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The Biomarkers of Concussions
Researchers across departments at UND explore the physiology of concussions
In front of a collection of athletic training students, Steve Westereng, LAT, ATC, MA, CSCS, chair and assistant professor of the UND Department of Sports Medicine, is talking concussions. Rolling up a ball of athletic tape and inserting it into a rubber glove, he inflates the glove and agitates it as students watch the tape-ball bounce about haphazardly in its makeshift cranium.
“Even if your brain is floating in fluid in your skull, do you think it’s fully immune to injury from this type of trauma?” Westereng (right) asks, admitting that the model is something of an exaggeration. “And do you think that just adding a helmet is going to stop that ball from moving in there completely? Not necessarily.”
It is for this simple physiological reason, says Westereng, that so many athletes, parents, and coaches have been concerned about sports-related concussions in the 21st Century.
Hearing these concerns, and seeing protocols come into use at the professional and collegiate levels, North Dakota legislators even took up the cause in 2011, adding a chapter to the North Dakota Century Code (NDCC) entitled “Concussion Management For Athletes and Teacher Support Program.” In addition to requiring schools and athletics organizations to institute real-time concussion management programs, the legislation provides for concussion education and training for students, parents, coaches, and teachers.
Legislation notwithstanding, even the most experienced clinician can have difficulty knowing for certain whether or not an athlete has suffered a concussion, says Westereng: “Management programs are good, but because everyone reacts to trauma differently, wading into that realm by setting up strict protocols is complicated not only medically but legally.
This is why there remains a pressing need to identify a more objective and accurate way for health providers and athletics organizations to determine who has and has not suffered concussion on the field or court.
Wondering if there was a way faculty and researchers at the UND School of Medicine and Health Sciences might contribute to a solution to this problem, Westereng called up his colleague Colin Combs, PhD. Chair and professor with the SMHS Department of Biomedical Sciences, Combs has built a career studying the mechanisms by which the inflammatory activation of brain cells contributes to neurodegeneration, particularly in the case of Alzheimer’s disease.
Westereng shared with Combs a study published last year in the Journal of Neurotrauma that explored the possibility of tracking specific biomarkers in athletes who had suffered head trauma to better diagnose concussion—as opposed to relying only on athletes’ self-reporting of symptoms.
“I said to Dr. Combs, ‘Do you know anything about this?’” Westereng recalls. “And he said, ‘Actually, I was looking into that already and wondering if someone here wanted to collaborate.’”
As it turns out, Combs explains, after a blow to the head the blood of concussed patients often registers higher levels of specific proteins. These levels remain elevated even after the patient stops reporting signs or symptoms of concussion, suggesting that the patient may still be in a delicate condition—even “injured” in a potentially serious way—even though she or he has been cleared to play again.
This problem got both researchers thinking and working on developing a study that could be done at UND, not only to give athletic trainers and physicians better diagnostic tools, but to alleviate the problem of return-to-play decisions being reliant on athletes’ self-reports.
“A non-invasive blood-based biomarker screening tool would be huge. Such a measure could be incorporated into a standard care practice for athletic trainers and other providers managing concussive injury,” Combs (right) continues. “What I imagine we could think about doing at UND is track patients over the course of three or four years with a combination of standard methods, new blood-based methods, careful neuropsychiatric exams, and maybe even EEG in some cases, to try to determine objective biomarkers.”
The need is pressing not only for the purposes of diagnosis and treatment, concludes Westereng, but because leagues and schools are increasingly seeing the legal value in improving their treatment of concussion, which results in over two million emergency room visits a year in the U.S. (a figure that does not include the large number of concussive injuries that go unreported or undiagnosed). In other words, the abundance of concussion-related lawsuits pending that target the professional sports leagues, the NFL being only the most obvious example, has spurred state and local governments and amateur athletic organizations to find better ways to protect their athletes’ brains and themselves from liability.
According to Westereng, data from across the nation suggests that parents are starting to limit their kids’ participation in at least football, especially at the junior high school level, because of their fear of concussion and chronic traumatic encephalopathy, or CTE.
“As long as we have sports in our culture, we’ll have to deal with concussions,” concludes Westereng, adding that while athletes have been getting larger and faster on average, it has been difficult determining whether or not there are more concussions now than in the past because of improvements in documenting and assessing concussions. “If you look at the statistics even from UND, back in the 1980s the average football player weighed about 215 pounds. Now, the line is full of 300 pound guys. The average player is up 15 or 20 pounds from what they were in the eighties. That’s not insignificant.”