Were to happen. When something happened to me, i dont think anyone noticed and, two, if they did notice, i dont think they knew what the do. Rose episode 4 of the charlie rose brain easy three, underwritten by the sloan foundation, coming up. Rose funding for charlie rose has been provided by and by bloomberg, a provider of multimedia news and Information Services worldwide. Captioning sponsored by Rose Communications from our studios in new york city, this is charlie rose. Rose tonight, we continue our exploration of the magnificent human brain with a look at sportsinduced trauma. We will focus specifically on its effects on young people kids and young adults make nearly 250,000 emergency room visits each year as a result of brain injuries from sports and recreation. Our increasing understanding of this traumas neurological effects have ignited a National Discussion about the risk of Contact Sports. Tori bellucci was an allmet Soccer Player at Huntingtown High School in maryland. She turned down a full soccer scholarship in college after suffering her firth concussion. She talks about her experience. Also here a Remarkable Group overscientists. Walter koroshetz of the National Institutes of health, Susan Margulies of the university of pennsylvania, Thomas Mcallister of the Indiana University school of medicine, dawn comstock of the university of colorado anschutz and dr. Eric kandel, of Columbia University and a Howard Hughes medical investigator. I am pleased to have them all here at this table. Tell me about concussions among young people. Sportsinduced brain trauma, sh has emerged, as you indicated, as one of the major Health Issues of our time. Why is that so . Let me put this in a bit of a perspective. There is a general consensus that team sports is extremely advantageous for young people. 50 million americans participated in group sports, in athletic competition, and this is beneficial in two ways. Athletic and social. From the athletic point of view, they learn early on that almost daily exercise is good for one, and many of them are likely to carry this forward for the rest of their life, ensuring them a healthier life span than they would otherwise. In addition to the physical values, there are also social values that come with it. One learns from team sports a sense of honesty, fair play, teamwork. These are very beneficial values that also help carry people through a lifetime. But a down side emerged recently, as you indicated. The media called attention to the fact that at the very highest level, professional football, soccer, basketball, there are traumatic brain injuries that are associated with sports activity, and some can lead to severe brain damage. And that has made us worry whether or not we are taking sufficient care of our young people to protect them from this, and this has become a national issue. President obama called a summit meeting on this in may in which he raised this issue. Could i have a brief tape, please . Concussions are not just a football issue. Young people made nearly 250,000 emergency room visits with brain injuries from sports and recreation. 250,000. The total number of young people who are impacted by this early on is probably bigger than we know. Rose so as president obama made absolutely clear, young people are particularly susceptible to traumatic brain injuries, and traumatic brain injuries is the leading cause of death and disability in young people. So we want to understand, you know, what this is about. What is a traumatic injury about . The brain is a ge gel gelatenoun protected by the skull. As a result of impact or inertia forces, there can be serious jarring of the brain as its moved rapidly back and forth within the closed space. Its only separated from this bony, inflexible skull by a fluid layer called the cerebral final fluid. Impact forces are from the physically bumping against the skull either by another skull hitting it, by hitting the ground, by hitting a soccer ball. But in addition to this, there are inertia forces which dont involve any contact at all. Its like a whiplash injury in which somebody bangs into your body and can shake up the brain or when you fall on the ground, it can shake up the brain. Often these forces interact with one another and have significant consequences on peoples neurological state. The traumatic brain injury varies from being modest to being moderate or severe. The modest injury falls into two categories. The vast majority, about 90 , recover within seve seven days. In some cases, even with modest injury, the recovery may take longer. With moderate or severe brain injury, the recovery takes longer. One of the factors that lead to this prolonged recovery, there are several. One is younger people are more susceptible than older people. Having had a prior concussion is particularly important for two reasons. One, prior concussion means it takes longer to recovery, but also one of the interesting, sad things of a prior concussion is if you had one concussion, youre much more likely to have a second concussion, and if youve had two, youre more likely to have a third or fourth one. So concussion is not only bad in itself, but what it does really for the future of the athlete playing. What are the predictors for the long recoveries besides prior concussions . There are severe initial symptoms. Loss of consciousness, if you have that, youre likely to have a prolonged recovery. In what career are you most susceptible for traumatic brain injury . Both in males and females, the peak injury occurs during adolescence, a period from about 12 to about 18, 19 years of age. And why is that so . And that is, everyone who has had an adolescent child realizes there are important brain changes that occur during adolescence. The two key ones well hear about later on are called tuning and myelination. The brain consists of nerve cells that make contact with another to a point of contact called the synapsis and the brain works by overproducing synapsis, produces many more than it actually needs to make sure that every kind of possible contact is covered. But with adolescence, the brain matures and inappropriate contact are gotten rid of, so those that are not functioning are gotten rid of, in order to streamline and make the brain function as a highly efficient computation device. As the brain enlarges, we need speed of communication between one region and another mediated by long structures called axons, and covered by myelin to increase production. Myelination is the process in which it is applied to ensure this. These are the two processes critical during adolescence and its due to these two processes going on that the brain is susceptible to injury. One to have the tragedies is because of the enormous susceptibility, we still have no pharmacological treatment for traumatic brain injury and it becomes more incumbent to use other measures, for people who are the coaches, trainers, the athletes and the person in the game to realize when a concussion has occurred, to immediately pull the athlete from the game and phot to let him return to the game on that particular day. In fact, they should not play again until they have been cleared by a health professional. So this is really absolutely essential. And in order to really, you know, discuss these issues in depth, we brought together a really extraordinary panel. We begin with tori, an outstanding Soccer Player and, because of several concussions, she has decided to give up competitive athletics and she now coaches Soccer Players to prevent them from having the kinds of difficulties shes had, and shes going to describe to us directly what its like to have a concussion. We have dawn comstock who is interested in the incidences of concussion. One of the kinds of circumstances what are the circumstances likely to bring this out. Thomas mcallister is interested in the cognitive behavioral consequences of concussion and doing a longterm study of College Students to see what the behavioral consequences is. Susan margulies is interested in actual through brain meek misms of concussion mechanisms of concussions and studies it in people and animal models, and Walter Koroshetz is wantin wantk about coming up with medical treatments. Rose tori, tell me what happened. I started playing soccer when i was four years old a little against my will. After my first practice, it was something i immediately loved and wanted to do all the time. So i played soccer. Since that day until i was a senior in high school. And around when i was 15 years old is when i got my first concussion. I really didnt know it was a concussion. I missed heading the ball and headed someone else. When i got home, i had a lot of headaches, was having trouble sleeping, but i didnt think it was a possibility of a concussion and i knew i had an important game the next day, so i decided to play anyways. Once i got to my game the next day, it was the semifinals in one of our state cup appearances. And i had gotten into a rough tackle and fell to the ground and hit my head on the ground pretty hard. And once i got up from the fall, i was kind of confused as to where i was, but i gained that back pretty quickly, but my vision was extremely blurry, head spinning, dizzy, but knowing it was an important game, i pushed on. After that, i went to the emergency room that night, after i finished the game, and it turned out i had whiplash in my neck and i did have a concussion. So i had to take probably a week off of school. I was very moody. I couldnt sleep. It was a very tough time for me. Rose were you going to medical care at this time at all in. No. When i went to the emergency room, they gave me a muscle relaxer for my neck. Other than that, i stayed home with my mom. She took off work. Rose thats the problem, not identifying the concussion. If, in fact, according to what youve already said, if there had been some identification, everybody would have insisted she not go back and play till it was cleared up. You went through how many concussions . I had five. Think its interesting to what degree did you know something was wrong but you didnt want to leave the field because you realized the team depended so importantly on you . I feel like, at that point, i would have tried to push through anything. No matter what my symptoms were, i was so competitive and my passion was incredible for the game to where i didnt want to stop, even if i knew something was terribly wrong with me. Instead of leaving the field, when they feel ill, they feel so rose and the n. F. L. Instituted a policy where a doctor examines anyone they feel might have a concussion when they come off the field. Today, how are you . A lot better but i still struggle with things. With my workload at school, i definitely have two to three headaches a week. Sometimes ill have headaches for five days without any break. My eyes have been struggling since my last concussion, which was almost two years ago. Both my pupils are not the same size all the time and, so, with that, its really difficult for me to be in lecture and be looking at the board and looking at the powerpoint and going back to my notes and that really, really city limits my headache. Are you under the care of scientists and physicians . Not anymore. After my last one, i havent really had to go back to the doctor other than telling them i have headaches and probably troubleshooting every idea we had. Rose your case is now well then because you were there at the obama summit with the president and you introduced the subject there. Yeah. Rose so youve become a part of the conversation, the impact of concussions. Which im happy about. Its unfortunate all this had to happen to me, but i think its something that needs to be talked about and known, so im glad i can be a healthier face for that. Rose how prevalent are concussions among young people . More prevalent than people realize. At the High School Age group alone, high schoolsanctioned sports, last year there were 160,000 concussions among Football Players, 60,000 among girl Soccer Players, 45,000 among boy Soccer Players and 20,000 each among girl basketball players and boys wrestlers, National Estimates based on National Insurance data. Over the last decade, concussions increased dramatically over time this is a time where scarylooking statistics might actually be something good. This rapid increase over time likely does not indicate a true increase in the incidence of concussion. High School Athletes havent grown dramatically bigger and stronger and faster over the last decade and most of the rule changes in the last decade actually improved player safety. I think what this image actually demonstrates with the dramatic increases weve had in education, in knowledge. The Young Athletes, their parents, their coaches, the policymakers have become more aware of this issue of sportsrelated concussion. Its recognized more readily. Exactly. Rose is it across the spectrum of sports or more Contact Sports . I think awareness was originally generated because of highprofile incidence at the professional level, but now it would be very difficult to find a parent to let a High School Athlete that couldnt at least explain some of the signs and symptoms of concussion and recognize that its important injury that needs to be addressed. Another thing this image demonstrates is concussion rates are significantly higher in competition than they are in practice. Rose yes. And part of this may be because athletes like tori simply dont want to come out of the game, but its also because there is more events of athlete contact that occur in competition compared to practice. These differences between competition and practice rates vary dramatically by sport, however. For example, in Boys High School ice hockey, competition concussion rates are 13 times high than practice cogs rates, while in girls softball, competition rates are only twice as high as practice rates. Rose how do you explain this . A lot of it tends to be just the activities associated with individual sports. Across the entire spectrum of all 24 sports that i study, the most common mechanism of concussion is athletetoathlete contact. So the combat or collision sports boys football, boys ice hockey, boys of lacrosse have more incidences of athlete to athlete contact. Youre more likely to hit your opponent than your teammates in practice. Rose let me turn to tom bennett and talk about what happens in concussion. From a clinical standpoint, tori described it but the force and the mechanics eric alluded to and well touch on, there is a disruption in brain function that is usually described as an alteration in the level of consciousness which simply means people may have incomplete memory for the event. May appear as described, may have headaches, blurred vision, sensitivity to light and noise or dizziness are particularly common along with headache. The other sort of major domain people will describe related to that are problems with thinking and usually the big ones are problems with memory and attention and concentration. The good news is that most times these symptoms gradually resolve over, lets say, seven to ten days or perhaps several weeks, but weve known for a long time that there is a Certain Group of folks for whom thats not the case, and the symptoms can persist for a fair amount of time. Whats interesting is that the way that the concussion happens and the way the brain is designed and the skull is designed and so forth actually predict nicely the kinds of symptoms that tori described, or you can see again these two forces, either one can be from the brain hitting the inside of the skull and the areas in red on that slide suggest the areas that are particularly vulnerable, and then whats important to know is that the skull is great at protecting the brain from a lot of things, but when you put the brain in motion and its moving out of phase with the skull itself, its rubbing up against a somewhat hostile Work Environment there, you can see on this cutaway of the image there are certain roughages and areas on the inside othe skull that make it more likely the brain gets damaged in those particular areas. But you dont even have to have that in order to have the damage that or the injury and symptoms that tori described. I think just the very movement of the brain itself, eric described it as a ge gelatinous material and the brain the moving and there are shearing forces and that can damage the delicate white matter fibers or axons. These are delicate and this twisting and action can damage that and damage the connectivity of the different brain functions. So putting it all together, the next image will show the particular brain regions which are most likely to be damaged, and what i think makes concussion and brain injury in general a sort of perfect storm, if you will, for the kinds of neuropsychiatric complaints tori described are these areas illustrated on the image map very nicely on to brain regions which are responsible for the symptoms tori described herself as having. So memory, for an example, is a particularly common complaint. This next image shows which brain regions are important, and memory function, i think if you compare that, the other image, you can see it maps on to that very, very nicely. Tori, i think, described difficulties with school work and lots of our athletes described that. They described it as not thinking as quickly, decreased information, processing. And then i thought it was interesting tori mentioned being moody, depressed. This is an enormously common complaint from people who have concussion and other types of brain injuries, so the whole Psychological Health aspect is impacted, and this next image shows, again, brain regions that are thought to be particularly important in depression and, once more, really, if you were to design an injury that was calculated to sort of damage cognition and neural behavioral symptoms, you couldnt have designed a better one, unfortunately. So the point of all this was that i think the symptoms that we see follow very nicely from what we know so far about the mechanics of how the brain is injured. Do you know why some people recover better than others . Well, eric alluded to some of the reasons that we know of. So folks who have had more than one injury tend to take longer to recover. Younger athletes may take have a more prolonged recovery. There is also an interesting link between other kinds of behavioral and psychological Health Issues, so folks who have had struggles with those kinds of concerns in the past, there seems to be an interaction with it. And then as well hear from dr. Margulies, the biomechanics, not every injury that looks the same is actually the same in terms of how the stresses and strains affect different brain regions. I think that may play a role. Finally, there is very interesting work suggesting genetic factors may impact this. So, you know, you and i might differ in terms of the genes that we have for Getting Better or getting not better after a concussion. Rose term turn to walter and talk about how the young brain is different. Right, charlie. So i think our brains are always developing, even in our adult life. New connections are being made. This is much more dramatic during childhood. The changes occurring in the young brain are just so dynamic. The energy that the brain uses peaks in late childhood and adolescence. The blood flow peaks in late childhood and adolescence, and, as eric said, the brain is a massive computer where the connections are just tremendously exuberant right at the beginning. Then its kind of like molded over time by activity and experience to make us who we are, and that molding period, as eric mentioned, is because connections that are not useful are taken over time, the synaptic pruning, and thats taking place in this time period. Everyone is more worried about things that occur during developmental stages. The myelination, thats one to have the latest things to complete itself in the developing brain. It goes on, the insulation around the wires that connect different brain regions goes on for many, many years into your young 20s, and that really determines the speed and efficiency of connections between different brain regions. So its a very dynamic period of time were talking about today. You make a very good point, walter. The learning mechanisms in the adult brain consist of two kinds the growth of new connections, for example with learned fear, and the retraction of connections with habitation, when you want toig norsomething. These occur in the pruning. You have the outgrowth and the habituation. Little bits of things are happening with you and i, but in the young brain its dramatic. Rose explain that again. You think about how your brain and skills develop over time, i you go through tremendos advances, executive function and planning. You know, the teenage brain, its questionable whether there is anything working in there at all, but, you know, over that period of time, it really changes, and this is the physical basis of that, this pruning. Rose my brain is influenced by every experience. Absolutely. Rose so at the end of the day its different than at the beginning. Absolutely. What youre seeing here is a spectacular representation of that. And how the brain can do this and get rid of connections that are inappropriate or unnecessary is just marvelous, and we dont go in detail the underlying mechanisms, we just know it occurs. Rose what parts to have the brain are most vol number. During the injury period, the temporal lobes, the frontal lobes when were talking about the circuit for emotion, depression and these executive function which are planning, attention. So all toris complaints fall right down these particular brain regions. Nothing shes had surprised you . No, ive heard this hundreds of times, same story. Rose classic. Susan, what about the the biomechanics . So well go back to the image eric has shown before in. Sports, the vast majority of impacts to the head, and tori described impacts to another player, impacts to the ground, theyre a result of a combination of linear and Rotational Movement of the head, and research has shown its the Rotational Movement of the head that causes the largest amount of sloshing of the brain within the skull. And tom had described how the distortions of those very delicate ax axons or nerve fibes in the brain, when theyre distorted, there is an spruption in their ability to communicate amongst different regions of the brain. We do know big distortions in the brain cause serious brain injuries, but as a bioengineer, i use animals and computation models to look inside the head and try and make the relationships from the amount of brain distortion and the amount of disruption of function. We have a lot of research that has happened over the years about serious brain injuries, but those types of more subtle changes that occur in concussion, we really have very little understanding of how much distortion of the brain tissue does it take to cause concussion d, so, that research is very much underway and its difficult to measure some of those subtle changes that occur in concussion in animals, so were working toward doing that. Part to have the problem is some of these changes are probably not reflected in an tomplicle changes. There may be transient changes in the brain that are difficult to pick up with our techniques. We know larger distortions can result in structural and more permanent functional damage. So animal models can help us identify what distortions are enough to cause those concussion symptoms, but we dont know that yet. There are a number of Acceleration Sensors that are available on helmets, in patches, mouth guards, and these sensors have been very helpful in helping us to understand the range of accelerations that occur if realworld scenarios, and they help us to understand that, for one person in the same scenario, they actually have very different accelerations that may happen. And they help us to really appreciate the chance someone, given that acceleration, the direction, how fast the head is moving, all contribute to the brain sloshing, but sensors cant tell us if a concussion haas occurred. Rose cannot. They cannot. They can only tell us what the acceleration of that head was. We need the athletes to tell us about their concussion symptoms. People respond differently to the same. Rose let me understand that. Seems like a critical point. There is no way that you can determine whether a concussion has occurred . From a sensor. Rose from a sensor. That is right. The sensor will only tell us what acceleration has occurred in the head. Different people respond to the acceleration differently. Their skull may be different, the brain may be tougher, different factors. Or they may have had a previous concussion. There are a number of settings of that brain that cause different symptoms for exactly the same acceleration. So we rely on people to report their symptoms and i think tori shared with us the challenge we have. So we actually think that large or small accelerations, we dont even capture a complete understanding of the risk of acceleration that might occur, so we need to have Something Like an xray for a broken bone or a blood test or something that can tell us. There is another thing that emerged here we need tone courage young people playing sports to be sensitive to their own well being and to report any discomfort that they feel. We have raised my generation pretty much the way you described this, to ignore and keep playing. We have to educate people not to ignore anything, to call a time out and make sure nothing serious is happening. Its a complete change. You have to consider 50 million kids are playing sports. Rose the idea of playing through the pain. That the what you did, kid. Weve seen dramatic improvements. In 2007, all the high School Athletes returned to play the same day. Last year, less than 2 . 8 that sustained a concussion in the 20072008 year returned the same day, now less than 2 . If you look at the week guidelines, in 2007, 30 of high School Athletes returned to play within six days and now its less than 10 . Certainly is a very good sign but even more could be helpful. Should be zero. Rose zero returning. Concussion is not an all or nothing phenomenon and any particular acceleration, we expect that a certain proportion of people might have a con concussion, have concussion symptoms, if their head moved with that abacceleration. We represent it with the risk curve you can see here, were at very high levels of acceleration, youre very likely to have a concussion, and at very low levels of rotational acceleration, youre unlikely to have a concussion. And this type of risk curve is very important, and ill talk about how it probably changes with age and other circumstances. When we think about equipment thats available to us, helmets are designed actually to prevent Skull Fracture and serious brain injuries. They are not designed to prevent con concussions. Technology is yet to identify a means to really effectively reduce the rotational acceleration that sloshing within the head thats happening in the brain itself. So at this point right now, helmets are very important Safety Equipment to wear to prevent serious head injuries and Skull Fractures, but there is a demand for products to really help in this range, this middle range where equipment can make a big benefit in terms of the injury risk for con concussion. Rose what kind of equipment will prevent what kind of concussion . You would like to reduce the amount of head rotation that is seen. You would like also to reduce upon contact the amount of head rotation. When the head hits the ground and the body continues to move, if the head is firmly attached to the ground with a lot of friction, then there is a rotation of the head if the body is continuing to move. So a frictional surface, a sliple surface that allows the head to move along and in a Straight Line or a material that allows to slow down or ramp down the deceleration that occurs when you hit another contact like an individual or a hard surface. We have the entire front of our car which provides us crush to slow us down when a frontal collision occurs. We need to slow down the rotation that occurs at impact. Rose and whats the most likely way that will happen, do you think . There are some Innovative Technologies that allows the head to slide but those are only good for helmets. Were still struggling on how to prevent these in unhelmeted incidences. Rose i just returned from the profile of a formula one race driver. They have a whole system to keep the head. To prevent the head rotation. Rose thats exactly right. So an impact at the level of the level of fitness will have an important effect, and that is one of the theories why women may end up being at more risk than men, if the neck strength is not as strong as a male. And there is data to show that, when women work on their neck strength, that actually the amount of head rotation thats experienced by an impact decreases. Rose the athleticism of these drivers is they work hours and hours and hours on strengthening their neck. You see them walk away from these horrendous crashes, and thats only recently, because there is a history of how these changes were made to the cars, and it was to prevent exactly what susan is saying which is this acceleration, deacceleration with these unbelievable impacts, so the fac that you can do that theyre available also for football, the collars. On the next slide, we see, after concussion a concussion is not like a bone fracture where its all over in an instant. Its the beginning of a progression of symptoms, some lasting minutes, hours, days. The glucose metabolism, the cerebral blood flow which provides important nutrients to the brain and oxygen is decreased after a concussion and if a repeated concussion occurs in the setting of an alreadycompromised brain, then the response to that very same brain deformation can be dramatically different and what tori told us about her symptoms of concussions or the next day when uh you had a second concussion, thats completely consistent of an injuried brain being on top of another injury and thats particularly devastating with worse and more longlasting symptoms. So we know the line is, if in doubt, sit it out. You should not go back into play until the symptoms are over. So the first risk multiplier, if you will, at the same level overacceleration will be was there a previous concussion and how long has it been and how severe were the symptoms of the previous concussion. I would say the second risk factor is age. So in the young brain, in the next slide we see how the young brain is changes over time and we see that the energy needs of the young brain peaked early on and that the cerebral brood flow is high blood flow is high. And if the symptoms of concussion occur with a decreased metabolism and decreased cerebral blood flow happen just when the brain is needing it most with development, you can understand why there might be prolonged symptoms that may worsen over time. So these biological contributions add on top of the mechanical. This is the most common cause of death in children. One of the factors that can increase risk is youth, prior concussions, these all move the risk higher for a given acceleration that there might possibly be a concussion. In addition, we think women might actually be at higher risk for concussion. Were actually not sure if the same tissue deformation causes a more profound response in women or if actually women will report their symptoms more. Rose more likely to . What we really need are those equivalent of the xrays or the blood tests. Rose one more evidence women are smarter than men. laughter thats actually a nice transition rose okay. Concussion rates vary widely by sport and gender. For example you see the concussion rates among girl Soccer Players is for every 10,000 girls playing soccer 21 sustain concussion. Among boys, its only 9. So the concussion rate is twice as high in girls compared to boys soccer and comparing girls d Boys Basketball its three times higher among girls than it is boys. Rose how many concussions is too many some. You never know when its going to be the last straw and thats why i had to quit. As much as i wanted to keep playing, say i got another one, i could be okay or i could be in bed for a year. I dont know whats going to happen to me, so i dont think we can say how many is too much. Rose whats the most concussion . What are the consequences . My third concussion was probably my worst one. I went out for a header and missed heading, once again, hit the other player and hit my head on the ground. When i came to, i never lost consciousness, but when i came to i was very disoriented, very confused. Once i realized where i was, i decided to keep playing. At that point, i didnt tell anyone because the following weekend we had the state semifinals. I wanted to keep it to myself because i really wanted to play. One day while at school, i was eating lunch and opening my jaw and i felt a crunching near my temple and i felt a serious crunching. So, obviously, i was very scared. I told my mom and we immediately went to the doctor. They were very concerned an they couldnt really tell me what it was. So after i was checked out they thought i had a Skull Fracture but turned out it was just fluid surrounding the skull from the impact. After that, i was probably out of school for two weeks straight, and i dont think ive been the same ever since. My grades dropped not significantly, but they did. I was terribly depressed, but didnt want to admit it. So from the outside, i probably looked okay, but when i got home, i closed my curtains, laid in bed, did nothing else. When i was in practice advising parents and student athletes, it was always, you know, learning from your experience. What was the impact of your last concussion . How did it impact your life, you school work, because the next one is going to be twice as bad. And thats kind of the message that i think people have to listen and make the reasonable choice. And i guess i would throw in this one other thing which susan mentioned was the fact that its not just the number but its the sequence and how close they are in time. So there is one very rare event, but it is, unfortunately, a fatal event. Its called the second hit phenomenon. In the second hit phenomenon, the brain has not yet recovered and this athlete goes out and hes a little dazed, not reacting normally, and that second hit caused another con concussion, caused the brain to swell and that can be fatal. Its a very rare event but goes to susans point that close in time concussions is probably the most dangerous thing. Rose because it causes the the brain to swell . You can get into brain swelling. You have the swelling to begin with, then hit it again and have the second damage. You have the brain swelling and the symptoms will be much worse and longer lasting and tori told us that because each concussion was worse than the one before it. Rose is there a problem with accurate reporting here . Sure. It starts even before the concussion, so people may be aware that there is a big emphasis on doing baseline, preseason testing of memory and attention and concentration, and if someone does have a blow, if tori had been tested with these tests of memory and attention, might have been able to diagnose a concussion because her performance might have dropped a little bit. But its now at a point where some athletes notice and they will not try as hard as perhaps they might on the preseason evaluation so that if they do have a blow or concussion, it will be more difficult to diagnose and, secondly, it will be easier for them to be returned to play before theyre, perhaps, ready. The other thing is not all symptoms occur right at the time of the injury. In fact, susan was describing equip Football Players with sensors in their helmets and measure the number of impacts and how hard they, are you find its really way more complicated than we thought, sadly, in terms of trying to say, thats the blow that actually resulted in the concussion. Part of it is tori just gave a great example of it is i hit the h head and then i hit the ground and then, you know and in some sports, combles comes by and knees you in the head as theyre trying to recover a fumble, so it can be three or four impact, whatever, in very quick succession. So it makes it difficult to know. Some of the athletes dont report symptoms till hours or days later. They come int into the trainer monday after a game and say over the weekend i had headaches, still a little dizzy, so reporting is really problematic. Thats are Animal Studies actually come into play because in the laboratory you know exactly what the head accel was and the direction. You can control the interval between the two of these and you can really try and understand whether how many whats the critical number and the interval. And understanding the rates and patterns of concussions in Young Athletes is dependent on our sources ofda at that. We get quite a bit of our data from clinical settings, but Young Athletes have so many choices to present to Clinical Care now. If when i was a kid, if i got hurt playing sports my parents took me to emergency or told me to suck it up till monday to see if i was better or feed to go to my pediatrician. Now my nieces and nephews can go to a critical care, Sports Medicine or pediatric concussion clinic. We dont have a National Surveillance system capturing data on athletes under High School Age. We honestly dont know whats truly going on in that age group. Heres another absolutely amazing thing that walter can speak to and that is this is a major problem and, yet, i can think of very few areas of medicine where such serious damage can occur and in which there is such ineffective therapeutic approaches at the moment. Why is that so . Well, i think the problem has been, as people said around the table, we havent been able to see anything in the brain in these cases, and, so, its likely been difficult for scientists to develop treatments. Good animal models, you mean. Or the human condition. When you do an imaging of a cukdz with ct scan or mri, you usually dont see anything. But the science is going to lead to something. The first video is an experience done by dorien mcgavins lab at the National Institutes of health and they have mounted a microscope that can see into the skull of a rodent and you can see in real time what happens i thin substance where there is a slight, tiny compression to the surface of the brain. On the left side of the image you see the normal brain. On the right side of the image with the compression, you can see the glial cells on the surface and the cells are dying. This is in real time. Second video well look at the glial response to the death. These ugly looking things on the left they call jellyfish microglial which plug the holes we saw developed on the previous video. Now, turns out there is a drying glutothion which give town the surface of the brain prevents this process from occurring. The drug is a free radical scavenger, so the brain uses oxygen for energy. The down side of that is oxygen use in the brain produces these chemicals that, if they get free, they can do a tremendous amount of damage and glute thyion saps these up. So maybe a glimpse to whats coming down the road, free radical salve jeer medications for concussion even. The two of you may comment on this with professional athletes, what some of the longterm consequences is including serious dementia coming out of concussions. This is tricky to explain. Well see on this next slide it speaks to what eric talked about which is the real concern that not only are these potentially, relatively shortterm consequences to multiple concussions, but there could be a possible longterm, very serious condition which is first described in boxes in the 1920s called dementia piewj pugilistica where the brain becomes shrunken and the person becomes very demented. On the bottom you can see a brain very involved in the disease, and there is tao in the brain, a protein. It produces palsy and dementia and this condition. Initially, we thought this was quite a rare event that required tremendous exposures, but unfortunately what we found more recently is that the brains of the n. F. L. Players often have very small deposits of this tao protein and you can see that in the middle panel but this is not a professional football player, this is an 18yearold football player. What we dont know is what is the clinical consequences of these small deposits of tao. We are, however, worried because there are experiments now that show tao can spread. So one theory is these are the beginning stage and that tao spreads throughout the brain to cause serious dementia. We dont know how frequent it is or the spread occurs in everyone. But thats the biggest fear. Rose no pharmacological treatments . At this time certainly none that are approved for use, an thatpart of that is, up until recently, we were convinced pretty much everybody would get better after concussion and on fairly short order, so there wasnt a lot of impetus directed toward trying to develop farnlg pharmacological interventions. Weve touched on an awareness of before people get injured, but educating folks about the nature of the injury such as the discussion at this table. Rose thats the Important Role tori plays, in part. Thats exactly right, and being able to let people know, in the first place, you had an injury, that doesnt mean your life is ruined, in all likelihood. The odds are you are going to get better, but here things you might expect to see happen and here are some of the accommodations you might want to make, but the expectation is you will get better, so setting expectations as opposed to cay t. S. Acatastrophizing this is go. Rose what should parent come away from this conversation . One of the most important points is to date weve spent a great deal of effort on improving diagnosis and management and looking for potential treatment modalities. Weve spent very little effort on primary prevention, keeping kids from being injured in the first place, and i think its important for kids to come away knowing there are things they can do to protect their Young Athletes. Rose and some question about changing the rules of the game . There have been pretty dramatic recommendations from the National Sports bodies over the last couple of years. U. S. A. Football, pop warner, the National Federation of High School Associations put out strong limitations limiting the number of days a week young Football Players are allowed to participate in full contact drills. Just yesterday u. S. Soccer put out recommendations athletes ten and under should no longer be allowed to head the ball if either practice or competition while playing soccer. Those are pretty dramatic efforts to keep kids safer and healthier by keeping them from sustaining a concussion in the first place. Rose what is your hope . I hope that we can become more knowledgeable on this. I dont want kids to shy away from playing soccer or playing sports because i think thats turned me into the person i am today and its really helped me with my character and teamwork and leadership, but i want us to know what to do if something f something happened to me, i dont think, one, anyone noticed and, two, if they did, i dont think they knew what the do. Rose summing this up, what should we know . Well, president obama heard that you were doing this program, and he sent me a message saying he would like to have one of the final words. So can we play his tape . So there is more work to do. Weve got to have better research, better data, better Safety Equipment, better protocols. Weve got to have every parent and coach and teacher recognize the signs of concussions and we need more athletes to understand how important it is to do what we can to prevent injuries and to admit them when they do happen. So we have to change a culture that says you suck it up. Rose thank you, mr. President. Well continue ploargs next time. Tell me what were going to do. This time, we spoke about physical injury, sportsinduced head trauma. Next program, were going to discuss how psychological consequences, psychological environments can produce serious damage to the brain. So poverty, brutal treatment of children by parents or by others, even some aspects of inheritance can have significant psychological and brain consequences that are really quite frightening. So well speak about the psychological parallel to this trauma. Rose thank you very much for coming. Thanks for having us. Rose see you for the next episode. See you then. For more about this program and earlier episodes, visit us online at pbs. Org and charlierose. Com. Rose communications captioned by Media Access Group at wgbh access. Wgbh. Org rose funding for charlie rose has been provided by the following and by bloomberg, a provider of multimedia news and Information Services worldwide. Announcer this is nightly Business Report with Tyler Mathisen a wheres santa . As investors wait on the rally to close on the year. So far it hasnt come. Should investors be concerned . Oil squeeze. Saudi arabia posts a record budget deficit thanks to a dramatic fall in crude this year. Could this further destabilize an already tumultuous middle east . And seeing stars. Star wars latest chapter is the fastest movie ever to rake in a billion dollars. Why that juggernaut may be good news for other movies and good news for hollywood. All that and more on nightly Business Report for monday december 28th. Good evening, everyone and welcome. Tyler is off this evening. It is the final four days of 2015, and its that