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Breakthrough Magazine

Heading in the Right Direction

Virtually every sport involves intended or unintended contact, and with that comes the inevitable risk of an injury that is getting well-deserved attention at the moment: concussion. In the medical and scientific faceoff against this form of traumatic brain injury, the University of South Carolina has developed an extensive playbook to achieve success.

Sports aren't a uniquely American pursuit, but there's something to be said for the range of options available here. If you're not into basketball, football, soccer or baseball, there's always lacrosse, ultimate Frisbee, hockey and rollerball — and plenty more, in all sorts of professional, semi-pro and recreational settings.

Every one of these sports involves intended or unintended contact, and with that comes the inevitable risk of an injury that is getting well-deserved attention at the moment: concussion. In the medical and scientific faceoff against this form of traumatic brain injury, the University of South Carolina has developed an extensive playbook to achieve success.

Building a network

In 2001, USC Sports Medicine physician Dr. Jeffrey Guy founded an innovative program for extending the university's reach to athletes of all ages: Sports Medicine for Athletes and Recreational Teams, or S.M.A.R.T.

An assistant professor of clinical orthopaedic surgery, Guy often deals in the operating room with the after-effects of athletics gone awry, and with the S.M.A.R.T program he brought his department, the College of Education and the Department of Family and Preventative Medicine together to get ahead of the game, both to prevent injuries and to diagnose and deal with their effects quickly and appropriately.

Twenty Midlands-area high schools, most with partnering middle schools, now participate in the program, which provides medical pre-screening for athletes preparing for varsity and lower level sports. It also puts USC athletic trainers on the fields of play and makes accelerated care available for those who are injured.

Youth monitoring through the S.M.A.R.T. program is in addition to USC Sports Medicine's coverage of not just the hundreds of student-athletes on campus, but also the club, intramural and recreational student population. And their reach also extends to Benedict College, S.C. State, Columbia College, Claflin University, Columbia International University and a consulting role with Coastal Carolina, Lander College, Coker College and USC Aiken.

With that kind of access to central South Carolina's sports world, the primary care physicians tasked with concussion care, Dr. Matthew Pollack and pediatric specialist Dr. Jeffrey Holloway, have their hands full because concussion diagnoses are growing in number.

Getting in the field

More concussions is actually good news, though, because the uptick in cases is thought to reflect an increase in proper diagnoses rather than an actual increase in concussion incidence. Better diagnostic results reflect, in part, the success of programs like USC's Department of Athletic Training, which is part of the College of Education and works closely with USC Sports Medicine.

We look at what it takes to get a concussion, and when we have these devices on the kids for an entire year, we can look certainly at the magnitude but also the frequency of the impact.
— Jim Mensch, Director, USC Athletic Training Program

With more than 200 undergraduate majors, it's one of the largest athletic training departments in the country, and the master's-level program boasts 40 graduate students. With those numbers, the program is able to place athletic trainers and clinical trainees on all sorts of fields of play, from youth leagues to USC's intramural competitions to football practices and Williams-Brice Stadium on game days.

On-field assessment of head injuries gets players to medical experts quickly, which has literally proven to be life-saving. Several years ago, ESPNU produced a documentary on Caleb Lott, a certified athletic trainer and USC graduate student working the sidelines of a high school football game who swiftly assessed that a player had sustained severe brain trauma.

The player was directed to Palmetto Health Richland in Columbia, which had a trauma team capable of identifying a brain bleed in progress and saved his life with an emergency operation.

Adapting new tactics

Near-immediate assessment is just one means of getting better concussion treatment out into the real world, and USC is pushing forward on another front: research to develop better prevention methods and improved treatments.

Jim Mensch, director of USC's athletic training programs, is leading a research effort that places small accelerometers behind the ears of youth football players and follows them over the course of the season.

"We are part of six states in a large study," Mensch says. "We look at what it takes to get a concussion, and when we have these devices on the kids for an entire year, we can look certainly at the magnitude but also the frequency of the impact."

They're also able to correlate concussions with other variables. In age-restricted leagues, for example, there might be a 200-pound 12-year-old facing off with a 75-pound 12-year-old. In weight-restricted leagues, two players might be the same weight but differ by three years in age and maturity, and the research data can help organizers determine the safest way of matching up growing kids of all sizes and skill levels.

"Something else we're looking at this year is coaches," Mensch says. "There's a program for USA Football, called Heads Up, that teaches coaches how to design practices with certain drills that show them the right technique, teaching the kids not to lower their heads. We're looking at how the players do with coaches who have gotten certification versus those that haven't."

Developing new strategies

USC researchers are also looking even further down the field for innovations.

"With concussion, therapies just don't exist other than rest," says Troy Herter, an assistant professor in exercise science. "We assume that rest will help, but compare that, say, to someone who comes in after having a stroke.

"Both involve brain damage. For stroke you want to get them out of bed, moving around, going to rehabilitation as soon as possible. The longer you wait, the worse the outcomes tend to be, but you take the complete and total opposite approach with concussion."

Herter is leading a group at Carolina collecting and analyzing data in a pilot concussion study. It builds on his years of research on stroke, an ailment that is different from concussion but, Herter says, does share many similarities.

Finding effective treatments requires better ways of determining which brain functions are affected by a concussion and to what degree. USC physicians are trained to administer the ImPACT test, a concussion assessment based on a roughly 25-minute computer exam that includes word and shape memory recall, speed in finding consecutive numbers randomly displayed on the screen and a series of questions about how the patient feels physically.

"The ImPACT test is not an end-all be-all, but it gives us an extra tool to assess and evaluate," says primary physician Holloway. "It can, for example, pick out that subset of the population that feels better, but their brain isn't quite back yet."

Herter and his USC colleagues are taking an approach that goes beyond ImPACT, which is largely a cognitive test, using what are essentially video games designed to differentiate a user's sensory and motor systems. Subjects interact with virtual objects through a robotic interface that simultaneously tracks hand and eye movements. This allows the researchers to quantitatively measure performance during increasingly complex tasks requiring skillful coordination.

The scientists can then break down the results to show whether there are specific deficits in seeing, in moving or in thinking that might underlie a person's inability to match their previous "high scores."

Being able to carefully measure all three systems, rather than just cognition as in the ImPACT assessment, the researchers hope they can develop new concussion therapies down the line, Herter says.

"People will come in after a stroke and they'll go through batteries of tests that say they're fine. Then they'll fill out a questionnaire and it's a different story," Herter says. "They say they have trouble driving the car or performing other daily activities. They'll say, 'I'm just not what I used to be,' but they may still get a clean bill of health.

"A similar situation might exist with concussion, but athletes will lie in order to return to the field of play. By developing objective assessments that mimic complex activities like sports, we can hopefully improve our ability to determine whether an athlete is actually ready to return to play."