Concussion Inc. (12 page)

24 June 2011..........

Dr. Richard Ellenbogen, co-chair of the NFL's reconstructed concussion policy committee, now has done his own star turn at NFLHealthandSafety.com.
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It contradicts the buffoonish demonstration of Dr. Joe Maroon.

The Ellenbogen video has useful information, but its message is muddled.

Ellenbogen emphasizes taking your time in an on-field evaluation of an injured player; Maroon, with no disclaimers, emphasizes how fast you can do such an evaluation (“efficiently and expeditiously” is his assonance). These two positions are not reconcilable. Will Ellenbogen use his authority to remove and disavow Maroon's video?

Ellenbogen's “first principle” is unassailably correct: “tailor approach to level of athletic play.” But this principle is undercut by the overall topic, which is a guide on returning athletes to play after they suffer concussions.

We all get it that NFL return-to-play protocols are being tightened (except, of course, when they aren't). The question Mom and Pop Football urgently want to hear the experts discuss, however, is not how to manage Johnny Gridiron's second concussion. It is whether they should be exposing their precious bundle of shoulder pads to a possible
first
concussion and to scores, hundreds, or thousands of lethal subconcussive blows. In short, is the sport of football a viable activity at all for youngsters? That would be the most fundamental “tailoring of the approach to level of athletic play.”

No one expects Richard Ellenbogen, speaking on an NFL website, to trash his client. But rather than handing down education about baseline neurological testing for little squirts — a concept both flawed overall and, specifically, impossible to reproduce at the amateur level — he should be making the broadest and most professionally responsible disclaimer of all: that everything he says on behalf of the league about return-to-play applies only to those so dedicated to football that they are willing to play Russian roulette with their mental health. Failure even to acknowledge the existence of a controversy on this crucial point exposes his lack of independence.

28 July 2011..........

As the old National Public Radio comedy segment “Dr. Science” used to demonstrate, you don't need “a master's degree in science” on your résumé in order to have a beakerful of common sense. A new study of neuropsychological (NP) testing as a tool of concussion management — soon to be published in the
American Journal of Sports Medicine
— provides further evidence that Dr. Joseph Maroon's ImPACT software has little going for it except its University of Pittsburgh Medical Center team's tainted National Football League connections, plus a doctorate in B.S.

In “The Influence of Musculoskeletal Injury on Cognition: Implications for Concussion Research,” four University of Toronto researchers conclude that athletes recovering from orthopedic injuries, which have nothing to do with traumatic brain injury, “also display a degree of cognitive impairment as measured by computerized tests.” The clinical relevance of this finding: “[A]thletic injury, in general, also may produce a degree of cognitive disruption. Therefore, a narrow interpretation of scores of neuropsychological tests in a sports concussion context should be avoided.”

On top of everything else we now know about how savvy athletes game the ImPACT system — by taking Ritalin to improve superficial cognition post-concussion, or simply by tanking their initial “baseline” tests to come off as naturally stupider than they are — we can see what the Maroonization of concussion management is all about. Like standardized testing of academic achievement, it is creating its own closed system of gimmicks, which measure mental acuity far less accurately than they measure how resourceful and well prepared the taker was in having been “taught to the test.”

With iPads, that principle is fine for developing a new-tech economy of “killer apps.” With public health, it's just a killer.

No matter how you slice and dice it, when it comes to youth concussions there is no substitute for reasonably knowledgeable and concerned people — coaches, trainers, doctors, parents — making sure their kids are OK … really, really OK … through use of their own powers of observation. Standardized NP testing misses the point badly, lets the NFL's multibillion-dollar marketing off the hook, and, not incidentally, further lines the pockets of doctors like Joe Maroon who brought us to this pass.

Which reminds me that Dr. Richard Ellenbogen, co-chair of the NFL's concussion policy committee, still hasn't gotten back to me on the dangerously mixed messages at the website NFLHealthandSafety.com. In Maroon's video there, he shows off getting a concussed player back to action “efficiently and expeditiously” with a “two-minute drill” evaluation. In Ellenbogen's video, he emphasizes that you need to evaluate the head-injured athlete across time.

So … which one is it, Dr. Chairman?

FoxSports.com's Alex Marvez reports that last night the league held mandatory conference calls with team officials to review new tightened-up protocols promulgated by Ellenbogen and his co-chair, Dr. Hunt Batjer. The slogan is “When in doubt, keep them out,” according to Gene Smith, general manager of the Jacksonville Jaguars.

“When in doubt, keep them out” is also the mantra of Ellenbogen's NFL safety video for the general public. But as long as phony solutions like ImPACT continue to cast a falsely reassuring shadow on the national concussion conversation, Ellenbogen's words are empty.

28 July 2011..........

Dr. Joe Maroon's interview with the
Intelligencer/Wheeling
(West Virginia)
News-Register
has all the standard Maroon tropes and a couple of new whoppers.
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On NFL return-to-play protocols, Maroon says that the league has mandated, as the first of three standards, that “you must be completely asymptomatic, in other words no headaches, nausea, vomiting, fatigue, sleepiness, drowsiness, at rest.” Funny, but in Maroon's video at the PR website NFLHealthandSafety.com, he says nothing about the athlete being “completely asymptomatic.”

Perhaps it could be argued that this point is so obvious that it doesn't even need to be said — but if so, then why does Maroon feel it is important enough to articulate today in his West Virginia interview but not in his official NFL website video of a few months ago?

Maroon makes this stunning remark: “I saw some statistics a few years back, if you look at the time that kids … spend in automobiles at the same time they could be on the practice fields … the incidence of injury from being in car accidents would be significantly higher than participating in sports.”

Even if Maroon is attempting to commingle brain injuries with all injuries, this assertion intuitively makes no sense. Of course, over time while in a car, as either driver or passenger, you run the risk of serious injury or death in a crash. But I would like to see the citation of “some statistics a few years back” suggesting that such incidence is “significantly higher” than the day-to-day injuries, minor and major, in football practices and games.

18 August 2011..........

“The ImPACT test, widely regarded as the go-to neurological exam to measure concussive blows, doesn't always accurately gauge a player's readiness to return to action. And you can cheat on it.”
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That is one of the bullet points from an excellent article in the current
LA Weekly
that highlights why “concussion awareness” is not the answer.

In 2008, Ryne Dougherty, a 16-year-old high school linebacker in Essex County, NJ, sat out three weeks following a concussion. But after taking an ImPACT test, he was cleared to play. During his first game back, he suffered a brain hemorrhage; he died within a week.

Dougherty's ImPACT results were ominously low, the family has claimed in a lawsuit against the school district. Additionally, according to the test results, Dougherty reported feeling “foggy” but still was cleared to play.

Further, reporters Jansen and Garcia-Roberts note, ImPACT's “real-world snags” include “price: At packages costing roughly $600 per school for the first year, ImPACT is too expensive for some districts. And many of those that do buy the program cannot afford to pay a specialist to administer it. Instead, that duty tends to fall on coaches or trainers.”

13 October 2011..........

Don't believe that ImPACT is worse than useless for high school football programs? The case in New Jersey of Ryne Dougherty, a kid who was killed in a game in 2008 — after suffering a concussion and being cleared to return to play three weeks later, with the assistance of ImPACT — illustrates how the tool will provide a veritable road map to the string of lawsuits that will bring down prep football.

And check out this unintentionally comical report from the Jackson County (Michigan)
Citizen Patriot
, under the headline “Orthopaedic Rehab Specialists ‘ahead of the curve' in helping treat athletes with concussions.”
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No one knows that better than Sullivan Evans, a ­Lumen Christi High School sophomore who suffered two concussions last year playing freshman football. The first one occurred after a helmet-to-helmet hit in the season opener.

“The ImPACT test proved it [was a concussion],” said his mother, Kristin Evans. “He said, ‘Now that I know what that feels like, I bet I've had six of those playing hockey.'”

It took four weeks before Sullivan's ImPACT test scores showed he was ready to return to action. Then in his first game back, he suffered another concussion. This time, it was six months before he was cleared to play contact sports again.

Wow, give these docs a Nobel Prize! They sent the kid back out there for a second concussion four weeks after his first one … but they sure guarded against that vaunted
third-concussion syndrome
!

The article proceeds, deadpan: “So far this fall, 89 athletes have suffered concussions, and Chamberlain said every school in the county had at least one football player out with a concussion for three to four weeks.”

19 October 2011..........

At today's Senate commerce committee hearing, Senator Tom Udall, as expected, directed a lot of outrage toward the spurious claims of the Riddell helmet manufacturer and other “Concussion Inc.” marketers — while saying nothing about how the NFL and its operatives were in bed with many of those same companies. With respect to Riddell, Udall noted that a doctor involved in the now-infamous 2006
Neurosurgery
journal study of Riddell's Revolution helmet had distanced himself from the way Riddell went on to quote the article in its commercials and promotions. But Udall couldn't spit out the name of this doctor: Joe Maroon.

Dr. Jeffrey Kutcher's testimony included a point glossed over by Udall:
the problem isn't just how Riddell exploited the Maroon/UPMC/NFL–funded study of the Riddell Revolution. The problem is that the study itself was shoddily designed and scientifically unsound
. In January, Maroon told the
New York Times
that the company's promos should have been more careful about his study's “limitations.”

Limitations, my foot — as Kutcher told the commerce committee, the
Neurosurgery
article had lousy controls in the first place and proceeded to play fast and loose with claims of percentages of reductions in the incidence of concussions among those who used the helmet.

Udall should haul Maroon before the commerce committee for a defense of his work, not just a secondhand and unnamed renunciation of the supposed bad faith exhibited by a patron and exploiter of his work. Maroon also needs to explain why, if Riddell's promos were so heinous, he never complained about them over a period of years, until the
Times
and Udall came along to ask questions about them.

Also at the hearing, Udall ripped the marketer of the supplement Sports Brain Guard — but conveniently without mentioning that Maroon is a prominent endorser of that product, too.

The approach of our government to the concussion crisis reminds me of the “fix” of the radio payola scandals in the 1950s. Back then we made sure to criminalize the acts of disc jockeys in accepting bribes for giving particular songs more airplay. Decades later, television producers would barter entire blocks of commercial time to station licensees and exploit numerous other loopholes in newly loosened Federal Communications Commission rules. But payola at that level, owner to owner, was perfectly legal. It was just business.

Now Udall and the commerce committee are devoted to bashing “sports equipment manufacturers [which] are exploiting our growing concerns about sports concussions to market so-called ‘anti-­concussion' products to athletes and their parents,” as the senator's press release put it.

Though my bête noire has been Dr. Joseph Maroon, the most amazing one-man medical conglomerate since Dr. Welbeck of Paddy Chayefsky's
The Hospital
, the issue is larger than Maroon. There is growing evidence that ImPACT is expensive and unreliable and — to get straight to the prompt of Udall's hearing — preys on the fears of parents, as well as the liability jitters of educators, while providing a false sense of security.

Unfortunately, Udall seems intent on getting to the nitty-gritty later rather than sooner.

21 October 2011..........

A popular new reform is the call for “independent neurologists.” However, there is no such thing as a medical authority empowered to make return-to-play decisions, especially within games.

The Philadelphia Eagles maintain that an “independent neurologist” cleared Michael Vick before the October 6 game against the New York Giants, but refuse to name him or her. Last Sunday, Vick got “dirt in the eye” and “the wind knocked out of him” against the Washington Redskins.