09:24pm Thursday 21 September 2017

Questions for Dr. Neha Raukar – Expert hopes Concussion spurs recognition of problem

PROVIDENCE, R.I. [Brown University] — The Christmas debut of the movie Concussion, which chronicles a scientist’s persistence in bringing consequences of head trauma in football to the public’s attention, may motivate more people to take sports head impacts more seriously, said a Brown University expert.

Dr. Neha Raukar, assistant professor of emergency medicine, works with concussed athletes from Brown and elsewhere. In 2013, she co-authored an influential Institute of Medicine report on youth sports concussions.

She spoke with David Orenstein about the potential impact the movie could have in motivating athletes and those around them to seek timely diagnosis and treatment. She also discussed the state of concussion research.

What do you hope people will think about after they see the movie?

I’m hoping that the movie will elevate the level of discourse about concussions. I hope that people understand that this is not an injury to not report and that it leads to long-term effects. People should be honest about their symptoms. Parents should encourage their child to be honest about their symptoms and parents should encourage their child to be evaluated if there’s any question of a concussion. There are still parents out there who don’t believe in concussions, who don’t believe it’s a real problem, who don’t believe that their kids can have one. I’m hoping that this will maybe convince them that this is a real problem and it should be taken seriously. Parents take ACL tears seriously and shoulder dislocations seriously. This should also be taken seriously.

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Concussion research
at Brown

What progress have we made since this became such a high-profile issue in recent years?

All 50 states now have legislation so coaches are educated on concussions and if they suspect one has occurred they pull the athlete from play to have them evaluated. That’s a big step. Parents are also becoming more educated. Referees are becoming educated and are calling kids out even when the coaches aren’t looking or the parents aren’t aware. There have been many sports where they have limited the number of contact days. This is fundamentally sound risk aversion. Now we’re not putting the child or the athlete in a position to sustain a concussion, so that’s helped reduce the number of injuries. We’ve done that at Brown. Proper fitting athletic equipment has also helped to reduce injury in general. There is more of a focus on proper technique, which has reduced injury.

Physicians and healthcare providers in general are becoming more aware of the injuries. Research in this field is evolving at a really rapid pace. There’s a subset of physicians and healthcare providers who are staying abreast of this literature and trying to disseminate information as quickly as it is being put out.

Has there been progress in treatment? What do you recommend to patients?

I’m noticing that patients are coming in earlier, and we are noticing that, like any injured body part, the brain responds better to prompt treatment. It has been enormously helpful that patients are coming in just with a suspected concussion, not even waiting for the diagnosis or for a couple of weeks.

A concussion is unlike a broken bone. With a broken bone, the injury occurs and the bone is broken. The damage is done. A concussion is a complex brain injury with the impact being the beginning of a chain of events. Thus, with a concussion, symptoms may not appear hours or even days after the injury. So any potentially concussive injury requires moving the athlete from play, caring for the athlete appropriately both acutely and during recovery, and then returning the athlete to play only when [the athlete has] demonstrated recovery and is no longer having symptoms. The individualized treatment plan often includes physical and mental rest as well as active brain rehabilitation. There is no standard or universal level of the duration of rest that’s needed, so patients are best treated with an individualized approach. We know that athletes who return to play before their brain has fully healed places them at increased risk for reinjury, for prolonged recovery, and for more serious consequences like second impact syndrome.

What new research excites you?

The explosion of interest in head injury is mirrored by the explosion in research. Current research can be broken down into prevention, diagnosis, and treatment. A lot of people are looking at diagnostic tools. Right now, concussion is a clinical diagnosis. We still don’t have the magic diagnostic tool, the biomarker. This could be a radiographic tool where we can just “see” the concussed brain, or something else. I think what’s going to end up happening is we’re going to have a panel of biomarkers, not just one thing. It’s interesting to see what the changes are of different proteins in various body fluids like blood, cerebral spinal fluid, and urine. It’s interesting to see what those panels may look like.

Also interesting are these sideline diagnostic tests. People trying really hard to find the right combination of tests on the sideline to help diagnose a concussion. We are currently exploring changes to the visual and balance system, hoping they give us clues to the diagnosis. … Now there are apps out there to try to help anyone, even lay people, diagnose concussions.

Research in treatment takes a longer time to establish. There are ideas that subthreshold exercise will help recovery. To date, there are no medications that actually heal the brain but there is some exciting research in the use of glutathione as a free radical scavenger. Research is a slow process and we’re still working on it.

Prevention involves equipment technology and rule changes. Technology has yet to identify a means to really effectively reduce the movement of the brain within the skull. However, the demand for equipment that can change the forces responsible for a concussion fuels research in this area. Changing the rules to limit the number of days the athletes can hit each other has resulted in fewer injuries. Having a medical professional on the sideline to help identify athletes is also helping to reduce the rate of missed injuries.

Good research requires good data. Different states are looking at creating their own registries because we don’t have data on how concussions affect youth athletes. We don’t have prospective data on what happens to a concussed athlete 20 years from now. The NCAA is creating a database and will follow kids through their careers and through their lifetimes to see what happens. The chronic traumatic encephalopathy that the movie talks about is all retrospective. It was taking out the brain of a dead athlete and trying to make the puzzle pieces fit, but when we do it prospectively we can speak intelligently about cause and effect.

What’s the most important thing we should be doing now to protect athletes’ health?

I think there are three things.

First is education. Knowledge is power. I think you educate the athlete and everybody the athlete is exposed to. So not just their coach, their parents, or their doctor, but I think the next level is to educate the school systems where the kids spend the great majority of their day.

Second, it is really important to make this diagnosis early. In Rhode Island, often this burden is placed on coaches and parents as most students do not have access to an athletic trainer. This is different from most other states — for example Pennsylvania, where 90 percent of the high schools have an athletic trainer. We need to put a medical professional on the sideline to protect our athletes.

Finally, realize this is not just a problem in athletes This is a problem for anybody. Anybody can get into a car accident, anybody can fall off the monkey bars. So this is a problem across the board and I think the movie will do a great job of elevating the level of discourse for all people. When in doubt, get checked out.
Note to Editors:
Editors: Brown University has a fiber link television studio available for domestic and international live and taped interviews, and maintains an ISDN line for radio interviews. For more information, call (401) 863-2476.

Contact: David Orenstein   401-863-1862


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