Concussion: Status and Next Steps

Editor's Note

The rising incidence of brain trauma from sports, military blasts, vehicle collisions, and falls prompted the faculties of Case Western Reserve University and its associated medical care programs in Ohio to convene a symposium, with the National Academy of Engineering and National Academy of Medicine, on all facets of concussion. In June 2015 experts and representatives in engineering, clinical medicine, military medicine, athletics, animal research, physics, and government engaged 650 participants at the Global Center for Health Innovation in Cleveland. This issue presents 14 short scientific papers based on their presentations—covering brain trauma epidemiology, mechanisms, diagnosis, treatment, and prevention—following a longer, comprehensive overview of concussion.¹

The information in this issue can enhance understanding of the nature and mechanisms of concussion. Years of experimental studies, initially focused on vehicle collisions, have evolved from crash simulations, animal experiments, tissue biophysics, and computer simulations to investigations of physical parameters of head impact through instrumented helmets, objective measures of cognitive function changes before and after sports engagement, and noninvasive imaging (e.g., functional magnetic resonance imaging, fMRI).

Over the last 10 years the neuropathology associated with symptoms of brain dysfunction has been revealed. Fortunately, these pathology diagnoses, at first done through postmortem assessments, can now be made by imaging methods (e.g., positron emission tomography, PET) in living athletes, veterans, and crash victims.

This information can be used to address a national problem that needs far more attention to prevention, diagnosis, and treatment, particularly concerning the risks to young athletes and servicemembers—and females in particular, as a paucity of data exists to address gender differences—of developing long-term behavioral and cognitive problems from multiple impacts.

The Way Forward: Potential Strategies

Compelling evidence presented at this symposium shows the urgent need for engineers, neuroscientists, and medical professionals to develop more precise information about how blunt trauma leads to brain tissue injury, how the effects of repeated trauma may accumulate over time, and how this accumulation results in long-term and progressive brain tissue damage and human behavior dysfunction.

Following are potential strategies to meet the challenges of concussion diagnosis and prevention and to determine optimal methods for treatment.

1. Establish a registry to track head injuries in pre–high school and high school sports, as is done for collegiate sports. A long-term medical history record, based on objective and quantitative measures, may enhance understanding of medical and academic outcomes for concussive events at all ages. A successful start of such a registry has been made by a consortium of colleges and the military service schools (cf. papers by Hack and Hainline). Pathological information is a critical part of this registry (cf. papers by Kovacs, McKee, and Perl).
2. Incorporate objective methods of assessment of cognitive changes before and during impact sport activities, as has been done in pilot programs for high school players (cf. Talavage paper).
3. Extend objective and easily implemented measures of neuromotor function (such as those developed by the Cleveland Clinic Concussion Center; cf. Alberts paper) to other athletic programs around the country.
4. Add to the blood biomarker research program (cf. Bazarian paper) assessments of pituitary function (cf. Budinger overview).
5. Investigate the sensitivity of a simple test of olfaction function (odor detection) to predict long-term consequences of brain trauma (cf. Ruff paper).
6. Engage bioengineers in computer simulations with accurate representation of material properties to demonstrate brain tissue strain fields associated with blasts and impacts over a range of stress rates, accelerations, and angular directions (cf. papers by Radovitzky et al. and Margulies).
7. Improve vehicle collision tests by incorporating heavily instrumented anthropomorphic dummies and other test devices to measure head and brain accelerations in automobile barrier test impacts (cf. Michael paper).
8. At the national level, encourage research to determine the efficacy of anti-inflammatory drugs as well as other agents to aid in the recovery of concussion as well as approaches to aid in treating axon and mitochondrial injury (cf. Smith paper and Budinger overview).

Acknowledgments

Case Western Reserve University hosted the June 2015 Regional Meeting on which this issue is based.² The objective of the meeting was to bring together leaders from a variety of disciplines to present to the scientifically inclined public the knowledge available about concussions. This was the fifth such meeting organized by local members of the National Academies to provide information to the public on a topical issue where scientific clarification of issues has been important. The previous events addressed biotechnology, energy, vaccine production, and shale gas and fracking.³

This conference would not have been possible without broad support from many donors and our program committee.

Major Donors

Case Western Reserve University, MetroHealth Medical Center, Taipei Medical University, and the Global Center for Health Innovation. Cosponsors were the Cleveland Clinic, Cleveland Foundation, Cleveland State University, Kent State University, Kelvin and Eleanor Smith Foundation, and University Hospitals of Cleveland.

Program Committee

Hunter Peckham (NAE), cochair, Case Western Reserve University

Jay Alberts, cochair, Cleveland Clinic

Thomas Budinger (NAE), University of California, Berkeley

Col. Dallas Hack, US Army Medical Research and Material Command

Trevor Jones (NAE), International Development
Corporation

Geoffrey Ling, DARPA

Robert Miller, George Washington University

Aram Nerpouni, BioEnterprise

And the following members at Case Western Reserve University:
James Anderson (NAE), John Angus (NAE), William Bud Baeslick, John Chae (NAM), Mark Griswold, Arthur Heuer (NAE), Robert Kirsch, Warren Selman

Special thanks are due to Tom Budinger, guest coeditor of this issue. The program committee is indebted to Tom for his herculean efforts, along with science writer Pamela Reynolds and Bridge managing editor Cameron Fletcher, for assembling these monographs into a cohesive account of the national problem of concussion.

P. Hunter Peckham (NAE)

Case Western Reserve University and
MetroHealth Medical Center

Conference General Chair

FOOTNOTES