Should Soccer Players Wear Head Protection?

MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. Lots of parents are relieved when their sons choose soccer over football as their team sport. Football is thought of as a rough and tumble game where kids can get hurt, soccer, not so much. And the parents whose daughters take up soccer are often thrilled their girls can play on a team without much risk of injury. But, unfortunately, the statistics tell a different story. The American Academy of Pediatrics finds that the injury rate in youth soccer is higher than football. And another study finds soccer players are more likely than football players to have suffered a concussion. Which leads us to the inevitable question: if football players wear helmets, why isn't there some kind of head protection in soccer, especially for young kids? It's a question that is far more controversial than you might expect. All this hour we'll be speaking with a series of guests, including some of soccer's best-known medical experts, to find out if the risk of concussion should make protective head gear a requirement for soccer players. For an overview of the topic, I'd like to welcome my first guest. Mark Zeigler is a sports reporter for the San Diego Union-Tribune, who frequently covers soccer. And, Mark, welcome to These Days.

MARK ZEIGLER (Sports Reporter, San Diego Union-Tribune): Thank you.

CAVANAUGH: Mark, when did you first start hearing about this idea of soccer players wearing head protection?

ZEIGLER: I think it was a little bit over – maybe around ten years ago in the early 2000s. I remember hearing about some studies in Scandinavia about the impact of head injuries in soccer and how significant they might be. And it was a little bit of an eye-opening study and I think, you know, it's one of those topics that's always sort of been an undercurrent in the sport and every now and then it sort of bubbles over and then it maybe goes away for a couple years and then it sort of comes back. So it's sort of been an on-again, off-again topic.

CAVANAUGH: Now, I understand several high profile soccer players, including Chelsea Goalkeeper Petr Cech, have suffered serious head injuries and they've started wearing a certain kind of headgear. Have those incidents raised concerns among soccer players and their parents when we're talking about youth soccer?

ZEIGLER: Well, I think so. I think what's happened, too, in the sport is it's become a much more physical sport and, you know, when you look at a soccer field, it's much bigger than a football field. You can stick a football field inside a soccer field and have lots of space around it. That's the first thing. And the second thing is, you know, football is concentrated in one sort of area with a line of scrimmage and most of the 22 players are around there, where soccer they tend to be much more spread out over this much bigger field. But what's happened over the years, as soccer's become much more athletic and a much more physical sport as many sports have—basketball is another example that started as a non-contact sport and now is very, very physical—soccer's become that as well. And so just the athleticism and the nature of the sport has made it much more prone to physical contact. In Petr Cech's case, he slammed into a goal post. And, I think, still some of those incidences are raising or increasing as well. So it's something, I think, has sort of gradually built over the years.

CAVANAUGH: I'm wondering, how have the large soccer organizations like FIFA and U.S. Soccer responded to a concern over head injuries because, as I say, you know, concussion is the third highest injury in soccer.

ZEIGLER: Yeah, you know, one thing people need to understand it's become a very politicized topic and very controversial because on both sides—and maybe this is being a little bit too cynical—but on both sides you have people who are trying to make money. Obviously, people selling headgear, the opponents are going to say, well, they're just trying to make money. You know, they're not really in it for the safety of the player. And that might not be true but that's what they're going to say. Well, on the flip side, you know, FIFA and, particularly, U.S. Soccer have quite a bit to lose if there's sort of this fear that, you know, you could get really injured in soccer. And I think, as you mentioned in your opening, one of the reasons people play soccer is because of this impression that parents have that it's really not as dangerous. And so they've done some things but I don't think they've maybe been as proactive as they could and they've commissioned – both bodies have commissioned studies but, you know, I've looked at some of those studies and said, well, they're very self-serving studies, they're not truly independent research. And so I think that there's a huge financial stake. When a player registers for a league or for a team, in many cases part of that registration fee goes to U.S. Soccer so they stand to lose quite a bit of money. When you consider millions of people play soccer across the world and across – particularly across this country, they stand to lose quite a bit of money if all of a sudden that number is significantly reduced.

CAVANAUGH: And, Mark, when you speak to players themselves, what do they think about headgear?

ZEIGLER: It goes back and forth. I mean, you're going to get some male players, very macho, who say I'm not wearing anything on my head. I mean, it's just part of the sport and, you know, I get banged around and sort of a badge of honor to have a concussion. And you get some others who maybe – who've, you know, hit their head or have had some issues and say it sort of gives them this – it's almost like wearing a mouth guard in football, it gives them the sense of protection, security, and puts their mind at ease when they're playing and allows them to be as aggressive as they need to be on the field. And so it really, really varies. You know, it – You talk to some players – Shannon MacMillan, I know, a local legend…

CAVANAUGH: Umm-hmm.
ZEIGLER: …she wore – she wore headgear and was, you know, I think maybe a little skeptical at first and after awhile she was really, really onboard with it. So, it – you know, again, it – You'll get answers from the best 20 players, you might get 20 different answers.

CAVANAUGH: You know, in the last – In recent years, let me put it that way, we have seen more and more sports go to some sort of protective headgear as a requirement, I mean, even pole vaulters have to wear helmets now. And I'm wondering how do you see this issue in soccer evolving over the next few years?

ZEIGLER: That's a good question. It's really interesting because, you know, I think there's two sort of issues here. One is, heading the ball, what does it do to you if you – particularly if you don't head the ball correctly. And the second is just the collision aspect (audio dropout) from that. And, you know, I think what we really need to see is some true, true large independent research now (audio dropout)…

CAVANAUGH: And we're…

ZEIGLER: …now that we do have headgear and so we'll just have to see how it goes but I could see it going both ways.

CAVANAUGH: Well, Mark, thank you. Your phone's going in and out a little bit so I want to thank you so much for talking with us. That was Mark Zeigler, sports reporter for the San Diego Union-Tribune, and he often covers the game of soccer. We're moving on now to my second guest who's here in studio with me, Jeff Skeen, founder of Full 90 Sports. It's a local company that makes a head protection device for soccer players. And, Jeff, thanks so much for coming in.

JEFF SKEEN (Founder, Full 90 Sports): Thank you very much, and good morning.

CAVANAUGH: What motivated you to get involved in this issue?

SKEEN: Well, I watched my daughter grow up playing soccer and as she progressed in her ability and age and competitiveness, I began to observe concussions occurring on the field, several of which actually happened to her.
CAVANAUGH: And so how do you – I understand that actually concussion is under-reported on the soccer field. So did your daughter know that she was injured right away? Or is it something that developed when she got off the field and, you know, maybe later that night or how does that – I'm just wondering, other parents when they watch their children, what do they need to look out for?

SKEEN: You know, that's a great way of really just framing this whole topic is really what a parent should look for and really what should the player look for. And you mentioned the reported concussion rates, and one of the interesting and unique things about a concussion is that it's an invisible injury and an injury that you have to rely upon the injured person to describe the symptoms so that you can properly diagnose it, whether they've actually been concussed. So when you talk about concussion rates, a concussion rate is soccer, depending upon the age group, ranges from 4 to 8% and that would be the, quote, reported concussion rate. But what the National Institutes of Health and others have said in consensus statements is that the concussion rate is about 10 times the reported concussion rate because approximately 90% of all concussions are not recognized or reported. So when you see a 4% concussion rate, it's probably really more like 40%. Some of the examples of that are Dr. Delaney at McGill University did a study of collegiate soccer and football players and found that the concussion rate among these collegiate soccer players was 62.7% of the players experienced at least one concussion during the season.

CAVANAUGH: Let me ask you, when your daughter was injured, how did she get injured? Was it in heading the ball? Was it in falling on the ground? How did she actually suffer these concussions?

SKEEN: In all of her concussions, the mechanism of injury was as Mark described earlier, which was a collision and not from deliberate heading of the ball. Another interesting point that Mark made was that, you know, back in the eighties and nineties, there were some studies out of Scandinavia regarding heading the ball and the incidence of longterm cognitive brain deficits occurring later in life. And the conclusion of some of those studies was that heading the ball causes these disabilities later in life. One of the problems, candidly, with those studies was from a scientific standpoint they didn't rule out concussions, so many of those players, of course, during their professional, you know, tenure as a soccer player, had many, many concussions, which we already know cause those conditions later in life. And so it probably was not the act of deliberately heading the ball.

CAVANAUGH: I want to get to the device that you have designed after seeing your daughter suffer these head injuries on the soccer field. What is this protective headband?

SKEEN: It's a relatively simple device. For your listeners to try to understand what it would be like, it's basically like a padded headband with a particularly type of calibrated material to be able to reduce the impact forces when your head strikes another hard object like another head or the ground or the goalpost, yet it's hard enough where it doesn't affect the heading of the ball so the ball will go in the same trajectory and the same direction and the same rebound speed.

CAVANAUGH: Now some – There are – I know that there are some medical experts that say—in fact, we're going to hear from some of them—that the – it really – this kind of device will not stop the rate of concussion. It just really won't do much good.

SKEEN: They're absolutely uninformed. I mean, I hate to say this. I don't – I can't speak to the credibility of the guests you've got coming. I'm sure they're absolutely wonderful. But what I can tell you is that this debate is not a scientific debate. If – I'll take any one of those physicians or doctors that say that and if you allow me to have their child sit next to another child and you ask them, let me slam their heads together with or without this on, I will guarantee you 100% of them will say let's put it on their head. So I'm not, again, speaking to the people that you've got coming on the show but I do directly know—directly know—many of these so-called experts that are paid by U.S. Soccer or paid by FIFA and these are the same people that, in the course of me trying to start this company, really just with the sole goal of trying to reduce the number of concussions, I've come across, you know, U.S. Youth Soccer wouldn't allow us to display even at their national show. They've refused to accept ads. So it's a political issue. It's not a scientific issue.

CAVANAUGH: I wonder, what testing, if any, has been done, though, on the efficacy of wearing protective headgear while playing soccer?

SKEEN: Sure, well, you can simply go to the July 2007 British Journal of Sports Medicine and there's a study called “The Effectiveness of Protective Headgear in Adolescent Youth Soccer.” And the conclusion was that it more than reduced the concussion rate by 50%. Now let me just go back and say that, you know, as a manufacturer of a safety device, we're not able to use live subjects in testing. I can't take a group of kids and bang their heads, you know, with it and bang their heads without it. So a lot of times the soccer organizations or people that are their spokespeople often ask for a type of research that is actually a felony if we were to do such research. So, for example, you don't see Ford packing in a family of four in a mini-van and crashing it against a brick wall. You know, you're using instrumented crash test dummies. And we, as all manufacturers of safety equipment, do that exact same type of testing and we know that a reduction of forces should correlate to a reduction of injury. Now we can't tell you exactly what the reduced injury rate will be but it's pretty logical that it will be. Otherwise, if you didn't believe that, there would be no seat belt, there would be no bicycle helmets because none of that evidence that the soccer community and their paid physicians are asking for is available for any other type of safety equipment.
CAVANAUGH: Now, I'm wondering, Jeff, sometimes when your protective headgear comes up in the discussion, some people say, well, you know, he's only trying to make a dollar for his company. And I think probably some of our listeners may be thinking that, too. I'm wondering, though, what do you think is the problem that the larger soccer community has with adopting some form of protective headgear for players?

SKEEN: I think it's exactly as you and Mark started the segment out talking about and that is that soccer is a rapidly growing sport. It's become one of the largest sports in the United States and it's certainly the largest participation sport in the world with 240 million players. There's a lot of stadiums being built that are counting on a lot of soccer fans. In order to have a soccer fan, it's better if they were actually a former soccer player. So they're really trying to embed this culture. And one of the fears that the soccer community has, because they have told me this directly, is that they fear that any discussion of headgear will make people think about head injuries in the sport and maybe deter a mother from signing their kid up at the sign-up table. And in my opinion, they've discounted the intelligence of these soccer moms and soccer dads and even the soccer players because in other sports where they've introduced safety equipment, there was much the same fear. I mean, it was the same thing with hockey helmets. It was only 20 years ago that people were not wearing helmets in hockey, and it was the same thing. You know, all of the people that are against it are basically traditionalists that fear change and, in this case, it is absolutely no different.

CAVANAUGH: I want to thank you for coming in and speaking with us. And our discussion about concussions, headgear and soccer will continue in just a few moments right here on KPBS.

CAVANAUGH: I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. We're talking about the head injury risks associated with the sport of soccer and most especially the risk of concussions in youth soccer. We just heard from an advocate of protective headgear for soccer players, Jeff Skeen. Now I'd like to introduce three medical professionals who have a great familiarity with soccer related injuries. Dr. Ruben Echemendia is a neuropsychologist who served as director of the Psychological Clinic at Penn State University for 15 years and now works in full-time independent practice. Dr. Echemendia currently works as a consultant for U.S. Soccer National teams, and the NHL. He's also past president of the National Academy of Neuropsychology. Dr. Echemendia, welcome to These Days.

DR. RUBEN ECHEMENDIA (Neuropsychologist): Thank you, Maureen.

CAVANAUGH: Dr. William Perry is a professor of psychology at the UCSD School of Medicine, past president of the National Academy of Neuropsychology. Dr. Perry is also a member of the Defense Health Board for Traumatic Brain Injury. And, Dr. Perry, good morning.

DR. WILLIAM PERRY (Professor of Psychology, UCSD School of Medicine): Good morning, Maureen.

CAVANAUGH: And my final guest, Dr. Margot Putukian, Director of Athletic Medicine at Princeton University. Dr. Putukian is a former soccer player and coach, who also serves as a team physician for the U.S. Soccer National team. Dr. Putukian, welcome.

DR. MARGOT PUTUKIAN (Director of Athletic Medicine, Princeton University): Thank you, Maureen.

CAVANAUGH: And we'd like to invite our listeners to join the conversation. Are you concerned about the risk of head injury to your child playing soccer? Did you ever suffer a concussion or head injury while playing soccer yourself? Give us a call with your questions and comments. Our number is 1-888-895-5727, that's 1-888-895-KPBS. Dr. Putukian, what's the latest information about how common concussions actually are in soccer?

DR. PUTUKIAN: Well, I think it's certainly – When you look at all sports, not just soccer, when you look at all sports, the incidence of concussion has been increasing, at least what's being reported. And I think as was pointed out by one of your earlier guests, you know, there's a lot of underreporting that occurs in many sports. Athletes are either fearful of being pulled out of activity, believe that their symptoms are mild and they sort of want to try to play through them, or they may not even realize that they have a concussion. So I think at the same time we're having a significant increase in terms of, you know, this being on the radar for parents, coaches and, certainly, athletic trainers and team physicians, and so we're better able to identify athletes that have concussion.

CAVANAUGH: Right, I know the NFL just decided to take concussion very seriously. They came out in December and talked about new rules for players who may have suffered concussion. I'm wondering, though, do we know how common concussions are in soccer?

DR. PUTUKIAN: Well, I think there's a lot of data and, you know, it's interesting because I think that the NCAA has injury surveillance data that – you know, they published a summary of their almost ten years of data, or more than ten years of data, in '07 and when you look at that, both soccer men and women have a concussion rate that's certainly up there but not as high as men's football, men's wrestling, and even women's ice hockey. So I think that it's very different. And then if you look at the high school data, the National High School Federation of Sport, they also, you know, give you some incidence of injury for boys and girls soccer that's, you know, if you look at the number of injuries that occur per athlete exposure, the numbers they have for, you know, boys soccer is 1.7, for girls soccer, 3.4 for every 10,000 athlete exposures. And you compare that to football and it's much less than – and boys hockey, let's say, is 4.3 so I think when you look at the overall scheme, you know, soccer is one of those sports where of the injuries that occur in the sport, you know, it's still in the top three but when you compare it amongst other sports, it's still got a lower incidence of injury, at least the college and the high school level, using that – the data I just talked about than football, let's say.

DR. PERRY: Maureen?

CAVANAUGH: Yes. This is…?

DR. PERRY: This is Dr. Perry. Bill Perry. Hi.

CAVANAUGH: Yes, hi, Dr. Perry.

DR. PERRY: I might add a few things. First of all, I just want to clarify a point that Mr. Skeen made. I'm a neuropsychologist here in the Department of Psychiatry and I work closely with my son's competitive soccer team here locally and serve as their manager for the Rancho Santa Fe Attack Team. I'm not paid by U.S. Soccer, unfortunately. But I think a couple of things need to be clarified because I know that in talking with parents, they're often fearful that heading, using the head to hit the soccer ball, could cause brain damage and there was reference to an early study where there was some indication of that. But most of the later studies and certainly some of the studies that actually Mr. Skeen was referring to have not shown that heading a soccer ball causes any neuropsychological damage or, to the best of our knowledge, any ongoing damage. And then secondly, as Dr. Putukian was just mentioning, that the rates of injury change with the level of intensity and competitiveness. So for those listeners who have young children who are signing up for soccer, the rates of concussion in – certainly in younger children both males and females is relatively low compared to collegiate level and elite soccer players.

CAVANAUGH: Thank you.

DR. PERRY: And then the final thing I might just say is that you may – your listeners may be surprised to hear that there are other sports that are not associated with contact, like basketball, where there is also an increase in concussions.

CAVANAUGH: Actually, quite correct. Thank you, Dr. Perry. Dr. Echemendia, I wanted to ask you, you know, there was, as Dr. Perry points out, this original concern about players heading the ball but that's sort of changed now. The concern about concussion in soccer is about collisions, either head-to-head or with the ground or – Can you tell us how our knowledge of the causes has evolved over time?

DR. ECHEMENDIA: Certainly. Well, first let me say that I'm not speaking for the U.S. Soccer Federation and I'm also not paid by the U.S. Soccer Federation as Dr. Skeen – or, Mr. Skeen…

DR. PUTUKIAN: Yeah, nor am I.

DR. ECHEMENDIA: …suggests. With respect to the heading issue, initially it was thought that heading the ball was the culprit and over time, as we began to examine that issue and we looked at the biomechanics of it, it was not the heading as Mr. Skeen said but, in fact, it was the head-to-head collisions that have occurred in the process of heading or throughout soccer. So that there was a national consensus panel that met and actually indicated that heading was not the issue in terms of longterm difficulties but rather it was the concussions. And that is where the energy has focused on at this point in time in terms of both detecting the injury and then evaluating it and managing it.

CAVANAUGH: Dr. Echemendia, would you say that there is a, I mean, an actual solid, reliable, medical data on concussions in soccer? It sounds like there've been an awful lot of studies in a lot of different areas. Would you think it's perhaps time to make one definitive one?

DR. ECHEMENDIA: Well, I don't think that there is such a thing as one definitive study. What you have to keep in mind is that our knowledge of concussions and the effects of concussions have really only evolved over the last 10 or 15 years so there's a lot that we don't understand about the injury. And the process of science is to slowly chip away at the different components as we begin to understand the injury more and more. Certainly there's a lot of room for some large scale studies and, in fact, with this very issue there are large scale studies that are needed to examine the efficacy of these headgears in a clinical situation.

CAVANAUGH: I see. And let me get your take on that, Dr. Perry, if I may. You clarified for us about where the concussions occur in soccer. Do you think there's enough evidence to support the use of head protection?

DR. PERRY: Well, I think it's important that if any parent or athlete feels that they are comfortable and want to wear head protection and it's allowed in the game that they should do so. But I think that people should recognize there are also some concerns with wearing head protection. In fact, there's a study that was done and they found that females that had head protection had increased acceleration when hitting a ball. And the concern there is that the head protection left people feeling an increased sense of vulnerability – nonvulnerability, of the ability to be aggressive in the game and may have actually increased their risk to injure themselves. So even wearing something like protective headgear has some concerns associated with it and I think the best intervention is education.

CAVANAUGH: And, Dr. Putukian, if I may…

DR. PUTUKIAN: Yes.

CAVANAUGH: …yes, I'd like you to get – weigh in on this as well.
DR. PUTUKIAN: Yeah.

CAVANAUGH: You already told us that the play is getting more aggressive anyway.

DR. PUTUKIAN: Yeah, I think, you know, aggressive play is increasing but, you know, I'll point out that the article that Mr. Skeen was talking about where, you know, he said there's an article that shows that the protective use of headgear in soccer, I mean, there's a lot of flaws in that article. It was nonrandomized, it was a self-report questionnaire study. And, you know, athletes that choose to wear headgear may feel that it provides them with some sense of protection that it doesn't. And I think, you know, I always come back to remember that headgear and helmets were – they're not designed to prevent concussion. There is no helmet out there that can prevent concussion. Helmets are put together and designed to prevent skull fracture and bleeds. So I think, you know – and as Dr. Perry pointed out, when you look at, certainly, the NCAA level, the college sports where they're wearing protection and not wearing protection, the concussion rates are – can be pretty close to each other. So I don't think that necessarily adding protection does much other than maybe give the athlete a false sense of protection.

CAVANAUGH: Well, let me…

DR. PUTUKIAN: Having…

CAVANAUGH: Yeah.

DR. PUTUKIAN: And having said that, though, there's one rugby study that showed that headgear didn't decrease concussions, it decreased some facial lacerations and contusions. So, I mean, again, that's sort of more comparable, I think, to soccer than American football.

CAVANAUGH: Well, Dr. Putukian, let me ask you then, in light of the fact that the report of concussion is increasing in soccer, what do you see as a way of reducing that? Is there a way of reducing it? Or are we just hearing about concussions that always occurred in soccer and more people are just reporting them?

DR. PUTUKIAN: Well, it's a great question and I think, you know, a partial answer is that second part of your comment. I mean, we're much more aware of it and I think that certainly is a good thing. I mean, I think we need to have increased awareness of what the signs and symptoms of concussion are. Every coach, you know, needs to know what those are. Every kid ought to know what they are and they also ought to know that it's not okay, this isn't like an ankle sprain. You can't play through this. And if you do play through this, you're risking serious injury, especially if you're a youth player. And then at the same time, there's other things that you can do. I mean, one of the studies that was a prospective study looking at elite soccer in FIFA, basically looked at mechanism and one of the things that they showed was that – or, demonstrated was that there was a fair number of injuries that were elbow or – elbow to head, upper extremity to head, the second common mechanism was head to head. And of the ones that were upper extremity blows, a fair number were related to foul play. So that's another area where, you know, we might be able to put some efforts into making sure that our referees are calling appropriate fouls and, you know, maybe a red card if someone ends up having a significant elbow to the head as you saw with Dick McBride in the last World Cup.

CAVANAUGH: Right, right.

DR. PUTUKIAN: So I think there's ways there's ways there and then finally making sure that little kids – I mean, for the most part when you're coaching youth soccer, most of the time they don't head the ball that often. But maybe, you know, making sure that we are – when they get to the age where they head the – start heading the ball, that they're using the appropriate size ball and that they're learning proper technique and that they're maybe looking at strengthening – neck strengthening as well because I think those all play a role.

CAVANAUGH: And Dr. Echemendia, that is a point with the type of ball that's used in youth soccer. Tell us a little bit more about that and what is the proper type of ball for really young kids to start out with.

DR. ECHEMENDIA: Well, it really depends on, as you said, their age and what the different groups have decided for their age and there are age appropriate balls that are out there. They're manufactured so that you lessen the amount of impact that's coming to the head. But I want to keep coming back to the point that the issue as we know it at this point in time is not the heading of the ball, but rather the contact that occurs in head to head or head to ground. So, absolutely, the youth athlete should be using the proper size ball for their age but at the same time we need to be looking at what happens with the collisions and evaluating those players that do have collisions.
CAVANAUGH: Okay, how do we evaluate players who have collisions because, as you know, in youth soccer there are a lot of collisions on the field. So how does one evaluate that while the play is underway?

DR. ECHEMENDIA: Well, it's difficult while the play is actually underway but if you see something where a child or a youth player has had a collision and it appears to be a collision that's out of the ordinary then, certainly, the coach should be talking to that athlete and observing that athlete to see whether they have any of the signs and symptoms of concussion, whether they appear to be at all disoriented, whether they are confused, whether they report being a bit dizzy, having headache, needing to look at those symptoms and evaluating them on the sideline to be able to determine whether that player can go back into play. That's important for both the coach to be able to do, for the officials to be able to do, and, as was mentioned earlier, for parents and players to be aware of what those symptoms are so that they can report those symptoms and we can take appropriate actions accordingly.

CAVANAUGH: We have to take a short break. When we return, we will continue to talk about the soccer concussion headgear controversy and taking your calls at 1-888-895-5727. You're listening to These Days on KPBS.

CAVANAUGH: I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. We're talking about the risk of head injury associated with the sport of soccer, most especially the risk of concussion in youth soccer. My guests are Dr. Ruben Echemendia, he's a neuropsychologist who served as director of the Psychological Clinic at Penn State University for 15 years, currently works as a consultant for U.S. Soccer National teams, and the NHL. He is also past president of the National Academy of Neuropsychology. Dr. William Perry is Professor of Psychiatry at the UCSD School of Medicine, past president of the National Academy of Neuropsychology. And Dr. Margot Putukian, Director of Athletic Medicine at Princeton University. She's a former soccer player and coach, also serves as a team physician for the U.S. Soccer National team. And we're also inviting our listeners to join the conversation. 1-888-895-5727 is the number to call. I want to start out by asking all of my guests, all the doctors, it's my understanding from talking with you for the last few minutes that none of you actually advise the use of protective headgear during soccer play, would that be correct, Dr. Putukian?

DR. PUTUKIAN: Yeah, that would be – You know, my standpoint is that, again, as Dr. Perry mentioned, if someone wants to wear it, I'm not going to tell them that they shouldn't. But I also don't feel that there's any role per se in terms of protecting against concussion.

CAVANAUGH: And Dr. Perry?

DR. PERRY: Yes, that's true. And I have a son that plays soccer and…

CAVANAUGH: Right.

DR. PERRY: …I don't have him wearing headgear.

CAVANAUGH: And Dr. Echemendia.

DR. ECHEMENDIA: I agree. I also have a son playing soccer and he does not wear headgear.

CAVANAUGH: And – But you're not advising against it either, are you?

DR. ECHEMENDIA: Well, no. I think that, as Dr. Putukian said, if someone feels comfortable wearing it and would like to wear it, then it is their right and their option to do so if it's accepted in the leagues where they are, and they are in most places. I think that it's also important for the public to know what is the scientific evidence for the use of this headgear or the lack of scientific evidence that exists.

CAVANAUGH: In speaking with you all, though, I get the feeling that there is a resistance to the introduction of protective headgear and am I getting the wrong impression, Dr. Putukian?

DR. PUTUKIAN: Well, no, I don't think you are. I guess, you know, one of the things that I think we always have to be careful of is sort of a knee jerk reflex to, you know, well, if it's – we put a helmet on it, we'll protect these athletes. I don't know if we're necessarily going to see that and/or whether maybe you see a change in a play and now they think they're protected and it's going to make it worse.

DR. PERRY: Right.

DR. PUTUKIAN: I see that there might be a role if you're a goalkeeper it may be a little bit different where there may be, you know, there the way they play is a little bit different. They're, you know, constantly diving at someone's, you know, feet or knees. And maybe there's a different role there in terms of if they've had an injury and they want to be protected like the athlete you mentioned.

CAVANAUGH: Petr Cech, yeah.

DR. PUTUKIAN: Yeah. Yeah. So – But there's a little bit of a resistance and maybe some of that comes from having been a player and, you know, I can't imagine putting a headband on my head and trying to play.

CAVANAUGH: Aha. There we are.

DR. PUTUKIAN: So I think that's that component of it as well because it's like trying to – you know, there's a touch on the ball that you have when you head it that you lose.

DR. PERRY: I'd like to add also that…

CAVANAUGH: Yes, Dr. Perry.

DR. PERRY: …if the emphasis is on headgear versus to underscore what Dr. Putukian said earlier, appropriate rule enforcement and emphasis on safe play, then we're doing the entire issue a disservice. I think that's – Personally, I think that's where we need to focus. Education, as Dr. Echemendia had mentioned, we have to educate the referees, the coaches, and the parents about what concussion is and how to identify it and how to intervene. And then we have to enforce appropriate rule play. And I think that's going to make a bigger difference than wearing headgear.

CAVANAUGH: We have a number of callers who want to get in on our conversation here so let me take a call now from Scott in San Diego. Good morning, Scott, and welcome to These Days.

SCOTT (Caller, San Diego): Good morning. I have two daughters, teenage, who have played soccer for five or six years. My eldest daughter plays competitive and is now on the high school JV team and just a couple weeks ago she had a collision with another girl on the soccer field from the other team where they both were going to try to do a header and the other girl, back of her head hit the front of my daughter's head, and subsequently the doctor determined because of symptoms like headaches that she had a mild concussion. And I have to say – And she's been told she shouldn't play any sports until the symptoms go away. But I have to say, I've thought about the issue of headgear, especially since the more active competitive soccer, I've been watching my daughter, and there certainly is, on the one hand, the stigma associated with it that if I said to my daughter you need to wear one of these protective headbands or something, her first reaction would be no, more because of the stigma of it. And I think that is a factor and then there is the question listening to you all whether it really would make a difference or not. So it's certainly a concern as a parent and a lover of soccer and with our primary goal wanting to protect our children…

CAVANAUGH: Right.

SCOTT: …but…

CAVANAUGH: Scott, thank you so much for your call. I'm going to take a call now from Amy in Encinitas. Good morning, Amy, and welcome to These Days.

AMY (Caller, Encinitas): Yes, hi. I just wanted to give some information. I've been a soccer player for awhile now and I play in a co-ed team in Encinitas and I've tried the Full 90 headgear…

CAVANAUGH: Umm-hmm.
AMY: …and I've gotten a concussion still, even wearing one, you know. And I'm all for safety but it's not about, you know, here it's not about safety, it's more about how the players are playing.

CAVANAUGH: Well, thank you. Amy, thank you so much for that. Well, Dr. Echemendia, the comment by Amy seems to bear out what you've been saying.

DR. ECHEMENDIA: It's true and I see that not infrequently in my private practice where I have players come in who have had a concussion even though they had been wearing headgear. So there is a real question about the efficacy of the headgear.

CAVANAUGH: But I also want to pursue this idea of a stigma attached to wearing headgear in socca – soccer, that is. And Dr. Echemendia, why? Why would there be – I mean, there's so many sports now where people have to wear headgear and it doesn't diminish the cool factor of the sport. I wonder what is the idea of not wearing it in soccer?

DR. ECHEMENDIA: Well, I think that what happens is that particularly in youth athletes, you're not one of – you don't typically want to be seen as doing something different than everybody else. You don't want to be seen as someone who may be weaker or more susceptible so there's a hesitancy to wear any headgear or any kind of protection that is not mandated or worn by everybody else.

CAVANAUGH: But isn't this stigma also in adult soccer?

DR. ECHEMENDIA: Yes, it's true in adult soccer as well, although adults typically should be a little bit more willing to step out and do what they think is correct but, in fact, you know, some do not. But the whole issue then comes back to there really are no efficacy data in terms of these – the use of this headgear in soccer. And, in part, that may be associated with a stigma as well.

CAVANAUGH: Right. Dr. Putukian, you were telling us that basically helmets and headgear are not designed to protect against concussion but do they reduce the incidence of concussion when they are used in other sports?

DR. PUTUKIAN: No. I mean, no, that was my point in terms of looking at – when you look at the college data. It's kind of hard to compare because, you know, it's not like you're going to say, well, let's play American football without helmets. But I can tell you that if you did, you would have a much lower concussion rate because you'd decrease your exposures. Kids are not going to hit each other if they're playing the sport of American football without a helmet. So, I mean, I think what you see the professional leagues doing in hockey and in football is saying we got to get rid of these exposures and these head to head hits. And they're doing it through, again, proper rule enforcement…

DR. PERRY: Right.

CAVANAUGH: And how…

DR. PUTUKIAN: …you know.

CAVANAUGH: And how are they going to be enforcing the rules differently then?

DR. PUTUKIAN: Well, they're going to have…

DR. ECHEMENDIA: Well, I…

DR. PUTUKIAN: Well, go ahead. Ruben can speak certainly on the NHL.

CAVANAUGH: Yeah, go ahead.

DR. ECHEMENDIA: Well, certainly there are rules in most of these sports in terms of hitting and when one commits fouls, and particularly in hockey we know that if you have a particular hit where you board somebody, you check somebody, you're forcing somebody's head against the wall or intentionally hitting them in the head, that there are penalties that can be enforced that then pull that player out of play for a specified period of time. It's also true in football. There are rules in effect with spearing and other rules that protect against the use of the head as a weapon or as a target.

CAVANAUGH: Okay. Let's take another call. Marko is calling from San Diego. Good morning, Marko. Welcome to These Days.

MARKO (Caller, San Diego): Good morning. I want to give an opinion about how to prevent these injuries.

CAVANAUGH: Yes.

MARKO: I agree with what has been said in the program about education so education of the players and education of the coaches and parents. I see two different ways to get this type of injury. I played semi-professional soccer and I am a professional coach so I – It's either a collision or the wrong way to head the ball. Heading per se is not a problem if you know how to do it. But if the goalkeeper bunts the ball really high and you want to get that ball and you don't get it really well, that hurts and that probably causes damage. As far as collision, if you – if you're encouraged by your parents and coaches to be aggressive and you don't know what they mean by that and you're just going to go blindly and hit somebody, so you have to know where your limits are and that comes with education and proper training.

CAVANAUGH: I wonder, Marko, would you have a problem seeing some sort of protective headgear introduced into soccer?

MARKO: I don't see a problem but I can see that how come – how can some players wearing that be picked on a little bit, and as it was mentioned also you don't want to be different. Maybe if everybody used it it would be no problem but I don't think that will prevent as much as knowing how the game goes and…

CAVANAUGH: Right.

MARKO: …avoiding collisions and not heading the wrong balls.

CAVANAUGH: Thank you s…

MARKO: And having the parents and coaches not to encourage and to be more competitive without the safety training.

CAVANAUGH: Thank you, Marko. Thank you for your call. Let's take another call. Tom is calling from San Carlos. Good morning, Tom, and welcome to These Days.

TOM (Caller, San Carlos): Hi. Boy, I've got so many things I'd like to say…

CAVANAUGH: Oh, we just have time for…

TOM: …so I'll make it short.

CAVANAUGH: Yeah. Uh-huh.

TOM: One, I think it's naïve to rely on referees to control the game after finishing 12 years of highly competitive soccer associated with some of the best teams in Southern California. My two children, one of them did suffer a concussion in a game. Actually, it was a high school game. But better education is definitely needed across the board as your callers and the panelists have said. But also, what's the harm? There's a stigma attached to wearing them. My daughter would've refused to wear one, in fact did, because other weren't wearing them. If it can improve the safety, that's a measure that is probably worth considering. Are there any longterm studies of repetitive head-butting? I've been under the, perhaps, misimpression that you suffer some kind of hemorrhaging every time you butt your head and if you, you know, are a center that's six foot, and you are relied on to do a lot of the air ball control, then maybe over a career of it, you could have some brain injury possibility.

CAVANAUGH: Tom, I'm going to have to stop you there. I really appreciate it. You brought up so many things, I don't think we can address them but let me ask you, Dr. Perry, if I may, about what Tom was saying about repetitive concussions. We know that they're very – they can be very damaging, especially when someone suffers them as a child.

DR. PERRY: Well, yes, that's slightly different from what Tom was saying. I just want to correct something that Tom had raised. There's no evidence that I'm aware of that – and I think head-butting, if he's meaning using your head to head the ball, that each time you do that that you cause brain contusions and have hemorrhaging. So that's not the case.

CAVANAUGH: He was saying that with a concussion, he thought that the brain hemorrhaged a little bit.

DR. PERRY: Well, there's – And to get back to your question…

CAVANAUGH: Umm-hmm.
DR. PERRY: …yes, with increased concussions you're at increased risk for further concussions.
CAVANAUGH: Umm-hmm.
DR. PERRY: And certainly there's a number of concussions that if a young player had, that then the family would need to consider whether or not they should continue on in the sport. And that's true of any sport or of any event. You know, if they fall and they hit their head repeatedly and have had concussions then you should question whether or not they should continue on. And I do want to go back to the issue of education and appropriate rule enforcement because I think it's so critical. I just have to disagree with the caller and standing on the sideline and watching a game as it increases in intensity, you can see the increased opportunity for injury to occur even if it does not happen. So I do think that if the referees were educated and saw children running recklessly that that's something they could stop and that would decrease the risk of concussion. But I don't think you're going to eliminate it in the sport. And then finally, I want to underscore what I said earlier, there is some concern that with headgear people feel a sense of invulnerability, a sense that they can increase their risk and may put themselves at increased risk for injury, so I don't think even if you instituted headgear in the sport, made it mandatory for all players, that that would, again, as Dr. Putukian said earlier, that would eliminate concussion. You certainly need to have rule enforcement, education and, in fact, it may—it may—increase risk.

CAVANAUGH: Dr. Perry and all of my guests, I'm afraid we're going to have to end it there. I want to thank you so much. Dr. William Perry, Dr. Margot Putukian and Dr. Ruben Echemendia, thank you so much for speaking with us and sharing your information with us this morning. So many people wanted to get involved in the conversation but we couldn't take your calls. Please go online, KPBS.org/thesedays. This segment was conceived and produced by Hank Crook as a project for the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism. Stay with us for hour two of These Days coming up in just a few minutes right here on KPBS.