This time, Hoge’s writings drew an immediate reaction from some of the nation’s leading brain injury experts, including Gordon. Their response, published in the same issue of the journal, took Hoge to task for minimizing the long-term consequences of mTBI and for suggesting that the proper diagnosis would delay recovery. “Education after a mild TBI has been found to reduce distress rather than exacerbate the condition,” they wrote. “The opinions expressed by Hoge et al. may harm service members and civilians alike by limiting the identification of persons who are injured and the provision of appropriate care, thereby causing unnecessary suffering, disability, and ultimately greater taxpayer expense.”
Other researchers grappled with the controversy over how TBI and PTSD were linked in a study that took some of the wartime politics out of the issue. That 2009 study looked at medical records of 124 randomly selected individuals who had sustained some of the milder injuries during the Oklahoma City bombing. Researchers pored through the survivors’ medical records to see if there was a correlation between any particular type of injury and the occurrence of PTSD. In the end, they found that the only type of injury that consistently predicted that a person would develop PTSD was a TBI. “The potential relationship between TBI and PTSD may therefore be one of reinforced neuronal circuits where TBI may sensitize the emotional learning or modulate memory retention,” the researchers concluded.
By now, the military was beginning to accept the notion that even mild traumatic brain injuries could change lives. As the Department of Defense searched for a solution to the growing problem, it looked to the model developed in the sports world for catching and treating concussions.
Chapter 6
Playing Defense
On any given Monday, the vast waiting room at the University of Pittsburgh Center for Sports Medicine is packed with patients injured over the weekend in western Pennsylvania, where football is as tightly woven into the collective psyche as the steel mill. Some are limping, some are using crutches, some are wearing slings. But many have no obvious signs of injury. These are the concussed: a couple of dozen high school teens, a handful of collegians, even an NFL pro or two. The season after leading the Pittsburgh Steelers to the 2006 Super Bowl title, quarterback Ben Roethlisberger—fresh off his second concussion in five months—could be found sharing that waiting room with schoolboy quarterbacks who idolized him.
On this particular Monday, Mark Lenkiewicz is leaning forward in his chair, his elbows on his knees, staring down at the floor while unconsciously wringing his hands. His white baseball cap is on backward and pulled so far down that it completely covers his short-cropped brown hair and almost obscures his eyebrows. He’s dressed like a typical teen, right down to the diamond studs in his earlobes, but even under an oversized T-shirt, his broad shoulders and thick neck give him away as a football player.
Lenkiewicz is abruptly brought back from his reverie when his mother taps him on the shoulder and nods in the direction of the familiar figure striding toward them. Mark Lovell, the director of the nation’s leading concussion clinic, has come to collect his patient. Lenkiewicz forces a smile, stands, and follows his neuropsychologist down the long hallway to the exam room, past the framed photos and jerseys autographed by Joe Namath, Lance Armstrong, Pelé, and scores of other sports heroes.
As they’re walking, Lovell is again struck by how much Lenkiewicz has grown. Five years ago, when Lenkiewicz first showed up at the clinic, he had just suffered a concussion in an ice skating accident. That concussion was so severe that Lovell had told the seventh grader to rest his brain by taking a month off from school and to protect against another head injury by completely avoiding contact sports. So Lovell was surprised when Lenkiewicz, now a high school senior, turned up in his office a week ago nursing a sports concussion. The skinny little kid Lovell remembered treating five years earlier had grown into a five-foot-eleven, 190-pound mass of muscle who’d been playing football for the past four years.
This time, Lenkiewicz had been going for a tackle at his high school’s summer football camp when he tripped over a fallen teammate and landed hard on the side of his head. As he lay on the ground, he pulled his helmet off and grabbed his head, trying to dull the excruciating pain. He rolled over onto his back, blinking as the bright sunlight intensified the pain. Everything was blurry. His ears were ringing, his stomach churning. As Lenkiewicz slowly sat up, the team trainer began to ask the standard set of questions: “What’s your name? Do you know where you are? Do you remember what you had for breakfast?” Then the trainer asked him to repeat three words: “Girl, dog, green.” Lenkiewicz could only come up with the first two. The trainer tried again: “Girl, dog, green.” This time Lenkiewicz got all three right, but in the wrong order.
The trainer helped him off the ground and then off the field. As Lenkiewicz sat on the bench, hunched over with his head in his hands, the coach appeared in front of him.
“Lenkiewicz,” the coach barked, “you ready to get back out there?”
“No, Coach,” Lenkiewicz replied, “I can’t.”
“Oh c’mon, it’s just a headache,” the coach urged.
“No, it’s not,” Lenkiewicz shot back. “I’m not going back out there. I need to see a doctor.”
As soon as Lenkiewicz’s parents got the trainer’s phone call, they raced the seventy miles from their home in the suburban Pittsburgh town of Baldwin to pick Mark up and take him to the hospital. In the emergency room, the doctor diagnosed a concussion and told Lenkiewicz’s mother that Mark could go home.
“Whoa,” Diane Lenkiewicz snapped, “aren’t you going to do a CAT scan?”
“He doesn’t need one,” the doctor countered. “It’s just a concussion.”
“No way,” she said, planting herself in front of the doctor, arms folded across her chest. “He’s not leaving here till he gets a CAT scan.”
Once the CAT scan confirmed that there was no swelling or bleeding in her son’s brain, Diane Lenkiewicz called the Pitt concussion clinic to make an appointment. The next day, Mark Lenkiewicz was describing his symptoms to Lovell, undergoing a complete neurological exam, and taking a neuropsychological test to measure any cognitive deficits. The computerized test showed that this concussion was almost as severe as the one five years earlier and that Lenkiewicz now had significant memory problems as well as slowed mental processing. Lovell sent him home with an admonishment to completely rest his brain and body for the next week and then to come back for a reevaluation.
This morning, as they walk down the hallway, Lenkiewicz is relieved to report that his concussion symptoms have cleared up. Now he’s anxious to retake the test to prove that his brain has healed enough for him to return to play. They enter the exam room—bare except for a chair, a table, a computer, and a framed Steelers jersey autographed by former fullback Merril Hoge—and Lenkiewicz sits down to take the test that will decide his football future.
Lovell began developing the test in the early ’90s while working with Dr. Joseph Maroon, the team neurosurgeon for the Steelers. Lovell and Maroon were looking for a way to diagnose and measure the severity of concussions without having to depend on athletes’ self-assessments, which were notoriously inaccurate and untrustworthy.
Maroon first recognized the need for a streamlined neuropsychological test after an argument with longtime Steelers coach Chuck Noll. Before practice one day, Maroon had approached Noll in the locker room at Three Rivers Stadium to suggest that the quarterback be sidelined. Looking up at the big, burly former NFL lineman, the diminutive Maroon took a deep breath and said carefully, “He can’t play in Sunday’s game.”
“Why not?” Noll asked brusquely.
“Well, he’s had a concussion and the guidelines say he shouldn’t play for two or three weeks,” Maroon explained.
“Who wrote the guidelines?”
“Well, I did, as well as a few other neurosurgeons and neurologists.”
“What basis did you have for writing those guidelines?
Don’t tell me I have to keep a player out if you can’t give me some objective data.”
Maroon got quiet. Noll may have been a coaching legend, having built the Steelers dynasty with a record four Super Bowl titles in six years, but he was no brain expert. Maroon thought angrily, “Who are you to know about this? You think you know more about medicine than I do?” But even before he heard Noll’s verdict, Maroon knew he’d lost this battle to the aloof and hardheaded disciplinarian known as The Emperor. “He can throw the ball and knows the plays,” Noll pronounced. “I see no impairment here whatsoever.”
Over the next few days, as Maroon replayed the argument in his head, he realized that Noll had a point. There was no real science supporting the guidelines. A onetime major-college football player himself, Maroon could understand Noll’s obsession with cold hard numbers in a sport where success is measured in yards and proven by stats. But he also knew firsthand what concussions could do to the brain, having suffered several as a smaller-than-average running back routinely crushed by bruising Big Ten linebackers.
He reached for the phone and called Lovell, who was then evaluating brain-injured patients at the same hospital where Maroon was chairman of the neurosurgery department. “Mark, he’s right,” Maroon said. “We do need objective information if we’re going to keep people out of sports.”
Both Maroon and Lovell had been impressed by a recently published landmark study that established the utility of neuropsychological testing in college football. After using neuropsych tests in players from ten colleges over four seasons, researchers from the University of Virginia determined that this was an effective way to measure cognitive deficits from concussions and to track recovery. Now Maroon and Lovell were eager to extend this protocol to the pros.
So Maroon went to Noll with a proposal. “Look, you told me to come back to you with some data,” Maroon said. “Here’s what I want to do.” Maroon’s plan to get the data had one catch: Noll would have to encourage his players to volunteer for a neuropsychological test that Lovell had devised. Noll thought it over, and realized there was no good reason to say no.
Though reluctant at first to be tested by a “shrink,” many of the players eventually agreed to meet with Lovell. Since it was before the boom in personal computers, Lovell had to rely on lengthy face-to-face interviews, standardized pencil-and-paper tests of memory and cognition, and a stopwatch to measure each player’s reaction time. For his breakthrough experiment in 1993, he tested twenty-three healthy Steelers in preseason training camp to provide baseline measurements, which could then be used as a comparison with tests taken during the season by concussed players.
One of those players was Merril Hoge. During the fall of 1994, soon after he’d left Pittsburgh to play for the Chicago Bears, Hoge was driven from a game, dazed and disoriented, by the sixth diagnosed concussion of his NFL career. In the locker room minutes later, he stopped breathing for fifteen seconds and briefly had no pulse or heartbeat. For three days, he couldn’t recognize his wife or daughter. A few weeks after being released from intensive care, he returned to Pittsburgh for another round of neuropsychological testing with Lovell and Maroon. Not surprisingly, the player who could no longer drive his car or balance his checkbook would score abysmally on the test. Pulling Hoge aside, Lovell and Maroon dug out the baseline results from the summer of ’93 and laid them down next to the latest data. “Look, Merril, here’s where you were,” Maroon said, pointing to the earlier results. “And,” Maroon went on, gesturing toward the new ones, “here’s where your brain is now.” Three days later, Hoge retired from football at the age of twenty-nine.
Seated now under the framed Merril Hoge jersey in Lovell’s exam room, Mark Lenkiewicz starts the computerized test that will determine whether he too will have to give up football. He’s taking the high-tech version of the old pencil-and-paper test that Lovell devised for the Steelers. With the proliferation of inexpensive personal computers in the mid-’90s, Lovell saw a way to make the test widely available to athletes of all ages at all levels of play. His computerized version had the added advantage of being more like Pac-Man than a neuropsych exam.
Lenkiewicz is as intensely focused on the monitor as he would be on a rival team’s linebacker, his right index finger tapping the mouse in anticipation. The test kicks off with a verbal memory drill: after each of twelve words flashes on the screen for 750 milliseconds, he’s asked to identify them from a list of twenty-four. The second drill is similar, only this time twelve abstract designs flash on the screen before he’s asked to recall which ones he’s seen. The next part of the test seems a bit more familiar to a football player used to memorizing a playbook. A jumble of X’s and O’s pops up on the screen, looking like a deranged version of the blackboard X’s and O’s that coaches use to diagram plays. Three of them are illuminated in bright yellow. Lenkiewicz has just a split second to memorize their pattern and position before the screen fades to the next challenge. Then, in rapid succession, a series of geometric shapes flashes on the screen: a red square, a blue square, a red circle, or a blue circle. He must left-click the mouse any time a blue square appears and right-click for each red circle, fully aware he’s being graded on both speed and accuracy. Suddenly the screen with X’s and O’s reappears, only this time the letters are all the same color. He must now recall and click on the three originally illuminated X’s and O’s. He’s halfway home. Without taking a breather, he blitzes through the final three sections of the test.
His twenty-minute ordeal behind him, Lenkiewicz heads to a conference room to join his mother and anxiously wait for the grading of his test. No matter how much better an athlete feels physically, there can be lingering symptoms subtle enough to go unnoticed by players, coaches, trainers, and even team medical personnel. The test is designed not only to ferret out the most subtle deficits, but also to catch athletes bent on covering up symptoms so they can get back to play sooner. No wonder kids fear the test that Lovell fondly calls “the grim reaper.”
Its real name is ImPACT, which stands for Immediate Post-concussion Assessment and Cognitive Testing. Since its development in the late ’90s as the first computerized battery of tests to objectively measure cognitive function in concussed athletes, ImPACT has become the gold standard for tracking their healing and recovery. While there are several other computerized tests on the market, none has caught on the way ImPACT has. Lovell’s test is now used by more than one hundred pro teams, more than five hundred colleges, and more than fifteen hundred high schools nationwide. And that doesn’t include the several thousand patients who come directly to Lovell’s clinic each year, some making the pilgrimage all the way across the country to the glistening glass structure erected on the site of a rusted steel mill hard by the Monongahela River.
In the conference room, Lenkiewicz drops into a chair next to his mother and they wait for Lovell to return with the test results. Diane Lenkiewicz turns to her son and says, “You know, Mark, no matter what the test results are, I don’t want you playing in Friday’s game.”
He shrugs and nods in resignation, setting his sights on the following week’s game. “I just want to be out there with my friends,” he explains. “If I get in for two plays, I’ll be happy. I don’t need another concussion. I don’t even want to play college football anymore. The coach says I can get a scholarship, but I’m not going to be somebody’s punching bag; if you’re a freshman in college, you’re just a tackling dummy. I might not wake up after another concussion, or I might be paralyzed. I just want to enjoy this season and be done.”
His mother smiles proudly. “I say, good for you! You have to have that attitude. It’s a healthy one.”
Just then, Lovell walks through the doorway, his nose buried in Lenkiewicz’s chart. Taking a chair, he nods to Mark and then fixes his gaze on Diane Lenkiewicz. “Well, Mark’s definitely making progress,” Lovell says. “He may feel a hundred percent back, but I don’t feel he is.” Lovell pulls a page from the chart and pushes it across
the conference table so the Lenkiewiczes can see the test results for themselves. “All of his scores certainly have improved,” Lovell says. “His performance in speed-oriented tasks is all the way back to normal, but his memory scores are not where we would like to see them. Given his concussion history, we want to make sure this completely resolves.” Lovell pauses and glances at a calendar. “Let’s see, the first game is—”
“He’s not playing,” Diane Lenkiewicz cuts in.
“Right,” Lovell says, nodding. “But what I want him to start doing is ratchet up physical conditioning.” Lovell turns to Mark and says, “You know the drill. Start to do some light jogging. If you get any headaches or dizziness, back off completely. The idea is not to push through it but to see if you can increase your heart rate without any symptoms. If you can tolerate the jogging for a couple of days, you can start building up gradually. And eventually I want to get you to the point where you can do full-out wind sprints and really be sweating without any symptoms whatsoever.” Lovell turns back to Diane Lenkiewicz and cautions her, “I’ll clear him for that—but not anything more.” She leans forward, elbows on the table, and assures Lovell that she’s already set the coach straight on that score.
Several days ago, when the coach told her he planned to start Mark in Friday night’s season opener, the short, stocky blond dynamo got up in his face and snapped, “I’m telling you now, this is the deal: Mark won’t be playing Friday.”
“But,” the coach sputtered, “he’s our fullback.”
“Well, you better find another one and train him now,” she shot back, “because Mark’s not playing. This is my kid, and I’m not going to have him sitting in a wheelchair eating Jell-O for the rest of his life.”
As she replays the story in the conference room, Lovell smiles and then tells her that Mark will need to come back in to take the test again. Lovell explains that Mark’s youth makes him particularly vulnerable to concussions because the brain doesn’t finish developing until the mid-twenties. What’s more, Lovell says, multiple concussions can add up and have a cumulative effect: even if Mark’s scores come back to baseline, another concussion might have a more serious impact, one that could be permanent. That’s why Lovell occasionally has to “retire” a kid from contact sports. But since he appreciates the value of athletic competition, Lovell assures the Lenkiewiczes that he’ll do everything possible to get Mark safely back on the ballfield.
The Concussion Crisis Page 16