Jenny Grimm took an elbow to the head from an opposing player that knocked her unconscious during her first lacrosse game in 2011 at Seton Hall University.
When the freshman came to later, Grimm began what she looks back on as the worst year of her life.
She is among the 10 percent of concussion patients who don’t recover within about six weeks. She suffered severe headaches and nausea for months. She struggled terribly in school and eventually moved back home to Getzville. Her memory and concentration trailed off so badly that she took to writing notes to remind herself of meals she ate.
“I can study for a test, and still, an hour later, I won’t remember a thing,” said Grimm, who transferred to Canisius College.
Part of her treatment for post-concussion syndrome involves assessing her recovery by exercising on a treadmill while monitoring such physiological indicators as blood pressure and heart rate. This may sound like a simple idea, but it’s actually a relatively new concept pioneered in Buffalo.
Researchers here, with a grant from NFL Charities, are building on their work on a “regulated exercise” treadmill exam to look at whether the same technique can serve as an objective, scientific test to determine when athletes can safely return to play after a concussion.
Such decisions are important because concussed athletes who return before complete recovery put themselves at much greater risk of follow-up head injuries. And those decisions often rely on judgment calls.
If the test being developed here proves reliable, it could offer trainers and doctors a clearer picture of when an athlete is truly ready.
“We’re trying to put some science behind the return-to-play decision,” said Dr. John J. Leddy, director of the University at Buffalo’s Concussion Management Clinic.
The approach could change the way professional and amateur sports team physicians make decisions about concussion recovery, according to Leddy and his colleagues, including Barry Willer, a UB professor of psychiatry and rehabilitation services.
Over the next 18 months, the UB researchers will test 35 to 50 athletes from the Buffalo Bills, Buffalo Sabres and area colleges, including UB, who suffer concussions in the 2012-13 season, as well as healthy control subjects.
As many as 3.8 million sports- and recreation-related concussions occur in the United States each year, according to an estimate by the federal Centers for Disease Control and Prevention.
However, the true number of incidents isn’t known because many athletes with concussions don’t report their symptoms, don’t go to an emergency room, or fail to have their symptoms recognized.
Repeat concussions raise risk
When an athlete suffers a concussion, the blow to the head causes movement of the brain inside the skull, which damages neurons. Concussions can cause a range of short- or long-term complications, including headaches, confusion, nausea, memory problems and personality changes.
Repeat concussions can increase the risk of damage. Grimm, for instance, suffered four confirmed concussions since 2009, but there may have been others.
“I didn’t often say I got hit in the head because you want to stay in a game,” said Grimm, who played lacrosse during high school at Mount St. Mary Academy.
The recommended protocol for concussed athletes is to rest initially, allowing the brain time to heal. Once players feel better, they embark on a graduated exercise program that begins with light aerobics, followed by a sport-specific exercise, then a noncontact drill and finally a full-contact practice.
These programs tend to be very individual, lasting days, weeks or months, depending on the severity of the brain injury and the player’s response to treatment.
Many athletes also undergo neuropsychological testing.
The medical consensus has been that athletes can return to play when they can exercise to the level of their sport without a worsening of symptoms.
Nevertheless, the thinking behind that decision can turn murky because it relies on subjective opinions by athletes about their symptoms and neuropsychological testing that might be open to interpretation.
Leddy and Willer doubt the reliability of the neuropsychological tests, a debated issue in the medical community, and believe the treadmill test could replace the early stages of the current return-to-play protocol used by physicians and trainers. At the very least, they suggest that the treadmill test could be a beneficial additional component in return-to-play decisions.
$100,000 grant from NFL
NFL Charities, the charitable foundation of the National Football League, recently awarded a $100,000 grant to researchers at the Concussion Management Clinic in the UB Department of Orthopaedics & Sports Medicine. It was one of 15 grants nationally totaling $1.5 million for concussion- or heart-related studies.
Leddy and Willer have completed smaller, pilot studies of a controlled, progressive exercise program using a standard treadmill test to successfully treat athletes with concussions.
In the test, patients exercise on a treadmill, slowly increasing the workload, until they can perform to a maximum amount without experiencing concussion symptoms. As they are walking or running, measurements are taken of their heart rate, blood pressure, pulmonary ventilation and cerebral blood flow.
The treadmill test is based on the idea that there are physiologic characteristics of individuals with post-concussion disorders that can be measured. Unlike symptom reports, the measures are objective and can’t be faked.
The test is based on the hypothesis that the body’s system responsible for maintaining blood flow in the brain may not work correctly in people with a concussion but can be restored to normal by controlled, graded symptom-free exercise.
“People with concussions can’t finish the test. They get dizzy, have headaches or lose their balance. We think the brain gets overwhelmed with blood,” Willer said.
With more people questioning the use of neuropsychological tests, the researchers said, the treadmill test may offer a more reliable alternative for use in acute concussions, not just in patients with persistent symptoms.
A ‘brave’ step in care
The treadmill test is gaining acceptance as part of the management of post-concussion syndrome.
Dr. Stanley A. Herring, a national concussion expert, characterized the idea as a “brave” step because it conflicted with conventional wisdom.
“People thought you would hurt patients with persistent symptoms by having them exercise. [UB researchers] had to remove that stigma,” he said.
But Herring – who is director of Sports, Spine and Orthopaedic Health at the University of Washington, co-medical director of the Seattle Sports Concussion Program, and a team physician for football’s Seattle Seahawks and baseball’s Seattle Mariners – said it’s premature to say whether the test will work for concussions in their initial phase. “The work on this needs to be expanded and validated,” he said.
In addition, given the millions of sports- and recreation-related concussions that occur each year, any test must be cost-effective if it’s to become a part of standard care.
“It needs to be affordable in both time and expense,” Herring said. “That is not a minor deal.”