Concussion, Inc.: The big business of treating brain injuries

This story was updated at 4 p.m. on Dec. 17, 2015

Entrepreneurs looking to cash in on public anxiety over concussions are flooding the market with pricey products that have no scientific merit — and opening concussion clinics staffed by “specialists” with no expertise in brain trauma.

Hundreds of these clinics have sprung up across the country, some of them run by dermatologists, orthopedists, chiropractors, and physical therapists.

“It’s so Wild West right now,” said Rosemarie Scolaro Moser, a neuropsychologist who has been treating and researching concussion for more than two decades at the Sports Concussion Center of New Jersey. “I would say buyer beware.”

Many clinic directors market themselves as “credentialed” concussion management specialists, but that term has no medical meaning.

It just indicates they’ve completed training offered by a private company that sells a controversial computer test for evaluating concussions — and that promises to help its legions of trainees launch and market their own clinics.

Concussion products, meanwhile, flood the market: A pressurized neck collar is touted as a sort of “bubble wrap” for the brain. Pricey mouth guards and helmet covers promise to reduce the risk for young athletes, even though experts say no external device can protect the brain from slamming into the skull. A $300 genetic test claims to identify a child’s risk of concussion from a mouth swab — though scientists say the research is far too immature for such tests to be of value.

Parents and athletes worried about brain trauma — a fear likely to be fanned by the upcoming movie “Concussion” — make up a large and avid market.

The Food and Drug Administration, for instance, has issued repeated and strong public warnings that dietary supplements can’t prevent or treat concussion. But interest has hardly abated; the market still teems with pills and powders that promise to aid concussion recovery with ingredients like fish oil, turmeric, and resveratrol.

Apps that purport to diagnose concussion are also proliferating, with names like “Brain Check” and “Play it Safe.” Neurologists say it can be misleading and even dangerous for parents and coaches to rely on them because they reduce complex brain injury to a simplistic algorithm.

“Some of these products are just silly. Everyone’s out to make a buck,” said Steven Broglio, a kinesiologist who directs the Neurotrauma Research Laboratory at the University of Michigan and is a lead researcher on a $30 million concussion study funded by the NCAA and US Department of Defense.

Dermatologists as concussion experts

Brain trauma experts say some of the growing anxiety about concussion is an overreaction. One concussion is not likely to lead to degenerative brain disease.

Still, concern about brain injury has spurred new laws in all 50 states and the District of Columbia that require a licensed health professional to sign off before a school-aged athlete can return to play after a concussion.

Those laws, in turn, have created a huge market for concussion clinics.

“I’ve had phone calls from doctors asking, ‘What do I need to do to start a clinic?’” Moser said. “I feel very uncomfortable — you can’t answer that over the phone.”

One online registry, far from complete, lists 517 concussion clinics across the United States. Another lists more than 900 clinics in the United States and Canada.

Some are affiliated with prestigious hospitals or staffed by physicians with long experience treating concussions. A few medical schools, including UCLA and the University of Michigan, offer training fellowships in sports neurology, sports concussion and neurotrauma. The American Board of Psychiatry and Neurology started a program last year to certify physicians to treat brain injury.

But the booming field is also drawing interest from health care professionals with no obvious expertise in neurology.

One clinic that opened this year in Florida is staffed by a pediatric dermatologist. Many are run by spine specialists and physical therapists. A clinic in New York is run by a provider of hyperbaric oxygen therapy, which a 2014 study showed had no effect on concussion symptoms.

“You see clinics popping up all over the place staffed by people who are not trained to examine the brain,” said Dr. Jeffrey Kutcher, a sports neurologist who started one of the country’s first concussion clinics at the University of Michigan a decade ago and also directs the NBA’s concussion program and consults for the NFL and NHL Players’ Associations.

“It’s an incredible deluge of opportunistic companies that are trying to cash in on this issue,” Kutcher said.

The rise of pop-up clinics

Kutcher and a number of concussion experts are most concerned with a company called ImPACT, based in Pittsburgh.

ImPACT has built a lucrative business selling 25-minute computerized exams that test skills such as memory, attention span, and reaction time. The premise: Get a “baseline” cognitive score before each athlete’s playing season and then retest them after any injury and through the recovery period to see how the brain is healing. Those who use the tests say they help measure the invisible damage that concussions can cause, and can be especially helpful when athletes downplay or lie about their symptoms. ImPACT sells its tests to professional sports teams, high schools, and colleges worldwide; its website advertises 800 tests for $1,200.

A number of companies, including the educational publishing giant Pearson, market similar tests directly to schools, teams, and parents. ImPACT’s tests are the most common, however, and are used by many of the most prestigious concussion centers in the nation, including the Mayo Clinic and Boston Children’s Hospital.

Those tests have raised eyebrows because some of the studies that found them most effective were conducted by ImPACT co-founder Mark Lovell, who didn’t always disclose his financial stake in the company when submitting those studies for publication. Lovell also sold the test to NFL teams while serving as the league’s director of neuropsychological testing.

Lovell and other ImPACT officials declined to comment for this article.

Critics are particularly concerned that ImPACT may be fueling the trend of pop-up concussion clinics staffed by providers who don’t have much scientific background in brain injuries.

In addition to selling the tests themselves, ImPACT sells training packages that promise to turn psychologists, physician assistants, nurse practitioners, and others into credentialed concussion management specialists.

Become “the local expert in scientifically-based and validated concussion management,” the ImPACT website promises.

ImPACT’s training, conducted both online and in person, covers everything from marketing and billing to interpreting the tests and predicting the clinical trajectory of concussions. Those who complete the full training, which costs about $400, become credentialed ImPACT consultants and are encouraged to set up their own concussion clinics. The company provides them with marketing materials, helps them with public relations, and lists them in its National Network of Doctors.

‘No clinician should wing it’

Before the training, “I was woefully unprepared to deal with concussions,” said Dr. John Baker, an emergency room physician.

He founded the Concussion Management Center of Central Pennsylvania five years ago, after being frustrated that he couldn’t help a young family friend who had a difficult recovery from a concussion. Baker said he found the ImPACT training helpful but also went beyond it, seeking out training at two established concussion clinics.

Baker now treats hundreds of concussions a year and says he still finds the injury complicated, nebulous, and sometimes quite difficult to treat. He worries about fly-by-night clinics opening up just to cash in on the business opportunity.

Decisions about brain injury “should not be made by someone who dabbles in it,” he said. “I hope when people are opening their clinics, they’re doing it for the right reason and not just to make money.”

The training that ImPACT provides is thorough — but it’s only a beginning, said Wilfred van Gorp, a neuropsychologist who uses ImPACT testing and other tools at the New York Concussion Clinic he opened four years ago. Van Gorp took ImPACT training at the company’s headquarters but said he only developed true expertise after treating many patients.

He and other veterans of the concussion field say it’s inappropriate to rely on just one computer test for diagnosis or treatment. Instead, skilled specialists use a number of tools, including cognitive tests; balance, movement and eye tests; and a painstaking discussion of medical symptoms, which can be subtle — and which some athletes try to hide so they can return to play more quickly. There are no blood tests or brain scans that can definitively diagnose concussion. A comprehensive exam can easily take more than 90 minutes.

“No clinician should just wing it,” van Gorp said. “If concussion isn’t managed correctly, people can get worse.”

The ‘Stupid File’

Those who work in concussion treatment say the boom in concussion clinics does have a positive side: Care from good concussion clinics is a vast improvement over the misdiagnoses that athletes often received in years past from untrained family doctors, pediatricians, and emergency room physicians.

But bad advice still permeates the concussion business.

Eli Hallak, the lead athletic trainer at St. Francis High School in the southern California suburb of La Canada, keeps some of the worst doctor’s notes his players have handed him. It’s labelled “Stupid File.”

“Didn’t see anything in MRI,” he said, reading from one note. (MRIs are not used to diagnose concussions.)

“You weren’t unconscious,” he read from another. (Only 10 percent of concussions lead to a patient becoming unconscious.)

“Acute migraine,” Hallak read from a third, sighing.

In all of these cases, the physicians said the concussed students were fine to return to football the very next day — advice that concussion experts say can be terribly damaging to injured brains.

Hallak, who acts as a kind of one-man concussion education team, sends long faxes back to these doctors. “We just have to keep educating,” he said.

Hallak has no shortage of options for his concussed players. There are nine concussion clinics within 25 miles of his school. Many of his student athletes receive care at Providence St. Joseph Medical Center in nearby Burbank, Calif., staffed by Dr. Michael M. Marvi, a neurologist and expert in stroke and movement disorders.

The clinic — with gridiron green carpet and sky-blue walls — would make any student athlete feel at home. It feels nothing like a hospital; with all the framed jerseys on the wall, it looks more like a Rose Bowl locker room.

Part of Marvi’s job is convincing young athletes — and sometimes their coaches and parents — that they really have been injured and can’t return to the game they love until their brain recovers.

“I feel like I’m the last line of protection for these athletes.” Marvi said. “They don’t recognize they have symptoms, or deny having them.”

With so many clinics around, however, Marvi said some parents and students “doctor shop” — they keep trying new clinics until they find a provider who will clear them to go back and play, regardless of their symptoms. “All they are looking for,” Marvi said, “is someone to say yes.”