The Concussion Crisis: Anatomy of a Silent Epidemic

I have added yet another book to my ever-expanding book shelf of sports concussion books: The Concussion Crisis: Anatomy of a Silent Epidemic by Linda Caroll and David Rosner (Simon & Schuster 2011).

The authors have done an excellent job of distilling a mound of information about the subject to fashion a highly readable book that chronicles a twenty-five year period in which concussions, once an issue no one wanted to talk about and about which medical science knew little, became a topic which now dominates the headlines, has prompted a growing majority of states to pass youth sports concussion safety laws, and triggered an explosion in medical research and product development.

The book is most valuable in providing an overview of that history. Many of the stories the book recounts will be familiar to readers, but are worth re-telling: the concussion stories of Troy Aikman, Steve Young, Zack Lystedt, Wayne Chrebet, Pat Lafontaine, boxers Jerry Quarry and Muhammad Ali, Mike Webster, Terry Long, Ben Roethlisberger, Chris Nowinski, and Andre Waters among them.

Carroll and Rosner also weave in poignant, personal stories about how concussions affected, not only other, lesser-known athletes, but soldiers in the military, victims of child abuse and car accidents. They give credit to some of the true giants in the medical community, including Dr. Robert Cantu, Dr. Mark Lovell of the University of Pittsburgh and co-developer of the ImPACT computerized neuropsychological test, Dr. Bennett Omalu (whose autopsies of the brains of Mike Webster, Terry Long and Andre Waters, are credited with jump starting research - now conducted largely at the Sports Legacy Institute in Boston - into the link between chronic traumatic encephalopathy (CTE) and concussions in athletes in contact and collision sports), and the University of North Carolina's Kevin Guskiewicz, whose research has collectively resulted in a sea-change over the past decade in the way concussions are diagnosed, treated and managed.  The book also includes stories about lesser-known doctors, like Wayne Gordon, a psychologist at Mount Sinai School of Medicine, who connected the relationship between "hidden" traumatic brain injuries (TBI) and cognitive difficulties such as learning disabilities, and chronic conditions, such as depression, alcoholism, even homelessness.

For these reasons alone, the book is a worthy addition to my growing collection of concussion books (not counting vanity books, the number has reached twelve) that have been published over the past five years.

One of my favorite stories was about a college soccer player, Melissa Inzitari, and her doctor, Jill Brooks. The smallest kid on her team at the College of New Jersey, she was "a dynamo, racing headlong into the fray, sometimes literally running up the back of an opposing player to get as much height as possible."  When, early in her sophomore year in 1996, she suffered a concussion from a collision with the head of an opposing player in the first half of a game, she kept playing despite worsening symptoms,

After a trip to a nearby hospital, where a CAT scan came back normal, doctors cleared her to return to play.  Despite constant headaches, increased sensitivity to light and loud noises (tell-tale symptoms of post-concussion syndrome), Melissa played through the entire season (dispelling the myth that it is only boys who play through pain). Over the next year, her symptoms continued to get worse. Finally, she underwent a battery of tests by Dr. Brooks, a neuropsychologist, who diagnosed her as having suffered a severe concussion, and told her that continuing to play had only made matters worse by not giving her brain a chance to heal.

Relentless in her determination to return to the playing field, Melissa kept lobbying Dr. Brooks to let her play. She kept saying no. Finally, years later, pregnant with her first child, she decided it was time to quit. She turned to coaching. Starting out as a coach on the same youth league club on which she had played as a young girl, she later coached at the high school where she had been an All-American. All the while, she educated her players - and Dr. Brooks' patients - about the dangers of concussions and the need to report all head injuries to coaches, trainers, and parents, not based on some abstract rule, but through what may be one of the most effective ways to educate athletes about concussions: the personal concussion stories of other athletes.

History not resource guide

To the extent the book attempts to provide sports parents practical advice about and serve as a resource for the evaluation and treatment of concussions, it is far less successful. To be fair, Carroll and Rosner are journalists, not experts in sports concussions, like Dr. William Meehan of Children's Hospital Boston and a MomsTeam expert, whose book, Kids, Sports, and Concussion, is, to this point, top on my list of "must reads" for sports parents.  They don't profess to offer advice of the kind Dr. Meehan and MomsTeam offers.

Indeed, my worry is that some of the information in the book. or lack of information, may mislead parents. Since Concussion Crisis is largely presented as history, there is little new information about developments on the cutting edge of science and technology, including promising new diagnostic tools like the King-Devick test, which has shown enormous promise in the initial assessment of concussion on the sports sideline.

Some of the information in the book is already outdated (an inherent limitation of any book and one of the great advantages of a web-based concussion resource center like that on MomsTeam, which is constantly updated to reflect the latest research and technological innovations).  In fact, I was surprised by the number of times I read in the source notes "narrative constructed from multiple newspaper stories" and televised reports, and how few times "a first person account" was listed. There were a number of times when I was left yearning for more information that would help sports parents in their roles other than straightforward recounting of historical events in the concussion timeline.

One such story that left me hoping the authors would clear up some misinformation, and consequently nervous about recommending this book to sports parents, was about Jamie Carey, a Stanford University basketball player, whose narrative, the author's notes say, was constructed from multiple newspaper accounts. 

The story of how Carey suffered more than eight known sports concussions and was cleared to play by a doctor at the University of Texas after she was denied medical clearance to play at Stanford based on her concussion history, is certainly illustrative of an ongoing problem in sports medicine: the lack of consistency in concussion management and the degree to which it is a matter of clinical judgment.  But in recounting the circumstances under which she was allowed to take the court for the Texas Longhorns, including a requirement that she agree to wear a "customized mouthguard designed for greater shock absorption,"  I believe the book sends the wrong message: that mouthguards can prevent concussions.

When I interviewed Carroll and Rosner, I asked them whether they were aware of any peer-reviewed studies showing that mouthguards reduce the risk of concussion. They admitted they knew of none. Then why suggest in the book that they did, I asked, or, at the very least, why not include a footnote to that effect? Ms. Carroll's response was less than satisfactory: "This book is more historical and we wanted to document stories. And, many of the decisions that athletes make are not necessarily the best ones. It is my personal opinion that there is no device that will prevent concussion."

Overall, I view the book as a positive addition to the concussion literature. But the Carey story, unfortunately, left me with a bad taste in my mouth.

Posted September 13, 2011