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NCAA chief medical officer reflects on progress of concussion research

NCAA Chief Medical Officer Brian Hainline speaking at the 2017 NCAA Convention. Jamie Schwaberow / NCAA Photos

With concussion and its consequences — particularly among those who play football — emerging as one of the foremost concerns in college sports, two veteran neuroscientists recently joined forces to edit a comprehensive review of sport and the brain.

NCAA Chief Medical Officer Brian Hainline and Robert Stern, director of clinical research at Boston U.’s Chronic Traumatic Encephalopathy Center, co-edited Sports Neurology, published in December as a volume in the prestigious Handbook of Clinical Neurology. The 512-page tome aims to encapsulate what is known about how sport, contact and concussion affect the brain. The 43 chapters document topics such as subconcussive brain trauma, neuroimaging and the neurologic benefits of sports and exercise.

Hainline spoke with Champion about the book and offered an update on the progress of the NCAA-U.S. Department of Defense Concussion, Assessment, Research and Education Consortium study. The undertaking, which launched in 2014, has received $64 million in funding so far. It is only beginning to yield findings, but researchers already are poised to influence how some sports are practiced and played and how concussions are diagnosed and managed.

CHAMPION MAGAZINE: What do you hope the impact of a book like this might be?

BRIAN HAINLINE: We had a few hopes. One was, let’s provide the most up-to-date and comprehensive text on sports and neurology ever written.

CM: Sure. Easy task. No problem.

BH: So, from that point of view, we’re really looking at clinicians. But there’s a lot of science in here, and there’s also a lot of sports psychology in here. So another goal is to move away from this singular look of sports neurology as being just for neurologists and broadening it to all sports medicine clinicians, to sports psychology clinicians, to the neuroscientist community, to public policy. This book actually touches on all of those.

CM: It’s probably difficult to boil this book into one big takeaway, but if a layperson walks away from this knowing one thing, what should it be?

BH: I think that it probably provides the most comprehensive update on sport-related concussion. We address it from all angles from an evidence-based perspective: how it’s managed in the emergency room, on the sidelines, all of the various manifestations. Then we take a really deep dive into neurodegeneration and the available evidence surrounding its association with brain injury. We explore in the narrative that there is an association between brain injury either at the subconcussive or concussive level and possible long-term neurodegeneration, but we don’t know that with certainty.

CM: You edited this with Bob Stern of Boston U., which produces studies about chronic traumatic encephalopathy that get a lot of attention from the media. Is there tension between Boston U.’s approach and the NCAA-Department of Defense CARE Consortium study?

BH: A lot of the perceived tension is driven by lay press. They have focused, almost uniquely, on the work coming out of Boston U., and that’s not at all to discredit Boston U. The press may be hypersensitive to its work. Not everyone agrees with the singular message coming out of Boston — but I think they’re doing great work. Bob Stern and I happened to have co-presented on several occasions. We’ve gotten to know one another, and we both really respect each other as scientists and as people who believe that sport is important for the public health. We actually cite these commonalities in our preface. Because of our mutual love of science and belief in sport as a public good, it makes sense for us to partner on this important effort.

CM: Regarding its work with CTE, you mentioned the layperson narrative, the press narrative. What do we get out of this book that articulates with certainty what we know about CTE?

BH: Well, I think it does two things: The narrative in the book, the consistent scientific narrative, is that there is some association between types of head impact and CTE, but we don’t know what that association means, so we need to continue to study and better understand that relationship. Equally important — in the final chapter that Bob and I wrote, we state that we don’t know what causes CTE, but then go on to share what we do know right now. So what the association will pan out to be, I’m just not sure. I think in a very fair-minded way, we probably give as comprehensive an update on the association as is out there, but also equally in a fair-minded way, we say, “This is all still speculatory.”

CM: Many of the researchers associated with the CARE consortium authored chapters. How much did the data collected there inform what went into the book?

BH: Not as much as I would have liked — just because, by the nature of a book, you’re almost a year behind by the time it gets published. The CARE literature was just starting to emerge when we published.

CM: Switching gears to CARE — of the early set of findings, is there anything that really jumps out to you as vital?

BH: There was a landmark paper that was published in the British Journal of Sports Medicine this spring that emphasizes how the culture of concussion safety has evolved. In the original NCAA concussion study published in 2003, the average return to play in college football players was about 6½ days after concussion. And 92% of repeat concussions happened in the first 10 days. The CARE study showed an average return to play time of greater than 15 days for football participants. And that where a second concussion occurred — the percentage was much lower now — it happened more than 50 days later, suggesting it’s an unrelated second event. I think it’s a massive cultural shift.

CM: What’s on the horizon?

BH: We have some emerging data that appears to suggest that some of the blood biomarkers are really panning out. Using anywhere between two and four biomarkers resulted in a significant degree of accuracy on diagnosing concussion.

CM: Diagnosis and then, in theory, monitoring recovery, or is that a step too far?

BH: That’s part of it, too. And researchers are also in the process of moving from having to take blood to just getting a little pinprick like we do in diabetes management now. I think the blood biomarkers have made substantial progress. And then regarding brain imaging, we’re seeing results that demonstrate recovery patterns after concussion or repetitive head impact, so these really meaty results are now starting to emerge.

Concussion Study Highlights

Thus far, the NCAA-Department of Defense CARE Consortium study has enrolled more than 40,000 participants and yielded more than 20 research papers. Some highlights from the study’s first five years:

Those who played football before age 12 do not demonstrate any neurocognitive deficits in college.

Exposure to impacts, not merely the force of a given impact, appears to have a higher correlation with eventual concussion. This finding suggests that a high magnitude of exposure, even to hits that produce lower levels of head acceleration, may have a priming effect.

Anxiety and depression are more prevalent among student-athletes who reported a history of more concussions. That effect was particularly pronounced among athletes who reported having suffered at least four concussions. 

The average time between a concussion and return to play among college football players has jumped to 16.1 days, up from a mere 6.7 days 15 years ago. In an older study, 91.7% of repeat concussions in football occurred within 10 days of the injury. That figure has since fallen to 3.7%.

Those who self-reported a concussion in childhood had more than double the risk of suffering a subsequent concussion than those whose first concussion occurred during adolescence. For every additional year that passed in life before the initial concussion, researchers identified a 16% reduction in the individual’s risk of suffering another concussion later in life.

About Champion

Champion magazine goes behind the headlines and beyond the scoreboards to celebrate the unique connection between Americans and college sports. Champion is published by the NCAA.