Tag Archives: juniorseau

There is Help for Battered Athletes and TBI patients!


A CT of the head years after a traumatic brain...

A CT of the head years after a traumatic brain injury

One of the doctors that has been at the forefront of the battle against traumatic brain injury (TBI) and chronic traumatic encephalopathy (CTE) is Dr. Daniel Amen. He has been working with athletes, military servicemen, and other brain trauma patients to provide a treatment regimen to help them to better cope with living with the effects of CTE and TBI — memory loss, dementia and depression. As Dr. Amen said recently, “My hope is that through increased awareness and education we can help these athletes before it’s too late.”

Since people with the CTE and TBI condition often do not have visible scars, it is hard for most people, including some physicians and other medical providers, to understand the extent to which short-term memory loss affects one’s ability to cope with daily living. Things that other people take for granted just takes much longer to do. Unless one is very organized, one can spend an inordinate amount of time looking for things that one needs on a daily basis. Just getting ready to leave the house for work or an appointment becomes a stressful  ordeal unless one has a routine that is not disturbed in any fashion.

Realization of the Consequences of Brain Trauma

It takes a while — maybe years for person with a CTE or TBI condition to fully understand that their brain no longer functions properly. Those that are lucky enough to have proper treatment may come to the realization sooner that those who do not receive treatment or worse still have to contend with skeptical or uncaring physicians and medical providers.

For instance, I have never had any neurological treatment or rehabilitation for the brain trauma that I sustained while working at Ameriprise Financial in July 2004. It took a number of years for me to realize that I had to take care of my own health rather than succumb to despair. I used my skills as a research analyst to search for articles on traumatic brain injuries so I could better understand what had happened to my brain and why I was experiencing short-term memory problems while my long-term memory was so crystal clear. In fact, I believe my creativity even increased as a result of the brain trauma resulting in a deluge of new and often very brilliant ideas. The only problem is that if I don’t write them down immediately,I would not be able to recall the  ideas after a short time. As I now sometimes joke that — my long-term memory is probably near genius level while my short term memory is significantly impaired. For someone that is particularly cerebral, with a background as a money market portfolio manager and an investment research analyst, one can only imagine my frustration with the situation. What I have essentially had to do is my own “self rehabilitation” using nutrition, naturopathic solutions, and coping mechanisms and systems that I have developed by myself which may not be the most efficient methods but nevertheless do work for me. Now I have the daunting task of going through an administrative hearing regarding the State of Washington‘s Department of Labor & Industries (L&I)‘s  premature termination of my medical benefits and I have to do it by myself, if I don’t get any legal help! A tall order for me but I am determined to go the distance to ensure that the State of Washington‘s Department of Labor & Industries (L&I) ensures compliance with workplace safety standards and more importantly, that L&I changes the way it treats workplace traumatic brain injury cases. A traumatic brain injury is not tantamount to a broken limb and should not be treated as such!

Coping with the Effects of Brain Trauma

Ultimately, one has to come to terms with the fact that the brain trauma has caused a fundamental change in one’s brain function. The best way to deal with the effects of the trauma is to accept it, the same way that one would accept the loss of a limb, and then find the best way to cope and live with it. It is not an easy journey coming to terms with the loss of brain function. High performance super athletes,  military servicemen, and intellectuals always like to perform at or above  a certain level of excellence.  It is very difficult and frightening for super-achievers that suffer a brain trauma to come to terms with the loss of a part or most of their  brain function. It is even more frustrating when one has to contend with all the pseudo-brain specialists that have never read a single pamphlet or sheet on brain science nor have any clue about the effects of CTE or TBI but think they know more than the brain specialists. Anabel Maya, a psychologist who is an expert on memory wrote an article titled “A Closer Look Into Memory” and she admits that she is fascinated by memory because of the amount of information that the human brain is able to store; however, she states that she does not completely understand memory — she is still learning about it!

Support of Family and Friends!

It is really important that people that have sustained brain trauma have support from their families and friends. Support also means understanding how the trauma affects the brain and how to help the person cope with the effects of the brain trauma. I am lucky to have the support of my family and close  friends and I will forever  be grateful to them. I would not have survived without their love and support! I have information on this blog that can help families to understand TBI and CTE and what role they can play to help their loved ones to cope and live with the condition.

You are not alone — there is lots of help!

Some people with a CTE or TBI condition receive treatment; however, there are a significant number of people like me that  receive little or no treatment and have to find ways to cope and live with the condition. The result of no treatment is despair and depression that eventually leads some to suicide! Some insurers like Zurich advise their clients to take precautionary steps to minimize workplace injuries, report injuries in a timely manner in order to start treatment soon after the injury occurs so that to that the employee recovers and returns to work resulting in lower worker compensation costs to the employer. Some employers don’t even bother to follow state mandated safety guidelines, do not report injury claims and time to ensure proper and timely treatment of their employees, and do not care what happens to the employee that has been injured due to their own negligence.  The only thing that matters to such employers is return to shareholders and management bonuses. The injured employee and their family be damned!They are much more interested in covering their tracks and paying the lowest premiums they can muster than doing the right thing!

However, there is help available.  Dave Duerson, Junior Seau and Ray Easterling did not need to take their own lives out of frustration, fear and despair! Most likely they could have been saved, if they had been under the care of physicians and other providers that specialize in the treatment of patients with CTE and TBI conditions.

Resources Available for Brain Injury Treatment

Amen Clinic: Dr. Daniel Amen of the Amen Clinic has a practice that focuses on helping former athletes,  servicemen and others that have sustained brain trauma. He has posted the article below on his blog to let people know that they need not commit suicide when there is lot of help available for them. You can visit his website to learn more and also for the contact information.

Brain Injury Research Institute (BIRI): Dr. Bennett I. Omalu, the forensic pathologist that discovered the presence of “Tau Proteins” in the brains of Mike Webster and other dead athletes and who coined the term “chronic traumatic encephalopathy” (CTE), and his partner Dr. Julian E. Bailes established the Brain Injury Research Institute (BIRI)  to continue their research on CTE and also to treat people that have sustained brain trauma and brain injury from multiple concussions.You can contact them by visiting their website.

Federal Agencies: The Federal Government has established  a dedicated section on its HRSA website to provide information and guidance to doctors, patients, and schools on dealing with Traumatic Brain Injury . The Center for Diseases Control (CDC) also has a section on its website that is dedicated to traumatic brain injury.

Military servicemen and veterans are returning from war with high incident rates of brain trauma which used to be generally diagnosed as post-traumatic stress syndrome. Now the Federal Government is on top of it game and military servicemen and veterans are receiving state of the art diagnosis and treatment for traumatic brain injuries. The Defense Departments’ Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (CDoE) was established in November 2007 to integrate knowledge and identify, evaluate and disseminate evidence based practices and standards for the treatment of psychological health and TBI within the Defense Department. The Defense and Veterans Brain Injury Center (DVBIC) serves active duty military, their beneficiaries, and veterans with traumatic brain injuries (TBIs) through state-of-the-art clinical care, innovative clinical research initiatives and educational programs.

State Agencies: Your best bet is to start with your State’s Brain Injury Association  of  America(BIAA). You can contact your State BIA‘s office by visiting the Brain Injury Association  of  America(BIAA)‘s website and then click on the map to select your own State.

Web: The internet abounds with information on brain injuries. You can do your own research using Google to type in keywords. Please see the tags on this page for examples of keywords that you can use for your search..

Brain Health Resources Blog: This blog has lots of information and links to help you to quickly find the resources that are available. If you have a question for me, kindly leave a comment and I will revert to you to guide you to find the information that you need.

Disclaimer: Please consult your own doctor first for guidance on your brain injury condition and treatment options.

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There is Help for These Battered Athletes

Shock, dismay and grief descended upon family, friends, and fans when news broke that former 12-time pro bowl NFL linebacker, Junior Seau had taken his own life.  The news came as shock to all, even those that were close to him, but this tragic story is becoming far too common.

Just two weeks ago, former Atlanta Falcons safety Ray Easterling, 62, shot himself in Richmond, Va.  His wife, Mary Ann Easterling, told news reporters that her husband suffered from depression, insomnia and dementia after his football career.  Another ex-NFL player Dave Duerson, a former Chicago Bears Pro Bowl safety, committed suicide nearly 15 months ago by shooting himself in the chest.  Duerson, 50, thought he suffered from dementia that fueled his depression. His suicide note included the request: “Please, see that my brain is given to the NFL’s brain bank.”

Post-death exams of Duerson’s brain showed he suffered moderately advanced evidence of chronic traumatic encephalopathy — a progressive degenerative disease related to repeated concussive blows. The disease has been linked to at least 18 deceased NFL players.

I just wrote about how serious a problem CTE is for athletes in contact sports and returning soldiers in last week’s newsletter and here we are again dealing with another heartbreaking story.  Junior Seau was a legend, but even legends cannot escape the ravages of chronic brain damage.  There is help for these athletes and anyone suffering from chronic traumatic brain injuries, depression, and irritability and memory problems.

I began studying the effects of football on brain health in 1999 when Brent Boyd, a former NFL player, came to the Amen Clinics.  After Anthony Davis came to the clinic in 2007 our work with active and former NFL players really took off when we partnered with the Los Angeles Chapter of the Retired NFL Players Association to perform the world’s largest brain imaging/brain rehabilitation study.

As part of the rehabilitation study we scanned the brains of 116 NFL players and found that 113 suffered brain damage and the level of brain damage was just awful.  People who have chronic, traumatic brain injuries, which almost all football players have because they get hit in the head thousands of times in their careers; have a much higher incident of depression and suicidal ideas and suicidal behavior.  Thirty percent of the players we studied had issues with severe depression.  That is four times the rate of depression among the general population!  Even worse, linebackers, like Junior Seau, who lead with their heads on the field, suffer the most significant damage.  The study showed patterns in damage to the front part of the brain and temporal lobes, under the temples and behind the eyes, which manage memory, mood stability and impulse and temper control.

The good news is the brains of contact-sport players and soldiers can be rehabilitated.  We have conducted three clinical studies with 116 active and former players from the National Football League here at the Amen Clinics and each study shows that it’s not only possible, it’s likely, that with a brain-directed health protocol, significant improvement can be experienced in decision-making, reasoning, depression, mood and memory.

Our studies found significant evidence that, fortunately, there are treatment protocols that can often reverse many of the symptoms caused by brain damage and improve brain function.

The studies include:

  1. Effects of Elevated Body Mass in Professional American Football Players on rCBF and Cognitive Function, Transl Psychiatry (2012) 2, eK, doi:10.1038/tp.2011.67.
  2. Impact of Playing Professional American Football on Long Term Brain Function. Journal of Neuropsychiatry and Clinical Neurosciences, J Neuropsychiatry Clin Neurosci 23:1, Winter 2011, 98-106.
  3. Reversing Brain Damage in Former NFL Players: Implications for TBI and Substance Abuse Rehabilitation. Journal of Psychoactive Drugs, 43 (1), 2011 Online publication date: 08 April 2011.

Junior may have damaged his pre-frontal cortex, which is responsible for decision-making.  Brain trauma symptoms can appear decades after the playing days and can include dementia, memory loss, violent behavior, obesity, mental illness and depression. And unfortunately, suicide is more common in people who have experienced brain trauma.

Playing football is a brain damaging sport and for those that are going to play it, my message would be to get your brain examined before you play and after you stop as well as any time you get a concussion.  The best way to prevent tragedies like these from happening aside from avoiding the things that are harmful to the brain, are early detection and treatment.  My hope is that through increased awareness and education we can help these athletes before it’s too late.

Source: http://70.32.73.82/blog/5758/there-is-help-for-these-battered-athletes/

Dave Duerson had brain damage


Updated: May 3, 2011, 12:45 AM ET

ESPN.com news services

BOSTON — Dave Duerson, a former NFL player who committed suicide in February, had “moderately advanced” brain damage related to blows to the head, according to the researcher who made the diagnosis.

“It’s indisputable” that Duerson had chronic traumatic encephalopathy, a disorder linked to repeated brain trauma, Dr. Ann McKee said Monday.

The findings were announced as part of an effort conducted by the Center for the Study of Traumatic Encephalopathy at Boston University’s School of Medicine. The CSTE Brain Bank has the brains of more than 70 athletes and military veterans, with football players comprising more than half of the athletes.

Duerson played safety in the NFL for 11 seasons, seven with the Chicago Bears, and was chosen for four Pro Bowls before retiring in 1993.

[+] EnlargeDuerson

Al Messerschmidt/Getty ImagesFormer Notre Dame and Bears defensive back Dave Duerson had brain damage when he committed suicide.

“Dave Duerson had classic pathology of CTE and no evidence of any other disease,” McKee said, “and he has severe involvement of all the [brain] structures that affect things like judgment, inhibition, impulse control, mood and memory.”

The body of Duerson, who was 50, was found in Sunny Isles Beach, Fla., on Feb. 17. He left a note asking that his brain be given to the NFL’s Brain Bank. He shot himself in the chest, “presumably” to preserve his brain for study, said Chris Nowinski, co-director of the CSTE.

The other co-directors are McKee, Dr. Robert Cantu and Dr. Robert Stern.

Duerson’s case was “moderately advanced,” McKee said. “The likelihood is that if he hadn’t had the CTE, he wouldn’t have developed those symptoms that he was experiencing at the end of his life and perhaps he wouldn’t have been compelled to end his life.”

Cantu said that such results normally are published first, but the Duerson family wanted them released earlier. Duerson’s former wife, daughter and three sons attended the news conference.

“We have been given the gift of closure,” said his son, Tregg. “We accept this gift with great humility, as we are mindful of other families that have lost loved ones and still bear the burden of unanswered questions.”

Duerson had at least 10 concussions in his NFL career, according to his family, and lost consciousness during some. However, he never was admitted to a hospital for them, Stern said. But he said it’s also important to address hits to the head that don’t cause concussions.

CSTE, created in 2008, is a collaboration between the BU School of Medicine and the Sports Legacy Institute, headed by Nowinski. The center has been aggressively researching head trauma in sports, and has received a $1 million gift from the NFL, which it has pushed for better treatment of concussions.

“We hope these findings will contribute more to the understanding of CTE,” the NFL said in a statement. “Our Head, Neck and Spine Medical Committee will study today’s findings, and as a league we will continue to support the work of the scientists at the Boston University Center and elsewhere to address this issue in a forthright and effective way.”

Fourth & Goal, a group founded by Baltimore Colts alumni designed to assist retired NFL players, called for more education, safer rules and improved care for those already affected by football-related injuries.

“Commissioner Roger Goodell has taken steps to address head trauma and concussion in the league,” group president Bruce Laird said in a statement. “However, more needs to be done to educate current players on the risks, to enact additional rule changes that reduce risk and protect players, and to improve care for those affected by debilitating football injuries.

“… We call on the NFL and NFLPA to take immediate action, including abandoning the proposal to extend the regular season to 18 games and improving the existing disability system.”

Duerson was a third-round draft choice by the Bears out of Notre Dame in 1983. He played safety on the team that won the Super Bowl in the 1985 season. He moved to the New York Giants for one season in 1990, playing in another Super Bowl, then spent his last three NFL years with the Phoenix Cardinals.

Cantu said there is no treatment for CTE and research is being done to find ways to identify it in living people.

McKee compared the condition of Duerson’s brain to those of other NFL players studied by the CSTE.

The damage wasn’t as severe as that seen in the brains of Wally Hilgenberg, a Minnesota Vikings linebacker who died at 66 of amyotrophic lateral sclerosis, or Lou Creekmur, a Detroit Lions lineman who died at 82 of dementia, she said. The damage was about the same as that in the brain of former Houston and Miami linebacker John Grimsley, who died at 45 of an accidental gunshot wound.

Nowinski said “the latest version of the NFL’s guidelines [on concussions]are well thought out. And, I think, with the state of the science today, it’s about the best we can do.”

But he said the problem starts much earlier, in youth football.

“The 6-year-olds are playing the same games as the pros when we know that their brains are far more susceptible to this damage,” he said. “My next focus is how do we change youth football so that a kid doesn’t show up in the NFL with 10,000 hits to their head already?”

The NFL said it will “advocate for the passage of Lystedt laws in all states” to protect athletes from concussions.

The Lystedt law was adopted by the state of Washington, effective in July 2009, and 15 states have passed similar legislation since then, the league said.

The Washington law requires school districts and leagues using school property to remove from games or practice players that are suspected of having sustained a concussion. It also prohibits them from returning until authorized by a doctor trained in concussions, and mandates that parents and athletes sign concussion information sheets.

It is named for Zackery Lystedt, who returned to a school football game after suffering a concussion when he was 13. He suffered brain damage and fell into a coma, but has regained movement in his extremities.

Nowinski wants more safeguards.

“It’s amazing to me that we have pitch counts in youth baseball to protect children’s elbow ligaments,” he said, “but we do not count how often we hit them in the head to protect their brains.”

Information from The Associated Press contributed to this report.

Source: http://sports.espn.go.com/chicago/nfl/news/story?id=6465271

Comments on blogs and news articles!


If the comments on blogs, new commentaries and news articles are any indication, I believe we are reaching a turning point in understanding of the effects of Traumatic Brain Injury (“TBI”) and Chronic Traumatic Encephalopathy (“CTE”).

ABC’s coverage of Junior Seau‘s suicide included exxtensive discussion of CTE and its reamifications. The ABC website also had several links to TBI information.

Comments on blogs and news articles have been very respectful and somber with most NFL supporters and fans suggesting that the football game would have to change for it to survive. Strategy and tactics would need to be emphasized instead of brute strength.

Here are more links and extracts of comments that give me hope that the public is gradually beginning to understand the implications of TBI and CTE. I just wish that Junior Seau, Ray Easterling, Dave Duerson and Mike Webster did not have to die for there to be a change in the way TBI and CTE is viewed and treated.

It is important that providers, friends , co-workers and family are not dismissive of the concerns of TBI and CTE sufferers. The ultimate result  is the sufferers’ early death when they see no other way out of their predicament. However, there are ways that one can cope with the effects of TBI and CTE.

Coping and Living with TBI and CTE — I have pages on this blog with information on Brain Injury resources and suggestions on how to live with TBI. Please share the blog with anyone that you know that can benefit from this information.

Here are some comments and links

#1: “I rotated through the VA Hospital as part of my training and this is the problem with our servicemen coming back from Iraq. They were being diagnosed with PTSD because of depression and suicidal ideation. However, the actual problem was actually TBI from exposure to road side blasts. Trust me when you see patients like this, you wish they would speak up sooner rather than later because the end result is by no means pretty at all.” Source: http://www.shaggybevo.com/board/showthread.php/110357-Colt-just-got-some-help?goto=nextoldest

My comments about Junior Seau’s suicide!


Junior Seau

Junior Seau (Photo credit: Dave Sizer)

I posted the following comments to a friend’s facebook Wall when he first posted the story of Junior Seau‘s suicide. At the time, I did not know much about Junior Seau; however, I had an inkling that the suicide could be CTE related. My sincere sympathy to Junior Seau’s family. May his soul rest in eternal peace!

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There has been a spate of traumatic brain injuries in the NFL which the NFL was not willing to acknowledge until 2010 when a Congressional Judicial

Hearing forced them to face the reality of what is happening to their retired players. Most of them sustained multiple concussions that were not treated but they were forced to return to play almost immediately. They live in constant pain and have short- and long-term memory losses which is like a living nightmare. Short-term memory is essential to daily living.

Pitt Football Alums Tony Dorsett at Gino Torre...

When Dave Duerson committed suicide he did so in such a way that he would not damage his brain so that it be could studied. It was a virtual sacrifice for medical research to help other players that are TBI sufferers. Tony Dorsett is also having similar problems and he has sued the NFL. It would not surprise me to find out that Junior Seau took the same path out of a life of misery of living with TBI.

The fact is that TBI is a new frontier for most doctors. Most of them don’t understand TBI and they are often dismissive of TBI incidents but the effects are degenerative so years after the victims, especially children and teens, that have concussions suffer with no explicable reason, There are also college players with TBI conditions.

The US Federal government is now focusing on TBI. They have a website and doctors are now required to do CT scans hours apart after a concussion incident because bleeding in the brain does not show up immediately after a TBI incident. Six or eight hours later — the bleeding shows up while the initial scan may have been clean. There are also guidelines for “return to play” for schools, colleges and the NFL. Players can no longer be returned to play immediately following a concussion incident. http://www.cdc.gov/traumaticbraininjury/

There has always been knowledge of “Pugilist’s Punch Drunk Syndrome” which was associated only with boxers. It was not until Dr. Bennett Omalu — a renowned Nigerian neuropathologist — examined the brain of Mike Webster and other players whose brains were sent to him after they passed that the understanding of TBI which he termed “Chronic Traumatic Encephalopathy” (CTE) and the implications of concussions among the general public and NFL players was understood. The concussion results in the deposit of “Tau proteins” (a gunk of dead nerve cells) in the brain which interferes with electrical signals in the brain and brain function that depends on which part of the brain is affected.

Most NFL players suffered multiple concussions which can occur over several parts of their brain so their brain function can be impaired in a significant way. Just imagine the nightmare of losing both your short-term and long-term memory and also being in constant pain from the injuries. There was no documented evidence of TBI in his case; however, everything that I have read about Walter Payton seems to also point in that direction. http://www.braininjuryresearchinstitute.org/archives/bennet-omalus-testimony-to-house-judiciary-committee/

As Dr. Bennett Omalu testified, the deposit of Tau Protein does not show up on CT Scans and MRI. It cannot be seen with the naked eye. It was only after he sent samples of Mike Webster’s brain to a lab for specialized exam that the tau proteins showed their ugly face. Like Dave Duerson, Junior Seau may have shot himself in the chest to avoid damaging his brain so that it can be studied. If it turns out that there are tau proteins, his family can be compensated when the NFL lawsuit is settled. The most important thing with TBI is awareness. When people understand what is really happening with their brain and how best to cope with and live with TBI, it is half the battle. The other part of the battle is finding a way to live with it so that you can minimize the impact and not beat yourself up over every setback but take the punches and roll with it!

This is why I set up my blog to help people to know that they are not alone and that there are resources available to help them cope with TBI (aka CTE). I feel that people will despair less if they understand the condition and have no fear of what is going on. Because it is not a visible injury, doctors dismiss it. When people think of a brain injury they expect to see visible scars. Most people including friends, co-workers and family members can also be very dismissive. However, families are also impacted in a very negative way and they also suffer when their loved one, often a former high performer, no longer functions at the level that they once performed and they are at a loss to understanding what is really going on, and helpless because they have no clue how to help the person. The more that people know and understand, the better for the TBI victim and their family.

I have to add that Dr. Bennet Omalu, a Nigerian, was attacked by the NFL. It was not until doctors at Boston University corroborated his work that the NFL accepted his findings. I spoke to Bennett and he told me that they did not believe him when he first published his work.  They even attributed the term CTE, which Dr. Omalu coined, to the Boston University researchers. Now he is widely recognized for his ground-breaking work. Dr. Bennet Omalu also collaborates with Dr. Daniel Amen to help the NFL players.

Read more: http://www.google.com/hostednews/ap/article/ALeqM5iVyZprPTUsS7r0vk1PQfdOWXzsjA?docId=1365dbb3557f41359bc44d67b21aad83

Dave Duerson and Chronic Traumatic Encephalopathy (CTE)


February 20th, 2011

Dave Duerson, the former Chicago Bears safety and part of the famed 1985 Super Bowl team, committed suicide last week at the age of 50. He died of a self-inflicted gunshot wound, but he chose to shoot himself in the chest versus the head.

This was deliberate.

“He had informed (his family) at some point that he wanted his brain to be studied so people could learn more about the effect of brain trauma and so kids could play the game more safely in the future,” [Chris] Nowinski said.

Although he had deemed his life as intolerable, Dave Duerson nevertheless wanted to preserve his brain so that it could be studied posthumously for evidence of chronic traumatic encephalopathy (CTE), an insidious and progressive type of dementia that seems to be caused by repeated head trauma – i.e. the type that Duerson experienced during his professional football career.

Duerson’s life over the past several years followed a pattern similar to that of former Pittsburgh Steeler center Mike Webster. After retiring from pro football in 1990, Webster’s life became plagued by debt, depression, family turmoil, and eventually homelessness. Similarly, Duerson’s marriage fell apart and his once successful business interests faltered while the man himself became increasingly distraught at his own cognitive and emotional decline.

CTE is not a new phenomenon, but it has been largely ignored – or actively downplayed – until relatively recently.

Be sure to check out the podcast we conducted back in 2007 with Dr. Bennett Omalu, a forensic pathologist and neuropathologist who was one of the first researchers to step forward and actively publicize this disorder. You can listen to the entire episode here:

“Dementia of Football”: The Next Major Public Health Issue?

Source: http://intrepidinsights.com/2011/02/20/dave-duerson-and-chronic-traumatic-encephalopathy-cte/