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NFL Concussion Policy: a Very Slow Work in Progress

Michael Phelan — Tue, 24 Nov 2009 14:36:43 GMT

With every new round of concussions in the NFL, it seems to me that the press and the NFL react as if dangerous concussions were a new issue in football. The multitude of stories about the brain damage, alzheimers-like symptoms, memory loss, depression, and suicidal behavior of former players like Andre Waters, Mike Webster, Tim Johnson and others get swept under the carpet as the NFL takes its predictable stance of delay and double talk on the issue of brain injuries. And, with the exception of the New York Times series on brain injuries in the NFL, the sports media typically looks the other way. Until now. Sports Illustrated's Ann Killion has written a piece in her Inside the NFL column accusing Commissioner Roger Goodell of business as usual just as he announced a new policy requiring teams to consult with independent neurologists following a concussion to one of the teams' players.

Ms. Killion cites the cases of the two quarterbacks who played in last year's Super Bowl. The Steelers' Ben Roethlisberger left Sunday's game against the Chiefs after taking a blow to the head and suffering concussion-like syndromes. But by Monday reports out of Pittsburgh described the Super Bowl winning quarterback as "fine" and capable of playing this week. Arizona's Kurt Warner also left his game against St. Louis after his head slammed into the turf. But the Cardinals are "optimistic" Warner will play this week. This, despite the fact that Big Ben suffered a serious head injury in a motorcycle crash and Warner suffered multiple concussions in the past. Ms. Killion concludes that "[t]he culture of denial and quick turnarounds runs too deep in the NFL to be changed by a commissioner's mandate."

This SI column follows a recent article in The New Yorker, in which Ira Casson, who co-chairs an NFL committee on brain injury, said he isn't sure what the solution is. "No one has any suggestions -- assuming that you aren't saying no more football, because let's be honest, that's not going to happen," he said.

Commissioner Goodell's new policy addresses an issue that has long been part of the problem in the NFL: the onflict of interest posed by leaving the decision about when a concussed player should return to full contact to a doctor employed by the team and the league.

Ms. Killion points out that the culture of denial trickles down to college, high school and youth football. Every day, coaches and administrators struggle with medical issues far beyond their capability. At Cal, Jahvid Best has been sidelined for two weeks after suffering a horrific end zone collision and concussion. In Florida, Tim Tebow -- who, in September, was knocked out cold and carted off the field vomiting -- hasn't missed a game (the Gators had a bye the week after Tebow suffered his concussion). But some observers think he hasn't been the same since.

On high school fields around the country, kids are carted off with concussions every week. In New Jersey last year, a junior linebacker was cleared to play after suffering a concussion. He suffered another hit, which ended up killing him. His parents are suing the high school and their doctor.

The violent hits are celebrated. The early returns to the field are deemed courageous. The head traumas of star players are underplayed.

The NFL sets the tone for it all. Commissioner Goodell took a step forward this week. But there's a long way to go.

Originally posted at InjuryBoard by Michael Phelan

Coping with Brain Injury During the Holidays

Michael Phelan — Mon, 23 Nov 2009 21:06:03 GMT

For victims of acquired brain injury, the time of year that once brought great joy may now be the most difficult time of year. Brain injury victims often struggle to cope with, among other sequelae, memory problems, obsessive compulsive behaviors, an aversion to loud noises, big crowds, and bright lights, decreased communication skills, and special diets. Imagine the terror of tying to cope with these issues while being expected to attend holiday parties and large family functions.

I read a wonderful piece in the Augusta Free Press advising brain injury victims how to cope with the holidays. Some suggested ways for making the holidays fun and less stressful for all, particularly when persistent cognitive /behavioral issues are problematic include:

1. Holiday shopping should be a fun activity and indoor malls are weather controlled and safe places for strolling on foot and/or for those wheelchair or walker assisted. However, the holiday period can make shopping less than a fun activity without preplanning. Start early to avoid the holiday crowds and use the opportunity to incorporate cognitive exercises into the planning. The individual with brain injury should make a list of gifts to be purchased or hand made, when possible, suggested gift ideas and estimates of costs associated with the gifts.

2. Catalogs that come in the mail this time of year are wonderful for gift ideas and also for estimation of prices. Take some time to sit down and look through a few as part of the independent planning phase.

3. Make out a simple budget before going to the bank and allow your family member with brain injury as much control of the funds as possible even though money management skills may be impaired.

4. Place greater emphasis on use of journals or calendars to record routine events as well as holiday activities. Schedule a week in advance, with a daily review to make note of any changes as they come up. Those accustomed to a daily routine may be better prepared when special dates and activities are written in the journal and/or on the calendar in colored ink for emphasis.

5. Each day, during the holidays, orient the individual by discussing the day’s activities over breakfast to avoid misunderstandings about changes from the normal routine. It is helpful to repeat this information several times during the day for those with severe memory problems.

6. If bright or flashing lights bother your family member and/or possibly trigger seizures, carefully plan any additional lighting that will be used during the holidays and avoid laser holiday lighting displays.

7. Crowded places and loud music may also bother some individuals and should be taken into consideration and monitored, if necessary.

8. Food is a big part of holiday fun and many of the foods may be very temptingly displayed. Parties, holiday family dinners, and open house gatherings are often scheduled at times that do not coincide with routine mealtimes, thus, presenting a problem for those whose mealtimes are more rigidly scheduled. You may want to offer a light snack at the regular mealtime to “tide him/ her over” until the main meal, or make whatever adjustments are necessary. For those with more severe cognitive deficits, which interfere with appropriate food intake, it may be necessary to help with monitoring to avoid overeating. It is very common for damage in the hypothalamus area of the brain to interrupt signals to the brain which help the individual know when their appetite has been satisfied, thus, many with brain injury need help with quantity control monitoring. Additionally, memory problems and attention can derail a persons resolve to watch their food intake to avoid excessive food and beverage intake. After a brain injury burning of calories may also be changed and individuals who could eat anything and everything before the injury may need to more diligently watch calories to avoid weight gain.

9. By all means don’t forget that increased activity during the holidays may be more fatiguing than usual so plan rest periods accordingly. This is particularly important when cognition and behavior are problems. Fatigue often increases confusion that can result in an outburst or other kinds of unpleasant behaviors.

10. Structure can be your best strategy for ensuring the entire family has a higher quality of life. Initially it takes effort to get the structure in place but it pays dividends in the end. Flexibility is a key word during the holiday season but planning and preparation will hopefully result in a happy holiday for family and friends.

Next comes New Year’s resolutions! Start thinking about ways your entire family can enjoy life more fully, fulfill the demands of your caregiving role and provide the best possible quality of life for your family member with brain injury.

Most of us take these simple pleasures for granted. As the father of a young adult with who suffers from the effects of brian injury and someone who represents victims of acquired brain injury, I know the importance of structure and routine in my child's life. There's nothing like the holidays to disrupt this routine.

Originally posted at InjuryBoard by Michael Phelan

Defense Neuropsychologists Want to Replace Jurors

Michael Phelan — Mon, 09 Nov 2009 16:14:14 GMT

Defense neuropsychologists are hell-bent on being able to testify whether they believe an injured person is telling the truth. They cannot be serious, you say. Determining the veracity or credibility of a witness is the exclusive province of the finder of fact. They are serious, and they've devoted a lot of time and energy coming up with a "consesus statement" wherein they agree they should be able to provide this testimony. See American Academy of Clinical Neuropsychology Consensus Conference Satement on Neuropsychological Assessment of Effort, Response Bias, and Malingering, The Clinical Neuropsychologist, 23: 1093-1129, 2009.

The crux of the "consensus statement" is that "neuropsychologists are capable and qualified to diagnose malingering," and that this diagosis "can be used to assist the trier-of-fact (e.g., judge, jury) in a legal decision-making process." Id. at 1099. The authors identify the types of people against whom they believe they are likely to offer this testimony. They include people seeking financial compensation for injuries, people seeking to be compensated for time away from work, soldiers injured during combat, and criminal defendants. Id. at 1098. Indeed, defense neuropsychologists have been complicit with the Veterans Administration's disgraceful efforts to deny benefits to our unfortunate soldiers who've suffered brain injuries from blast-induced injuries suffered in Iraq.

These forensic defense neuropsychologists are publishing their own literature and creating their own consensus statement to justify their defense testimony. Rather than get too bogged down fighting them on their own turf, I prefer to stick to long-standing jurisprudence. The neuropsychologists freely admit that they are trying to divine the witness's intent, and comment on his or her veracity and credibility. One passage from the consensus statement says, "[i]n considering the diagnosis of malingering, the clinician is explicitly making a determination of intent: more specifically, a determination of intentionally exaggerated symptoms and/or diminished capability with the goal of obtaining an external reward." Id. at 1097. In other words, they want to testify that your client is lying by either faking symptoms or feigning an inability to perform a task. Fortunately, most states' statutory and/or case law provides that a determination of the veracity or credibility of a witness is the sole province of the jury and not the proper subject of expert testimony. See e.g., Pritchett v. Commonwealth, 263 Va. 182, 186-187 (2002), and Brown v. Corbin, 244 Va. 528, 532 (1992)("The issue of a witness's credibility falls squarely within the jury's province, and is one which a jury can resolve without any expert testimony to assist it.").

Originally posted at InjuryBoard by Michael Phelan

NFL Players Ass'n Announces Formation of Concussion and TBI Committee

Michael Phelan — Mon, 05 Oct 2009 15:32:45 GMT

Below is the Press Release from the NFLPA Communications Director:

FOR IMMEDIATE RELEASE Contact: Carl Francis

Carl.Francis@nflplayers.com

202-756-9169

NFLPA ANNOUNCES FORMATION OF

CONCUSSION AND TRAUMATIC BRAIN INJURY COMMITTEE

For the past few months, the NFL Players Association, led by Executive Director DeMaurice Smith, President Kevin Mawae, Medical Director Dr. Thom Mayer and Arizona Cardinals wide receiver Sean Morey, has been working on compiling support for a special committee to address the issue of head trauma among professional football players. Today, the NFLPA announces the formation of the Concussion and Traumatic Brain Injury (TBI) Committee.

The NFLPA Concussion and TBI Committee will address two fundamental, timely and critical issues facing professional football players: first, the diagnosis, treatment and prevention of concussions and TBI in active players; and second, the long-term cumulative effects of isolated or repetitive TBI in NFL players as patients in order to discover how these effects can be reduced and eliminated.

DeMaurice Smith issued a statement saying, “The health, safety and welfare of our players is never just an issue of collective bargaining. While we have already raised this issue in the CBA negotiations and Dr. Mayer participated in the first meeting, this committee and the work we do around the health and safety of our players will extend much further. The creation of this committee was designed to bring both independence and expertise to the ongoing analysis of serious head injuries so we can better protect our players. I am confident that Sean Morey and Dr. Mayer will lead this team to gather more comprehensive data and provide real solutions for our players, both past and present.”

The Concussion and TBI Committee will be co-chaired by Sean Morey and Dr. Mayer. It will also be comprised of other active players, former players, researchers in the field of TBI and physicians with expertise in neurological injuries.

# # #

Joanna Comfort
Communications Coordinator, Communications

1133 20th Street, NW
Washington, DC 20036
(P) (202) 756-9170
(F) (202) 756-9310
NFLPLAYERS.COM

Originally posted at InjuryBoard by Michael Phelan

Long Term Risks from Concussions are Real

Michael Phelan — Fri, 02 Oct 2009 16:33:58 GMT

As scrutiny of brain injuries in football players escalated the past three years, with prominent professionals reporting cognitive problems, academic studies supporting an association, and autopsies of former NFL players revealing brain damage resembling advanced Alzheimer's disease, the National Football League and its medical committee on concussions have steadfastly denied the existence of reliable data on the issue. The league pledged to pursue its own studies, including one at the University of Michigan's Institute for Social Research.

The Michigan study commissioned by the NFL reports that Alzheimer’s disease or similar memory-related diseases appear to have been diagnosed in the league’s former players vastly more often than in the national population — including a rate of 19 times the normal rate for men ages 30 through 49. The study has not been peer-reviewed, but the findings are consistent with several recent independent studies regarding NFL players and the effects of their multiple concussions.

Dr. Ira Casson, a co-chairman of the concussions committee who has been the league’s primary voice denying any evidence connecting NFL football and dementia, said: “What I take from this report is there’s a need for further studies to see whether or not this finding is going to pan out, if it’s really there or not. I can see that the [survey] respondents believe they have been diagnosed. But the next step is to determine whether that is so.” The NFL is conducting its own rigorous study of 120 retired players, with results expected within a few years. All neurological examinations are being conducted by Dr. Casson. In any legislative body, a sure way for one to kill a bill one opposes is to recommend that the matter be sent back for further study. It sounds like the NFL is taking pointers from the politicians.

In the meantime, from the Pop Warner to the college football level, hundreds of on-field concussions are sustained each week, with many going undiagnosed and untreated. The players who are properly diagnosed are often released prematurely back to full contact. Youth and college football programs take their cues from the NFL, so it's time for the NFL to step up, acknowledge the problem, and take the lead in prevention.

Originally posted at InjuryBoard by Michael Phelan

Criticism of Defense Malingering Test Gaining National Traction

Michael Phelan — Sun, 20 Apr 2008 19:38:23 GMT

On March 5, 2008, I criticized the use by professional defense neuropyschologists of a controversial malingering test called the Fake Bad Scale. See Fake Bad Scale: Weapon of Defense Neuropsychologists, http://www.injuryboard.com/members-area/BlogPost.aspx?blogid=372&postid=232632. In that blog, I pointed out the fact that the test was designed so that a person with traumatic brain damage and/or serious physical injuries was likely to fail the Fake Bad Scale (FBS) and be deemed a malingerer or faker.

I was interviewed by Sylvia Hsieh of Lawyers Weekly USA who has since published an excellent article on the topic. Click here to read Sylvia's article on the Fake Bad Scale. http://www.lawyersweeklyusa.com/index.cfm/archive/view/id/430456

Ms. Hsiegh correctly points out that the FBS is biased against women, the disabled (including physical and cognitive disabilities), and those suffering from post-traumatic stress disorder. Thanks to the good work of trial lawyer Dorothy Clay Sims, a Hillsborough County, Florida court ruled that the FBS was "not an objective measurement of effort, malingering, or over-reporting of symptoms."

Perhaps the most outrageous use of the FBS has been against wounded Iraq war veterans and defense contractors. Ms. Hsiegh reports that the FBS has been used in suits brought under the Defense Base Act against returning Iraq war contractors who claim post-traumatic stress disorder. I've also read about the FBS being used against war vets to deny coverage or treatment for claimed brain injury symptoms caused by brain damage suffered during roadside explosions. Our government should not be using this bogus test to demean our brave soldiers!

Originally posted at InjuryBoard by Michael Phelan

Alarming News Regarding Repetitive Head Trauma

Michael Phelan — Tue, 27 Jan 2009 17:37:51 GMT

Clinical researchers reported today that postmortem examination of the brain of a recently deceased 18 year old high school football player showed early signs of an incurable debilitating brain disease caused by repetitive head trauma. This finding has major significance in ongoing study of the effects of the sports-related concussion, which threatens athletes from Pop Warner football to the NFL. No scientist had previously documented the degenerative brain disease known as chronic traumatic encephalopathy (CTE) in a football player younger than 36.

CTE is caused by multiple head injuries and results in symptoms similar to early-onset Alzheimer's. Had the 18 year old lived, neurologists say he eventually would have developed early-onset dementia that would have advanced unabated until his death. CTE studies reveal brown tangles flecked throughout the brain tissue. The brain damage affects areas that control emotion, rage, hypersexuality, and even breathing. CTE is a progressive disease that eventually kills brain cells.

The New York Times ran a series of articles last year on CTE in retired NFL players. A confirmed feature of CTE is that years after a NFL player leaves football, the disease begins affecting his personality and behavior. Several former NFL players have recently died disturbing deaths. Houston linebacker John Grimsley, 45, accidentally shot himself; Eagles defensive back Andre Waters, 44, shot himself; and three Steelers, Mike Webster, 50, who died from exposure, Terry Long, 45, suicide by drinking antifreeze, and Jason Strzelczyk, 36, died in a head-on truck crash fleeing from police who were pursuing him after he left the scene of a previous crash.

This latest finding better cause all youth coaches, trainers, and parents to wake up to the very serious dangers from concussions.

Originally posted at InjuryBoard by Michael Phelan

US Lacrosse Confronts Concussion Epidemic

Michael Phelan — Wed, 07 Nov 2007 08:55:54 GMT

Two days after his team won the National Lacrosse League championship, Jay Jalbert was laying in a hospital bed recovering from his seventh concussion. Jay was forced to retire from professional Lacrosse. Four weeks after taking a routine shot off his face mask, Denver Outlaws goalie Trevor Tierney was still experiencing symptoms of his seventh concussion. Concussions are prevalent in contact sports from the youth to the professional level. The bad news for Lacrosse is a recent report in the Journal of Athletic Training concluded that concussions were the third most common injury in men's and women's lacrosse.

The good news is that, unlike the NFL, US Lacrosse, through its Sports Science and Safety Committee is taking seriously the severe health hazards of concussions. US Lacrosse has taken a significant step toward addressing the issue by partnering with ImPACT, a concussion management firm. Two major issues being addressed are players returning too early from concussion and players who have suffered multiple concussions. Returning to play too early can lead to prolonged post-concussion symptoms or more severe brain damage if another head injury occurs before the first concussion heals completely. The league is also studying the cumulative damage of multiple concussions, something the NFL should have done long ago. The league is utilizing the ImPACT test to help determine if it is safe for a player to return from concussion. Players take a baseline neuropsychological test of cognitive function at the start of the season, and then retake the test if a concussion occurs. Medical professionals have quantitative data to assist in determining if the brain is healed.

Parents and other advocates should also push for better helmets and better/mandatory mouth guards. Water and air cushioned football helmets were available in the 1970's. There is no excuse for the flimsy helmets worn by hockey players, which do very little to protect the brain. Lacrosse helmets could also offer more protection.

Originally posted at InjuryBoard by Michael Phelan

Hold Your Child Out of Sports Following a Concussion

Michael Phelan — Tue, 05 May 2009 15:24:28 GMT

I know many well-meaning parents who are guilty of allowing their child to be rushed back into contact sports following a concussion. Whether the concussion is suffered in a car accident or a sports-related incident, the same issue typically arises- the child wants to go back to sports immediately after getting checked out at the hospital. I know enough about mild brain injury to know this is usually a bad idea, particularly for children who have had multiple concussions. I've often struggled with the internal debate between not wanting to interfere with another family's decision and knowing that one can suffer mild brain damage that may not show up on the hospital CT scan. I now have a new study to cite to fellow parents.

Using a computer-based training program created to assess athletes with concussions and determine when it was safe for them to return to sports, researchers at The Children's Hospital of Philadelphia followed 116 children at an urban Level 1 trauma center over two years. The tests revealed an alarmingly high rate of cognitive deficits in nearly all patients during initial testing. The program tests specific abilities, such as attention span, memory, nonverbal problem solving and reaction time. Almost all patients tested below the 25 percentile in at least one area; the majority demonstrated significant impairment for all four subtests.

The test also assesses the degree of concussion symptoms, and the majority of children with concussions demonstrated an abnormal symptom score. The follow-up group demonstrated significant improvement in neurocognitive performance on all four subtests as well as an improvement in their symptom scores. Prior research has demonstrated that children are more likely to sustain another concussion if they return to sports or exertional activities prematurely. In addition, high school athletes recover more slowly than college or professional athletes. Presumably the same is true for children with concussion from non-sports related causes.

The authors of this study recommend that a qualified healthcare provider perform a formal assessment after hospital discharge and before a concussed child is allowed to resume exertional activities, particularly contact sports. The referenced article appears in the May issue of the journal, Annals of Surgery.

Originally posted at InjuryBoard by Michael Phelan

Another Former NFL Star Says, "There's Something Wrong With My Brain"

Michael Phelan — Fri, 02 Feb 2007 09:16:09 GMT

Middle linebacker, Ted Johnson, was the captain of the New England Patriots in 1998 and 2003, and helped the Pats win three Super Bowls before retiring in 2005. According to a story in the New York Times, Mr. Johnson now

forgets people's names, misses appointments and...can become so terrified of the outside world that he locks himself alone inside his Boston apartment in bed with the blinds drawn for days at a time.

Mr. Johnson told the Times,

"There's something wrong with me. There's something wrong with my brain. And I know when it started."

Ted Johnson's brain injury started in August 2002 when he suffered a concussion in a preseason game against the Giants. He now believes that Pat's Coach Bill Belichick went against the team trainer's medical advice and rushed Mr. Johnson back into full contact practice drills. Johnson sustained another concussion two days later and suffered more concussions over the next three seasons, each of them exacerbating the previous brain injury.

Mr. Johnson's neurologist, Robert Cantu, M.D., said he was convinced Johnson's cognitive impairment and depression "are related to his previous head injuries, as they are all classic postconcussive symptoms," and that "they are most likely permanent." In fact, Dr. Cantu said: "Ted already shows the mild cognitive impairment that is characteristic of early Alzheimer's disease [which]...relentlessly progress over time...[such that when] he's in his 50's, he could have severe Alzheimer's symptoms."

Mr. Johnson's brain injuries have not only caused him to suffer depression, loss of memory, and diminished cognitive abilities, but have also ruined his marriage. He has a two year old and one year old child, and he and his wife are getting divorced. Mr. Johnson attributes the decline of his marriage to the behavior caused by his concussive symptoms and resulting addiction to anti-depressants. Mr. Johnson decided to go public with his story when he read about Andre Waters, the former NFL star who committed suicide last November and was later found by a forensic pathologist to have had significant brain injury caused by concussions suffered during his career with the Eagles. I blogged about Mr. Waters's tragic case earlier this month. The NFL needs a strong director of the NFL Players Association and Gene Upshaw is not that man. The coaches are making too much money and are under too much pressure to win to be trusted to put a player's health first. The Players Association must step up and do what is necessary to prevent more cases like Ted Johnson's, Andre Waters's, and Mike Webster's, and to ensure that the league provides the brain injury rehabilitative services that these players need. Right now, the league is clearly turning its back on the players.

Originally posted at InjuryBoard by Michael Phelan