Working Bodies: NBA head injuries

The motto of ESPN.com's HoopIdea is "Basketball is the best game ever. Now let’s make it better." Working Bodies is a new HoopIdea series about being as smart as possible in keeping NBA players healthy. First up: The health topic in modern professional sports -- head injuries.

Football is in upheaval over concussions -- not because the game has become more dangerous, but because we now know things we didn’t a few decades ago. In a nutshell, blows to the head come with an evolving list of medical risks including a collection of life-altering short-, medium- and long-term health problems, including headaches, depression and dementia. The suicide rates are alarming.

Easy solutions are not good; good solutions are not easy. The implications for the sport are profound enough that some -- Malcolm Gladwell comes to mind -- have predicted football's demise, or close to it.

By and large, basketball has seen all this from afar and breathed a sigh of relief. Studies have shown many sports have profound issues to wrestle with here, but basketball has not made the list.

Even so, the league has been proactive, having contracted with respected University of Michigan neurologist Dr. Jeffrey Kutcher, who has served as a sports concussion expert in testimony before Congress as well as in various roles at the American Academy of Neurology, Michigan NeuroSport and at the NFL. Kutcher is leading the implementation of new head injury protocols to keep players safer -- by increasing the likelihood head injuries are detected and treated, and to keep concussed players from taking the floor.

But the challenge is a big one.

The more experts learn about blows to the head, the more they learn how hard it is to classify any as without long-term health implications. And basketball, though not a collision-based sport like football or hockey, is a contact sport with more blows to the head than you would think.

NBA players, says Kutcher, "are not taking the repetitive hits like they are in football or in hockey, but they do get hit, quite a bit. They may be mild bumps, those kinds of things, but certain brains are susceptible to trauma more than others and to be able to monitor brain health over the course of the season and a career is something that we have to do regardless of the level of impact."

Watch NBA basketball, and it’s only a matter of time before you see someone take a hard blow to the head. Pau Gasol and Anthony Davis have suffered high-profile concussions this season, but they represent a tiny fraction of the instances when heads are rattled by hitting elbows, knees or the floor. Even more common are whacks to the face, temple, top of the head and back of the head on what are usually considered "good, clean basketball plays." In basketball, blows to the head are nothing like as common as in football, but they are a regular part of play nonetheless.

Some of those that look mild can have serious effects. The human brain might be the most sensitive and precise instrument in the history of the planet; hitting it on the hardwood is analogous to swinging a hammer at a Ferrari engine. Might do nothing, might have a dreadful effect. And it’s hard to know; sometimes a small shot is all it takes.

Even soccer headers are under scrutiny now. There is no way to say, with any medical certainty, “that was nothing” about any shot to the head. Telling one from the other is almost impossible for anyone but a neurologist with millions of dollars in diagnostic tools and lots of time.

In the concussions-focused documentary "Head Games," Douglas Smith, a neuroscientist from the University of Pennsylvania, cautions that “15 or so percent of people with a single concussion have persisting cognitive dysfunction, meaning they don’t go back to school or to work or just carry on life the way they had it. They have long-term, persisting problems after one concussion.”

In a presentation at the University of Michigan, Kutcher says skipping the proper care is a mistake: “The biggest risk is their injury is going to be a lot more complicated. ... Instead of a seven-day concussion, it’s going to be a seven-week concussion. Instead of two weeks, it’s going to be six months.”

“This is very new to basketball”

Gerald Wallace earned the nickname Crash for his willingness to throw his body into the fray. It was an honorific, but by 2008, Wallace, then with the Bobcats, had suffered four concussions in four seasons, the latest coming from a Mikki Moore elbow that left Wallace unmoving, lying flat on the hardwood.

This was before the NBA’s concussion program was in place. The Bobcats trainer at the time, Joe Sharpe, had so few tools at his disposal to deal with Wallace’s condition that he sought counsel from the NFL. "I talked to the Panthers medical staff and asked them to maybe help me out in this situation," said Sharpe in a report from The Associated Press.

"I'm not saying we're behind the ball, because this is very new to basketball," said Sharpe at the time, and he was right. Until recently, few people considered concussions to be a basketball issue. From the league’s perspective, that has all changed.

The NBA’s new program

Today, the experience of Wallace and Sharpe would have been much different. Before the 2011-12 season, the NBA contracted Kutcher to design and implement a cutting-edge concussion protocol. Every concussion case is diagnosed by the team medical staff and then reviewed by Kutcher. Though he does not have the final say in whether a player is cleared to play -- that is still the purview of the team physician -- Kutcher does act as a league-wide quality control in concussion diagnosis.

Kutcher installed a three-part diagnosis and treatment procedure. In the preseason, players fill out a form designed to show aspects of typical cognitive functioning, as well as a personal and family history of brain trauma. Kutcher says this helps “understand how [the player’s] brain may or may not be set up to produce symptoms when it's injured.”

Players also undergo tests with the Axon Sports neurocognitive tool to measure things like reaction time, memory and distractability. To understand the impact of a blow to the head, it helps to first understand a player’s normal brain functioning.

During games, all NBA trainers have a second form, essentially a checklist, to help decipher when to pull a player. For many years, being "knocked out" -- a total loss of consciousness -- has been the rule of thumb for telling who is concussed. We now know concussions come in many more varieties. This test is designed to help team trainers determine whether a blow to the head requires a player to come out of the game.

Underlying all of that is the reality that concussion symptoms can take hours, or even days, to present themselves.

The team staff goes into action, Kutcher says, any time there's a blow to the head: "It’s not 'come see me in my clinic and I’m going to give you a diagnosis and fill out a form and send you on your way, come back and see me in a month.' It’s 'I saw a big hit, I’m now going to evaluate you. If you pass everything, I’m not going to turn my back on you and let you play then check in in a week. I’m going to watch you every series, I’m going to watch you up and down the court, I’m going to watch you at halftime, I’m going to talk to you after the game. It’s a continued process and a concussion sort of requires that approach, which speaks to how different management is in the upper levels of sports when you have the resources to do that."

Also new in the NBA is that once diagnosed with a concussion, NBA players must pass through the league’s “return to play” protocol, a more involved series of tests.

“Since they have no diagnostic, objective test for concussion,” Kutcher says, “we’re basically challenging the brain once it is essentially not producing symptoms at rest -- how can that brain handle first straight-up physical exertion, then more interval training, then agility and so on and so forth, tracking the brain at each level to make sure the injury is over.”

Like most injuries, the brain will not heal without rest. But resting the brain is not as simple as resting, say, an ankle by donning an immobilizing boot. Even watching TV could tax an injured head and extend a brain injury’s duration. Kutcher’s protocol is designed to ensure players get the rest they need to recover, and is a key reason players like Anthony Davis and Pau Gasol have been kept from competition.

What NBA trainers don’t know or can’t control

NBA medical staffs do incredible work to not only treat injuries but also to keep players from breaking down during the grinding 82-game season. But, as Kutcher says, treating concussions “requires knowledge of how to examine the brain of a living person, first and foremost, and that is not something that in general is taught in the sports medicine curricula either at the athletic training level or the physician level.”

Kutcher says NBA physicians and trainers have been happy to have him as a resource when it comes to brain injuries. The NBA distributes educational videos to trainers and physicians, and Kutcher consults with team medical staffs at their twice-yearly league-wide meetings.

The flip side of Kutcher’s point is that, at a typical NBA game, there are trainers and physicians on hand with decades of know-how looking after injured knees and shoulders and the like. But the neurological knowledge doesn't run anything like as deep.

Further complicating things is that a lot of the most valuable insight comes from players themselves reporting symptoms. But concussed players often do a poor job, because of the concussion, even identifying what's abnormal. In addition athletes are under tremendous pressure -- from the coaching staff, from themselves, from economic incentives -- to under-report symptoms and play through injuries of all kinds.

Watch this video of Doc Rivers, in the 2009 playoffs, urging a clearly woozy Glen Davis to sprint back on defense after being dropped by a Dwight Howard elbow. Or listen to Hornets coach Monty Williams -- who says he received about four concussions as a player -- say the NBA’s concussion policy seeks to “treat everybody like they have white gloves and pink drawers” after his star rookie, Davis, was held out with a concussion.

Former player Paul Grant, who says he suffered a few concussions in his short NBA career, says he did not report his symptoms because “you don’t make the team in the training room.”

“You got to play,” Grant says. “You got to get on the court. You got to do whatever you can to get on the court.”

Kutcher says “the policies need to reflect the fact that it’s a team effort to diagnose concussions and look out for injuries, because the injured athletes oftentimes don’t know they're injured.”

Kutcher also warns that yanking players every time they get hit in the head can encourage players to hide symptoms.

What is a trainer to do? Many players don't want to be pulled from games and have incentive to under-report symptoms. Many coaches see concussion protocols as an imposition. Even the NBA’s own expert calls the sideline test an imperfect tool. Is it any wonder many blows to the head result in the injured player simply running back on defense?

More hits to the head than you would think

It’s Dec. 17, and Tim Duncan is sitting on the floor with his head down, having just been leveled by a Kendrick Perkins elbow to the jaw. Nine players continue around the fallen forward, and somehow the Thunder miss. The Spurs take off the other way. Duncan staggers to his feet, grips his knees and stares intently at the floor.

Duncan would rejoin the action when it returned to the Thunder end of the court -- but his game lacks zip. When the Thunder insert the overactive Nick Collison, Duncan loses him repeatedly. In a matter of minutes, the Thunder build a game-deciding lead and Duncan is pulled from the game, not to return.

A mere four seconds after Duncan sits, there is another hard blow to the head. Thunder star Russell Westbrook drives the middle and elevates higher than almost anyone else can ... but loses his balance at the peak of his jump with help from Duncan’s replacement, DeJuan Blair. Westbrook falls from the sky, smacking first his wrist and then his cheek on the hardwood.

These plays are more common that you might imagine. In New York that night, Tyson Chandler was called for a flagrant foul for hitting Jeremy Lin in the head while, in Orlando, a Kevin Love elbow to the face felled Glen Davis.

No easy answers

For decades, NBA players have been chided for not playing when they might be able to fight through injury, and phrases that make head injuries sound almost fun, such as “he got his bell rung,” pepper the basketball lexicon.

The reality is that now we know even minor blows can contribute to real medical problems. Sometimes it’s indecent to play on.

There have been big improvements; no NBA trainer will need to call the NFL to find out what to do about a concussion. But there are still many blows to the head in the NBA, and little experience in neurological diagnoses on site.

Future science may allow for immediate, accurate testing on the sideline. Player movement tracking could one day alert trainers when a player’s head rapidly changes directions in a way suggestive of concussive impact. Or perhaps one day sports neurologists will be mainstays on sidelines, ready to combine an NBA trainer's powers of observation and real-time diagnosis with a specialist's knowledge.

Until then, there’s no substitute for caution.