Dr. Andy S. Hipskind, chief medical officer for IU Athletics (left); School of Optometry assistant professor Nicholas Port (center) and IU football neurological consultant Dr. Terry Horner (right) at a recent IU football game.
BLOOMINGTON, Ind. – As football and other contact sports face mounting concerns over the cumulative effects of concussions, two Indiana University scientists continue their work on a portable, sideline device that can quickly detect signs of mild brain trauma.
Since 2010, Nicholas Port and Steven A. Hitzeman of IU’s School of Optometry have gathered baseline data on the eye movements and balance of IU athletes, as well as athletes as Bloomington North and South high schools and local club and youth sports. To help develop their device, the duo received a pair of two-year grants in 2014 – one valued at $429,000 from the National Institutes of Health and the other a $120,000 award from the Indiana Spinal Cord & Brain Injury Research Fund.
To measure concussion symptoms, Port devised a system that consists of eye-tracking goggles within a self-enclosed, shoebox-sized device and a balance platform based on technology in Nintendo’s Wii gaming system. By comparing an athlete’s baseline numbers with similar tests after a high-impact blow, testers can quickly determine whether an athlete suffered a concussion and should be withheld from competition.
So far, data on more than 1,000 athletes — as well as 69 concussions – have been collected, about two-thirds of which came from football, Port said. Although there is not yet enough information to produce statistically valid conclusions, the preliminary results are sobering.
“They show that some ocular and motor performance can be severely impaired during the acute phase of a concussion, which is the first 10 minutes to an hour after a concussion occurs. When possible, we like to test the affected athlete within 10 minutes of the event,” Port said.
Such findings also indicate age- and gender-based differences in how long it takes to recover from a concussion, Port said. To help determine such findings, Port and Hitzeman consulted with Dr. Terry Horner, an IU-trained neurosurgeon at Methodist Sports Medicine in Indianapolis who serves as a neurosurgical consultant for the Indianapolis Colts and IU football.
Amanda Madsen (left), Billy Means (center) and Dr. Steve Hitzeman (right) perform baseline eye-movement and balance tests on an IU athlete.
“We’re seeing recovery times for a college athlete typically range from seven to 11 days, while with high school athletes, it takes almost twice as long. We also see that female athletes generally take longer than males to recover,” Port said.
“Why do we see that? It probably has to do with differences in upper-body strength. If you can anticipate a heavy impact, you can contract your upper cervical segment and transfer more of the impact force to the entire body, rather than subject your head to rapid acceleration and deceleration. The stronger you are, the more impact you can manage.”
Once fully refined, such technology could help eliminate scenarios such as what occurred Nov. 22, 2015, in an NFL game between the St. Louis Rams and Baltimore Ravens when Rams quarterback Case Keenum was sacked and hit his head on the turf.
Despite the Rams sending their head trainer on the field to talk with Keenum — and the presence of an NFL injury spotter at the contest — Keenum remained in the game. He was sacked again two plays later and fumbled the ball. Only after the game was it found that Keenum had suffered a concussion.
“The research being conducted will add an objective approach to this problem by developing a device that not only measures symptoms on-site, but eliminates an athlete’s ability to fool athletic trainers, physicians and coaches into thinking they are fit to play,” Port said.
In some cases, athletes may not be aware they sustained a concussion until days after the fact, said Orlin Watson, head athletic trainer for Bloomington North High School, which had about 15 students take part in the study during the past two years.
“We explain to our student-athletes what it feels like to have a concussion and why it is important to report symptoms,” Watson said. “But you’re still dealing with subjective information. A device that can provide objective, unbiased information would serve as a valuable tool for athletic trainers in treating and diagnosing concussions.”
Dr. Andy S. Hipskind, senior assistant athletic director for sports medicine and chief medical officer for IU Athletics, concurred:
“A portable, on-site tool such as this will potentially benefit all athletes by taking some guesswork out of concussion management and prevent further possible injury through better decision making on whether an athlete returns to playing in the immediate competition.”
The eyes have it
The link between concussions and degenerative brain trauma stems largely from the
work of forensic pathologist Dr. Bennet Omalu, now a clinical professor at the University of California, Davis. In 2005, Omalu and colleagues at the University of Pittsburgh linked chronic traumatic encephalopathy, or CTE, to the death of former NFL player Mike Webster. The finding was the basis of the recent movie “Concussion,” with actor Will Smith portraying Omalu.
CTE is a degenerative brain disease found in persons with a history of repetitive brain trauma, such as concussions. Since then, several similar cases surfaced among deceased NFL players. The NFL initially called for the paper’s retraction before acknowledging the CTE link in 2009 and making rule changes designed to reduce head injuries. Sanctioning bodies for college and high school football took similar steps as the dangers of concussions gained greater awareness.
Port’s research into concussions began shortly after meeting Hitzeman upon joining IU’s faculty in 2005. Beforehand, Port earned a Ph.D in neuroscience at the University of Minnesota and did his postdoctoral training at the National Eye Institute’s Laboratory for Sensorimotor Research.
Hitzeman, an associate professor emeritus of optometry, has a longtime connection to IU athletics that ranges from being a volunteer statistician to serving as team optometrist. Through that experience, Hitzeman offered an intriguing hypothesis.
We’re seeing recovery times for a college athlete typically range from seven to 11 days, while with high school athletes, it takes almost twice as long. We also see that female athletes generally take longer than males to recover.”
– Nicholas Port, assistant professor, IU School of Optometry
“He told me that he thought he could predict an athlete’s performance — literally who would do well and not as well — based on their eye movement,” Port said. “My approach to science is that everything is bogus until proven otherwise. But by 2008, we decided to do a longitudinal study.”
Initial analysis proved intriguing, as the first year’s data began to separate certain athletes — and teams as a whole — into distinct groups, Port said. But as they prepared to collect more data in 2009, growing concerns about sports-related concussions inspired them to shift their focus.
Starting in 2010, Port and Hitzeman spent the next three years gathering baseline data on IU athletes. Though they were able to document 30 concussions, several opportunities were lost.
“Sometimes it was as simple as folks forgetting to call us,” Port said. “We needed more boots on the ground. We needed trainers working with us that we could loan to the athletic department so we could have a constant presence among our athletes.”
After securing the NIH grant, Port and Hitzeman hired trainers Billy Means and Jon Wicks for permanent assignment to IU athletics. In 2014, an Indiana State Department of Health grant enabled the hiring of Amanda Madsen, who works with Bloomington’s high schools.
The additional funding not only enabled the collection of full data sets, but the development of several prototype concussion detection devices, which offered clues for refinement.
“We need to make them much smaller and lighter. Each unit weighs about 4.6 pounds and we would like to get that down to about 1 pound,” Port said. “We also want to change our balancing mechanism. Our current platform does not like soft surfaces, while a waist-mounted accelerometer provides a good approximation of when a person drifts away from their center.”
Although other scientists explore concussions, the focus that Port and Hitzeman place on the early phase of concussions puts them on the cutting edge of such research, Port said.
To stay ahead, the next step is to apply for new grants, upgrade the devices and conduct clinical trials, Port said. Eventually, they hope to commercialize a “cheap, easy-to-use and portable” concussion diagnosis tool with the aid of the Indiana University Research and Technology Corp.
IU researchers conduct outdoor assessments of young athletes’ eye movement and balance.
Other goals include identifying additional biomarkers that diagnose concussions, obtaining more data on recovery times and improved concussion protocol guidelines that athletes must complete before returning to action.
In 2013, a Chronicle of Higher Education survey found that nearly half of major-college football trainers have felt pressure from coaches to speed the return of concussed players to the gridiron. In 2010, an NCAA survey unveiled as part of a lawsuit found nearly half of responding universities said they returned athletes to the same game after a concussion diagnosis.
“Some schools are very conservative when it comes to protecting their athletes, but others may abuse them,” Port said. “When you see a player get hurt and leave the game showing signs and symptoms (of a concussion) after a blow to the head in the first half and they’re back out there playing in the second half, I question whether the current guidelines are being followed.”
So far, there have been mixed indications of safety improvements among NFL and NCAA players. According to a 2011 study commissioned by the NFL Players Association, kickoff-related concussions declined 43 percent between 2010 and 2011, which contributed to a slight drop in total concussions reported. In 2015, the NFL reported 36 percent fewer concussions since 2012 and a 63 percent decrease in player fines for illegal hits.
Yet in January, the NFL revealed that diagnosed concussions during the 2015 season increased 32 percent over 2014. A recent study in the American Journal of Sports Medicine also indicates that concussions among NCAA football players appear to have increased between 2009-10 and 2013-14, but that reporting improvements may be a cause.
NFL CONCUSSIONS SINCE 2012
- 2012: 261
- 2013: 229
- 2014: 206
- 2015: 271
Additional work remains in other sports such as hockey, wrestling and soccer, the latter of which has widespread youth participation, Port said.
“You just had U.S. Soccer reduce headers in practice for players between ages 11 and 13, yet they are still OK in games,” he said. “What exactly are the risks that are posed to a youth soccer travel team? We really need to get to the bottom of what the real risks are.”