Steven Broglio on Concussions, Football and Informed Choice – #31
Steve Hsu: Thanks for joining us. I’m Steve Hsu.
Corey: I’m Corey Washington. We’re your hosts for Manifold.
Corey: The Super Bowl is this coming Sunday, and our topics for today are concussions and football. Our guest is Dr. Steven Broglio, professor of Athletic Training and of Neurology and Physical Medicine and Rehabilitation at the University of Michigan. Dr. Broglio is the director of the Michigan Concussion Center and the NeuroTrauma Research Laboratory where he oversees clinical care, educational outreach and research on concussion prevention, identification, diagnosis, management and outcomes. His research has been supported by the National Institutes of Health, the National Collegiate Athletic Association, and the Department of Defense. Dr. Broglio was awarded the Early Career Investigator Award by the International Brain Injury Association and the Early Career Award by the National Athletic Trainers Association and a fellowship in the American Academy of Sports Medicine and National Athletic Trainers Association. Welcome to Manifold, Dr. Broglio.
Steven Broglio: Thank you for having me. Pleasure to be here.
Corey: The topic of concussions is near to my heart because I’m a serious football fan. I played football as a kid. I also care about the wellbeing of the players, and I’m sure that many of our listeners are in exactly the same situation. Let’s begin with a couple of definitions. What is a concussion?
Steven Broglio: Great question. In the literature, there are somewhere in the neighborhood of about 101 different definitions of concussion. I’m on a working group right now, working on 102, but I would say the most broadly used definition is a complex pathological process induced by direct or indirect forces on the brain that results in a constellation or a presentation of clinical symptoms. That’s pretty vague. I think maybe the easiest way to think of it is a force directly or indirectly applied to the head and then result in some clinical presentation. Typically, we see headache, nausea, fatigue, difficulty concentrating, difficulty remembering, things of that nature.
Corey: How do people commonly get them?
Steven Broglio: I deal pretty exclusively with sport injury, but you can have concussion really from any direct force or indirect force to the head so motor vehicle accidents, slipping on the ice, hitting your head when you fall. We have a large national study now in college students so we have all sorts of interesting mechanisms that we see there. We have typical top bunk in the dorm. I woke up too quickly, hit my head on the ceiling. We have one case of somebody that sneezed and hit their head on a desk. There’s any mechanism you can think of where you have a force to the head can result in concussion.
Corey: Are the results to this study out, because I recently read something about college student concussions being far more common than thought? It could be coming from [crosstalk 00:03:08].
Steven Broglio: It’s probably not our work. Our work is called the CARE Consortium, the Concussion Assessment, Research and Education Consortium. It’s funded by the National Collegiate Athletic Association, Department of Defense. It’s primarily focusing on sport-related injury and varsity level athletes at 30 institutions across the country. We also have the four military service academies involved. At those institutions, we have every military cadet is eligible to participate. At West Point or Air Force or the Naval Academy, it’s about 4,500 or so cadets that are eligible to participate in the study every year.
Corey: In connection with football, the thing you hear probably next in line after concussions is about CTE. CTE stands for chronic traumatic encephalopathy.
Steven Broglio: Correct.
Corey: Can you explain to us what that is and how it’s diagnosed?
Steven Broglio: CTE is actually, if we look back in the literature, we give a retrospective look at the literature. It was first identified around 1928 by Harrison Martland. He was a pathologist in New Jersey. He really described the clinical presentation of what we now think to be CTE in retired boxers. He identified memory impairment or memory issues.
Corey: There’s a term called punch drunk, right?
Steven Broglio: Exactly. It’s these memory impairments and some motor control issues. He’s the one that first came up with the term punch drunk. Maybe about 10 or 15 years after that, then maybe a better name or more scientific name was developed, dementia pugilistica. It’s the same thing. It’s just a different term. In the ’70s, the pathology of the disease was first identified. We’ve gone from clinical presentation in the 1928 or so, I think in 1973 this pathology was identified, and it is these irregular protein deposits in the brain that were at the time they’re associated with boxing, but nobody really understood why they were there. These are former boxers. They have this issue.
Corey: Was it known to be tau at the time?
Steven Broglio: That’s a good question. I don’t know. I’d have to go back and look at a lab paper from ’73. It’s been quite some time since I’ve looked at it. Then in 2005, the first what we call modern CTE case was identified, and this is Bennet Omalu in Pittsburgh. He was the pathologist for Allegheny County. This is the autopsy of Mike Webster. This is the Concussion movie. This is what that story is based on. That was the first modern CTE case where in that paper, he didn’t directly say football caused these protein deposits and then the issues that Mike Webster was having. He just said, “I had a former football player. We found these protein deposits. They may be related but you need more study.”
Steven Broglio: That was 2005. That spawned this modern era of research largely run by the Boston University group. They’ve been on the front of it. They’ve published a series of case studies. I think their most recent paper was 110 or 111 NFL participants, former NFL players. They identified CTE I think in 110 out of the 111 and so you commonly will hear 99% of football players, former NFL players have CTE. There’s a few caveats to that. One is you can only diagnose CTE post-mortem. There is no way to diagnose it in the living.
Corey: That’s something I’d like to get into because I heard that there’s a potential diagnostic tool that can be done while you’re still upright.
Steven Broglio: Correct. There are people that are working on it. There is a technique called PET imaging, positron electronic tomography. Basically what they do is they’ll inject a radioactive dye into you. The die will cling to these protein deposits in the brain and then you do an imaging scan and look for areas in the brain that are lighting up. It’s not refined enough to be diagnostic yet, but people are working towards that. It’s in the research stages, but my sense is that probably within 10 to 15 years that will have some in vivo diagnostic technique for individuals.
Corey: My impression of the 2005 paper is not only did it direct attention to football, but it actually raised the question of how many other sports are people really subject to this risk for? For a long time, we thought it was just boxing. If you stayed away from boxing, you’re okay, but it doesn’t really look like that anymore.
Steven Broglio: Right. It definitely shifted the focus off of boxing onto football, but some of the workout of Boston, they’ve identified CTE in, I’m trying to remember some of the cases, former professional wrestlers, soccer, former soccer athletes, ice hockey athletes. This is not a joke. I believe there was a former circus clown that got shot out of a cannon, that was his job, but it’s this repeated force to the head that causes this damage. Quite sadly, domestic violence, people that have long histories of domestic violence. I think there’s a couple of reported cases of that as well.
Corey: This also isn’t a joke, but I think there’s a case allegedly where someone was a heavy metal fan and you apparently … My wife was a death metal fan. You spend a lot of time basically rocking your head aggressively up and down that way. This person in this case study allegedly got some traumatic injury from doing that over long periods of time.
Steven Broglio: That one, I don’t know. I’d be interested. I could maybe dig around after I get back.
Corey: Death metal.
Steven Broglio: Exactly. Death metal in CTE. I have heard theory of running may cause CTE so you could imagine pounding on the pavement, but that I am pretty dismissive of, only because if that were the case then our entire species would have CTE. We’ve been in upright for millions of years and we’ve run because we had to, to hunt and gather and etc. We’d all have CTE if that were the case and we just wouldn’t have survived. The running one, that’s probably not true. The death metal one would be interesting.
Corey: I think you already raised a real question about how often football players get it because, of course, the study were a set of people who actually had symptoms of CTE, and I think the real conclusion was out of 110 people with symptoms, this is how many people actually had CTE. I was just looking at a study that came out in 2019. I think it said in a survey of 3,500 former NFL players, average age 53, one in eight reported serious cognitive problems. That compares to about 2% of the US population. It is more common in people who played 10 or more seasons, about 12.6% versus 5.8. Risk rose with seasons played. Every five seasons of play was associated with a nearly 20% increased risk.
Steven Broglio: Right. I am of the belief that CTE, it is a thing. What I don’t know is what is the true incident. I do not believe it is 99% of NFL athletes. I place NFL athletes as the world’s most at risk population. Typically they have very long careers. If you think about starting as maybe a middle school or even younger, playing through high school, two, three, well three or four years of college, depending on how long they played for, careers in league are pretty short, but it’s a lot of exposure over a number of years. I cannot think of another sport where the number of head impacts with and without concussion is equivalent to that. Even boxing in the modern era, at least, they’re not exposed to that many, the same volume of head impacts as a football player.
Steven Broglio: I think probably this one in eight, just my intuitive guess is if the highest rate is probably in the 15, 20, maybe 25% range of that NFL group, and that’s just my intuition. I don’t have any data to back it up. Nobody has ever done an epidemiological study of NFL athletes or call it former college athletes or former high school athletes to understand what the epidemiology is of CTE, but I seriously doubt it is 99%.
Corey: My again untutored impression is that this kind of injuries look like they’re continuous. It seems like you could go anywhere from having more or less a perfect brain to have a severely compromised brain and everything in between. I’m really skeptical about having an artificial cutoff saying this person has CTE or cognitive impairment according to some definition. It just seems like numbers of concussions increase by counts. It seems plausible that you could simply have a continuum of cognitive impairments in football players. In other words, choosing to count by finding the number people who are above a certain arbitrary threshold. It seems that those could be risk all the way down from one concussion.
Steven Broglio: The one thing I should clarify is I think the original argument that Omalu put forward and stayed around for a number of years was it was concussion that caused CTE. I think now the thinking is it is probably head impact exposure with and without concussion.
Corey: Which is even more continuous, right, because these are absolutely constant in football.
Steven Broglio: Right. If you look at a high school athlete, I think the average, we’ve done some work in this space looking at just exposure to head impacts in high school athletes, and the average is about 650 impacts in the season, but the span is pretty large. It can be anything from two impacts and you’re a place kicker, you’re a punter all the way up to 2000, 2,200 on I think we had a defensive end or something that had some crazy number of head impacts. 650 is the average just as a ballpark figure. The collegiate athletes are a little bit higher than that. They play longer seasons. They have longer preseason. They have more games through the regular season.
Steven Broglio: In the NFL, I have not seen any good data on the NFL to understand what their exposure is like. No one has been able to capture that, but they are actually very proactive in limiting the number of contact practices per week. I can’t remember what the current CBA says, but I think it’s one or less practices, contact practices per week.
Corey: For NFL.
Steven Broglio: For NFL. I think the CBA is coming up pretty soon. That may or may not change, but I know that was added into it last year.
Corey: As I recall, Ivy League schools banned contact practices.
Steven Broglio: Ivy League schools largely based on the work that Dartmouth was doing, they did ban contact practices. Obviously, games are games. Some of that is injury prevention overall, trying to reduce concussion. Some of it is if our first string players aren’t injured during the week, then we can put them on the field on Saturday and we stand a better chance of winning. This is what Dartmouth did, but I think they went on to win the Ivy League championship that year that they implemented it and then it got rolled out on a larger scale.
Corey: Not to impair a win percentage.
Steven Broglio: A lot of things work that way where somebody tries it and they do better or the same and then, okay, well-
Corey: … but not better on the same on lack of head injuries. Better on the same on winning games.
Steven Broglio: On performance. Correct.
Corey: You mentioned some of the positions at high and low levels of contact. In a study I quoted, they found that kickers, punters and quarterbacks had the fewest concussion symptoms in the NFL, followed by wide receivers, defensive backs, lineman and tight ends. Running backs, linebackers and special teams players had the most.
Steven Broglio: That would roughly parallel the work that we did at the high school level. Quarterbacks are protected during the week so they don’t get a lot of exposure during practices obviously. Even during games, unless there’s a sack or something, they don’t get hit that much. Your skill players, your receivers, your defensive backs tend to be less as far as total number of impacts. The difference being is when they get hit, they’re typically going full speed and so the magnitude of that impact is higher. The total numbers, the skill players are that next in line. Then, you actually go to running backs, tight ends. They’re at the next level. The linemen are the ones that are every play, they’re making contact, typically making contact with the head, and they have the highest total exposure.
Steven Broglio: What you’re telling me, I’m not sure which study that is, but what you’re telling me tends to line up with what we see at the high school level.
Corey: Mike Webster, the first case was a lineman.
Steven Broglio: I think he was a center. I don’t really remember. I think he was a center, but yes.
Steve Hsu: Pittsburgh Steelers.
Steven Broglio: He was a Steeler. That I know. Yeah.
Steve Hsu: I think he was a center.
Corey: I do recall people learning it’s a lot of these small contacts that often can lead to problems, but it seems like it’s a quantitative phenomenon. Can we say that there are definitely many more small hits than there are large hits, but presumably each large hit is worse than individual small hit? It seems like you can’t discount these large hits because they could do severe damage.
Steven Broglio: Correct. I think you’re totally right. I don’t have any science that can back up what you … I agree with what you just said. I don’t have any science that can back that up [crosstalk 00:16:16], but intuitively, I would agree with you that a bunch of little hits, and I’m just going to make up a number, maybe 10 little hits is equal to one big hit, but even little hits come across the spectrum. In some of our data, we’ll see I think the average acceleration for a head impact at the high school level is about 25 G, but that spans anything from 15 G up to we have impact data of 100 G and there’s no concussion or we’ll see … and this is where it gets complicated from a diagnostic standpoint. We’ll see let’s say I have 100 G impact, no concussion. You get 100 G impact, that’s a concussion, or I get 100 impact today, no concussion, but I get an 80 G impact next week, concussion.
Steven Broglio: One of the challenges we’ve tried to understand from diagnostics and understanding the injury is why … Clearly, person to person variants makes sense. We’re variable, but why even me today, me tomorrow is a different metric.
Corey: One theory I heard was that it probably depends on whether you’re prepared for the hit or not. Is there evidence for that? Presumably you can brace yourself if something is coming. That’s supposed to be a bad thing actually for an auto accident. Maybe you could clarify that a little bit.
Steven Broglio: Mixed martial arts will tell you the same thing. The data that we have is if you know the impact is coming, you can tighten the neck down. I don’t want to get into too much physics with your audience, but basically-
Corey: No. Please do. Just jump into it.
Steven Broglio: You basically have a larger effect of mass. The force that’s being imparted upon you from the opposing player, they have to move more weight. If everybody remembers Jerry Maguire, the human head weighs eight pounds, which isn’t quite right. If I can tighten my neck down and I can have my head and body function as one unit so now that you’re moving let’s say 200 pounds and not eight pounds.
Corey: Twice the better to get hit when you’re in a car than on a bicycle.
Steven Broglio: Exactly. When I talk about the Gs of acceleration that we’ve measured, this is all post impact acceleration. Whether they brace or not, we don’t know, but we’re measuring what the head is doing after the impact occurs.
Steve Hsu: You can imagine mechanically you get 100 G but maybe the angle of exactly how your brain sloshes makes a difference. Right?
Steven Broglio: Right.
Steve Hsu: You could have a lot of variance.
Steven Broglio: Great point. There’s a lot of discussion around what part of the impact or what causes a concussion, whether it’s the linear acceleration or it’s the rotational acceleration. The animal model and some of the computer modeling would suggest that it’s the rotational accelerations that actually causes a concussion, not so much the linear forces, but they’re so tightly linked one to the other. I think the correlations are 0.98, 0.99, something like that that. We talk a lot about linear acceleration. It’s just conceptually easier for myself included to handle.
Steve Hsu: Your equipment though can actually measure the angular acceleration as well.
Steven Broglio: It’s an estimated one. We’ve pushed the manufacturers to put in … It’s a six signal axis accelerometer. [Crosstalk 00:19:13].
Corey: Sorry, let’s stop. Seriously. Stop and describe what you’ve got inside helmets and what it measures.
Steven Broglio: Unfortunately, it’s a football only system but it does give us a lot of good information, but it’s a six-single axis accelerometer system that estimates center mass motion. They’re only linear accelerometers and they then estimate rotational acceleration from that. We’ve tried to get them to put in gyroscopes. When the system first came out, gyroscopes were cost-prohibitive. Obviously, now they’re not, but basically the company have said it’s just not worth our investment what we think we’ll get on the return. We feel it’s a reasonable estimate of rotational, but it’s not perfect.
Corey: Have you observed any gender differences in your studies because you’re focusing just on football, I guess, but there’s … My small understanding of the literature. Young girls seem to be at higher risk of concussion than boys. It’s probably thought that maybe because they have weaker neck muscles and so their head gets accelerated when boys doesn’t. Is that total BS?
Steven Broglio: No, it’s part of it. Our national study is actually … Every varsity athlete at the institutions that are participating are eligible. Our overall sample is about 40% women, but at the academies because we have cadets involved, which are very heavy male, it brings down our overall average. If you look at just NCAA athletes, it’s basically 50/50 male/female.
Steven Broglio: As far as reporting in injury rates go, if you look at sex comparable sports, male, female, so soccer, basketball, baseball, softball, women tend to report higher rates than men. There’s some discussion as to why that is. Some is this neck musculature issue, so women just don’t have as much muscle mass in the neck as men do relative to head mass so they can’t stabilize as well if they know that impact is coming. There is some early data to suggest that at various points during the menstrual cycle, women may be more susceptible. That’s fine. It’s early data. I don’t disagree with it. It’s just not totally fleshed out.
Steven Broglio: I think the single biggest thing is that women are more likely to report symptoms if they have it. I think we’ve probably been all around … Well, we’re all men here. We were all 16 years old at one point, and you hide a lot of things, and particularly the culture around football and some of the other sports, it’s the suck it up, get it back out there. I think the culture around concussion has changed a lot in the last 10 years for the better, but it is still there. Women are just more honest about concussion reporting, about just a lot of things. They’re more willing to disclose what’s going on and seek medical attention.
Corey: What’s the range of acceleration in the case of a soccer head? Because you obviously don’t have a helmet so do you have any idea of how that compares to football impacts?
Steven Broglio: Yeah. There’s some literature on this and I’m just trying to remember the numbers. I feel like it falls into the 30 to 50 G range. I’m a little hesitant to say that number because I just am not recalling exactly. The thing with soccer is that routine soccer heading is highly unlikely to cause a concussion. About 90 to 95% of concussions in soccer are head to head collisions, so two athletes going up for the same ball and then colliding heads. That threshold is probably the same across a male soccer player and a male football athlete or that threshold is probably the same, which tends to hover around the 90 to 100 range, but there’s there’s some variance around that.
Steve Hsu: Is a knockout punch in boxing or MMA, is that actually due to the higher acceleration that you’re imparting or is there something else that’s involved in knocking someone out?
Steven Broglio: I don’t know about the … I’ve never seen data on the acceleration, but it’s more about what part of the brain is being affected by it. Consciousness is housed basically in the brainstem. I think it’s that rotational component, a real big rotational component affecting the stem that causes it.
Steve Hsu: I was going to say in MMA, there’s some folk wisdom that when guys cut weight too aggressively and they don’t fully rehydrate before the fight that they’re more susceptible to being knocked out. Does that seem plausible to you?
Steven Broglio: We’ve had this discussion about dehydration status and relative to cerebral spinal fluid volume in the brain because that acts as an internal cushion. I don’t know the answer to this. I don’t have a strong enough physiology background to give you a direct answer, but to me, intuitively, it would make sense of I’m dehydrated, my cerebral spinal volume goes down, I don’t have as much of a cushion and therefore I’m more susceptible. That may explain some of the day to day variance that we see between people because hydration status changes pretty quickly. Even within one day, I think we all know that you can become dehydrated pretty quick, let alone out running around on a field or something like that.
Corey: I want to come back to soccer briefly, a sport which I know essentially nothing about, but I do recall a study again, and I don’t know how solid it was, where they looked at basically number of heads that someone had during a season and they correlated it with college performance on one particular metric. They found basically a linear correlation. The more, the worse you did in general. I guess it seems consistent with the idea that it doesn’t require a large hit to actually impair someone cognitively. I had a friend who played soccer. He says to intuitively understood going back, way back that he should simply miss every head he tried and he was successful.
Steven Broglio: I don’t know that study. I can tell you we’ve done a series of studies in football athletes where we look at pre-season to post-season performance, our group as well as other groups, and the findings are pretty mixed. I would say the only consistent thing that we see as well, maybe let’s just say ability to perform a memory task pre-season to post-season. That doesn’t change, but you may find some subclinical changes on an MRI or a DTI scan. What I would tell your audience though is that just because we can measure something, it doesn’t mean it means something.
Steven Broglio: The analogy I always give is somebody may have gone to McDonald’s for lunch today. You eat that Big Mac. Your blood lipid spike. It doesn’t mean you’re going to have a heart attack tonight. The body is incredible at adapting and repairing. Just because that change is there, it doesn’t mean there’s anything to it that you need to worry about.
Corey: There’s huge uncertainty.
Steven Broglio: There’s a lot of uncertainty right now. There’s a lot of questions that we don’t have answers to, but there’s a lot of people working on it really hard to try to figure it out.
Steve Hsu: When your neighbor comes to you for advice about whether their kid should play soccer or football, say in high school, what do you say to them?
Steven Broglio: I would say it is a conversation for the parent and the child. If it fits the child’s personality and the kid wants to play, then I say it’s fine. I’ll just give a perfect example. My nephew who I think he’ll be 16 in a couple of weeks, he wanted to play football a couple of years ago, but he is 5’6″ and he might be 100 pounds. My sister-in-law said, “Well, what do you think?” I said, “I wouldn’t be worried about brain injury, but I think orthopedically, he’s going to get destroyed.” I had a bigger concern that way.
Steven Broglio: I think every case, it’s unique and you just have to take into consideration the child, the child’s attitude, what they want to do> What else is available to the child? Is this just like I have a passing interest in the sport or is this like I’ve wanted to be a football athlete since I was two years old? That’s my advice.
Steve Hsu: Are we seeing a decline in interest in football among families in the US?
Steven Broglio: That’s a good question. The data I’ve seen on this is mixed. I’ll read some data that will say like, oh, in this part of the country, it’s going down, but in this other part of the country, it’s the same or it’s maybe going up.
Corey: Let’s be really specific. It seems like it’s tanking in the northeast. Some of these schools are having a really hard time, and some just shut down their football programs entirely.
Steven Broglio: That definitely is happening and so-
Corey: The part of the country that cares most about your brain as far as I can tell.
Steven Broglio: It’s not as simple as to say concussion is causing this problem because I think as all of us probably when we were growing up, what were your sports? You had football, basketball, wrestling, baseball, maybe soccer, but now you can add in lacrosse to that. Soccer is way more mainstream. You can add in lacrosse, ice hockey. There’s a lot of other sports that are coming online that I think give kids more opportunities to do different things other than just football. I’m not saying concussion in those particular cases. I’m not saying concussion hasn’t fed into some of that, but there’s also other opportunities for student athletes.
Corey: It’s possible, but, look. Again, I don’t know exactly the motivation, but the conversation is very, very strong where I’m from, in Massachusetts. People think it’s often just crazy to have your kid play football up there. It’s just the whole tide has turned against the sport in those parts of the country. Granted we’re losing population in general. I’m just shocked when I go back there and I have a conversation about football and the general sense is why would anyone do that? I come out here. It seems like there’s some mild concern, but it’s a really radical difference in culture. They did not exist when I was growing up. There’s one family I knew who is far lefty, they had no TV. They did not want their kid playing football, but that was it.
Steven Broglio: Boston University is ground zero for CTE research, so that doesn’t entirely surprise me.
Steve Hsu: I wonder whether, like in the Ivys, I guess, they’re down to … Did we say one contact day a week?
Corey: I think they’re none.
Steven Broglio: I think the Ivys are non-contact all the time. The NFL is one contact a week I believe.
Steve Hsu: Wow. I got to imagine most of these Ivy players, their skills probably decay while they’re in college. Can they actually tackle as well when they were seniors in high school with zero contact practices?
Steven Broglio: I think when we say it’s zero contact practice, it’s zero contact to the ground. They still do tackling drills. Dartmouth has been actually very progressive in this space. They have these robots. They’re tackling dummies on wheels that are remote control. They will do tackling drills with these robots that are actually quite agile. I would encourage your viewers, listeners to go on to YouTube and just type Dartmouth tackling dummy and all sorts of videos come up.
Corey: I’m sure Boston will soon have a robot that actually can give you a realistic run for your money.
Steven Broglio: Right. I think they’re doing things like that or they’re just doing what are termed thud drills where you run a drill at half speed and then you just wrap up but you don’t take somebody to the ground. It reduces risk for not only concussion but also for orthopedic injury.
Steve Hsu: Do they practice blocking too? When they run a play on these zero contact or low contact practices, is there no helmet to helmet between offensive linemen and the defensive linemen?
Steven Broglio: It’s a good question. I don’t know. I haven’t been to watch any of the practices. I don’t know the answer to that. I can ping some people I know in the Ivy League and find out after the fact, but I don’t know right now.
Steve Hsu: I’m just curious because I don’t think you can do anything really realistic in either blocking or shedding a block without having some helmet to helmet contact.
Steven Broglio: Yeah. I just don’t know. I wish I did.
Corey: It’s interesting. This actually gets to … We’re jumping a little bit ahead, but we talked about the fact that linemen are the most at risk. I know this is heresy to serious football fans, but my sense is the best way to lower the risk of CTE and lower level trauma is just to go to something like the scrum you have in rugby. Don’t have linemen not in the four point stance, have them standing upright, essentially grappling with each other. One plays like that. You’d eliminate a lot of this initial contact. I know maybe in 50 years, football will look like this, but if you want to stop the contact you just talked about, which is what happens in a line hundreds of times a game, you have to do something like that.
Steve Hsu: It doesn’t save the running back and the linebacker.
Corey: You’re right, but the most at risk is the lineman. You’re right.
Steve Hsu: Is that right? More than the linebacker?
Steven Broglio: I just want to clarify. We don’t know who’s at most risk. We know that linemen have the greatest exposure, but we don’t know that that necessarily means they’re at greatest risk because we don’t know … Outside of head impact exposure, there are likely other things that may or may not influence risk.
Corey: If it’s this big contact versus small contact, linebackers have a lot of these heavy hits, right?
Steven Broglio: They have heavy hits. Outside of the exposure, you can think, okay, what’s my genetic profile? What’s my physical activity after I leave the League or retire from my sport? What’s my diet like? What’s my environmental exposure like? There are all sorts of things that feed into this. We’ve had lots of conversations recently around sleep. You can imagine linemen, in the League, a lineman is 6’6″, 320, 330. They are massive individuals. I would venture to say a lot of them have sleep apnea so their brain doesn’t clear out at night because of apnea. Maybe that is part of the problem that they’re struggling with. This is all speculative. I don’t have the answers to these things, but these are things that we talk about. Maybe these are other things that are adding in to the effect.
Steven Broglio: I just want to clarify. We don’t actually know who’s at greatest risk, but linemen do have the greatest exposure. That I can support, but who has the greatest risk, I don’t know.
Corey: I’d like to turn a little bit to actually what’s happening inside your head during these hits. Do we know specifically what it is about the hits in the contact that damages your brain? Is it damage to the vasculature that then leads to blood flow being cut off or is it actually damage to the cells themselves or the processes?
Steven Broglio: This gets into the neurobiology of it, and it gets a little bit out of my area so I’m going to give high level overview as I understand it. Relative to CTE as I understand it, within the neuron, you can almost think of it like a highway system so nutrients can move. They’re structured by microtubules. Those microtubules are structurally supported by tau protein. We all have tau protein in our brains naturally. It’s there for a good reason. What we think happens with concussion or a head impact without concussion but at a certain magnitude is that tau protein breaks loose and then phosphate molecules bind to it and it becomes sticky. That sticky tau molecule then lays down deep within the fold to the brain. If you look at the brain, it’s got deep crevices in it. It’s deep within that fold that those tau proteins lay down.
Steven Broglio: I say that because there are a lot of other neurological disorders that have tau protein deposits. Alzheimer’s is one of them, but the way Alzheimer’s lays down relative to CTE, it’s a different pattern. That’s what makes CTE unique. We see these tau protein deposits deep within the folds of the brain. We also see what we term perivascular, so around the vasculature, around the blood vessels on the brain. That pattern is this unique process.
Steven Broglio: I mentioned sleep earlier. One of the conversations we had is, okay, if linemen have this high exposure, presumably then they have more phosphorylated tau that’s floating around, but because they don’t sleep well, they can’t clear it out quite as well. Maybe that accelerates the process. This is all just theory and conversations that we have, but this goes to the … It’s probably more than just I got hit in the head a bunch of times. It’s other things that are going on.
Corey: This comes back to the emerging research on the value of sleep. It seems like one of the real functions of sleep is simply flushing out essentially the waste from your day’s brain activity.
Steven Broglio: That gets way out of my area, but yes, that’s my understanding. When we rest, the brain, the glymphatic system opens up. All the waste gets flushed out. It’s a restorative process that takes place.
Steve Hsu: I’m curious if there’s any work in animal models on this. Are there any little mice that are being hit by tiny boxing gloves?
Steven Broglio: Maybe not boxing gloves, but Bill Meehan in Boston, he’s done some work with this. I don’t know his work incredibly well, but people do use animal models because it’s nice and you can sacrifice the animal at the end of the experiment and look and see what’s going on. Like all animal studies, it’s not a perfect one-to-one correlation with humans, but it does give us some insight as to what may be going on and lead us in different … inform our decisions that we’re making.
Corey: You mentioned a second ago that there was a distinction between essentially the distribution of tau in Alzheimer’s and CTE. A few years ago, there was thought to be a link between ApoE4, which is the gene that gives you high risk for Alzheimer’s, and CTE. It looks like for my … It just proves the literature recently that that connection looks much less clear right now.
Steven Broglio: Yeah, I think some of the early case series at the Boston University group published, I think they were looking at ApoE4 status. It was mixed. I think they had done some additional case series that they published. It’s more mixed. It doesn’t appear, from my understanding of it, it doesn’t appear to be this direct link like you have this ApoE4 allele and you’re destined to go down this road. It may be a risk factor, but it doesn’t appear to be the factor.
Corey: I’m curious. Now I want to hop into a little bit of discussion of prevention treatment. When you watch a football game, what’s going through your head, having studied this intensively? What do you see that the rest of us are probably not paying attention to?
Steven Broglio: I’ll be quite honest. I’m not a football fan, and that’s not because of what I do. It just never happened.
Corey: If you’re strapped into a chair and your eyelids are forced open, you had to look at a football game, what do think you might see?
Steven Broglio: I enjoy it for the athleticism. Some of the ability … I’m an athletic trainer by trade, so I’ve spent time on a sideline. Some of the things that they do, the athletes do is just incredible, the speeds that they can do it. I enjoy it for what they can do, sport being sport. If there’s an injury, I pay attention to what the medical staff is doing and more of how are they handling it? I would never question what somebody is doing on the field or on the sideline from a medical standpoint, but just how are they doing it? How are they evaluating and looking at it that way?
Steven Broglio: I would say I don’t have a moral issue with the sport of football. I think it can be improved and made safer. I think the game of football has been made safer since the day it was started. It’s evolved incredibly since early 1900s when we had deaths on the field because we didn’t have helmets and all sorts of other things that were going on. That was from subdural hematomas and skull fractures. We don’t have that anymore because we invented the helmet and we got rid of the flying wedge. The game will evolve as the game has always evolved, but we need sound science to make informed decisions to make that happen.
Steve Hsu: Corey, you’re always on me for why I don’t like the NFL. I used to watch both college and pro football, but now I can’t be bothered to watch pro football but I still like college football. One factor, it’s not the main factor, but one factor is when it’s the NFL, it’s older guys. When I see the collisions and the hits they’re taking, I do think about the health impacts for those guys later on in their life. It’s a little easier to ignore that when they’re 18-year-old kids. That is one of the reasons why I just don’t like watching the NFL that much.
Corey: That’s incredibly honest, Steve. Your denial accounts for your love of college football.
Steve Hsu: You mean denial that the younger guys are getting injured?
Corey: Yeah. That’s going to last longer because they have longer lives ahead of them.
Steve Hsu: Well, I don’t know. Actually, maybe the guys who play college and then don’t make it in the pros, maybe their probability of having these problems, brain problems later in life is not that high. Right?
Corey: It probably isn’t. That’s right.
Steve Hsu: Only some small fraction of the guys playing on the college game are probably destined to have this problem. Whereas, in the NFL, it’s a much higher percentage.
Corey: Although it’s Pyrrhic victory in some way because these guys are sacrificing. They have some risk to the brain and their bodies, although they’re probably not going to get the payoff that guys who actually make it in the NFL are going to get.
Steve Hsu: They still get the glory of playing for their college teams.
Corey: That’s true.
Steve Hsu: Anyway, these older guys, some of the players in the NFL are getting … I don’t care about quarterbacks because they’re not really that much in the line of fire, but even some of the linebackers and running backs, they can be pretty older guys. I think like, man, this guy is getting killed out there.
Corey: I don’t know if you saw the Marshawn Lynch press conference.
Steve Hsu: Where he retired or almost retired.
Corey: He retired and then he came back. He recently gave a little press conference about basically protecting your brain and your body long term. It’s exactly how you do this actually. But he suggested the guy should do this. He’s diversified himself economically pretty early on. He owns a bunch of different businesses. He’s an older guy, and I think he’s really, really … I don’t want to say he’s cold blooded about it. I think he sees that there are obvious risks, but he’s going to maximize the benefits from it and then presumably probably get out after this year. We’ll see.
Steven Broglio: When I talk to former players, there are certainly some that would say, “I would never do it again. I have orthopedic issues. I feel like I have cognitive issues.” They’re retired, but they’re still, I’m trying to think, people I’ve talked to in their 30s and 40s aren’t really showing anything, but they have concerns, but they’re not showing anything. I would say broadly, the former players I’ve talked to, they would say I would do it again in a heartbeat. If I get it, I get it, and if I don’t, I don’t.
Steven Broglio: My take on it is you enter college and you’re 18 years old and you’re an adult and you can make that decision. Particularly in the modern era, I think it’s disclosed. Nobody is hiding anything anymore. They can make that decision, and it’s up to them at that point what they want to do.
Corey: The way I view this is your life is a curve basically, and you can live life the way I do, which is you have a long curve. You don’t get very far above the axis. You’re just above zero for a very long time, very safe, fairly boring life. People may prefer that life. It’s life that I’ve lived. You can go for this life where you shoot way up and went out at the stadium with 60,000 people screaming at you. Maybe shorter life. You may have physical problems afterwards, but man, it’s exciting while it lasts. Who’s to say, right?
Steve Hsu: Yeah. Who is to judge? The one thing I would say is people should be informed of the risks if we know them.
Steven Broglio: Yeah. I think the League in particular, I think they were in denial mode. I think there’s some question around some of the science that they were publishing in the late ’90s, early 2000s. I would say that after that group of scientists got dismissed and that committee got reformed, I would say of the professional organizations, the NFL has been the most proactive. They donate the most money for research, and they are trying things in an informed way, so changing kickoff rules and trying to work with the athletes with one contact practice a week and things like that.
Steven Broglio: I don’t want to get into nitty-gritty here, but there are other sports where there are parts of the game that have nothing to do with the game that causes brain injury. There are very easy things that could be removed or altered from other sports that would make it a lot safer and it’s still in there probably for just pure entertainment.
Corey: I want to talk a little bit about what’s happened to football the last couple of years to try to make it safer. Helmets are better, but I don’t know how. Can you explain to us the ways in which helmets have changed?
Steven Broglio: Sure. I think we all know the original helmets were leather. They were implemented I think in the ’30s. I think in one year, there were 13 or 14 … This was in the ’20s. There were 13 or 14 on-field deaths from skull fracture and bleeds. Teddy Roosevelt at the time got the Ivy League presidents together and said, “Figure out a way to fix this or I’m banning the game.” That group, that commission actually eventually is what became the NCAA to protect student athletes. The leather helmet was invented.
Steven Broglio: I think shortly after World War II, we had the suspension style plastics were coming around so we had the hard shell. You actually see an increase in C spine injury at that point because you could go in head first with a hard shell helmet. Then, we got head first contact got eliminated or head down contact got eliminated.
Corey: When was that?
Steven Broglio: I want to say in the ’70s. I don’t remember the exact time that the rule change went in. We start adding more and more padding. The original hard shell helmets were the suspension like canvas straps on the inside suspension system and then we started adding more and more padding. I should say that as we moved into the hard shell helmets, they were really designed to prevent skull fracture because that was the initial on-field problem. Then, as we moved into the modern era of concussion, so this was around 2005 with the Omalu paper, concussion became an issue, and people started worrying about concussion, and can we build a better helmet that is concussion-resistant? Some people think we can build a concussion-proof helmet. I disagree with that, but that’s another argument.
Corey: That’s a massive [crosstalk 00:44:38].
Steven Broglio: Exactly. It wouldn’t be a practical solution. I’m trying to remember what year, but the Virginia Tech group started testing helmets for concussion resistance, and they published it. They made the data public. You can go to their website. If you just type in Virginia Tech star or star helmet, anybody can pull up these ratings for football helmets. They have hockey helmets, bicycle helmets. I think they have lacrosse helmets. I’m not positive about that. Mom and dad need to buy a helmet for their son that wants to play football. You can see the top rated concussion helmet and get a price and you can make a decision as to what helmet to buy. Because of the advent of that rating system, the companies now want to be the top, and so they have invested the dollars to improve their technology to basically get better and better in the ratings. That is driving improved helmet technology and concussion resistance.
Steve Hsu: Has anybody tried la very big soft helmet, quite a bit thicker than a regular helmet but very soft material? It seems like that would eliminate, that would absorb a lot of the energy.
Steven Broglio: Right. One of the challenges with football helmets is, one, you need durability, and that’s durability across a season, but that’s even durability within a game. For a while, I think somebody came out with a carbon fiber shell helmet. As you can imagine, carbon fibers is relatively fragile. It cracks, and so it just doesn’t last, and obviously it’s crazy expensive.
Corey: It’s a billion dollar business. How much would they lose?
Steven Broglio: It’s a billion dollar business for the NFL, but it’s not for your local high school.
Corey: Why isn’t the NFL using it?
Steven Broglio: They were talking two or three helmets a game type of situation and it just-
Steve Hsu: They could afford that.
Steven Broglio: Well, I don’t know where it went. I know that they were talking about it. I don’t know where it went. You have this durability issue. You have temperature issues because you start in August when it’s 95 out and then you end in November and it might be 30 out or even colder in some parts of the country. There’s a lot more than just put a giant pillow around their head. Soft materials are great, but they have to be able to rebound basically instantly because the next impact may be milliseconds away. There’s all sorts of challenges that go into it. I’ve gotten some very interesting emails from people saying like, “I’ve solved the problem,” and you take one look and you’re like, “That’ll never work on a field.”
Corey: Steve, this is a huge digression, but there’s a longstanding math problem called Fermat’s Last Theorem. People would write into this journal when they had a solution to it. The journal editors simply had a pre-written card saying thank you for your submission regarding the proof of Fermat’s Last Theorem. You’ll find an error on line X. They’d type in the number to send it right back. You could do this for all your suggestions.
Steven Broglio: I like that.
Corey: How about changes in the game? Because there had been a number of the past couple of years to void … sorry, diminish contacts. One is you can’t hit a defenseless player. Another is that they’re now having kickoffs if their touchbacks go back to the 25 yard line to discourage people from running things out of the end zone. I’m curious. Do you think that these might have significant effects on concussion or is this … I know this is subjective. Do you just eliminate the kickoff?
Steven Broglio: Yeah, there’s a lot of conversation around the kickoff. Kickoff and punt are the most dangerous place during the game because you basically have everybody running full speed. I think some of the players will describe it as it’s a car crash, it’s a train wreck, that type of thing. I think the League’s move to move the kickoff line and then to move the touchback distance, I think they were trying to reduce risk. I think it gets very tricky because while they are making these rules changes, and my gut tells me likely they are reducing risk, the willingness of players to report injury is increasing. It’s not an injury that they’re less willing to hide.
Steven Broglio: Carson Wentz is like a perfect example of this. It’s a playoff game. He very easily could have hid that injury and kept going, but he chose to report it and got pulled from the game and may have caused the Eagles the game. I don’t know. Hard to say how that would have gone.
Corey: Edelman looked like he hid one in the game against the Falcons.
Steven Broglio: Right. I think reporting rates are going up, and I encourage that. I think that’s a good thing, but trying to understand, okay, we’ve put this new rule in place, which reduces risk, but simultaneous with that, our athletes are feeling more comfortable with reporting injury. The data get pretty fuzzy. I don’t think changing the kickoff rule has hurt the game at all. I don’t think it has put players at greater risk. I have no issue with it.
Steven Broglio: I’ve long been a proponent of, like you talked about, hitting a defenseless player. When that happens, just making the fines so incredibly severe that it will never happen again. I think while you couldn’t put a financial fine on a college athlete or a high school athlete, then you can start taxing gameplay. Players can get ejected for that game, but what if we change it to you get ejected for that game and the next two? Same thing with high school. All of that could be done. I think it would be a massive deterrent, at least for the intentional things. Some of the unintentional stuff, it happens fast. These guys move very quickly and things happen in a split second. Sometimes the physical body is in motion and you just can’t change that direction in time.
Steven Broglio: There’s going to be some subjectivity to it and there’s going to be mistakes from the officials if they were to go down that road. I think ultimately if we want to protect the athlete’s health, that may be something we want to consider.
Steve Hsu: It seems like the Ohio State Clemson game where I think the Ohio State D-back got ejected, which what I thought was unintentional, he came in with the crown, but it was pretty clean and unintentional and he just got ejected. It seemed like that could have caused Ohio State the national championship.
Steven Broglio: It’s always difficult. I’m trying to remember that one in particular, and it’s not coming to mind, but I know I’ve seen other times where the offensive player will catch the ball, the defensive player is coming in and sees the defensive player coming and they tighten down, and they almost lower themselves into the line of fire, and then the penalty goes to the defensive player. That’s where the subjectivity I think is … There’s going to be mistakes there until we can figure out a way to make it fully objective. I think ultimately, I think it will … My idea is somebody may say like, “that’s ridiculous because,” and it’s something I haven’t thought of, but if we go down this road, I think it’s a way that we can try to reduce at least the intentional ones.
Steve Hsu: Corey, what’s the future of football?
Corey: Many people predicted that it’s going to become less and less popular just as boxing has, although of course boxing has metastasized into all this other stuff like MMA. Although I think if you aggregate all these sports that are probably less popular, boxing was at its peak. I would assume that it would probably become less popular over time. I go back and forth. I can’t tell if I’m a fan or an addict, but I’ll pledge myself not to watch this sport and then I’ll end up giving in week five. I assume there’s some people actually strong enough to resist, but they’ve got to change. I think some of the change needs to be a little more dramatic, but that just may be wishful thinking on my part.
Steve Hsu: Do they have to change? Maybe once we know the science and the risk, maybe people will just say if these players want to take the risk, they’re highly compensated, let them play. Maybe it’ll go that way.
Corey: It could definitely. I think it may be wishful thinking. Not that I have a certain stake in this, but yeah, you’re right. Look, NFL is incredibly profitable and it may be as profitable as ever. Although I think certain parts of the country are turning on football, the rest of the country is not, and they’re expanding across borders. Maybe it’ll just be something that people allow there’s a certain risk to and will enjoy the game, enjoy watching people. Take it.
Steve Hsu: Do you actually watch football games? Are you actually sitting on a couch for three hours on a Sunday?
Corey: No. Do you really want to know?
Steve Hsu: Well, kind of. Yeah, I’m curious because I can’t justify the time. Even the college games that I care about, I’ll watch the highlights after the game or something.
Corey: I generally only watch New England Patriots games because I’m a single team sports fan. I have one team in all the sports. It’s the Patriots. What I’ll typically do is I will wait to see whether they win the game or not. If they win the game, I’ll watch the game, sometimes the whole, but mostly in condensed version on the NFL app.
Steve Hsu: You TiVo it? Oh, the NFL app.
Corey: Yeah. They have a condensed version where they cut out all the other stuff and the last 45 minutes.
Steve Hsu: Do you pay for that?
Corey: Yeah. The app costs me to see all the NFL games across the year. It’s 100 bucks.
Steve Hsu: Wow.
Corey: What’s interesting is since they got ejected, since they lost early on in this playoffs, I’ve been shocked because actually, it’s the first time in 10 years, I’ve actually enjoyed the playoffs. That’s usually so stressful for me. I actually don’t enjoy the games, but I’ve watched other teams. They’re fabulous to see. I’ve been able to chill a little bit. It’s opened up a world where it’s all before it’s been just knuckles to the edge, trying to hope the Patriots get through this.
Steve Hsu: Have you ever analyzed why you care so much?
Corey: No, it’s totally crazy. It makes no sense at all. I identify with Tom Brady, and that just makes no sense. This guy, I have no connection to him. He lives in like a different universe from me, but yet somehow there’s some animalistic tribal thing. In fact, he plays for a town that I lived 90 miles from growing up, although he’s from California. Who knows what he’s like? Somehow I’m deeply … It’s been imprinted on me that I’m attached to this.
Steve Hsu: You’re a Patriots fan before he showed up.
Corey: Yeah, I was a Patriots fan through all the rough years. I was there when they got blown up 45 to 10 by the Bears in ’86. I was in Nicaragua listening on Armed Forces radio when that happened. I listened to the whole thing.
Steve Hsu: Super Bowl shuffle.
Corey: Yeah, it was bad news.
Steven Broglio: I think you’re a Brady fan because he’s a Michigan grad.
Corey: That’s right. I have to say. In every part of the country, the Patriots are the most hated team in sports, but this is one of the few areas where you can actually covertly be a Patriots fan. I’ve said, look, wearing a Patriot’s hat around is like wearing a MAGA hat. You have the same reaction to it. I had one my dad sent me. I wore it for a day, and I’ll never take that thing out again. You just get this real, real negative vibe even here.
Corey: We’re almost at the end of our time. I’d like to come to treatment because that’s something which I think there’s been a fair amount of change. I can’t remember. Before they just told you to sit in a dark room. Now they take a more proactive approach. I shouldn’t say that. You actually since you’re in this field.
Steven Broglio: You’ve pretty much summarized it. I don’t think I have anything else to add. Certainly probably 10 years or so ago, the recommendation was this idea of cocoon therapy, so totally shut somebody down, dark room, no computers, no TV, no texting, no nothing. The idea being is you wanted the body or the brain to have full access to everything it had so it could recover. What turned out to happen was that when you isolate somebody, then you actually start to increase symptoms that are unrelated to the concussion. Particularly if you have a student athlete who is falling behind with school, particularly like a type A student athlete, they’re falling behind with school. They feel excluded from their team. They get all of these symptoms that are associated with isolation and not related to the concussion.
Steven Broglio: As the concussion symptoms come down, these isolation symptoms go up and then disentangling that as a clinician becomes crazy hard. What we realized is that if you allow people to do activities of daily living, so just go and participate in the things that you do, so long as it doesn’t make symptoms worse, that was a way to avoid some of these isolation issues. That then started spiraling into … I shouldn’t say spiraling, but started growing into what we now term as active rehab. This idea of, okay, so probably for the first 48 hours, don’t do any physical activity. Just rest. Almost like you sprained your ankle. You’re not going to go out and run the next day. Maybe around day three, let’s go for a light walk and let’s see how you go. Day four, okay, maybe we’re going to go for a longer walk or maybe it’s a really light jog or maybe an exercise bike is a better example where you’re not bouncing.
Steven Broglio: People are really starting to experiment with early exercise interventions as a way to accelerate the healing process. If you think about it, we do this with orthopedic injuries all the time. If somebody has an ankle sprain, you don’t just say like, “Go sit on the couch and do nothing for the next two weeks and it’ll magically get better by itself. It will get better, but we know that if you exercise and move it, it will get better faster.” We’re starting to work with that. There’s some really creative work. John Leddy, who’s at Buffalo, he’s been at the forefront of this for 10 years or so.
Steven Broglio: Johna Register-Mihalik at North Carolina, she’s doing some really cool stuff where she does physical activity combined with cognitive tasks where she’ll have people on an exercise bike doing math problems or doing memory tasks and things like that. She’s really starting to push the envelope with it and trying to get people back faster but in a safe way. It’s not all about just speed, but it’s also doing this in a safe way.
Steven Broglio: The other thing that has happened over the last 10 years is there’s been this standardized return to play protocol. This is a five or six-step process where over time, once the athlete can get through a full day of school then they can go for a jog as we start to ramp up their sports specific activity. You can imagine with soccer, it starts off with some dribbling and then some passing, and then maybe we do some controlled heading, and then we do a controlled practice, and then we do an unrestricted practice and we’re like, okay, you’re ready to go. We have some work from the CARE Consortium study that I helped lead where that alone, that extra five or six days of recovery time in that slow ramping back into the sport actually reduces the risk of same season repeat injury. It takes it to almost zero. We were able to compare directly with some historical data from the early 2000s to the modern era. It’s pretty cool to see how these things have really improved the safety of the athletes who wants to get back out there.
Corey: It sounds like this … This research I sent is very, very new because I had a girlfriend who had a … She was hit by a car maybe three years ago, and she wasn’t quite told to stay in a dark room, but she’s basically told to stop almost all of her activities and don’t go to work. Don’t be very active. It sounds like she was still a little bit under that general sense of really, really reduce your activity. This hasn’t quite spread out, or if it’s spread out, spread out very, very recently.
Steven Broglio: Yeah, it’s probably not mainstream yet. One of the things that the Concussion Center at Michigan, we’re really pushing our outreach efforts because we want to make sure that this type of information amongst other things that we’re doing, it gets pushed out. The clinicians, the physicians, the nurses, the athletic trainers, the physical therapists, so they have access to cutting edge information and they can help your girlfriend or they can help somebody’s child that has an injury because it’s moving fast. You quoted a couple of studies today that I was like, oh, I got to go back and look. I don’t remember. I haven’t heard of that one. This is what I do all day, every day. Even I can’t keep up with everything. It’s coming out so fast. When you think of a primary care physician where concussion is just one sliver of what they do, it even gets harder for them. We’re doing the best we can to get the information out there.
Corey: Steve Hsu, any other questions?
Steve Hsu: No, it’s been great chatting with you. I’m sorry I wasn’t in the room to meet you in person.
Steven Broglio: I enjoyed it thoroughly. I’m glad you’re able to dial in and chat with us.
Corey: Steve Broglio, thanks for coming.
Steven Broglio: My pleasure. Thanks for having me.