Concussion Inc. (14 page)

“Health care is booming business in Western Pennsylvania,” says the
Pittsburgh Tribune-Review
:

The industry's impact in the region last year was $15.8 billion, and health care employed more than 112,000 workers, according to a report published by the Hospital and Healthsystem Association of Pennsylvania. The number represented 10.5 percent of the total workforce in Allegheny, Westmoreland, Washington, Beaver, Butler, Fayette, Armstrong, and Green counties.

Health care continues to dominate the local landscape as UPMC and West Penn Allegheny Health System, the two largest providers, fight for patients and insurance customers in the region.

Highmark Inc., the region's largest insurer, has ­proposed acquiring West Penn Allegheny for $475 million. Because of that merger, UPMC intends to terminate agreements between its doctors and ­Highmark.
13

UPMC owns 19 hospitals and had 2011 operating revenue of $9 billion — up from $8 billion in 2010. “The system employed 54,000 people in Western Pennsylvania, including more than 5,000 physicians. Its hospitals admitted and observed more than 234,000 patients. CEO Jeffrey A. Romoff earned $4 million in 2009, according to public tax disclosures.”

The part about the UPMC turf war with West Penn Allegheny Health caught my eye. In 1999, Dr. Maroon made regional business news when he and his celebrity-studded practice at Allegheny General Hospital — West Penn Allegheny Health's flagship — jumped to UPMC.

As it happens, last October I was contacted by Dr. Jack Wilberger, the neurosurgery chair at Allegheny General and a vice president of West Penn Allegheny Health. “Our Concussion Center is becoming more robust as more and more realize the issues you describe,” Wilberger told me. I have since noticed that Wilberger occasionally lands a dissenting quote in the Pittsburgh press coverage of UPMC's management of hockey star Sidney Crosby's long recovery from a series of concussions.

None of this should be taken as an endorsement of Jack Wilberger; I don't know Jack Wilberger from Jack. But “health care is booming business in Western Pennsylvania.” That much I know.

6 March 2012..........

The UPMC media relations department never responds to my inquiries, and that hurts my feelings. Peer-reviewed studies show that I get between 30.07 and 43.24 percent madder than baseline every time UPMC flacks ignore me.

However, the indefatigable Dustin Fink of the
Concussion Blog
yesterday did receive an unsolicited email from Chuck Finder, who joined the UPMC staff recently after years as a sportswriter for the
Pittsburgh Post-Gazette
.

Last week Fink wrote an unflattering analysis of UPMC's hype of its new “concussion recovery predictor” model.
14
Whereupon Finder contacted Fink. Below, as a public service, I reproduce Finder's entire message, including the memo from UPMC's Brian Lau responding to Fink's questions.

In Nos. 1 and 5, Lau asserts that symptoms such as fatigue and headache can exist without concussions and are sometimes confused with them. Of course, the same point makes the “sensitivity” percentage claims for the ImPACT system — to the hundredths of a percent! — meaningless. We have no way of knowing if concussion symptoms are abating or if mere “concussion-like symptoms” are abating. Two can play this circular logic game.

In No. 4, UPMC explains that its recovery-predictor study has no “traditional control group.” English translation: There is no control group.

Dustin,

First, please allow me to introduce myself. My name is Chuck Finder, and in my previous life as a sports writer I penned more than a few concussion ­stories/series in my 25 years at the
Pittsburgh Post-Gazette
. I joined UPMC in mid-January to help represent their Sports Medicine and Concussion Program work.

Folks here noticed your Feb. 29 blog questions prompted by their Cut-Off Study news release, and Brian Lau — one of the co-investigators — typed up answers for you.

Use them however you choose: They can be for your edification solely or, if you wish, you have UPMC's approval to post them as they are …

Chuck Finder

UPMC Media Relations

*****

[BRIAN LAU MEMO]

1. Why would you neurocognitive test anyone with ­symptoms, while still recovering?
   

   The symptoms after a concussion — fatigue, headache, etc. — are non-specific findings that may or may not represent a concussion. Moreover, some athletes have some of these same symptoms at baseline. Neurocognitive testing has traditionally been used to determine the presence or absence of a concussion. This study adds to other preliminary evidence that neurocognitive testing while an athlete has symptoms during recovery may also assist in predicting length of recovery. A previous study showed that symptoms used alone had a 40.81% sensitivity in predicting protracted recovery. When neurocognitive testing was used with symptoms, the sensitivity in predicting protracted recovery increased to 65.22%.
   

2. Are the numbers based upon the ImPACT “norms” or a baseline calculation?
   

   There are no numbers in this study requiring the use of norms or baseline calculations. We used the numbers from the first ImPACT tests and determined cutoffs off that.
   

3. Is this experiment repeatable with other measures?
   

   This is the first study to attempt to set cutoffs for prognosticating return to play early after injury. As recommended in the discussion section, we hope that this study encourages other groups to conduct similar studies to evaluate the value of cutoff scores.
   

4. Where are the control groups?
   

   It should be noted that this was an observational study that followed athletes, whom underwent a structured recovery program. It was not designed to compare two different diagnostic modalities or treatment intervention. Therefore, the traditional control group vs. study group that compares traditional practice with a novel diagnostic tool or treatment is not represented in this study. However, recovery from a sports concussion usually takes less than 14 days. In this study, the athletes were divided into protracted and short-recovery based on this time frame. As such, the short-recovery group may be considered the control group because it represents the natural recovery time following a sports concussion.
   

5. Is the accuracy of ImPACT that sensitive (is there even one accurate enough to make this assessment)?
   

   ImPACT testing has been shown previously to have a high degree of sensitivity (81.9%) and specificity (89.4%) in diagnosing concussions (Shatz et al.,
   Arch Clin Neuropsychol
   , 2006). The sensitivity and specificity in prognosticating the recovery time following a concussion has only recently been studied. A recent study showed that when ImPACT testing and symptoms were evaluated together, there was a sensitivity and specificity of 65.22 and 80.36%, respectively. The effectiveness of ImPACT testing as a prognosticating tool should be further validated and we hope that this study will encourage others to do so.
   

6. What did each individual do for management of the concussion in the two days?
   

   All athletes were followed by certified athletic trainers who made the initial on-field diagnosis of a concussion. These certified athletic trainers were also trained in the graded extertional activity protocol used in this study which requires athletes to be symptom free at rest and to be cleared by clinical concussion specialists. Therefore, in the time frame prior to initial neurocognitive testing (mean: two days), athletes were kept out of practice and game situations.
   

25 September 2012..........

The
Pittsburgh Post-Gazette
is in the middle of examining how “UPMC has come to dominate Pittsburgh's landscape, much like the steel industry did.”

Part 1 of the series includes the following account of a questionable land deal between UPMC and my favorite physician-piñata, Dr. Joseph Maroon, in 1999, the year Maroon was recruited away from Allegheny General Hospital:

Dr. Maroon also was a prolific real estate investor and had bought about three dozen parcels on the North Side.

At the same time UPMC announced that Dr. Maroon was coming to work for the hospital, the surgeon sold UPMC a group of his properties for $5.2 million — real estate which cost him a fraction of that to acquire.

UPMC still owns all but two of the parcels it bought from Dr. Maroon in the deal. But 13 years after UPMC completed the transaction, the property is valued about $1 million less than the purchase price.

In 1999, both UPMC and Dr. Maroon denied there was any tie between his move to UPMC and the purchase of the property.

Dr. Maroon did not return calls seeking comment for this story.
15

Give that
Post-Gazette
reporter, Sean D. Hamill, an ImPACT baseline test at once!

19 October 2012..........

The feds have indicted Dr. Joe Maroon's former UPMC and Pittsburgh Steelers colleague, Dr. Richard Rydze, for human growth hormone trafficking.

Rydze made six-figure purchases of HGH by credit card from internet gray-market drug dealer Signature Pharmacy. He was busted by ESPN's Mike Fish.
16

..........

1
sports.espn.go.com/espn/otl/news/story?id=4724912
.

2
The interview is viewable at
youtube.com/watch?v=g8jqCZ4yUrs
.

3
See
www.thepostgame.com/features/201101/tpg-exclusive-nfl-orders-raiders-head-coach-hue-jackson-end-ties-company-linked-bann
.

4
See Maroon's piece of the hype at
www.sportsbrainguard.com/sbg.aspx
.

5
www.nytimes.com/2011/01/23/sports/football/23helmet.html?ref=sports
.

6
blog.4wallspublishing.com/2011/04/23/critics-evidence-debunk-­concussion-testing-in-football.aspx
.

7
Video was originaly available at
nflhealthandsafety.com/2011/01/20/performing-a-neurological-exam/
.

8
Video was originaly available at
nflhealthandsafety.com/2011/07/13/dr-ellenbogen-on-concussions/
.

9
www.theintelligencer.net/page/content.detail/id/557704/-Sunday-Sit-Down—TODAY-S-GUEST–Dr–Joseph-Maroon.html?nav=510#.Tj_rrgQagV0.twitter
.

10
“Concussions Take a Terrible Toll on America's Young Athletes,” by Steve Jansen and Gus Garcia-Roberts,
www.laweekly.com/2011-08-18/news/concussions-take-a-terrible-toll-on-america-s-young-athletes/
.

11
www.mlive.com/sports/jackson/index.ssf/2011/10/orthopaedic_rehab_specialists.html
.

12
The documents are available at
muchnick.net/upmcgrantyr1.pdf
, ­
muchnick.net/upmcgrantyr2.pdf
,
muchnick.net/upmcgrantyr3.pdf
,
muchnick.net/upmcgrantyr4.pdf
,
muchnick.net/upmcgrantyr5.pdf
.

13
www.pittsburghlive.com/x/pittsburghtrib/business/s_779870.html
.

14
See
theconcussionblog.com/2012/02/29/upmc-and-recovery-predictor/
.

15
www.post-gazette.com/promohomepage/2012/10/02/PG-Special-­Report-UPMC-Forging-a-Giant-Footprint-1/stories/201210020227
.

16
sports.espn.go.com/espn/otl/news/story?id=3831956
.

CHRIS NOWINSKI AND ALAN SCHWARZ

8 March 2011..........

Having lambasted Dr. Joe Maroon for his sundry commercial associations, I cannot fail to explore a controversy last week sparked by articles in the Boston business press reporting that Dr. Robert Cantu had some kind of advisory status with the innovative Xenith helmet company. Cantu, of Boston University, the physician who diagnosed Chris Nowinski's concussions prior to the launch of his Sports Legacy Institute, is one of the leading lights in chronic traumatic encephalopathy research. Fasten your chinstraps for a complicated tale of hype in the world of venture capital.

I am not alleging here the kind of blatant corruption suggested by the deep-seated symbiosis of Maroon with the Pittsburgh Steelers, the NFL, WWE, UPMC, ImPACT, the unregulated supplements Vindure and Sports Brain Guard, and the Riddell Revolution helmet. That particular custodian of the Hippocratic oath has turned himself into a walking infomercial.

But do Cantu and Xenith themselves pass the “Caesar's wife” test of discouraging even the appearance of impropriety? You decide.

Xenith, LLC is a Lowell, Massachusetts, based company started by Vincent Ferrara, who played quarterback at Harvard in the 1990s and, indeed, lost most or all of one season to a concussion. (He happened to be four years ahead of Nowinski at Harvard.) Ferrara then got his M.D. and, upon finding himself most interested in the business side of health care, his MBA at Columbia.

I am not an expert and I have no opinion on the benefits of Xenith's helmet model. If it has the potential to prevent injuries and save lives, then great. In a phone conversation with me last Thursday, Vin Ferrara said all the right things about the primacy of education — how no piece of head hardware can substitute for safer playing technique and a smarter athletic mindset.

In a 2007
New York Times
story on Ferrara's company — written by concussion beat writer Alan Schwarz — Dr. Cantu said a good bit more.

Schwarz's article asserted that the Ferrara helmet's 18 thermoplastic shock absorbers filled with air “can accept a wide range of forces and still moderate the sudden jarring of the head that causes concussion.” In addition, unlike traditional foam helmet lining, the disks do not degrade after hundreds of impacts, according to laboratory tests.

Cantu told the
Times
this was “the greatest advance in helmet design in at least 30 years.” He was identified as an informal advisor during the helmet's development with “no financial relationship with the product.”

In September 2010, Xenith issued a press release announcing it had raised $10.5 million in equity financing. The release cited the marketing inroads of the company's X1 football helmet. Dr. Cantu was nowhere mentioned.
1

However, until very recently — that is, some time past the September round of PR — Cantu was still on the Xenith website (Xenith.com). Ferrara told me that Cantu had asked that references to him be removed several months ago.

By law, Xenith was required to submit paperwork to the Securities and Exchange Commission about its $10 million financing threshold; the filing became public on February 25. Three days later — a week ago Monday — a spate of articles about Xenith appeared in online versions of Boston business magazines. Citybizlist.com, for example, wrote:

Xenith helmets have been recorded to reduce the risk of concussion by as much as 60%, and players have reported a 70% reduction in the incidence of headaches. Xenith advisor Dr. Robert Cantu, co-director of the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine and one of the nation's leading experts in concussion management, called it “the greatest advance in helmet design in at least 30 years.”
2

The
Boston Business Journal
and its offshoots also erroneously reported (and subsequently retracted) NFL Hall of Fame quarterback Warren Moon's participation in the Xenith investment group.

Ferrara shared with me his email to the leadership of the National Operating Committee on Standards of Athletic Equipment, in which he said he had “absolutely no idea why anything came out today, and Xenith had no involvement in this whatsoever… . [Xenith's September press release] in no way mentions concussions, concussion reduction, the NFL, Warren Moon, Bob Cantu, or anything else that is being printed in these recent posts. I have received numerous calls, emails, etc., about these releases, and I am truly baffled as to how this transpired. I have already emailed Jeff Pash [NFL attorney] to inform him of this as well.”

I also spoke last Thursday with Cantu, who reinforced that he has never been a paid advisor for Xenith. “Have I talked with people from that company about their products? Yes. I do that with a lot of companies,” Cantu said. “But I have not received money from any of them.”

I'm not sure what to make of all this. In my experience, business journalists don't ordinarily have the enterprise to research and publish deep backgrounders with short turnarounds — let alone inaccurate ones — every time a company makes a routine SEC filing.

I also think that, while the root 2007
Times
article carefully disclaimed Cantu's equity interest in Xenith, the story as a whole smells of social networking in the old-fashioned sense — the kind involving Ivy League elites well practiced in planting high-toned hype in the Newspaper of Record. Would a start-up elsewhere located and with a worse-connected CEO have been able to get this kind of ink?

It was wrong for Riddell Helmets, aided by NFL-funded research conducted by Joseph Maroon, to be making the kinds of statistical safety claims now under investigation by the Federal Trade Commission.

It was also wrong for Robert Cantu and Xenith to have gotten mixed up in their own brand of fledgling and unverifiable braggadocio.

As the public witnesses a statistically significant population of athletes dying young, often by their own hands, leading doctors cautiously emphasize how much is yet to be understood about the scope and magnitude of traumatic brain injury in contact sports. I just wish the same doctors would be correspondingly modest about the commercial products designed to mitigate it.

18 May 2011..........

The
New York Times
and the
New Yorker
are responsible for elevating the concussion issue from the sports pages to the national agenda. However, in my view, they frame the story inadequately.

The
Times
would prefer to spur much too gentlemanly an outcome: a reprise of President Teddy Roosevelt's football reforms of a century ago. The problem is that this sport and associated ones are no longer character-building rituals by Ivy League elites buffing their résumés in anticipation of careers on Wall Street and in other ruling-class institutions. Football today is a global multi-layered mega-industry. The urgency of reducing the human toll of this culture, across all classes and races, exceeds the scope of legislating helmets or any other piece of hardware, or mumbling bromides about changing the way that players block and tackle.

In its January coverage of the controversy surrounding Riddell helmets, the
Times
quoted Dr. Maroon — co-author of the
Neurosurgery
article that was the basis for the company's promotion — as claiming Riddell quoted him out of context. But Maroon was not asked if he ever so complained, in public or in private, prior to the initiation of a Federal Trade Commission investigation of Riddell.

In his January article in the
New Yorker
, “Does Football Have a Future?”, writer Ben McGrath quoted Maroon as calling the
Times
' Schwarz “the Socratic gadfly in this whole mix.” Maroon added, “What we're seeing now is [a] major cultural shift, and I think Alan took a lot of barbs, and a lot of hits, initially, for his observations.”

26 May 2011..........

Chris Nowinski has done valuable work on the concussion crisis in sports. That work is also limited and flawed.

He is the subject of a profile in today's edition of the
Harvard Crimson
, the student newspaper of his alma mater.
3
Clearly and deservedly,
Crimson
reporters Emily Rutter and Scott A. Sherman take note of Nowinski's value. They may not realize that the Old Ivy orientation of their account also reveals his limitations and flaws.

The story has it all: Nowinski's Harvard and football pedigree; his fascination with and employment by World Wrestling Entertainment — which led to his debilitating, career-ending concussions; and his decision to write a book about brain trauma in sports and start the Sports Legacy Institute.

The revealing passage, from my perspective, was this:

With the help of Alan Schwarz, at the time a freelance sportswriter for the
New York Times
, he got in touch with publishers.

“I thought his manuscript was great,” says Schwarz, who had written one book on baseball statistics and was working on another.

As I reflect on what I find both inspiring and dissatisfying about Nowinski's career advocacy, the (obviously indispensable) Schwarz/
Times
connection is instructive. It reminds me very much of the phenomenon surrounding
Freakonomics: A Rogue Economist Explores the Hidden Side of Everything
, a 2005 bestseller by Steven Levitt and Stephen J. Dubner.

For my money,
Freakonomics
is a pedestrian book, but my opinion doesn't matter. In any case, I'm more interested in the process of its creation.
Freakonomics
grew out of a profile of Levitt by Dubner in the Sunday magazine of the
New York Times
. The two Steves then decided to collaborate on a book. And get this:
the epigraph of every chapter of the book wound up being a quote from Dubner's
Times
magazine
profile of Levitt.

Talk about a hall of mirrors!

I wish Nowinski the very best, both with his brave personal battle to survive post-concussion syndrome, and his likely as-yet-­undiagnosed own case of chronic traumatic encephalopathy, and with his campaign to spread the word about and temper the brutality of football and other sports.

However, with respect to the latter, I also observe that his voice is skewed, at times even muted, by his ready access to the resources of both our Newspaper of Record and the National Football League (the latter thanks to a $1 million NFL grant to the Sports Legacy Institute's sister Center for the Study of CTE at Boston University Medical School). You can see it in the increased corporatization of SLI's message and in the current carefully adumbrated coverage by the
Times
of football helmet safety and promotion. So much more remains unsaid: the accounting for the tobacco-level scandal of NFL-branded research over the last generation, and the structural solutions we must be devising as a society, outside of willy-nilly litigation on behalf of the many lives ruined and prematurely ended by this system.

Above all, I'm convinced there is a need for more than just Chris Nowinski's voice on this critical issue.

27 May 2011..........

Today I received the following email, with the subject line “What you don't know”:

is that all I did — based solely on the public-interest aspect of his message, and long before I was even an employee of the
Times
— was introduce him to a few people. And they quickly blew him off. He didn't find a publisher for his book for another 12 months, and completely independent of me.

More importantly, your comparison to Leavitt and Dubner is incorrect, misleading and borderline ­offensive. (Despite the fact that both of them are friends of mine.) Regardless of how they might have met, those two are collaborators and business partners, and make no bones about it. Your strong implication that Chris and I are either of those two things is something I recommend you correct.

Third, and most serious, your characterization of the
Times
coverage as “carefully adumbrated” — which, I'm assuming for now that you know, means presented somewhat incompletely in an effort to be vague or misleading. As far as I know your concern with the ­coverage stems only from your Maroon-­connection-to-Riddell-study issue. Even if that were an issue, which I know it is not for reasons of which you are totally unaware, you have some nerve casting the entire work that way.

I kill myself for six months to expose a serious ­safety problem — and even conspiracy — in youth football, cause sweeping changes (some about to be announced) and investigations by the CPSC and the FTC, and you sit back and decide that one small issue you think you've found with it makes it “carefully adumbrated”? Wow.

I am not above criticism. But misinformed and careless criticism pisses me off. When you accomplish one-tenth of the good for the world and kids that I — or for that matter, Chris — have on this subject, then you'll really have something.