Why Flag Football Until High School

WHY FLAG FOOTBALL UNTIL HIGH SCHOOL

CHRIS NOWINSKI, PH.D.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF MY RELEVANT BIOGRAPHY

• Founding CEO, Concussion Legacy Foundation • Co-Founder, Outreach, Recruiting, Education, and Public Policy Leader, Boston University CTE Center • Co-Founder, VA-BU-CLF Brain Bank • Ph.D. in Behavioral Neuroscience from BU School of Medicine • All-Ivy League DT for Harvard University

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF IT’S TAKEN A DECADE TO GET HERE • It took me over a decade of studying CTE, & over 300 cases of CTE in football players, to come to this conclusion

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF FLAG FOOTBALL UNDER 14 FIRST PROPOSED

Criticism from colleagues:

"I don't know what is magic about the number 14. People suggest radical solutions, but is it practical? Is it going to be done?“

"I don't feel like we need to have all the science lined up before we make policy decisions, but those decisions should be made based on common sense and science rather than randomness."

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DISCUSSION OUTLINE

1. CTE definition 2. CTE causation 3. Modifiers of CTE risk & phenotype 4. Flag Football Under 14 5. Football industry response 6. Legislating Safety

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WHAT IS CTE?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF PUNCH-DRUNK

• First named in 1928 by Dr. Harrison Martland

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF A NEGLECTED DISEASE?

• Prior to 2005, there were only 45 cases Primary Trauma Source 45 of CTE in the Boxing 39 medical Head banging behavior 2 Soccer 1 literature! Circus clown 1 Battered spouse 1 Epilepsy 1 ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 8 * Source: McKeet et al. 2009 © 2011 SLI MICROTUBULES INSIDE THE AXON

• Inside the axons are microtubules, which are stabilized by Tau protein molecules.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF AXONAL TRANSPORT

• Live imaging of axonal transport in hippocampal neurons

Keith A. Vossel et al., "Tau Reduction Prevents Aβ-Induced Defects in Axonal Transport," Science Express, Published Online September 9, 2010. ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ABNORMAL TAU IN THE AXON

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 2015 NINDS CTE CRITERIA • In CTE, the tau lesion considered pathognomonic is an abnormal perivascular accumulation of tau in neurons, astrocytes, and cell processes in an irregular pattern at the depths of the cortical sulci.

Tau antibody staining of neurons and Lower field photo illustrating the neurites in perivascular pattern (arrow focal nature of the tau staining at pointing to blood vessel). depth of sulci (asterisk at bottom of sulcus).

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF MODEL OF ROTATIONAL BRAIN INJURY

Videos courtesy of Dr. Joel Stitzel, Wake Forest University - [email protected] ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF MILD CTE

Reported symptoms:

Stage I: (mean age 28) Headaches and issues related to attention and concentration

Stage II: (age 44) Symptoms expand to include depression, explosivity and short-term memory impairment

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF SEVERE CTE

Stage III: (age 56) Cognitive impairment and problems with executive functions, specifically planning, organization, multitasking and judgment

Stage IV: (age 77) Full-blown dementia (i.e., memory and cognitive impairments severe enough to impact daily living) in 90%

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF CTE in an Active College Football Player • Co-Captain of 2010 Penn Football Team • Began playing football at 9 years old

• Committed suicide April 26, 2010, at the age of 21

• No history of concussion • No history of mental illness • Mentioned doing poorly in two classes to his parents the day before hanging himself in his off-campus apartment

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 17 OWEN THOMAS – STAGE 2 CTE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF 18 DAVE DUERSON

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DAVE DUERSON

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF NEW YORK TIMES

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF THE PEOPLE BEHIND THE NUMBERS

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF IS CTE CAUSED BY HEAD IMPACTS?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Walter J. Koroshetz, M.D. National Institutes of Health Director, National Institute of Neurological Disorders and Stroke

“I don't think there's any wiggle room. It's pretty clear this is due to head injury. Whether there are other things involved, and when it starts, that's hard to know, but I don't think there's any question that it's related to head injury.”

March 6, 2014. ESPN

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Daniel Perl, M.D. Professor Director of CTE Research Department of Defense Uniformed Services University

“CTE is only seen in the setting of repeated head trauma. At the end of the day, this is produced by head trauma. I'm sorry, that's what all the research says.”

March 6, 2014. ESPN

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Individuals may have a higher risk of developing CTE in the future if they engage in activities that increase their chances of having repetitive hits to the head.

Researchers currently do not know the incidence and prevalence of CTE, but they do know that CTE does not occur only in athletes. The greatest risk factor for CTE is the number of years of exposure to repeated head or brain injuries (subconcussions in particular).

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF RISK MODIFIERS FOR ENVIRONMENTAL EXPOSURES – IS SMOKING A MODEL?

Smoking CTE 1 Packs per Day Hits per Season 2 Age at First Exposure Age of First Exposure 3 Years of Smoking Years of Brain Trauma

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF LEGEND STUDY – BEHAVIORAL DYSREG • Cumulative Head Impact Exposure Predicts Later-Life Depression, Apathy, Executive Dysfunction, and Cognitive Impairment in Former High School and College Football Players. Montenigro PH, Alosco ML, Martin B, Daneshvar DH, Mez J, Chaisson C, Nowinski CJ, Au R, McKee AC, Cantu RC, McClean MD, Stern RA, Tripodis Y. J Neurotrauma. 2016 Mar 30.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF META-COGNITION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF EXECUTIVE DYSFUNCTION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF DEPRESSION

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF APATHY

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF COGNITIVE IMPAIRMENT

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF PITCH COUNTS

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF RISK FACTORS – ENVIRONMENTAL EXPOSURE

Smoking CTE 1 Packs per Day Hits per Season 2 Age at First Exposure Age of First Exposure 3 Years of Smoking Years of Brain Trauma

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF EARLIER AGE OF 1ST EXPOSURE TO TACKLE LINKED TO EARLIER ONSET

AnnalsOF ofSYMPTOMS Neurology 2018.

• 246 American football players – 211 CTE (126 CTE-only) – 35 without CTE (26 with progressive pathologies, 34 with symptoms)

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF AGE OF FIRST EXPOSURE TO TACKLE FOOTBALL AND CHRONIC TRAUMATIC •ENCEPHALOPATHYFootball players have been starting tackle younger

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF AGE OF FIRST EXPOSURE TO TACKLE FOOTBALL AND CHRONIC TRAUMATIC

• EachENCEPHALOPATHY additional year of youth tackle football was associated with earlier cognitive sx by 2.4 years & behavioral/mood sx of 2.5. • Starting before age 12 was associated with an onset of symptoms 13 years earlier.

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF RISK FACTORS – ENVIRONMENTAL EXPOSURE

Smoking CTE 1 Packs per Day Hits per Season 2 Age at First Exposure Age of First Exposure 3 Years of Smoking Years of Brain Trauma

• Contact sport athletes (80% football players) who played 9 or more years had 6x greater risk of Lewy Body Disease, which causes Parkinson’s disease symptoms, that those who played 8 years or fewer.

• In the community-based cohort, years of contact sports play were associated with neocortical LBD (OR = 1.30 per year, p=0.012)

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ALL-TIME GREATEST DEFENSE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF BENEFITS UNIQUE TO TACKLE FOOTBALL?

The consensus top 5 NFL players all-time did not play football until high school

1. Jerry Rice 2. Jim Brown 3. Tom Brady 4. Lawrence Taylor 5. Walter Payton

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF EXPERTS DISCOURAGE YOUTH TACKLE

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WHO OPPOSES THIS?

“There is no injury or concussion spike in Bantam hockey that would offset the 400 per cent increase in concussion risk that we see in Pee Wee leagues that allow body checking.” - Dr. Carolyn Emery

Emery CA. Risk of Injury Associated with Body Checking Among Youth Ice Hockey Players. J. Am. Med. Assn 2010. Black AM 2017 Br J Sports Med. 2017 Dec;51(24):1767-1772. ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WHY DID THEY MAKE THE CHANGE? "What we find is that an 11-year-old brain is more susceptible to concussion. The 11- and 12-year-old brain is not cognitively developed to anticipate being hit.

So if you can't anticipate it and you can't protect yourself, you're putting yourself in a predicament to suffer a more severe injury." - Kevin McLaughlin

Mihalik J, Blackburn JT, Greenwald RM., Cantu RC, Marshall SW, Guskiewicz KM. Collision Type and Player Anticipation Affect Head Impact Severity Among Youth Ice Hockey Players. Pediatrics 2010;125(6): e1394-e1401. ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF THE NFL THINKS IT’S BAD FOR BUSINESS

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF POP WARNER

• Jon Butler, executive director of Pop Warner: – “First, we have a duty to football. This means too much to people and has for so long we can’t turn our back on it. We figured out tobacco. We figured out asbestos. We’ll figure this out.” (August 22, 2019)

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF USA FOOTBALL PILOTS PROGRAM TO ATTRACT MORE YOUNG PLAYERS • USA Football CEO Scott Hallenbeck – “My son started playing tackle football at 7, and I still wonder if that was the best thing to do. When you look at it from a skill development lens, why can’t flag football be like T-ball is for baseball? You can learn how to play football without contact.” (AP, August 16, 2019)

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF FOOTBALL STATE LAWS

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF STATES WHERE LAW HAS BEEN FILED

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF BEST DEFENSE FOR YOUTH TACKLE FOOTBALL IN ILLINOIS • Geoff Meyer, president of the largest youth tackle football program in Illinois:

“The science, in fact, concludes that it is the continuation of playing that could contribute to the risk of developing CTE or other problems.”

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Source: CDC

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF WOULD YOU SIGN UP FOR THIS?

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF LET’S USE COMMON SENSE

1. Do I really have to convince you that hitting a child in the head hundreds of times is a bad idea?

2. Audience survey 1. Does anyone hit their own kids in the head? 2. How about yourself?

3. Of course we, as educated adults, don’t get hit in the head voluntarily!

ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF THANK YOU

Email me: [email protected]

• @ChrisNowinski1

• @ConcussionFoundation

ConcussionFoundation.org

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