-- It's August, and that means it's football time. The Steelers are back in camp, Ohio Valley teams are practicing and colleges are back on the field. As the team neurosurgeon for the Pittsburgh Steelers, a position you've held for several decades now, what concerns do you have with the well being of the players at all levels - professional, college, high school and even Pop Warner level?
Dr. Maroon: The most important concern at this particular time with the heat wave is appropriate hydration and conditioning. Hydration becomes extremely important because of the possibility of heat stroke and also because when dehydrated and feeling weaker, there's less protective reflexes particularly when it comes to contact. The conditioning of the cervical muscles, the appropriate fitting of good equipment, particularly helmets, and then the basics particularly at the high school level of proper blocking and tackling techniques become critical. Once these are covered, then it becomes a matter of instituting those principles - blocking and tackling correctly - and not using the head as a battering ram but using it appropriately in a head up or a side position.
-- The incidence of concussion among athletes remains high, with about one of every five athletes expected to suffer a concussion at some time during this season. A study released a few weeks ago also shows a possible link between concussions and the risk of Alzheimer's and dementia as a person gets older. Are we doing enough to ensure brain safety?
Dr. Maroon: Let's start with what a concussion is. A concussion is a transient or temporary disturbance of neurological function usually associated with complete recovery. A transient disturbance of neurological function can mean a ding - where you see stars, you have a very brief, blurred vision or headache - or it can be associated with loss of consciousness. ... When we're talking about concussion, only 10 percent of the concussions are associated with the loss of consciousness. Most people used to think that you only had a concussion when you were knocked out. Not so. Ninety percent of concussions are the transient disturbance of vision, memory impairment and reaction time is diminished. What's happened is we've become extremely more aware of these seemingly minor disturbances that we're learning are not necessarily always minor.
In other words, if you go back to play before the symptoms have completely cleared you're much more likely to have another concussion with less force, less impact and a more prolonged episode of recovery.
What the NFL, what high schools and colleges are focusing on now is No. 1, identifying the concussion when it has occurred, which in the past quite frankly has been overlooked, and No. 2, not returning these individuals until the brain's had the opportunity to recover.
To that end, what I have developed along with Mark Lovell, my associate who's a neuropsychologist here in Pittsburgh as well, we developed the IMPACT system. IMPACT means Immediate Post Athletic Concussion Testing. It's a 20-minute neuro-cognitive test that you take at a PC ... we can test 100 patients in 30 minutes. In 20 to 30 minutes we can get a baseline in terms of their ability to process information, their memory, their reaction time to 1/100ths of a second, and their visual and verbal ability to handle constructs. With that baseline, we then, when an athlete has a transient disturbance of neurological function, retest them and compare against the baseline.
The NFL now has mandated three things before you return to play: No. 1, you must be completely asymptomatic, in other words no headaches, nausea, vomiting, fatigue, sleepiness, drowsiness, at rest. No. 2, You must also be completely asymptomatic after aerobic activity, or exercise. And No. 3, you have to return to your baseline testing with IMPACT. If those three criteria are met, you can return to play. The NFL has also reduced the number of practices with contact ... so they're cutting down on the number of impacts to the head and instituting the guidelines. ... This should not only trickle down but should be enforced by the NCAA, at the high school level and also the little league level. There are only 1,900 people in the NFL. There are 1.4 to 1.5 million at the high school and college level and close to 3 million at the Pop Warner league, so if we can get uniform adaptation of these criteria it will go a long way to reducing the problems of concussion.
-- How big of a push needs to be made at the lower levels of sports to get a uniform standard for appropriate testing of head injuries? I can recall during my playing days getting my bell rung and then the coach yelling to get back on the field.
- Dr. Maroon on concussions in U.S. soldiers
- Dr. Maroon on working with the Pittsburgh Steelers
- Dr. Maroon on the Ohio Valley
- Dr. Maroon on parents' concerns with contact sports
- Dr. Maroon on repeat concussions
- Dr. Maroon on the benefits of exercise
- Dr. Maroon offers advice to athletes returning to practice
- Dr. Joseph Maroon full video
Dr. Maroon: It was the same with me. I don't know how many concussions I had. Playing at St. John's in Bellaire and Indiana University - I was the smallest guy in the Big 10 the years I played (Maroon played tailback and safety). It was common (for coaches to ignore concussions) but it wasn't appropriate for what we know now. The problem now is with repeated concussions, repeated head injuries before the brain has had a time to repair itself, there's a condition called chronic traumatic encephalopathy ... which is what was diagnosed in (former Steelers) Mike Webster, (Justin) Strzelczyk, (Terry) Long, and (former Philadelphia Eagles' player Andre) Waters and several other big name athletes. The question is this is a syndrome that develops several years after play, according to those who have written about this. An associate of mine, Dr. Russell Blaylock ... we have put forth what we call a unifying hypothesis that explains what happens in the brain in post-concussion syndrome. These are athletes who continue to have symptoms. ... We believe that what happens is that there are particular cells in the brain called microglia, and they are the brain's innate white-blood cells, so to speak. They get activated with trauma, infections, toxins and they secrete agents that are very inflammatory and these inflammatory agents cause what we term neuro-inflammation, or inflammation of the brain. ... We're suggesting there are ways to attack inflammation with some natural compounds that might reduce the incidence and the consequence of these diseases.
-- You mentioned soldiers. Is the military taking a more serious approach to concussions or brain injuries in soldiers?
Dr. Maroon: There are about 300 concussions per month in soldiers in Afghanistan and Iraq. Many of these have long-term consequences. The military is every bit as involved if not more so than the NFL. Our belief is that's what good for an NFL quarterback is good for a (soldier) on the front lines in Iraq (and Afghanistan.) The IMPACT system is now being evaluated by the Army as a baseline test and subsequent follow-up.
We have already baselined about 35,000 Special Forces soldiers ... and on a PC, even in the field, you can do another IMPACT test, compare it to the original and have a good idea about the individual's abilities.
-- Younger athletes. Should parents of younger children be concerned with sports such as football, soccer or others where head injuries can occur?
Dr. Maroon: I saw some statistics a few years back, if you look at the time that kids ... spend in automobiles at the same time they could be on the practice fields ... the incidence of injury from being in car accidents would be significantly higher than participating in sports. And yet the lessons learned on the fields of friendly strife ... are very substantial. So yes, there should be concern. They should be concerned that the right equipment is obtained, they also should be concerned that they have IMPACT testing before they start, and they should be concerned if a concussion occurs that they're managed appropriately.
-- Let's say a youngster goes to football practice this week and comes home with a persistent headache after a helmet-to-helmet hit. What should his parents do?
Dr. Maroon: It's not an emergency unless there's a deteriorating level of consciousness, or a progressive increase in the severity of the headache. If there is, they should go to a hospital. If it's I just don't feel right ... and that persists then they should see their physician the next day.
-- Working with the Steelers, what is the main difference you see in how athletes are treated at the professional or even the college level following a concussion with how they may be treated in high school or, even worse, Pop Warner leagues?
Dr. Maroon: I think the testing is the main thing, although (testing) is now ... becoming much more prevalent. There still are schools around the country that probably are not current with what has been recommended at the higher levels. I think it is incumbent on the principals, on the trainers, on the coaches to make sure they are keeping with the most current guidelines for managing head injuries and concussions.
-- Let's stay with the Steelers for one more question. You've worked with some interesting characters and legendary coaches during your time there, including Chuck Noll. What's been your favorite memory?
Dr. Maroon: Probably the most poignant memory is with Coach Chuck Noll. It's why we're sitting here today. Coach Noll asked me to be the team doctor in the early '80s and in 1990, I told him that his starting quarterback, David Woodley, couldn't play against the Dallas Cowboys the following week and he said, why? And I said because he's had a concussion, and the guidelines say he has to stay out for three weeks. And he said who wrote the guidelines, and I said well, a committee of doctors, and I happen to be one of them. (Noll asked) which criteria did you use, what data did you have to substantiate that criteria. And he said look, Maroon, he looks good to me, he can throw, catch, he knows his plays, he's not having any symptoms. If you want me to keep a player out of football I want objective data from you. Not your impression or guidelines. That's when I called Mark Lovell ... and said as chagrined as I am, he's right. And Mark, who's a brilliant neuropsychologist, he and I ... put together the first IMPACT test. I went back to Coach Noll, 'Coach, if you want data, then I have to have baseline on the whole team.' And he thought about it and said OK. So in 1990 was the first time we instituted in the NFL baseline testing for concussions. ... We now have more than 1.8 million kids that we baseline ... and we're just partnering this week with Dick's Sporting Goods across the country. Dick's is going to donate over $1 million to test kids throughout the country through a joint program with Dick's and IMPACT.
-- Let's move on to passion: exercise. You've completed 70 triathlons - seven of them Ironman triathlons, which involves a 2.4-mile swim, 112 miles of cycling and a 26.2 mile run - so it's clear that physical activity plays an important part in your life. With your medical practice and other obligations, where do you find time to train for such a grueling event?
Dr. Maroon: John, in order to do what I do in surgery ... the surgery I do is kind of an endurance sport in a way, in the sense that you have to be totally focused, concentrating at all times and your hand-eye coordination has to be perfect. I've tried it both ways in the sense that at one point in my life I was deconditioned, not working out, and I wasn't functioning at the highest level I could. I learned that if I spent an hour a day in some kind of physical fitness program, that my mind, my body, everything works at a much higher level. Staying in condition is not an option for me, it's a necessity. I have to do that in order to function at the level I want to function at.
-- So why triathlons? That's kind of the exercise extreme.
Dr. Maroon: I'm also a very goal directed individual. For some reason I can't force myself to work out unless I have a goal, and that goal is usually a race. It challenges me to push - there's a saying that you never know what your limits are until you try to exceed them. It's one of the things I do enjoy, when you think you can only go so far and then you go beyond that. It's very gratifying and uplifting.
-- As you mentioned, there was a time in your life when you were out of shape and returned home to Ohio, had some things going on in your personal life. What role did exercise have in helping to turn your life around?
Dr. Maroon: Aerobic exercise is the very best anti-depressant that anyone can ever ... ask for. I had a period in my life when I had some major family problems and I became pathologically depressed. I found that anti-depressants, various pharmacologic agents were totally ineffective. And one day Don Jebbia said hey, let's go for a run. I said I haven't run for five years, I don't think I can make it around the track, but I did at the Triadelphia track. I made it around four times, I was 20 pounds overweight, sluggish, totally out of it. And that night was the first night I slept in three months.
I went back the next day and did a mile and a quarter, then a mile and half, and pretty soon I started feeling better, sleeping better, eating better because my body wanted better fuel, and I increased my running and started to get sore knees. Then I read about triathlons and cross training, got a bike, started riding, and then was intrigued ... that was in the early '80s. I watched the Hawaiian Ironman Triathlon, which is something I never dreamt I would be able to accomplish, I couldn't even do a 10K race. Until I did a 10K race. Then I did a little mini-triathlon, and then five years later I was able to compete in the Hawaiian Ironman.
-- What's your favorite part of the Ironman events?
Dr. Maroon: (Laughing) Getting an IV in the medicine tent afterwards. ... I like the bike the best. The run is sheer pain. After swimming 2.4 miles and biking 112 in 90 to 95 degree heat and crosswinds, you get off the bike and say now I have to do a marathon. You've just got to reach way down.
-- Where would you place exercise in the pyramid of overall well-being in a person's life?
Dr. Maroon: It's absolutely a daily point that must be touched. It's like food, exercise, avoiding environmental toxins and reducing stress. Exercise helps you diet, it helps your stress reduction, and it's nothing but a positive.
-- Health and longevity play an important part in your life and in your medical practice. In your latest book, "The Longevity Factor: How Resveratrol and Red Wine Activate Genes for a Longer and Healthier Life," you write of how natural substances found in red wine, dark chocolate, and green tea are key to a disease-free life. First off, what is resveratrol?
Dr. Maroon: Resveratrol is a natural anti-oxidant that's found generally in red wine. It was found by a scientist named David Sinclair, who's head of the anti-aging lab at Harvard University, to activate particular genes involved with survival and energy metabolism. When we were on the Savannah in Africa hundreds of thousands of years ago, we lived in feast and famine. Our bodies are conditioned to ingest as many calories as we can when they're freely available. That's what has contributed to the 60 percent obesity (rate) of people in the United States. The problem is that we don't have famines. Because when we would have a famine we would burn up the fat that we saved, and when we really got low on fuel, we would activate these particular genes called the sirtuin genes, that are now called the survival genes.
Fasting is a very good thing and we found that resveratrol can activate these same genes without fasting. So in a way you can have your cake and eat it, too.
-- Fish oil is another substance you advocate for its Omega-3 acids. Given that, what is your take on the average American's diet?
Dr. Maroon: It shows in what's happening, as I mentioned 60 percent of the people are overweight or obese. It's atrocious. The fast-food stuff we consume, the excessive sugar and the carbonated drinks with phosphoric acid that leaches calcium out of our bones, it's just a very unhealthy diet for most people. ... It's easy for me to get on a high horse and condemn. The problem ... when somebody has limited income, as so many people in this country do, they're making choices for more amounts of food - the potato chips, the pretzels, the soft drinks - it's a lot cheaper than organic vegetables, tomatoes and good grades of meat. It's a complicated socio-economic problem.
-- Last question: How much of your success do you attribute to growing up in the Ohio Valley?
Dr. Maroon: That's a very good question. I've really not thought about that. I would say 90 percent, if not 100 percent. Gen. MacArthur had a great saying, and he had it inscribed over the doorway of the gymnasium at West Point. ... The saying is, "On the fields of friendly strife are sown the seeds that on other days and other fields will bear the fruits of victory." When you ask me that question, the first thing that comes to my mind are the football fields in Bellaire. Donkey field, which was nothing but gravel and dirt and rocks, where I learned you don't quit, you persevere no matter what the odds are, you maintain your integrity and honesty in play, and you remain loyal to your teammates and the people you work with.