I’ve got to plead some ignorance when it comes to both head injuries and the NBA’s new(ish) concussion protocol. I didn’t know much about either before this morning. I’m still no expert, but, ya know, baby steps.
Like many people, I read Malcolm Gladwell’s 2009 New Yorker piece on concussions and recoiled in horror. Since then, I have watched the science develop from afar, my relationship with football growing more morally ambivalent, my understanding of brain trauma evolving with time, my agony at hearing the news of a player suicide recurring too often.
When I heard that Junior Seau killed himself, time froze.
I was a 49ers fan growing up (still am), and the 1994 team — with Deion and Merton Hanks doing that swag stuff, before we knew it was a word, before it became the new-millenium “gnarly” — was my favorite thing ever. I’m surprised I didn’t wind up in the hospital with a snapped neck trying to do that Merton Hanks dance in my bedroom.
The only aspect of their Super Bowl rout over the Chargers that bothered me was that it happened to Junior.
I was such a fan.
I was an offense guy before that, a Jerry Rice guy, first and foremost. Ronnie Lott was my dude, too, but that 1994 Niners squad turned me. It was the final kick I needed to care more about the grimier side of the ball, although it was somewhat ironic that it took that All-World eleven-man combo, playing with such flash, to push me over.
But two guys, other than Lott, laid the foundation the proceded that switch: Derrick Thomas and Junior Seau. I was a little young for prime L.T., so it was those two linebackers that started to make me see why defense mattered more.
If you know the NFL, you know what happened to D.T.
Car crash. Tragedy. Such a loss.
I remember being happy that him and Joe Montana got to play together at least. I rooted for Joe and Derrick to make the Super Bowl after the best QB in history left the Bay.
But to see Junior’s untimely passing, so young, too?
Man. Kick to the gut.
It was just over a year ago. I was in Miami, attending a business convention about weather. Three days later, I would drive four hours north to watch the Pacers beat the Magic in Orlando in round one of the playoffs. I remember thinking about Junior, and more his mom, her soul wailing on live television, during that long drive, alone, whipping a rental at 90 through the dull Florida swampland, hoping to shave enough minutes off of the commute to make it in time to listen to Stan Van Gundy speak to the media before the two o’clock tip.
(I made it. He was funny and Van Gundyian. The Pacers almost collapsed but won in overtime. The Magic have a nice arena. I enjoyed the trip.)
This is all preamble to say that my understanding of concussions is little, and my emotional reaction to them is large. In the past year, I’ve seen a few 60 Minutes-type pieces, read a few magazine features and tried to keep up on the phenomenal work my bros Beckley Mason and Henry Abbott have done on basketball-related concussions over at TrueHoop.
But, mostly, my outlook on concussions has more to do with the memory of watching Junior Seau’s mom fall to pieces on live TV last May than it has to do with actual knowledge of how the human brain is affected by blunt-force trauma.
Like a good little pretend journalist, however, I’ve tried to do my research on the matter before trying to add any insight to the George Hill situation.
After suffering a concussion when colliding with a Tyson Chandler screen during the first quarter of Game 4 (video of the play above), he was a late scratch from yesterday’s attempted close-out game against the Knicks. The Pacers proceeded to play like a team that lost the only reliable point guard on their roster.
It was gross basketball that I did not care to watch. It was a laughable display of turnovers, really.
The team seems to badly need Hill. If he can’t play, that significantly ups the likelihood that the Knicks can pull off an improbable come back after trailing 3-1 in this series.
It’s bad news.
But while I get that basketball is not football, mostly, it’s bad news for George Hill.
Not the Indiana Pacers. Not the Indiana Pacers fans.
Again, I don’t know crap about crap when it comes to brain trauma, but I’m a precautionary principle guy through and through, so my instincts tell me that, if Hill isn’t 100 percent, he shouldn’t be playing basketball in the next few days. Maybe not in the next few weeks.
This series is a giant moment for the Pacers franchise, but this is a man’s brain health. That’s not about walking around with pain in your knee everyday when you’re 54 years old. It’s a lot bigger.
That said, we have no idea how severe this concussion was. As I’ve come to understand it, since he flew to New York and went through shootaround and was walking around the arena and talking to people before the game, that means his symptoms were likely mild. But, as I’ve come to understand it, the lack of severity of symptoms doesn’t necessarily mean the recovery time will be shorter than it would be if the symptoms were more limiting.
Like all injuries, brain injuries heal with rest. How much Hill needs to recover is a great unknown, certainly to me, almost definitely to him and probably even to the doctors giving him medical advice.
Looking at other players’ recovery times seems problematic, because brain health seems like perhaps the most unique-to-an-individual type of health there is. (Again, no M.D. Just guessing on that.)
Nevertheless, here is a graphic ESPN put together on time missed by a few NBA players who have suffered concussions.
Again, take this with a grain of salt. None of the names on that list are “George Hill,” and none suffered his specific injury. Medical science has not reached the point where this equates to the typical “meniscus tear: four to six weeks” prognosis for recovery.
Here is some related recovery information that Abbott and Mason compiled for TrueHoop.
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 scary stuff.
Brian Scalabrine, who suffered three concussions in one month, shared his story of recovery with Mason for TrueHoop.
The story is I got hit in the head and more than likely I would have sat out the entire year … except that [Kevin] Garnett was out with the little knee thing he had, then Leon Powe tears his ACL.
So we’re sitting there playing Chicago in the first round and at that point I go back to “I don’t care if I’m 70 percent, I don’t care if I’m 50 percent, I have an opportunity right now to play in the playoffs.”
The only two bigs we had were [Kendrick] Perkins and Big Baby [Glen Davis]. I was the third rotational big man, and I got a chance to play a ton of minutes in the playoffs. So I said, Hey, the long-term repercussions of this, I’ll deal with later. I’m going to push through and play.
More from Scalabrine.
The symptoms were this: I couldn’t sleep longer than three-and-a-half hours. So every three-and-a-half hours, I would wake up for two hours, then try to go back to sleep for three hours, then I’d wake up again.
Another symptom was that I couldn’t handle light, at all, so I’d wear dark, dark sunglasses all the time. And every time I tried to exercise, I would get really light-headed. So for me to be cleared, I had to be cool on all three.
Well, I just lied.
At the end of the day, I made that decision and I was happy with that decision. I’m completely fine with that because I look for opportunities; I was an opportunistic guy. I played 11 years in the NBA without a lot of talent, so I tried to take advantage of the opportunity in front of me. Regardless of how I felt, I was playing through that. I just said I’ll just deal with this stuff later.
I just told the doctor, Man this is great! I don’t have any issues with light, I’m sleeping better, I’m doing this, I’m doing that.
Were those things happening? Eh, not really. I wasn’t sleeping much better, I wasn’t feeling much better. But at the end of the day, there was an opportunity to play, so I played. That’s the decision I have to live with, and I’m completely fine with it.
Again, again … This isn’t to equate Scalabrine’s situation directly to Hill’s. They are different injuries.
At some point, George Hill is a grown-ass man and he will come to a grown-ass man decision on if and when he can play. Will he feel ready to suit up in Game 6 on Saturday and/or for any subsequent games this season against the Knicks or Heat or (let’s get wild with it) the Grizzlies or Spurs?
Knowing what I do about NBA athletes generally and George Hill specifically, I’m guessing he will try to play as soon as he can. He’s a local kid playing for a hometown team that is desperately in need of his services, and he wants his team to reach the Eastern Conference Finals and then win the NBA Finals. Moreover, if this team loses to the Knicks, or the Heat, or the Grizz/Spurs, I believe he wants to die with his teammates as that ship sinks. Everyone raves about how close knit this group is. I can’t imagine how difficult it would be for him to sit on the sidelines and watch his team lose.
The hurdle to doing so, other than Hill’s personal opinion on his ability to play, is the NBA’s concussion protocol, established in December 2011 before the start of the lock-out shortened 2011-12 regular season.
I asked NBA public relations head Tim Frank for the details of the multi-step process that must take place before a player can return to the court. He broke down the following details in an email.
- If a player is suspected of having suffered a concussion, or if he exhibits any signs or symptoms of a concussion, he is removed from a game or practice. The team’s medical staff then evaluates the player.
- If a player is diagnosed with a concussion, he may not “return to participation” on the same day. (This is I believe what happened yesterday with George Hill, who was diagnosed yesterday for the concussion suffered on Tuesday during Game 4, only after having flown to New York and participating in shootaround on Thursday before Game 5.)
- The player is barred from all team activity until he free of symptoms “at rest.” He will continue to be held out of all activity until he has “no appreciable difference from his “baseline neurological exam” (which every player takes in the preseason) and his “baseline score” on the computerized cognitive assessment test (also taken by every player in the preseason).
- Once the player is symptom-free at rest, with “no appreciable difference from his baseline tests,” he must complete the NBA’s “return-to-participation protocol,” a multi-step process of increasingly strenuous exertion tests, before being cleared to play. The series of physical tests advances from: (1) a stationary bike to (2) jogging to (3) agility work to (4) non-contact team drills. After each step, a player must show no concussion symptoms. Then he can advance to the next step. If a player shows concussion symptoms, testing stops until he is symptom-free. Once he is, he can resume testing, beginning with the last step he passed before showing concussion symptoms.
- The team physician oversees this process and ultimately makes the decision to clear the player, but that doctor must consult with the NBA’s director of the concussion program.
- Frank concluded his email with this: “It’s important to note that there is no timeframe to complete the protocol. Each injury and player is different and recovery time can vary in each case.”
TrueHoop published more details about how the protocol works in the real world, including some background information on how the preseason “baseline” tests are conducted.
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.
All this shows the formidable logistical difficulties the Indiana Pacers face before they can get their point guard back on the court. There is a lot to go through in a very short period of time, especially if we’re talking about a potential return tomorrow night for Game 6 in Indiana, when the Pacers will have another chance to end the Knicks’ season.
Still, it’s strange to me how all this stuff is being discussed, by and large. Most accounts, to me, carry the implication that the process is the barrier from Hill playing.
In a way, sure.
But his health — a recovery following brain trauma — is the actual issue.
My guess is that George is, at least in part, bemoaning the same logistical hurdles that many fans are. Like Scalabrine, and regardless of the league’s ongoing effort to educate players about brain injuries, he might just not care. He might just want to play as soon as possible.
That’s fine. His call, as long as the doctors sign off on it.
But that’s the whole point here: The protocols were put in place for just this reason. At least in part, this system was put in place to protect the players from themselves.
The Pacers need a capable point guard. But George Hill has to make the best decision for George Hill before even considering that fact. It’s just a game.
UPDATE: The concussion protocol description, as explained by the NBA, has been altered since original publication to better explain the process.