Concussion Inc. (13 page)

Well known but not well reported is the fact that a number of team physicians, or the institutions employing them, have tangled financial relationships with their clubs. These call into question their ability to provide down-the-middle player diagnoses and return-to-play prognoses.

For example, the University of Pittsburgh Medical Center is a corporate sponsor of the Pittsburgh Steelers, in addition to being its preferred health care and sports medicine provider. (UPMC has the same relationships with University of Pittsburgh sports teams, but those are intra-­institutional and more intuitive.)

NFL spokesman Greg Aiello told me that sponsorships do not compromise medical care: “League policy is that team hospital, medical facility, or physician group sponsorship cannot involve a commitment to provide medical services by team physicians.” Aiello also pointed out that Article 39 of the new collective bargaining agreement (CBA) with the NFL Players Association details “Players' Right to Medical Care and Treatment,” stating: “The cost of medical services rendered by Club physicians will be the responsibility of the respective Clubs, but each Club physicians' primary duty in providing player medical care shall be not to the Club but instead to the player-patient.”

The CBA does seem to attempt to tighten the principle that a team physician's primary duty is the care of the player, regardless of contractual relationships with teams outside the four corners of the medical-services contract itself. As a pro football beat writer put it to me, “All players are allowed to choose their own surgeons for surgeries, but clearly teams like when players use the teams' docs.”

The NFL's position is that there is no linkage between ­sponsorship contracts and medical services. But breaches of the league's ­professed new culture of “concussion awareness” and extra caution reach ever-more-­farcical levels. Heavily lawyered verbiage on doctor independence and true Hippocratic independence are not one and the same.

24 October 2011..........

Mark Lovell — consultant for the NFL and WWE, director of the University of Pittsburgh Medical Center Concussion Program, and co-owner of ImPACT Applications, Inc., the Pittsburgh-based company that markets concussion management software — may not have disclosed financial conflicts of interest in grant applications to the National Institutes of Health over the past decade.

The substance of the applications themselves is accessible online, but the module relating to conflicts is blocked under old NIH rules. Those rules were recently revised to make conflict disclosures publicly viewable on grants moving forward.

Lovell has not responded to an email requesting clarification of his conflict disclosures. Susan Manko, the UPMC media relations specialist on sports concussions, has not responded to the same message, or to a fax or phone messages.

Examination of NIH's online database shows that between 2002 and 2005 Lovell was listed as the project leader on at least four grants from the federal agency for research on sports concussions and fMRI (functional magnetic resonance imaging). These grants totaled more than $2 million: $538,499 in 2002; $554,652 in 2003; $571,292 in 2004; and $588,429 in 2005.

We already know that Lovell (a Ph.D. neuropsychologist, not a medical doctor) was the NFL's director of neuropsychological testing at the same time his company was selling testing software to teams. This new development raises the additional issue of whether undisclosed financial conflicts supported Lovell in securing public funding to underwrite research and development for a for-profit company, ImPACT Applications. (ImPACT stands for immediate post-­concussion assessment and cognitive testing.)

Lovell joined UPMC to coordinate the efforts of, among others, Maroon (then vice chair of neurosurgery, as well as Pittsburgh Steelers neurosurgeon) and Charles Burke (an orthopedist who was team physician for the Pittsburgh Penguins hockey team). Another charter program staffer was non-M.D. neuropsychologist Michael Collins, who had published a multi-part, multi-site study of concussion effects and return-to-play evaluation methods in the
Journal of the American Medical Association.

Asked about NIH conflict-of-interest disclosure policies, the NIH Office of Extramural Research said, “Investigators are expected to disclose their significant financial interests to their institution.” However, at the time of these grants, those disclosures were not part of the records released to the general public on request.

28 October 2011..........

A program entitled “Town Huddle: Concussions in Sports” was scheduled for next Tuesday at the Western Pennsylvania Sports Museum in Pittsburgh. The event (co-sponsored by the University of Pittsburgh Medical Center, ImPACT Applications, Inc., the Western Pennsylvania Interscholastic League, and television station KDKA) has been postponed until further notice — “due to some scheduling conflicts,” a museum spokesman told me.

I was especially amused by the note, “High school athletes are encouraged to wear their jerseys or team colors.”

Panelists were to have been Andy Russell, a linebacker on the Pittsburgh Steelers 1970s Super Bowl teams, plus the Big Three of ImPACT: Dr. Joe Maroon and his UPMC/NFL/WWE business partners Mark Lovell and Micky Collins.

31 October 2011..........

The chairman of the Senate commerce committee — which twice failed to mention Dr. Joseph Maroon by name at obvious junctures of its October 19 hearing on sports concussions — was the recipient of a $2,000 campaign contribution from Maroon in 2007, Federal Election Commission records show.

During discussion of the Riddell claim that its Revolution helmet reduced the risk of a football concussion by 31 percent, Senator Tom Udall of New Mexico noted that this figure came from an article published in the February 2006 issue of the journal
Neurosurgery
. Udall went on to explain that the co-author of the article had told the
New York Times
that he disagreed with Riddell's use of the 31 percent figure without also acknowledging the “limitations” of the study.

That co-author of Riddell's study, unnamed by Udall, was Maroon.

Later in the hearing Udall
did
name Tim Bream, head trainer for the Chicago Bears, as someone who had spoken favorably of the Riddell Revolution helmet in one of its promotional videos.

Udall also gave Maroon a pass on his endorsement of the supplement Sports Brain Guard, whose marketer claims that it “protects against concussions.” Earlier this year, as reported here, the company's website, SportsBrainGuard.com, included a photo of Maroon and a testimonial quote from him. He is no longer there.

Maroon donated $2,000 to Rockefeller on May 29, 2007 — the largest of Maroon's four most recent campaign contributions totaling $4,500. The others were, in 2010, $1,000 to Joe Manchin, West Virginia's other U.S. senator, and $500 to Senator Arlen Specter of Pennsylvania (who is no longer in office), and in 2011, $1,000 to Senator Orrin Hatch of Utah.

According to the database maintained by the Center for Responsive Politics, Maroon over the past 20 years has contributed to various politicians, the Democratic National Committee, and the American Neurological Surgery PAC. One of Maroon's employers, the University of Pittsburgh Medical Center and its corporate parent UPMC Health Systems, has spent millions of dollars on Washington lobbying.

According to the Sports Brain Guard website, the product was created by Dr. Russell Blaylock and developed by Newport Nutritionals, a company based in Irvine, California. There is no contact information listed for Blaylock either at his personal website (RussellBlaylockMD.com) or at the Sports Brain Guard site.

1 November 2011..........

In a finding that exposes just how aggressively, misleadingly, and ­perniciously ImPACT concussion management software is being marketed,
Concussion Inc.
has uncovered ImPACT and University of Pittsburgh Medical Center documents advising potential purchasers that not even baseline neurocognitive tests are needed in order to safely use their expensive, for-profit product.

Baseline testing is the holy grail of “concussion awareness.” The evidence of its fraudulence, as usual, is hiding in plain sight. Examples:

• In talks at medical conferences, neuropsychologist Jamie Pardini of the UPMC Concussion Program discusses “How I Manage Concussions.” At
  Muchnick.net/pardini.pdf
  , you can download a PDF file, which appears to include slides shown to the audience, perhaps a PowerPoint presentation. Look at slide number 8, “Clinical Protocol: Neurocognitive Testing.” The first point on the timeline, pre-concussion, states, “Baseline Testing (Not necessary for decision making).”
  
• The lead story of the December 2005 issue of the
  CIF News
  , the newsletter of the California Interscholastic Federation, was a promo for ImPACT under the headline, “ImPACT Technology Ensures Safe Return to Play After Concussion.” The article was written by the company's director of sales and marketing. It states, “[I]n the event that baseline testing is not possible, ImPACT has a normative database of thousands of non-injured athletes, and such data can be used effectively for adequate comparison and deciding safe return to play. Thus, ImPACT may now be used effectively in a clinical setting when baseline data is not available for comparison.”
  
• ImPACT Applications, Inc.'s own website tackles the question head-on (so to speak). Here's the explanation from the FAQ page (ImPACTtest.com/faq): “Yes, the program can, and should, be used even without a baseline. In the report summary scores (composite scores), the norms are printed out and automatically tabulated. The raw score is accompanied by a percentile which indicates where they fall relative to healthy age and gender-matched controls. For example, if the composite score falls at the 5th percentile … that would indicate 95 out of 100 non-concussed individuals would perform better than the athlete that is being tested. By understanding their pre-injury status, this data can be extremely informative and helpful. For example, a typical A/B student should be around the 60th percentile or higher on all composite scores, those that are C students should typically fall around the 40th percentile or higher and those with learning disability or very poor students could fall as low as the 20th percentile or so and be considered within normal limits. We use the program all the time without baselines and the data is very helpful for clinical management.”
  

I don't think UPMC and ImPACT would be able to find many, if any, experts who were not already on their payroll who would be willing to assert that a “normative database” could responsibly substitute for individual baseline tests. Young people's brains are still growing and changing, and their responses to standardized tests fluctuate year to year, even month to month, with variances that make the UPMC and ImPACT claims here almost criminally unsupportable.

All this does not even to get to the general flaws of subjective neurocognitive tests, which have already been widely discussed: the reality that test-takers sandbag the baseline tests with deliberately dumb answers and boost their scores on repeat tests with the help of Ritalin.

30 November 2011..........

The National Institutes of Health yesterday fulfilled my Freedom of Information Act request and supplied five documents from the University of Pittsburgh Medical Center's multimillion-dollar grant application and progress reports on concussion research for the period 2001–06.
12

This is no mere underwriting of purchases of lab equipment or travel to scientific conferences. It is a major subsidy, including compensation breakdowns, for a monumental public health study. The grant shows tens of thousands of dollars of annual remuneration for Mark Lovell, Dr. Joseph Maroon, Micky Collins, and others.

As noted previously, the NIH conflict-of-interest disclosure by UPMC is not included with this document release. The federal rules put the control of the public release of that disclosure in the hands of the grant recipient itself.

One of the more intriguing loops left unclosed by this release is: What happened at the back end? Did UPMC ultimately report out conclusions from its fMRI study?

28 February 2012..........

Neurosurgery
has published a new paper claiming that healing time from a concussion now can be predicted with more precision. Remember that
Neurosurgery
is a virtual house organ of the NFL and historical repository of canned, cooked, and unethically produced articles on traumatic brain injury. UPMC today put out a press release:

The study, one of the first to examine concussion prognoses, showed that specific neurocognitive “cut-off” scores derived from ImPACT™ (Immediate Post-concussion Assessment and Cognitive Testing) improved clinicians' ability to predict which sports-related concussions could take longer — as much as five times longer — to rehabilitate than others. They found, in as many as 85 percent of the cases, the scores could warn athletes, parents, coaches, schools, teams, and health professionals when a concussion is likely to take on average a month to heal.

Micky Collins, the UPMC program director who co-owns the for-profit ImPACT Applications, calls the study “a game-changer” because it augurs “a way of determining within two days of injury who's going to take a month or longer to recover.”

Meanwhile, in the neglected common-sense wing of youth concussion research, another journal,
Brain Injury
, has published a paper by Université de Montréal neuropsychologist Dave Ellemberg buttressing the intuitively obvious case that teenagers are far more vulnerable than adults in this area. Furthermore, Ellemberg says, a first sports-related concussion “will result in six months to a year of neurophysiological side effects for adolescents, adults, and children alike.”

29 February 2012..........

Pittsburgh is the national capital of Concussion Inc. — and proud of it!