Archive for June 8th, 2011

More of What Alan Schwarz of The New York Times Doesn’t Cover About the Inadequacy of Dr. Joseph Maroon’s ‘ImPACT’ Concussion Management

No doubt some casual readers of this blog think I’m doing an excessive metaphorical tap dance on Dr. Joseph Maroon, the visionary co-founder of ImPACT Applications, Inc., as well as the team neurosurgeon for the Pittsburgh Steelers, a widely quoted spokesperson for the National Football League’s concussion policy committee, a stalwart of the University of Pittsburgh Medical Center, partner in the company licensing the research behind the supplement Vindure, endorser of the supplement Sports Brain Guard, author of The Longevity Factor, and septuagenarian triathlete. Plus, of course, medical director of World Wrestling Entertainment, in which capacity he treats head injuries both real and imagined. Maroon is also the co-author of the NFL-funded study of a new football helmet design, and the overzealous promotion of that study by the Riddell helmet company is now under federal investigation.

These same readers may also wish I’d call a halt to my proverbial soft shoe on Alan Schwarz of The New York Times, the baseball statistical nerd who, by his own modest account, “[killed] myself for six months to expose a serious safety problem – and even conspiracy – in youth football.” Maroon praises Schwarz in The New Yorker, Schwarz quotes Maroon uncritically in The Times, and Schwarz tells me flatly that Maroon is a not an issue in the larger national sports concussion scandal, “for reasons of which you are totally unaware.”

I point these readers and others to author-journalist-blogger Matt Chaney’s January 28 post, “Brain Expert Omalu Wants Longer Rest for Concussed Football Players,” http://blog.4wallspublishing.com/2011/01/28/brain-expert-omalu-wants-longer-rest-for-concussed-football-players.aspx.

The subhead of Chaney’s article: “Sideline concussed juveniles for three months, says the breakthrough neuropath; Neuropsychological testing lacks validation and might be harmful, critics caution; NFL players rebuke theory of ‘safer’ football through their ‘behavior modification’”

Here’s most of the section headed “Critics Doubt Efficacy of NP testing for concussion diagnosis, ‘return to play’”:

Today’s general view that concussion management works or can work in tackle football is rendered highly suspect, if not effectively discredited, by independent review and mounting adverse opinion of experts and witnesses like players.

Linebacker Fujita notes he hasn’t been measured on neural baseline for two NFL seasons. Might not matter, anyway, for NP testing has taken a systematic beating by reviewers of late. Observations and findings of medical literature from 2005 to 2010, listed without full author groups or first names, include:

*Randolph et al, 2005, for Journal of Athletic Training: “Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion, no NP tests have met the necessary criteria to support a clinical application at this time. Additional research is necessary to establish the utility of these tests before they can be considered part of a routine standard of care… until NP testing or other methods are proven effective for this purpose.”

*Patel et al, 2005, for Sports Medicine: “Numerous guidelines have been published for grading and return-to-play criteria following concussion; however, none of these have been prospectively validated by research and none are specifically applicable to children and adolescents.”

*Mayers, 2008, for Archives of Neurology: “Current guidelines result from thoughtful consensus recommendations by expert committees but are chiefly based on the resolution of symptoms and the results of neuropsychological testing, if available. Adherence to this paradigm results in most injured athletes resuming competition in 1 to 2 weeks.”

*Duff, 2009, for ASHA Leader: “Indeed, the identification and management of concussion has become a growing public health issue. Considered to be the fastest-growing sub-discipline in neuropsychology, concussion management poses unique challenges and opportunities for those working with school-aged children. … There is no consensus on the best course of action for concussion management. In fact, there are as many as 22 different published guidelines for grading concussion severity and determining return to play. … Developers are working to collect data regarding reliability, validity, and clinical utility of these (NP) tools; independent replication is still forthcoming.”

*Echemendia et al, 2009, for British Journal of Sports Medicine: “Post-injury assessment requires advanced neuropsychological expertise that is best provided by a clinical neuropsychologist. Significant international differences exist with respect to the training and availability of clinical neuropsychologists, which require modification of these views on a country by country basis.”

*Covassin et al, 2009, for Journal of Athletic Training: “…little is known about the use of baseline neurocognitive testing in concussion assessment and management. … We found that the majority of ATs (athetic trainers) are interpreting ImPACT results without attending a neuropsychological testing workshop. … The use of baseline-testing, baseline testing re-administration, and post-concussion protocols among ATs is increasing. However, the ATs in this study reported that they relied more on symptoms than on neurocognitive test scores when making return-to-play decisions.”

*Maerlender et al, 2010, for The Clinical Neuropsychologist: “Although computerized neuropsychological screening is becoming a standard for sports concussion identification and management, convergent validity studies are limited.”

*Piland et al, 2010, for Journal of Athletic Training: “Obtaining (self-reported symptom) statements before a concussion occurs assists in determining when the injury is resolved. However, athletes may present with concussion-related symptoms at baseline. … In other words, some post-concussive symptoms occur in persons who have not sustained concussions, rendering the specificity of alleged post-concussive symptoms suspect.”

*Schatz, 2010, for American Journal of Sports Medicine: “Computer-based assessment programs are commonly used to document baseline cognitive performance for comparison with post-concussion testing. There are currently no guidelines for how often baseline assessments should be updated, and no data documenting the test-retest stability of baseline measures over relevant time periods.”

*Comper et al, 2010, for Brain Injury: “Despite the proliferation of neuropsychological research on sports-related concussion over the past decade, the methodological quality of studies appears to be highly variable, with many lacking proper scientific rigour. Future research in the area needs to be carefully controlled, repeatable and generalizable, which will contribute to developing practical, evidence-based guidelines for concussion management.”

*Eckner et al, 2010, for Current Sports Medicine Reports: “The sports medicine practitioner must not rely on any one tool in managing concussion and must be aware of the strengths and limitations of whichever method is chosen…”

Unfortunately, software packages like ImPACT, long criticized for its direct connections to the NFL, are widely employed as cornerstone for concussion evaluation and typically by untrained clients, as literature and news reports confirm.

 

Irv Muchnick

Near-Death in Japan Pro Wrestling, With Real Fallout

Other developments have kept me from staying on top of the harrowing recent incident in pro wrestling in Japan, from which a veteran performer remains in critical condition after getting beaten up by a younger wrestler in the dressing room prior to a match – on top of having taken at least one hard chair shot to the head on earlier shows. See the coverage at Cageside Seats by Keith Harris:

The story here combines elements of two appalling episodes at World Wrestling Entertainment that I covered last year. One was the near-death of WWE legend Ricky Steamboat. See “Watch Linda McMahon’s Wrestler Ricky Steamboat Get Beaten to Within an Inch of His Life Last Month on ‘Raw’ by Inexperienced Fellow ‘Soap Opera’ Cast Members,” July 22, 2010, https://wrestlingbabylon.wordpress.com/2010/07/22/watch-linda-mcmahon%E2%80%99s-wrestler-ricky-steamboat-get-beaten-to-within-an-inch-of-his-life-last-month-on-%E2%80%98raw%E2%80%99-by-inexperienced-fellow-%E2%80%98soap-opera%E2%80%99-cast-members/, plus earlier coverage.

The other was the de facto manslaughter of WWE’s Lance Cade – who, as private punishment for a breach of dressing-room etiquette, was punished on live TV with more than a dozen chair shots (including a stiff one to the head in a move supposedly banned a year earlier). Cade fell into prescription painkiller addiction and died two years later. See “WWE Hall of Famer Shawn Michaels Should Speak Up on What Happened to Lance Cade,” February 14, https://wrestlingbabylon.wordpress.com/2011/02/14/wwe-hall-of-famer-shawn-michaels-should-speak-up-on-what-happened-to-lance-cade/.

 

Irv Muchnick


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