“Back in the Game”: A Concussion Book That Stands Out In Crowded Field
While the pile of concussion books in my office continues to grow taller, seemingly with every passing day, one that will stay at the top of the very short pile of my favorites is Back in the Game: Why Concussion Doesn’t Have To End Your Athletic Career (Oxford University Press, New York 2016) by sports neurologist Jeffrey Kutcher, M.D., and award-winning sports journalist Joanne Gerstner.
The collaboration of Ms. Gerstner, a first-rate, professional journalist with a background in reporting on sports science, and Dr. Kutcher, one of the nation’s top concussion researchers and clinicians who lives, breathes and eats concussions every day for a living as the National Director of The Sports Neurology Clinic at The CORE Institute™ in Brighton, Michigan, and for whom I and my staff at MomsTEAM have enormous respect, is a match made in publishing heaven.
A straightforward, elegantly written, concise, and well-organized 215 pages, Back in the Game stands out in a crowded field, not just as a primer on concussions for a parent, coach, or athlete, but for its incisive and often pointed criticism of the way our national conversation about concussions and the long-term effects of playing contact and collision sports has been shaped – some would say warped – by a media that too often eschews fact-based reporting in favor of sensationalism and fear-mongering.
The title of the book alone tells you that Gerstner and Kutcher are not out to scare the reader, not out to make sensational, scientifically unproven, claims about the long-term effects of concussions, but that they prefer instead, like I, to live in the “land of the real.” Eschewing the extremes occupied by the loudest voices in the national concussion and youth sport conversation, the ones who either deny there is a serious issue that needs to be addressed (who they characterize as the “just a knock to the head” crowd) or have become so convinced that contact sports inevitably result in lifelong disability that they are so fundamentally unsafe that they should be abolished, they opt instead for the common sense middle ground – a place where MomsTEAM and I have been all along – a perhaps mythical place where it is possible to have a “more thoughtful, science-based” dialog about the role of sports in our kids’ lives. (It’s been a pretty lonely place to be, to be honest; I’m glad to have some company!)
The book accomplishes what it sets out to do. I know, because, when I was done reading, it was if I had just had a long, thought-provoking conversation with Kutcher and Gerstner – perhaps while sitting in the bleachers watching a high school football game on a Friday night – during which I not only learned the essentials about the identification, treatment, and management of concussions, that a concussion doesn’t have to end your child’s athletic career; but, just as importantly, that you simply can’t trust a lot of what you read or hear about head injuries on television, radio, or on Twitter.
The book begins, appropriately, with a chapter debunking common sports concussion myths and fears, mostly perpetuated by the media. Kutcher correctly identifies the tradition of contact sports and the peer-enforced ethic to be tough as reasons why so many athletes, even knowing the dangers from continuing to play with concussion symptoms, don’t tell anyone about their symptoms. He bemoans a culture in which “leaving the game or admitting they were hurt was not an option” and in which an athlete’s teammates, winning, or their own ego are prioritized above their health (a culture which, I should point out, our new 5-step SmartTeams™ concussion education program is designed to change).
A helpful explanation of what a concussion is and isn’t is followed by a section in which Kutcher clears up the confusion in the minds of many between concussion (a term which, he says, should only be used to describe the injury or the immediate effect of the injury resulting from concussion forces transmitted to the head), post-concussion syndrome (symptoms patients experience for several months at a time when they are likely no longer concussed), and the problems former athletes, especially in contact sports, experience with their thinking, mood, and memory later in life, when they are no longer concussed, and the serious neurological condition they have as a result of playing sports is not itself a concussion and likely more the result of how often they were hit than their concussion history.
Kutcher and Gerstner then introduce what I view as the book’s most valuable contribution to the concussion book genre: the medically inaccurate memes parents, coaches, and athletes are receiving from the media which have created a “tangible mounting fear of concussion” and a “state of near panic” about concussions, causing parents to avoid contact sports for their children based on “irrational fears of injury” which fail to weigh in the balance all the positive aspects of sports participation.
While the media’s emphasis on the heartfelt and tragic stories of athletes dealing with mental illness and those who commit suicide may sell newspapers, improve ratings, or get a website more clicks, the concern, Kutcher and Gerstner argue, is that it is driving the conversation to emotional places from which it’s an easy leap to conclude that contact sports, such as American football, must be a dangerous endeavor, only leading to pain and despair.
As a journalist and consumer of social media, I have been a frequent critic of the way media reports on concussions and head injuries. As someone who has tried every day to ground my advice on sports safety issues on science, I couldn’t agree more with Kutcher and Gerstner when they argue that such memes “seem like fact, only because anybody with a little knowledge – and sometimes a lot of agenda or desire to gin up a false debate – can get on television or radio, or go on a Twitter rant to vent their thoughts to a large audience without challenge or fact-checking.”
While the public has become more receptive to discussing concussions as an issue in sports, it is also heartening to know that the authors share my belief that the facts of the discussion have become “garbled” as a result of the media’s morbid fascination with the heartbreaking stories of athletes, including Dave Duerson, Junior Seau, Kosta Karageorge, who were assumed to have had concussions and then committed suicide because of depression. Players who die, sometimes through suicide, are declared “with great fanfare” to have gotten CTE from concussions, when the reality, the authors say, is that concussions and long-term effects like CTE “are two completely different processes that may not even be related.”
The big problem, medically, says Kutcher, is that “we are not even close to understanding the connections that might exist between sports, concussions, depression, suicide, and CTE,” so that linking concussions with suicides, is, in his view, “tenuous, and in a greater sense, also quite irresponsible.” Again, while he’s preaching to the already converted (I have been saying much the same thing for years), it is a message that all sports stakeholders need to hear.
The authors then move from an expansive and philosophical discussion of the role of the media in the concussion conversation to the nuts and bolts of concussion education, laying out in a series of well-organized chapters and in step-by-step fashion how concussions are identified, diagnosed, and treated, beginning with a discussion of the use – and misuse – of baseline computerized neurocognitive tests, the need for immediate removal from play when concussion is suspected, what to do in the first few hours after concussion, and the recovery process that follows. I found particularly helpful the way Kutcher and Gerstner divide the recovery from concussion into three phases (acute rest, relative rest, and gradual exertion phases), and use a mnemonic (B.R.A.I.N., which stands for Bike (B), Run (R), Agility (A), “In Red” (I) and No Restrictions (N)) to describe the basic framework for graduated exercise return-to-play protocol most experts recommend.
Subsequent chapters discuss post-concussion syndrome and second-impact, an excellent discussion of the links between concussion, sports, depression (with a particularly useful section on the three different kinds of depression and how to keep them straight when all three are present at the same time) and suicide. I found particularly informative their discussion of how suicide rates in general, and among former National Football League players in particular, can be and have been affected by messaging in the media – a phenomenon called the “suicide contagion” – and how, unfortunately, the media, in its coverage of the suicide of players such as Junior Seau and Dave Duerson, has consistently ignored all seven of the recommendations of the Centers of Disease Control on how to avoid spreading that contagion, including not presenting simplistic explanations for suicide, not engaging in repetitive, ongoing, or excessive reporting of suicide in the news, and not providing sensational coverage of suicide.
While some of this information is new (particularly the sections on depression and suicide), much of it covers ground that has been plowed many times before in other books and websites such as MomsTEAM (and our new SmartTeams concussion site on which you reading this post). Yet Kutcher and Gerstner somehow manage to come up with ways to convey the information in fresh new ways and easy to understand terms.
Chapter Seven, entitled “How Athletes Can Help Themselves,” returns to a theme introduced at the very beginning of the book – that our sports culture teaches athletes, particularly at the elite level, to play through pain and play with concussion, with sometimes dire consequences – and the need for athletes, parents, and coaches to recognize that athletes are “not destructible, they can get concussed, and they need to be honest when they are hurt,” or as the authors advises athletes: “Say something. To Somebody. Please.”
As with many concussion books, the authors use the stories of former elite athletes, in this case, two-time Olympic gold medalist and World Cup-winning soccer player Kate (nee Sobrero) Markgraf and pioneering X-Games snowboarder Ellery Hollingsworth, to personalize the message that “if an athlete is hurt, if they do not feel right, if they know something is wrong in their gut … they should ultimately feel empowered to say something. Giving answers they think their coaches, teammates, or family want to hear doesn’t help anybody in the end.” The challenge that they, like I, have long recognized is to actually get an athlete of any age to actually think that way.
As MomsTEAM and I have always done, Kutcher and Gerstner stress the need for athletes to become educated about concussions, to be leery of television productions, movies, or other media that have been produced for shock value, to ask themselves about the motivation that person has in getting their message out, to question their sources of information, and to rely on trusted resources for their concussion information (it was an honor for MomsTEAM to be included among those resources in the book’s appendix).
The advice Kutcher and Gerstner provide to parents and coaches, much of it from former elite athletes who are now standing on the sports sidelines as parents, is solid and grounded on common sense. Parents, they say correctly, need to recognize that their child’s coaches are not like professional or elite coaches, that most are unpaid volunteers, and that many may not know more about concussions than they do. They advise that if parents see something that looks dangerous or not totally right, they need to speak up, perhaps not directly to the coach, but through proper channels, such as the booster club, athletic director, parent representatives, or athletic trainers.
As for coaches, they admit that they have to “walk a fine line between advocating toughness and discipline during play and leading athletes to believe they should play through injury and pain,” and that, while concussion awareness has improved, there is still a great deal of resistance to changing the “warrior mentality” common to many contact and collision sports.
Like the advice we advance in the concussion education game plan developed under our Mind Matters Challenge grant from the NCAA and Department of Defense, Kutcher and Gerstner take the view that: anything short of athletes being totally responsible and accountable about their brain health is unacceptable; that coaches and the athletic training staff need to communicate from the start of the season the message that there “is no heroism or credit given for playing through a concussion” but that “it’s unwise, it’s dangerous” and will not be tolerated; and that mandated concussion education of players, coaches, parents, and leagues – a position MomsTEAM has advocated for a decade – would do a lot to make contact sports safer
The penultimate chapter (“Changing the Game: On and Off The Field”) provides a useful, if familiar (at least to MomsTEAM followers), summary about protective equipment (helmets and mouth guards), warnings against the use of impact sensors and baseline testing in diagnosing concussions), and short, somewhat perfunctory discussions about innovative training techniques (“heads up”, helmetless tackling etc.), strength training, proper hydration, and rules enforcement in reducing concussion risk.
If the book seems to be losing steam at this point, Kutcher and Gerstner end it on a high note, returning one last time to a discussion of the outsized influence the media has had, and continues to play, in the messaging about concussion.
Regardless of whether the early sports concussion landscape is seen as being defined by the 2009 New York Times article headlined, “Dementia Risk Seen in Players in NFL Study”, as Kutcher and Gerstner argue, or the 2007 Times article, “Expert Ties Ex-Player’s Suicide To Brain Damage,” as Jean Marie Laskas argues in her outstanding book, Concussion, the influence of messaging in the discussion about head injuries in sports is a constant.
The reality, as they point out, is that the “multitude of voices across the different media formats, speaking about sports and concussion, whether it is a sports fan with no medical knowledge on Twitter, a former NFL player doing color commentary on ESPN, a sportswriter with Sports Illustrated, or even a TMZ tabloid reporter, all lend to a confusing cacophony. But the idea is always the same: driving traffic, gaining a following, and if a business, making money.”
The result, unfortunately, is that alleged “truths” are established – whether it be that playing football causes dementia or causes CTE, or that CTE causes players to commit suicide – which are not, at least not yet, supported by actual science in peer-reviewed studies or published in the medical literature. Instead, they are “supported” (if that’s even the right word) by something much less reliable, in the case of the 2008 Times article, by a phone survey commissioned by the NFL.
As Kutcher correctly observes, “whether in the media or in the political process, medical science very typically does not make for good storytelling. … There must be a highly charged and emotional narrative attached to any research or science for it to significantly capture the public’s attention.” The problem in the case of sports and brain trauma is that, as I know all too well, the public has been mostly been hearing the last decade, not from respected scientists like Kutcher, but from those who have the “loudest megaphones and get in front of the most cameras.” That they have little scientific knowledge or training, whether their message is based on facts or not, has, as he points out, often been beside the point: when they “take to social media in force to put out their ideas – mostly unchallenged- about their own personal conclusions” the result is “critical thought takes a backseat while emotional narratives play the starring role.”
As distressing as this all may be, and despite the troubling concussion = dementia narrative that has gained so much traction in recent years from anecdotal reports spread in the media without any context, Kutcher isn’t giving up hope that, somehow, the public will come to understand that, just because something is in print or broadcast doesn’t make it the truth, and hoping that journalists themselves will begin to “question assumptions, [and] dig a little harder to understand the more difficult concepts,” so as to be able to “craft a clear and nuanced message for public consumption.” I would like to share Kutcher’s optimism, but, after so many years fighting a rearguard battle for truthful, objective reporting about head injuries in sports, I’m afraid I’m not as sanguine about the chances of that ever happening.
In the meantime, though, one thing is clear: thoughtful, informative, factually accurate books like Back in the Game, books which help all those with a stake in sports to carefully assess the risks of sports against its benefits; books which see critical thought and a comprehensive approach as the keys to maximizing brain health over a lifetime, books which see it as a responsibility which all sports stakeholders must share as a team, will always have a honored place on my bookshelf.
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