The Concussion Assessment, Research and Education (CARE) Consortium was established in 2014 with a $30 million grant from the NCAA and Department of Defense. The institutions recently committed another $22.5 million to fund the second stage of the study.
Thomas McAllister, MD, chair of the Department of Psychiatry at Indiana University School of Medicine, leads the study’s administrative and operations center. He sat down to answer questions about what the CARE Consortium has learned so far and the vision for the next phase of research.
What has the consortium accomplished since it was established?
In the first phase, we were able to establish a national concussion research network consisting of 30 participating institutions across the country. We have been able to enroll nearly 40,000 student athletes and military service cadets in the study and have collected data on more than 3,300 athletes and cadets with concussions, making this the largest study worldwide to date of sport-related concussions.
Unlike other studies in the past that have focused predominantly on male football players, this study includes both men and women in all sports. In fact, a third of participants in the study are women. We are gathering more accurate data by assessing such a diverse range of students and cadets.
Talk about the importance of this network and the research taking place.
It is important to do research on concussions for a couple of reasons. In the first place, it is a very common event. Somewhere between 3 million and 4 million people a year have a concussion. That’s a lot of people who are sustaining a mild brain injury.
Secondly, in the past we used to think that pretty much anybody who sustained a concussion got better quickly. Over the years we have come to appreciate that, while that is true for a great number of people, there are a significant number of folks who have long-term side effects from a concussion. This is particularly true of people who may have more than one concussion or have repeated concussions.
The biggest concern of late has been that some people who have repetitive concussions, or are exposed to repetitive head impacts, may develop a neurodegenerative condition late in life called chronic traumatic encephalopathy.
The concern has been, How worried should we be? We have lots of youth who are engaged in contact sports associated with high rates of concussion. How worried do we need to be that they are going to have long-term effects of these injuries? There’s a lot of data that we need to generate to ascertain how big of a public health problem we have with concussion.
What have you learned so far?
Some of the initial findings that we’ve found of interest from the first four years of the study have to do with how long it takes to get better from a concussion. Everybody assumed from earlier data that you have a concussion and you’re back to normal within two weeks. It turns out that while that’s true for some people, the average amount of time it takes for people to return to play is really closer to three weeks or even four weeks.
The other interesting thing is that even when athletes tell us they’re all better, when you ask them to return to graded exercise protocols or sport-related activity, many of them will develop a recurrence of symptoms. Let’s say a football player was injured, and 14 days later they’re not having symptoms, they’re able to tolerate football-related activity and they go back in the game. When we study them with a variety of measures such as MRI and other brain scans, it turns out that we’re still seeing some residuals of the concussion. Even though the athletes may feel they are back to normal, their brain may not be completely back to normal.
Whether that’s a cause for concern is yet to be determined. But this idea that there may be a disconnect between when people think they’re recovered and when their brain says they are recovered is something that we’re pursuing more actively.
It also turns out that it seems to matter what sex you are in terms of how quickly you recover. It seems to matter whether you are injured in a varsity sport versus some other activity. Those are some of the issues that we’ve been studying so far.
We’re just at the point where a lot of data on biomarkers—things that we might measure in blood or in saliva—might be able to give us clues as to how severe their injury was, or whether a person is going to be someone who recovers quickly or takes a longer time to recover.
How will the second phase of the study be different than the first phase?
The next phase will pivot from a focus on the acute injury to determine if there are cumulative effects of concussion and/or repetitive head impacts.
Think about somebody who has engaged in a contact sport that is associated with repetitive head impacts. They’ve been doing that for years at a time. Maybe they weren’t even diagnosed with a concussion, but might there be some adverse effects from just hitting your head over and over again? There is some evidence in the literature that may be so, but it’s not from large samples, and it’s not enough to actually inform policy in a meaningful way.
In the next phase, we will not just be focusing on the athlete when they are acutely injured, but at the end of their career in college, or at the time of their graduation from college or a military service academy. We will do another series of assessments and compare the results in people who are hitting their head a lot and having multiple concussions, or even a single concussion; to two other groups:
- Other athletes and cadets who are not diagnosed with a concussion but have had repeated head impacts
- And another group of athletes who are not hitting their heads repetitively
We will be able to say how worried we should be about this question of more than one concussion and repetitive head impacts. I think that’s going to be really exciting and provide some useful information to inform the public health concern.
Why is the Department of Defense involved?
The study includes cadets from military service academies such as West Point, the Naval Academy, the Air Force Academy and the Coast Guard Academy. In fact about 40 percent of our participants with concussion are from one of these service academies. The wars in Iraq and Afghanistan made it clear that brain injuries, including concussions, were a very common problem for our military personnel. The Department of Defense was very interested in funding research that would help us learn more about brain injury and how to treat and prevent long-term effects of concussions.