A New Stage Play Tackles Athletes And Head Injuries

Can the repeated brain injuries suffered by some athletes cause problems with brain function later in life? A new play, Headstrong, opening next week in New York, looks at athletes and head trauma, and the high price some athletes end up paying for playing the game.

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IRA FLATOW, HOST:

This is SCIENCE FRIDAY. I'm Ira Flatow. In contact team sports, how well you can hit the other player counts for a lot. Body-checking in hockey, getting your bell rung in football, that's the pleasant euphemism for getting hit in the head, well, it's all just part of the game, right?

Well, there's a growing body of evidence showing that those hits to the brain can do long-lasting damage to athlete's brains, damage that changes the structure of the brain, that might be causing psychological changes like depression or poor impulse control, leading in some cases to suicide.

So how many hits is too much? Should we do more to protect players, or is getting hit hard, oh, well, that's the price you pay for playing in the big leagues? Those are some of the questions being asked by coaches, parents and doctors, and they are questions also being tackled in a new play "Headstrong" that's opening here, it's opening here in New York.

It's going to be opening next week, and joining me now to talk more about it are the director of the play, one of the actors who star in it and a couple of scientists who are researching what happens when you get hit in the head?

WILLIAM CARDEN: Billy Carden is the artistic director of the Ensemble Studio Theater. He's also the director of this play "Headstrong." Thanks for joining us today.

It's great to be here, Ira.

FLATOW: Actor Ron Canada plays aging football legend Duncan Troy in the play. Thanks for being with us.

RON CANADA: Oh, thank you, Ira, for having me.

FLATOW: You're welcome. Annegret Dettwiler-Danspeckgruber is associate research scholar at Princeton Neuroscience Institute, that's at Princeton University. Thanks for being with us today.

ANNEGRET DETTWILER-DANSPECKGRUBER: It's a pleasure to be here.

FLATOW: Jeffrey S. Kutcher is the director of Michigan NeuroSport. He's also the chair of the Sports Neurology Section at the American Academy of Neurology and assistant professor in the department of neurology at the University of Michigan in Ann Arbor. Welcome back to SCIENCE FRIDAY, Dr. Kutcher.

JEFFREY S. KUTCHER: Thank you, Ira, good to be back.

FLATOW: Billy, let's talk about the play. It's almost like it's ripped from the headlines today.

CARDEN: It is a little ripped from the headlines. I mean, this was a play we commissioned from Patrick Link, the playwright, a year ago. He gave us a one-page proposal to tackle this subject. And I think he's a longtime football fan himself, and his family are all football fans, and he's managed to really take on the very tough questions that this issue raises in terms of how much we love a sport but also what that may be costing the players who are playing it and how we reconcile that with ourselves and with them.

So it's - the play, I think he's done a wonderful job of capturing that dilemma and really from - has created characters that really are very specifically portrayed at different points of view.

FLATOW: And very true to life as we - as we who follow sports and follow this, know it to be.

CARDEN: Right. I think it's very - you know, there's a wonderful authenticity to what he's written, and I think the character that Ron plays, Duncan troy, is like an iconic football figure and really, in many ways, embodies what we would consider the soul of the game. And that's very important.

FLATOW: Ron Canada, you do play that iconic football hero, and are - in the play, your character is upset at the attack on football.

CANADA: Well, right. He's very much entrenched, Duncan Troy, the character I play, in the warrior ethic of football, especially as practiced at the highest level, the NFL, and he has excelled for 14 seasons. So he very much wears the NFL shield, you know, on his heart, and any - he views anything that limits the manly characteristics of the game, the amount of courage that it takes to go onto the field, as an attack on the game and a way of life as he sees it.

FLATOW: And he says if you play football - one of the great lines, I remember from seeing the play, is what happens if you take out the violence from football, you have soccer.

(SOUNDBITE OF LAUGHTER)

FLATOW: Something like that, right?

CARDEN: Yeah, that's in the conversation between the doctor and his agent, who's trying to get a contribution of brains. But my character says, if you take the hitting out of football, what do you get? Checkers - which is a great dramatic line. I think what you get is a kind of chess, but for dramatic purposes, it makes the point.

Well, I think the other point that Patrick makes in the play, is that if you're going to have heroes, you have to have danger. And how do you, you know, how do you not have real danger to have real heroes?

FLATOW: But one of the points, a central point driven home, and that is sort of the conflict of the play, is: Do the players - do the heroes know how much danger they are in, in playing that game? And are they aware that there is the risk? Are they told about it? Is it kept secret? And I see that you're shaking your head, Annegret, at this idea, yeah.

DETTWILER-DANSPECKGRUBER: Yeah, definitely. I mean, this component is absolutely brilliantly displayed. And obviously the complexities of also what the effects of these hits, you know, have in the - obviously exhibited by the behavior of the role of Duncan, and then obviously with the death in the family and what this might provoke as a complexity of - ranging from tremendous guilt feelings to what the family has to put up with is - comes out, really, in a very poignant way.

FLATOW: Jeffrey Kutcher, I know you haven't seen the play, but it deals with something called CTE that has been seen in some ex-football players. Tell us what that means.

KUTCHER: Well, Ira, that's a great question. You know, CTE means different things, depending on how you look at it. One way would be what are the changes that the brain is undergoing because of repetitive that you see under a microscope, on slides at autopsy, when you can examine the brain. Once somebody is deceased, you see changes that are in a pattern that we think is due to repetitive trauma to the brain.

What it means, clinically, is sort of the big question, is when does CTE start to produce symptoms in people, what do those symptoms look like, how do they progress, what is the disease itself. We're really just beginning to describe the natural history of what CTE means in a living person and especially when we're looking at things that are very, very common in the population in general, such as depression and dementia. Those things become difficult to tease out.

FLATOW: CTE is chronic traumatic encephalopathy, right?

KUTCHER: Correct.

FLATOW: And let's talk a little bit more about it with Dr. Dettwiler. What are some of the changes that might happen in the brain after a concussion?

DETTWILER-DANSPECKGRUBER: So typically, I would say there's - one thing that is pretty established is the metabolic vulnerability that you - has been demonstrated, definitely on the research level, in the brain after concussion. And there are neuro-metabolic changes that can be captured through an imaging, an advancement imaging technique called magnetic resonance spectroscopy.

And it measures in certain brain areas, and there's a choice where it can be measured, that there can be changes in these neuro-metabolites, and they actually - as far as it is documented, by now they're definitely there until one month post-injury.

There's an Italian group that has provided quite some substantial evidence for that. There have also been functional changes demonstrated by several groups. That's when a person forms, in general, typically a working memory task, because that's one of the typical symptoms of concussion that has been established clinically, I mean, one of many, but one that we can measure most easily.

And there is evidence that these functional changes also persist.

FLATOW: Is it cumulative? Does it add up over the years if you're an athlete?

DETTWILER-DANSPECKGRUBER: Right, and there is some very recent evidence that yes, they do obviously accumulate, and that's the big question: How many hits are too many, and when do these possibly chronic traumatic encephalopathy changes occur? When do they start?

And that I think still a very open question, which we don't know. The other imaging modality, which might be maybe closest to capturing these changes in the structure of the brain, is diffusion tensor imaging, which where there is one study - I would say, it's emerging evidence that there might actually be not only physiological or metabolic changes but possibly structural changes in the brain.

And that's obviously a very big issue.

KUTCHER: Ira, if I could...

FLATOW: Yes, Dr. Kutcher.

KUTCHER: If I could clarify a little bit about maybe two different entities that people are discussing here, one is concussion, and one is the chronic traumatic encephalopathy. And they're actually quite different entities, and we shouldn't presume that concussions are even related to CTE mainly because what was being described as the metabolic changes that can be demonstrated, have been demonstrated up to 30 days after a concussion was diagnosed, that may not have anything to do with the more chronic changes at the cellular level.

It might. We don't know. And so one thing that I want to be clear about is that the development of CTE does not require anybody to ever have a clinical concussion. It's more so the repetitive trauma force to the brain itself that probably leads to structural changes that lead to a degenerative process that then becomes CTE later in life.

FLATOW: That makes it even more mysterious then. If you do not get a concussion, if you're an athlete, you may think nothing wrong is happening.

KUTCHER: That's true, and the point here is that, you know, a brain has to develop symptoms, has to produce a clinical effect to bring a concussion to the fore so that the athletic trainers and the physicians and even the teammates or whoever know that it's there.

But do I think that if somebody has a bit hit on a football field or on an ice rink, and they're injured, they don't always produce symptoms, and so those people don't get the diagnosis of concussion, yet they're still injured, and that adds even another layer to the complexity of the problem.

DETTWILER-DANSPECKGRUBER: Yeah, and if I may maybe add to that, also once a player has had a concussion and might become symptom-free doesn't mean that things have normalized on the brain level. That's a huge issue.

KUTCHER: Exactly.

FLATOW: All right, let me ask you, Billy, are your characters based on real-life people?

CARDEN: To a degree. I mean, I think two characters were inspired by two people who's done a lot of work in this field. One is Bennet Omalu, and the other was Chris Nowinski. And just for the record, Chris asked us not to mention him in relation to the play, so I don't - I want to respect that. But I think those were - those two characters, you know, really inspired Patrick in terms of people who were involved in this and what they're learning about it.

Bennet Omalu was the pathologist who first looked at Mike Webster, a very famous center for the Pittsburgh Steelers who died at the age of 50, and when Bennet Omalu looked at his brain after he died, that's when he saw the signs of CTE.

FLATOW: We're going to take a break and come back and talk lots more with Willie Carden, Ron Canada, Annegret Dettwiler and Jeffrey S. Kutcher. Our number, 1-800-989-8255. You can also tweet us @scifri, @-S-C-I-F-R-I, talking about concussions and the brain and also CTE, learning that they're two separate things. Stay with us. We'll be right back after this break.

(SOUNDBITE OF MUSIC)

FLATOW: I'm Ira Flatow, this is SCIENCE FRIDAY from NPR.

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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow. We're talking about concussions in sports and about a new play at the Ensemble Studio Theater here in New York called "Headstrong," directed by Billy Carden. When does it open?

CARDEN: It opens Monday, next Monday, April 30.

FLATOW: And it's play until?

CARDEN: It's playing until May 13 at 549 West 52nd Street in Manhattan.

FLATOW: Beautiful little theater over there on the West Side. Ron Canada is - plays legendary football player Duncan Troy. It doesn't look like it took you a lot of homework to get into that role.

CANADA: No.

(SOUNDBITE OF LAUGHTER)

CANADA: It really didn't. It - I finally got a chance to use all this previously useless knowledge that I've acquired over 50-some-odd years of watching football. I saw my first professional football game in 1960, Johnny Unitas and the Baltimore Colts against the college all-stars led by John Hadel. And it set me on fire, and I've been sucking in information about this sport.

I'm, you know, addicted to it like a great number of Americans, but...

FLATOW: But you already realize, interesting being in the play, you realize that you're going - you're making a choice as a football player, knowing what the consequences might be.

CANADA: Right, the character of course is making - argues that everybody who gets on the field in the NFL knows the risk. And I've heard this statement made by many, many professional football players, talking about, you know, realizing that when they step on that field, anything can happen.

And there have been, you know, a couple of instances, not too many, where there have been tragedies: Darryl Stingley paralyzed for life. They all know that that can happen. Joe Theismann's career ended horribly in one second.

FLATOW: Right, but here we're also talking about people who are possible suicide victims because of the - of getting hit too much in the head and suffering from depression and people dying in their 20s and young lives that I think most people, Jeffrey Kutcher, don't realize, don't hear much about.

KUTCHER: Well, Ira, I think we have to be very careful with that kind of assumption that the suicides and the depression that goes with them is a direct result of head trauma. I think in some cases, it certainly is a risk factor, but like I said, it's - being so common, being something that happens, we have to be careful not to make that link.

We don't have data to support that that's what's going on clinically, that being...

FLATOW: And can you ever get that data?

KUTCHER: Sure, so you can. Actually, you know, one of the things that some of my colleagues and I are working on is a national sports concussion outcome study that is hoping to enroll athletes in many sports in their teens and high school, follow them through their college careers, their professional careers and to death and during that whole time measuring cognitive function, measuring mood scales and imaging and getting a sense - and the impacts they're taking, the number of impacts, the degree of force and being able to finally get a cohort study that will allow us to answer these questions and say yeah, this is how many hits is too many hits.

FLATOW: Can you have CTE and not have any symptoms of it?

KUTCHER: That is - that goes back to the point I made before, which is depending on how you define it. There have been some athletes who have died that have had the changes in the brain, who died from heart disease or some other issue, who had no neurological symptoms. It would be sort of akin - one of the analogies that's been made is, you know, you have some atherosclerosis, does that mean you have heart disease?

And what point does it become a clinically relevant factor? I think you can have both. You can have CTE and not be symptomatic from it, or you can have the more progressive, dementing neurological problem that I think is what people are describing.

FLATOW: And in fact, Billy, the play opens with a scientist who is trying to collect the brains of people who...

CARDEN: Well, actually he's not a scientist. He works with a scientist, but the character of Nick Merritt is actually - yes he does. He comes to ask for the brain of a football player who's died - from his widow.

FLATOW: Trying to, through autopsy, figure out what the brain damage is.

CARDEN: That's right, because right now, that's I think - and both our scientists can help us with this, but I think that's the only way we can really detect it.

KUTCHER: Currently that's essentially true. I think there are some advanced neuro-imagining (unintelligible) that is starting to come online that will allow us to analyze brains in living people, but right now that's not a sort of ready-for-primetime technology.

FLATOW: Let's see if we can get a phone call or two in here. Clayton(ph) in Austin, Texas, hi Clayton.

CLAYTON: Hi, Ira. I know everyone's metabolism is different, but I think I've got a great example in myself and my brother. Forty years ago, I played college football, probably had three or four concussions over the course of four years and never had any symptoms whatsoever.

My brother was an Olympic boxer, who over the course of his three or four years, probably took hundreds, if not thousands, of blows to the head. And he had no symptoms for 20 years, and then they suddenly manifested themselves. And at this point in time, he has severe neurological problems and depression.

And I think the fact that it happened so quickly and such a long time after was a real surprise to all of us.

FLATOW: Thank you for that information. Dr. Kutcher, any reaction?

KUTCHER: Yeah, I think that actually illustrates two very good points. One is sort of the differing amounts of force or dose of impact over time and how that might give us different clinical outcomes, in other words a football player versus a boxer, somebody who takes, you know, maybe a couple hundred or a thousand or so hits over a career versus many thousands.

And the second point would be that every brain is different. Every individual brain is different, every individual injury is different, and so if the brothers were reversed, if our caller had been the boxer, would he be in that position or not, and, you know, chances are not, but we don't really know that. I think it really highlights the fact that everybody's different in this situation.

FLATOW: You know, there's interesting stories coming out recently, and there was an article in the New York Times just a few days ago about soldiers who are - who have - don't think that they're getting any kind of effect, post-traumatic stress disorder, seemingly tied to percussions, you know, being on the battlefield during things explode a lot and not realizing that that may be connected.

KUTCHER: Exactly, and that's a whole other set of forces that we need to understand how those affect the brain in a sort of sub-clinical sense. In other words, it's not producing an effect at the time, but when they come home, months later, years later, is there a clinic effect that you can then measure.

FLATOW: What do you need to make the connection and then to - and can we get to a point where we will be able to - and I'll ask Dr. Dettwiler also - to be able to do a non-invasive test of athletes and say you've had too much.

KUTCHER: We would love to have the test that could diagnose concussion but also diagnose CTE in a living person. The - you know, the real issue here is it's difficult, unless you're looking at a whole population and following them forward, to be able to delineate out, to remove the other possible factors that could be accounting for these thing.

So you have to, you know, think about things like mood disorders, genetics, you know, other co-morbidities that could be contributing to each of these cases.

FLATOW: Dr. Dettwiler?

DETTWILER-DANSPECKGRUBER: Well, I think that's now not necessarily, with regard to detecting CTE, I think there's a long way to go until we would have any objective tool available to us. However, to possibly come up with an additional assessment tool for sports-related concussion and when is it safe for a player to go back to play might be something more feasible.

And possibly an imaging marker, which we don't have yet, but we are working on it, down the road could provide that possibility.

FLATOW: Well, I want to thank you all for taking time to be with us today: Billy Carden, artistic director of the Ensemble Studio Theater, also director of the play "Headstrong," opens on Monday, play for a few weeks.

CARDEN: Yes, until May 13th.

FLATOW: May 13 here in New York.

CARDEN: Yeah.

FLATOW: Great play, I saw it this week, it's terrific.

CARDEN: Thank you, Ira.

FLATOW: And the acting is terrific. You're terrific in it also, Ron Canada.

CANADA: Thank you very much.

FLATOW: And also thank you Annegret Dettwiler, associate research scholar at Princeton Neuroscience Institute at Princeton. Thank you. And Jeffrey Kutcher, director of Michigan NeuroSport and chair of the Sports Neurology Section at the American Academy of Neurology. Thank you all for being with us today.

KUTCHER: Thank you, Ira.

DETTWILER-DANSPECKGRUBER: Thank you.

CARDEN: Thank you, Ira.

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