Ongoing Evolution: Understanding Concussion's Effects

What are the latest developments in concussion and concussion care?

Dr. Seifert: Concussion has continued to receive significant media attention over the last year. Ongoing developments of NFL, NHL, and NCAA concussion litigation highlight the passion that surrounds this controversial topic.

A new study, published in September 2014,¹ suggested that high school athletes continue to lack adequate knowledge about concussions, which may influence their decision to report symptoms. This serves as a reminder to all that despite significant progress over the last decade in the field, further education and knowledge is gravely needed at the grass roots level.

In May, the NCAA and the Department of Defense announced a $30 million fund dedicated to research and education about concussion awareness. This should help continue to establish much-needed evidence based medicine with regard to concussion treatment.

In July of this year, the American Academy of Neurology held its first annual Sports Concussion Conference. This was the first comprehensive, multidisciplinary conference of its kind in the United States and was attended by nearly 500 international participants.

Dr. Balcer: One of the biggest stories to emerge around concussion this past year was just how much underreporting there is for concussions among athletes. In August 2013, we published a study² based on an anonymous survey of 262 collegiate athletes, and we found that 43 percent of them said they had hidden a concussion to stay in the game, while 22 percent of those individuals said they would underreport in the future. These findings were very humbling.

In that same issue, Brian Hainline, MD, Chief Medical Officer of the NCAA, who also happens to be an NYU Langone Clinical Professor of Neurology, wrote an editorial addressing the reasons for this underreporting in athletes, encouraging neurologists and sports medicine physicians to be at the forefront of understanding this problem if they’re going to be part of the solution.³

Emily Kroshus, ScD, of the NCAA Sport Science Institute has built on this work and authored concussion surveys and reporting, examining ways we can change behavior. There remains more to be done in terms of education. So many high-profile incidents have occurred where you’re watching a game on television, and you see a hit that suggests a player should be evaluated immediately, but the player remains in the game for a few plays until they’re helped off the field.

This issue is about changing the culture—not just the reporting piece of concussions, but what happens in the locker room, how teammates treat each other following a concussion, and whether there’s pressure to return to the game. I recently spoke to a group of high school students and told them when it comes to reducing concussion risk, “Being a good teammate can be a start.” They were excited there was something they could do themselves.

Research into sideline testing has also been a top story around concussion. Some neurological exams can be subjective on the sidelines and our research suggests adding a simple vision performance measure could catch some of the concussions that are being missed. That’s why tests such as the King-Devick test are so important. These tests enable an athlete to get examined doing something they normally do—in this case reading numbers—in a quick and helpful way, rather than relying on subjective measures.

I think people are generally becoming more aware of concussion and have been watching these stories more in the past year. And they’re beginning to notice what occurs. How that will affect behaviors or attitudes remains to be seen.

Dr. Galetta: A big story that’s emerging that links with underreporting is the undetected concussion problem. Despite increased national awareness, some athletes and sideline evaluators may not adequately recognize the signs and symptoms of concussion.

Some surveys suggest there are 10-times as many concussions that are undetected than are detected. Along a similar line, Doug King, MD, and colleagues, wrote a recent paper showing that in rugby players undetected concussions are quite common.⁴ He routinely tested his rugby players with the King-Devick test and found that undetected concussions were three to four times more common compared to detected concussions.

We’ve all witnessed these incidents on television or from the stands, where a player takes a hard hit and returns to the game without evaluation. It’s a real challenge for the sideline evaluator: Did that athlete just have a meaningful neurological event? For the athlete, it can be very difficult to know what fleeting symptom is important and what symptom you can ignore after colliding with someone. Sometimes, there is not enough time to process it all.

This will be a new story going forward: How do we detect the undetected concussions? The detection of concussion during a game is very challenging for physicians and trainers, and if the athlete doesn’t report, the subtle signs are sometimes not recognized. We might get some help from these new head impact sensors or helmet telemetry devices, which have been recently evaluated.⁵ These tools may answer the question: Is there a type or degree of impact that warrants an evaluation regardless of the athlete or trainer observation?

The undetected concussion problem brings full circle the need for effective, quick sideline assessments. Tests don’t replace judgment, but they certainly have a role.

What were some of the important overlooked stories?

Dr. Seifert: Researchers at UPMC and the University of Pittsburgh announced the development of a simple test that identifies concussion symptoms that are often undetected on standard testing. The new test concerns the vestibular ocular system, which is responsible for integrating vision, balance and movement. Visual issues, fogginess, and dizziness are the symptoms associated with the worst outcomes in concussion patients. These ongoing symptoms are often the rate-limiting step in an individual returning to activities of normal daily living.

Dr. Balcer: Concussions in youth sports deservedly get a lot of attention, but on the other end of the age spectrum, long-term effects of retired athletes exposed to contact sports and the risk for chronic traumatic encephalopathy (CTE) was talked about less during the past year compared with previous years. There exists a major need to find ways to prevent these changes or stop them in their tracks, given this potential risk. We need to explore ways to identify people, using eye imaging markers like PET scans, and we’re part of a large grant to study this problem.

Another important emerging aspect of monitoring is helmet telemetry and other ways of determining the force and angle of impact for head hits.⁶ This information will be most useful if correlated with sideline test scores and symptoms of athletes.

What do you think 2015 has in store for concussion care?

Dr. Seifert: I believe there will be continued focus on the “Return to Learn” aspect of concussion management that is often overlooked. While return to play receives the majority of focus in layperson discussions, the academic and cognitive component can be the most frustrating portion of recovery for patients and clinicians alike. As more quality research emerges regarding cognitive rest, this will help guide clinicians and ease the transition back into a classroom setting for our student-athletes.

Also, many ongoing studies are examining the utility of serum biomarkers with regard to concussion diagnosis and management. Biomarkers such as S-100 Calcium-Binding Protein, Neuron-Specific Enolase, and Glial Fibrillary Acidic Protein could potentially give practitioners the ability to detect cerebral dysfunction at onset, recognize the window of vulnerability post-concussion, and ultimately detect individuals at risk of long-term cognitive problems.

Dr. Balcer: We’re seeing around the New York area that youth leagues are getting more and more involved with concussion management. We’re seeing this at a grassroots level, and parents especially are getting more involved. In 2015, I expect this awareness to increase. We hope through our research and outreach efforts, parents can see that simple vision tests can liberate some of the guesswork around spotting a concussion during a game. I think we’ll see more movement on that front.

We also anticipate more research into potential markers of cognitive impairment in athletes. The focus isn’t going to just be on professional football. Do college athletes have sequelae down the line? Do military personnel?

For patient management, I expect more exploration into the role of exercise in making patients feel better following a concussion. We haven’t even seen trials of the simple interventions we do for patients, let alone drugs yet. But, we need to focus on developing measures—such as visual or performance measures— so that when those trials come to bear, we know what imaging methods and other testing might help identify people with concussions and see how well the drug works.

Dr. Galetta: In 2015, I anticipate companies will continue their early efforts of exploring the potential use of pharmaceutical approaches to improving outcomes following a concussion. Even basic rest versus exercise protocols need to be evaluated and validated. We don’t fully understand the best timing regarding return to play.

Next year, researchers will continue their work to develop better sideline protocols. Realistically, this is going to be an evolutionary process. But as we gain more information and dispute other information, there will be a slow movement in the right direction of what we should be doing in terms of concussion detection, education and treatment.

We’re at the stage right now where we recognize the problem—there is still a debate on the extent of the problem. But through continued research efforts, we can get better at addressing concussion patients before they manifest, when they manifest and after they manifest.

Tad Seifert, MD, Norton Neurology Services in Louisville, Kentucky.

Laura J. Balcer, MD, MSCE, Professor in the Departments of Neurology, Population Health, and Ophthalmology and Vice Chair of the Department of Neurology at NYU Langone Medical Center.

Steven L. Galetta, MD, Philip K. Moskowitz, MD Professor and Chair of the Department of Neurology, and Professor in the Department of Ophthalmology, NYU Langone Medical Center.

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