UM neurologist warns of concussion misinformation
Jeff Kutcher, University of Michigan associate professor of neurology and director of U-M's NeuroSport Program, is one of the foremost authorities on concussion research. Kutcher is on the sideline for every Michigan football game, and recently he spoke candidly about his role as concussion expert with his colleague, Dr. Anthony Alessi, a Connecticut-based neurologist.
Alessi, a team neurologist in the New York Yankees organization and also a ring-side physican, hosts "Healthy Rounds," a radio program on WTIC in Connecticut.
Kutcher was Alessi's guest last Saturday before Michigan's game at Rutgers. These are Kutcher's only public comments since the Michigan-Minnesota game on Sept. 27 after which Michigan was under the national spotlight for playing a concussed player.
He did not speak specifically about the late-game events when quarterback Shane Morris took a hard hit that apparently caused him to stumble and wobble as he got up, needing assistance to stand from a teammate. Morris stayed in for the next play before leaving the game because of an injury to his left ankle. A miscommunication on the sideline allowed Morris to return to the field for one play after that.
Kutcher on the radio show offered detailed analysis of his approach on the field to potential concussions and the communication among the team physicals and athletic trainers.
Alessi opened the show setting the scene from the game.
"Their quarterback was struck very hard during the game, and he began to hobble," Alessi said. "All we know at that point was he stayed in the game. We do not know anything about his injuries and he by some circumstance was put back into a game. With that it set off this firestorm. The player was not severely injured in any way, shape or form. But the fact is he was put back in the game, and this gained national attention, something that wouldn't probably gain national attention if it were not the University of Michigan."
Q: Jeff, why are you here in Connecticut doing this interview when you could be doing it with Matt Lauer, and second of all, what is the message we need to get across to people?
Kutcher: "As a physician, obviously I've been asked to speak ... about what happened, and we simply cannot speak about our patients, and what happens during medical evaluations and management decisions. ... At the end of the day, I'm not a PR guy, I'm not a media guy, I'm a doctor, right? I take care of patients, that's what I do. I'm here to ... hopefully really get to the core of some of the issues without of the media stuff that's been attached to it."
Q: What is a concussion; how is it defined?
Kutcher: "Given the discussion of the (Michigan-Minnesota game), I think this is a really important point to start off with. A concussion is a type of traumatic brain injury, it is ... always a transient injury. Typically several days to a week or two in duration. Other traumatic brain injuries can be more serious. Instead of a functional disruption of brain function, you can have a structural problem inside the skull. You could have a bleed, things that are actually more life-threatening, more urgent. When you talk about deaths in football, those are the injuries creating those deaths, not concussions. Concussion is not a deadly diagnosis. That being said, if someone is concussed and has that injury ongoing, they are at risk of further injury. That's why we have to be vigilant and do our best to identify athletes who have been concussed and remove them from further risk as soon as possible."
Q: How real is the second-impact syndrome?
Kutcher: "It is a real diagnosis that is very, very rare, exceedingly rare. If you look at the medical literature and the published cases of second-impact syndrome and you parse through and look at the ones that follow that pattern of concussion second hit, there are only a couple cases that reach that definition ever published. When you think about the millions of athletes that are concussed around the world every year, it is a very rare condition, indeed. There's also the possibility that there are first-impact syndromes, individuals who, perhaps, shouldn't be playing sports at all who get a hit that is significant enough to cause an injury, not concussion, but something more serious than that."
Q: How would you best describe the experience of trying to work on a sideline?
Kutcher: "Worst seat in the house couldn't be more true as far as watching the play. Of course, you have to be there to watch your patients, and evaluate your patients, so you can't have it both ways. It is an environment that is ever-changing, it's an environment that is in many ways unpredictable. You are always faced with challenges you have never seen before.
"... There are multiple injuries to deal with at a given time on a sideline. Really, it is organized chaos, is one way to put it. It is a difficult place to practice. ... People watch replays and see things on television, and they think they know what they see, they think they understand the facts. Perhaps in some cases they are given a description of what happened without being there, without seeing what's going on, without having to deal with the environment. Those who have not been there, those who have not done it, speak from no experience at all."
Q: Who's on your sideline?
Kutcher: "That's probably similar to most college programs, especially of our size. It starts with the athletic training staff. These individuals are essential, they are the linchpin, the front line. They are specifically trained to evaluate, triage injuries, look at a complex situation and understand what is the most critical decision to make at that given time. They decide who the physician needs to evaluate. They control and run the sideline from an injury perspective. They also talk with the coaching staff and provide that sort of communication mechanism, because on a sideline there's a lot of communication going on, so you have to have a hierarchy.
"We have four full-time athletic trainers assigned to the football program, as well as some student athletic trainers. We have three physicians with responsibilities -- an orthopedic surgeon, a primary care sports medicine physician and a neurologist, myself."
Q: Often there's more than one injury -- the obvious injury and the not-so-obvious injury. How do you work through that on the sideline?
Kutcher: "Everybody has a role to play. From my perspective as a neurologist, my role is to first and foremost make sure there is not an emergent neurological condition, somebody is not in a state where they need to be taken to a hospital or some kind of emergency setting as soon as possible. The next decision if there is not an emergent situation is: Is there a more mild traumatic brain injury, such as concussion? The diagnosis of concussion is something that is quite difficult at times, and sometimes it's very easy. I will say without question, watching a hit on a video and seeing a neurological symptom should always lead to a concussion evaluation, but does not always lead to a concussion diagnosis.
"I have heard over and over this week that you can see a stumble and, look, he's obviously concussed. Nothing could be further from the truth. There are other explanations for neurological symptoms. So after somebody has been declared to not be in an emergent state, and you are thinking there may be a concussion, the next decision is: Can they go back to playing? Until you do that evaluation, you can't make that determination."
Q: What do you look for to pull a player off the field?
Kutcher: "Any sign of brain dysfunction; it comes down to that. You can stumble for a lot of reasons. You can stumble for brain reasons that aren't concussions. If you see somebody is off-balance, if you see there are obvious neurological problems with their memory, how they're communicating, the orientation, how they're thinking, all of that, that should kick off a concussion evaluation. The diagnosis, if it's made -- obviously they're out for the game or that day of participation of whatever they're doing. Clearly, any athlete who has neurological symptoms you cannot explain and feel confident about an alternative diagnosis should never go back to the field."
Q: No timeout charged if you have to investigate a concussion -- does that help us?
Kutcher: "I can't speak specifically to the rules of football, but my understanding is an injury timeout is applied to any situation where player must be taken off the field, so if that applies to concussion or any other injury, that needs to be applied consistently and liberally."
Q: Is it not applied as frequently to concussion as an obvious orthopedic injury?
Kutcher: "No question. We often see athletes who are showing some signs of neurological dysfunction who shake it off and go back to the huddle, and the official does nothing about it, sort of ignores it. Those situations we have to get better at from an officiating standpoint."
Q: Another point, spotters. Is it time to have medical spotters?
Kutcher: "Yes, no question. (Against Rutgers) we will have spotter in the press box. It is not a practice at the college football level. I know of a couple programs that have been doing it for a year or two, and it is something the University of Michigan will be doing every game.
"... Anything we can do to get information to the people who can stop a game in an instant. ... Physicians do not have the ability to call timeouts, so we have to get better communications system, and having a spotter is a step toward that."
Q: Should there be a standard protocol if a concussion or any brain injury is suspected?
Kutcher: "Those protocols are set in place and work very well. The thing that gets lost is there is no one way to diagnose a concussion on the sideline. At the end of the day, you have to do a neurological examination in some form or another. You can have tools to help you. I know of no one protocol test that is going to say in every case this is concussion or not. Certainly any time you can have a player in a quiet environment without distractions, you are going to perform a better neurological examination."
Q: What is the future of football? Numbers have gone down in participation at the youth level.
Kutcher: "From my perspective, there is a future for football. It will continue to evolve and change. I've dedicated my career to improving the neurological health of athletes at all levels. Will football look different two years, five years, 10 years from now? To some degree, yeah. I'm evaluating former NFL players all the time at 10, 20, 30 years out of the league.
"People lose track of the fact the majority of former NFL players in my clinical experience and, actually, published data, will not have a neurological problem in their 70s and 80s. We need to put things in perspective and understand there is a lot of misinformation out there, there is a lot of hype, a lot of people looking to attach themselves to an issue and every chance they get, every crisis they see, and they try to magnify the issues. What we end up with, if we have a medical issue and we have more non-physicians talking about it than physicians, that information getting across not accurate and sometimes can be flat out dangerous."