Even a mild traumatic brain injury is still a traumatic brain injury

Football and military combat seem worlds apart in most ways, but they share a few commonalities. One is the devotion of players and soldiers to their teams -- in play or in battle, a soldier doesn’t want to let his team down.

Another link between these realms is a risk of significant, long-term brain damage from repeated mild brain injuries -- otherwise known as concussions.

As a medical officer for the U.S. Air Force and as a clinician here at Duke, neurosurgeon Gerald Grant, MD, has seen injuries from both fields, and although it’s unusual for neurosurgeons to focus on nonsurgical brain injuries, Grant and his colleagues at Duke are determined to find a better way to detect and treat them.

“When a severe traumatic brain injury occurs in a patient, there are well-established treatment guidelines we follow to help manage these injuries,” says Grant.

“But right now, out of 100 grade-1 concussions, we can’t tell who’s at risk for significant injury if they return to the game. And we don’t want to keep healthy players out of the game if we don’t have to.”

For those who are at risk, though, the consequences can be grave. “Those are the kids who get hit again and get significantly worse, or may even die. And you see one of those . . . you just never want to see that again.”

Most concussions -- barring previous concussions -- get better with time, usually within seven to 10 days. So it’s not worth it to be too aggressive with treatment, says Grant -- since with physical, mental, and emotional rest, most patients will get back to normal function.

The trick is to determine, sometimes in the heat of play, when a mild concussion has occurred. Many of these injuries don’t have clinically detectable symptoms -- at least not right away -- and even a brain scan would be normal. But the injuries may still be there.

Grant and Duke neurologist Danny Laskowitz, MD, are developing a blood test that could detect biomarkers that signal the presence or absence of a brain injury. “It’s still in the investigational stage,” Grant says. “There’s still a lot to understand for this test, because it needs to be very sensitive so that we do not miss any injuries. It also might not be just one blood marker we’re looking at; it might be a panel of five.”

Current concussion testing for soldiers and athletes begins with the physical assessment on the field. Protocols have shifted since the days of sending players who are symptom-free back into the game, says Grant.

In cases where the injured player shows no obvious symptoms, the current rules for re-engagement require that player to try exercise -- off the field -- to see if increases in heart rate and general exertion unmask symptoms. There are also neurocognitive tests available that can be given on the sidelines. These tests can be very useful, especially if baseline testing is available.

“There’s a lot of pressure on coaches to keep athletes in play,” says Grant. “And the players themselves often underreport symptoms. Combat soldiers are no different and often will downplay their symptoms since they don’t want to leave their comrades. I believe that we can really make a difference by finding better tools to detect these injuries -- to be proactive and keep these kids out of play until it’s safe.”