Penn helps enrich scholarship on concussions

Talk of concussions has blanketed the news in recent years, most frequently concerning items about sports, especially football. Barely a week goes by, it seems, without a story of an athlete retiring early or in his or her prime due to fear of concussions or because of multiple concussions, or of an athlete donating his or her brain to research after passing away.

Popular depictions of a concussion show an individual’s brain bouncing back and forth in his or her skull, almost like a nut rattling in a shell—but this is inaccurate, says Douglas Smith, the Robert A. Groff Professor of Neurosurgery at the Perelman School of Medicine and director of the Penn Center for Brain Injury and Repair.

“There’s really no space [in the skull] for the brain to bounce around like a pinball,” he says.

More exactly, when a person suffers a concussion, Smith says brain tissue is rapidly accelerated, causing it to swirl around within the skull, with different areas pushing and pulling against one another. This can damage the nerve fibers that make up the network connecting neurons throughout the brain.

“Having a concussion is like causing a blackout of a city, where loss of consciousness is due to the network going down, or a brownout where regional disruption of brain signaling is responsible for the classic ‘dazed and confused’ symptoms,” Smith says.

Some individuals who suffer repeated concussions are at risk for developing chronic traumatic encephalopathy (CTE), a progressive brain disease that causes Alzheimer’s-like dementia.

Currently, no diagnostic neuropathological criterion exists to define CTE as a specific disease entity. With a nearly $3 million grant from the National Institute of Neurological Disorders and Stroke, Smith and John Q. Trojanowski, the William Maul Measey-Truman G. Schnabel, Jr., M.D. Professor of Geriatric Medicine and Gerontology at Penn Medicine and director of Penn’s Institute on Aging, are leading an international team of researchers to establish one.

The investigators will search for common pathological changes in the postmortem brains of more than 200 patients with a history of traumatic brain injury and compare them with more than 1,500 postmortem brains from patients with other types of neurodegenerative diseases.

If the researchers are successful in identifying unique neuropathological characteristics of CTE, Smith says they may be able to use non-invasive measures to evaluate these changes in living patients who are at risk of CTE. Examining patients over an extended period may provide an opportunity to test potential therapies aimed at reducing neuropathological changes with CTE.

Smith says their findings have the potential to extend beyond sports, as there are many other circumstances where people could have repetitive head impacts, such as service in the armed forces and domestic abuse.

“In reality, concussion is very common, with new estimates of over 5 million cases in the U.S. each year,” he says. “In particular, it’s hard for males to get out of adolescence without having one or more concussions. Kind of jokingly—but in a way, it’s true—the No. 1 genetic risk factor for concussion is having a Y chromosome. It just drives risky behavior.”

In 2014, the NCAA and Department of Defense partnered on the Grand Alliance: Concussion Assessment, Research and Education (CARE) Consortium, the largest-ever study of concussions and head impact exposure. Consisting of more than 30 institutions and in excess of 25,000 students, the Alliance is looking at a broad spectrum of athletes and concussions during their college years.

Penn joined the CARE Consortium in March; the University team is being led by Christina Master, a sports medicine pediatrician at the Children’s Hospital of Philadelphia and an associate professor of clinical pediatrics at Penn Medicine.

Working closely with Penn Athletics and Student Health Service, Master says beginning this summer, all athletes at Penn in all sports will be included in a concussion prospective cohort registry study where they will be evaluated and given a baseline, pre-injury test during the preseason to determine any changes in their brain from season to season.

Athletes in contact sports, such as football, basketball, and field hockey, and non-contact sports, such as swimming and track and field, will be given baseline tests in order to make contact and non-contact comparisons.

“Penn Athletics has already done a lot in terms of extensive baselining of their athletes so this is just an extension of a lot of the work that they’re already doing,” Master says.

Eric Laudano, associate athletic director for sports performance at Penn Athletics and head athletic trainer, says the University has a strict policy and protocol to ensure that concussion management and concussion safety is a department priority.

“That includes a battery of baseline testing that our athletes go through, it includes follow-up testing through our team physicians that our athletes go through,” he says. “Then, based off of the team physicians’ evaluation, the testing follow-up results, and the recommendation of the physicians, we follow a strict Return to Academics and Return to Athletics protocol.”

If a physician determines that an athlete needs neurocognitive rest, he or she could be given academic as well as athletic restrictions, such as a ban on reading or limiting time in front of a computer screen in order to rest the brain.

Players can self-report concussions, concerned players can notify medical staff to check on a teammate, or the medical staff can, on their own volition, evaluate and talk to a player they observe take a hard hit or fall. Athletes with concussion-like symptoms are held out of practice or a game, given a series of tests, put through the concussion management plan, and prohibited from returning to action until cleared by a physician.