Research and science of concussions: Diagnosis, treatment, prevention

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In our quest to better understand concussions — specifically in conjunction with this series of stories — what follows is a primer on defining and diagnosing concussions, as well as a brief overview of some of the most promising and intriguing theories and research surrounding treatment and prevention.

Research on concussions is ongoing in labs across the country, so this is by no means a comprehensive list of everything that’s out there.

concussions

Diagnosis
Think you tore your ACL? You’ll likely go in for an MRI.

Suspect you might have contracted mononucleosis? There’s a blood test for that.

But suffer a blow to the head? There’s no conclusive diagnostic test that can tell you whether or not you’ve sustained a concussion.

“Believe it or not, we don’t have a gold-standard definition of what a concussion even is right now,” said Dr. John Leddy, the director of the Concussion Management Clinic at the University of Buffalo. “It remains a clinical diagnosis, that means it’s a diagnosis made by the history taken and the physical examination performed. There’s no one diagnostic test to confirm a concussion in everybody.”

The Concussion in Sport Group, an international panel that has authored five editions of the Consensus on Concussion in Sport, gives us the most accepted current definition of concussions in the athletic space:

“Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:
— SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
— SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
— SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
— SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.
— The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).”

The CISG also provides recommendations on how best to diagnose a concussion on the sidelines during competition, and these suggestions serve as the basis for many policies and protocols put in place by organizations and governing bodies.

Although CISG recommends using the SCAT5 (Sport Concussion Assessment Tool, 5th edition) and Maddocks’ questions (At what venue are we today? Which half is it now? Who scored last in this match? What did you play last week? Did your team win the last game?) to determine if a concussion has occurred, it emphasizes that because there is no perfect diagnostic test, it is impossible to rule out a concussion, and therefore athletic trainers, coaches, athletes and parents should err on the side of caution.

Dr. Kevin Guskiewicz, a neuroscientist and nationally recognized expert on sport-related concussions at the University of North Carolina, reiterated that point.

“I tell people that these concussions are like snowflakes,” he said. “There’s no two alike.”

Many college athletic departments and professional sports leagues use the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) testing program developed at the University of Pittsburgh to establish a baseline and conduct post-injury testing.

It is also the program that Texas Advantage uses and the one we will be posting for public use on VolleyballMag.com.

Another important characteristic of concussions to note is that symptoms sometimes don’t pop up until days after the initial injury, so even if a concussion is not diagnosed at the time of injury, follow-up assessments should be administered in the following days.

Since this gray area in diagnosis makes it difficult to make return to play decisions and provide adequate treatment, researchers have been working to develop a more precise way of diagnosing concussions.

A company called Oculogica developed a table-top eye-tracking device called EyeBOX that uses eye movement and other domains of brain function to determine whether or not an individual has suffered a concussion.

As the patient watches a video on the EyeBox screen, a binocular camera tracks the movement of each eye and quantifies speed, coordination, and range of motion. Those data points are then plugged into a complex algorithm, which scores the severity of a brain injury.

Other eye-tracking technology for concussion testing is available, however, unlike most of those, EyeBox does not require a baseline test.

EyeBox is currently in clinical trials and in pursuit of FDA approval.

A recent study out of Penn State indicates that microRNAs, small fragments of genetic material, are released by brain cells when they attempt to repair themselves after a concussion. Those microRNAs then appear in the patient’s blood and saliva and can be tested for.

Not only could this determine when a concussion has occurred, it might also be able to indicate levels of severity and predict which patients would suffer prolonged symptoms.

The FDA recently approved a blood test that is said to evaluate for mild traumatic brain injury, aka concussion; however, it is important to realize that this blood test predicts the presence or absence of intracranial lesions, aka brain bleeding, in order to determine whether or not a CT scan should be performed. It cannot actually diagnose or, conversely, rule out a concussion.

“A negative blood test means that proteins were not released—not necessarily that there was not a mild concussion,” said Joseph Fins, a professor of medicine and medical ethics at Weill Cornell Medical Center, in an interview with Scientific American. “If it’s assumed that a patient did not have a concussion because the test is negative, and then the patient resumes the sporting activity, the effects of the next head injury can be augmented.”

Treatment
Once a concussion has been diagnosed, the athlete and medical team faces another challenge. How to handle the recovery period and treatment?

Until recently, many doctors and experts recommended complete physical and cognitive rest until symptoms completely subsided, but recent research has determined that this “cocoon therapy” may not be beneficial, especially when concussion symptoms take more than the typical 10 to 14 days to fade.

“People thought if you did too much right after a concussion, you could damage your brain and delay your recovery, but we’re showing now that you can start doing this stuff even within the first week of a concussion and it’s safe, as long as you do it the right way,” Dr. John Leddy said. “So trying to push the envelope a little bit and get people active in a controlled way, even while they are still symptomatic within days of a concussion.”

Leddy and his team at the Concussion Management Clinic in Buffalo pioneered the Buffalo Concussion Treadmill Test (BCTT), an exercise-based test that helps doctors understand when an athlete can safely return to play.

During the BCTT, the patient begins walking on the treadmill at a brisk walking pace and every minute the incline is increased and the patient is asked to rate how hard they feel like their body is working and their level of symptom severity. The administrator of the test records those answers, along with the patient’s heart rate.

Patients are then given an exercise prescription based on 80 percent of the maximum heart rate they reached without symptom exacerbation. They are instructed to exercise at this level for at least 20 minutes a day without exceeding their heart rate constraints.

The treadmill test is important because it helps patients return to physical activity as soon as possible after a concussion, which has been shown to speed up recovery.

Cocoon therapy has typically also included cognitive rest in addition to physical rest. But a study out of Southern Methodist University found that performing mild problem-solving tasks as soon as four days after a brain injury can improve memory function and prevent the development of depression and anxiety, which often arise after a concussion.

“What’s becoming clear,” Leddy said, “is that prolonged rest, weeks and weeks or months of rest, is not only not doing anything, it’s probably harming people.”

The most common treatment for most concussion sufferers consists of acetaminophen for headaches and inflammation, rest, and perhaps physical, psychological, and vestibular therapy for cases where symptoms last longer.

At the University of North Carolina, Guskiewicz works with Tar Heel athletes suffering from post-concussion symptoms, putting a focus on vision therapy and dual tasks, activities that force the athlete to do a motor task combined with a cognitive task. One example Guskiewicz provided was asking the athlete to balance on a piece of foam while doing a memory task.

“These dual tasks I think are really important because it’s rarely the case that we put an athlete back into play where they are only needing to do one thing, where it’s all a motor task or all just a cognitive task,” Guskiewicz said.

Some individuals, especially those who are suffering from longer-term symptoms after a concussion (approximately 10 percent of concussions result in chronic symptoms) or who have had a number of concussions in their life, may be looking for something a little more drastic.

A few concussion clinics have popped up around the country, including Cognitive FX in Provo, Utah, and Plasticity Brain Center in Orlando, Florida, the latter of which was made famous in former NHL player Daniel Carcillo’s recent video for The Players’ Tribune in which he details his struggles with the long-term effects of multiple concussions.

Although the treatments provided at these clinics have not yet been scientifically proven, they offer concussion sufferers something they can’t get from many other places–a plan of action.

Both Cognitive FX and Plasticity Brain Center offer a week-long targeted therapy — almost like boot camp for your brain. The sessions include cognitive therapy, occupational therapy, vestibular ocular therapy, psychotherapy, and nutrition and sleep education.

The downside of these treatment centers is that they can be prohibitively expensive, and they are not covered by most insurance policies.

Plasticity Brain Center addresses this issue of insurance coverage with a video on its website. In it, Kate Milam, a patient enrollment advisor, says that insurance companies don’t cover this treatment because they see it as an “overuse of therapy.”

“We can’t hold ourselves back by what insurance will pay for,” Milam said, “We can’t allow insurance companies to dictate the care that is required, the level of intensity, the frequency, the duration of therapy that’s required to reach your goals, to change your brain. If we did what the insurance companies allowed us to do, people wouldn’t get better.”

A Florida-based company called Prevacus has taken another route in its pursuit of relief for concussion sufferers. CEO Dr. Jake VanLandingham and his team–with backing from Brett Favre, Kurt Warner, Mark Rypien, Abby Wambach, Kerri Walsh Jennings and other former professional athletes–are on the hunt for a pharmaceutical solution.

The drug they’ve developed, PRV-002, is a synthetic neurosteroid administered through the nasal cavity within 10 minutes of the diagnosis of a concussion.

“(Concussion is) an inflammatory disorder with some oxidative stress,” Dr. VanLandingham explained. “This is a simple drug. The key is most drugs don’t get in the brain. We’ve formulated the drug where it is safe, long-lasting and could get to your brain within minutes, and it reduces inflammation, swelling and oxidative stress.”

In animal studies, the Prevacus team noted a reduction in the behavioral pathology associated with brain injury symptoms, including memorial impairment, anxiety, and motor/sensory performance.

“We were able to improve memory within 24 hours following the head injury,” VanLandingham said. “We were able to improve balance and neuromotor activities–the way you walk, the way you move, the way you responded to different angles–and then we were also able to show a reduction in swelling production and inflammation and a reduction in oxidative stress at the molecular level.”

PRV-002 is in the process of seeking FDA approval and will soon begin human trials.

Another pharmacological solution may grow out of research being conducted at the University of Miami. The team of researchers at the Miller School of Medicine hypothesized that a combination of CBD (a cannabinoid derivative of hemp) and an NMDA antagonist (an anesthetic) could bring down post-concussion inflammation and reduce symptoms including pain and headaches.

The Miami team’s five-year animal study showed that the combination therapy improved cognitive functions and did not result in adverse effects; however, the scientists admit that much more research needs to be done before the drug can be declared a cure for concussions.

Maybe the answer won’t come from a lab.

The world of massage therapy is offering an alternative treatment. It’s called Cranial/Structural Frontal/Occipital Decompression and it’s part of a practice developed by Don McCann called Structural Energy Therapy, or SET.

The theory goes like this. After a concussion, there is swelling and cellular damage in the brain. Through targeted massage, compression, and manipulation of joints in your skull (yes, there are joints in your skull), a therapist uses the lymphatic system in the brain to drain excess fluid out, which after about five sessions leads to the lessening of post-concussive symptoms and better neurological functioning.

“We call it the ‘Big Pump,’” said Ben Keyes, a sports and orthopedic massage therapist in Winter Park, Florida, “but my patients call it the ‘Big Squish.’

“I place one hand underneath their head, they’re laying on their back, and I put my other hand on their forehead, and then just start rocking with the cranium. There are different pressure levels, because of that maze, that mechanism of the fluid that has to be pumped out,” Keyes explained. “So once that’s done, there are some other manipulations of the suture joints, the squiggle marks on the skull, to make sure that they are open and working well and stretched out.”

Here’s how SET founder Don McCann explains it in an article on his website called “Effective Non-Invasive Treatments for Concussions:”

“The fluid from the bruising of the brain after concussions that causes swelling within the cranium often becomes trapped and can’t properly drain. Sometimes this is from a restriction of the normal cranial motion from the injury that prevents adequate pumping of the cerebral spinal fluid, and sometimes the adhesions in the connective tissue around the brain that was damaged by the injury traps this fluid. The Cranial/Structural techniques mobilize the restricted cranial motion, increase the pumping of the cerebral spinal fluid, and release the adhesions.”

Since adding this concussion treatment to his menu of services, Keyes has seen his entire career focus change.

“It’s pretty emotional when you can get a real shy 15-year-old girl or some big, heavy NFL guy whose limbs hang off the table and they get up and they’re like, ‘I’m good,’ and they give you a hug,” Keyes said. “I’m a nerdy medical massage therapist. I don’t get hugs, typically.”

Prevention
Some researchers, instead of hunting for a treatment, hope to limit the number of concussions that occur in the first place.

In 2017, the NFL partnered with Under Armour and GE to create the Head Health II competition, which handed out $20 million to companies developing technologies that could reduce concussions. Three companies were chosen out of 500 applicants: Vicis, creators of a high-tech helmet; Viconic, which developed smart turf with enhanced impact protection; and Army Research Laboratory, designer of specialty straps that tether the head to the body and prevent snapping head motions.

Another company, Q30 Innovations, has channeled the biology of woodpeckers and head-ramming sheep to develop the Q-Collar, a C-shaped device that fits around the back of the neck and compresses the jugular to decrease the amount of fluid leaving the brain. The result is an increase in blood volume inside the brain and a tighter fit inside the skull, so there is less “slosh” when a blow to the head occurs.

The Q-Collar is also awaiting FDA approval, however, some NFL players are already wearing it in competition and it has been approved for commercial sale in Canada.

Outside of knee pads, volleyball players compete mostly without protective gear. However, you may have noticed over the past few years, the occasional player taking the court with a soft helmet or headband.

These athletes have typically suffered concussions in the past and are hoping to prevent subsequent injuries, but many experts deny the effectiveness of this type of headgear, and the NCAA does not grant medical waivers for soft headgear intended to prevent concussions in non-helmeted sports. (However, headgear can still be worn to cover lacerations and sutures.)

In its 2013 statement on the matter, the NCAA said, “It is important to note the lack of clinical evidence supporting the value of the soft or padded headgear in the prevention of sports-related concussions. The NCAA recommends caution in using these devices to permit medical clearance of a student-athlete if they would otherwise not be medically cleared to participate in their sport.”

Dr. Guskiewicz explained it like this, “(Helmets are) not preventing movement inside the skull, which is really what happens, the movement of the brain causes the shearing or stretching of neurons and that’s what ultimately causes a concussion. Second of all, it can give a player a false sense of security.”

Instead, Guskiewicz said not to overlook the low-tech solutions. Every parent and coach has a video camera on their phone, and almost every sporting event is filmed. From that footage, technique can be analyzed, patterns can be recognized, and changes can be implemented.

“We don’t need to add equipment or some new gadget,” he said.

Despite all the media attention, the horrible stories of pain and suffering emerging from everyone from youth volleyball players (like the ones featured in this package) to former NFL players, Dr. Guskiewicz made sure to emphasize the positive movement the scientific community has made and is making when it comes to understanding, diagnosing, and treating concussions.

“We’re in a much better place today than we were 10 or 15 years ago,” he said. “We use neurocognitive tests and balance tests, and there’s newly evolving vision tests, gait tests, so it just takes some of the guesswork out of it. We’ve done a better job of educating our athletes about the signs and symptoms of concussion and the importance of reporting their signs and symptoms when they think they may have been concussed, and we’re also educating our coaches better than we ever were.”

1 COMMENT

  1. Hello Megan Kaplon,
    Nice job. We thought you might find it helpful to know that there are FDA cleared eye-tracking devices, or nystagmagraphs (named for measuring tracking nystagmus beats of the eye), and ours, Neuro Kinetics Inc. is one http://www.neuro-kinetics.com. Interesting that you uncovered the Miami study on cannabinoids as they are using Neuro Kinetics’ I-PAS™ to evaluate the effectiveness of the drug.

    Lastly, i will leave you with the recent INDYCAR decision to add I-PAS to its concussion evaluation protocol https://www.neuro-kinetics.com/project/indycar/ .

    Feel free to call us anytime for more information. you may call me, Howison Schroeder, or my colleague Susn Zelicoff at 412-963-6649

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