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Heady Ambitions

The University of Florida is involved in a landmark concussion study in alliance with the NCAA and U.S. Department of Defense.

By Florida Gators

March 31^st, 2015

A NEW ERA

GAINESVILLE, Fla. — Collisions and subsequent injuries have occurred in football since the days of leather helmets. However, increased concerns about safety and growing media attention have created more awareness about concussions in recent years.

A concussion is a traumatic brain injury that affects the way the body’s most complex organ functions. The effects are usually temporary but often include headaches and problems with concentration, memory, vision, balance and coordination.

Still, concussion studies remain at an infant stage and much remains unknown about the injury in comparison to most sports-related ailments.

To help advance knowledge of head injuries and their long-term impact on athletes and service members, the NCAA and U.S. Department of Defense announced a $30 million initiative called the NCAA/DOD Grand Alliance that launched last summer with 11 schools and the four service academies as invited participants. It’s the most ambitious study of its kind ever conducted with the goal of enrolling 37,000 athletes and service personnel. Based on prior clinical and research efforts, the University of Florida’s Athletic Association was included in this group.

“There’s a lot going on. It really is an exciting time to be doing this research,’’ said Dr. Jay Clugston, a team doctor and assistant professor of community health and family medicine who heads UF’s concussion research. “There is a lot for us to contribute and learn.”

The UF Sports Concussion Center is located at the O'Connell Center.

Clugston heads UF’s Sports Concussion Center, a division of UF’s Student Health Care Center, and has been studying concussions and their impact as part of the Florida football team’s medical staff since 2005. Clugston and his associates work closely with Florida’s athletic trainers in all sports, with a heavy emphasis on football, women’s soccer and women’s lacrosse, the sports at UF that produce the most concussions.

Balance testing is a key component in concussion management and part of the NCAA-DOD study.

A primary component of the joint concussion study by the NCAA and Department of Defense is to build a more comprehensive data bank with research from selected schools and the service academies. UF has had its own concussion data bank since 2013, with retrospective data included that dates back to 2005.

Each of the athletic program’s approximate 500 student-athletes is given baseline tests at the Sports Concussion Center prior to participating in his or her first practice. These tests include a standard battery of cognitive and balance tests, along with a vision measure called the King-Devick Test.

The King-Devick Test is one method Clugston and his team have used since 2011. The test is a two-minute challenge that requires an athlete to read single-digit numbers displayed on cards or on an iPad. UF collects baseline data for the King-Devick Test as with all of its concussion tests, and if an athlete is suspected of suffering head trauma, he or she is re-tested.

If the time needed to complete the test is any longer than their baseline result, the athlete is removed from play and further evaluated.

UF and the University of Pennsylvania were the first schools to implement the King-Devick Test as part of their concussion management programs.

“That’s something we feel is important to add in to the other concussions tests that we already do,’’ Clugston said. “It’s the only one of the simple tests that really looks at vision, and vision is a big component of the brain.”

UF has used the King-Devick Test since 2011, which is administered here by UAA Research Coordinator Jon Boone.

The UAA’s current concussion research program began in 2011 when it partnered with Banyan Biomarkers, which is based in Alachua, Fla., to study blood biomarkers to detect sports-related concussions. The project continues today and has evolved in recent years to include advanced magnetic resonance imaging (MRI) techniques — under the direction of Dr. Keith Peters, department of radiology — and football players using in-helmet sensors to measure the impact of hits.

These additions were started in part from funding provided by the NFL/GE Head Health Challenge to Banyan Biomarkers and from the Florida High Tech Corridor matching-funds program. Clugston, the principle investigator for the blood biomarkers and helmet sensor portions of the study, says that UF collects blood samples at the start of each football, women’s lacrosse and women’s soccer player’s career for all athletes who voluntarily enroll in the study.

Each athlete is given the opportunity to enroll, and they are given the same clinical care under UF’s concussion management plan regardless of their participation.

In addition, each enrolled UF student-athlete is tested again if they sustain a concussion and then at the end of his or her career to have a comprehensive history from their time as a college athlete. The study has recently received UAA and Institutional Review Board (IRB) approval to add men’s and women’s basketball starting next season.

“We felt like this was an area where we could really make an impact for our student-athletes. We have a set of student-athletes that train at the highest level, function at the highest level and compete at the highest level. They are a good set of kids to work with and also, they have some interest in their health and their own well-being and felt like this is something they would want to be involved with, too.” — Lynda Tealer, UF executive associate athletics director for administration

UAA Research Coordinator and certified phlebotomist Dewayne DuBose handles blood samples from UF student-athletes.

A key element to the UF concussion research program is the blood samples UF collects. The samples are processed and stored inside a minus 80 degree Fahrenheit freezer located in a locked room adjacent to the football team’s training room before shipping off to an offsite lab for testing.

Once athletes give a baseline sample, blood is collected again if they suffer a concussion to see if there are increased levels of several proteins in their blood. According to various studies, increased levels of protein markers signal potential damage to the brain and researchers are trying to learn more about whether the proteins are reliable biomarkers to gauge presence and severity of concussions.

While more research is being done now than ever before, Clugston said heightened media attention has outpaced the actual level of knowledge about concussions, one reason he was enthusiastic about joining the NCAA-DOD study.

“It is the biggest concussion study ever undertaken. There is so much unknown about concussions,’’ Clugston said. “This is the first attempt to get a big enough group of data to actually show what’s going on. It kind of builds on the stuff we’ve been doing. They wanted to have schools that are successful athletically, that have success in research, and had an interest in this. We were fortunate to be invited to do it. It will help us inform and educate our athletes better.”

UF has collected more than 450 blood samples from student-athletes since 2011.

Heady Ambitions

Heady Ambitions

As part of the NCAA/DOD study, new data is collected daily. This rapidly accumulating data then needs to be input accurately and securely into a national database.

Inside a small room at the UF Concussion Center, Clinical Psychology Research Coordinators Breton Asken and Zac Houck spend a great deal of their time quality-checking and entering UF’s data to be combined with similar data from the other schools and service academies in the study.

The study will shed important light on the natural history of concussions, including how the injury appears in athletes at the time of diagnosis and how the injury resolves.

Financially, the three-year NCAA/DOD study has pumped $400,000 into UF’s research efforts in recent months. UF has also benefited from various grants related to UAA research programs the past few years, including a combined $1.2 million from Banyan Biomarkers, NFL-GE Head Safety Challenge, and the Florida Tech Corridor Council.

Breton Asken, standing, and Zac Houck review data from UF's NCAA-DOD concussion study.

Zac Houck inputs data from UF into the NCAA/DOD study's growing data bank.

Athletic trainers, team physicians and other sports health providers have gained a better understanding of concussions and their symptoms due to increased awareness in their field over the past decade. As athletes across all sports have become bigger, faster and stronger, concussions continue to be an issue despite technological and design improvements in modern equipment.

Football is the sport most in the national media spotlight in regard to concussions, but the injury is also prominent in hockey, soccer and other contact sports.

“There is a big focus on finding objective ways to detect concussions,’’ Clugston said. “Currently, we can’t see the injury. We have to test people for it with functional tests before they get injured, and then repeat those same tests after the injury. There is no other injury we do that for.”

Paul Silvestri, head athletic trainer for football, plays a key role in injury diagnosis during games.

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An infographic describing the three most common brain injuries.

As part of Clugston’s work with Paul Silvestri, the head athletic trainer for football, 30 Gators used helmets last season that were equipped with sensors to measure the impact of hits to the head they took during practices and games throughout the season.

The data from the sensors is obtained through the technology of Riddell’s Head Impact Telemetry Systems (HITS) and monitored with the help of the football helmet company’s Sideline Response System (SRS) station, which is manned by Matt Graham behind Florida’s bench. Graham is a member of the Gators’ equipment staff.

Research assistant Matt Graham records data during a game from Riddell's Head Impact Telemetry Systems.

Another component of UF’s concussion research involves a test that evaluates an athlete’s cognitive skills after he or she suffers a concussion. The evaluation, called Immediate Post-Concussion Assessment Cognitive Testing (ImPACT), is a 30-minute computerized evaluation that involves a series of challenges to gauge memory, visual motor speed, reaction times, and other skills that can be impacted as a result of a concussion.

The test is usually administered in the first two days after an athlete is concussed as well as later in the process to assist with return-to-play decisions. These post-concussion ImPACT tests are compared to their baseline test to determine the severity of the symptoms.

UF has used ImPACT in its concussion management program since 2002 on the heels of studies performed in the late 1990s by Mickey Collins (now of the University of Pittsburgh Medical Center), at the time a clinical psychology intern. Collins’ studies were crucial in the development of computerized neuro-cognitive testing of athletes.

Clugston said ImPACT is helpful to determine if and where a player is having trouble. The results of all the post-injury assessments and physical exams help the sports health staff discover deficits that need rehabilitation prior to an athlete’s return to normal activity.

A diagram produced by the HITS program UF uses to monitor the location of impacts a player sustains over a season.

The ultimate goal of UF’s concussion research team and that of the NCAA/DOD study is to learn more about concussion diagnosis and recovery to better manage and prevent them. Specifically, the hope is to be able to outfit sports medicine personnel with the tools and information necessary to provide each athlete with targeted, individualized care most conducive to recovery.

The testing commonly used today could be altered if the $30 million study reveals that certain methods are better than others or new ways of testing emerge as the data bank expands.

What everyone seems to agree on is that researchers have a lot to learn about concussions.

“We want to be a part of the solution,’’ Tealer said. “We are willing to work hard in doing that. We have really competent and talented people involved. It’s really about trying to find out the best practices, the best treatments, the best diagnosis — trying to get to the root of the problem.”

Dr. Jay Clugston, standing, reviews information from UF's concussion studies with assistant Matt Graham.

Clugston and his staff are not only interested in finding more answers about concussions through their research, they also seek to educate student-athletes, their families, coaches and the public.

“I can’t think of a better population to study than college athletes. We have baseline results on all of them, and we have medical staff at every practice and competition to care for them when needed. After an injury we can see them immediately and almost every single day until they’re better [if they suffer a concussion], and we can follow up with them in the future over the course of their careers with us. So many of the athletes have been interested in what we are doing and willing to help out. They are an amazing bunch.” — Clugston

A letter UF now sends to parents of student-athletes about concussion awareness and its studies in the field.

BONUS VIDEO

UF Health profiles Clugston’s research and some of the ways the UF Concussion Center gathers data for its research, including the use of helmet sensors during practice and games.

Footnotes

Words by Scott Carter; photos by Tim Casey. Major contributors to UF's research -- NCAA, Department of Defense, Banyan Biomarkers, NFL-GE Head Health Challenge, and Florida High Tech Corridor.

FootNotes

Words by Scott Carter; photos by Tim Casey. Major contributors to UF's research -- NCAA, Department of Defense, Banyan Biomarkers, NFL-GE Head Health Challenge, and Florida High Tech Corridor.

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