Concussion update: Paul George and the NBA

This panoramic view shows the Chicago Bulls banners hanging at the United Center.

This panoramic view shows the Chicago Bulls banners hanging at the United Center. Yes, the Bulls are successful and will rise again and yes, I am a fan of Da Bulls.

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:

  1. Head trauma should set off alarm bells. The stimulus alone is cause for concern.
  2. 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.
  3. 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.
  4. 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.

 

 

 

10 Comments »

  1. Completely agree with your assessment. Wish you could/would develop a global group of medical experts who could get media attention to fight for future athletes re : head trauma protection. I am a bicycle rider and read a recent article in Bicycles Magazine about the development of new technological design called MISP in bicycle helmets. I plan to purchase a new helmet with this new design. I am currently auditing your Neurobilogy Coursera class. It is wonderful and I especially love your enthusiasm. You are exceptional!

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    • Thank you for your very kind comments. Biking is a sport where equipment can make a huge difference in protecting the cranium. I learned from a twitter follower (Gareth Craze) that rugby has fewer concussions than American football because of methodology rather than equipment. Rugby players are taught to tackle using wrestling moves and tackling must involve use of the arms. I guess that tackling with the shoulder is where the problems come in.

      In any case, it is unfortunate that biking is so dangerous and I hope the new helmet helps.

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  2. This topic resonates with me now more than ever, and I appreciate you choosing it. I work as a Paramedic in Pittsburgh, PA and recently (April 30th) had a patient repeatedly strike my head off a concrete sidewalk for about 2 minutes. A one minute loss of consciousness occurred. After regaining consciousness, I felt fairly ok. I was somewhat disoriented, but mostly I was livid at what had just occurred. There was a few hour delay before I really began to feel the effects. I became extremely tired, developed nausea/vomiting, had a severe headache, and noticed visual and auditory disturbances among other things. I was rather certain it was a concussion but nonetheless took a trip to the ER. Scans were all clear (certainly a plus). But, I was aware that my concussion was still quite present. Per policy, I had to follow up with a worker’s comp doc. We also have access in our area to a concussion clinic run through UPMC. My worker’s comp doc told me to do nothing for 10 days, other than rest any time I felt tired. I like naps. I understand rest is good. But after day 5, I felt like I was getting worse. Still, I followed her orders. Fast forward to the follow up visit 10 days later. “You can hold a conversation, and you passed a cranial nerve test. I’m sending you back to work.” HAHAHA. Thankfully, I have also passed a 12 month first aid class (paramedic program) and can read beyond a 2nd grade level to know that the doc’s answer was unsatisfactory. So I took it upon myself to make an appointment at the concussion clinic, of which she (doc) did not approve. (The concussion clinic is full of some ridiculously knowledgeable neuropsychologists. But according to her, they’re not real doctors.) Fantastic fella there assessed me with some pretty stellar (and very well researched) cognitive tests, and we had a nice little chat about – wait for it- how I’m actually feeling! Woah, what a concept! I failed the tests miserably, and the wonderful neuropsychologist suggested at least 6 weeks off with some different types of therapies incorporated in as well. (Reality of 8 weeks or more – due to the obviously unpredictable volatility of my job and the likelihood of another noggin’ thump occurring). Since I’ve probably already bored the readers, I’ll make the rest short. Comp doc didn’t approve the concussion clinic, so now what little amounts of progress I had made are no longer occurring; all of my energy and mental capacity are being ushered into legal nonsense (and writing this reply because I love your blog so much).

    Any other info you have, or websites/books/journals that you’d like to recommend, would be appreciated. Not only for myself, but also for me to pass along to the comp doc who seems to think we’re still in the 70’s when it comes to concussion treatment.

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    • Your story just burns me up. Maybe not as much as it burns you but quite a bit nonetheless.

      I hate to malign neurologists as a group but I am because neurologists as a group have failed to acknowledge their ignorance regarding head trauma. I am not an MD but as an informed outsider, I don’t see that the word concussion has much meaning. Blows to the head should be treated as concussions are now – with rest from ordinary activities. Furthermore, why is the brain treated differently from the rest of the body. When are bruises the worst? The day after the injury when the tissue has had a chance to swell. Physicians of other ilks know this but neurologists are taking a picture right away? Neurologists’ (and ER and other MDs trained in the neurology model) disdain for neuropsychologists is another sign of modern medicine’s belief in molecules over behavior. However, to me, behavior is the most reliable – not the most dismissible – output of the brain. We should look at behavior and look very carefully as the neuropsychologist at the concussion clinic did for you.

      Finally, while I teach medical students, I am not a physician. Therefore I would not be listened to any more than would the neuropsychologist that you saw. This is to explain why I cannot answer Ken’s plea to assemble a group of medical experts. I would not be considered one and I am not, just a very concerned and moderately informed outsider. I just wish neurologists would be more open to their ignorance about head trauma.

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  3. This is a HUGE problem, which doesn’t get nearly enough attention.

    There is a bunch of activity here at the University of Michigan, including study of high school football players.

    http://www.kines.umich.edu/movement-magazine/feature/new-faculty-member-brings-national-expertise-concussion-consequences

    Your point is so important and so obvious (if anyone bothers to think about it) — “behavior is the most reliable – not the most dismissible – output of the brain. ” It’s as though the establishment is treating brains as though they were bones or muscles…. [shaking head]

    I’m glad my kid was a swimmer!

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    • Thanks for the link. Study is important and data are key. Unfortunately facts have a funny way of not driving policy as much as people’s original views do. It’s hard to change people’s views with facts. See Change comes when some emotional magic happens and then more and more people start viewing the same facts differently. I hope that studies such as that at U Mich will contribute to the domino effect that leads to efficacious policy changes to decrease the incidence of sport-related head trauma.

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      • I agree that facts alone are not enough, but I think, sometimes, the facts have to be overwhelmingly unassailable before opinion begins to shift. I’m thinking about smoking……………. I remember getting on airplanes and having the airline magazine say “Sit back. Relax. Light up a cigarette.” !!!!!!!!! I never thought that opinion about whether it was ok to smoke everywhere, all the time, would change. I’m very happy I was wrong!

        (I’m also thinking about climate change, and am hoping we are about to experience a huge shift in opinion there……)

        Here’s info I just got this morning, about more research into concussion and head injury: http://record.umich.edu//articles/u-m-key-partner-national-concussion-research-initiative

        I noticed the “and head injury” and wondered if this addition has the same impetus as the shift from “global warming” to “climate change.” I suspect precisely naming the issue may often be part of becoming unassailable.

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  4. Hi Prof. Mason,

    Thanks for expressing & reinforcing this important viewpoint. I think most people and organizations really do place a high value on safety, and thus it is more a matter of education & awareness than anything else. In sports, we absolutely cannot rely on athletes to make this kind of call, because to be great competitors athletes are used to pushing past their limits, both physically & mentally.

    I do have one basic question, I hope it doesn’t sound silly: When someone suffers head trauma, why is it critical that they refrain from physical activities immediately? Is it a danger that they will receive another head blow that might greatly magnify the effect of the first trauma? Is it that they might suddenly collapse, causing other injuries? Is it because physical activity will somehow worsen the effect of the trauma (e.g. by increasing blood flow to the brain)? I suspect it is one or more of the above, but I’m not quite sure…

    Thanks!
    -Charlie Chung

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    • Hi Charlie, It’s not a silly question at all. And I don’t know why at a mechanistic level. But in the case of Will McKamey (see ), there was simply physical activity – no head trauma or impact at all reported – that preceded his death. Now that was on top of a history of a previous concussion. My assessment is that we don’t know what happens in the brain, to neurons and glia and in the extracellular milieu, after a head impact. But whatever happens appears to make at least some people more vulnerable to even just activity.

      I would disagree with your assessment that most people and organizations place a high value on safety. I wish it were so but I would argue that the evidence is that it is not so.

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