track the number of concussion evaluations that have some element of a player self-report. So for this year, for example, it's about one-third of those player evaluations for a concussion that have some element of self-report, and that's as reported by the sideline unaffiliated neurotrauma consultant in their reports.

So, we do look at that from year-to-year to see how that number is doing and that's about in line with where we've been.  I'll say also anecdotally, those of us on the sidelines like me, certainly Leigh, the medical staff members, Dr. Curl who is on the phone, all of us perceive that that culture of self-reporting continues to grow and continues to be a change over where the game was in general maybe a decade ago because I think players understand the magnitude of the injury and what's involved with that.  Obviously, you know, I was quoted recently about a fairly high-profile player on that very issue. That's a difference, right? We want to highlight and encourage that. I called that player heroic for doing that because it illustrates where we have changed in that way. 

LEIGH WEISS:  I agree, I think the culture is changing and even my experience from the sideline we are seeing more self-report and players will come forward and say, 'I just don't feel right.  Can you take a look at me?  Can you get the UNC involved and the team physician.' 

DR. ALLEN SILLS: One other thing I'll mention with regard to that, we had an all-time medical number high of medical timeouts called this year: there were 19.  For those of you familiar with that program, it's our ATC spotter, our eye-in-the-sky calling down to identify a player that may be injured.  19 was an all-time high; we're again very proud of that and comfortable with that.  Two of those 19 players were actually diagnosed with a concussion in-game and removed. 

So again, back to your point.  We have continued to build our detection efforts and I think that we feel very comfortable with the system we have in place.  We're always looking to improve it, but we want to be as wide with our net as we can in terms of screening and evaluating players and I think that our system has showed that change. 

QUESTION: You said you were at 19. What was the previous high before? 

DR. ALLEN SILLS:  I think last year there were 16, which is a previous high. 

JEFF MILLER: And to emphasize the conservative culture around it, as Allen pointed out, only two of those players were diagnosed with a concussion, and that's something we try to emphasize.  Always more work to be done.  But as Allen said, 19 it's a higher number, from our perspective, that's a good thing.  It means players who may need medical attention are receiving it.

DR. ALLEN SILLS:  And we did 485 concussion evaluations in games this year, in preseason and regular season games, which is again about the same number that we have been doing and essentially we screen between three and four players for every one concussion we diagnose. Far more players that are screened that do not have concussions than the ones we diagnose, but again, we're very comfortable with that because we want to have a program that has a low threshold for triggering an evaluation. 

 QUESTION: That 485, that's in-game evaluations, so that's not necessarily having to do with the 224? The 224 is total that might have been discovered during the week? 

 JEFF MILLER:  That's correct.  Or a player potentially didn't need an evaluation.  If you lose consciousness on the field, which is one of the parts of the protocol, okay, off to the locker room you go.  Those don't happen frequently but just to put some color. 

 DR. ALLEN SILLS:  But the flipside of the question, we feel very confident that the decreased number is not because we are doing fewer screenings.  In other words, our screening and detection efforts have not lessened in any way. 

 JEFF MILLER:  One more topic and then we'll open it up totally to questions. I touched on lower extremity injuries, focus there, efforts that are being made in that space against knee, ankle, foot, hamstring issues.  So Dr. Mack, let's go back to the statistics on that and if Leigh and Allen can pick it up from there with some color against it.

DR. CHRISTINA MACK:  So lower extremity injuries in the NFL make up over 60 percent of the injuries that occur in NFL players, so they are an ongoing point of emphasize for injury reduction across many facets.  In some cases in 2019, we did see lower extremity injury rates trend in the right direction. 

For example, ACL tears – which are shown on the screen – are down by 10, which is about 18 percent, and MCL tears down from 132 to 109 which is a 17 percent decrease and a low for recent years.  That drop in MCL injuries was notable on special teams which will be a point of investigation between now and the Combine to better understand whether or not that decrease is related to rule changes.

And so again, the goal for the time period between now and Combine and then beyond is to keep taking these dives into this evidence, better understand the numbers and see if we can attempt additional drivers to reduce injuries. 

 Lower body soft tissue injuries, such as hamstring and adductor strains are also a key point of focus.  Strains are less severe injuries than the ligament tears that we just talked about.  However, muscle strains impact more players, they have been stable over time and they actually result in almost as high a burden as ACL tears, so again, a key emphasis for reduction.  40 percent of those injuries, such as hamstring strains, happen in preseason practices.  And so I'll turn it over to Leigh and Dr. Sills.

 DR. ALLEN SILLS:  Obviously we're pleased to see ACL and MCL injuries go down, but we don't yet quite know enough why they went down, so that's something again as Jeff mentioned that we'll be digging into between now and the Combine. 

 QUESTION: How are you defining ACL and MCL tears?

 DR. ALLEN SILLS:  You want to talk about our definition of ACL / MCL tears? I mean, it's the data entered by the athletic training staff.

 QUESTION: So it can be partial?

 DR. ALLEN SILLS: It can be partial.

DR. CHRISTINA MACK:  One important point there is when we look at these numbers, we look at MCL tears that result in missed time – but that's such a big spectrum.

 DR. ALLEN SILLS:  As Dr. Mack mentioned, 60 percent of all the NFL injuries are to the lower extremity. If you look specifically at the most common injury among NFL players, it's the lower extremity strain -- it's a hamstring or adductor strain.  As we start really thinking about focusing in and trying to make interventions, we spend a lot of time talking about the concept of injury burden. 

 

Injury burden is not just how many or the raw numbers, but it's also how much time do players miss.  And so as we look at injury burden, a couple of injuries really jump out. We mentioned the lower extremity strains, obviously the knee ligament injuries you heard us talk about and the ankle sprains.  So we are putting workstreams against each one of those specific injuries, similar to what we did with concussion.  We're trying to understand who's being injured, how they're being injured, what are the factors driving injury, and then obviously what are the levers that we can pull to potentially affect those injuries. 

So some of those things we did in 2019 were part of that. We tracked the cleats that were worn by every player in every game and what the relative injury rates were with each cleat.  We also undertook an engineering analysis of different turf systems so we can understand what are the relative properties and which turf systems seemed to perform well in the laboratory and how they test and what are the on-field injury rates of those turf systems. 

 And then we are analyzing injuries and looking at when do they occur, sort of the timing, which Leigh will get into here on this slide and how training may affect that and what are sort of the biomechanical factors. 

 So again, all of that work is ongoing and as I mentioned there are three big focuses: the soft tissue strains, the knee ligament tears, and the ankle sprains. 

 Leigh is heading up the task force that we call our Lower Extremity Soft Tissue Injury Task Force.  I wish that had a great acronym.  But what we have asked Leigh and his group to do is look at this in a very multi-dimensional way and see how can we develop strategies that reduce these injuries. 

 I will just say as a point of pride, Leigh's committee is a model of where we are going with this because it includes not only physicians, athletic trainers, but also sports scientists, sports performance people, strength and conditioning coaches, biomechanists.  So you have a whole range of perspectives on how these injuries may be occurring that are coming together to address this.  So Leigh, let me turn it over to you to talk about what you're doing.

LEIGH WEISS:  As Dr. Sills mentioned, I'm real proud of the group of people we've been able to put together for this committee. It's multi-disciplinary: athletic trainers, physical therapists, physicians, as Dr. Sills mentioned, performance and sports science folks, and strength and conditioning.  We've worked very closely with the NFLPA and Dr. Mayer and his team of experts because we are really trying to wrap our hands around the breadth of soft tissue injuries. 

As Dr. Sills and Dr. Curl will support, stability in medicine is usually a good thing, however when you look at stability of soft tissue injuries over the past five to six years, they've been relatively high and here stable is not a good thing.  That's our task, really, to drive these numbers down.

So if you look at the slide, our focus has been, really, on the onset of training camp, and we see an influx of these lower extremity soft tissue injuries during the first ten days of training camp and we centered a lot of our attention around these first ten days in identifying where we can look to reduce some of these injuries, what are the risk factors for some of these injuries. 

We've scoured the international literature.  We've leveraged experts nationally, internationally, and we believe a lot of these injuries that occur during the first ten days of training camp are relative to training load.  So distances, durations of practices, speeds that are being covered, and all those different metrics.  We know that there's an influx of performance data that's being captured by clubs during practice, a lot of the wearable technologies, the catapults and the Zebras are capturing athletic movement, so how much is a player doing at any given session?

We know the Next Gen Stats that we capture on game day through Zebra is giving us that benchmark.  So it telling us what the players need to be prepared for and what are the demands of an NFL Sunday or an NFL Monday Night.  So hopefully our goal is to see how we're preparing players relative to what their demands are of an NFL game. 

What we are hoping to do is take some of this wearable technology data and overlay it with our injury surveillance data to get an idea of what are the risk factors leading players towards injury.  This is a big deal.  Not only from a player availability standpoint from a club perspective, but from a player perspective, you know, it's their availability, their ability to make a team, their ability to perform at the highest levels and their ability to stay healthy and to us is paramount. 

You know, based on the ISS data, the first ten days of training camp are very important to us, and we are trying to really challenge all stakeholders to really look at their practices and identify where we can kind of fix this. 

 So from a coaching perspective, can something be done on the practice planning part? From an athletic trainer and physical therapist and physician standpoint, we can modify rehabilitation and return to play and return to activity? From strength and conditioning, planning and training and conditioning, and how are we training our players through the off-season program and early through training camp? And the players, how are the players preparing their bodies in the five weeks leading up to training camp?

 So all those factors, if we are able to take little bites off each one, eventually we are going to be able to get this number down.  I know it's a big lift and it's not something we are hoping to accomplish overnight, but I think we are moving in the right direction by really looking at loads and player training and involving all the important stakeholders.

DR. ALLEN SILLS:  As Leigh said, we're really just getting started here.  There's a lot more work to be done but I'm excited about where we're going with this, and as he said this is going to have implications throughout our calendar but also through all levels of football and through all levels of sports, so it's an exciting time to see this blended effort and looking at all these different ways to solve a common problem. You want to just describe what this slide is?

LEIGH WEISS:  Yeah so part of our 2019 initiatives were really just to educate the stakeholders I just mentioned. So, earlier in the year, we sent a two-page memo, kind of newsletter to all the coaches highlighting some of the findings in various literature and research in team sports. 

You know, there's been a lot of research in this area in Australian Rules Football and Premiere League Soccer and it relates to training loads and how teams or how players are preparing for programs. So we sent coaches literature, a narrative on what's out there in the literature: how does duration of practice, how does high-speed running, how does volume at the onset of training lead to injury or can reduce the risk of jury?  We also sent this infographic with six strategies on how to potentially reduce the soft tissue injury at the start of training camp. 

So we need to recognize that the players report to training camp with various levels of physical conditioning.  We need to understand that each player brings their own footprint with them, and each has their own significant injury history or insignificant injury history.  You know, plan.  We want the coaches to plan these practices using the best data and using the best science, gradual durations, kind of working their way into a full practice.  We want to vary duration of practice.  So the literature has shown that the same type of practice for multiple days in a row can lead to monotony in training.  So by varying training not only from a duration standpoint but from a load standpoint can help mitigate the risk of injury. 

Monitoring the players' workloads, which many of the clubs are doing with some of the wearable technology and then educating players.  Obviously, training load and what the players do on the field is only one piece of the puzzle.  Risk factors for soft tissue injury may also include hydration, recovery, nutrition and those different factors.  So we're trying to take a global approach to this, and this was part of our coaches' education.  We prepared a video and infographic for the players which we were able to get to them prior to the start of the off-season program, or prior to the start of the break before training camp, and I think if you're interested in that, it's available on playsmartplaysafe.com for your reference.

One piece of the puzzle and we hope to continue this education over the next year, not only with the coaches and the players but also with the athletic trainers, physical therapists, physicians, strength and conditioning coaches, and everybody involved in the process. 

JEFF MILLER:  Thank you, Leigh. One additional point, another joint effort with our friends at the Players Association, working hand and glove with them working on ways to better identify and reduce injuries under Leigh's leadership. 

I'll wrap here in a second, a couple quick hits.  A lot of the program and events that we run are tied to these priorities, as you might imagine. 

For example, next Friday at Super Bowl: 1st & Future. We'll have the next iteration of that where we shared, as we did last year, a certain amount of injury data with the public, data analysts, data scientists specifically to say, what can you find in this data. Last year it was around the punt play.  A number of people identified the blindside block as contributing factor to the risk in the punt play and that helped inform the conversation around eventually eliminating the blindside block. 

This year we are taking a look at lower extremity injuries, so we are sharing information around injuries, player speeds, player movements, turf systems, cleats, importantly, humidity, precipitation, all other things, to see what data scientists can identify in that big amalgam of information that they can pull out that we can potentially use to further focus our research, we're really excited about that.  That will be next Friday and you're all invited to attend. 

Next, importantly in helmets, which I referenced earlier, this year for the first time in a couple of years, we are modifying, the engineers are modifying the helmet testing protocol.  This is important because it's an evolution based on what we have learned from the review of more than 800 concussions on the field. We know with greater specificity the speeds at which players are traveling when they get hurt, the locations on the helmet where they are hit and all of those are now factored into the new evaluation, which we think is great because the outcome of that, again, done with the Players Association, will better inform players and equipment managers and others on better-performing helmets.

So that's really exciting for us and it's also an important step on the way to something we have talked about for a couple years which is position specificity around helmets.  Not only will the tests continue to evolve and the helmets continue to evolve, but around that testing we will get to a place at some point soon, next year or two or three, where we will test helmets in the laboratory against representative conditions for a particular player position. That obviously is going to make their choice of helmets even more specific and that's great from our perspective. 

Additive to that, we announced our Helmet Challenge, which is an effort to recruit new ideas in helmet technology.  This is about an 18-, 20-month program with a $3 million price tag attached to it, up there in the upper right.  We announced that and we are looking at additive manufacturing, 3D printing, all sorts of new technologies and trying to bring in entrepreneurs, innovators, small businesses and others into this community. If they bring something that tests significantly better than our best-performing helmets, then they're going to win a really substantial prize and hopefully move the helmet marketplace even further.  We are seeing a lot of really good evolutionary change and we are ready for revolutionary in this space, and that's the point of that.

Lastly, AWS, Jennifer touched on, we're getting going on that this year. It's going to be a huge point of emphasis for us, take up a lot of our time.

And lastly, again the caveat at the beginning, we're going to know a lot more at the Combine and we're happy to chat with you again then and talk about the outcomes there and hopefully answer some of the questions there that go unanswered today. Speaking of questions? 

On the pilot mouth guard sensor program:

JEFF MILLER:  The key point there is that it is in fact a pilot program. It's more about the ability to collect the data, recruit players to participate and find that the data can actually transmit in ways that we can make some sense out of it.  All of those are successful and so we will look to expand the project next year.

In terms of the processing of data, which is I think where your question goes, we're still working on that.  I don't think there's going to be substantial insight because really the focus was, and I think we've said this publicly, it's a pilot program. Can we actually make this thing work? And it turns out the technology is pretty good.  It does work and it transmits a fair amount of information.  But, it's a relatively small number of players, dispersed against a number of different positions, so I don't think the results from this year are going to drive any new technologies or drive rules changes. But over the course of time, we are encouraged that that's going to be an avenue that we are going to spend a lot of time pursuing. 

On data on cleats:

JEFF MILLER:  The overlay of the injury prevalence or injury rate per cleat is something we are studying right now, as I think Allen mentioned, collected every cleat that every player wore on every play for the first time across the league and have some pretty good data from previous years, or a previous year. 

QUESTION: I thought it was just eight teams?

JEFF MILLER:  Eight teams in our ID tag -- we are also trying to manually collect that information across all clubs. So obviously there's inaccuracy or potential accuracy differentiation between that which is collected electronically and those that are collected manually.  Nevertheless, we are going to have a data set of information. 

 

As you know, we are giving you pre-Combine injury results today. The work that's going to go into measuring the cleats and the cleat types that players are wearing against those injuries is a process. That's something we'll share with the Musculoskeletal Committee in four weeks. So if there are substantial insights, we'll share those with you then, but the short answer, no, we don't have that right now. 

On marijuana and CBD:

DR. ALLEN SILLS:  So let me start with first of all, the charge of the pain management committee is to look at all forms of therapy that can improve the treatment of pain in NFL players, period, full stop. 

So that means that everything is under consideration.  As we do that, you know, that committee is looking at it on a very strong evidence basis.  You know what does the evidence really show us? Because if we are going to recommend or approve any kind of therapy for NFL players, again, whether it's equipment or treatment or intervention, we'd have to pass an extremely high standard of proof.  That's the charge we've given the committee. 

But in doing that, we have asked them to look at everything that's out there, whatever those products may be.  I will add one area of specificity.  A lot of times people use the word marijuana, medical marijuana, CBD, cannabidiol and they sort of use them interchangeably.  They actually do have specific meanings.  And I say that only to say that the focus of the event we had last week was around CBD, specifically cannabidiol, which is one of the compounds within the marijuana plant. 

So as far as where the committee's work is on that, it's ongoing and it's very active.  Again, they are looking at it not from a policy-making standpoint or anything relative to our drug testing participation.  They are just asking what is the state of the science and what can we say about safety, what can we say about effects on performance, both good and bad.  That work will continue on and anticipate we'll have more to say about it in the coming months.  Does that answer your question? 

On the Washington Post's reporting on Dr. Omalu and CTE:

JEFF MILLER:  Thanks for the question.  Certainly read the article that was in the Post. Thinking about it, it occurred to me that in the time that we have spent in this job, Allen too, we have been really the beneficiaries of the advice of a lot of really smart, capable scientists, clinicians, and academics and one theme that has always come through to me from listening to them and following their lead is that science moves forward by consensus, and debate in the scientific community is nothing new. 

So the role have they advised us that the NFL can play has been one of funding research.  And so what we have done, and I think we've been very consistent in talking about this, is that the league has put tens of millions of dollars against a lot of the hard questions that the scientific community wrestles with around head injury: what are the long-term effects of concussion? What are the different neurodegenerative diseases that potentially need to be researched? Whether it be through relationships with the Department of Defense, through our Scientific Advisory Board, through vast concussion studies led by different academics institutions, I think that we have done that and followed the recommendation of those many experts who have advised us to say, it would really help the science move forward faster if the NFL invested money in this or that research project and we've done that. 

I think personally I'm very proud of the integrity of the work that goes on there.  The negative is it takes time, right.  Science doesn't evolve overnight and so we don't necessarily know all the answers to all the questions that people want answers to and yet that's not stopping the changes that are made. 

I consider our role to be twofold.  One is to invest research dollars where they are most needed based on advice of the scientific community. And secondly, not to wait for the outcomes of that research, but also to change the game in ways that minimize the amount of head contact that our players experience and we've done that I think. 

We're not done, but rules changes, the data-infused efforts that we've talked about endlessly during the course of this presentation, equipment changes, the effects of those rules changes, how practices are run, and all those sorts of things.  So there's a lot more to do, but I think those two tenets are key:  put the dollars where the scientific community can best use them, and don't wait on the results.  Keep changing and evolving our game to make it better for the players who play it and the players who are going to.  So I guess, Mark, that's my reaction to what I read yesterday.

On pain management and mental health, collaboration with the U.S. military:

DR. ALLEN SILLS:  Well, I would just say that there are some people who are involved with that work at the VA who are members of our player health advisory panel. So short answer yes, we want to -- as Jeff said, we look to find the best experts that we can in all these areas and bring them in to help advise us. 

Specific to that question, I know there are individuals that have been involved with that work in veterans and in the military who are members of the Pain Management Committee and you may want to speak to that further, but I think that is very important to us. 

Again, in fact, something that Leigh said, I hope every caught his statement that you know we are talking with Australian Rules Football, we're talking with World Rugby and we want to be as collaborative as we can be to learn what others have done whether it's in the lower extremities or in the mental health area. 

DR. NYAKA NiiLAMPTI:  While we make sure we bring in experts in the space, what are the practical things that individuals can do so we talk about making sure that you are seeking support for the symptoms you are experiencing.

On patterns in mental health:

DR. NYAKA NiiLAMPTI:  So I believe -- and this is what we see, is that this population, what happens here, it's a microcosm of what we are seeing in the wider public, right. So I think stats will tell us that 25 percent of the population will suffer from some anxiety disorder in their lives; 16 percent of people have some kind of depressive symptoms -- post-traumatic stress, substance abuse. I think things that we see in this population are very reflective of what's seen in this area in the larger public. 

On mental health and retired players:

DR. NYAKA NiiLAMPTI: The behavioral health agreement in and of itself, the way it's implemented right now, is at the clubs.  We know that players are coming into the NFL now having mental health resources that are embedded in the athletic department.  So they are going to come in already with some awareness of mental health literacy and some awareness of the resources and what we know is the more they are willing to use these resources while they are active players, the easier it is going to be for them to continue to use these resources or to have the skills they develop while they're active player as they transition out. 

The behavioral health agreement in and of itself, the way it's been implemented, has been within the clubs, working with the active player population. But then we also know the player ecosystem is also inactive, so a lot of the clinicians actually work with the former players in the community, so there is a lot of overlap in those areas.

On VICIS's status and its implications:

JEFF MILLER:  Thanks for the question. I'm glad you were able to join the call. VICIS has demonstrated in my mind that you could build a better helmet.  You can build a substantially better helmet with a little engineering discipline and a little bit of creativity. That was terrific and that was demonstrated by the fact that they led our helmet testing I think three years in a row with the ZERO1, and apparently had a new model coming out soon which may have even outperformed the 1.  Those are obviously terrific things.

And so for those of us who look at it and are in the business of trying to stimulate change to the helmet manufacturers, it gives us a lot of reason for optimism.  Given the business process they're in now, I'm very hopeful that this isn't the end of those technologies; that we will continue to see them in some form of fashion when they go through their receivership and come out the other side, and we'll keep an eye out for that.

And to the very specific point that you raised around players were in the VICIS helmet, it's still being reconditioned.  As long as it can be reconditioned and put into a good form and there are parts available, it will still be permitted on the field per our rules with our players.  It's not necessarily the end of the story, and as I referenced earlier, I hope that the story continues and continues in a positive direction.

A lot of our programmatic efforts are focused on stimulating change in the helmet marketplace, like we did when the VICIS won one of our competitions and took away a pretty good-sized prize to get them started into that marketplace. So we are going to continue to work on efforts to promote innovation, bring new actors into these spaces and hopefully continue to contribute – in fact I know continue to contribute – to the data and tools necessary for the helmet companies and for others to make inroads into that space and continue this innovation.  As I said before in my little trademark line there, we want to continue to see evolution, but we are really more interested in starting a revolutionary change in helmets, and I think that we are going to continue to see that in the coming years despite this hiccup for VICIS. 

On the impact of player self-report and culture change on concussion data:

DR. ALLEN SILLS:  Thanks for the question and I love when you say we are doing an even better job, that's really helpful.  You raise a great point and I'm going to give you a little bit of a long-winded answer.  Stick with me. 

I have no doubt that our detection efforts are in a far different place today than they were say ten years ago.  So trying to compare total numbers of concussions over that long a period is really, really difficult.  The detection efforts have changed dramatically and as I have said before and will continue to stand by, while no one's detection efforts are perfect, we have a really robust system in place which we feel according to our data, 99 percent of concussions that occur on game day over the last few years. We don't have this year's final numbers back yet. So you're correct to say that as players report more and as we do more detection, that would theoretically drive that number higher. 

At the same time, I would offer to you and say if you are trying to look at an effect of something like a rules change like lowering the helmet behavior or even of equipment, you have to consider more than the number of concussions.  That would be I guess on of the take-home messages.  We don't look at the concussion number only and say, oh, it was a good year or a bad year as far as that goes.  

We are looking at things like how many helmet-to-helmet blows were there and what was the nature of the contact and what was the severity of the injury.  So you have to really take a more of a comprehensive look, and that's why, to simply say, it was a good year, bad year based on what the concussion numbers is, is really I think an incomplete picture of what the full story is.  We will be analyzing all of that, and as you said clearly player self-report is a good thing and we want to continue to encourage that and we do think that that is reflected in our data to show that we are doing a better job, if you will, of detecting concussions that we have maybe in the past.   

On measuring the success of mental/behavioral health programs:

DR. NYAKA NiiLAMPTI:  I think that there's multiple ways, right.  So one of the things that we look at is increased utilization.  So clinicians can talk about, you know, they are being more integrated; so they are being much more active.  They are being utilized for referrals, whether that's internally or externally.  We look at the NFL Lifeline – one of the resources we have in mental health space – what do the numbers look like on that end.  Again, the question is: are players reaching out and are their family members reaching out to use some of the resources that are already in place, whether that's determined via the aggregated data we get from the EAP, those kinds of things. 

The other piece is, how many players do you see who are starting to reach out around mental health concerns, or making sure that there's that wider awareness of the importance of focusing on this.  We are looking at a number of different things and putting all those pieces into place saying, are we moving the needle forward.

DR. ALLEN SILLS:  One other thing I would add is the literacy of the coaches.  We see more head coaches taking an active role in many case standing up next to the clinician, saying, "This is Nyaka, she's our team clinician. She's a really important part of our staff and make sure you all know who she is and use that resource." Again, we are seeing that happen more and more around the league, which is a very positive change.

DR. NYAKA NiiLAMPTI:  This is the first year for example that a lot of the clinicians – while mostof the clubs already had clinicians – this is the first year that a number of them were at the training camp, traveling with the team and being fully embedded into that culture. 

On the XFL's game data:

JEFF MILLER:  That's really more of a question that our Competition Committee is probably going to address more than us. To the extent that there's health and safety implications for those rules changes, sure we would be interested and would probably spend time talking to them.  But at this point, I think it's really more of a competition committee question. 

DR. ALLEN SILLS:  But we work and collaborate with their health advisors, so there's communication back and forth.  In fact, I believe their Chief Medical Officer is on our Head, Neck, and Spine Committee.

JEFF MILLER:  Yeah so they're all friends of ours, and colleagues.

QUESTION: You're confident that if they discovered something new, you'd be open minded?

JEFF MILLER:  No question.  Very open-minded to learn whatever we can learn and from whomever we can learn it.  That said, we work with the NCAA too.

DR. ALLEN SILLS:  I was going to say referencing our work with college and professional leagues around the world, that's part of the our mission is to collaborate and share knowledge in both directions.

On tracking lower extremity injuries and weather:

LEIGH WEISS:  To answer your first question, we are in the process of looking at how teams practice and what their injuries look like and if Dr. Mack and her team are leading the charge on that. 

And does weather impact soft tissue injury?  You can't rule it out.  Weather has implications to hydration and recovery, and we are also -- maybe something is cleat or surface-interfaced.  We are taking a holistic approach and we are kind of looking at everything under the sun that we can. 

On youth football:

DR. ALLEN SILLS:  Yeah, I would just say obviously we continue to monitor all that data and research.  We're obviously not making policy there. 

The thing that I like to emphasize when people ask me about that, I feel like what matters at every age is reducing head contact.  You know, when you want to talk about what we absolutely know scientifically, we don't need to do a study to show that banging your head against something is not a good idea for the brain. 

The changes that we have talked and made in the NFL -- better equipment, how you train, how you practice, how you use your head or don't use your head, the lowering of the head behavior, all of these changes – that applies at every level and every age of sport. So I wouldn't, personally, myself say, oh, you know, those things only matter after a certain age. You know, they matter in the continuum of every level of participation, and by the way, they are not just unique to football.  They are unique to all sports.  So that's what I think, as a scientist and as a researcher and as a clinician, as I see patients in my office and parents and we have these discussions, it's about how is your child being taught and what are the techniques and what's the equipment, what's the supervision, do they have a concussion protocol, is there an awareness of the severity of the injury, what are the detection efforts. Those, to me, are the really, really important questions that I want to know no matter what the sport is or the level of play. 

JEFF MILLER:  I would just add we have been very supportive of USA Football's efforts to certify coaches so they better understand how to teach the game, signs and symptoms of concussions, adoption of emergency action plans, whatever the case may be. And we have seen, you know, Pop Warner and others change the rules, and I think that's probably a good evolution and people should continue to focus and talk about that. 

We probably should spend more time with other levels of the sport, just the health and safety side, forget the rest of it, in terms of what we can learn from them or what they can learn from us.  It's an ongoing conversation. 

DR. ALLEN SILLS:  The take-home message is we believe that reducing avoidable head contact is the key to safety in all sports.   

On mental health resources for current and former players:

DR. NYAKA NiiLAMPTI:  So I can't speak to specific players. One of the things that is a challenge -- so I'm a psychologist.  One of the things that we talk about is how the mental health system works.  You know, we can make resources available, make sure that we have removed as many barriers to access to resources as we possibly can and make sure that they are culturally competent and put them out there. 

What we talk about is making sure that someone who has a good -- if there's a concern about someone who needs mental health support, making sure that someone who has a good relationship with that person is the one who can kind of help bridge the gap and get them connected to something. 

So I think that's the stance we've taken when we talk about providing peer-to-peer education, as well as education within the building for people who are not clinicians. 

DR. ALLEN SILLS:  One thing I would add, you know how with our concussion protocol we talk about a lot of different people can activate that protocol.  It can be a spotter, a physician, a teammate, it can be a game official.  The same way with behavioral health, anyone in the club, in the team medical staff, in the player engagement staff, is empowered to – there is a robust team within the team, for example, a mental health group that meets within each club each month which consists not only of a mental health clinician, team physician, athletic trainer, chaplain, director of player engagement. So the point is there are multiple touchpoints within the club and we encourage people to actively raise concerns if they have them about a teammate, a coworker, whoever that might be, and so it is a point of recognition and emphasis for us. 

On whether sensor technology has a role in flagging an injury:

DR. ALLEN SILLS:  That would make all of our jobs a lot easier as team physicians and consultants. I think right now we are not at the point of being able to do that because that is a very heterogeneous injury; meaning that what we know in the clinical area is the same blow delivered to several different individuals produces very different outcomes, right. 

If four of us get the same blow, I might be knocked unconscious, Jeff might have a concussion, Nyaka might be fine and Megan's head might come off.  There are varying outcomes that can occur. 

So we don't yet understand enough about the basic type of physiology to know why that is. So to say, you know, if you get above this force level it's going to be an injury, but below it, you're safe.  We're not at that point.  Obviously a lot of people are researching that question, and I think we'll continue to learn more about it. 

But I'll give you a spoiler alert:  I don't think it will ever be quite that simple.  We know in medicine there's so many individualized factors and host factors that affect how people absorb energy, and also there are other things about, you know, the angular rotation, for example.  It's not just the linear impact.  It's the angle; it's the rotation; it's the velocity, the direction and probably the person's previous history and what injuries they have had in the past.  We see that in musculoskeletal. 

I don't know that we'll ever get to that point but certainly it's an area of ongoing study and the better the data that we have, like this mouth guard sensor data, the more we'll be able to start to approximate the next set of research questions that need to be asked. 

JEFF MILLER:  Yeah, let me finish where we started I guess. The goal, the long-term goal of our relationship with AWS, is the creation of the "Digital Athlete" platform, which is a version of individualized medicine to better understand how an individual human performs, is more likely to react and hopefully someday can predict somebody's risk profile against particular injuries so we can intervene as needed. 

Allen's discussion about the fact that -- there's a fair amount of vagueness around particular injuries or human reaction to those injuries is a hurdle.  But the collection of really specific data and the application of that through artificial intelligence or machine learning or all these other different methodologies that we are pursuing with our partners is going to get us closer to closer over some period of time to being able to understand how a particular individual is going to behave, and to intervene where necessary, and treat where appropriate and get that player the best possible health he/she can be. 

So, your mind goes to a similar place to where ours does and we are putting resources against it.  It's not space age, but it's not here today, either.

DR. ALLEN SILLS:  Another part of that answer, something you've heard us articulate several times:  We want to see head contact reduced. So while we want to learn about these levels and how people respond to it, I think that we also have just, again, a continued, ongoing major focus and commitment on reducing head contact because we know we don't need to prove that point. 

 

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