The advice used to be simple: “Shake it off. Get your head back in the game.”
But these days, when athletes get their “bells rung,” everyone from players to parents, coaches to NFL commissioners, is tuned in to the long-term effects of concussions. The advice now ringing in their ears is the polar opposite: “You’re benched, so take some time and get your head straight. When in doubt, sit it out.”
“I emphasize three points up front. You can play through pain, but you should not play through brain and spinal injuries. Those can wreck your life. Second, medical decisions trump competitive decisions – always. Third, we need better interventions,” said Dr. Hunt Batjer, the new chairman of neurological surgery at UT Southwestern Medical Center and one of the world’s leading authorities on sports-related head injuries.
Dr. Batjer, holder of the Lois C.A. and Darwin E. Smith Distinguished Chair in Neurological Surgery, is not only a world-renowned surgeon but also president of the Neurosurgical Society of America and co-chair of the NFL Head, Neck and Spine Committee. He has been a major force in the NFL’s efforts to raise awareness on concussions and bring practical tactics to the field, as co-chair of its concussion committee.
“If the head is moving and the head stops suddenly, the brain doesn’t stop. It reverberates back and forth, and often an impact at one end injures the brain most severely at the opposite end of the head, just because of that movement back and forth,” Dr. Batjer said of the challenges researchers face in trying to understand concussion. “But if you can get down into impact biomechanics, which we’re trying to get to, angular and linear acceleration determine which types of things cause concussive symptoms. These are ways we can impact meaningful rule changes.”
The addition of Dr. Batjer to the existing lineup of UT Southwestern’s field of leaders in brain injury has cast the medical center as a star player in brain injury research, education, management and development of eventual treatments. He and others across the campus already have begun teaming up.
“We’re really at the cutting edge of promoting concussion awareness, detection and treatment,” said Dr. C. Munro Cullum, chief of psychology and professor of neurology and neurotherapeutics, who has served as the neuropsychologist for the Dallas Cowboys for a decade and for the Dallas Stars even longer.
“What’s great to see is all the attention that’s given to concussions nowadays, especially in youth sports. Ten to 20 years ago, nobody was worried about concussions. The increased awareness is helping us identify concussions earlier, hopefully getting kids out of harm’s way quicker, and getting better treatment for them,” said Dr. Cullum, who holds the Pam Blumenthal Distinguished Professorship in Clinical Psychology, is the president of the Society for Clinical Neuropsychology and is past-president of the National Academy of Neuropsychology. “But there is still a lot we don’t know about concussions, which is why it’s both interesting and vitally important to do this research.”
In 2010 the Centers for Disease Control and Prevention estimated as many as 1.7 million people per year may suffer traumatic brain injury (TBI), 300,000 of which are sports-related concussions. In the past decade, soccer and football led the way for concussions in high school and college-age students, comprising 8.9 percent of all high school and 5.8 percent of all college athletic injuries, respectively. Surprisingly, girls experience a higher rate of concussion in high school sports than boys.
“The problem with concussion is that it’s not like a broken finger. You can’t see the broken bone sticking up through the skin. And sometimes the symptoms don’t evolve for 24 to 36 hours, so it is a challenge to get the diagnosis right,” Dr. Batjer said.
Scientists still don’t know who is most vulnerable to the effects of concussion, which biological mechanisms to target, or even the best evaluation tools. Some research, for example, points to individual risk factors.
“Two people can take the same sort of blow to the head, and they may have very different symptoms,” Dr. Cullum explained. “One might have prolonged symptoms; one might have symptoms resolve the same or next day. It’s really quite variable, so there probably are no doubt neurobiological factors at play.”
One of those may be an abnormal protein called Apolipoprotein (apo) E4 that’s been identified in many people with Alzheimer’s disease. That protein, when present, seems to be a risk factor for other diseases as well. Researchers are eager to investigate whether having that specific protein, or perhaps other proteins, in their genetic makeup may contribute to longer or less successful recoveries when it comes to concussions.
“And that’s just the tip of the iceberg,” Dr. Cullum said. “We think there may be other factors as well, when you think about the complexity of concussion, and how it occurs. The skull is one protective factor against brain injury, but our skulls differ in thickness and shape, and there is also different musculature in the neck. Furthermore, no two concussions are exactly alike. Basically, when you’ve seen one concussion, you’ve seen one concussion.”
Dr. Batjer’s data show, for example, that some of the highest rates of concussion are in women soccer players, suggesting that factors such as shoulder breadth, depth and musculature may be protective in some situations.
But UT Southwestern researchers are making inroads.
Dr. Joshua Gatson, assistant professor of burn/trauma/critical care, is on the hunt to identify biomarkers for brain injury, characterize signaling pathways of neuro-protection after injury and test various interventional therapies. Among his studies are investigations into compounds such as resveratrol, found in red wine, and vitamin D, which might help reduce inflammation after head injury.
“There haven’t been any completed human studies yet, so this is really the first look at resveratrol’s effect on traumatic brain injury in athletes,” he said. “The main goal of our research is to protect the brain immediately after each episode so that we can decrease the cumulative effect of these sports concussions.”
Recently Dr. Gatson found that mice subjected to a mild TBI and treated with resveratrol within minutes of their injury showed a decrease in inflammation and cell death in their brains.
Dr. Gatson’s research also has indicated that estrone, one of the three naturally occurring estrogen hormones in the body, may aid in reducing inflammation and cell death in the brain. His latest study, in mice, is the first to demonstrate that estrone provides those anti-inflammatory and antioxidant capabilities after TBI and is the first to reveal the cellular pathways that are involved. The study also demonstrated that estrone is involved in promoting an increase in the expression of the brain-derived neurotrophic factor, which promotes cell survival.
Dr. Munro Cullum serves as neuropsychologist for the Dallas Cowboys and Dallas Stars.
“So if you give these drug therapies shortly after injury, they are thought to increase repair mechanisms,” Dr. Gatson said.
Dr. Cullum is researching and developing new testing methods to help detect brain injury and its effects, including joint studies with organizations such as UT Arlington and Pantego Christian Academy, where baseline testing of students is helping provide researchers a better understanding of the effects of concussion.
UT Southwestern researchers also launched the largest comprehensive study of former NFL players employing the use of neuropsychological testing, neurological assessments and neuroimaging. They found that mild cognitive deficits and depression were more common among retired players than in the general population and that these neurobehavioral changes correlated with white matter abnormalities in the brain. However, that study, a joint effort led by Dr. Cullum and Dr. John Hart Jr., professor of neurology and neurotherapeutics and psychiatry at UT Southwestern and medical science director for the UT Dallas Center for BrainHealth, along with Dr. Kyle Womack, assistant professor of neurology and neurotherapeutics and psychiatry, also found no evidence of cognitive impairment in the majority of ex-players.
“In 60 percent of our participants – most of whom had sustained prior concussions – we found no cognitive problems, no mood problems and no structural brain abnormalities. Many former NFL players think that because they played football or had concussions, they are certain to face severe neurological consequences, but that is not always the case,” Dr. Hart said.
Former Dallas Cowboys fullback Daryl Johnston, who participated in the study recently published in JAMA Neurology, helped recruit other players to take part.
“Having played 11 years in the NFL and taken countless hits, I’ve heard about the struggles of the players who came before me and the challenges regarding their quality of life,” Mr. Johnston said. “Former players can find out if there is an issue, and if you catch it early or late, there are things you can do to improve your condition. The brain is regenerative for life, and we can restore faculties that just a few years ago were thought to be lost.”
Strategies for energizing and coordinating research efforts in sports-related head trauma are proving an excellent pairing with initiatives in play to bolster sports medicine, traumatic brain injury research and centering neurologically related services at Zale Lipshy University Hospital.
“Right now the best recommendation for recovery is rest for the brain and time healing,” said Dr. Cullum. “We don’t yet know what specific interventions best assist recovery, but we need to learn that, and we need to learn which patients will benefit from which treatments, in addition to a better understanding of who may be at higher risk for prolonged post-concussion symptoms.”