University of Michigan researchers, athletes playing a key role in massive study on causes and effects of con – MLive.com

Jada Dayne knew something wasnt right after she banged a soccer ball off her head during a match two years ago.

The then-University of Michigan junior was focused on covering an opposing player when the ball struck her on the side of her head unexpectedly. She tried to shake it off as play continued, but just moments later, the ball was headed back her way, and she instinctively headed it back upfield -- just like she had done numerous times per game as a defender.

Immediately, she felt dazed and took herself out of the game.

I wanted to wait for a sub, but I was sitting there, like, Wow, Im not good," Dayne told MLive in a phone interview. I literally ran off through the opposing teams walkway. It didnt matter to me; I (needed) to get out. I was like, Im about to throw up.

Ive had plenty of these (concussions), but this time (was) so different. I normally had never thrown up. That was the only time I threw up from concussions.

Dayne, who played at Michigan from 2016-19, doesnt know the exact number of concussions she had during her soccer career but said it was at least four or five. Typically, the only symptom associated with her injuries was a headache for a few days. But this last concussion was different.

Not only did the Waunakee, Wisconsin native have to sit out athletics for multiple weeks, but her daily life was also affected. She struggled to form a complete thought while speaking, and focusing in the classroom became a vexing task.

Like I could be looking for the word pencil, and I could have a whole sentence, and in the middle of a sentence, like I wanted to say pencil, but I couldnt remember the name of it, Dayne said. "If youre supposed to be learning new things, you could be present in the classroom, but you could also not be mentally present. Its very hard to explain to people. Like how is it that Im listening, but I just cant comprehend in that moment?

Thats probably one of the more frustrating parts. You dont feel like yourself.

Jada Dayne during her Michigan career. (Photo used with permission from Michigan Photography)

Now, a massive research study involving University of Michigan researchers and athletes, as well as researchers and players across the country, is looking to better understand issues involving traumatic brain injuries.

Dr. Steven Broglio, a professor of kinesiology and the director of the Michigan Concussion Center, has seen his fair share of violent hits in football and hockey in his 20-plus years studying traumatic brain injuries, but not all of them have resulted in concussions. He also has witnessed many innocuous plays in non-collision sports lead to concussions.

The NCAA and U.S. Department of Defense launched a massive study in 2014 that includes thousands of participants from 30 colleges and military service academies across the country. The NCAA-DOD CARE Consortium is a primary element of the to-date $67-million study that involves two components: a clinical study core, which aims to define how symptoms and physical signs manifest and evolve over time in different people, and the advanced research core, which seeks to identify how the brain is affected from head impact exposure.

Broglio estimated that about 300 people are working on the study in some capacity, including about 30 at Michigan.

Spearheaded by Broglio, Michigan is leading the clinical study. According to the latest publicized numbers from the CARE Consortium, more than 44,000 student-athletes have participated in the study with data captured on over 4,300 concussions. However, Broglio said the study has now enrolled close to 55,000 student-athletes with about 5,500 recorded concussions.

He said about 90 percent of student-athletes at Michigan are enrolled in the CARE Consortium. Each athlete takes a baseline test when they arrive on campus as freshmen. Staff gathers personal and medical history from each athlete before putting them through tests that gauge cognitive function, balance and memory.

Michigan Concussion Center director Steve Broglio and Griffen Feinberg watch Allyssa Memmini perform a concussion test. (Photo used with permission from UM photography/Katie Alexis)

After an athlete suffers a concussion, they will retake the test, giving clinicians and trainers the ability to compare the data to the athletes baseline. The focus of phase two of the study, Broglio said, is to see if and how athletes change over the course of their college career.

"We have all this data of the athletes and cadets from when they enter the study as freshmen, and now we are getting data on what they look like as they're walking out the door," Broglio said. "Do concussions alter the way they function? Do head impacts without concussion alter the way they function? Or just participating in your sport change the way you function? What do four or five years of sports exposure do to the athlete, and is there a detectable change at that point? It's kind of a short-term snapshot of long-term effects."

Since March, Broglio said they are no longer recording new concussion data but rather focusing on interview student-athletes as they graduate. While the coronavirus pandemic has forced the doctors and researchers to work remotely, they can still talk with student-athletes virtually.

Broglio said the plan is to move into phase three in spring 2021, which will incorporate annual online follow-ups with graduated athletes to monitor their brain health until they die.

"That is the big vision," Broglio said.

Key preliminary findings

While Broglio understands it will take decades to truly gain an understanding of long-term effects of head injuries, he said he is encouraged by the preliminary findings. Researchers have already published dozens of papers from their data.

"I think the misconception that comes with a study like this is that we collect data for 30 years, we publish one paper at the end, and we're like, 'OK, here's the answer.' It just doesn't work that way. It's more about small findings along the way, and do those findings add up or all point in the same direction? And that's not just our study. It's also what are other people from around the world doing? Are we all kind of pointing at the same thing? You're approaching it from different angles, but kind of coming up with the same answer. When you have that consensus around kind of a unified answer, that's when you go, 'A-ha, this is the new knowledge. So while I think we're doing great work, our work is not the only work being done in this space."

What differentiates the CARE Consortium to previous concussion studies is the massive cohort of athletes examined across multiple sports.

In the past, Broglio said, studies were mostly focused on men's collision sports, such as football, hockey and lacrosse. Now, whether it is a female soccer player suffering her first concussion or a football player suffering his fourth, clinicians will have baseline data for both to compare and see if they recover at the same rate.

Of the recorded concussions in the CARE Consortium so far, about 40 percent are female athletes, despite not being involved on collision sports. But according to Datalys, which tracks NCAA injury data, women's ice hockey -- a contact but not a collision sport -- had the third-highest concussion rate among NCAA sports between 2009-10 and 2013-14, trailing wrestling and men's ice hockey. Women's soccer was fifth, ranking just behind football.

"Women definitely get concussions at higher rates than men," Broglio said. "When you look at comparable sports, no one is exactly sure why, but neck strength is one possible factor. Women have smaller neck strength relative to head mass, so when they get hit, they're not able to stabilize quite as well. Then, in my opinion, probably the single biggest factor is women are more honest in their reporting."

While women might be more inclined to report concussion symptoms, Broglio said men have come a long way in becoming more forthright in reporting symptoms.

Broglio and other researchers with the CARE Consortium conducted a comparative analysis of college football players from the CARE Consortium data from 2014-17 to the NCAA Concussion study from 1999-2001. They found that concussion in college football is managed more conservatively than 15 years ago, with improved clinical management and return-to-play protocols, and more honest reporting from athletes cited as key factors, Broglio said.

Based on the data analyzed from the 701 football concussions from the CARE study and the 184 concussions in the NCAA study, CARE athletes were withheld from play for an average of 16 days after injury -- nearly 10 days longer than concussed football players in the earlier NCAA study.

Because of the more prudent approach, the rate of same-season repeat concussion in CARE was 41 percent lower than the NCAA Study, and CARE athletes were at significantly lower risk of repeat concussion within the first 10 days after initial injury.

Since 2015, NCAA-member schools must submit their policy for detecting a concussion and return-to-play protocol for NCAA approval. After an athlete is diagnosed with a concussion, they must complete a multiple-step process before returning to game action:

1. Symptom-limited activity.

2. Light aerobic exercise without resistance training.

3. Sport-specific exercise and activity without head impact.

4. Non-contact practice with progressive resistance training.

5. Unrestricted training.

6. Unrestricted return-to-sport.

Each step typically takes at least 24 hours, and a physician must sign off before the athlete can return.

"The athletes are reporting symptoms for longer, so they're not suppressing, 'I have a headache,'" Broglio said. "It's game day and they have a headache, they're more likely to report that now. The other thing that's happened is we have this mandatory gradual return to play that takes, I think six or seven days depending on how you work through it. That just didn't exist in 2001, so that combination of this longer reporting period of three or four days for symptoms, and then this add-on of six or seven days of this return-to-play progression, that's where those 10 days kind of come from.

"Back in 1999-01, when that first study was being conducted, somebody would have loss of consciousness, and you would put him back on the field same day. Somebody walks to the wrong sideline because they got hit, you would chuckle and be like, 'Oh, Johnny Ron walked to the wrong sideline, let's bring him back and put him back in the huddle.' I'm not so bold to say it never happens anymore, because certainly mistakes are made, but it just doesn't happen today."

Research drives best practices

Michigan Senior Associate Athletic Director Darryl Conway, who oversees student-athlete health and welfare at the university, said most Wolverines student-athletes return to play within seven to 14 days after initial injury, but noted that is not always the case.

He said new research from Broglio and the Michigan Concussion Center continues to drive best practices on the front lines of student-athlete care.

Before every school year, Conway and his staff will conduct a health and safety presentation to all Michigan athletes and coaches, with a large segment dedicated to concussion.

"I think they really inform us well," said Jake Slaker, a forward on Michigan's hockey team who just completed his collegiate career last season. "I think they do a good job of just informing us what to look out for. At the end of the day, it is one of those things where you can't really diagnose it. You can't really just take a test like an MRI and be like, 'oh yeah, you have a concussion,' like you can with a broken bone or whatnot. They do a good job of informing us what the symptoms could be, whether that is minor or to the extreme. I was lucky enough to never have suffered a concussion at school, but some of my teammates did. Our training staff and our coaches did an unbelievable job making sure the kid felt back to normal before he could even think about skating again."

While CARE researchers are studying blood biomarkers and the use of MRIs in the diagnosis of concussion, there is no current gold standard test for concussion, meaning it remains a clinical diagnosis.

That puts added responsibility on the student-athletes to be honest in their reporting. With a large number of former NFL players who have been diagnosed with chronic traumatic encephalopathy, or CTE, in the past decade, most athletes have a better understanding of possible long-term consequences if they do not take proper precautions after suffering a traumatic brain injury, said Phil Johnson, director of athletic training for Michigan's football team since 2000.

"The whole concussion leads to CTE leads to suicide, I don't know if there's direct lines to those, specifically --I don't think there are -- but that's one of those things that has helped get athletes where they need to go a little quicker as far as taking care of things," Johnson said. "You have a teammate that really gets concussed and they see the guys that take it seriously and how well those may go versus a guy that kind of keeps sloughing it off and doesn't think they have a problem. Then they don't take care of themselves well and you see these post-concussion syndromes and things that really take time to resolve. Those are some of the examples that I think the players really pay attention to."

Nevertheless, there will always be athletes who try and mask certain symptoms in order to try and return sooner. Dayne said that is why the return-to-play protocols are so vital.

I think the thing is with the protocols is, its not the fault of the people that are giving it to you (doctors and trainers doing the examinations), its the fault of the players that are really so eager to go back to play, she said. A lot of it is based on how you feel, except for the physical test. Like if youre dizzy, you cant do nothing about that one. I tried to get away with it a bunch of times, and then they try me on the physical test, and I failed faithfully.

Dayne credits Michigan womens soccer trainer Mike Hickey for being stringent with her during her career.

He wants to see us out in the field as soon as he can, but he wants to see us out there healthy, which is one of the greatest but most annoying things, she said. "I got annoyed one time. He said I had a concussion, but I felt great the next day. But the day before I couldnt balance on one foot and I couldnt remember what they were trying to tell me in terms of numbers (memory concussion test), but I felt great the next day.

He laughed at me, like, Haha, no (you cant play).' But youre mad because you want to play the sport you came there to play, you know?

Conway said Michigans entire staff is also well adept at spotting and diagnosing concussions. There are 34 athletic trainers in the department.

During a football game day, Johnson is on the sideline, along with the team's head physician, Sami Rifat, and another physician. Michigan also has a trainer watching from the booth to monitor the game from above. Johnson said there are also a handful of student athletic trainers on the sideline to assist. While Johnson's staff is also observing for other possible injuries, he said it catches about 80-90 percent of suspicious hits that happen in real time.

"It's a sledgehammer," Johnson said. "Any big hit that anybody sees, we will follow up as a guy comes over (to the sideline), 'Hey, any issues?'" Johnson said. "You get a pretty good sense of looking at a guy's eyes -- we see these guys every day hours a day throughout their careers, so you have a pretty good idea by the time they're playing in Michigan stadium of what they look like, how they respond, and what's normal. And when that's not normal, it stands out to you. Then we'll get them to the physician."

Johnson has been at Michigan throughout the evolution in concussion research over the past two decades. He said the biggest change has been more active dialogue between coaches, athletes and medical staff. College athletics -- football in particular -- is a billion-dollar industry. Coaches want their best players on the field at all times, and a few plays with a top player on the sidelines getting evaluated for a head injury could have significant ramifications on the outcome of the game.

"The coaches no longer apply that pressure (of clearing players to return to the game)," Johnson said. "I'm speaking from my experience, coach (Jim) Harbaugh has never pressured me to put a guy, who we think could have a concussion, back in the game. I'm not even just blowing smoke there. I have never seen it, but that is a little bit intrinsic, right? At the end of the day, wins and losses are important, but really the student's health is what our focus is.

"As time has evolved, I mean there's enough nightmare stories in the media for us, or that we hear from other student-athletes and other staff, that would be a big problem."

Future of concussion safety in athletics

Sports leagues across the globe continue to update rules to improve players safety. At the college level, the NCAA has implemented several new policies in the past decade to help protect athletes. Just in football alone, it has moved the kickoff location to the 35-yard line to encourage more touchbacks, implemented a new targeting rule that includes the disqualification of the offending player and banned two-a-day practices after finding 58 percent of the football practice concussions over the course of a year occur during the preseason.

Broglio said the CARE Consortium reports its research findings to the NCAA and the organizations Chief Medical Officer, Brain Hainline.

"Once we submit an abstract or paper and it gets published, then we make sure that that information gets back to them so they have the data they need to inform policy," Broglio said. "I, along with some other people in the study, have sat in on some policy meetings just to provide information so they can make those decisions. Brian Hainline is a very clearly data-driven guy. He wants the best, the most up to date information so he can make informed policy decisions."

While new rules and advancements in equipment technology have helped make athletics safer, Broglio said there will always be risks when playing sports. That is why proper diagnosis and management is so important.

I dont think we will ever eliminate concussions from any sport, he said. Its just nature of human condition -- if youre going to participate in any physical activity, then youre going to be at risk. I think there are things that have been done that have improved concussion risk in management for that matter, but I still think theres a lot of room to go.

For Dayne, she has no regrets about playing college soccer, despite suffering multiple concussions. Although she said she sometimes struggles to think of a certain word or two while speaking, she believes she has fully recovered from her concussions. She just wishes she had the knowledge she has now before she arrived at Michigan.

At the end of the day, Im good, she said. Im healthy and I cant complain. I really did have great treatment. It was just, I think that prior to coming into college, high school never asked you if you ever got a concussion. And thats not just high school sports, thats club sports, too. And I feel like I might have gotten a couple prior to then. So college was asking me like, Sometimes do you feel like this or this,? Im sitting here like, Wow, I felt like this so many times before now, but nobody has ever asked me about those. And I dealt with it on my own and continued playing. So I feel like had those things been addressed earlier, it never would have been an issue.

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University of Michigan researchers, athletes playing a key role in massive study on causes and effects of con - MLive.com