ARTICLE IN BRIEF
The co-directors of the first AAN-sponsored conference on sports concussion discuss what is known and where new research is needed in sports concussion.
On July 6, just one week before the AAN's first major conference on sports concussions, a US District Judge preliminarily approved a new settlement between the National Football League (NFL) and former players that would remove any cap on financial restitution for long-term effects of head injuries experienced during their careers.
The NFL concussion controversy, as well as several tragic deaths of high school football players in recent years, has done much to raise public awareness of the risk of sport-related head injuries. Until the past decade, such injuries and their latent effects on the brain and nervous system were viewed, at least outside of the neurological community, as primarily affecting professional boxers like Muhammad Ali.
On July 11-13, the AAN hosted its conference in Chicago, gathering together experts from a number of fields invested in preventing sports concussions and milder head trauma. Neurology Today asked conference co-directors Jeffrey S. Kutcher, MD, and Christopher Giza, MD, what they hope the conference would achieve. Dr. Kutcher is an associate professor of neurology at the University of Michigan and director of the Michigan Neurosport Program in Ann Arbor, while Dr. Giza is a neurologist specializing in pediatrics and an expert in traumatic brain injury at the University of California, Los Angeles Ronald Reagan Medical Center.
WHAT WAS THE IMPETUS FOR THIS CONFERENCE AND WHAT DID YOU HOPE WOULD RESULT FROM IT?
Christopher Giza (CG): This conference was intended to be truly interdisciplinary, with speakers and attendees who are neurologists but also colleagues from the many other disciplines with expertise in sports concussion, including neuropsychologists, sports medicine, psychiatrists, certified athletic trainers, and others. It was also intended to focus closely on the evidence, to delineate more clearly what we know, what we think we know, and where we need to know more.
WHAT AREAS CURRENTLY NEED MORE ATTENTION?
Jeffrey S. Kutcher (JK): We need greater attention to critical thinking and data-driven decision-making across the board. That being said, for me, there is nothing more important than truly understanding the long-term consequences of playing our popular sports. Millions of youth are exposed every year. Clear messages of caution, and even fear, are disseminated throughout the media daily, yet we really don't have any reliable data that speak to this issue.
CG: Several areas are in critical need of more attention, as is mentioned in both the AAN evidence-based guidelines and the  Institute of Medicine review, “Sports-Related Concussions in Youth: Improving the Science, Changing the Culture.” [See the Neurology Today story about the Institute of Medicine report: http://bit.ly/IOM-nt.] One is to use education, practice, and policy to change the culture of concussion symptom reporting and management. Given the large numbers of young athletes affected, pediatric-specific assessments and management plans need to be developed.
An area of critical importance centers on determining the relative risk of chronic neurocognitive impairment in individuals exposed to multiple concussions or “subconcussive injuries” and the determination of what proportion of these impairments are stable if exposure to repeated injury is minimized, as well as what proportion are progressive or neurodegenerative. The current presumption, based on selected autopsy case reports, implies a high risk for neurodegeneration. But good clinical studies using cognitive testing in a broader cross-section of living patients are just starting to be conducted.
MANY WALK-IN CLINICS ARE ADVERTISING “BASELINE” CONCUSSION TESTING FOR STUDENT ATHLETES. ARE THESE BASED ON SOLID RESEARCH PARAMETERS AND ARE THOSE ADMINISTERING THEM SUITABLY TRAINED TO CONDUCT TESTING?
JK: This is perhaps one of the most critical problems we face today. Baseline testing is only part of concussion management, and is really just a piece of a comprehensive neurological evaluation. Baseline testing is easy to do, but difficult to do well. Even worse, once performed, the tests are frequently misused. Too many athletic institutions behave like baseline testing covers their need for a comprehensive approach to concussion management, but nothing could be further from the truth.
CG: The current concussion guidelines caution against overly depending on a single test in the assessment of concussion, and recognize that concussion is ultimately a clinical diagnosis. Thus cognitive testing — particularly computerized cognitive testing — may be used to acquire individual baseline data and this may be helpful in concussion assessment. However, no single examination should be used as the sole diagnostic determinant of whether a concussion has occurred.
HOW IMPORTANT IS BETTER UNDERSTANDING OF THE LONG-TERM EFFECTS OF REPEATED SUBCONCUSSIVE HEAD IMPACT, ESPECIALLY IN YOUNGER PLAYERS?
JK: In short, it's the most important issue that we face. None of us want any athlete, especially our younger ones, participating in activities that might negatively affect their long-term brain health or performance.
CG: Existing studies of living ex-professional athletes suggest that there are detectable neurocognitive impairments that correspond to the duration of exposure to contact sports/risk. None of these studies have currently presented longitudinal data, so definitive determination of progressive neurodegeneration is still premature. Studies of younger contact/collision athletes have not consistently detected neurocognitive deficits — only about one-half have shown impairment, while the others have not. So this remains a significant challenge for the field until more age-specific data are gathered and rigorously analyzed.
HOW EFFECTIVE ARE CURRENT SIDELINE CONCUSSION/SUBCONCUSSION RECOMMENDATIONS, AND HOW WELL DO YOU THINK THEY ARE BEING FOLLOWED?
JK: I do think that we've made significant progress. We are starting to see fewer mismanaged injuries and more critical thinking going into making neurological decisions. We have a long way to go, however, both in creating dynamic and comprehensive evaluation techniques and in disseminating good information across the entire landscape of sports.
CK: The current guidelines across a broad range of professional organizations provide valuable, unbiased management recommendations. These include removal from contact risk/play if a concussion is suspected, and not returning the athletes to play until they've been evaluated and recovered.
WHAT IMPROVEMENTS COULD BE MADE?
JK: There are many. I would like to see a greater respect for the complexity of the “return to play” decision. It is a medical decision, one that not only looks at the current injury in a comprehensive manner, but also includes the totality of the patient's neurological and sport-related health. Too many people assume that you can make these decisions using protocols or simple tests. This is not only inappropriate, but could also be dangerous. I would also like to see more responsibility in the media. I would like to think the media has a responsibility to check facts and understand the agendas of those they interview. Science is not opinion. Both are necessary and both are important, but one should never mistake the two.
CG: The field of sports concussion is changing rapidly. New groups are becoming increasingly involved in sports concussion, and the number of relevant research publications is steadily increasing to help cover the gaps in our knowledge. Clearly, an update to the evidence-based guidelines within the next three to four years is warranted, just to keep up with ongoing research. Importantly, a standardized definition of concussion (and subconcussion and post-concussion syndrome, if possible) would be helpful for clinical care protocols, but also serve as an indication of the challenges still facing the field of sports concussion.
HOW CLOSE IS THE FIELD TO DEVELOPING A CONSENSUS DEFINITION OF POST-CONCUSSION SYNDROME (PCS)?
JK: PCS is unfortunately quite common and usually misunderstood, both by patients and providers. I don't think we are very far away from developing a consensus — we don't need any breakthrough science or a tremendous body of new work. What we need is clear thought, critical thinking, and a concerted effort from multiple fields to get on the same page. This is one of the very clear goals of this conference.
CG: To advance the field, it is critically important to develop standard/consensus definitions for concussion, subconcussion, post-concussion syndrome, so that we may more readily study these entities and plan for optimal recovery.
This is the first in a series of articles that will look at new research, policies, and practices on and off the field in traumatic brain injury and concussion.