Authors: Mark Fainaru-Wada
“Were the studies double-blinded?” Noll asked. “What are the metrics? I need more information.”
Maroon fumed. Noll was undeniably sharp, but who was the doctor here? But the more Maroon thought about it, the more he had to admit that Noll was right. As common as concussions were, there was not a lot of useful information about the injury he could cite to justify his opinion that Bubby Brister shouldn’t play.
In the long history of brain research, the concussion was still regarded as the neurological equivalent of a stubbed toe. The injury was as underrated by the medical profession as it was by the NFL. There was little research money devoted to it and it had no glamour, particularly for an area of study whose mystery and vastness are often compared to the study of the universe. There was widespread confusion about what a concussion was, not only in the general population but also among doctors and researchers; dozens of definitions had been floated and discarded.
The fact that concussions were practically an afterthought was perplexing when one considered what actually occurred. The brain is essentially an
oddly shaped sphere of Jell-O, crammed inside a box, covered in a shallow layer of cerebrospinal fluid. This gelatinous material
contains a kind of electrical grid—hooked up to an EEG, the brain can power a toy train—that transmits information through the body via microscopic fibers called axons. When someone is hit in the head or stops suddenly, the brain is jolted against the skull’s jagged interior, distorting or even severing the axons and interrupting the function of the synapses, the connections between the fibers of the brain. The immediate effect depends on where the connections are and the extent of the damage. Some people go temporarily blind. Others lose their memory or balance or become irritable. When the blow is particularly violent, the entire system short-circuits, like a neighborhood blackout, and the person loses consciousness.
In that context, you wondered why people hadn’t taken concussions more seriously. But the focus had always been on catastrophic head injuries such as skull fractures or hemorrhages. In sports, what little research there was occurred almost by accident. One pioneer in the field was a genial, wisecracking neuropsychologist at the University of Virginia named Jeff Barth. “In the late seventies and early eighties,
nobody thought mild head injury was a problem,” said Barth, who resembled Hulk Hogan and liked to splice the wrestler’s picture into his scientific presentations. “When you’d go to the doctor or the ER with a mild head injury, they’d say, ‘Just take a couple days off, take some aspirin, and you’ll be okay by Monday.’ ” As part of his work at Virginia, Barth saw emergency room patients from the Charlottesville area and other parts of Virginia. He and his colleagues began to notice that out of the hundreds of head injuries they treated each year, the majority were the so-called minor variety that involved either no loss of consciousness or blackouts lasting only a few minutes.
Because there were so many—Barth counted more than 1,200 concussions over a two-year period, often from traffic accidents—he decided to study them to see if he could improve treatment. He and his colleagues soon discovered that these mild head injuries often weren’t so minor. “We did a three-month follow-up, and lo and behold, we found that about one-third of mild head injury patients hadn’t returned to work,” said Barth. “I thought, ‘Wow, that’s amazing! Why
is
that?’ ”
His findings struck a chord. The
Wall Street Journal
ran
a front-page article in 1982 that described concussions as “a silent epidemic.” Barth
was riding high until he went to a conference and presented the study to some of his colleagues.
“It was one of the worst days of my life,” he said.
As he stood at the podium, the audience bombarded him with questions and doubts. Maybe Barth was testing only people who weren’t very smart. Maybe they didn’t return to work because they had an excuse from the doctor. What was his control group? “I thought to myself: ‘How can I get out of this?’ ” said Barth. “ ‘Maybe I can fake a seizure.’ ”
Barth decided he needed a more rigorous study. The important thing was to find patients who were likely to have concussions and were available for follow-up. “My initial idea was we could test all of the Psychology 101 students at the University of Virginia, follow them around campus and hit them with a two-by-four, and then test them again,” he joked. Other groups were considered, including race car drivers and boxers. Finally one of his colleagues, Bruno Giordani, said: “What about football players? They run and hit things.”
Thus was born an entirely new field: sports neuropsychology, the study of the brain under the influence of sports. “Unfortunately, some of my colleagues who like to get at me, they don’t call me the Father of Sports Neuropsychology, they call me the
Grandfather
of Sports Neuropsychology,” Barth said.
Barth started to perform tests on Virginia football players to measure their baseline performance—before they got conked on the head—on tasks such as word recognition and number sequencing. He and his colleagues positioned spotters at practices and games to be on the lookout for head injuries, then tested the players immediately after an injury occurred to measure differences in brain function.
The first experiments, in 1984, were a disaster. Out of the 100 or so players who participated, there were only a few documented concussions. Virginia was terrible that year, and before he was fired, the beleaguered coach shut down Barth’s experiment in midseason. But Barth persisted. The next year, he expanded his study to include the Ivy League schools and what he referred to as “a real football team,” the University of Pittsburgh. This time,
the results were startling: Out of 2,350 players who participated, 195, or more than 8 percent, sustained verifiable concussions. More than half still had headaches at least five days after the
injury occurred. About a quarter still had signs of memory loss, nausea, and dizziness. Most of the symptoms cleared within 10 days.
What had started as an attempt to measure the effects of minor head injuries after traffic accidents had become a harbinger of football’s soon to be tumultuous future. Barth’s major discovery was that concussions might be regarded as “minor” injuries by coaches, trainers, and even doctors, but they weren’t minor to the people who incurred them. He published his results in 1989. “Through further data review and analysis, it is our hope that we can provide the football community, and sports medicine psychologists in particular, with a brief and easily administered set of neuropsychological assessment tools that will aid team physicians,” Barth wrote.
Now, two years later, Joe Maroon was faced with exactly that scenario. Chuck Noll wanted his quarterback, Bubby Brister, back on the field. Maroon, the Steelers’ doctor, didn’t agree. But he had no real tools to justify his assessment. As it turned out, Maroon had participated indirectly in Barth’s study. In addition to his work with the Steelers, he was the neurological consultant for the Pitt Panthers—the “real football team” from Barth’s experiment. Maroon didn’t have enough concrete data to prevent Brister from playing, but perhaps here was a way to get at it.
Maroon went to the chief neuropsychologist at Allegheny General, Mark Lovell, and explained the situation.
“You know what, Mark?” Maroon said of Noll. “He’s right.”
Brister ended up playing, but that was the beginning of the story for Maroon, not the end.
To that point, the sports medical community had viewed a concussion as an invisible injury. You couldn’t x-ray it or scope it or put a cast on it, so how serious could it be? Barth had shown that a player might appear normal, but if his brain wasn’t functioning properly—as measured by changes in short-term memory, executive function, ability to reason, and so on—that was an indication the injury hadn’t healed. As simple as it now seems, that discovery was groundbreaking.
Maroon says he didn’t see a financial opportunity in the diagnosis of concussions until years later, when a colleague pointed it out to him.
This was still in the sleepy early days of the NFL’s concussion crisis, and Maroon was merely looking for answers. He approached Lovell to try to figure out a way to better justify his on-field decisions to Noll and the players. But it was exactly the type of out-of-the-box idea that got Maroon’s wheels spinning.
Joe Maroon was a neurosurgeon with a flair for business. He had picked it up from his father, a Lebanese immigrant who had hustled out a living in the Ohio River Valley by catering to the needs of the miners and rivermen. Charles Maroon operated Bridgeport’s only bowling alley, serviced vending machines throughout the region, and built a truck stop in the northern tip of West Virginia. He owned a building that housed a strip joint called the Lucky Lady Lounge. Maroon worshiped his dad and decided to go into medicine only after thinking long and hard about whether he wanted to defy his father’s wishes that he become a lawyer. Despite his size—about 5-feet-5, 160 pounds—Maroon attended Indiana on a football scholarship, started at halfback for two seasons, and was a scholastic All-American. When he was in his early forties, his wife left him and his father died in the same week. He briefly left medicine and went back to Bridgeport to run his father’s truck stop, a midlife crisis that left him suicidal. Exercise helped save him. He became a health enthusiast and ran triathlons all over the world. Still competing in his sixties and seventies, Maroon wrote a book called
The Longevity Factor
in which he recommended a number of
novel “secrets” to a long and healthy life.
As admired as Maroon was, there was a whiff of opportunism about him that some of his colleagues found distasteful. He seemed to combine his neurosurgery practice and his entrepreneurship in ways that pushed the envelope. Maroon touted the wonders of red wine and fish oil as the keys to staving off everything from depression to Alzheimer’s disease to death itself. No one doubted that he believed what he was promoting—Maroon looked great, a trim man with a full head of graying hair—but he often seemed to have an angle.
When Maroon sold his neurosurgery practice to the University of Pittsburgh Medical Center, some of his colleagues were surprised to learn in the
Post-Gazette
that UPMC had agreed to purchase real estate owned by Maroon for $6.22 million. “Joe has a lot of great qualities, he has legions of patients
that legitimately adore him,” said one doctor who worked with him for years. “He’s done well at the professional level in all respects, including with the Steelers. But everything has to have an immediate entrepreneurial angle. You can’t just appreciate it for whatever its value is, you know? There has to be: ‘How can we take advantage of that?’ And that’s the thing that to me is a little off-putting.”
Shortly after the Bubby Brister affair, Maroon sat down in the cafeteria at Allegheny General with Mark Lovell and laid out what he was thinking.
Lovell (pronounced LOVE-uhl) didn’t have much experience in sports, but he had
personal experience with concussions. During his junior year of high school in Grand Rapids, Michigan, he was picked up hitchhiking by a drunk driver and was thrown through the windshield when the car crashed into a parked car. “My head went through and then recoiled back,” he said. “If you look at my nose, you can see that they kind of sewed it back on.”
Lovell needed 120 stitches. But what he noticed over time was that the more serious problem was his head. For the next several years he had migraine headaches. “I had a concussion, but nobody called it a concussion,” Lovell said.
Lovell was reserved and soft-spoken, with straight brown hair, a goatee, and an earnest manner that later made his role as one of the most controversial figures in the NFL’s concussion saga seem incongruous. His specialty was neuropsychology—Jeff Barth’s world—a relatively modern discipline that seemed to baffle everyone around him. Lovell’s father, a Grand Rapids auto mechanic, proudly introduced his son as a “psycho neurologist.” Lovell’s fundamental job was to assess brain function, and Maroon had come to him with an intriguing proposition.
Maroon wanted to see if Barth’s experiment could be adapted to the NFL. He wanted to know specifically if Lovell could design a neuropsychological test that could be used to establish baseline data for the Steelers and then use that test to assess changes in brain function after a concussion. If there were major changes, Maroon would have quantifiable data to present to Noll and help guide his decisions about whether a player should return. Lovell quickly agreed. The test itself wouldn’t be hard. Barth already had administered it to college players, and so it was
really a matter of updating the test—actually a series of tests to measure memory, executive function, and so on. The tests already existed; they were used to assess stroke patients, people with dyslexia, accident victims—any number of neurological disorders. The hardest part was devising an exam that could be administered in the heat of a game. “The thing I learned very, very quickly is that you didn’t have an abundance of time to do this,” Lovell said. “Neuropsychologists at that point would spend four or five or six hours with a patient. That doesn’t work in sports.” At most Lovell would have 15 or 20 minutes, maybe half an hour. He borrowed liberally from Barth’s study and other neuropsych tests that were floating around and tried to keep it all to one sheet of paper.
Maroon went to Noll and Steelers owner Dan Rooney for approval. The test wasn’t expensive—it was all done with paper and pencil—but the team needed to make the research subjects—the players—available. Noll and Rooney agreed under the condition that the testing would be voluntary. Anything more would have to be cleared through the NFL Players Association, and that wasn’t likely.
The players greeted the idea with suspicion. Many thought the team was literally trying to get into their heads by assembling psychological profiles that could be used in contract negotiations. Or secretly administering IQ tests. Or looking for potential deviants. The NFL already put rookies through the controversial Wonderlic test, which Lovell described as “a test to see if you’re too stupid to play in the NFL.” He didn’t want his test to be confused with that. “I didn’t blame the players,” he said. “I said, ‘This has to be seen as something that’s only for injury management.’ ”