A team of researchers led by Dr Clare Fraser and Dr Adrian Cohen at the University of Sydney is studying the causes, assessments and treatment of concussion in sport to prevent long term brain injury and death.
With no accepted, singular diagnostic tool for concussion, the team is working with Randwick Rugby Union Club to validate concussion tests that will aid the development of a more accurate system to diagnose mild traumatic brain injuries (mTBI).
The researchers have worked with the club for the past three years, collecting data from a range of tests including XPatch accelerometers attached to players, transcranial magnetic stimulation (TMS), cognitive tests, balance tests, salivary biomarkers and MRIs. So far this data has allowed researchers to compile baseline metrics that is improving the detection and diagnosis of concussion in players tested during and after games.
Dr Cohen says the aim of the research is to develop a set of objective tests and measurements to assist in the diagnosis and treatment of concussion.
“Concussion reflects the amount of energy the brain absorbs from an impact and can be very difficult to diagnose,” says Dr Cohen, an adjunct senior lecturer at Sydney Medical School and founder of Headsafe.
“Less than 10 per cent of people who suffer a concussion are knocked out and many symptoms are not apparent to those watching. We need to take the subjectivity out of it.
“Every impact and reaction is different for every player. There are a range of mitigating factors that can affect the likelihood of concussion. So far, international research has established that impacts that inflict G forces of more than 95G are likely to cause a concussion. However, multiple, smaller, cumulative impacts can also result in a concussion.”
Neuro-ophthalmologist Dr Clare Fraser of the University of Sydney’s Save Sight Institute is part of the team researching how the processing of information from the eyes can be used to diagnose concussion. She said the main issue when it comes to addressing concussion is its broad definition and underestimated danger to player health.
“Our main concerns regarding mTBI surround the lack of strong diagnostic criteria and that there are a lack of objective markers for diagnosis. Players risk serious health complications if they return to play too soon,” says Professor Fraser.
“They risk ongoing brain injury if they receive a second impact before recovering from the first. Players also risk long term degenerative brain diseases including chronic traumatic encephalopathy (CTE), dementia, personality/mood changes and psychological disturbance including depression.”
The goal for the researchers is to develop a test that can accurately and objectively diagnose concussion and be used by non-medical professionals at all levels of sport with a view to preventing long-lasting damage, especially to developing brains in children and adolescents. It is believed that visual testing may prove to be the most reliable, portable and easiest to implement test in schools and amateur sports.
“Unfortunately, only professional sports teams have doctors on the sidelines,” says Professor Fraser.
“We hope our research will improve the way concussion is diagnosed across all grades of sport and will make it safer for all players. In particular, we hope these tests can be used by sports trainers, coaches and teachers to guide them on when to remove a player from the field and send them for assessment and possible treatment.”
The need for a uniform concussion test in rugby and other sports has become more apparent in recent years with former players from the National Football League in America suing the code for repeated head injuries they claim have left them with long-lasting effects. In Australia, former National Rugby League player for the Newcastle Knights, James McManus, is suing his former club for allegedly failing to properly manage a series of concussions over his career.
The issue has been made more serious by the deaths of several junior players around the world from Second Impact Syndrome. The players died following a second blow to the head before they had fully recovered from a previous concussion, causing the brain to swell catastrophically.
Dr Cohen said that while sporting codes in Australia (including Australian Rugby, the NRL and AFL) are talking tough on concussion, more needs to be done to appropriately address it.
“Policy is only as good as its enforcement. We’ve recently seen incidents in professional sport where it was clear to spectators that a player was concussed yet allowed to remain on the field by medical and coaching staff. That is dangerous to a player’s health and, as has been seen in the past, can lead to significant adverse health consequences.”
Dr Philip Boughton at the University of Sydney’s Faculty of Engineering & Information is working with Fraser and Cohen to develop a suite of technologies to better detect and assess traumatic brain injuries. Boughton and a team of PhD and Masters students are developing wearable biosensors to monitor impacts.
“We’re trying to build technology that can track and relay real-time data on the acceleration, deceleration and rotation of players’ heads and necks. We want these biosensors to indicate not only concussive single impacts but also tell us when several smaller impacts could add up to a concussion,” he said.
“At the moment we are in the prototype stage, however the plan is to implant this technology into a mouthguard. The hope is when a force that is likely to result in a concussion or brain injury is detected, the mouthguard will change colour or vibrate, alerting the player, training staff and referee to the injury.”
“We hope that by developing a mouthguard it will be something that will become available to players at all levels of sport – from amateur through to fully professional athletes,” says Dr Boughton.
Throughout the 2017 rugby season the research team will do a range of tests on players from Randwick Rugby, including ground-breaking visual tests that measure disruptions in the brain’s visual stimulus processing.
“We predict that if there is diffuse brain injury (concussion) that electrical impulses generated from the eyes will be reduced or slowed and this change can be measured using our technique,” says Dr Fraser.
“We hope this will provide a quick and reliable measure to diagnose concussion and also reveal when an injured player showing good recovery.”
Already Dr Fraser has found the wearing of tinted glasses has assisted some athletes to deal with light sensitivity arising from head injuries. She is also completing research into specialised reading exercises to improve concussion symptoms such as blurred and double vision.
Assisting with the testing and monitoring of the players is Castlereagh Imaging through the use of Magnetic Resonance Imaging (MRI) machines.
CEO of Castlereagh Imaging, Dr Julian Adler says the difficulty with concussion is that even MRI can fail to detect it but can be useful in ruling out other brain injuries.
“We’re still working on detecting changes in the brain that directly correlates to concussion and mTBI. MRI though is the most far reaching imaging resource we have and is useful in helping to exclude other brain injuries that could mask a concussion,” says Dr Adler.
“We are yet to establish a breadth of knowledge that allows us to diagnose concussion through the use of MRI, but we hope through this research we will help to lift the veil on mild brain injuries and develop clearer diagnosis criteria.”
Dr Cohen said the research team isn’t trying to “soften” sport but make it safer for athletes and educate sports teams and the community about head injuries.
“Sport has so many positive benefits but we need to ensure players are aware of the risks they are taking. We also need to increase our understanding to give participants and their families confidence that we are looking after them throughout their careers and after they stop playing.”
Dr Cohen is also the founder of not-for-profit charity Headsafe, and is extending a global Rugby Player Health Research Project to Australia. An online questionnaire covers general and psychological health, whilst specialised visual, TMS, MRI and biomarker tests on retired Australian rugby, rugby league, AFL, equestrian and non-contact athletes will add to this important international collaboration with centres from the UK, New Zealand and Canada.
Players can enroll at http://www.leedsbeckett.ac.uk/ukrugbyhealth/