For years, University of Pittsburgh Medical Center's concussion team has preached three little words.
Yet those words _ "concussion is treatable" _ rarely appear in the medical literature.
It turns out UPMC was a silo, but it wasn't alone. A paper published this month in the journal Neurosurgery, whose primary authors are three UPMC researchers, represents the first major statements of agreement on concussion treatment. The document resulted from a meeting in Pittsburgh last year involving 38 concussion experts from across the U.S.
"I'll be darned, but it was really neat to see we were all arriving at similar solutions even though we were working independently," said Micky Collins, director of the UPMC Sports Medicine Concussion Program.
But the symposium, which took place last October in Pittsburgh, was criticized at the time for a number of reasons _ that it was funded by grants from UPMC and the NFL, which has a checkered history of concussion research; that it was closed to the media and the public; and that it brought together a small group of participants.
"We were mindful of all the issues you described, and they were thought of before the meeting took place," said Collins, the paper's lead author. "This was done to help the field. It was the only reason it was done."
The experts sought to dispel the idea that concussion is a permanent injury that cannot be treated, although their 16 consensus statements did not recommend particular treatments.
"This is the very first time that a group of experts have convened and issued a statement that concussion is treatable, and the impact of that statement should not be understated," said David Okonkwo, one of the primary authors, who is clinical director of Pitt's Brain Trauma Research Center. "It is exceedingly difficult to find those words _ quote, 'concussion is treatable,' end quote _ in the medical literature, and we chose to focus on that because that would be the best catalyst for what's needed next in the field."
The paper calls for further research in that area, although it also challenges the idea that rest is the best approach. For about a decade, UPMC has advocated for more active treatment, and its concussion clinic offers therapies for specific symptoms, like headaches or eye problems.
"Patients who sustain comas from major brain injuries are actively rehabilitated over many, many months," Okonkwo said. "If it's true for someone with a severe traumatic brain injury causing a coma, why wouldn't it be true for a less severe injury causing a concussion? Ironically, there is no evidence to support the concept of rest in spite of the fact that it's been the dogma of the field for a long time."
Collins said the conference could have involved many more participants, but due to the budget and logistics of the meeting, it needed to be private and kept to a small group. And he maintained that the group represented diverse thoughts and disciplines, from athletic trainers to neurosurgeons. Non-voting participants from organizations such as the NFL and the National Institutes of Health also attended, but Collins and Okonkwo said they had no say in the meeting's content and output.
"This wasn't a cherry-picked group," Collins said. "We wanted the people involved in this meeting that have done extensive work in this topic."
Of the 38 authors listed in the paper, 20 had current ties to the NFL or the NFLPA _ whether as grant recipients, team doctors or unaffiliated neurotrauma consultants who work on the sidelines of games. Several others list connections to the UPMC-developed ImPACT tool, which assesses concussions and is used by the league. Those connections were disclosed in the paper. The NFL and UPMC did not comment on the size of the grants that funded the meeting.
"One of the reasons why many of the participants in the team approach meeting have ties to the NFL is because the NFL has engaged the help of many experts in the field over the last several years as it tries to improve player health and safety in football," Okonkwo said.
"There were some concerns by some prior to the meeting being held, (but) I thought the meeting was run as egalitarian-ly as any meeting I've been at," said Robert Cantu, an expert on concussions and CTE at Boston University, who advises the NFL's head, neck and spine committee. "We were all peers, we all had clickers, we all had one vote on every topic that was being discussed."
William Barr, a neuropsychologist at NYU Langone's Concussion Center who has long been critical of ImPACT, said the meeting involved "a lot of the big hitters" in the concussion field and agreed with much of their consensus.
"There's not too much here you can argue with, in the sense that, yeah, we certainly need more guidance on how to treat concussion," said Barr, a former consultant with the New York Jets, who was not invited to the symposium. "There are clear facts in there that nobody can disagree with."
Yet he did express some concerns. For example, he worries the push for active intervention could prompt patients to seek treatment for issues that aren't really there _ or that would go away on their own.
"I think most people in concussion centers have good intentions," said Barr, who works at one such center himself. "They want to help people and do a good job and all that. But what has happened with the concussion center model is people are being treated for things they don't need to be treated for."
The question of when to start therapy as "the elephant in the room" at the symposium, Cantu said. He noted that patients can aggravate their symptoms _ not to mention spend a lot of time and money _ by taking on therapies too soon after a concussion.
"But how quickly after that should you get going if the symptoms haven't cleared up ... that's not certain," he said.
The paper recommends further research on that issue and several others, such as biomarkers (like blood or brain imaging) that can be used to test concussions.
"The value of sports and recreation in the lives of our youth and in the health of our fellow Americans is substantially higher than the risks of concussion are," Okonkwo said. "We need to continue to work as hard as we can to further minimize those risks of concussion to the greatest possible extent and to identify the best tools technologies and treatments for concussion."
