PM R 10 (2018) 655-660

www.pmrjournal.org
Point/Counterpoint

Guest Discussants: Scott R. Laker, MD, Christine Greiss, DO, FAAPMR,

Jonathan T. Finnoff, DO
Feature Editor: Jaspal R. Singh, MD

Football Participation and Chronic Traumatic Encephalopathy

CASE SCENARIO
A 13-year-old male athlete presents to the clinic with his parents for a preparticipation physical examination.
The athlete has participated in soccer, baseball, and track in the past but is very interested in joining the
football team this year. His parents are hesitant for him to participate in football because they have heard about
a brain injury in football players called chronic traumatic encephalopathy (CTE). They would like your advice
regarding whether their child should avoid football due to the risk of developing CTE. The athlete is an above-
average student and aspires to go to college and become an engineer. He has no significant medical or surgical
history. Specifically, he has never sustained a previous brain injury. He does not take any medications. He does
not have a history of psychiatric disorder or learning disability. He denies smoking, drinking alcohol, or taking
illicit drugs. His family history is significant for migraine headaches in his mother and maternal grandmother.
Dr Scott Laker will argue that the benefits of participating in football outweigh the risks of developing CTE and
would counsel the patient to participate in football if they so desire. Dr Christine Griess will argue that collision
sports, especially American football, increase the chances of CTE and would counsel the patient not to participate.

Scott R. Laker, MD, Responds

All physiatrists who care for youth athletes should be
prepared to have this conversation, and all sports medi-
cine providers should be well versed on the topic of safety
in youth tackle football. I would recommend if one is not
current on this literature base or uncomfortable with the
vagaries of this clinical situation that a referral to a sports
medicine specialist be made. This family is seeking advice
about chronic traumatic encephalopathy (CTE) as it re-
lates to youth tackle football. It is important to clarify that
this family is asking for a preparticipation physical, where
the standard for disqualification would be the clear and
present danger of injury or death due to participation. I
feel that this standard for disqualification goes above and
beyond the current understanding of CTE and places the
provider who chooses to disqualify an athlete from
participation in football due to the risk of CTE in an un-
tenable and unsupportable position. In addition, the pro-
vider should ask themselves, “Am I willing to de facto
disqualify every youth athlete I see from participating in
football, even if the family supports participation?”
The preparticipation physical evaluation involves a thor-
ough history and physical examination, recommendations
for necessary follow-up testing, and determination of the
safety for participation. From an ethical standpoint, the
physician performing the preparticipation physical evalu-
ation is duty bound to provide impartial information so that
the athlete and their parents can make an informed con-
sent to participate (ie, autonomy) and to support the
health of this athlete (ie, beneficence) [1]. The final deci-
sion regarding participation on the football team will
largely be up to the parents rather than the child. I would
clarify that I do not have a personal stance on his partici-
pation and would support their decision to participate, not
participate, or to defer the decision until the athlete is
older and more information is available. Although the
American Academy of Pediatrics recommends vigorous
discouragement of participation in youth boxing, it has no
similar policy statement for football [2]. I would give the
family examples of situations in which I would recommend
disqualification from participation in football (eg, atlan-
toaxial instability, multilevel KlippeleFeil anomalies, etc).
The major symptoms associated with CTE include
cognitive decline, behavioral abnormalities, and mood
changes. These symptoms cover a wide spectrum of

1934-1482/$ - see front matter ª 2018 by the American Academy of Physical Medicine and Rehabilitation
https://doi.org/10.1016/j.pmrj.2018.05.001
656 Football Participation and CTE
severity, are nonspecific, and are associated with other
diseases, not all of which are associated with head
trauma. CTE has been identified in deceased athletes
who participated in soccer, ice hockey, boxing, and
martial arts; military personnel; and victims of domestic
abuse [3]. It is more accurate to describe CTE as a dis-
ease associated with exposures to repetitive head
trauma rather than a football disease.
Pathologically, CTE involves the abnormal deposition
of tau-protein and amyloid plaques in specific regions
of the brain. The pattern of this deposition is specific
to CTE and distinct from other tau-opathies. In addi-
tion, the disease itself is distinct from other neurode-
generative diseases like Alzheimer disease or Parkinson
disease. A consensus panel published a set of diag-
nostic criteria for CTE [4]. It is still a disease that is
confirmed on autopsy, and prediction of its presence in
living individuals is not currently possible.
The current literature supports a theory of repetitive
brain trauma, including concussive and subconcussive
blows, as the leading risk factor for the development of
CTE. Much of the current research is focused on iden-
tifying the disease accurately in living individuals.
Unfortunately, we do not know which athletes are at
greatest risk and cannot stratify athletes into risk pools for
participation. Perhaps most importantly, we do not know
the “threshold” of trauma a human brain can tolerate
without exhibiting long-term effects. Clearly, the majority
of retired professional athletes exposed to repetitive brain
trauma live long, full, healthy lives. However, we know
that some athletes are suffering from a poorly understood
form of dementia that we associate with similar exposures
to those who remain asymptomatic.
The available literature suggests that CTE is not a
disease that stems from involvement in youth football.
When confirmed, it is found in former professional and
collegiate American football players, boxers, and mar-
tial artists. There are no current studies available for
the long-term neurocognitive health of youth football
participants. For the purposes of this family discussion,
we will make the assumption that we are talking
participating in football through high school but not
beyond. As such, the most relevant data are those
published by Deshpande et al [5]. This cohort study
reviewed nearly 2700 male athletes (834 played football
and 1858 did not) in the graduating high school class of
1957 and evaluated their cognitive function and
emotional status at 65 years of age. The authors found
no cognitive or depressive differences in athletes who
Christine Greiss, DO, Responds
Lately, it is not unusual to see the words football and
chronic traumatic encephalopathy (CTE) in the same
sentence; both are individually and simultaneously hot
topics. The main issue here is whether this child’s
participated in high school football compared with those
who did not participate. Secondary outcomes, like
heavy alcohol use, anger and hostility indices, and
cognitive scores at age 72 years, were also similar.
A more complete understanding of CTE will require
longitudinal studies of individuals with and without expo-
sure to repetitive head trauma, with and without neuro-
cognitive complaints, and with close attribution of other
contributors (eg, alcohol, drug use, psychiatric diagnoses)
[3]. In addition, there is an inherent selection bias for the
athletes who have donated their brains to the study of this
disease. We may be finding CTE in artificially greater per-
centages of studied brains, as athletes without symptoms
may be less likely to donate their brains for study.
In this case, the child has no previous medical his-
tory of concussion or concussion-modifying factors (eg,
psychiatric disorders, learning disability, etc). Other
than his age of <18 years [6], I feel that the partici-
pation in football for this child is safe, given our cur-
rent understanding of CTE, and would not advocate
against his participation. I would recommend that the
family spend some time discussing this decision among
themselves and with their son. It is not medically
reasonable to disqualify him based on the available
literature and the current standard for disqualification.
In addition, disqualification is not defensible in this
scenario, given the athlete has no clear risk of injury or
sudden death and that the sport is considered safe for
participation [7].
References
1. Herring SA, Kibler WB, Putukian M. Team Physician Consensus
Statement: 2013 update. Med Sci Sports Exerc 2013;45:1618-1622.
2. Council on Sports Medicine and Fitness. Tackling in youth football.
Pediatrics 2015;136:e1419-1430.
3. Asken BM, Sullan MJ, DeKosky ST, Jaffee MS, Bauer RM. Research
gaps and controversies in chronic traumatic encephalopathy: A re-
view. JAMA Neurol 2017;74:1255-1262.
4. McKee AC, Cairns NJ, Dickson DW, et al. The first NINDS/NIBIB
consensus meeting to define neuropathological criteria for the
diagnosis of chronic traumatic encephalopathy. Acta Neuropathol
2016;131:75-86.
5. Deshpande SK, Hasegawa RB, Rabinowitz AR, et al. Association of
playing high school football with cognition and mental health later
in life. JAMA Neurol 2017;74:909-918.
6. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on
concussion in sportdthe 5(th) international conference on
concussion in sport held in Berlin, October 2016. Br J Sports Med
2017;51:838-847.
7. Mitten MJ. When is disqualification from sports justified? Medical
judgment vs patients’ rights. Phys Sportsmed 1996;24:75-78.
participation in football ultimately increases his chances
of developing CTE.
CTE is a neurodegenerative tauopathy characterized by
the deposition of hyperphosphorylated tau (p-tau) protein
 S.R. Laker et al. / PM R 10 (2018) 655-660
as neurofibrillary tangles, astrocytic tangles, and neurites
in multiple clusters around small blood vessels of the cor-
tex, typically beveled in the sulci. Clinically, CTE manifests
as behavioral and mood changes, memory loss, cognitive
impairment, and ultimately, dementia. Like many other
neurodegenerative diseases, CTE is definitively diagnosed
only by postmortem neuropathologic examination of brain
tissue. It has been postulated to be associated with recur-
rent concussive and subconcussive injuries (ie, repetitive
head impacts [RHIs]).
American football is a collision sport in which head
impact is a routine occurrence. My concern is that unlike
soccer, baseball, or track, it is the repetitiveness of head
impacts on the football field, not necessarily a single
forceful impact or concussion, that may increase the
chances of developing CTE. In 1 study of 177 football
players who were found to have CTE, there was a corre-
lation between years of football exposure and severity of
CTE, with high school football players displaying mild CTE
on histopathology and players in the National Football
League (NFL) displaying severe CTE [1]. Therefore, I
would advise this child against participating in football.
Furthermore, the risk of sustaining some sort of head
impact (whether concussive or subconcussive) occurs not
only during games but also during practice. The front of the
head is the most common location of impact for contact
drills. Open-field tackling has the greatest average hori-
zontal acceleration and results in significantly greater
torsional acceleration, creating the perfect recipe for
axonal injury. Multiplayer tackling drills increase the chance
of RHI. It has been demonstrated that high school football
players intentionally use their helmet to hit opposing
players during all forms of tackling [2]. Hence, RHIs simply
cannot be avoided. Even in the absence of concussion,
neuroimaging demonstrates microstructural changes in
certain white matter tracts of some asymptomatic football
players after a single season [3]. It is theorized that these
are a result of repetitive, subconcussive blows to the head.
This child is 13 years old. Children in this age group have
more space between their brain and the skull. This allows
for more intracranial brain movement during rapid accel-
erations and therefore “room to shake” on impact, thus
making younger athletes more susceptible to injury during
a delicate neurodevelopmental time. Contrary to previous
belief, we now know that youth are at greater risk of injury
at lower-impact severities compared with adults. Likewise,
they are more likely to suffer persistent symptoms [4].
Current research is attempting to bridge the knowledge
gap between concussion and CTE. Brains of teenage athletes
who had documented concussion were autopsied and found
to have astrocytosis, myelinated axonopathy, microvascular
injury, perivascular neuroinflammation, and phosphorylated
tau protein pathology. These are all hallmarks of CTE [5].
Hence, this is not just a disease of the elderly. Furthermore,
decreased axonal conduction velocity in the hippocampus,
and defective synaptic neurotransmission in the prefrontal
cortex, also were discovered in this population. Some argue
657
that this may explain the manifestation of neurocognitive
deficits that develop after RHIs [4,5].
Although this 13-year-old child denies having sustained
a concussion, it is difficult to say whether that is accurate.
Evidence shows that even professional players in the NFL
have a distorted interpretation of a concussion. A study
examined former NFL players’ understanding of the
concussion definition [6]. These NFL players reported 5
times the number of concussions after being educated on
the symptoms that a concussion diagnosis entailed. If a
professional NFL player cannot consistently or accurately
report concussions, how can we expect this young
adolescent to keep track of concussions and subconcussive
injuries? Furthermore, male participants are more likely to
sustain a concussion from a contact sport, experience loss
of consciousness, confusion, and suffer behavioral changes
after a concussion and are less likely to report injury
compared with female participants [7]. This creates a
recipe for disaster by increasing the chances of RHIs,
potentially subjecting this child a lifetime of deficits, and
predisposing him to the development of CTE.
As a result of frequent head impacts during football
practices and games, research suggests that neuro-
cognitive changes may develop in the absence of a clini-
cally diagnosed concussion [8]. There is a chance that he
will have problems learning new material because of
inattention and poor memory. He may not be able to sus-
tain his above-average grades in school. He may tempo-
rarily be out of school because of symptoms and may have
to return on a modified schedule. Compared with collegiate
athletes, neurocognitive deficits in this younger age group
with less brain maturity may take longer to resolve even
when concussion-related symptoms have dissipated [9].
This child with a bright future may face behavioral prob-
lems as a result of playing football. He is at risk for psychiatric
symptom development, sleep disturbance, and irritability,
despite a negative history of such [10]. In this delicate
adolescent age when there is already a pre-existing struggle
with identity and personality development, the impact that
a parallel neurobehavioral problem can have on this child
could be overwhelming. Some studies demonstrate signifi-
cant long-term neuropsychiatric and cognitive sequelae
based on age of first exposure to American football. Younger
age, before 13 years, predicts increased odds for clinical
impairment, self-reported neuropsychiatric symptoms, and
impairment in executive function [11]. Contrary to previous
belief, these ominous symptoms last longer than mere days
to weeks, and, if persistent enough, could possibly be the
first signs of CTE. For instance, football players who sustain
concussive injuries have a 9-year risk of developing clinical
depression after retiring from the game [12].
As noted, subconcussive impacts that do not result in
clinical signs or symptoms are speculated to lead to al-
terations in cerebral structure and function later in life.
The parents of this child are rightfully concerned. They do
not want to render their son as another statistic. They are
aware that they cannot avoid RHIs (asymptomatic hits) or
658 Football Participation and CTE
concussions (symptomatic hits). Moreover, the line be-
tween RHIs transitioning into CTE has not been defined.
We do not have a “magic number” reassuring this athlete
that he will not develop CTE if he avoids hitting his head
more than “X” amount of times. Even when good coach-
ing, team culture, and modified technique are imple-
mented, it is nearly impossible to standardize these well-
intentioned “changes” in football.
This child is an above-average student with an
excellent profile who wishes to become an engineer in
the future; why pose a risk to these chances, and suc-
cumb him to a lifetime of learning difficulties, behav-
ioral problems, or other deficits? We constantly counsel
patients against exposing any other organ in the body to
such negligence, why not the brain? We live in an era in
which we advise our children to wear seatbelts, limit
screen-time, and count calories. Moreover, we have
become sharpened on determining the appropriate age
for drinking, tobacco purchase, and driving.
In a time in which cognitive capacity is attractive,
complexity of the mind is cherished, the value of mental
health is appreciated, and the speed of information
processing determines success, it would be calamitous
to put such a valuable and irreplaceable organ, this
child’s brain, at risk by allowing him to participate in
football at the age of 13. After all, he only has one.
References
1. Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological eval-
uation of chronic traumatic encephalopathy in players of American
football. JAMA 2017;318:360-370.
Scott Laker, MD, Rebuts
I disagree that Dr Greiss’ discussion supports the
conclusion that participation in youth football for a
healthy 13-year-old boy would result in “calamity.”
There is no evidence presented that suggests participa-
tion in youth football results in CTE. Should this athlete
decide to play in junior high school, high school, college,
and beyond, the discussion should change to address
these different playing environments and the current
understanding of the risks for CTE development in each.
The current state of understanding allows for all pro-
viders to responsibly allow youth athletes to participate
in football.
I have no doubt that my colleague wants only the
very best for her patients, as do we all. However, I
have concerns that these well-intended conclusions
overreach the evidence. Dr Greiss cites only 1 article
that uses CTE as an outcome, and it is a study of 202
deceased football players. She neglects to note that
neither of the 2 brains of athletes with only pre-high
school football participation showed signs of CTE [1].
2. Kurimaya AM, Nakatsuka AS, Yamamoto LG. High school
football players use their helmets to tackles other players
despite knowing the risks. Hawaii J Med Public Health 2017;76:
77-81.
3. Horbeck K, Walter K, Myrvik M. Should potential risk of chronic
traumatic encephalopathy be discussed with young athletes? AMA J
Ethics 2017;19:686-692.
4. Post A, Hoshizaki TB, Zemek R, et al. Pediatric concussion:
Biomechanical differences between outcomes of transient and
persistent (>4 weeks) postconcussion symptoms. J Neurosurg
Pediatr 2017;19:641-651.
5. Kriz PK, Mannix R, Taylor AM, et al. Neurocognitive deficits of
concussed adolescent athletes at self-reported symptom res-
olution in the Zurich Guidelines Era. Orthop J Sports Med 2017;
5:2325967117737307.
6. Alosco ML, Jarnagin J, Tripodis Y, et al. Utility of providing a
concussion definition in the assessment of concussion history in
former NFL players. Brain Injury 2017;31:1116-1123.
7. Tanveer S, Zecavati N, Delasobera EB, Oyegbile TO. Gender dif-
ferences in concussion and post-injury cognitive findings in an
older and younger pediatric population. Pediatr Neurol 2017;70:
44-49.
8. Servatius RJ, Spiegler KM, Handy JD, Pang KCH, Tsao JW,
Mazzola CA. Neurocognitive and fine motor deficits in asymptom-
atic adolescents during the subacute period after concussion. J
Neurotrauma 2018;35:1008-1014.
9. Yeates KO, Beauchamp M, Craig W, et al. Advancing concussion
assessment in Pediatrics (A-CAP): A prospective concurrent cohort,
longitudinal study of mild traumatic brain injury in children: Study
protocol. BMJ 2017;7:e017012.
10. Brent DA, Max J. Psychiatric sequelae of concussions. Curr Psy-
chiatry Rep 2017;19:108.
11. Alosco ML, Kasimis AB, Stamm JM, et al. Age of first exposure to
American football and long-term neuropsychiatric and cognitive
outcomes. Transl Psychiatry 2017;7:e1236.
12. Russell K, Selci E, Chu S, et al. Longitudinal Assessment of Health-
related Quality of Life following Adolescent sports-related
concussion. J Neurotrauma 2017;34:2147-2153.
This study is too small and too divergent from our
scenario to inform our decision. It would be most
accurate to say that we have an early and incom-
plete understanding of CTE, especially in youth
athletes.
The remainder of her response is mostly based on
small, retrospective, observational studies, with a heavy
reliance on self-report and outcomes that have nothing to
do with CTE. Throughout her discussion, there are strong,
definitive conclusions based on early data. For example,
her conclusion that a study of 15 adolescents with a his-
tory of recent concussion (average 53 days postinjury),
showing no abnormalities compared with controls on
symptom scores or ImPACT testing but only slight differ-
ences to norms on a test designed for acute concussion,
suggests that football creates “a recipe for disaster” and
that the child may face a “.lifetime of deficits” and
“.predisposes” him to CTE is ludicrous [2]. At most, this
study is underpowered and shows mixed results, none of
which have anything to do CTE.
 S.R. Laker et al. / PM R 10 (2018) 655-660
The statement suggesting that prolonged symptoms
could be “early CTE” is pure speculation and flies in the
face of the current understanding of concussion and
postconcussion syndrome. If anything, Dr Greiss makes
an argument that the acute and subacute consequences
of concussion make football an unappealing sport for
this young man.
The urge to be paternalistic and err on the side of
overprotection is strong in youth athletics but must be
tempered with objectivity and respect for autonomy.
We must stay consistent in our approach and let the
evidence guide our medical decision-making. We must
Christine Griess, DO, Rebuts
As professionals, patients come to us for advice. There-
fore, our duty is to educate. Beyond the sports partici-
pation physical, these parents are doing the right thing
by questioning their son’s participation in football.
Disqualification of youth from tackle football is currently
a major discussion item among members of the American
Academy of Pediatrics because of the uncertainty that
lies between subconcussive blows and CTE. In October
2015, the Academy concluded that rule enforcement by
coaches, removal of tackling altogether, expansion of
nontackling leagues, delaying the age at which tackling is
introduced, and more placement of athletic trainers on
the sidelines would decrease the number of subcon-
cussive impacts on the field [1]. It states, “The American
Academy of Pediatrics recognizes, however, that the
removal of tackling from football would lead to a
fundamental change in the way the game is played.
Participants in football must decide whether the po-
tential health risks of sustaining these injuries are out-
weighed by the recreational benefits associated with
proper tackling.” Is that not similar to the statement,
“swim at your own risk?” We are in the dark ages of this
emerging science and cannot afford to be naı̈ve. It may
take years before these changes are implemented in
each high school across the country. Until then, this child
is not safe and the parents cannot be expected to give
informed consent on an unclear matter such as this.
CTE is a structural, not a functional, diagnosis [2].
Parallel to dementia, and metaphorically to coronary
artery disease, CTE is a disease that progresses over
Jonathan Finnoff, MD, Guest Commentary
For physicians practicing sports medicine, this scenario
is not uncommon. A healthy, smart, and athletic young
athlete wants to participate in a contact sport, and
their family has concerns about the long-term risks
associated with such participation. Both Dr Greiss and
Dr Laker make well-formulated arguments supporting
their respective positions. It is well established that
659
not allow our personal beliefs, no matter how altruistic,
to overwhelm the available science.
References
1. Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological evalu-
ation of chronic traumatic encephalopathy in players of American
football. JAMA 2017;318:360-370.
2. Servatius RJ, Spiegler KM, Handy JD, Pang KCH, Tsao JW,
Mazzola CA. Neurocognitive and fine motor deficits in asymptomatic
adolescents during the subacute period after concussion. J Neuro-
trauma 2018;35:1008-1014.
time [3]. We may not be able to find the direct corre-
lation or specific factor linking repetitive head injuries
to CTE. Similarly, how many drinks lead to cirrhosis?
How many smoking years lead to lung cancer? How much
fried food ingestion leads to coronary artery disease?
During the prohibition, a physician could prescribe
alcohol to a woman in her second trimester. In the
1940s, physicians “prescribed” tobacco to ameliorate
symptoms of some minor illnesses. Prior to the late 20th
and early 21st century, we were ignorant about the
direct link between tobacco use and cancer, coronary
artery disease and myocardial infarction, or alcoholism
and cirrhosis. Later, we recognized the correlation.
Likewise, we have emerging evidence that repetitive
subconcussive blows during tackle football are not
completely benign. It would behoove us as practitioners
to go above the call of duty and warn our patients of the
significant risks of permanent brain injury with football
participation and recommend that they not participate.
References
1. Badgeley MA, McIlvain NM, Yard EE, Fields SK, Comstock RD.
Epidemiology of 10,000 high school football injuries: Patterns of
injury by position played. J Phys Act Health 2013;10:160-169.
2. McKee AC, Stern RA, Nowinski CJ, et al. The spectrum of disease in
chronic traumatic encephalopathy. Brain 2013;136:43-64.
3. Montenigro PH, Bernick C, Cantu RC. Clinical features of repetitive
traumatic brain injury and chronic traumatic encephalopathy. Brain
Pathol 2015;25:304-317.
repetitive concussive blows to the head cause neuro-
pathologic changes. However, the clinical manifesta-
tions of this neuropathology are less clear. Thus, there
isn’t a definitive “right answer” to the question posed
by this scenario.
One thing that is clear is the negative impact of not
participating in sports. There is an epidemic of inactivity
660 Football Participation and CTE

and obesity that is striking not only our nation but the
entire world [1]. Estimates suggest that 42 million chil-
dren globally are overweight or obese, and that most of
these children remain overweight or obese throughout
their lives [1]. It is well established that inactivity and
obesity negatively impact health by predisposing to
multiple different pathologies such as diabetes mellitus,
hypertension, dyslipidemia, heart disease, musculo-
skeletal disorders, mental health problems, and certain
forms of cancer [1]. Furthermore, inactivity and obesity
significantly reduce lifespan [2]. When weighing the
potential risks of contact sports participation against the
well-established risks of inactivity, one must be very
careful about deterring a child’s enthusiasm for sport
since it may lead to dire consequences.
Although there may not be a definitive “right answer”
to the question posed by this scenario, there certainly is
an appropriate approach. This approach involves
providing the athlete and their family with all of the
available information about the potential positive and
negative ramifications of participating in a particular
sport and helping them make an informed decision
regarding participation. If they choose not to partici-
pate in that sport, I believe it is important to help them
identify a viable sports alternative. As physiatrists, we
are uniquely qualified to provide this counseling since
the foundation of our specialty is exercise prescription.
Embrace this powerful skillset and let the tenet “Exer-
cise is Medicine” help guide you through the complex-
ities of clinical medicine.
References
1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national
prevalence of overweight and obesity in children and adults during
1980-2013: a systematic analysis for the Global Burden of Disease
Study 2013. Lancet 2014;384:766-781.
2. Grover SA, Kaouache M, Rempel P, et al. Years of life lost and
healthy life-years lost from diabetes and cardiovascular disease in
overweight and obese people: a modelling study. Lancet Diabetes
Endocrinol 2015;3:114-122.

Disclosure

S.R.L. Department of Physical Medicine and Rehabilitation, University of J.T.F. Department of Physical Medicine and Rehabilitation, Mayo Clinic School of
Colorado School of Medicine, Aurora, CO Medicine, Rochester, MN
Disclosure: nothing to disclose Disclosure: nothing to disclose

C.G. Department of Physical Medicine & Rehabilitation, JFK-Johnson Rehabili- J.R.S. Department of Rehabilitation Medicine, Weill Cornell Medicine, 525 E.
tation Institute, Edison, NJ 68th Street, 16th FL, New York, NY 10065. Address correspondence to: J.R.S.;
Disclosure: nothing to disclose e-mail: jrs9012@med.cornell.edu
Disclosure: nothing to disclose

Web Poll Question

For the Case Scenario presented in this Point/Counterpoint, which approach would you recommend?

a. Counsel the patient and family to participate in football.

b. Counsel the patient and family against participating in football.
To cast your vote, visit www.pmrjournal.org

Results of January’s Web Poll*

For the case scenario presented in this Point/Counterpoint, which approach would you recommend?
40% Continue the patient’s opioid prescription
60% Discontinue opioids
*Due to low polling response, results are not statistically valid.

Results of May’s Web Poll*

For the case described in this Point/Counterpoint, which treatment would you recommend?
25% Adipose-derived stromal cells (ADSCs)
75% Bone marrow aspiration concentrate (BMAC)

*Due to low polling response, results are not statistically valid.