Interview Tom Talavage

An associate professor of electrical and computer engineering at Purdue University and co-director of the Purdue MRI Facility, Talavage authored a study [PDF] that found cognitive damage in high school football players who had not been diagnosed with a concussion. "Nobody really expected to see this at the high school level," he tells FRONTLINE. "And we certainly didn't expect to see it throughout the season in such a large percentage of the players." This is the edited transcript of an interview conducted on March 1, 2011.

• Background on his study and its surprising results
• The consequences of poor football technique
• Do head injuries spell the end of high school football?
• How blows to the head impair a player's memory
• Change the culture of football, and you'll make it safer

What is the study? What were you looking at? And how?

The original intent for this study was to look at football players and understand why some players experience concussions from a particular blow or series of blows they experience to their head, whereas other players who experience very similar blows did not.

The way we were originally going to go about this study was to have football players come in before the season, undergo some neurocognitive testing, just to evaluate how readily do they perform certain simple tasks related to working memory or detecting and remembering patterns on a screen. And then we also were going to do neuroimaging where, in particular, we're using a technique called functional magnetic resonance imaging, fMRI, which looks at blood flow in the brain and therefore tells us what regions of the brain are involved in a task.

We wanted to evaluate these players before the season using these techniques, monitor the blows they experienced to the head during the season, then have them come back at various points during and after the season to determine whether or not we were detecting changes in the neurocognitive testing or the functional imaging, relating to these concussions in particular.

So the original intent of the study was to study concussions in people who had similar hits. It turns out that concussion rates in a high school football game are not insignificant, but on the order of less than 10 percent, or around 10 percent of the players during the course of a season will get a concussion. So on our particular football team we were studying, they had about 50 players, and so over the course of that season, they experienced five concussions, it turned out.

But we didn't experience any for quite a few weeks. And we decided we would start bringing in some of our controls, some of our players who had not experienced concussions, to just begin to understand whether or not there were any consequences from the blows that they were getting to their head.

What we found, by the end of the season, was that in 50 percent of the players [who] were brought in who were not concussed, we were detecting changes, either in their computer-based testing and/or in their functional MRI data, showing that something had changed in the way their brain was performing a particular set of simple tasks.

This was not unexpected [on] the basis that we know that blows to the head have some long-term impact. There are certain football players who have retired from the NFL who have notable damage in their brains, even in the absence of a history of concussion. But it was unexpected from the point that nobody really expected to see this at the high school level, necessarily, and we certainly didn't expect to see it occurring throughout the season in such a large percentage of the players.

Now, that first year, this was a relatively small group. But we've now completed a second season of monitoring our football team, and we have the exact same story, where about 50 percent of the players who did not experience a concussion are showing changes in their computer-based testing or in their neuroimaging data. So what this is telling us is that the subconcussive blows, these blows that do not result in overt symptoms, are changing the way that their brain works. Most likely this is a compensation, a way to overcome a short-term deficit.

So now what we're very interested in understanding into the future is, can we predict where these deficits are occurring based on where the likely injury is occurring due to the mechanical forces associated with being hit? And then, do those deficits tie to what we see in these ex-NFL players who have retired and have this significant brain damage? Is there a connection?

Are we seeing the beginning of this where, if more of these players were to succeed in terms of their football playing, go on to play in college, go on to play in the NFL, is that why we have a higher risk of dementia and Alzheimer's-like symptoms in ex-NFL players or people who have played professional football for a long period of time relative to the general population?

Why were you surprised to find these results in high school?

... Ours is one of the first few studies, if not the first, to extensively study players who are not symptomatic, who do not have symptoms associated with concussion in terms of slurred speech, they're dizzy, blurred vision, slow to process. This was really one of the first times that a group of people who were brought in for analysis were participating actively in a sport -- particularly in a sport involving blows to the head -- who were just healthy. ...

So you're looking at people who are not showing --

Any signs.

-- or otherwise symptoms of concussions.

We don't know if we put them in a clinic if they would show symptoms, but they certainly are not showing any signs that would lead to them going to see a doctor. The athletic trainer, who's very familiar with them, is not seeing any cause for him to send them to the team doctor, and their families aren't seeing any cause to have them investigated. So they are, for all practical purposes, asymptomatic.

And we think one of the main issues that comes out of this is that this is probably far more prevalent than expected. Already it was anticipated, from previous literature, that only about 50 percent of concussions are likely actually reported … by the players. They don't want to come off the field; they want to keep playing. So we expected to at least find a few players who would show some level of impairment.

But now, after two seasons, where 15 of our 29 players who were not concussed who are showing some level of functional symptom, meanwhile, we have about eight to 10 concussions. Either that 50 percent is an underestimate or not reported, or we really are now seeing something that's slightly different.

In truth, it really is something different, because a classic definition of a concussion is really given based on a series of tests that are essentially provided to an individual. On a sideline, you may be asked to count backward from 100 by 7, or to recite a list of three words I give to you, or to maybe tell me the day of the week, or maybe recite the months of the year backward. And all of these tasks, it turns out, rely upon our verbal system, on our ability to repeat and convert information into speech.

What we have found with these functionally impaired individuals, as we're calling them, is that the vast majority of them are showing symptoms not in the verbal system, but in their visual memory system. So this is a system that is not going to be called upon when I need to verbalize information or communicate information, but it's a system that, when we give them a specific task, say, "Here's a screen filled with Xs and Os; where were the Xs?," or their performance degrades as they accumulate these blows to the head.

And we do find that there's a pretty strong correlation between the number of blows that they are experiencing, in a reasonable window of time, and the level of their performance. So the more hits they've taken to the head, the more their performance on these tasks and the more their functional MRI activation is altered. So that's where we're now saying there must be some level of injury taking place. The question becomes where, and does this level of injury produce any long-term consequences, or do these players recover by the next season?

But you weren't expecting to find this in these players. This was a control group.

Yes, this was a control group. …

Our initial thought was that we had done something wrong with the computer testing or somehow messed something up in that regard. But when we ultimately went back and we finally evaluated our neuroimaging data at the end of the season, we were noticing that quite a few of our players were showing very wrong activation patterns relative to what we had seen of the players prior to the season. And when we finally looked and evaluated and cross-checked these lists, we were finding that the people whose brains were now behaving very differently were the same people where we were showing a difference in the neurocognitive testing.

And that's really when we finally were able to put it all together and say we have a deficit. It's not just that they didn't take the test seriously; it's not that they just didn't want to be taking the test. It's that their brain simply couldn't do the tasks as well; it's operating less efficiently.

And this is because of the repeated blows to the head that aren't producing concussions, but are blows to the head nonetheless.

That's correct. We strongly believe that. Our data strongly support that argument.

We've had a few people try to argue that this is just, "Well, they've had alcohol consumption," to which the question, well, it doesn't make a lot of sense to us either. Why would they be drunk only during the season and not outside the season? And why would it correlate with the number of blows they took? "Oh, well, maybe they wanted to medicate." But the reality is, the literature actually exists to argue that unless these players were actively rip-roaring drunk, their fMRI activation would not be changing in the areas where we're seeing the change. So we know that's not the cause.

Other people have claimed it might be a motivational issue. But the one thing we can argue is during the second season, the correlation between the degree of neurocognitive-testing impairment and brain-activation impairment is not necessarily strong. The presence of neurocognitive impairment matches having a brain-activation change, but the degree doesn't. So we know that their brains are truly impaired at this point, and the most probable cause is that these players are taking a lot of blows to the head.

Our particular team, there's two contact practices every week -- Tuesday, Wednesday -- game on Friday. Some of these players are averaging over 100 to 150 blows per week to the head of at least 14 G's [gravitational force] -- for a reference, getting a little head slap in the back is somewhere on the order of about 10 G's. So it's not necessarily a substantial blow at 14 G, but it's a pretty good indicator that if you get enough of those over a period of time, it adds up. …

Who are the players on a high school football team typically who are sustaining those sorts of hits?

The players who are experiencing the most blows of any sort are really the linemen and the linebackers. And this makes sense, because on every single play, a wide receiver can run down the field, but he doesn't necessarily get hit, particularly if the ball's not thrown to him or it's just a running play and he's just blocking and he may be, appropriately, using his arms and shoulders. Quarterbacks, they get hit, but not that frequently. But the linemen are taking a blow basically every single play. …

So this group, in particular the linemen, what's been interesting is that the players who are most significantly impaired, not just from the standpoint of taking a large number of blows, but they're also the group that tends to take a large number of blows to the top front of the head. And the top front in the head, in our data, tends also to correlate with failures on these memory components. And we think that's a pretty interesting finding, because of course that seems to have a potential coupling to this long-term deficit in terms of potential risks of dementia, potential risks of this chronic traumatic encephalopathy [CTE], where you have essentially scar tissue forming [on] the brain.

How many blows are these linemen taking? ...

Our lead lineman, so to speak, accumulated over 1,700 blows to 1,800 blows in each of the two seasons that we studied [him]. So for one of our players, he's taken about 3,600 blows over the course of two seasons that exceeded 14.4 G's.

And this is just the season. This isn't the off-season.

This is just in the season. So when he's doing practices and games, so there are about -- there's 10 weeks in their season, roughly, so that's about 30 practices and games there. And there are about eight to 10 practice sessions involving contact prior to the season. So overall, in fewer than 40 sessions, these players, some of these players are accumulating as many as 1,700 hits to the head.

And if it's a high school football team worth its salt these days, it's practicing beyond that in the off-season.

Yes, that's correct. So they do certainly have off-season practices. So we are monitoring them during the official contact period, when there's official contact allowed. But certainly many of these players participate during the summer, in 7-on-7 tournaments or other types of drills, where there won't be quite as significant [amount] of contact, because they're often done without pads, in some cases without helmets, but certainly these players are still going to experience some level of contact.

And this doesn't even begin to address the fact that certainly many of these players are doing this recreationally with their friends, out at the park or in the yards, likely tackling, likely involving them falling to the ground, potentially involving them hitting their head on the ground or on each other's legs or arms or what have you. Within the context of the season, we can track them. We know what happens during the season is a function of these blows, and certainly there's another multiplier to account for the remainder of the year.

How long term do you think these effects are?

This is where we don't know yet. We've only been able to complete two years of the study thus far, and we're looking forward to starting season three this fall.

What we have found [is] that the players who underwent this study in season one and came back in season two -- it's 16 returnees from season one to season two -- their preseason data from season two is very similar to their preseason data from season one. So clearly there's not a precipitous drop-off after one season.

The question that comes from this, though, is we are uncertain whether this is 100 percent recovery, or is it 99 percent recovery? The sensitivity of the tests that are being applied here isn't precise; they aren't perfect. If it's 100 percent recovery, that would be wonderful, and then we really wouldn't expect there to be any long-term consequences from playing football. Obviously, that's probably unlikely to be true.

So instead, the question becomes, is this 99 percent, 98 percent? If it's 99 percent, you probably won't from year one to year two see a difference, but in the future, when we're able to study freshmen through their senior year, and we have a couple of players who have expressed an interest in continuing to participate in our study while they're playing in college, after five, six, seven years, now if it's only 99 percent recovery, you might get to the point where you can start to see that there actually is a downward trend in their performance.

So we're hopeful this long-term element of our study will start to elucidate the question of, is it really full recovery, or are we starting down that path that can lead to long-term consequences for these players? ...

How is their memory impaired? And whether they're recovering fully or not, what are you seeing that's happening?

What we're seeing is that when we give players a relatively straightforward task in terms of letters being shown on a screen, and your job is to match the letter you see on the screen now, to decide is this the same letter as was shown two letters previous, a two-back task, or the same letter as was shown one previous, a one-back task, what we're finding is that the very simple task of "Does this letter match the ones that I was just shown?," the activity in the brain starts to increase as you've received more and more blows to the head, which suggests that now the brain is having to work harder and harder to perform this relatively simple task. And what we find is that when we evaluate their brain's response to that two-back task, so "Does this letter match the one that I was shown two letters previous?," we start to see that some regions of the brain continue to increase, but other regions of the brain start to decrease. And when we're getting a decrease, what it is suggestive of is that the individual is no longer able to do this task using the same method they previously have used.

So in a letter task on the screen, what you have is a letter shown on the screen, and I want to remember that letter; I have two options. I can remember the letter, A, as a sound, a phoneme, or I can remember the particular orthographic shape of the A, the actual shape of the letter. What we're finding is it appears that most of the time, even though when the subject is doing this task, they are very frequently subvocally rehearsing the letter they're looking for -- "I'm looking for an A, or A, B," something to that effect -- what we really find is that their brain is mostly using the shape of the letter to trigger, yes, that's what I'm looking for. And what we're finding is the more and more impaired they're becoming, in the two-back task, they start shifting more and more to that verbal strategy as opposed to the visual strategy.

And this is about memory.

And this is memory: How am I determining what I'm looking for? This working memory load of "What shape, what letter am I seeking to find?," they're moving to A; they're shifting from a visual memory procedure to a verbal memory procedure. And this type of shift, when you're suddenly moving from strategy A to strategy B, suggests that the brain is now no longer able to perform strategy A under the conditions of that test.

Whether this means that the brain has a more limited capacity to perform its work because it has been injured -- that's the most likely cause -- and so the question then, it probably means that this task A, the strategy A that it normally wants to use, is probably fast, probably energy-demanding, and now the brain cannot support that activity, so it just stops recruiting that pathway. And so that's why we see in the fMRI this drop in activation.

The key point to make in all of this is that our players are still able to do the task at the same performance level as they did prior to the season. But now their brains are using a different strategy to get there. And the key is, after the season, they return back to their first strategy, so that's why we're able to argue that there really must be something taking place in the brain, where they're going from a very good level of performance, dropping down, and then now they're coming back up once they're no longer experiencing a regular large set of blows to the head.

And there's a correlation between the number of blows and the level of impairment?

There's definitely a correlation between the number of blows they've experienced in the week preceding the assessment and the level of impairment. That also happens to correlate to the total number of blows they've taken during the season. But the reality is, if a player tends to take a lot of blows in one week, they tend to take a lot of blows in every week. So teasing apart that number is yet to be done.

I know you can't say this conclusively, but say that there are long-term effects; that you don't just come back to 100 percent; that there is this small degradation every year. Play that out for me. What does that look like in four or five years?

So what it probably would mean is that in four or five years, that these individuals are starting to experience difficulties with ... visual tasks. So odds are good this might have an effect on spatial reasoning, mathematical capabilities. There's the potential, as I've said, that this could actually be memory function. ...

I think we suspect that we would see that these students are having a little more difficulty in their mathematics courses, in their art-type courses or design courses as a function of the amount of damage they're taking during a particular season. So we certainly would expect to find a deficit maybe within the semester involved in football.

There's a little bit of a confound here, though, in that most of the players who are playing in high school football, for example, most high school eligibility is determined only by your grades during the semester of the season. So these players also tend to spend a lot more time on their academics during the season, which could potentially mask any effects we would really expect to observe. So a larger question would be, as I said, getting into maybe standardized testing and understanding, do we see changes in standardized testing over time?

So, to be really reductive here, are we basically saying football makes you dumb?

(Laughs.) There's a risk. There certainly is a risk of it. But I don't want to say that it's football necessarily makes you dumb. I think it's a very important point to be made here: that we're seeing the consequences of very large numbers of blows to the head coming from, in our particular case, two contact practices a week, each lasting two to three hours, plus a game every week.

There are teams that don't practice with contact every week. There are teams that might have different techniques. This is actually going to become a player-specific issue. So this is not a necessary consequence. I want to make sure that that's not conveyed. It's very important to understand that football in and of itself does not make you dumb.

The complexities of actually understanding a play, understanding your role, understanding a scheme, they're pretty challenging. They're actually really, really tough. But certainly playing with a poor technique, playing in a situation where you are exposed to a lot of physical damage, has the risk of impairing your abilities. I don't want to say it makes you dumb. It impairs you. ...

How much of what you're seeing do you think is due to poor technique? And what is that poor technique?

I think a good portion, a fairly good portion, at least 50 percent, probably is a large function of technique. ... Some of the players that we have on our team have not very good technique, to be quite honest. And what you'll find is, they will launch into a play, and they will lead with their helmet. Other players will more correctly keep their head up, try to get their arms up as a blocking technique, or when they're rushing, they will try to get their arms up as a means to push the offensive lineman out of the way. Those technique differences lead to a very large difference in the total number of blows experienced and where those blows are experienced on the head.

For example, from season one to season two, we have a particular offensive lineman and a particular defensive lineman. Both years, they were basically numbers one and two in total numbers of hits. Our offensive lineman in the second season decided he was going to change his technique, mostly because he's very interested in playing at the collegiate level. His change in technique drastically reduced the number of blows he experienced to the top front of his head and had a moderate reduction in the total number of blows he experienced.

When we brought him back during the season, there were definitely differences. In the first season, he was clearly one of our functionally impaired group. He clearly was showing substantial changes in his neurocognitive testing on the computer that persisted beyond the season, and he showed changes in his fMRI that persisted beyond the season. Here, in the second season, his neurocognitive testing never detected any deficits, and from an imaging perspective we saw substantially less change in his fMRI activity. There's still some, because he's still getting hit, but his technique changed the distribution. ...

So even when we talk about the number of hits mattering, it's not really just the number. It's also where. That's got to be a line of future research, to understand that distinction.

And the "where" can be controlled.

The "where" is what you can control with technique.

So the second season, we also had an opportunity to examine and monitor a second local team. Now, we don't have the same types of data from them, but we got to observe them, and we did a little bit of videotape of them. And there's a dramatic difference between the technique across our two high schools. Whereas the team we've really been studying has a large number of players who do lead with the helmet and experience a large number of blows with their helmet, our second team has a much greater tendency to get arms up for blocking, and they tend to, at least from observation, to take many fewer blows to the head. And we think this has a potential effect on their neurological health.

Which team wins more games?

The team with better technique.

Really?

They are in a different class, but they were state champions last year, and this year I believe they still got to the regional final, whereas our other team was 1 and 20 over the two seasons. ...

Whose responsibility is it to teach good technique, and what are the consequences that you're seeing of lack of good technique?

Obviously, you hope that during the practices the coaches are doing everything they can to emphasize proper technique to the players. And I think certainly that's their intention. How much they necessarily understand technique is, I think, a fair question at times.

One of the things that we've kind of discussed as a group is that when you used to have these lower-tech helmets, leather helmets or even no helmets years and years ago, you really were obligated to learn to tackle properly, which really meant kind of leading in with the shoulder, bringing the arms around, and your third point of contact was the head. But your head was the third point of contact sort of incidentally, because you physically can't get the shoulder on somebody, the arms around somebody without the head making contact.

What has seemed to happen is, as we've developed the technology and the helmets have become stiffer and harder and done a better job of protecting you from, say, dying on the field due to a skull fracture, you actually end up with a weapon. It's a great weapon, and people like to use it. ...

It has a greater tendency to stop the other player. It hurts him when it hits him. It's a much stronger impact on his body, [has a] greater tendency to knock the ball loose; therefore it's kind of become a tactical weapon. But the consequence of that is you're now imparting a lot more force on the defensive player's brain than was previously experienced.

So this is actually an interesting point, because I think most people think it's the guy that's getting hit. When we see the NFL cracking down on hits, it's because ... [a player hits another player] and knocks him out. But the reality is, every time [the player] is hitting somebody, he is doing damage to his own brain, potentially. So he almost needs the protection potentially more than that one player he hits hard once, because that person isn't taking 150 blows per week to the head. He may get a concussion, but we treat concussions, because we can detect concussions. ...

The player who's continuing to hit his head, continuing to show these functional deficits, we don't know that he's got those functional deficits because we're not normally looking for them. We don't have means to detect them on the sideline. He keeps playing, potentially keeps injuring himself; he may actually be at greater risk of long-term deficits. So that's kind of an issue related to that.

So the technique effect here is that if you really look at some of the great NFL players -- for example, let's look at a [former NFL cornerback] Ronnie Lott or a Ray Lewis [linebacker for the Baltimore Ravens] -- tacklers, hard tacklers, and you watch the footage of their biggest hits, almost every single one of those biggest hits, you will see that they lead with a shoulder, not with their helmet. They're doing a much better job of tackling, and that may be why they have such long careers in spite of their sort of reputation as violent defenders. The truth is, they're probably not hurting themselves as much as a player who would be leading with his head all the time.

But where does this bad tackling technique come from? Where have you seen it on a high school level?

On the high school level, you'll see an offensive lineman who will launch off the line, keeping his head low. His goal is to stay low, like his coach is telling him. But what he does is, instead of keeping his center of gravity low, he lowers his head. He's no longer seeing the field. He just launches straight forward, hits himself in the top of the head.

A defensive tackler comes in, and instead of getting a shoulder on the player, he launches in with his head, hits first, often doesn't succeed in tackling the player. But he kind of seems to get credit for the fact that he tried to lead with his head, and he tried to hit him really hard. And we kind of glorify that, even though the fact is he actually failed to tackle the player. ...

What do you see in practice?

In practice we actually see that some of this technique deficit may be unintentionally encouraged by the coaches, where they often have players just line up, one across from another, and run forward and hit one another and tackle one another, or attempt to tackle one another. And they essentially are getting a reinforcement on the basis of "Wow, that was a really hard hit," and that really-hard-hit percept comes from the loud "bang" you get when their helmets hit one another and collide with one another. And they'll do this sometimes for 15, 20, 25, 30 minutes at a practice.

And ultimately, it's not clear that this is actually teaching them how to tackle, because they rarely bother to wrap one another up. Their primary goal seems to simply be, you know, like rams, hit one another.

If this type of behavior is encouraged, it's entirely possible that these people are missing the point, then, about what they're supposed to do on the football field, and then are just locked into a mode of "I'm going to hit him hard, and I'm going to hit him hard with my helmet."

And that's unfortunate, because that's not really what the coach is wanting to come out of that drill. But it may be what the players are taking away from it.

Now, we talked a little bit about CTE [chronic traumatic encephalopathy] and what researchers are beginning to see later in football. We know what's been going on in the NFL, and with [Penn defensive end] Owen Thomas, who died and whose brain was opened and they found CTE. ... Do you think that what you're finding in these players could eventually be CTE?

Yes, we do, mostly because of the fact we are observing changes in how the brain is operating, even though we're seeing them primarily on a short-term level, and we haven't had an opportunity to look at a long-term level. We shouldn't be seeing changes in brain metabolism, the way the brain is operating, unless something is not operating correctly.

If something is not operating correctly within the brain, that probably means that there has been at least a short-term deficit or a short-term damage to some region of neural tissue. If that short-term damage is not allowed to heal, it will become permanent damage. Therefore, we really do believe that we are seeing kind of the headwaters of what is essentially this CTE.

Now, whether what we are seeing in our players, for these particular players, will result in CTE is unclear. At that point, we probably have some level of a genetic component: How rapidly do we heal? How susceptible are we to CTE as an individual? Therefore we don't, can't, we aren't going to say that these players are going to get CTE. But we do strongly believe that what we are seeing has a severe risk of becoming that if these players continue to play with this type of technique, continue to take these numbers of blows to the head, and do this for many, many, many years.

A player who stops after his high school career, I wouldn't go so far as to say that this will become CTE. Even if a player goes on to college, I wouldn't necessarily say this goes on to become CTE, but I would certainly assume and believe that the risk increases the longer they continue to play and continue to accumulate this number of blows to their head.

What does this mean for the future of high school football?

This is not the end of football. ... None of the damage these players are accruing, none of the blows they're accruing are really a necessary component of participation. If we get a better understanding of how the energy associated with a blow is getting transferred to the brain, we should be able to reduce the risk of that neural-tissue damage.

If we can improve technique so that players are not getting hit in particular portions of the head, or are making it more difficult for themselves to be hit in different portions of the head, or they hit with that portion of the head less often, we should be able to reduce that hit count, that number of blows they're taking.

And I think a very fair question is, how often do we really need to be involved in contact practice? Our particular team has two contact practices per week. At least two-thirds of the blows experienced by these players are taking place in practice, because not everybody is playing every weekend.

So you're now saying, well, if I have a player who accumulated 1,800 blows, and I can knock out 1,200 of those blows over the course of the season, I'm now talking about a player who's really only taking 600 blows to the head over the course of the season. Well, by and large, our players who are down in the 60-blows-per-week-or-less level aren't really showing that much in the way of deficits. They aren't showing much in the way of impairments. So I think there is at some point a way we can play with these other factors that will not affect either the game or the quality of play. ...

Teaching proper technique, we can reduce the number of blows that these players are experiencing. Working with the helmet designers, we can potentially even reduce the amount of energy transmission that's taking place to the brain. At the present time, it's not yet clear that the helmets are actually reducing the energy being delivered to the brain. Some of them may actually be amplifying it; some of our data suggest that. And we can really work on how often our player is getting hit.

We can still play the game, and we can still play the game at a high level. I think this is where the case of Saint John's in Minnesota -- we're talking about a team that does not have contact practices, yet has won championships at its particular level of collegiate football. We don't have to be a bad team just because we don't practice. Instead, maybe we're a better team. Maybe we focus more on technique, proper technique, proper blocking, proper tackling technique. Maybe we focus more on knowing exactly where we're supposed to be on our play, what our blocking scheme is, what our defense scheme [is].

There's nothing here that says that we can't improve the health and the safety for football players without affecting the quality or even the style of play of football. We can keep playing football. We really can. And we can keep playing football at the high school level. We just have to maybe be a little bit smarter about how we go about doing it. ...

However, we're talking about high school football. And especially in some parts of the country --

It's religion.

-- that's a very hard culture to change.

The largest issue we do have, or the largest concern we have, really, is about the culture. There is an ingrained culture where football is life. ... Football is life for many people. It's called a religion in some cases, with justified basis there. Changing the culture is hard. But I think that if we are able to change some of the equipment, improve the equipment, we can do a concerted effort in terms of education of athletic trainers, of coaches, I think we have the potential to change it. ...

As I said, locally, when we're looking at our two teams, the team that has what you would really call better technique, they're extremely successful. So there's no evidence that not having all of this contact is a bad thing. And I think even if you, again, staying within high school, but taking just a moment to say if some of these players are going to the NFL, NFL doesn't have contact practice on a regular basis. Most of the time they'll have pads once in a while. But it actually tends to be newsworthy when a team practices in pads.

It's not a necessary component. We can practice, we can be good a football without all this contact.

How concerned are you about the fact that high school players at the high school level are bigger and faster and stronger now?

I think the fact that high school players today are bigger and stronger and faster has a very large effect on why we're starting to see maybe more of these consequences. I mean, on our particular football team, there are players who are bigger than Jack Lambert and Jack Ham who were on the Steelers defense in the 1970s. They're bigger; they're faster; they're stronger.

And we're still having these two practices a week. We're still having particular drills that have been used for 40 years. But high school players of the '70s were a lot smaller and a lot slower than today's players. So this may be one of these issues where we can maybe use it as a lever point to encourage coaches to alter their strategies, to alter their training, to alter their practices; get them to recognize that their players really are bigger, really are stronger, really are faster than they were when all these drills and techniques were originally developed or originally put into practice by coaches.

Yeah, we need to change. We need to adapt with the times; we need to adapt with the players. I think if we can do that, that really can help. ...

To your knowledge, are you the first to have started producing these results concerning players who haven't had concussions?

Yes, particularly at the high school level. There are a couple of other folks who have looked at uninjured players, and have results that actually are mirroring ours. There's a group at Dartmouth ... that has done neurocognitive testing on nonconcussed football players. And their numbers reflect ours in that about 50 percent of those players were showing impairments. But they weren't following up in many of the other aspects that we've incorporated into our study. And their results are about contemporaneous with ours, so we've both been looking at this in the last couple of years.

But you're the first on the high school level.

We're the first on the high school level, and we're the first to be actually trying to publish and raise awareness that these blows that don't produce overt symptoms really are of importance.

Tell me about the publicity around your findings. … What are the reactions? Has it been controversial?

As a general rule, the publicity and the reception has been very positive. From the sports medicine community, from the athletic trainers and really the team doctors, as one of them put it, "You're not really telling us something we didn't already kind of know was out there." And I think that's true. I think everybody had a feeling within the athletic training community that something was happening to those players who weren't necessarily showing symptoms.

From the larger public, I think there has been a larger set of questions, because I think without there being sort of an alarm or a statement previously made by doctors, I think there was just the assumption from the public that everything is just fine and healthy and everything, which is a little bit unfortunate.

But for the most part, they've been interested in understanding this. They've been interested in trying to understand what can we do about this. I believe we've had a good reception from the perspective that no, this does not have to be the end of football. The truth of the matter is that football makes too much money and is too big a part of our culture. It's not going away anyway. So I think that would be an overreaction to begin with. I think ultimately people have to realize that the goal here has to be how do we improve the safety for everyone. ...

Are you getting through to people?

A little bit. One by one, if nothing else. So certainly with the three of us who are the primary investigators, ... we periodically get calls from athletic trainers at various parts around the country, from athletic trainers who want to talk to us and understand this better. I think, by and large, we've been successful in convincing them that no, they don't need to get out of the business of working with football. Instead, they need to focus on improving the conditions for football players and helping them understand more how they can play without hurting themselves or without being hurt. So that's been good.

And I think for the most part the media has largely understood that we're showing there's an effect. We're showing there's a short-term effect. We can't yet link this to long term, so we really don't need to go completely panicky. But we do need to understand that there is a significant risk of there being a linkage to long-term deficits. So we really need to examine this more completely and really need to come to a better understanding of what's happening to these players so that we can find ways to prevent that.

As when we've talked to communities, they've been very positive about this, very interested in this. The general public has been very interested. Team doctors have been, by and large, extremely interested, as have athletic trainers. And neurosurgeons have been very into this as well. So I think that's great. I mean, the neurosurgeons are interested because this really has implications outside of football, not just within football. ...

What do you see as the biggest culprit or the biggest obstacle in the way of getting football to the safer place you describe?

The culture. As we've discussed previously, the main issue is getting those people who are currently coaching the game, currently refereeing the game, currently announcing the game to recognize that there are particular activities that, while they may be visually exciting, and they may sell tickets, these are today's gladiators, and we don't really want to go down the path where our gladiators are dying out there on the arena floor, so to speak.

So we really need to focus on changing the culture; that that really big hit where the guy led with his head is praiseworthy and is a good thing. We need to really get back to emphasizing proper tackling technique, really reinforcing the spearing rules, particularly at the high school level, where spearing basically happens every play, but the referees don't call it, because they don't want to call a penalty on every play. We need to get them to do that.

We need to get the coaches and the athletic trainers and the team doctors a little bit more aligned with one another in terms of, when do I really want to assess a player? When do I want to determine whether or not a player is healthy, and allowing me as the athletic trainer in particular to take that player off the field for a period of time, recognizing, "I know he's the star, and I know that the team is not going to be very good if he's not on the field for a certain number of plays, but for his health and his long-term potential, and really, for later in the season, I need him to take a break"?

If we can overcome the culture, where I'm going to go out there even if you have to tape my arms and legs back onto my torso, with regard to the head, we really have the potential to change it. ...