Chaney: Football’s Legal Fire

24 Apr

Matt Chaney has written on the issues surrounding football – legally – mainly at the juvenile level.  In this lengthy blog post (found HERE) Chaney talks about;

  • Football Lawsuits Surge Against Schools
  • Court Defenses and Safety Concepts Hardly Shield Juvenile Football
  • ‘Concussion Testing’ Unlikely to Prove Valid in Court as Diagnostic
  • Various Injuries and Issues Pose Legal Bombs for Juvenile Football
  • Should Juveniles Play Tackle Football in America?

As with about everything that Chaney has produced it is WELL WORTH the read and time.  Below is the topic on the “concussion testing”, I have taken the entire chapter with permission from Chaney;

Many well-publicized experts, led by neurosurgeon Dr. Robert Cantu and North Carolina professor Kevin Guskiewicz, designate written and computerized neuropsychological testing as legitimate standard of care for cerebral injury in American football.

The claim is contentious and central to the divide between those authorities who believe “safe” football is possible versus those who disagree. The latter side ranges in mindset from mildly optimistic for positive reform to the belief no need exists for the sport, especially where kids are concerned.

The side pro-concussion management is led by commercial developers of testing, “football experts” with MDs and PhDs—supported and promoted by the NFL, NCAA, public schools and youth leagues—who contend their studies validate intuitive-based assessments for detecting brain injury among athletes.

For the burgeoning service industry of brain trauma in sport, so-called concussion testing leads technologies in marketing.

The No.1 product, computerized ImPACT, has racked up thousands of sales for millions of dollars based on a wide public trust—even if without a page of independent literature affirming diagnostic quality.

“Concussion testing” is the popular remedy to crisis in football, touted as solution by news media, coaches, school administrators, game officials, trainers, physicians, researchers, educators and politicians.

But NP assessments have not faced court scrutiny to-date while attracting an impressive opposition that grows louder.

No longitudinal study supports the methods and instruments as valid and reliable for diagnosis and return-to-play assessment, and though developers promote the product as “Valid. Reliable. Safe.” their fine print states concussion testing should only be one tool of a multi-faceted protocol. ImPACT developers have ignored my requests for interview.

If anything of real record, concussion testing accumulates denouncement, led by informed critics and a decade of negative peer review.

In the military, officials and insurers say the computerized test ANAM lacks independent validation, and some suggest it a failure. The tool “is insensitive and nonspecific,” Lt. Gen. Eric Schoomaker, Army surgeon general, told lawmakers. “It misses about a quarter to a third of (soldiers) who are concussed and includes about 50 percent of (those) not concussed.”

Christopher Randolph, professor of neurology at Loyola University, has compiled unfavorable reviews on NP testing of athletes for years, recently finding faults in “baseline” testing of ImPACT software—designed and marketed by associates and a physician of the NFL, neuropsychologists Mark Lovell and Micky Collins and neurosurgeon Dr. Joseph Maroon.

“The use of baseline neuropsychological testing in the management of sport-related concussion has gained widespread acceptance, largely in the absence of any evidence suggesting that it modifies risk for athletes,” wrote Randolph, detailing unacceptable ImPACT rates of false-positive and false-negative results for his 2011 article in Current Sports Medicine Reports.

Dr. Bennet Omalu, pioneer football neuro-pathologist, said ImPACT testing is “a fraud” as concussion diagnostic, criticizing anyone claiming it a quick fix, ranging from marketer to politician, for epidemic brain trauma in the game.

“ImPACT testing is not a diagnosis tool,” Omalu, chief medical examiner of San Joaquin County, California, said in a phone interview. “It is a forensic follow-up to monitoring a patient, to evaluate the amount of damage. Using (computerized) testing in the acute phase of injury can actually make the symptoms worse. Am I making sense?”

Journal reviewer Dr. Lester Mayers cites lack of specificity and sensitivity of NP products on mass market. “Basically, they’re all unsuitable for clinical work with concussions,” Mayers said, estimating 20 to 25 percent of afflicted athletes are missed.

The public rhetoric and expectation of ImPACT for solving football’s head injuries, much less protect game personnel in court, leaves independent experts confounded.

“The response is infantile,” said Mayers, director of sports medicine for Pace University Athletics, during a phone interview. “The ImPACT people have taken over the idea that somehow they can tell you when it’s OK that the athlete goes back.”

Insurers see problems already, before a possible trial test like the pending Dougherty family lawsuit. Some insurers determine computerized concussion testing raises liability risk for schools and personnel and decline to underwrite the practice, for concern of either misuse or faulty technology.

Most recently, a statement of the Army Surgeon General’s Office reads in part: “the scientific community has yet to identify an objective biomarker or other test that accurately determines when the brain has completely healed from the concussion.”

State governments stop short of explicitly mandating suspect NP testing for school athletics, among anti-concussion laws passed nationwide. Indeed, politicians know a large portion of juvenile football cannot afford the purchase and employ of software applications.

The typical statute does present an implied standard of intuitive-based brain assessment, serving society’s predominant goal for quickly returning injured athletes. But politically charged perception of effectiveness, buttressed by media and echoed by law, does not guarantee proving validity or even reasonableness of concussion testing in court.

And critics deride new measures as minimalist, anyway, except for effecting increased liability risk and caution around contact sports. The laws’ commonly broad language require removal of a presumed symptomatic competitor until clearance by a general practitioner or lesser technician, most assuredly involving NP testing.

Resultant practices in juvenile football are less than ideal overall, or legally inadequate, according to follow-up reviews and observations.

Many athletic trainers do not understand or want to employ computerized assessments like ImPACT while many physicians feel challenged or reluctant as well.

Dr. Charles Tator, Canadian neurosurgeon and researcher on sport-related brain trauma, emphasizes no objective assessment protocol exists, much less a user-friendly model employed in minutes on an acutely concussed athlete who cooperates and reliably self-reports.

“The best method of assessing the effects of a concussion is through a trained observer, a trained physician and a compliant patient. If you have a physician who isn’t trained and a patient who does not want to be compliant, you get nowhere,” Tator told The Toronto Globe and Mail.

“There are two types of cognitive tests. There is the interactive test—20 minutes, $50—where you come up with a numerical score as a baseline and redo half-way through the (athletic) season and see the difference. Sounds good on paper, but does it work? We don’t know the answer. Some doctors and experts rely on these tests, while others say they’re unproven.”

“I’m somewhere in the middle,” Tator continued, “but I know this: I rely on formal, neuropsychological testing, by which I mean a few hours of a neuropsychologist’s time to assess a player’s cognitive functioning. It’s very costly, unfortunately, so you can’t apply it to everybody.”

In American sports medicine, authorities tell me that many neurologists cannot handle concussion in athletes until years of acquired experience, extensive trial-and-error along sidelines.

Even Dr. Cantu, NFL brain researcher and drafter of NP testing format, a foremost promoter of “concussion management,” an authority trusted by millions of parents and children in American sport, had to acknowledge in late 2010 that “the majority of physicians who are in practice today would not be qualified to manage athletic concussions.”

All sum, “concussion testing” likely cannot prove effective and defensible as a “reasonable” standard of care, per tort definition, for tackle football organs and personnel in America.

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39 Responses to “Chaney: Football’s Legal Fire”

  1. A Concerned Mom April 25, 2012 at 08:55 #

    Chaney’s writing is always very thought provoking, and as Dustin said, well worth reading.

    Our school corporation uses ImPACT testing for high school athletes, and perhaps even middle school. Even if ImPACT isn’t all it’s claimed to be, I can’t help but wonder if it creates a potential problem for school systems which don’t require the same level of care for younger athletes. It’s my understanding that our school corporation believes it can only be held liable for any injury sustained at the bantam football league level if the injury results from a failure to adequately maintain facilities (don’t know if this has ever been tested in court). High School Football players not only take a baseline ImPACT test, but they have access to an athletic trainer (and I heard the athletic trainer set some limits on full contact practice), and an ambulance is at home games. All high school and middle school athletes are required to have a sports physical on file.

    In comparison, the bantam program didn’t provide any concussion information at all (a parent meeting was held, but health and safety issues were not addressed), the players weren’t required to submit sports physicals (which would have provided the pediatrician with an opportunity to address the risks of concussions with the parent), and they had no access to an athletic trainer. When injuries started to occur, it was difficult to get anyone to address the possible equipment and coaching issues which were contributing to them (which I perceived as a lack of motivation stemming from a lack of accountability).

    Even though some experts question whether or not children under the age of 14 should be allowed to play football, school systems and lawmakers, in some instances, seem reluctant to require youth leagues to meet minimum standards of care, because they are run by volunteers and there are resource limitations. As a parent, once I started reading online after my eight-year-old was concussed at practice, I was appalled by the lack of care exhibited by the school corporation, the bantam board members, and coaches for the children in their care.

    In fact, I find myself appalled whenever I read about lawmakers, church groups, and the YMCA fighting against the application of youth concussion laws to young players. Considering that my son’s coaches didn’t even bother to stop practice when he was clearly injured, I say even though coaches at the youth level tend to be volunteers, they need some incentive to do the right thing. I believe that with appropriate training, most volunteer coaches would try to do the right thing, perhaps with the exception of football, where it may take the culture some time to change – just read Dustin’s mailbag post for confirmation on the cultural problems.

    On a separate issue, I can’t help but wonder, what’s going to happen if a student athlete’s ImPACT scores after an injury don’t return to baseline. Is it possible that the athlete’s parents may attempt to take some action against the school for sponsoring a sports program which resulted in a measurable decline in the student’s cognitive abilities? What types of reactions have doctors and athletic trainers seen from parents when ImPACT scores don’t return to baseline?

  2. Jake Benford April 25, 2012 at 10:41 #

    The concerns you raise are spot on. This is why so many of us are pushing to have full contact football be eliminated until 1) the athlete is older and 2) the program has enough money to have medical personel on site, ie: hight school.

    Unfortunately, in my experience, the reaction from parents so far is push back, wanting to get their kids back before they are ready. I often have to ask them if I told them their child had a heart injury, would they still be questioning the medical staff.

  3. Educator Mom April 25, 2012 at 12:04 #

    I think ImPACT testing has to be a tool in the toolbox. And I have personally found that as my son’s Impact scores, so go his grades in school.The ImPACT test gives us another visual of what is going on his brain along with documenting symptoms and academic struggles in school.

    We need to keep educating and encouraging a multi-faceted approach to diagnosing and treating these brain injuries, especially in kids. And frankly, lets start using the words “brain injury” on a regular basis. The word “concussion” just seems to bring about complacency. There are too many kids whose lives are being unalterably changed because of a few minutes in a sporting event where the coach or parent did know enough or care enough to get them out of the game. I was having a conversation with my younger son about a book he was struggling with. I reminded him that his older brother had read that same book when he was several years younger. My son’s comment to me was, “But Mom, that was when he was smart.” The comment cut me to the core. If someone had taken his brother out of the game (wrestling match) after the first blow to the head instead of the third, maybe his life would no be so changed. How many more times will stories like this have to happen before we learn…

    • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 25, 2012 at 21:07 #

      My graduate training and related applied clinical experiences emphasized that an adequate neuropsychological assessment requires the utilization of a comprehensive battery of reliable and valid tests.

      Unfortunately when computerized screenings are discussed re brain injuries, many lay persons and professionals are not aware that:

      1- The computerized test mentioned above by Educator Mom is a screening device and NOT a thorough neuropsychological assessment.

      2- A review of professionally/peer reviewed and published literature previously cited on this Concussion Blog has raised significant concerns re the reliability and validity of such computerized screenings.

      3- Computerized screenings are neither sensitive to all the subtleties of a brain injury/concussion nor are they comprehensive in nature…that is, the SCREENINGS are not thoroughly assessing the 3 major brain functions: cognitive, emotional and physical.

      4- My PhD in the area of Clinical Psychology was completed during 2004. The below 4 quotes (i.e.; A, B, C, & D) are citations from my 2004 Dissertation entitled:

      A Preliminary Investigation of Active and Retired NFL Players’ Knowledge of Concussions

      A) “In an extensive review of research pertaining to mild brain injury, Reitan & Wolfson (2000) strongly cautioned that many researchers who have examined mild brain injury have typically not employed comprehensive neuropsychological test batteries in their methodology. The authors perceive this as a major flaw in evaluating the impact of mild brain injury, because they firmly believe that standard neuropsychological test batteries have frequently been shown to be sensitive to both focal and diffuse brain damage. They also pointed out that researchers typically have limited their assessment and focus due to a premature presumption that neuropsychological impairment is limited to a rather narrow range of deficits, and that a restricted range of tests is all that is required for adequate neuropsychological assessment. Our clinical experience suggests that mild brain injury produces diversified and even widespread neuropsychological losses in some patients (p.97).”

      B) “The medical evaluation component of a brain injury assessment is also highly suspect since typical medical assessment methods (i.e., neurology exam, EEG, brain-imaging techniques) utilized in determining adverse effects of mild brain injury are rather gross and insensitive, and thus false conclusions may be derived which report no neurological deficits were sustained (p.43).

      C) A similar perspective pertaining to false conclusions was shared by McClelland (1996) when he cautioned, “…the absence of evidence is not evidence of absence” (p. 566). This view was reiterated by Gronwall (1991), who stated, “…it is impossible to prove the null hypothesis. Failure to show a deficit does not prove that no deficit exists, and the neuropsychologist has a responsibility to make sure that appropriate tests for assessment are selected” (p. 257).

      D) Damasio (1994), during a case presentation in which he discussed a particular patient, also noted problems with tests not being sensitive enough to adequately measure brain dysfunction/ impairment; he declared that “a problem here lies with the test, not with the patients. The tests simply do not address properly the particular functions compromised and thus fail to measure any neurocognitive decline” (p. 41). In the same vein, through the devising of more sensitive and precise tests designed to further scrutinize concussions and the postconcussion syndrome, it is highly probable that an organic basis will be uncovered (Robertson, 1988).

      As I read and reflect upon perspectives shared within this Blog, I believe sincere individuals would benefit from becoming familiar with the contents of my 2004 Dissertation…which includes a snapshot of the evolution of concussion/brain injury knowledge that has existed in the professional literature for a significant period of time.

      • Educator Mom April 25, 2012 at 22:41 #

        As I said, the ImPACT test was one tool to help in the identification of our son’s concussion. He has also gone through a full battery of neuropsychological evaluations as well as speech, O.T. and P.T. The ImPACT test was used early on, along with actively monitoring physical and cognitive symptoms. When it became clear that he was not one of the majority who would recover within weeks, the other evaluations came into play. The team approach incorporating a variety of tools has been essential to his care.

        In our experience, the trouble has come when those who are unaware or uneducated don’t understand the tools or how they are helpful. We have found that to be true with our son’s primary care physician, his school administration, teachers, and school psychologist, not to mention friends and family. The school, in particular, seems to find fault with any evaluation. They finally capitulated to our request for a 504 12 weeks after we delivered the neuropsych report. And even then, they attributed the need for a 504 to “sleep disruptions”, not his concussion. And we have heard many comments like “just get over it”, “maybe he has developed ADD”, “he’s just being lazy”, and “his parents expect too much of him”.

        In short, I’m not sure it will matter what testing or evaluations we do until the sports and education community choose to educate themselves on the seriousness of this injury and the struggles these kids face.

  4. Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 25, 2012 at 23:19 #

    Am curious as to what specific standardized tests and other approaches comprised:

    “a full battery of neuropsychological evaluations” ? Thanking you in advance.

    • Educator Mom April 26, 2012 at 22:10 #

      Here is a list of the neuropsychological testing he has been through thus far: VMI, BASC-2, CPT-II, COWAT, D-KEFS: Tower Test, EOWPVT-4, GORT-4, Grooved Pegboard, NEPSY, Rey-Osterrieth Complex Figure, TOWL-4, Trail Making Test, WISC-IV, WRAML-2: Verbal learning subtest, WJ-3, Rivermead Behavioral Memory Test 3rd Edition. This testing occurred within the children’s neurotrauma clinic that has been treating him since his injury. This testing has been used as a tool along with observations from us, as his parents, and his teachers to help identify his post-injury cognitive deficiencies.

      The school itself has now opted to do it’s own evaluations and testing as we continue to seek support in the classroom for him. Although the school has a “TBI specialist”, I am not sure what his/her experience or training is in dealing with concussed adolescents. Thus I am not too optimistic about their testing or the outcomes that may come from it.

      • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 27, 2012 at 00:29 #

        Appreciate the assessment information.

        Please take time to think about the below requests.…

        If it is not being personal…an ok with both you and your son…

        1— Were these tests administered as one assessment or over a period of time?

        Were any of the tests readministered…if so, which ones and how many times?

        2— What strengths and weaknesses did the assessment findings reveal?

        3– I am curious how he performed on subtests that involved visual information processing skills…tests/subtests such as Block Design, Symbol Search, Trail Making, Rey-O…

        4—-What were the presenting symptoms that he initially displayed within the first several days after suffering the concussion, and perhaps continues to display?

        5—Re the school staff testing your son…were you provided with the names and descriptions of the tests and the option to decline the administration of these tests and employ your own private clinician?

        6— Does he generally experience atypically fatigue, have increased headaches, sensitivity to lights or typical ‘noises’/sounds, or difficulty with attention and sustained concentration and problem solving as the day progresses?

        7— How has his quality of vision (i.e., acuity, focusing, scanning, tracking, visual perception) been since sustaining the concussion?

        8—What has your family observed re your son that seems different since sustaining the concussion.

        Again thank you for your consideration.

      • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 27, 2012 at 05:59 #

        PS….Was any assessment of his emotional status conducted?

        (Hopefully this PS will post AFTER my other assessment response.)

      • A Concerned Mom April 29, 2012 at 09:31 #

        Dr. Brady,

        Thought you might be please to see some doctors addressing subtle personality changes after concussion.

        http://www.drdavidgeier.com/hidden-dangers-concussions/

        “He stresses that sports neurologists must utilize every tool at their disposal – history, neurologic exam, cognitive testing and comparisons to baseline tests, and assessments of personality changes. “All of them have to resolve and return to normal before the athlete can return to play.”

        Edwards points out that the personality changes are often the last symptoms to resolve, usually lasting much longer than headaches. Plus, they are often very subtle. “Unless we ask about these changes in personality, we would never even know.””

      • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 29, 2012 at 09:53 #

        Appreciate the emotional information…and url.

        In my Dissertation I recommended that concussions be called ‘subtle brain injury’ for many of the reasons that have outlined by various comments over time within this Blog.

        There is clear science to the emotional issues…as some persons adhere to the perspective that personality changes/influence are adversely impacted (pun intended) by damage to the frontal lobes.

        Phineus Gage’s well documented personality changes after sustaining a brain injury is an historic piece of concussion/brain injury history. Suggest you Google his name for more info.

    • A Concerned Mom April 29, 2012 at 12:18 #

      A three foot long tamping iron was blown through his brain, and although he “fully recovered,” his personality changed and he eventually had epileptic seizures. (I wonder if anyone claimed he was displaying maladaptive “sick role” behavior?)

      http://www.deakin.edu.au/health/psychology/gagepage/Pgstory.php

      “He was also impatient and obstinate, yet capricious and vacillating, unable to settle on any of the plans he devised for future action. His friends said he was “No longer Gage.””

      “In February 1860, he began to have epileptic seizures …”

      “He fully recovered from the injury …”

      • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 29, 2012 at 13:08 #

        Great article that capture Gage’s tragic post brain injury experiences !

        Railroad history during the 1800′s provides some of the historic background re brain injuiries / concussions. May I suggest the the following article for additional eye-opening info re concussion perspectives. Dr. Evans (a neurologist) has written several interesting & informative articles on concussions.

        Evans, R. W. (1994). The postconcussive syndrome: 130 years of controversy. Seminars in Neurology, 14, 32–39.

      • A Concerned Mom April 29, 2012 at 13:44 #

        I haven’t been able to find the article you referenced. I believe I found his website though:

        http://rwevansmd.com/Publication.html

      • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 29, 2012 at 20:26 #

        I obtained Dr. Evan’s journal article thru visiting my local medical library.

      • A Concerned Mom April 30, 2012 at 06:28 #

        Dr. Brady,

        Thank you – I assume I would need to see if it would be available at any of the nearby college/university libraries.

  5. BryanATC April 26, 2012 at 17:11 #

    Dr. Brady,

    Could you list the full battery of tests (specific) that you would propose that every person suffering from a suspected concussion should go through? Also, if you even know, please list what the corresponding costs would be for each of those tests.

    While the arguments surrounding ImPACT (and other similar computer based tests) remain, I think there is more to look at with this issue. The goal concerning concussions should be whether appropriate and adequate care is being provided to ensure a safe return to play following the injury.

    First, is a concussion protocol that includes baseline and post injury testing on a computer based screening program (as well as clinical evaluation) better than having only a clinical evaluation to go by?

    It appears some say that computer based tools are not appropriate, yet fail to get an alternative that is both cost effective and logistically feasible to implement on a large scale. There needs to be some sort of pre and post injury comparison and if something is too expensive or logistically complicated to implement then it won’t happen. If someone tries to convince me a baseline of some sort (no matter what type of test it is) is not needed, I will proceed to tune them out because there is no way ANY type of test is sensitive and accurate enough to determine what deficit there is “post injury” with something “pre injury” to compare it to.

    I’m not saying that a more complex and sensitive battery of tests is not a more complete diagnosis and evaluation of a mTBI, but it’s not always possible to do everything possible every time. I can’t believe that using a less sensitive test with the appropriate understanding that it is NOT the panacea concerning the injury is worse than nothing.

    If solution A is the old way of evaluating concussion….

    Solution B is adding a computerized screening tool for pre and post injury evaluation….

    Solution C is completing the more comprehensive and more sensitive tests clamored for by some (hopefully listed by Dr. Brady somewhere after this post).

    If Solution C is too cost prohibitive to enact, I’m not going to go back to Solution A when Solution B is a better standard of care. I don’t care how much someone says C is better than B, it is idiotic to not use B at all if possible.

    It is already a struggle to have the population take this injury more seriously. If we make the subsequent care so complicated and costly they’ll simply go back to ignoring it.

    So please Dr. Brady, if (from the way you talk) we should not even use computer based tools, tell me how what I should implement for my 1,000 contact sport athletes every year instead? (How much time and how much it would roughly cost would be nice as well if you know).

    Thanks

    • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 26, 2012 at 21:48 #

      May I suggest you reread and reflect upon my comments…and the professional literature that has been cited in present and past Blogs pertaining the significant questions re the reliability and validity of concussion screening instruments.

      • BryanATC April 28, 2012 at 10:47 #

        Dr. Brady, I’ve tried reading the plethora of posts you’ve made and I can’t come to a conclusion about what you do endorse (except in vague terms). I clearly know what you don’t endorse, but that doesn’t help those of us who are point people in treating this issue.

        Educator Mom listed 13 tests (that I would assume are more comprehensive and sensitive than a computer based NP test) and you come back with 8 issues you still apparently have with the testing her son has received.

        All of that testing and you still apparently aren’t satisfied.

        Why can’t you just give a simple list of what tests and evaluations you feel every individual suffering from a concussion should undergo? I’ll take your word that your decisions are based on documented research.

      • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 28, 2012 at 13:25 #

        Bryan,

        1– Posts are not tied to endorsing or not endorsing…just asking people to be aware of many flaws with assessments…and to not make an uninformed / inadvertently incorrect decision re the ‘perceived findings’. To me there is a science and an art involved with the assessing a concussion/brain injury.

        2—There are legal concerns to consider…
        if you as a AT clear a person to play related to a performance on a computerized test…or any other test…you may be held liable for the injury should the athlete suffer another concussion. If you are summoned to court…it will be common for attorneys to ask you what you know about the reliability and validity of tests used to clear a person for RTP. Then the issue of false positives and false negatives will arise… ImPact has been criticized in the professional literature for reliability and validity issues. Furthermore, the instrument attempts to screen a narrow area of brain functioning.

        Along the same lines, I would not be surprised to see your liability insurance increase since you are evaluating concussions/brain injury…and insurance companies will perceive this type of assessment as a risk assessment.

        2- Assessing a concussion/brain injury is complex and cannot have a cookie cutter type of approach…especially if you accept the premise that there are many faces of a concussion.

        3- Standardized testing may not be sensitive to detecting brain injury. As Lezak prophetically said during the last century…perhaps we will not know the true effects of a concussion until the brain is autopsied.
        And now the CTE findings are emerging!!

        Lezak and Reitan (cited below) have also argued that an assessment of brain injuries should incorporate a thorough and comprehensive evaluation of cognition, emotions and physical limitations. I concur with their perspective.

        (Reitan)
        a premature presumption that neuropsychological impairment is limited to a rather narrow range of deficits, and that a restricted range of tests is all that is required for adequate neuropsychological assessment. Our clinical experience suggests that mild brain injury produces diversified and even widespread neuropsychological losses in some patients (p.97).

        A thorough evaluation goes beyond self-reports…as Dr. House says…people lie…or perhaps more gently…minimize issues. I have found this statement to be especially true when evaluating emotional issues.

        4- Not finding a deficiency on a test/subtest does not mean there is no brain injury…as I previously quoted Damasio…the problem lies in the test not being sensitive to detecting the injury…and thus obtaining a possible false negative.

        5- Re the Educator Mother…my further questions were not asked because of dissatisfaction…but to more clearly comprehend what the specific assessment findings were…Due to the potentially sensitive nature of the questions and corresponding responses…a discussion with the Educator Mom is continuing offline.

        6- Please read and reflect upon the concussion writings of Gronwall, Evans and others cited in my wife’s, Flo, and my 2 sport-related concussion articles published by NASP online during June 2011. Also note that Gronwall wrote about the cumulative effects of sport- related concussions during the 1970’s.

        7- My knowledge of concussions has accrued from graduate training, applied clinical experiences, discussions with colleagues, a review of the literature, and my own personal journey with a ‘mild concussion’.
        My PhD research was the 1st study of NFL players’ knowledge of concussions. The Dissertation contains an eye-opening amount of historical references on the topic of concussions.

        8– I think we are battling a cultural issue that idealizes sport participation and normalizes injuries along with numerous interwoven conflict of interest (COI) issues…these variables overlap… and allow for certain persons/institutions to financial benefit at the cost of the athletic and disposable gladiator.

        Citation from my 2004 Dissertation re Conflicts of Interests (COIs):

        After reviewing differing perspectives pertaining to the ways COIs may bias scientific endeavors and resultant “scientific evidence,” an apparent caveat emerges when professionals and the general public over rely, or solely rely, on “scientific” and quantifiable test or medical findings. Voicing concern that human interests and related social forces influence “the direction and content of scientific research,” Martin (1979) specifically cautioned about accepting research being conducted under the cloak of “science” (p. 85). Martin also stressed the importance of recognizing the interconnection of “powerful, wealthy and prestigious social forces: government; large corporations; and universities whose research is also frequently funded by the prior two social forces.”

        Martin also interrogated science’s own biases, which were revealed when scrutinizing the “fundamental presuppositions underlying science,” (p.6) and also through scientific findings selectively employed to validate “a human interpretation of the [natural] world” (p.86).

        It should also be pointed out that the institution of sport has become intertwined with these social forces.

        9. If a parent places / allows a child / adolescent to participate in sports…money should be allocated to anticipate the possible need to pay for a comprehensive concussion/brain injury assessment. To me, the evaluation(s) become(s) an inherent cost of sport participation…as a concussion/brain injury may occur.

        10. I believe the prime purpose of the brain injury assessment should be to protect the overall health and well-being of the youth…not to primarily ascertain or assist in determining if/when the athlete should return to play.

        Hope the above response info is helpful..as I need to scoot to work…

    • Matt Chaney April 30, 2012 at 10:38 #

      Pardon me for sticking my nose back in the debate, but I want to clarify that my comment pushed down below, posted April 26 18:00 hours, is in direct reply to BryanATC and wholly in support of Don Brady. Indeed, there is no simple answer at this point, no cost-effective, logistically feasible prevention for any football hazard. A real “solution” is about as accessible as a Greyhound bus to Mars. Again, the legal experts and others pertinent whom I consult, or those whom you consult, will confirm THERE IS NO STANDARD OF CARE presently for alleged “concussion management,” and the typical mass-marketed NP tests have nil hope of proving, in court, to meet the mandated “reasonableness” standard for diagnosing and monitoring concussion. There is no objective standard or tools for diagnosis, no consensus definition of what “concussion” state even constitutes. The latest research strongly indicates brain trauma is often undetectable by any “symptom” and can remain months and longer–especially in children and adolescents. There are like 20 differing “expert” guidelines on brain injury, non-child specific, and not a single page of longitudinal data to back anyone’s theories–and yet guys like BryanATC poke at Don Brady. Talk to your football-buddy experts, dude, if you have a problem with vague, useless philosophy. Go ahead and trust them all the way to court; a judge or jury will understand experts like Don Brady perfectly… OK, I’m out again here, for long while I promise. Continue. Pick my carcass.

  6. Matt Chaney April 26, 2012 at 18:00 #

    Right, Don Brady is off base… NOTHING of risk prevention proposed by anyone in 140-some years of American football to date is worth squat, including “concussion testing,” “steroid testing,” “safe football,” “modern equipment,” “proper contact,” “heat safety,” “catastrophic injury research”—whatever. NONE has worked in the least to reduce stupid health risk, and foremost because the game environment is so bloated and ill-equipped. Any talk of “cost effectiveness” and “logistic feasibility” is ridiculous for law-mandated “reseasonable” medical prep and response. You cannot even afford to find and hire enough competent coaches. Until the American football environment reduces by at least 90 percent, until the game acknowledges all hazards up front, and until tight regulation is in place, NOTHING CAN PREVENT ANYTHING terrible. Gimme a break.

  7. Jake Benford April 27, 2012 at 00:40 #

    I feel like I am jumping into shark infested waters here, but here goes…
    As idiotic as it may be, football and other contact sports are not going away, especially not in this country. For all intense and purposes, the NFL has replaced religion in the US, and is quickly going global. If anything, participation will likely increase in the near future.

    So where does that leave Bryan and the rest of the front line corps trying to keep their athletes as safe as possible on a shoe string budget? Here is my answer, as another front liner;
    1) Educate as many as possible. The media is now helping this cause, but make yourself available to answer as many questions as possible, and make sure all of your athletes, coaches and parents know you head injury protocol, the rational behind it, and that it is not flexible.
    2) Yes, use your base line test, either paper or PC based, so that you have some comparison when you suspect a head injury, understanding that this is just one tool that we all use to help guild management.
    3) Recognize when someone is not recovering as predicted and make sure you have specialists that you trust to refer them to who can complete a larger, more time consuming and expensive battery of tests.
    4) Be an advocate for these student athletes when they and their family are getting resistance from uneducated educators.
    5) If you have the time and/or energy, become involved with the legislation that advances the cause. This includes legislation that call for removal of all athletes suspected of any head injury until cleared by a physician trained in concussion management, limiting contact in practice, and eliminating full contact programs below the high school level.

    • A Concerned Mom April 27, 2012 at 06:24 #

      Do you have any suggestions for parents who want to become involved with legislation that advances the cause? I think there is some benefit to sharing personal stories with state legislators, because it illustrates the need for legislation. Are there other ways parents can help advance this issue? Are there advocacy or other groups we could join that you know of? (I tried contacting everyone I could think of, but I have a limited background on this issue, and don’t know if my approach was as effective as it could be.) Perhaps another way to phrase the question, is what would those who’ve been involved in treating concussed athletes/children like to see parents do?

      Thank you

    • Matt Chaney April 27, 2012 at 07:08 #

      Politicians are a complete waste of time in sport issues. Forget it. Been there, done that for 30 years in the epidemic of muscle drugs in football. Every pol is bought off by football and/or is religious fan of the game, like Jake says, or too dumb to grasp complex, entrenched and frankly incurable problems. So, what to do? Right now, certified athletic trainers–as one of the positive developments of modern football–your imperative move is to stand up and demand that any program that cannot hire an ATC MUST BE SHUT DOWN NOW. You really have no other priority at moment. And most politicians would back you, not to mention city administrators, school administrators and INDEPENDENT, credible experts in medicine, science. Right on, Jake, Big Money football PLAYED BY CONSENTING ADULTS remains firm as our prime entertainment content in multi-media, but the tackle sport with juveniles is in serious hock right now, and it should be. To assume juvenile football will be around in five years without dramatic reform is like, well, following the Yellow Brick Road at beckon of our Great Wizards, the football-suckling “experts” who have nil solid answer right now, and they know it. This isn’t very complicated, folks, what must be done about American football, but it ain’t gonna be easy. That’s just life in America during tough times, and let’s not kid ourselves, properly handling and restricting the gross excesses of blood-sport football has to be accomplished. If we can’t succeed the game is gone, period. Rome lost its gladiators, finally.

  8. A Concerned Mom April 27, 2012 at 07:50 #

    I am curious to see if insurers are going to get more involved on the issue of youth tackle football.

    http://responsibility-project.libertymutual.com/blog/sports-injuries-should-we-watch-/?src=keyword_s=msn_K=SportsConcussions_C=Sports_G=SportsInjuries_SportsInjuries_M=broad#fbid=yFuD-Lctu31&src=keyword_s

    “Football players, often viewed as superb athletic specimens, are increasingly being viewed as medical specimens, because of significant long-term health effects from repeat head injuries.”

  9. A Concerned Mom April 27, 2012 at 08:08 #

    http://kdvr.com/2012/04/23/guardian-protects-kids-from-concussions/

    Please watch this video – didn’t Dustin and some others ask Guardian for back-up information on their claims? Just watch those little bobble headed kids (a big thanks to Chris Nowinski for highlighting the biomechanical issues) hit even harder now that they’re protected by the “guardian.”

  10. joe bloggs April 27, 2012 at 09:27 #

    First , I must agree with several commenters that certified ATCs are a requirement for a school to offer any collision sport. If you can’t afford an ATC then you can’t have collision sports. ATC need to report to be hired and report to school administration not athletic directors or coaches.

    Coaches in all sports need serious training. Just because one played the sport 10 or 20 years ago, things do change, does not qualifty one to coach a sport or lead children. Further, I see no evidence children under 14 should be playing helmet and pads football. There is no evidence it increases their skills. Forget the rational offered by many parents that my child will get a scholarship or go pro. Genetics have much more to do with someones ability to make the cut then anything else. The physical and pyschological profile of a scholarship athlete and a professional athlete is extremely distinct. Tom Brady, 2 time SuperBowl winning QB for the NE Pats, did not play until he was 14 and Jason Pierre Paul, NY Giant rookie standout, until his junior year in high school. The variance in these athletes characteristics is extremely small. If your child does not fit this profile he is little more than a tackling dummy. Spend your money buying lottery tickets to pay for college or better yet put the money in a 529. Coaching is also a significant factor and very few schools have high level coaches.

    I have also heard the missive that, “I had multiple concussions, and I am fine.” You are fine now but who knows in a couple of decades. You might have been President instead of being in a municipal job. Harry Carson, HOF NY Giant, has stated clearly that regrets playing and refuses to let his grandson play. Simlar thoughts have been expressed by HOF DB Lem Barney and numerous other distinguished players.

    I do believe in NP testing as one element along with balance, psycho screens etc. of a protocol to assess and treat athletes. Complex cases should be referred out to a board certified neuropsych but they are few and far between, expensive and may not take sports referrals. It is tough, but we are dealing with a child’s brain. The old maxim when in doubt keep them out. Any coach worth his salt knows when he has great player with pro-potential and knows it is best to keep him off the field in his long-term interest. The world is not going to end because some kid can’t take the field. Coaches and parents need to get real and take it down a notch.

    Chaney is correct that youth football is at risk because it is poorly funded, managed and fails to account for its true costs. Insurance companies will not only abadon schools but also equipment makers (it is happening already). Football should be left to programs that are professional at all levels and depending on the outcome of current research certainly left to young adults, if not adults.

    Sports are great and most children should play, but it is a game. It is not the NFL, NBA, etc. Have fun, stay fit and stay healthy.

  11. A Concerned Mom April 27, 2012 at 10:46 #

    http://insurancenewsnet.com/article.aspx?id=327898

    “Cantu said football, lacrosse, hockey and soccer are sports that expose athletes to a higher risk of concussions. He said he was surprised that insurance companies are wading into youth sports injuries because of a lack of good data on youth concussions.”

  12. george beres April 27, 2012 at 13:50 #

    Avarice (money) is the key. The NFL is in a separate dimension. But football flourishes today because it means big income for the schools that play the games and the media that cover them. Making money seems to be more important to educators and sports editors than the health of the kids. – George Beres, a former university sports information director.

    • Don Brady, PhD, PsyD, NCSP, Licensed Psychologist April 30, 2012 at 22:25 #

      George, nice to hear from you.

      Seems we are expressing similar thoughts…your post & my post:

      I think we are battling a cultural issue that idealizes sport participation and normalizes injuries along with numerous interwoven conflict of interest (COI) issues…these variables overlap… and allow for certain persons/institutions to financial benefit at the cost of the athletic and disposable gladiator.

  13. Jake Benford April 27, 2012 at 14:43 #

    A Concerned Mom

    I would not give up on politicians yet. You just have to remember who and what they are. Their main motivation is to get re-elected or move up the ladder. To do that they must make constituents happy. You also need to remember that they do not come up with any of the laws that they “author”. Basically all of these ideas started as a grass roots campaign or by some lobbyist.

    If you go to their door as an individual, you will get nowhere (unless you have a lot of money to put towards their campaign). If you educate other parents, follow the laws being passed in other states, form groups, sign petitions, and then go to your legislator, things will get done. It needs to be the voice of many.

    • Matt Chaney April 27, 2012 at 15:10 #

      Wrong, Jake, wrong, and for the very reasons you cite in the first paragraph. When the public finally moves as a body to “get things done,” especially at behest of a politician, Congress, whomever, whatever, this game will be already gone. Too late. How long do you think you have to act in such manner, by the way, to save American football in its epic crisis? The fuse of implosion is already lit, and 1905 is a cakewalk by comparison for olden King Football. As footnote, cite one freaking politician or entire Congress, state legislature anywhere, that has done anything to reform health hazards of this sport. And, no, not Teddy Roosevelt. Anybody who says Ol’ T.R. accomplished squat is drinking Gridiron Fool-Aid Classic, the original strain of Fantasy Football.

      • Matt Chaney April 27, 2012 at 15:14 #

        Again, Jake, guys like you have the power to lead, not neutered politicians. You, athletic trainers, take charge and then minstrels like politicians follow, singing your song.

    • A Concerned Mom April 28, 2012 at 08:01 #

      I understand what both of you are saying. Due to personal circumstances, I’m focused on education and reduction in hitting at the youth level. I may be wrong, but I think there’s a chance to see some positive change in this area due to the following:

      (1) Cantu coming out and saying kids under 14 shouldn’t play contact/collision sports as currently played (Omalu has come out to, but unfortunately he doesn’t get the same media coverage),

      (2) NFL lawsuits and statements of former players,

      (3) Actions of groups involved in sports safety (NATA and others),

      (4) results of new research, and

      (5) actions of some lawmakers who seem to actually care about youth athletes (CA Assemblymember Mary Hayashi launched a new concussion education website – youthconcussion.com).

      I recognize many who comment here have much more extensive backgrounds in this area. I appreciate the efforts and feedback from everyone trying to make youth sports safer (and my concerns extend beyond youth football, my terminology may not be entirely accurate, but youth soccer coaches probably should tell players not to head goalie drop kicks).

      • Matt Chaney April 28, 2012 at 09:21 #

        I hear ya, Concerned Mom, and I’m outa here after this for awhile. I ain’t trying to spoil no one’s fun; unfolding reality’s doing fine there without me. Just be precise on what Cantu is saying now versus what he believes: He says now that 14-under shouldn’t play football IF, to quote his quackery, the game ‘can’t get the head out’ of contact. Now, it doesn’t take a PhD, tens of thousand hours study, investigative journalism citations, brain surgery, whatever, to understand that stance is silly. When you see players lining up to collide butt-to-butt, Cantu’s good there. However, when we see the real Dr. Cantu finally stand up and say: ‘No kid 14-under should play collision sport, period,’ then his true power manifests and you will see impact change. I think Robert Cantu is the key opinion leader at moment, regarding the state of 14-under football, period. And I think he knows it. Meanwhile, I highly respect your work, Concerned Mom, and admire many of the voices I see here. I will be reading.

    • Educator Mom April 29, 2012 at 19:55 #

      They passed concussion legislation in our state. And yet there is now teeth to it. It required coaches, refs, and athletic trainers receive concussion training and for parents and athletes to be offered or advised of concussion training/information. And yet I have observed an indoor and outdoor soccer league in the last week who are not in compliance. When I asked a friend of mine who is a legislator, who I would report this to, she indicated that there is no one to report to and not really anyone to follow up with. The best that could be done would be to get the local rep who serves the area these leagues are in to send a letter suggesting they comply with the law. So much for legislation!

      • A Concerned Mom April 29, 2012 at 21:36 #

        I think legislation might be a step in the right direction. In my state, it doesn’t even apply to youth sports clubs and leagues. If the law had applied to my son’s league, I would have written a letter to the members of the league’s board indicating that they were not in compliance with applicable law. I would have also notified the school corporation that a sports league using their facilities was not in compliance. If such failure were brought to the attention of the insurance carriers for the league and school corporation, it’s possible the insurers would pressure them to adhere to the law.

        I don’t know if that approach would have been successful, but at least it would have provided me with a stronger starting point. (If there are any readers here with a legal background, perhaps one could provide some helpful suggestions for you.)

        To be honest, I was amazed to discover that youth sports clubs/leagues operate without any oversight. In the situation you describe, if the soccer league in question is a member of USA Soccer, or another umbrella organization, then perhaps you could write to that organization. Umbrella organizations often have certain rules that their member clubs must adhere to, and I imagine operating within the law would be one.

        TCB is one of my favorite blogs, but MomsTeam is another favorite, and by reading there I learned so much about what youth sports programs are failing to do to provide safe conditions for children and teens. A few months ago NATA came out with a document outlining various safeguards to prevent the most common causes of sudden death in youth athletes. I didn’t realize that coaches employeed by schools weren’t aware of what they needed to do to keep athletes safe. I also assumed sports programs were set-up with safety in mind. I had no idea there were so many unaddressed problems with youth sports. I now realize just how important those annual sports physicals are.

  14. concussionsolutions May 1, 2012 at 09:42 #

    This conversation has been great. Would like to put my “two cents” in. None of the now 34 state concussion laws mean anything without anyone on the ground pounding boots and following through with any sort of true management of this injury. Just like Educator Mom says. Great! There is a law in our state! Now what?? Without the “foot soldiers” (certified athletic trainers) at any of these high schools or youth sporting events, who the hell do you think is going to step in a say anything?? No one. Although awareness has certainly risen in my area, there are still plenty of these dumb ass folks who will turn a blind eye to their own kids who have clearly sustained a concussion!! It is what it is. I would love to have these conversations at a true face-to-face round-table discussion with a committee of legislators, parents, coaches, physicians, the lay person, etc. I hate feeling like I’m hiding behind a computer, but it’s great to have this resource at the same time. I personally like the idea that if you cannot afford to hire certified athletic trainers at your school/organization for the health and safety of the student athlete than you should not be allowed to play that sport. Contact or otherwise. I personally know schools that have the money allocated to hire a certified athletic trainer but choose to spend that money on something else (uniforms, unnecessary equipment, etc). Tell me that is not idiotic and that that schools priorities are not a$$ backwards!!

    I personally handle all concussion management and education in my area for about 3000 student athletes and the surrounding communities. I’ve done numerous talks/presentations for local organizations such as the Kiwanis Club, etc. not to mention all of our coaches for our 30 high schools that we cover, student-athletic trainer workshops at the local University, a local physicians association, parents, and on and on. The key is having one message from one person who is knowledgeable of the current events and research surrounding this topic. I dedicate my days to having that “courageous” conversation with folks who are still close minded to the fact that this is a problem if not addressed properly. What drives me every day is the fact that I am educated on this subject more and more each day in the process and if it helps make the game safer for my children then I have done my job.

    Common sense must prevail in these times and with the facts sitting there in black and white it’s time to make some tough adult decisions about the proper way to handle a student athlete that has sustained a brain injury. No one can “think” for us. Coaches. Stop it! Parents. Stop it! It’s time to swallow your pride and do what’s right (WHATEVER that may be).

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