Throughout this week, we’ve brought you a three-part series examining the constant pain that NFL players play through and the methods and medicines they rely on to get back on the field as soon as possible. The links to our series can be found here.

As part of our reporting for this extensive project, earlier this summer we spoke with Dr. Julian Bailes. Now a renowned neurosurgeon for NorthShore University Health System near Chicago, Bailes was a team doctor for the Pittsburgh Steelers from 1988-98 and is still a neurological consultant to the NFL Players Association. He has also worked with the Study of Retired Athletes at the University of North Carolina and is an expert on chronic traumatic encephalopathy (CTE), a degenerative disease found in athletes with a history of repetitive brain injury.
We spoke with Bailes about the state of football, the escalating concerns about the game’s safety, the increasing awareness of concussion dangers and the pressures that both players and team medical staffs face in a high-profile, high-intensity bison. Here are some of Bailes’ most poignant thoughts from that conversation.
Star Tribune: With your concussion expertise, with where things are now in football, what more can the NFL be doing to protect players in a sport that is inevitably dangerous?

Bailes: "The NFL has done a lot and a lot recently especially. So what more could the NFL do? Well, I think they've done a lot and I acknowledge that. But I think where we're going with this is I think we have to work to take the head out of the sport. I think we have to take head contact out of football as much as possible. I played 10 years. I've been a sideline doctor 20-some years. I get it. I know that's easier said than done. It's fundamentally changing the sport. Players don't like it. A lot of fans don't like it. But I think that's where this is headed. And as much as possible, I think we have to take head contact out of the sport.

"I'm the medical director for Pop Warner football -- we're the largest youth football organization in the country. And we're going to be the first level to alter policy on that. The NFL hasn't done it. The NCAA hasn't done it. The National High School Federation hasn't done it. We're going to be the first level to begin to legislate or mandate or control for the exposure to head contact. You ask me, ‘OK, Doc, that's really pie in the sky, sounds great. How are you going to do that?’ There are several ways. One, you enforce the rules that are already in the books, which I think the NFL has started to do. And that's made the NCAA work harder at doing so. And I've been advocating for the last few years taking the linemen out of the three-point stance. Why? A couple reasons. [Dr.] Bennett Omalu and I have performed brain autopsies on seven former NFL players, all linemen without a prominent history of concussion, who all had CTE even without a history of concussion. The second reason is that one of the latest things in the discovery and the science and moving the bar of our understanding of concussions medically and scientifically has been the research done with accelerometers placed in the top of helmets. That's been done at the NCAA level, at the high school level. There was just a small report from Virginia Tech a few months ago at the youth level. And that has shown a lot of head impacts in football. And if you play through college, the average player will have had 8,000 head impacts by then. But what we're finding in some of that work is that, yeah, there are dramatic high velocity [hits], those 120 g-force hits in the open field to the wide receivers, to the quarterbacks. But we're also seeing that linemen are getting 20 to 30 g-forces on nearly every play. So those are the two main reasons that I use to try to back up my statement that I think we need to get linemen out of the three-point stance. They already start off in a squatting position for passing plays. Why do we have to have this ubiquitous, gratuitous, mandatory head-to-head contact on every play that studies are showing now can deliver significant g forces? Why not just take that out? That's what I'm trying to advocate now. It's falling on deaf ears and nobody is that interested. But I think that's where we're going.

"Another place I advocate change across all levels is to start reducing contact in practice. Once the season starts and you know who your players are and who the starter are and positions are won, why do you need to have an abundance of contact in practice? Right there, you could eliminate well over half of the exposure."

Star Tribune: Given your expertise, I wanted to ask you also about the pressures for team medical personnel – doctors, trainers, etc. It seems to be a very complicated role to assume for many reasons in sort of achieving that trust on a two-way street between the players and the medical staff. That’s inherently difficult given the pressures for these guys to play. So many of the players we’ve talked to, past and present, acknowledge that they’re wired from the time they’re in middle school to not miss time on the field. So that leads them to withhold information from team doctors. In essence, they don’t want to admit they’re hurt for fear of being held out. The team needs its players back on the field. The players themselves want to be back on the field ASAP. Now you as a team doctor have to make sound medical decisions that often may provide a force pulling from the opposite direction. So I wondered what your perspectives are on that dynamic as part of the sport?

Bailes: "There are pressures. But now more than ever because of our increased understandings of the dangers of these injuries, there should be less pressure in a way. I was a team physician at the NFL level for more than a decade. And back then, I think there was more pressure. Not because you had people interfering. You didn’t have Bill Cowher interfering in our work. But we as doctors didn’t fully understand the magnitude of some of the injuries. So now, there is that greater understanding. And with concussions, it’s pretty clear-cut. If there’s any doubt, you sit ‘em out. And they don’t return until the symptoms have subsided and they’ve been cleared.

"There used to be far more gray area. Two years ago, the NCAA came out with a rule that every university in the country, Division I to D-III, had to have a written concussion management plan and a separate return-to-play plan. I was part of the committee with that and we really emphasized with that document and that policy that at the NCAA-level that you had to work hard to prioritize safety. If there’s any doubt, you pull them out to evaluate them. And once you determine that they had a concussion and didn’t just get their breath knocked out or have some other problem, then they don’t go back to play in that game or that practice. And they don’t return until they’ve been cleared."

Star Tribune: Still, players themselves make that admission that they don’t fully disclose their injuries at times. Even concussions. They don’t want a red flag that can pull them off the field. How does that make things more complicated for a team physician, knowing that during a given consultation, you may not be getting the 100 percent truth from these guys?

Bailes: "That’s always been a problem with concussions. Concussion is an injury you can’t see and the symptoms are subjective. Ordinarily you can’t see it. The symptoms are headache, dizziness, can’t sleep, maybe some memory problems. So the symptoms, by and large, you can’t see them. So you depend on the athlete or the patient to report those to you. That’s always been a problem with concussion. And the other thing is that there has been a problem that I would call cultural. And that is the whole problem starting back when concussion was not understood and it was minimized in its significance. We would say a player was dinged and players were encouraged to get back in the game. There’s still some of that today. But less than ever. And it’s a matter of players being willing to admit that, 'Hey, I’m not right.' Even though we don’t see a big swollen knee and that guy looks normal and talks normal, it’s OK for him to admit that he doesn’t feel right. It’s OK to sit out. That’s a change in culture.

"You may remember a couple of years back that Ben Roethlisberger sat out a game or two at the end of the season. And it was disclosed he had a concussion. And while it wasn’t a bad concussion, he just didn’t feel right and didn’t think he should play. That was the right decision. But Hines Ward criticized him. And there was some backlash. And then Hines Ward, to his credit, recanted. But that was an example of what I call the cultural problem."

Star Tribune: That level of peer pressure is so ubiquitous, that seems to only add to the difficulty for these players to make the smart decisions even when they know the smart decisions.

Bailes: "You’re right. That’s what we have to slowly work to change. We need younger kids and their parents to read and learn and understand that it is OK to change and it is OK to sit out if you're hurt."

Star Tribune: During your time with the Steelers, what were some of the unique dynamics present during that era, with injuries in general, as team physicians tried to look after the wellbeing of the players while operating under the pressures of this business? That dynamic exists where it’s understood that players need to play as soon as possible and that’s sort of the unspoken reality in the air. So how does that impact things?

Bailes: "In that era, what made things difficult is we didn’t understand nearly what we know know about concussions. Number two, since we didn’t know as much, there were probably more pressures then to send guys back into action than there are now. There wasn’t the appreciation by players, coaches, trainers and wives of the implications for guys returning too soon. And we probably had more coaches back then involved in trying to sort injuries out. Not in a malicious way or an inappropriate way. We didn’t have the scientific back-up. We didn’t have all the education that the media has brought to the public so that they understand this. And thirdly, we were also fighting a culture of ‘Hey, you got dinged, you got headaches, too bad. You’ve got to man up and push through it and play.’ There was more of that because of all of our common ignorance of the problem. We didn’t know what we know now and it wasn’t accepted then that it’s OK not to play if you don’t feel right."

Star Tribune: Will gaining that acceptance be a slow process?

Bailes: "Yeah. We’re in the midst of it now. Example, you look at James Harrison’s comments after the Colt McCoy hit last year and the players’ general resistance to these changes. It’s, 'Are we changing the sport too much? Isn’t this still a contact sport?' I get it. I understand the reservations.

"But take the suicide of Junior Seau. In my eyes, that could be a milestone event. It was purely speculative that he might have had CTE – we don’t know that yet – and there are other causes of suicide. But his death really ratcheted up the discourse and the debate almost like never before because he was such a great and beloved player. So we’re still in the midst of trying to get a collective grip on this as both players and coaches and also as fans."

Star Tribune: What is the level of your expertise on Toradol and your medical knowledge of the benefits and fears of that drug?

Bailes: "I’m not a pharmacist, obviously. But I know about Toradol. We had started using it during my time with the Steelers. And I was also a team doctor at West Virginia for 12 years. And when Toradol came out, it was a highly attractive drug because it was a very effective pain reliever that was not a narcotic. We used it quite a bit. And I think in my experience we used it quite effectively for pain control. We use it in the hospital setting, we use it in surgical situations and for patients who come to the emergency room. And we’ve used it in the athletic setting. Again, one of its greatest attributes to me is that it’s not a narcotic."

Star Tribune: Some medical experts will say that when used properly, Toradol is an incredible drug. It’s got that anti-inflammatory kick to it. It allows guys to feel normal for a while. And when used judiciously, it’s absolutely perfect for the game of football. So then how do we address the fears and questions over volume of use? How much is too much? The FDA warns that it’s not to be used five days consecutively. Yet a lot of NFL veterans will tell you they take it once a week, before every game for 16 games. So how do we determine how much is too much?

Bailes: "I’m not a real expert on Toradol. The warnings that are standard and the potential side effects are there. But some of the side effects are a one-in-a-million kind of thing. For most patients, I think it’s a very safe and effective drug. But you have to remember that over the years, athletes have been prone to use NSAIDs [non-steroidal anti-inflammatory drugs] thinking that they were safe because they were non-narcotic and very effective. And there were guys who would then eat them like candy. So I think everybody has a tendency to think that if something is safe and non-narcotic, they can take it if they think they’re having chronic pain ... I think overuse of NSAIDs and not just Toradol is a tendency amongst athletes for the right reasons.

"I have never seen significant problems with Toradol. I think, like most drugs, if used correctly, it’s safe and it’s very effective. And more than that, there are not a lot of alternatives." 

Star Tribune: On the topic of painkillers, during your time with the Steelers and I guess to an extent at West Virginia, what in your opinion is the key to keeping that in check? Players will often say that the ease of access to painkillers isn’t necessarily anyone’s fault. Because a lot of times in order to get a prescription for a painkiller, all you need to do is show significant pain. And when you’re a professional football player, it’s not very hard to exhibit those symptoms? So how do team medical staffs control that part of the game and safeguard it?

Bailes: It has always been an issue. But understand it’s also an issue in the general public. I do brain surgery and some spine surgery. And all of those patients, a certain percentage are going to have significant pain and a certain percentage are going to need a painkilling drug, whether that’s a narcotic or something like Toradol. And then there will be a smaller percentage of people who drift toward abuse. They have some pain and it’s magnified and their response is to take a narcotic. And so you have to deal with athletes the same way you deal with a patient who’s had a work injury or a patient who’s had a brain tumor taken out. You have to deal with it on an individual basis.

"As a physician, you have to be very, very in tune to what’s going on. And you have to have a very low threshold for cutting them off and then giving them an alternative or helping them to find whatever assistance they need if you feel they’ve gone too far and have an abuse problem. It’s something we monitor with all of our patients. I don’t think dealing with athletes is any different."

Star Tribune: With painkillers, do you sense that significant strides have been made in the past 20 years in regards to the ease of access that NFL players have to those kinds of drugs? Are we protecting players as much as they need to be protected?

Bailes: "I think it’s probably dependent upon the practice of each team’s medical staff. In my time with the Steelers, I never saw any signs of delivering and giving out excessive narcotics or other drugs. I think it’s a team-by-team thing. Even back in 1988, we approached it the same way and I never knew of or saw a problem of passing out too many pain meds. But it definitely always has been a potential problem. And it remains a potential problem now."

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