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Outside the Lines: Concussions: What Doctors and Players Know and Don't Know
But when the topic is concussions, injuries to the human brain, it is more important to understand what we do not know. One thing doctors must understand is the overpowering will of the elite athlete to compete, to win regardless of the injury, no matter the consequences.
One leading player who has battled multiple concussions would nearly pass out at practice following his return. He would lean on nearby players for support until his dizzy spells passed. His teammates were sworn to secrecy. And the doctors never found out.
In several hours, Troy Aikman returns from his ninth concussion. Until now, Aikman had the final decision upon his return. That has now been taken from him.
Aikman says he has never ignored medical advice on when to return from a concussion. But a source close to the team tells ESPN Aikman did exactly that last year, leading to his second concussion in two weeks.
The dangers and the unknowns of this injury to the brain are examined now by Mark Schwarz.
Mark Schwarz, ESPN Correspondent: Troy Aikman has had nine concussions. But doctors can't competently say how much punishment Aikman's brain can take. Nor do they know how many concussions is too many or when it is safe to return to the field after a concussion.
In fact, scientists don't agree about what exactly a concussion is.
Mark Lovell, PHD, Neuropsychologist, UPMC: That's one of the things we've been battling against over the last 10 years or so is that there are some different definitions of concussions floating around out there. And we're all trying to get on the same page.
Collins: With a concussion, you're not going to have the pain to tell you what's going on. You're going to have these sometimes difficult-to-understand symptoms.
Dr. Joseph Maroon, Pittsburgh Steelers neurosurgeon: If you have a fracture of your elbow, it's very obvious. But in the brain, it isn't obvious.
Schwarz: What makes concussion management so difficult is that there is so little data. And experts say they don't know a doctor or trainer who doesn't have some degree of uncertainty about just when it is safe to return a concussed player to action in a contact sport.
Dr. Charles Burke, Director, NHL concussion program: Trying to tell Troy Aikman with objective, clear evidence of whether he can play or not, we unfortunately don't have that type of information because when you're dealing with the brain, we don't have tests currently to measure the functioning of the brain, or in this case the malfunctioning of the brain.
Lovell: We don't know exactly what number you have to have to have significant problems. But we do believe that it's not good to continue to have concussions.
Schwarz: But not all concussions are created equal. Outside The Lines reviewed the medical records of a high school senior from western Pennsylvania who suffered his first and only concussion last month in a football game. The player did not exhibit the classic signs most high school team doctors and trainers associate with concussion. He never lost consciousness, did not experience amnesia, and his CT scan was normal.
Voice-over: Four weeks after his injury, he came to the University of Pittsburgh Medical Center, where doctors have developed a neuropsychological exam which they feel is most valuable with younger athletes. The test revealed dramatic deficits in memory, processing speed, and reaction time. Though doctors called this a temporary decline, they were stunned by the numbers, 40 percent below expected brain function.
Collins: It's like giving the brain a physical. We do it with the knee and the ankle and hernia. You know, you've gone through a physical before. Why not incorporate baseline neuropsychological testing for the brain, the most important organ we have?
Schwarz: Doctors here at the University of Pittsburgh Medical Center have already gathered baseline data from thousands of high school and college athletes around the nation, data that can later be used for post-concussion comparison.
The NHL has mandated baseline testing since 1997. The NFL has not made it mandatory.
And according to the league, Dallas is one of between two and four teams that has not begun collecting data. In fact, Aikman was tested this off season for the first time after already sustaining eight concussions.
Aikman: I don't know that anybody can really say that one week is enough time. Is two weeks enough time? It's just such an abstract amount of time that they say to wait.
But nobody really knows. Nobody even knows what the long-term effects of concussions are.
Schwarz: A researcher at the University of North Carolina who recently concluded an exhaustive study on concussions suggests it would not be out of the realm of possibility that in his early forties, Troy Aikman's brain might be as dysfunctional as former boxer Jerry Quarry's (ph). Remember, Quarry was afflicted with pugilistic dementia.
Steelers neurosurgeon Dr. Joseph Maroon calls that pure speculation.
Maroon: There is no way that I or any physician that I know can be absolutely definitive and say that this behavior will absolutely lead to permanent brain damage. Troy Aikman could have Alzheimer's Disease. He could develop a heart attack. He could develop a stroke. He could have any number of catastrophic problems occur in 10 or 12 years totally unrelated to his concussions.
Jerry Jones, Cowboys owner: I'm comforted by the fact that every study that we've been privy to, and the things that Troy has looked into, is that there is no evidence of any long-term, lasting impact from the head trauma that he's suffering right now. That's encouraging.
Aikman: I'm a football player first. And I think right now that I don't feel that the risks outweigh the enjoyment that I still get from playing.
Merril Hoge, ESPN NFL analyst: I understand the thinking of the passion towards the game. But it also tells me he doesn't truly understand. He hasn't been in his home and then went to a restaurant he's went to 100 times and not been able to get home three weeks after a concussion like I was. I mean, I was completely lost in this world.
Schwarz : Merril Hoge is a former NFL fullback. After being cleared to play, Hoge suffered a career-ending concussion just weeks after a previous head injury. This summer, he won a $1.55 million judgment against a former Chicago Bears physician.
Six years after his injury, Hoge says he cannot get through two paragraphs of a newspaper without losing his concentration. What would Hoge like to tell Aikman?
Hoge: I know he was just recently married. And probably children are part of that future. I mean, do you want to enjoy your children? Do you want to remember your child's name? I mean, do you want to be able to go to their school and be able to get back to your home by yourself?
Schwarz: Until last November when he suffered his eighth, Troy Aikman never missed a game following a concussion. But Aikman confirmed his concussions are now being treated differently. The decision about when he can safely return is no longer a matter of him telling the team he's ready. The decision now involves the team as well.
For Outside The Lines, I'm Mark Schwarz.
Ley: And when we continue, I'll be discussing concussions and player safety with Merril Hoge, also with a long-time NFL executive, and with a leading expert on the treatment of concussions, all on Outside The Lines.
Ley: Our topic is concussions. And joining us this morning from ESPN Headquarters, Merril Hoge, whose eight-year NFL career ended with two concussions during the 1994 season. Merril works for ESPN as an NFL analyst.
From Houston, CharLey Casserly, the general manager of the expansion NFL Houston Texans. He spent 22 years in the front office of the Washington Redskins.
And from Morgantown, West Virginia, Dr. Julian Bailes, chairman of the Department of neurosurgery at West Virginia University.
Dr. Bailes, we just heard Troy Aikman say no one even knows what the long-term effect can be. What part of your professional soul is worried about him coming back into action today?
Dr. Julian Bailes, Chairman, Department of Neurosurgery, West Virginia University: Well, we do know that there are some players who have gone on to have significant problems. And we have completed and set up the Center for the Study of Retired Athletes at the University of North Carolina in conjunction with the NFL Players Association and the West Virginia School of Medicine.
In our preliminary study of 1,200 retired players, we found that the ones who had a lot of concussions during their career, a higher number than we would have expected have gone on to have problems as they've gotten older.
Ley: So I'm a layman. I hear nine concussions. Aikman is coming back. He never missed any playing time until late in this series of concussions. Do you believe he should be coming back? And I know you're not his doctor and you haven't seen his charts, but what does your medical head tell you?
Bailes: Well, I think it's cause for concern. Of course, that's his personal decision with his family and his physicians and his team.
But yeah, I think it is cause for concern. And we found that if you have over four concussions during your professional career that it may be a higher incidence of problems as you get older.
But there's a lot of factors. There's a lot still we don't know of course about the long-term effects.
Ley: CharLey Casserly, should a player like Troy Aikman had until just recently, should a player have the final signoff on whether he can play?
Charley Casserly, Houston Texans General Manager: No, I don't think he should. I think the medical people should have the final say.
Now saying that, do the medical people have enough knowledge to make that decision? That would be my question to the doctor.
When we were with the Redskins, we took it out of the player's hand and put it into the doctor's hand as much as you could. Now you had an example here of an unnamed player who had symptoms. The doctor never knew about it. So you'd like to have the doctor make that decision if he has all the information available to him that he needs.
Ley: Merril, what about the will of players who will do anything to get on the field? In fact, the jury in your case could have awarded you more money. But they said that you didn't necessarily report all the symptoms.
Hoge: Oh, and that's one of the problems I think with this, Bob, as you look at the cognitive testing I know that Dr. Bailes and Maroon and Dr. Lovell were part of. I think that kind of helps take away some of the lying that's going to go on with athletes.
On the cognitive testing, a player can't lie with that. I think that there's a baseline that they have. When they go back to compare it, it helps them maybe reevaluate how significant the concussion was, how long the symptoms are lasting.
I think the most important thing with all of this, so much is talked about what they don't know and what we don't know, there's one thing that nobody can argue about. The brain is your most vital organ. It should be treated as such.
You know, being cleared and be asymptomatic for seven days, having follow-up, I mean, those are important things that should happen to athletes. For as much as they don't know that he is completely cleared before he returns back to play in a sport that is going to be contact immediately when he steps on even the practice field.
Ley: You mentioned baseline testing. Troy Aikman had baseline testing, but only following his eighth concussion.
Jerry Jones, the owner of the Cowboys, we should point out we invited him to appear this morning, but he was unavailable. Jones says that he does not advocate baseline testing for all players. Let's listen to his comment here.
Jones: What we do in every case is get any player the very best medical diagnosis and the very best medical advice that he can get. I want to remind you that every player can and does go get third parties and fourth parties to give them an evaluation on their physical injury or their illness. That's as it should be.
Ley: But, Dr. Bailes, Jerry Jones says he doesn't believe in mandatory baseline testing. Do you?
Bailes: Oh, I would have to argue with him and say that the medical and scientific literature differs from that and has shown that the baseline testing is vital to determining if a player really has abnormal tests later.
Ley: How much would that cost? It's not mandatory. There are a handful of NFL teams that don't do it. What would it cost an NFL team, or even the league to do it at the combine, to test every incoming player so they have a starting point on brain function?
Bailes: Minimal. I don't know, $1,000 or something. I mean, the testing has been computerized now. It's very easy to administer.
But the cost is negligible. The reward is so much out of proportion to what it would cost. It's the effort and the determination to look at it in a different way I think which is required.
Ley: Merril, there's a controversy on the field right now in the National Football League. There are some new lighter helmets out there. Some players are wearing them. Some have given them up because they have seen cracks in them. In fact, the Giants' trainer and the Dolphins' trainer are advising their players not to wear them.
Have you talked to any players about that? What do you make about this and the level of player knowledge on this problem?
Hoge: Well, player knowledge I think is improving. You know, you talk about the equipment. Anytime we can advance equipment, that's going to help.
But truly understand the brain. I mean, the helmet is to protect the skull. It doesn't protect the brain.
I mean, concussions are going to be part of this game. So the more we can educate and evaluate the player and the doctors, I think it's imperative.
And, Julian Bailes, you were talking about the cognitive testing that Jerry Jones is against. I mean, that is ridiculous. That is the one way doctors and players can go back and look at it on paper and say, "Listen, you say you feel great. And you may look good. But look at your testing."
I mean, it's something that you have concrete evidence to show the player and say, you're not where you need to be. And with the brain, you've got to be functioning at a high level where you were when you hadn't had that concussion.
I think that's ridiculous. That's one thing that the doctors can utilize to support when they say, "You know what, you can't play for another two weeks."
Ley: I know, CharLey, you're beginning a brand new team, a lot of policies being put into place. Do you have an initial feeling on whether your medical staff will have baseline testing with the Texans?
Casserly: Well, I really can't answer that from this point of view. We haven't gotten to the point of interviewing people and making those decisions.
I think what's said by Merril as a player, what's said by the doctor is common sense. I would think that we'll probably end up doing it. I think the advantage we'll have is in two years there will be a lot more information than there is available today.
And I think the testing will be better, and we can learn more about baseline testing because there has been some disagreement in the past about that. But in two years, I think all of us are going to be a lot smarter on this.
Ley: We're going to continue and pick up on exactly when a player should get back into action. We will have more with Merril Hoge, with CharLey Casserly, and with Dr. Julian Bailes in a moment as we talk concussions OUTSIDE THE LINES.
Ley: And we continue on the topic of concussions with Merril Hoge, Charley Casserly, and Dr. Julian Bailes.
One of the great questions, gentlemen, on concussions, when should a player be put back into action? We have another comment from Jerry Jones talking about how timing enters into it, specifically even what part of the season we're at.
Jones: It does make a difference if you're right at the end of the season getting ready to go into the Super Bowl, getting ready to go into some key games, especially since all data that we have so far don't point to any lasting effects, long-term effects, from the head trauma.
Ley: Dr. Bailes, I'd like your reaction to that comment.
Bailes: Well, again I'd like to have to disagree. I'm not sure what he means by evidence points to no lasting effects of permanent trauma. I don't know if he's talking about Troy's case in particular.
But let me say this. There's neuropsych testing. There's balance testing. There's new MR scanning that can be done, imaging on the brain.
There are various ways now that we have an ability to get a handle now on what's going on. And I think we have to be very diligent in making sure the player is asymptomatic, no symptoms before they return. That's the big problem with concussions, getting a second one before the first one's effects have cleared.
We've even showed alteration in brain glucose metabolism up for a week after an ordinary concussion. So there's a lot more that we know now than perhaps is being portrayed in that simplistic response.
Ley: Charley, team physicians are exactly that. They're retained by a team. They're paid by a team. Certainly, every physician takes the oath and does his best. But is there the perception that whoever pays that doctor the loyalties will sway that way, and that's why players need to go out and get second and third opinions, beyond just getting second and third opinions?
Casserly: Well, I think -- my experience with players is this, is that -- a couple of things. One, I think if the player feels he has confidence in the doctor, then I think even though possibly in the back of his mind he might think, "Well, that doctor is being paid by the team," I think he'll trust the doctor.
I think what you're seeing nowadays is players coming from one team to another. And with the advent of free agency and people moving around, players will develop relationships with doctors early in their career. And if they have confidence in the doctor, even though if they're with a new team, they're going to go back to that other doctor.
Then you have the agent. The agent might have a relationship with the doctor. So you have a lot of other things that can play into this, just not that the team is paying the doctor.
Ley: Merril, what would you tell a player who asked you advice? I'm sure you've counseled people who have had this problem, as far as seeking medical care and who to listen to.
Hoge: Yeah, well, I agree with everything Charley Casserly has just mentioned. You know, the evaluation process, the information I tell players is that the doctors are the gatekeeper. They are really the only person that can allow a player to go back and play.
And I think the most important thing for an athlete who's had a concussion is to educate himself. Now that really -- that responsibility falls on that doctor. He has got to tell that doctor what that player -- what the signs and symptoms, and most importantly the risks, are in returning back to play.
The asymptomatic, there's a thing called waxing and waning. And that means for three days a guy could be completely cleared up. And his fifth or sixth day, they can revert back to some of those symptoms.
That's why it's so important that when you evaluate that player, you continue to evaluate him, reevaluate him. He's asymptomatic for a full seven days through exertion and not exertion before they return to play. And if they go through all of that, you talk about the retrograde, anterial (ph) grade memory.
I mean, that's a whole different area of testing that if a doctor is really smart, knows what he's doing, he can't -- an athlete can't fool him. He'll be able to test all of those areas. And as long as he has done those for seven days, they are evaluated for those seven days, I think a player can go back and play.
But it's the evaluation before a player goes back, the education that player has, information you give back to the doctor, all of which I didn't have. I wanted to mention to you, Bob, I know that you mentioned the jury and what they had mentioned in my case. None of those signs, symptoms, or risks were ever brought to my attention before I returned back to play.
Ley: Charley, I had a researcher in this area tell me that until several years ago, he felt that there was a two-tiered level of medical care on this issue in the NFL, that star players got the Cadillac neurological treatment and the worker bees did not, and that media attention has changed that. Do you think that was possible?
Casserly: Bob, I can only talk to you about the Redskins. And we treated every single player the same way. And in Houston, we'll treat every single player the same way. They're human beings first.
Ley: And Dr. Bailes, in one sentence, what is the greatest unknown that we need to educate ourselves about both medically and as laymen about this?
Bailes: Well, one big thing is the misconception that you have to be knocked out cold to have a concussion. In athletes, only about 10 percent are knocked out. So confusion, and in a worsening case amnesia, are the hallmarks of concussions in athletes.
Ley: All right, gentlemen, thank you very much. We'll all be watching Troy Aikman very carefully today.
Thank you to Merril Hoge, to Charley Casserly, and to Dr. Julian Bailes.
And when we continue, more on the after effects of the firing of Indiana's former head basketball coach Bob Knight.
Ley: We brought you last week's program from the Indiana University campus in Bloomington in the wake of the firing of Bob Knight.
And among our many e-mails to our Outside The Lines inbox, online this letter, a viewer from Tampa, who wrote: "The hypocrisy of the media totally disgusts me. Too often I see reports demanding that someone get tough when an athlete gets into trouble. Coach Knight's way has been cast aside for the feel-good, don't-be-critical, don't-be-demanding teaching, coaching, afraid-to-discipline mindset of today. If I were a president, I'd be on the phone right now begging Bob Knight to work for me. But then again, I'm a dinosaur like Coach Knight, whose day sadly has come and gone."
From Tennessee: "Indiana students need to realize, number one, basketball is not a religion. It is a game. Number two, Bobby Knight is not a god. He is an irresponsible human being. Number three, how lucky you are to be going to college, and once you are there basketball should be entertainment, not a priority in your life."
And a concise communication from Iowa: "Absolute power corrupts absolutely."
The best way to be in touch is online at ESPN.com. On the front page, type the keyword otlweekly. You'll have complete access to video on demand and transcripts of all our Sunday morning editions, plus a place to register your opinions and suggestions.
Our e-mail address, email@example.com. And thanks for being in touch.
Ley: Great rivalry, and will the Giants go 4-0? We will see tonight. ESPN's NFL Sunday Night Football following "NFL Primetime." The game at 8:00 Eastern, prime time at 7:00 Eastern, Washington in New Jersey to take on the Giants.
And a reminder, "SportsCenter" coming along in 30 minutes, followed by "NFL Countdown" with reports from the game sites of all the critical games, including the Jets and the Bucks.
If you missed any portion of this edition of Outside The Lines, we will be re-airing as always on ESPN2 at 10:00 a.m. Pacific, 1:00 p.m. Eastern time.
I'm Bob Ley. Now to Times Square, Dick Schaap, and "The Sports Reporters" from the ESPN Zone.
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