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Author: Brian W. Hainline
The National Collegiate Athletic Association (NCAA) is the national governing body of intercollegiate varsity athletics. About 460,000 student-athletes from 1,100 schools are involved in the organization, which represents 23 sports and 90 national championships. The NCAA has taken a leadership role to enhance understanding and mitigation of concussion.
Concussion is one of nine strategic priorities for the NCAA Sport Science Institute, which I oversee as the NCAA’s first chief medical officer (appointed in 2013). The other strategic priorities are mental health; cardiac health; overuse injuries and periodization; doping and substance abuse; nutrition, sleep, and performance; sexual assault and interpersonal violence; athletics healthcare administration; and data-driven decisions. All of these areas represent important public health concerns in sports, yet understanding of causes, effective strategies for mitigation, and methods to acquire knowledge are limited.
For example, there is no adequate definition of concussion reflecting the injury mechanism or localization in the brain. The accepted definition is limited to an imprecise description of the symptoms of concussion: a change in brain function, following a force to the head, that may be accompanied by temporary loss of consciousness but is also identified in awake individuals, and that has measures of neurologic and cognitive dysfunction (Carney et al. 2014). From a data-driven decision-making perspective, information is lacking about the range of consequences of concussions, the preferred treatment, and when to allow a concussed athlete to return to play.
Athletic and Military Concussion
Concussion incidence in the United States is estimated at 3.8 million per year (Iverson et al. 2004), over 300,000 of which result from sports collisions (Gessel et al. 2007). As shown in figure 1, however, football fatalities associated with concussion and other head and neck injuries have been declining.
The rate of concussion for intercollegiate sports overall is shown in figure 2 (Zuckerman et al. 2015). The highest-rate sport is men’s wrestling, a contact sport. Note, however, the high level of risk in many women’s sports—soccer, ice hockey, basketball, and lacrosse. Women’s lacrosse is a noncontact sport, while men’s lacrosse is not, yet the concussion rate for women’s lacrosse is higher. Understanding of the reasons for differences in concussion between the sexes is poor, although it goes beyond differences in neck strength and includes mechanisms of contact and differing neurophysiological responses.
There are many similarities in the NCAA and Department of Defense (DOD) missions to mitigate injury and in the events that lead to traumatic brain injury in sports and military activity. For example, most NCAA head injuries are classified as mild (i.e., concussion), and 97 percent of the traumatic brain injuries in US veterans of the wars in Iraq and Afghanistan are mild; of those, about 85 percent happened in a way that is biomechanically similar to a sport concussion, while only 15 percent resulted from blast injuries (Cameron et al. 2012), which are biomechanically distinct from direct physical trauma.
Moreover, NCAA student-athletes and military servicemembers share many demographics: they are similar in age, athleticism, risk taking, and the practice of pushing themselves to the edge of excellence. One crucial difference is that there is more control in the college athletic environment than in the military theater.
NCAA-DOD Grand Alliance Study
Because of these similarities and the need to close the concussion knowledge gap, the NCAA and DOD are collaborating in a landmark study titled NCAA-DOD Grand Alliance, which consists of the CARE Consortium and the Mind Matters Challenge (NCAA 2014).
Concussion Assessment, Research, and Education (CARE) Consortium
This initiative is the largest prospective, clinical, longitudinal study of concussion in history. The two primary aims of the study are to determine the natural history of concussion and to define neurobiological recovery after concussion. The three primary study centers are the Medical College of Wisconsin (Michael McCrea, principal investigator), Indiana University (Tom McAllister, PI), and the University of Michigan (Steven Broglio, PI). The 3-year study is being conducted at 30 NCAA member schools, including the four service academies. At every site each student-athlete in every sport undergoes an exceptionally rigorous baseline exam and serial exams after concussion.
In addition, the advanced research component of the CARE Consortium is evaluating neurobiological recovery in seven sports: men’s football, men’s and women’s lacrosse, men’s and women’s ice hockey, and men’s and women’s soccer. This research is taking place at four schools, where student-athletes in the seven sports wear a head sensor during competition and practice, and undergo baseline genetic testing, assessment of blood biomarkers, and postconcussive brain imaging studies that are synced with the TRACK-TBI methodology1 (NINDS 2012). After an injury or suspected injury, baseline measurements are repeated as shown in figure 3.
It is anticipated that in 3 years, 35,000 student-athletes will be enrolled in the clinical study and about 1,600 student athletes will be enrolled in the advanced research core. The conservative estimate, based on a 2 percent concussion rate, is that there will be 750 concussions in the clinical study and 75 in the advanced research core.
There are active discussions to extend this study in a Framingham model to over 35 years, and to expand enrollment to precollege-level sports.
Mind Matters Challenge
The NCAA-DOD Mind Matters Challenge is an education and research challenge open to all NCAA schools and the public at large (NCAA 2014). The education component of the challenge calls on participants to develop, within one year, compelling educational content and delivery that will help change the culture of concussion in young adults. For the research challenge, applicants must describe a 3-year study to provide methods to change the culture of concussion and perceived norms for coaches, student-athletes, parents, administrators, and the public at large. Six winners have been chosen for the educational challenge, and eight for the research challenge.
New NCAA Guidelines
In January 2014 NCAA and medical organization colleagues met to develop interassociation guidelines—for concussion, football practice, and independent medical care—aimed at helping to mitigate and manage sport-related concussion.2 The guidelines have been endorsed by eleven prominent medical organizations.
The medical care guidelines state that coaches do not make medical decisions. Athletic trainers and team physicians (primary athletics healthcare providers) must make all medical decisions with unchallengeable autonomous authority.
The year-round football practice live contact guidelines are based on best available evidence. They are an important start, but we ultimately hope to individualize guidelines based on emerging head sensor data.
The concussion diagnosis and management guidelines may not seem particularly revolutionary, but in some ways they are. Developed by clinical experts who pioneered the field, one accepted method for assessing concussion and guiding decisions for return to play is known as ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). ImPACT provides trained clinicians with neurocognitive assessment tools, and is the most widely used and most scientifically validated computerized concussion evaluation system.
But ImPACT alone is insufficient. Rather, a multimodal method of preparticipation assessment is needed, and the postconcussion phase must emphasize return to learn as much as return to play.
Some of these changes can help, but they must also be updated with emerging data and consensus, including changes in the rules of sport. For example, when the rules of football prevented spearing in the 1970s, the incidence of cervical spine injuries decreased dramatically (Bailes et al. 2007). More recently, when the kickoff in football was moved five yards closer to the end zone, and the ball placement from a touchback moved five yards the other way, the concussion rate fell 50 percent relative to all other injuries.3
But no matter how safe the rules for all contact, collision, or even noncontact sports, the risk of concussion cannot be eliminated. Sport brings exceptional benefits that must be weighed against the risks. Our goal is to continually improve safety in sport through data-driven decisions and consensus. At the NCAA, we believe that progress is well under way.
Bailes JE, Petschauer M, Guskiewicz KM, Marano G. 2007. Management of cervical spine injuries in athletes. Journal of Athletic Training 42(1):126–134.
Cameron KL, Marshall SW, Sturdivant RX, Lincoln AE. 2012. Trends in the incidence of physician-diagnosed mild traumatic brain injury among active duty US military personnel between 1997 and 2007. Journal of Neurotrauma 29(7):1313–1321.
Carney N, Ghajar J, Jagoda A, Bedrick S, Davis-O’Reilly C, du Coudray H, Hack D, Helfand N, Huddleston A, Nettleton T, Riggio S. 2014. Concussion guidelines step 1: Systematic review of prevalent indicators. Neurosurgery 75(Suppl 1):S3–S15.
Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. 2007. Concussions among United States high school and collegiate athletes. Journal of Athletic Training 42(4):495–503.
Iverson G, Gaetz M, Lovell MR, Collins MW. 2004. Cumulative effects of concussion in amateur athletes. Brain Injury 18(5):433–443.
Kerr ZY, Dompier TP, Snook EM, Marshall SW, Klossner D, Hainline B, Corlette J. 2014. National Collegiate Athletic Association Injury Surveillance System: Methodology during 2004/05–2013/14 academic years. Journal of Athletic Training 49(4):552–560.
NCAA [National Collegiate Athletic Association]. 2014. NCAA, DOD launch Mind Matters Challenge. Press release, November 6. Available at www.ncaa.org/about/resources/media-center/news/ncaa-dod- launch-mind-matters-challenge.
NINDS [National Institute of Neurological Disorders and Stroke]. 2012. NINDS Common Data Elements, Appendix II: Imaging parameters for MRI and protocols for MRI and CT. Bethesda, MD. Available at https://commondataelements.ninds.nih.gov/TBI.aspx#tab= Data_Standards.
Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS. 2015. Epidemiology of sports-related concussion in NCAA athletes from 2009–2010 to 2013–2014: Incidence, recurrence, and mechanisms. American Journal of Sports Medicine 43(11):2654–2662.
1 The Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study is funded by the National Institute of Neurological Disorders and Stroke (NINDS) and housed at the University of California, San Francisco.
2 The Safety in College Football Summit was held January 22–23, 2014, in Atlanta. The three sets of guidelines are available at www.ncaa.org/health-and-safety/; the list of summit participants is available at www.ncaa.org/health-and-safety/appendix.
3 Personal communication with Tom Dompier, Datalys Center, January 2015.