Panacea: nearly impossible in the concussion realm

30 Aug

Definition of PANACEA: a remedy for all ills or difficulties.  Even though there are many products and claims out there finding a panacea for the concussion issue is impossible at this point.  Recently we have been examining the faulty claims made by companies about how they feel they can solve the concussion issue, mainly in sport.  Realistically it is an exercise in misinformation and even borderline fraud; and the reason why is simple.

Every brain and individual is exactly that; unique.  How can a product or protocol even come close to addressing the billions of people on this planet, let alone the millions that play sport.  Bluntly, the only panacea for mTBI is to live in a bubble and don’t move, seriously, don’t move.

Peter Keating of ESPN has been on the forefront of the concussion issue in the NFL and everywhere else since at least 2007 and as part of the World Wide Leader’s series on concussions he recently wrote what me and other feel is a pure journalistic masterpiece.  Before anyone starts claiming that I am against neurocognitive testing remember that I utilize this platform as well.  The most decisive point I can make is that what we have now at our disposal are just a myriad of tools that can help us do the job.

Let us break down the Keating article a bit here;

Concussions have become big business in the football world. With 1,700 players in the NFL, 66,000 in the college game, 1.1 million in high school and 250,000 more in Pop Warner, athletes and families across the country are eager to find ways to cut the risks of brain injury, whose terrifying consequences regularly tear across the sports pages. And a wave of companies offering diagnostic tools and concussion treatments are just as eager to sell them peace of mind.[...]

There’s just one problem. Many scientists who are unaffiliated with ImPACT don’t think the thing works.

“Through amazing marketing, the ImPACT guys have made their name synonymous with testing,” says William Barr, an associate professor of neurology and psychiatry at New York University and former team neuropsychologist for the New York Jets. “But there’s a growing awareness that ImPACT doesn’t have the science behind it to do what it claims it does.”

Marketing is a huge business, affecting the thoughts and processes of potential customers drive sales, period.  The issue becomes evident when what we are being told by business and individuals falls in the gray area.  The oft utilized part of advertisement that allows the consumer to decide what is true or not, even if the audience is not educated.  As Keating states there is plenty of research and public sentiment that back up claims (his focus in the piece being ImPACT), yet there are contradicting claims as well;

Yet a study — really a study of studies — published last year in Current Sports Medicine Reports reviewed the entire span of research on ImPACT and concluded: “[T]he false positive rate appears to be 30 percent to 40 percent of subjects of ImPACT … the false negative rate may be comparable. … The use of baseline neuropsychological testing … is not likely to diminish risk, and to the extent that there is a risk associated with ‘premature’ return-to-play … may even increase that risk.”

The overriding issue with some companies is that some of the bedrock research used to tout information is often littered with conflict of interest (COI).  Reading this blog you will find many, many references to this by Don Brady, PhD of New York; it was an entire section in his dissertation (I am hopeful he will post some sections of his COI in the comments).  In Keatings article he devoted and unshrouded information not fully understood by the public;

These overlapping roles have sometimes led ImPACT’s executives into dubious, industry-funded research. Lovell is a co-author of the notorious 2004 paper in which the NFL’s concussions committee found there was “no evidence of worsening injury or chronic cumulative effects” from multiple concussions in NFL players. And Collins, Lovell and Maroon cowrote a 2006 paper that found the Riddell Revolution helmet reduced the relative risk of concussions in high school football players by 31 percent. Riddell has trumpeted that research ever since. But the helmet maker had given grant money to UPMC, its vice president of research and development cowrote the paper, and reviewers blasted the work, using phrases such as “serious, if not fatal, methodological flaw” and “substantial conflict of interest.”

Moreover, Lovell and other scientists affiliated with ImPACT have often failed to identify their potential conflicts of interest when publishing research. In 2007, an ESPN.com investigation found that “on at least seven occasions since 2003, Lovell has authored or co-authored studies on neuropsychological testing, including papers directly evaluating ImPACT, without disclosing his roles in creating and marketing ImPACT.” In one case, the journal Brain Injury strengthened its conflict-of-interest policy after getting a complaint about Lovell’s work. In another, Maroon and Collins reviewed a paper Lovell wrote for the journal Neurosurgery without ever disclosing their roles as fellow corporate officers at ImPACT Applications.

Why does this matter?  It matters because everyone needs to be aware of what they are getting into and signing on for.  Take for example a school who buys a product that has the claims and excellent marketing that create belief in said product.  Only to find out later that what they believed to be a remedy or panacea is not working.  Not only did it cost money for them up front, but down the road it could cost them money by implementing a practice or protocol that endangered individuals.  This can be the case for eleventybillion different products for a multitude of different things that a school does.

What needs to be recognized in this ever-changing landscape of concussions, particularly in sports, is that being safe is the best option; but getting there and definitions of “safe” are to different and subjective.  I truly believe that no one wants to end sports, hell we NEED sports for many more positive reasons.  What we need to do with the concussion problem is to gather facts, implement best practices at the current time, based on as much science as possible.  In lieu of hard fast science, then a conservative approach must be taken.  This is a brain injury and the brain is not very good at healing itself; slogans like “when in doubt – sit them out” are great ideas.  Only if sitting them out includes more than 12 hours.  Keating ended the article with great advice and echos how I feel on the subject;

The bottom line is this: Neuropsychological testing in general, and ImPACT in particular, can be part of an overall exam. Any athlete suspected of having a concussion needs to see a healthcare professional trained extensively to deal with brain injury and not just trained to administer a test. Those professionals should examine athletes’ symptoms, balance and medical history along with his or her cognitive function and should have the final say in return-to-play decisions in the interests of athletes’ long-term health. “The confluence of symptom assessment, balance assessment, physical assessment, neurocognitive assessment and clinical interview is the ‘best practice’ approach,” says Philip Schatz, professor of psychology at St. Joseph’s University.

That might seem unrealistic or expensive. But when it comes to concussions, as Mayers puts it, “There are no simple answers.”

 

 

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10 Responses to “Panacea: nearly impossible in the concussion realm”

  1. joe bloggs August 30, 2012 at 10:12 #

    This is an outstanding article. ImPact and its promoters, UPMC, Mark Lovell, Mickey Collins and Joe Maroon need to have their feet put to the fire. For years they would say anything to sell their product; baseline every two years, baseline at home, you don’t need a baseline just compare it to the kids school performance.

    The breaches of scientific ethics, cooking research, receiving NIH grants [Irv Muchnick tried to find out whether UPMC reported conflicts of interest and was sandbagged], Riddell money and NFL money. The key to the troika’s effort was to simply make as much as they could and damn the science.

    Most school bought this because the NFL used it. Something needed to be done and you could not go wrong following the NFL. Of course, the NFL is being sued by 3300 former players. On the I dare say, if this board existed 10 years ago, ImPact would be have been just another Brain Pad.

    Now for some questions:

    Can the NFL explain why it continues to promote, market and use ImPact? Collins, Lovell and Maroon are ethically challenged researcher of almost uniquely poor quality. As clinicians, it seems these fellows coined the term concussion like symptoms to skirt the rules. As we have seen over the years, numerous players miraculously pass the ImPact test and return to play in a few days. On the other hand, maybe the next NFL promotion will be Peyton Manning will show you how to sandbag. We all know this concussion stuff is for sissies. Perhaps Katherine Snedeker (SportsCapp) can ask Roger Goodell how the NFL continues to support these people.

    Can Drew Brees, Executive Committee member of the NFLPA, explain why he takes a million dollars for promoting ImPact with Dick’s to sell it to children below 13? ImPact present no data that supports the test is valid for children this age. The article makes it clear ImPact has trouble for patients above 13. I guess these are not his kids and it is some nice change. I wonder what else Dick’s sells that has such questionable underpinning.

    Given that both the NFLPA and NFL shill for Impact it would be nice for Roger Goodell and De Smith to say something. Both always babble about there concern about health and safety, maybe that is really their health and safety. Players and youth athletes might get pushed back as their is a lot of money in spinning a story about interest in concussion.

    Can the certified ImPact NPs explain why they did not catch that Impact had reliability problems? it would be nice to hear from Phil Schatz, I wonder how much he cost. Maybe these people are selected because they have a certain clinical flexibility that let’s them overlook such things? It will be interesting to see how some major hospitals who are shilling this product respond as it exposes a lack of either competence of diligence.

    it is nice that after Wells Fargo played a major role in financial crisis so decide it is good thing to play a major role in the concussion crisis. Perhaps it might explain its lack of diligence in promoting this product.

    Will NATA just sit there and stay mute. Probably, they rent a good amount of both space to ImPact.

    In the end, concussion in sports has been managing appearances. ImPact played that role with the assistance of NATA, NFL, NFLPA, NCAA, Dick’s, Wells Fargo and Drew Brees. Let us not forget the press with only Keating and Muchnick calling these guys out every other media outlet has promoted ImPact’s virtues. The media needs to answer.

    I do believe in NP testing as part of a complete protocol. I always have. I also always knew Collins, Lovell and Maroon were selling dubious science. Find a new program; buying from these guys is supporting people who will say or do anything for a buck. They can’t and shouldn’t be trusted.

    You can always use SCAT2 and balance testing as a first line until you find a product you like.

    • Dustin,

      Before I place several excerpts of my 2004 Dissertation I wish to remind readers of 2 articles that my wife, Flo, and I wrote for NASP last year and were published online during June 2011.

      You graciously introduced your readers to these 2 documents in a previous blog. Both articles briefly raised concerns re the presence of Conflict of interests within the sport-related concussion (SRC) field.

      Furthermore, I wish to credit 2 persons for the development of the expansive Dissertation chapter. my Dissertation chair, Ken Suslack, PhD, a licensed clinical psychologist, and a retired and quite famous anonymous NFL Player who both strongly urged me to write an extensive section on a very under-addressed ethical topic.

      Below is an excerpt from the Sport-Related Concussion: Mythand Facts that briefly spot-lights conflict of interest (COI) concerns.
      ================================================
      Excerpt:

      Myth: After sustaining a concussion, return to play (RTP) standards employ objective, evidence based standards that drive same-practice multidisciplinary treatment.

      Fact: “The science of concussion is at early stages, and therefore, management and return to play decisions remain largely in the realm of clinical judgment on an individualized basis” (McCrory et al, 2005, p. 202).

      Various authors have raised concern that expert based opinion and related clinical judgments may be subject to conflicts of interest (COI) (Brady, 2004; Goldberg, 2009; Kelly & O’Shanick, 2003; & Thompson, 1993). It is imperative, therefore, that accurate, unbiased, and in-depth knowledge of SRC’s and related management approaches be gathered from a multidisciplinary team of health-care professionals who are adequately trained and free from conflicts of interest.
      .
      Post Script….Dr.Huizenga’s 1994 text citation was inadvertently not included in this article—he was a former NFL team physician.

    • Joe,

      Below is a previous post that I made to TCB back in march 2012.I believe these views overlap with some of your perspectives.

      An excerpt from my 2004 Dissertation re NFL Players’ Knowledge of Concussions seems approriate. It pertains to:

      1- the need for a multidisciplinary team — no one discipline should ‘control’ the assessment or return to play /school. The brain is much to complex for one discipline to (attempt to) comprehend the brain functioning and dysfunctioning of a concussed indvidual.

      2- The brain affects 3 major functions: physical, cognitive and emotional (suggest the use of the term ‘emotional’ rather than social/behavioral – as ‘emotional’ is a more precise base term…)…and these 3 functions are intertwined…and separated for discussion purposes only.

      3- There is a ‘science’ and an ‘art’ involved in the asessement and management of each concussed athlete…as all concussions are not the same and must therefore be individually assessed and managed .

      4- Caution must be exercised re accepting rush to judgment assessments and management / return to play/school approaches… Supporting research must be replicated and free from conflicts of interest (COIs). A former anti-drug abuse public announcement emphasized: “a mind [brain] is a terrible thing to waste…”. This protective perspective readily applies to the concussed athlete’s brain.

      5- THERE IS MUCH UNCERTAINTY and a corresponding lack of desired preciseness re concussion assessment and management. Athletes, parents, treatent providers from all health disciplines and others concerned with the health and safety of the student/athlete or adult athlete need to be aware of, and cognitively digest, this fundamental fact.

      ======================================================

      The 2004 NFL Players’ Concussion- related Dissertation excerpt follows:

      The complex, varying, and individualized central nervous system response to a brain insult and resultant concussion injury not only justifies but requires a comprehensive assessment from a readily available and qualified multidisciplinary team of health care providers (McKeag, 2003). The utilization of a multidisciplinary team is particularly essential since consequences of TBI include both neurological and non-neurological consequences. In order to fully protect the athlete’s health and corresponding safety, return-to-play risks also need to be comprehensively assessed and thoroughly explained via a concerted effort of a multidisciplinary health care team. Suggested members of this health care team include the following: physician, neurologist, neurosurgeon, psychologist, neuropsychologist, optometrist, opthamologist, athletic trainer, speech pathologist, occupational therapist, and physical therapist. Equally important is the carefully culled input from close family members and significant others to assist in the concussion assessment and return-to-play decision-making process.

      The uniqueness and subtleties of each concussion warrants an exploratory process that analyzes presenting concussion symptoms with an investigative clinical judgment. Therefore, this methodical and investigative process requires the inclusion of approaches that utilize the science and art of medicine (A. Joachimpillai, personal communication, September 15, 2003; Meeuiwisse, 2002). The utilization of a logical and investigative clinical judgment process is a core component of the concussion evaluation and the return-to-play assessment process since it has been clearly pointed out that many of the current neurocognitive and neuroimaging instrumentations and evaluation techniques are generally not sensitive enough in assessing and detecting mild brain injury (Bleiburg et al., 1998; Damasio,1994; Lovell, 1998). This lack of sensitive test instrumentation also acknowledges the limitations of a scientific methodology that only utilizes concrete, and thus observable, data as the sole valid and reliable data for drawing conclusions.

      • excerpt from 2004 dissertation

        After reviewing differing perspectives pertaining to the ways conflicts of interest (COIs) may bias scientific endeavors and resultant “scientific evidence,” an apparent caveat emerges when professionals and the general public overrely, 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.” It should also be pointed out that the institution of sport has become intertwined with these social forces. These research issues, raised over 20 years ago, remain prevalent today, as evidenced by the current COI controversy.

      • Dissertation excerpt:

        , failure to provide acceptable health care services is also unethical. This particular concern has long been raised within the sports field and in particular by the National Football League Players Association (NFLPA) (Moore, 1982). In a 1982 article, the sports medicine coordinator for the NFLPA advocated for “improved medical care that he thinks is lacking in the injury world of professional football” (p.162).

        Moore (1982) also pointed out the existence of apparent COIs existing for team physicians and athletic trainers via conflicts in their dual roles of “allegiance to their team owners and the best interests of their patients”(p.162). Huizenga (1994), a former team physician for the Oakland Raiders, voiced similar perspectives pertaining to these two medically related concerns.

      • Some more excerpts: and That’s all folks…similar to Loony Tunes

        hope they are perceived as being both enlightening and troubling…

        ================

        Thus, it seems that team physicians, along with other health care providers and researchers, need to become more aware of the potential of COIs to undermine or compromise the patient-professional clinical care or research relationship; they also need to be held to a more stringent standard of accountability in order to protect a dependent patient’s interests….

        ========….
        Thompson (1998) … voiced concern about the possibility of the funding source influencing the choice of the specific research topics and related research questions for investigation.

        =====================

        Recently published NFL-sponsored research on concussion by Pellman et al (2004) may easily be construed as an example of perceived or potentially compromised and biased research. The glaring omission and failure to disclose various research members’ roles as NFL team physicians or other health care consultants, arguably may “violate the public trust and subsequent credibility of the investigators” (DeAngelis, Fontanarosa, & Flanagin, p. 89). The full and transparent disclosure of multiple relationships is considered essential for maintaining the credibility of the researchers, along with effectively addressing potential bias (DeAngelis et al., 2004)
        ———————————–

        The potential for COIs and a subsequent erosion of public trust seems quite apparent if proactive and clearly visible and stated disclosures of financial and nonfinancial ties are not consistently promulgated by concussion researchers, expert panel/committee members, and/or manuscript reviewers and editors. Therefore, just as specific sources and amounts of funding for drug-related research and other secondary interests need to be clearly enunciated (Lemmens et al., 1998), sources and amounts of funding for sports-related concussion research, multiple relationships, and other secondary gains should also be openly acknowledged and clearly described in all research presentations and corresponding journal articles. This is so that the audience/reader may become fully aware of possible health care provider biases that may have adversely impacted the research findings being reviewed. Such a perspective is similar to Krimsky and Rothenberg’s (1998) view that authors’ COIs should be shared with readers so that they may become aware of, and personally judge, the credibility of the article’s contents.

        =======================

        Remember the 15 minute sit-out rule ? below is the “scientific basis”

        Recent support for the existence of sports-related clinician bias may be found in Kelly and O’Shanick’s (2003) discussion of the formulation of the 1997 AAN concussion management guidelines. The presenters shared that the Quality Standards Subcommittee of the American Academy of Neurology–which devised these concussion management guidelines–included NFL team physicians. These team physicians reportedly influenced the committee’s decision that determined that a timeframe of 15 minutes was ample time for an athlete to “sit out” after sustaining an initial concussion. This recommended timeframe was reportedly not based on empirical evidence but was arbitrarily and directly related to the 15 minute quarter of a football game, so that an athlete would be able to return to play in the same game he sustained the initial concussion, if the symptoms resolved” (Kelly & O ‘Shanick, 2003).

      • Dissertation excerpt:

        Former NFL players share their views re conflict of interests ( COIs )

        Several months ago, when football player, Terrell Owens, returned to the competition after sustaining a concussion earlier in the game, former All Pro NFL player and current Fox TV sports announcer and attorney, Cris Collinsworth, created controversy when he declaimed:

        team doctors and players have a messy, triangular relationship. It’s not a one-on-one

        situation where my doctor tells me what he thinks is best for me. With a “team doctor,” by definition you’re dealing with someone who has been hired by the club, so there are conflicts of interest…I would have a “players” doctor on the sidelines, someone hired by the players (Orlando Sentinel, Sept 15, 2003).

        It should be noted that the NFLPA advocated for a players’ physician over 20 years ago (Moore, 1982). Further input on this topic was provided by another player who responded to this writer’s survey. The athlete offered his unbridled perspective pertaining to COIs and some NFL team physicians when he opinedthat

        “they are soulless gatekeepers protecting the money, that’s why they are there” (anonymous NFL player, personal communication, September 16, 2003).

  2. Robert A. Arnone, D.C. August 31, 2012 at 07:24 #

    Great article, I especially agree with the statement from psychology professor, Philip Schatz:
    “The confluence of symptom assessment, balance assessment, physical assessment, neurocognitive assessment and clinical interview is the ‘best practice’ approach,” says Philip Schatz, professor of psychology at St. Joseph’s University.
    A complete and thorough consultation and examination is what helps us in determining what sort of condition they have gotten themselves into and then what we can or cannot do to help them.
    The cognitive testing is only one piece of the puzzle, well-said.

  3. joe bloggs August 31, 2012 at 14:07 #

    You know you have become a joke when the Onion lambasts you, http://www.theonion.com/articles/doctors-sidney-crosby-has-greatly-improved-ability,29394/

    Doctors: Sidney Crosby Has Greatly Improved Ability To Hide Concussion Symptoms Lately

    Go Mickey, Mark and Joe. UPMC the hallmark of excellence in concussion treatment.

  4. Mark Picot September 1, 2012 at 08:04 #

    http://sports.espn.go.com/nfl/news/story?id=2314899

    One of Keatings first story’s on concussion 2006.

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