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A 17-YEAR-OLD’S DEATH POINTS TO FLAWS IN CONCUSSION TEST
THE WALL STREET JOURNAL
By Matthew Futterman
April 18, 2017 12:21 p.m. ET
Kenny Bui died in 2015 after being cleared to play football weeks after a concussion. The largest-ever study of athlete concussions now indicates many athletes are similarly being sent back on the field while at heightened risk of injury.
New research is raising questions about how quickly athletes at all levels of sports are being sent back to the field after a concussion.
Everyone said Kenney Bui was fine to return to the football field.
The 17-year-old defensive back at Washington’s Evergreen High School, where he kept a 4.0 grade-point average, suffered a concussion in a game on Sept. 4, 2015.
Two weeks later, a doctor cleared Bui to begin practicing again. Bui also passed a cognitive test administered by the school’s athletic trainers that revealed his brain was functioning as well as it had been before the season.
Then on October 2 of that year, in a game against Highline High, Bui left the field groggy after a collision. He lost consciousness on the sideline, and was rushed to a nearby hospital, where he underwent surgery. Three days later he died.
“We followed the standard protocol,” said Terri McMahan, athletic director for the Highline Public Schools, which includes Evergreen High.
New research suggests that the protocol might need to be reexamined. The preliminary findings of the largest-ever study of concussions show that even after athletes are able to pass a battery of tests, their brains might not be fully healed. This means athletes of every age and ability—from high-school soccer players to NFL wide receivers—are potentially being sent back on the field when they are at heightened risk for brain injuries.
“There is a period of vulnerability after the athlete’s cognition is recovered but before the brain is recovered,” said Michael McCrea, professor of neurosurgery and neurology and the director of brain injury research at the Medical College of Wisconsin.
McCrea is one of three scientists leading the CARE Consortium concussion study, which has for three years tracked the health and injury records of 28,000 college athletes, as well as athletes and cadets at the service academies.
That research is raising questions about what for years has been the accepted method for deciding whether an athlete has recovered from a concussion: a physician’s check-up combined with a digital test of cognition. The cognition test—the industry standard is created and sold by a company called ImPact—gauges attention span, reaction time and other cognitive skills against the athlete’s performance in those areas before the start of the season. When the headaches and other clinical symptoms subside and the athletes perform as well on the test as they did before the season, they get to return to the field, a process referred to everywhere from youth soccer to the NFL as “protocol.”
Kenney Bui, died in October 2015 weeks after suffering a concussion in a high-school football game. Bui was cleared to play again after cognitive tests showed he was recovered.
However, McCrea and his team of researchers say their findings, based on advanced neuroimaging, suggest that may be too soon. They believe the research should hasten the need to make advanced brain scans more widely available and, in the meantime, push trainers and doctors to be more cautious about when they allow athletes to begin play again.
A preliminary paper from McCrea’s group using a small sample of athletes in the Journal of Neurotrauma in 2015 first hypothesized about the lag between diagnostic and biological results. Now McCrea’s group has additional studies currently in peer review using the much larger sample. McCrea said the early findings show that the biological symptoms of an injured brain last significantly longer than the clinical signals that health professionals gauge through symptoms and cognitive testing. That finding is crucial because scientists know that after an initial concussion there is a time of heightened danger when athletes face a major risk of significant injury or even death if they experience another head trauma.
“Ultimately, we want to know not only when the athlete is recovered but when his or her brain is safe and ready to play,” McCrea said.
It’s not clear where Bui was on that spectrum when he returned to the field.
McMahan bought theImPact test and hired four athletic trainers who learned how to administer the test and analyze its results shortly after she began as athletic director for Highline Public Schools in 2010. Bui took the test before the 2015 season, just like every other Evergreen football, soccer, basketball and volleyball player. The Evergreen protocol required him to take it again in September before he was cleared to return to play.
McMahan wonders whether Bui suffered another brain injury after he returned to practice and didn’t tell his coaches. “That is what I think about on a regular basis,” she said.
Ngon Bui, Kenney’s father, referred questions to his lawyer, Richard Adler. Adler didn’t return messages.
ImPact, a closely-held San Diego-based company, was created by neuropsychologist Mark Lovell and neurosurgeon Joe Maroon.
Maroon and Lovell, who worked closely with the Pittsburgh Steelers in the 1990s, initially set out to design a neuropsychological test to establish a baseline for cognitive performance among the players that they could compare with results gathered after players suffered concussions. For instance, players had to perform memory exercises, such as listening to a series of numbers and repeating them backwards and forwards.
Two decades later, exercises like these form the central components of ImPact’s signature product, the Immediate Post-Concussion Assessment and Cognitive Test. More than 7,400 high schools, 1,000 colleges and universities, 200 professional teams and select military units rely on the test to evaluate recovery from mild traumatic brain injury.
“We don’t claim to be the be-all and end-all,” said Michael Wahlster, chief executive at ImPACT since 2013. “We do think we are a cornerstone.”
Wahlster said he understands that although new research may show that in certain cases brain injuries linger after cognitive performance recovers, his product is the best tool available while scientists test those findings further.
While there are other cognitive tests that gauge recovery from concussion, ImPact’s products in 2016 became the first of the type to be approved by the Food and Drug Administration as a Class 2 medical device, a classification that requires the presentation of reams of clinical data to support claims of reliability and safety. The test, which cost between $435 and $1,300, with special volume pricing discounts for school districts and state programs, has been administered more than 13 million times since 2006.
Wahlster said the objective test provides no wiggle room for interpretation, removes the guesswork from diagnosis, and prevents athletes from lying about lingering symptoms so they can get back on the field.
But McCrea and others say the latest research suggests that cognitive tests alone are not enough.
Dr. Philip Stieg, chairman of the Weill Cornell Brain and Spine Center, who also evaluates players with head injuries during New York Giants games, said he considers cognitive tests along with clinical criteria, such as whether there are lingering headaches, sleep issues, or sensitivity to light. He has also kept athletes off the field when their scans continue to show contusions on the brain, no matter how well they perform on cognitive tests or how well they say they are feeling.
Stieg compared the discordant results around concussions to evaluating patients with pneumonia, who might no longer feel congested even though chest X-rays and other testssignal an infection. But he said further studies are needed before brain specialists can begin making clinical decisions based solely on scans.
”It’s the balance between the clinical findings, the laboratory research, and what are we seeing radiographically,” he said.
Wahlster, theImPact chief executive, said it isn’t realistic to think that every kid who suffers a concussion will be able to undergo a series of brain scans and MRIs. “We don’t make diagnostic claims,” he said. “Right now we give providers the best device to help make them do that.”
Write to Matthew Futterman at firstname.lastname@example.org