Klay Thompson's uncertain status highlights lack of understanding on concussions

Sam Amick | USA TODAY Sports

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The most important role player in the NBA Finals is a man you have likely never heard of.

Dr. Jeffrey Kutcher, the director of the league's concussion program that was put into place four years ago, will play a major part in deciding Golden State Warriors guard Klay Thompson's playing status for Game 1 of the NBA Finals after he suffered a concussion in Game 5 of the Western Conference finals last week.

Unlike the many coaches, teammates, family members and fans who are hoping against hope that their team can win it all for the first time since 1975, Kutcher's only concern is Thompson's long-term health. And after all the progress that has been made regarding head injuries the past few years, Kutcher – who directs the sports neurology program at the University of Michigan and is widely considered a leader in his field – isn't about to let the momentum stop now.

"Just the idea that the NBA has a neurologist who does these things (pleases me)," Kutcher told USA TODAY Sports in a phone interview. "Look at 10 years ago, and nobody was even talking about these kinds of things.

"I'm happy we've come as far as we have. I think we are doing a very good job of protecting athletes, and the one thing I would say is, the important thing is that every time we consider a concussion with an athlete, we take a step back and look at the overall picture of good brain health."

The bigger picture, in other words, matters far more to him than Thursday's game. Thompson returned to practice Monday, but has not yet been cleared for Game 1.

Despite the fact that the NBA is widely considered one of the safest sports when it comes to concussions, the league's protocol was put in the spotlight of late when back-to-back head injuries to MVP Stephen Curry and Thompson threatened the basketball fate of the league's most dominant team. Considering the NBA has had an average of 13 diagnosed concussions since the 2011-12 season, with that number fluctuating between five and 20 during those four years, the Warriors' situation was an undeniable exception.

According to the web site InStreetClothes.com, which is run by certified athletic trainer Jeff Stotts and examines injury situations in professional sports, the average time missed by a player this season because of a reported concussion was 8.9 days. The median return time, according to the site, was five days. The NBA's concussion policy has no set timeline to return, but a player must satisfy the 'return-to-participation protocol' that includes several steps of physical exertion being completed without the return of any and all symptoms. The team physician makes the final call on whether the player will play, but that person must first discuss the return-to-participation process and decision with Kutcher before doing so.

Yet this is not the NFL, where there were a reported average of 144 concussions during the past three seasons and where, as Kutcher noted, a player may take between 800 and 900 hard hits during the course of a season. There are 10 players on the court at once in basketball, with hard hits easily witnessed and the general goal for all involved to move around your opponent rather than through them.

All of which made the Warriors' situation so unique.

Curry fell hard to the floor in Game 4 of the conference finals, but managed to steer clear of a concussion (it was deemed a contusion) and played on. But Thompson's case has been far more complex, with the 25-year-old taking a knee to the head in the fourth quarter and initially passing the physical and cognitive tests that were given by the Warriors' medical staff in the team's locker room.

Thompson returned to the Warriors bench and was cleared to return, but never re-entered the game. Afterwards, he developed 'concussion-like' symptoms that include vomiting and led to further testing. Yet he wasn't officially diagnosed with a concussion until Friday morning, with his agent, Bill Duffy, telling USA TODAY Sports the day before that Thompson had appeared to be clear of a concussion and a visit with a neurologist the following morning leading to the final verdict.

The 'digital doctors,' as some have deemed the many skeptics on social media and electronic places beyond, were quick to criticize the Warriors for appearing unclear about the diagnosis. But as Kutcher explained, the science behind concussions still has even the most qualified of experts searching for clarity.

"Examining the brain is a very complex thing," said Kutcher, who declined to discuss the specific case of Thompson or any other player. "One of the fallacies, I think, about concussion diagnosis – and I've been dealing with this for years in the media and in the public – is that you can always diagnose a concussion 'yes' or 'no' at a given point in time if you just look hard enough. That is a fallacy. The reality is that there are concussions that produce no clinical effect at all, not only no symptoms but no findings on examination or through specific testing. Nothing shows up until an hour or two later or even sometimes the next day."

The process for handling a concussion like Thompson's begins every offseason, when players take part in baseline testing that serves as the mental benchmark of sorts that they must meet if and when they are later tested for a concussion. The test, which is deemed the 'Standardized Assessment of Concussions' and is used across the sporting spectrum, involves a series of questions that test both short-term memory and – five minutes later – the person's ability to recall.

"(After a hit) you also pay close attention to eye movements, and to examine the eyes closely – how they're moving, how they're reacting to different stimuli," Kutcher said. "You do a very close evaluation of balance and coordination. And then essentially you are, over that time period, listening to the player of course. You're understanding how they're feeling, if they're experiencing anything. If you're in a situation where someone doing the evaluation knows the player well – which would be the majority of our cases – in that situation you're making a lot of more subtle judgments about how they're behaving, what their personality is like. So in the short of it, what we try to do, again, is provide a certain framework that is very specific about the steps that have to be taken and looked at."

There's one key change from the baseline testing and testing that occurs after a hit, however: the words used with each specific athlete are changed so as to ensure that no cheating can occur.

"(Athletes) will remember the words they did in baseline, write them down, keep them around, and make sure that they have them, so that they sort of beat the system a bit," Kutcher said. "For those reasons, we use different forms that have different words and different number sequences to make sure that effect isn't in play. Other than that, you really are performing the same evaluation after an injury."

From Kutcher's vantage point, he has seen significant progress when it comes to athletes understanding the importance of taking concussions seriously.

"The thing that I'm most proud of is the overall awareness," Kutcher said. "And not just awareness, but the level of education across the league, whether it's the players, the medical staff, even the management personnel. It's really easy to watch television or read some media outlet or what have you and hear a lot of concussion stories and think you know what's going on.

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"But I feel like, as a group, that there's a good level of education and I think that has really bore out in some of the things that we see with not only players bringing symptoms to team medical staff's attention in a timely manner, but also looking out for their teammates and not having any second-guesses from coaching staffs or anything like that. That's a great thing."

What would be even better, of course, is a concussion machine that could definitively say whether or not an athlete has one in the first place.

There are ways to garner clues, among them a functional magnetic resonance imaging device (FMRI) that, according to psychcentral.com, measures brain activity by detecting changes in blood oxygenation and flow. But as is the case with so many other technologies, it detects the possible effect of a concussion rather than the concussion itself.

"As you can imagine, there are dozens upon dozens of companies that are trying to get a foot in this market, whether it's a blood marker or some kind of imaging marker or that kind of thing," Kutcher said. "They all kind of fall short for the simple reason that most of those things are either measuring the clinical effect of the injury – the injured brain is not always going to produce a clinical effect – so if you're trying to base the magic test on the clinical effect, you're always going to fall short because it's so variable person to person. Some of the other things will measure one aspect of the physiology of brain tissue that's been hit, but those effects, again, are not specific to sort of experiencing force.

"So if you have an FMRI machine, for example, that looks at the physiological changes, and you see changes in the brain, that could be from head trauma or that could be from sleep deprivation or being depressed or being on medications or all kinds of things. It's not as straight forward as you might think."

Kutcher does see some hope, specifically with an Israel-based company with which he consults that's called ElMindA.

"It's looking at brain waves while somebody is performing a task," he explained. "And if you do that enough over and over again, doing a repetitive task … the idea is that it's a technique that allows us to measure brain network activity. And that starts getting one step closer to being able to measure the injury itself."

Whether Thompson plays in Game 1, Kutcher is hopeful that this latest case study is yet another chance to educate the public about concussions. He's the first to admit that he's still learning the best way to handle these situations, too. There are more changes, and hopefully more health, to come.

"We certainly have more to go, and that's why our protocol with the NBA – much like the other that I know about in professional sports and deal with directly – every year we re-evaluate and we look at 'Are there new tests? Are there new approaches? Are there new things that we need to think about?'" he said. "That's what we try to do in a program like this."

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