Concussion update: Paul George and the NBA
I was watching the NBA basketball game between the Miami Heat and the Indiana Pacers when Paul George fell down and suffered at least one blow to his head. I initially saw two blows – one when Dwayne Wade’s knee hit the back of Mr George’s head and one when Mr George’s head hit the floor. Upon looking at the play again on YouTube, Mr Wade’s other leg also hits Mr George’s head with what is at least a glancing blow. The broadcast of the game went quickly to commercial (after a handful of replays) and I turned off the game. I learned the next day that Mr George returned to play. A YouTube video shows Mr George holding the back of his head while walking back out to the court, giving the impression that Mr George went immediately back onto the court after the injury.
The NBA Concussion Policy Summary states:
“If a player is suspected of having a concussion, or exhibits the signs or symptoms of concussion, they will be removed from participation and undergo evaluation by the medical staff in a quiet, distraction-free environment conducive to conducting a neurological evaluation.”
I want to consider two textual points in this excerpt from the short “Evaluation and Management” section of the Policy. The first is “If a player is suspected of having a concussion”. Watching from home, I suspected that Mr George had suffered a concussion. I find it not-believable that the possibility of a concussion did not occur to the Pacers medical staff, if not the coaches themselves. So let’s assume that at least one person on the Pacers staff suspected that the head blow that Mr George suffered may have caused a concussion.
I note that the NBA policy does not state who is doing the suspecting. The policy is stated in the passive voice. Failure to assign responsibility for concussion oversight may imply a shared responsibility among all staff but is realistically likely to lead to a pass-the-buck attitude, culminating in no one taking ultimate responsibility.
The second textual point is that the NBA policy states that an “evaluation by the medical staff in a quiet, distraction-free environment” must occur when a concussion is suspected. I don’t know whether Mr George returned to the court immediately after the commercial break as suggested by the YouTube video. For that matter, I don’t know whether he ever left the court. The video makes it appear that Mr George remained on the court during the timeout. This is not a brain-respectful approach.
It appears that the Pacers medical staff asked Mr George some questions which he answered to their satisfaction. Regardless of where this inquisition took place [courtside or locker room], what information was used that resulted in Mr George returning to the court? News reports inform us that Mr George said that 1) he lost consciousness briefly after hitting his head; and 2) he suffered from blurry vision for the remainder of the game. The video record provides evidence that the back of Mr George’s head hurt. So for those of you keeping score at home that amounts to three signs of a concussion. Yet Mr George returned to play. This is in violation of the NBA policy, “If a player is diagnosed with concussion, he will not return to participation on that same day.”
Let’s review the facts:
- There was a blow to Mr George’s head.
- The back of Mr George’s head hurt.
- Mr George briefly lost consciousness.
- Mr George suffered from blurry vision.
The first two facts are ones that all could see. The blow to Mr George’s head alone raised suspicions of a concussion in countless viewers around the world. Yet, the Pacers organization did not even “suspect” that a concussion had occurred until the second two facts were reported by Mr George long after the game was over. Why didn’t the Pacers organization suspect a concussion immediately? Apparently, because when the Pacers staff talked to Mr George just after the injury, Mr George did not report any signs of a concussion, including the two cardinal symptoms that he later admitted to having experienced. And the Pacers accepted this Pollyanna version of events from a man whose head was just hit very hard and who was playing in a personally very important game. Hmmmmm.
The conflict of interest inherent in letting an athlete be the arbiter of his or her health and ability to play on is staggering. Using an athlete’s self-report to judge their ability to play is akin to trusting a restaurant to make their own health inspections and give themselves a time-out if they find any violations.
Many may think that Mr George’s motivation to play is financial and indeed his salary is astronomical. Yet NBA players under contract get paid whether or not they play in any one game and whether or not they are injured. I believe that the real motivation for an athlete to lie is in order to play, to get back into the game. Athletes want to play for the fun of sport. The playoffs surely added to Mr George’s motivation. But I think that at the root is the fact that Mr George, like people everywhere, want to play games.
What exists to counteract an athlete’s strong desire to play? The knowledge that concussions are dangerous and can seriously impair long=term brain health. Yeah, dream on. As I have discussed in a previous post, future events are discounted heavily. And bad health in the future due to a blow to the head today is not a sure thing; rather it is a possibility. Faced with the immediate possibility of playing and possibly being the difference-maker in a playoff game, the far-off and heavily discounted possibility of eventually developing dementia or Parkinsonian symptoms has no chance. As Eric Freeman writes, other NBA players including the superstar LeBron James, explicitly say that they would lie to continue to play after suffering concussion symptoms: “I think all of us would have played through it under the circumstances.”
The system for detecting and managing head trauma in athletics is deeply flawed. The head that undergoes a forceful blow or a rapid acceleration or deceleration is in danger of reacting badly. An adverse reaction to head trauma may become evident in minutes to days – in which case we call it a concussion – or symptoms may not appear until years later in which case we call it chronic traumatic encephalopathy (CTE). In either case, the resulting neurological problems are serious and life-altering.
So here is my manifesto:
- Head trauma should set off alarm bells. The stimulus alone is cause for concern.
- We must not wait for self-report of symptoms (particularly when a self-interest in continuing activities exists). An interview with even the most compliant individual may not reveal a very real, even severe injury.
- We must not wait for evidence of brain swelling on a medical scan. The adverse reaction can be biochemical rather than structural, microscopic rather than grossly apparent.
- Treat all head injuries with a time-out from regular activities. Play it safe with your brain – assume that head trauma has altered operations inside the cranium.
I feel very passionately that the standard management of concussions must be changed to accurately reflect our levels of knowledge and ignorance about the sequelae of head trauma. Professional athletes make the news but head trauma happens to huge numbers of young athletes as well as people injured in car accidents and various mishaps.How we approach head trauma is important to all of us. The next person affected could be our grandmother, brother, niece or best friend.
On this blog I keep coming back to the topic of concussions just as Piers Morgan kept coming back to gun control before getting the axe from CNN. Of course, I don’t have anywhere near the reach of Mr Morgan. The one advantage of my obscurity is that I can continue to shout from my molehill of a pulpit without anyone stopping me. Hopefully some of you will listen.