photo of football player under concussion study What do the 300-pound National Football League players you watch on Sundays have in common with kids in youth sports? Plenty, when it comes to wanting to prevent head injuries.

Kristy Arbogast, PhD, Co-scientific Director of the Center for Injury Research and Prevention at Children’s Hospital of Philadelphia, is also an engineering consultant to the NFL Players Association (NFLPA) and part of the NFL’s effort aiming to reduce head injuries.

“What we’ll learn at the pro level — thanks to all of the NFL’s resources — will trickle down to kids,” Arbogast says. “The advances in material science and design will create a path to improved protective equipment for kids.”

What resources is she talking about? In 2016, the NFL pledged to spend $100 million to support medical research and engineering advancements to make the game safer. The league earmarked $60 million of that for what it calls the Engineering Roadmap, a program designed to better understand the biomechanics of head injuries in pro football and create incentives to improve protective equipment, including helmets.

Arbogast’s work with the NFL and NFLPA focuses on two areas: testing helmets every season to determine which ones provide the most protection and creating advanced sensors to track the severity of impacts to the head.

Up close with the Eagles

The goal for testing football helmets is to provide NFL players with scientific information to help them choose ones that offer the most protection. During the 2018 season, for the first time, the NFL and NFLPA prohibited players from wearing the 10 low-performing helmet models of the 34 tested. This means more than 200 players will move to helmets that have been shown to be better performers.

Arbogast and Eagles wide receiver Mack Hollins starred in an educational video for players, coaches and club personnel about helmet performance. The video is posted on the NFL website, PlaySmartPlaySafe.com.

Interestingly, data on concussions among NFL players — there were 291 reported concussions last season — correlate with the helmet testing: Players wearing higher-rated helmets had fewer concussions. “Though it must be said that no helmet can prevent all injuries,” Arbogast stresses.

Taking a bite out of head injuries

When it comes to monitoring the severity of hits to the head, Arbogast and her co-researchers at Biocore, a Virginia-based firm, determined no devices on the market met their specs for usability, accuracy and the ability to measure severe impacts seen at the professional level. Helmet sensors aren’t close enough to the head itself. They opted for an “instrumented mouthguard,” then developed a prototype that is being tested by the University of Virginia football team this fall and is being considered for a limited NFL pilot in 2019.

While mouthguards are not required in the NFL, 75 percent to 80 percent of players wear them. “The goal is to be able to accurately measure the motion and acceleration the head experiences during play — not to pull players off the field,” Arbogast says. “We want to measure differences by position. Offensive linemen could have more impacts, but less severe ones. A wide receiver might have two or three hits a game, but they may be of higher severity.

“Players already wear different shoes and pads depending on their position,” Arbogast says. “When we have quantitative data by position, we could design improved helmets that are position-specific.”

CHOP research aims to improve concussion diagnosis

Just as the pros have protocols to determine if a player has suffered a concussion, youth, high school and college teams also follow procedures to figure out if a player has been injured. However, current concussion diagnosis is largely dependent on each child’s self-reported symptoms, which are subjective. Do they feel foggy? Do they have a headache? Are they extra sleepy? Are they having trouble concentrating?

photo of a football player getting undergoing a test Arbogast and Christina Master, MD, CAQSM, a CHOP sports medicine specialist, are researching quantitative assessment tools, such as eye-tracking and devices that measure blood flow in the brain, to see if they can enhance the accuracy of diagnosing a sports-related concussion.

The five-year study measures balance, visual and auditory processing, and eye movements in healthy athletes before a season begins and again at the end. That data is then compared to measurements from children who come to CHOP’s Concussion Care for Kids: Minds Matter program for treatment of a suspected concussion. Male and female athletes from the Shipley School in Bryn Mawr, PA, have volunteered as the healthy control subjects.

“First we need to determine which of the assessments we are exploring — or which combination of them — help identify someone with a concussion and help characterize what type of deficits they are experiencing,” says Master. “Having this type of objective data can improve diagnosis, guide management, and hopefully predict how soon the child can return to school or to sports.”

Next step: better concussion treatment

The first line of management of concussion is rest. However, Master and her sports medicine colleagues recognize the amount and timing of rest and return to activity is unknown and likely different for each child.

CHOP is partnering with University of Buffalo and Boston Children’s Hospital in a multisite, American Medical Society for Sports Medicine study that is exploring the role of exercise to improve recovery from concussion. The first patients, age 13 to 18, were enrolled in July.

Questions they seek to answer include: How many days after a concussion should exercise start? What type of exercise? How frequently? How intense? For how long?

“Most patients recover from a concussion in about two to four weeks,” Master says. “It is possible that carefully prescribed and supervised activity after acute concussion may shorten the course of recovery and potentially prevent the development of persistent prolonged concussion symptoms beyond a month. This is one exciting path to finding a way to help them return to their pre-injury lives sooner.”

The eyes have it

Another avenue CHOP is exploring is vision therapy. Concussion can disrupt the binocular function of the eyes. National Institutes of Health research showed this line of treatment was effective in children who have these types of vision issues separate from concussion. CHOP is partnering with Mitchell Scheiman, OD, PhD, Dean of Research and a professor at the Pennsylvania College of Optometry and a world-leader in vision therapy, to develop specific treatments for concussion patients with these vision disorders.

“Students look at the board at the front of a classroom, then at their notes on their desk, then at a computer screen,” Arbogast says. “Adjusting to those different distances can be problematic after concussion and cause symptoms. We think vision therapy is the rehabilitation that some children need.”

Master says, “As clinicians, we want to be able to do something to actively treat these kids. We believe there is a combination of early rest, supervised and prescribed exercise, as well as possibly vision therapy and vestibular therapy (to help with balance and motion sensitivity) that can be used to develop a tailored approach to managing a child’s concussion.

“Taken together, these studies are providing the evidence that will help us better diagnose concussion and then develop a personalized medicine approach where an individualized combination of therapies will be used to accelerate each child’s recovery. Add in Kristy’s NFL work toward understanding the impacts that lead to injury and designing better protective equipment, and we’re making strides toward prevention, too.”