Concussion Inc. Read online

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.9

  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.”10 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.”11

  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.

  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 Oc
tober 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.