By Matt Chaney

Posted Saturday, April 23, 2011; revised Monday, April 25, 2011

This post is Part 1 of an analysis series titled Brain Trauma Dictates Epic Football Reform, which will culminate with independent recommendations for steps imperative to the blood sport’s survival at public schools, colleges, and likely the professional level.

Today’s official effort against gridiron brain trauma recycles the old “safer football” concept.

In the NFL and trickling down to colleges, schools and youth leagues, “behavior modification” of players involves teaching “proper contact,” or “form tackling” as known in 1976. Coaches tell football players to hit without using heads, as if hogs might be taught to fly.

Current purveyors of the theory, led by Chris Nowinski and Dr. Robert Cantu of the Sports Legacy Institute, and NFL commissioner Roger Goodell—who funds the Nowinski nonprofit with $1 million—propose action reminiscent of the plug-in electric football game, with plastic players bumping across the vibrating surface, hooking at shoulders in ring dances.

And that’s only the beginning of hocus-pocus remedy for rampant head injury in American football.

While mysteries are daunting for the problem, like positive diagnosis of concussion, mere clinical intuition guides the varied protocols of diagnosis and judgment for when players are fit to compete again. No random clinical trial of legitimacy has been attempted.

The growing national setup worries Dr. Lester Mayers, concussion researcher of Pace University athletics, who joins experts like Dr. Bennet Omalu in sounding alarm over football’s touting concussion testing as valid, which is parroted by most media.

These critics warn football conducts potentially dangerous “concussion management” based on incomplete research for assessing symptoms, and many brain-injured players are prematurely returning to contact, all ages, typically within days.

Indeed, radiology techniques are demonstrating holes in concussion testing, notably of studies at Purdue University, where functional MRI reveals that sub-concussive brain injury in prep players is missed by standard external assessments through computer.

At Purdue, teen football athletes displaying brain injury through diffusion tensor imaging, an fMRI technique, are registering normal state in intuitive-grounded baseline tests and monitoring systems of neuropsychology.

Last month in Washington, lawmakers heard a military concussion test fails badly, the Website www.nextgov.com reported. The test, Automated Neuropsychological Assessment Metrics, “is insensitive and nonspecific,” said Lt. Gen. Eric Schoomaker, surgeon general of the U.S. Army. “It misses about a quarter to a third of (soldiers) who are concussed and includes about 50 percent of (those) not concussed.”

Insurance companies inform military officials that the assessments lack scientific vetting for validity and reliability, and carriers have alerted schools in Washington state that concussion testing could raise liability stakes for personnel who administer the tests in error, The New York Times reported.

Meanwhile, concussion testing takes a thrashing in independent peer review.

Current Sports Medicine Reports recently published another scathing analysis by Christopher Randolph in Chicago, professor of neurology at Loyola University, who details glaring faults in “baseline” testing of hot-selling ImPACT software employed by youth leagues, schools, colleges and pro sports. “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,” Randolph observes.

Since 2005, Randolph is among reviewers for several journals who find unacceptable rates of false-positive and false-negative results for ImPACT, among popular brain assessments developed and marketed by academics and doctors associated with the NFL and benefiting from the league’s pervasive publicity machine.

“It is a major conflict of interest, scientifically irresponsible,” Randolph told ESPN The Magazine in 2007. “We are trying to get to what the real risks are of sports-related concussion, and you have to wonder why they (NFL experts) are promoting testing. Do they have an agenda to sell more ImPACTS?”

The marketing succeeds, with sales to a thousand schools and hundreds of colleges thus far, and media only increase exposure of ImPACT in the furor over concussions, especially in football.

An overwhelming majority of journalists, politicians, educators and football experts ignore the accumulating evidence rebuking concussion testing as invalid and unreliable, choosing instead to endorse the quick-fix notion and push it for mandate by law.

“With the tools to properly manage concussions and implement safety precautions, parents, coaches and students can change the culture of school sports for the better and keep our students safe on the field and thriving in the classroom,” declared U.S. Rep. George Miller, of California.

Such rhetoric confounds Mayers. “The response is infantile,” he said. “The ImPACT people have taken over the idea that somehow they can tell you when it’s OK that the athlete goes back.”

The engineers and marketers of ImPACT, neuropsychologists Mark R. Lovell and Michael W. Collins in Pittsburgh, did not respond to questions about their product recently forwarded them. Lovell is the former NFL director of NP testing, and his consulting for the Steelers franchise spurred development of ImPACT software. Collins is on the Steelers medical staff and consults for other teams. A third partner in the product is Dr. Joseph Maroon, Steelers neurosurgeon who serves on the NFL committee overseeing concussion management.

“The topic of sport-related concussion has been highly visible in the media over the last few years… and the issue of concussion management in the NFL even has reached the point of Congressional hearings,” Randolph wrote in the January-February edition of Reports. “What consistently is missing from these debates, however, is a rational, empirically-based discussion of the true risks associated with sport-related concussion, the potential for any given management strategy to modify these risks, and the actual evidence that such risk modification can be achieved. In addition, there has been little attention paid to the clinical validity or psychometric characteristics of (computer) baseline tests, despite widespread use of these measures.”

Randolph, characterizing utility of the tool as “clinical guesswork in most cases,” concluded: “It is clear that, to date, the baseline tests used in sport-related concussion management programs lack sufficient clinical validity and reliability for their intended purpose.”

Mayers cites lack of specificity and sensitivity for NP tests on the market. “Basically, they’re all unsuitable for clinical work with concussions,” said Mayers, director of sports medicine for Pace University in New York. “They don’t have the reliability, the accuracy or the validity, the three technical terms for the use of neuro-psych work. They’ll miss 20 to 25 percent of athletes who have concussions, and this has been used by the NFL and the National Hockey League, and the NCAA is considering mandating this.”

Word is that the NCAA will soon require concussion testing of all member schools, with NFL officials and experts behind the push, and Mayers says these factors helped his department adopt computer assessment, posing a dilemma for him.

Mayers authored a 2008 review published by Archives of Neurology, concluding a concussed athlete should be sidelined at least four to six weeks, but he notes football’s current “standard of practice” for brain trauma includes NP testing and fast return to play, so he conformed at Pace. “I really believe four to six weeks (recovery time) is appropriate, but it’s not the standard of community,” he said. “So I could be sued by an athlete I held out for four weeks, if he chose to do so.”

A neurology journal has approved publication of a new Mayers review, which denounces computerized concussion assessment, he said.

More medical voices doubt concussion testing. Dr. Randall Benson, imaging expert and neurologist at Wayne State University, warned Congress last year “that neuropsychology is not an exact science,” a fact echoed by Dr. Jeffrey Kutcher, of Michigan Neurosport, testifying for the same committee. “Relying on protocols is, in my opinion, potentially dangerous, clinical protocols, as they assume that concussions are similar enough to each other to fit a predetermined paradigm,” said Kutcher, who serves on committees for the NFL and American Academy of Neurology.

Dr. Omalu, practitioner of science and law, says concussion testing amounts to “fraud” in the context of accurate, reliable diagnosis, and it can be harmful during initial days following trauma—when most injured athletes, suffering chemical disruption of brain cells, are subjected to mental strain of the programs. The online ImPACT test lasts 20 to 30 minutes and presents memory challenges involving colors, texts and forms.

“ImPACT testing is not a diagnosis tool,” said Omalu, chief medical examiner for San Joaquin County, California, and director of autopsy for the independent Brain Injury Research Institute. “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.”

Doctors outside sports medicine would agree, Omalu added, and apparently many who work in athletics, given media reports of concussed youths prescribed isolation with total layoffs ranging from a month to two years.

Dustin Fink, a certified athletic trainer in Illinois, seconds Omalu. Fink discourages computerized testing until a concussed athlete is free of symptoms such as headaches, memory loss and unsteadiness. “I use the NP tests as a baseline to educate the athlete about what some signs and symptoms could become present and as a true baseline when they think that are ready to return,” said Fink, an injury authority whose popular Website, theconcussionblog.com, serves as information clearinghouse.

Fink believes “money grab” drives overuse of concussion testing, and he generally supports Omalu’s publicized stance that longer rest is needed for concussed athletes. At Shelbyville High School, where Fink works, “we are seeing recovery times on the average of 24 days,” he said. “More and more evidence suggests that a 28 to 42-day (layoff) period may be necessary.”

In previous reports on Chaney’s Blog, Omalu has proposed concussed juvenile football players be sidelined at least three months. Omalu says NFL players should rest one to three months with diagnosed concussion, depending on severity and technology for treatment, which he advocates to be functional MRI that isn’t approved by the league.

Only sports in civilian life will quickly return the brain-injured to activity, and a practice of general medicine calls for strict isolation lasting days and longer, involving no stress mentally and physically.

In the military, researcher Craig Bryan, a psychologist and professor at the University of Texas Health Science Center, recently concluded that three days of isolation, removed from sunlight, was optimum for beginning treatment of concussed soldiers.

A neural consultant for the New York Jets once discouraged use of NP testing on a football player until symptoms abated, based on a large NCAA study he’d co-authored, and quickly found himself out of the league.

During a 2004 conference in New York, neuropsychologist Bill Barr remarked that “the research indicated that the best time to do neuropsychological tests on players with concussions was after their symptoms had completely cleared, usually five to 10 days after the trauma,” Peter Keating reported for ESPN in 2006.

Jets physician Dr. Elliot Pellman confronted Barr after the conference, and the neuropsychologist ended up losing both his job with the team and his place in league research. “NFL teams, Barr understood, preferred testing players just one to two days after a concussion, allowing for quicker diagnoses and returns to play,” Keating reported.  

Barr, of the Comprehensive Epilepsy Center at NYU, did not respond to a recent interview request.

Matt Chaney is a journalist, editor, teacher and restaurant worker in Missouri, USA. For more information, including about his 2009 book, Spiral of Denial: Muscle Doping in American Football, visit the homepage at www.fourwallspublishing.com.

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