(L to R): Penn Neurosurgeons William Welch, MD and John Lee, MD; Penn primary care physician, Bill Duffy, MD, with Pennsylvania Hospital primary care physician and Eagles team doctor, Gary Dorshimer, MD, on the field at an Eagles game
It’s hard to believe that a mere 10 years ago concussions were not a part of the lexicon for professional athletes and even less so for youth and high school athletes and kids or older Americans who indulge in contact sports for fun.
With Super Bowl 50 approaching, I sat down with M. Sean Grady, MD, chair of Neurosurgery here at Penn Medicine, one of six Penn Medicine neurosurgeons who for the last three years have served as independent consultants on the sidelines at every Philadelphia Eagles home game: one team member sits on the visitors side, one on the Eagles side providing their clinical expertise in cases involving head trauma and concussion.
Grady explained the genesis of all this concussion talk and explained his role on the sidelines, and where the field is headed (no pun intended).
When did all the concussion talk/fear begin?
Grady: We’ve known for a long time that there was some risk of dementia as a result of long-term participation in contact sports. This data was first gleaned from the brains of boxers with brain atrophy (weakening and shrinkage) seen on autopsy at death. This research has been around for about 50 years.
It has only been in the last 10 years that we’ve seen greater knowledge of this same risk in NFL football players, which brought the subject of concussion and traumatic brain injury (TBI) into the public conscience. The work of Bennet Omalu, MD, the protagonist in the recent move, “Concussion,” was the first to report on this after his examination of the brain of Pittsburgh Steelers player, Mike Webster, at his passing. What he saw was a diseased brain that was similar to what had been previously seen in boxers and known as chronic traumatic encephalopathy (CTE). While his findings were not new to the field, per se, Omalu’s diagnosis and the NFL controversy that followed received a great amount of publicity, spurring public concern about the issue.
Ten years later, what more do we know about concussions and head trauma?
Grady: Research over the last 10 years has shown that NFL players have a higher rate of neurodegenerative disorders (Alzheimer’s and Parkinson’s for instance) than an age-matched non NFL-playing population. We have also now moved passed the notion that a concussion is simply a rite of passage in a game like professional football and understand that there is a real long-term risk that comes with concussions, thanks in part to Omalu’s findings.
Talk to me about how the NFL, in particular, has adapted to this new understanding.
Grady: Over the past few years, the league has made some rule changes in an attempt to make the game safer for its players. For one, the kick-off now takes place further down the field as a way to better ensure that the ball goes into the end zone, thus avoiding a race for the ball and resulting head injuries. There are also several trained observers in a booth high above the field at every game reviewing each play for suspicious behavior that might signify a head injury and require a stoppage of play. And, the NFL in combination with the NFL players association, instituted the role I serve in, as an unaffiliated neurotrauma consultant.
Penn Neurosurgeons, Gordon Baltuch, MD and M. Sean Grady, MD, mingle on the field following a recent Eagles game. Welch, Lee, Baltuch, Grady along with Penn neurosurgeons Paul Marcotte, MD, and Ali Ozturk, MD, serve as independent neurotrauma consultants at every home Eagles game.
What is your role at each game?
Grady: We diagnose concussions and make and return-to-play decisions working with, but independent of, the NFL team physicians.
Our diagnosis is made using several measures: we talk to the player and make a visual evaluation as to whether the injured player looks or acts dazed or confused or exhibits a loss of consciousness. We also administer a basic neurological test known as a Sport Concussion Assessment Tool, or SCAT 3, which includes a cognitive and physical evaluation, delayed recall, and a balance assessment score. Finally, we take their helmet so they cannot return to play too soon.
Players complete the SCAT 3 at the start of the season so we have baseline results to which we can compare any results following injury. We then make a diagnosis and advise the player, coaches and team physician. The NFL’s concussion protocol keeps players with a known concussion out of play and practice for four to five days. I think increasingly a head injury is understood by players and coaches alike to be no different from an ankle or knee injury: the body needs ample time to heal before it is safe to use the injured area again. There are also now known long-term consequences to not letting the brain heal from a traumatic injury such as a concussion, leading all parties involved to respect our decision and follow our guidance.
What’s next for the field in understanding concussions and traumatic brain injury?
Grady: We need to be able to understand how many concussions puts a person at risk for long-term injury and disease; what age should kids be exposed to contact sports, whether it is football or any other contact sport such as field hockey, soccer and rugby; and we need better tools for diagnosing concussions. Imaging studies are now underway that hope to demonstrate the proliferation of abnormal proteins in the brain with each subsequent concussion or brain injury. I am optimistic that in five to 10 years there will be an identified, agreed upon brain or blood biomarker for concussions.
Concussion Research Underway at Penn
Here at Penn, Doug Smith, MD, director of the Center for Brain Injury and Repair and Scientific director for the Big 10/ Ivy League Consortium on Concussion, along with Robert Siman, PhD, a research professor of Neurosurgery, are some of the pioneers in identifying a blood biomarker—a protein which shows up at increased levels in the blood of concussed patients—that could signify a concussion. This protein, known as SNTF, is one hope at a better diagnosis, with better treatments to follow. Smith and colleagues from the U.K. recently published a paper on the history and legacy of traumatic brain injury.
Penn is also at the fore of research aimed to understand how these head injuries lead to a brain pathology similar to that of patients with Alzheimer’s, Parkinson’s and related dementias through the work of John Trojanowski, MD, PhD, director of Penn’s Institute on Aging, in collaboration with Smith.
Mind Your Brain!
Grady and Smith will also present at Penn’s 2nd Annual Mind Your Brain conference, Friday, March 4th on the Penn Medicine campus. Spearheaded by Candace Gantt, a traumatic brain injury survivor who was cared for at the Hospital of the University of Pennsylvania after a devastating bike accident, the free conference provides resources and information for TBI survivors, their families and friends that can help on the journey to recovery. This year’s conference will focus on veterans with traumatic brain injury and will also feature a TBI survivor’s panel and the latest in research and patient care from Penn neurotrauma researchers, neurologist, neurosurgeons, therapists and more.