 My name is Prem Paul. I have the pleasure and honor of being Vice Chancellor for Research and Economic Development. Thank you very much for joining us today for our fall Nebraska lecture. The second of the 2014 Chancellor's Distinguished Lecture Series. Today's lecture is being web streamed live, so I also want to welcome those who are joining us via the web. For those of you who use social media, the Twitter hashtag for today's lecture is hashtag nevlecture. We would also like to extend a special big red welcome to any UNL alumni and other guests who are joining us today. So please, let's thank all of you for coming. I want to give a special recognition to Athletic Department for their hospitality for hosting this presentation. Actually, a few years ago when we started talking about the Center for Biology, Brain and Behavior, we gathered here to learn about all the great things that were happening and the visioning of this particular center. So we've been thrilled with our partnership with Athletic Department. This is one-of-a-kind partnership between athletics and academia, and I can say at least in the U.S., but I think that I won't be stretching it too much if I say that maybe it's the only one in the world. I think that this particular facility, we have very superb research facilities. Actually, in the east side, we have two research centers. Center for Brain Biology Behavior and the Nebraska Athletic Performance Lab. This unique partnership puts UNL at the forefront of health and performance research and is a national and international model for such collaborations. So I want to thank first to Dr. Tom Osborn that we worked with for his collaboration and now I want to say how delighted and thrilled we are that Sean Eichhorst has been an absolutely fantastic colleague and thanks for his leadership and enthusiastic collaboration. Steve Waterfield, Associate Director and Mark Bohm, whom I have worked with, they are extremely supportive of this collaboration. Nebraska Lectures are an interdisciplinary lecture series designed to foster communication among students, faculty in different academic areas at the university, and among citizens of Lincoln and Nebraska. These lectures are sponsored by the UNL Research Council in cooperation with the Office of the Chancellor, the Office of Research and Economic Development, and the Osher Lifelong Learning Institute known as OLI. A warm welcome to any OLI members who joined us today. Those of you who are not at the university, what is the Research Council? I think you know about the Chancellor's office and possibly in our office, but the Research Council is made up of faculty and they help us make sure that the research is strengthened and they also have a little bit of money. So they give us seed grants, so they are very popular amongst our faculty. And these Nebraska Lectures, the faculty are nominated and then selected by the Research Council. And the criteria for selection is that those faculty members that are selected, they have made major research accomplishments, they are well known, but they also have the ability to be able to take this science and communicate to the general public. So it is an honor, the highest honor that Research Council bestows on our faculty. So a few words about today's format. Following our lecture, Dr. Tala Awada, Chair of the Research Council and Professor of Natural Resources, will moderate question and answer session. At this time, I would like to introduce Chancellor Perlman who will introduce the speaker, but I want you to know that Chancellor Perlman has been absolutely fantastic supporter of not just this particular collaboration, but the entire research and the progress that University has made in many, many areas. So please join me in welcoming Chancellor Perlman. Thanks, Prem. It always boosts my week when Prem introduces me. It is my pleasure to introduce today's speaker, Dr. Dennis Molfiz, the Mildred Francis Thompson Professor of Psychology and Director of the Center for Brain Biology and Behavior. Dr. Molfiz is an internationally recognized expert on the use of brain recording techniques to study the relationships between brain development, language and cognitive processes. Since joining the UNL faculty in 2010, Dr. Molfiz has been instrumental in establishing UNL's new Center for Brain Biology and Behavior, which is housed across the way in the New East Stadium addition. The Center and our collaboration with Nebraska Athletics promises to expand our understanding of brain function and its effect on human behavior. Dr. Molfiz, the Scientific Director for the Joint Big 10 CIC Ivy League Traumatic Brain Injury Research Collaboration, can't imagine what the acronym for that is, that focuses on sports-related head injuries. He also served on the National Academy of Sciences Committee on Sports-Related Concussions in Youth that reported its findings at the White House last fall. He holds a doctorate and a master's degree in psychology from Penn State, earned his bachelor's degree from Oklahoma City University, a fellow of both the American Psychological Association and the American Psychological Society. He is the Editor-in-Chief for the Scientific Journal Developmental Neuropsychology and has served on numerous national scientific panels. Concussions in sports seems to be almost constantly in the news and for good reason. There's much we don't know and mounting evidence suggests the consequences of a concussion can linger long after athletes return to play. UNL's efforts to understand how the brain processes information before and after concussions are promising, this work could lead to better ways to prevent, diagnose and treat concussions both in athletics and in the broader society. Concussion research is a growing strength at this university. Dr. Molfiis and his team, along with our partners in athletics, are working to expand our understanding of how brain functions affects behavior. Today, he will tell us more about his research and about what we know and don't yet know about concussions. Please join me in welcoming Dr. Dennis Molfiis. Thank you very much for the great introductions. This is probably one of the few times I met with Prem that he did not ask me if we had any new grants, so I appreciate that as well. But I do meet with him next week, so I think that will be at the top. So with that, let me get into this. I would like to put in a plug for this National Academy of Sciences report. This is a web, so if you go to the Institute of Medicine or National Academy of Sciences website and just do a search for concussion in sports, it will bring up this icon for the book, and it's a four megabyte download that's free. Or you can pay $75 and get the soft cover version, but four megabyte is what I would recommend, of course. We actually have two members of our faculty here, Dr. Art Erlander, who we stole from Dartmouth heartlessly, joined our Center for Brain Biology behavior group, was on this national committee, and then I, of course, had an opportunity to serve and learn a great deal about the phenomena from a bunch of exceptional colleagues. We'll talk a little bit about concussion. Concussion certainly is brain damage. I'm, for better or worse, the opinion that it's permanent brain damage, but that it reflects also a very dynamic mechanism of the brain to basically restructure itself moment to moment. I would wager that virtually everybody in this room has had two, three, four concussions, perhaps more. My mother eludes to the fact that when I was an infant, I had this propensity, and on the, we had backyard ports that was concrete, and there were no straps back in those days to keep little critters in our high chairs, and I had this propensity to stand up, fall over being top heavy, in which case you would pick me up, dust me off, put me back in, and I would repeat. Not one to learn readily, unfortunately. But again, I think what's going on here is that the brain just has an incredible ability to keep restructuring itself. And we see that in terms of the way we learn information. You're constantly rerouting information within the brain or synapses or restructuring. They connect with different cells moment to moment, different other neurons, and this is probably all part of this process. It also is very useful in helping virtually all of us to maintain our productivity and ability to perform well, in spite of the fact that we have had some concussions. However, for some percentage of the population, this becomes more critical, and then also, of course, given the nature of the concussion, this becomes even more serious. Concussion generally is seen as being what's called a mild traumatic head injury, mild TBI. So it's in that group. Moderate to severe head injuries almost always involve more severe structural damage. With all the research that's out there, we have yet to find evidence of structural, growth structural deformities in the brain following concussion. There are things that are occurring at the micro level, but at least at growth structural levels. We don't see that with concussion, but again, that does seem to be there for moderate to severe head injuries. There are a number of issues. This is great in terms of, if I have magnifying glasses on my glasses, I could probably see the screen. We have different rates that are reported if you get on CDC's web page that report roughly about 1.6, 1.8 million. Emergency room visits for people with head injuries. Colonel Dallas Hack, who runs the Department of Defense, the largest group looking at head injury in this country, puts a figure at more at 4 million. The scary part of the 4 million figure is that approximates the annual birth rate in the United States, which at this point is about 4.1 million. So we now know where all the crazy drivers come from. Interestingly, even in military personnel, the way they get concussions is pretty comparable to what we see in terms of the U.S. general population. Most of their concussions occur in car accidents, slipping, hitting their head on cabinets and those sorts of things. Relatively few, and certainly there are head injuries that occur in military action, but the vast majority, relatively few, actually occur in action. But the percentages for mild traumatic brain injury or concussion are pretty much the same, about 77% in the military, 75% in our general U.S. population. Of those who experience a head injury, 75% in our general population experience a concussion, 25% or moderate to severe, usually about 4-5% in both military and in civilian populations. There are a lot of symptoms with concussion, and actually symptoms are a primary way of diagnosing whether concussion has occurred. Symptoms, though, it turns out, are not particularly reliable. They have to require the individual to disclose that they have a symptom, and some people, especially in athletic conditions, don't want to tell you they've had a concussion because that takes them out of the game. They get less playing time, and if they're looking for the future and possibility of professional sports or just for the thrill of the game admitting they've had a concussion, I can curtail that because they're going to be taken out of play for some period of time, go through some type of neuropsych exam and then evaluate it to see at what point they can return to the game safely. But these are a common list of symptoms. You can have many symptoms, and they may all disappear within an hour, two hours, perhaps a day or two. Normally, symptoms don't persist much beyond perhaps a week or so, sometimes two weeks, but most of them pretty much disappeared after that. About 10 to 15 percent continue to experience some symptoms that for some could be as long as perhaps a year. That's for a single concussion. One wonders how much time does it take for a concussion to occur, and this is some work that was published by Peleman back in around 2006 or so. But this is just a cartoon illustrating what happens within 25 milliseconds. It's 25,000th of a second after, let's say, a hit to the side. You've seen tight ends go up to catch a football, for example, and it's a great, beautiful catch, and all of a sudden you see them hit from the side, you see the head snap back and forth, and then, of course, they then come in contact with the turf. But this movement of the head just from a mechanical standpoint, there's a lot of tissue inside the skull. That's going to move, and what happens is as it moves, there could be potential for some tearing of structures. In fact, there's a lot of things that seem to occur that we know about, at least using animal models that occur at the more molecular level in terms of the brain. But even just having the major corpus close and that connects the left and right hemisphere, have that, have pressure on it between the two hemispheres as the brains rotating because of the hit may well produce some of the trauma that could have lasting results. If we look at the micro level from the very top, there's a little blue thing at the very top, which is basically a connection coming in from another neuron. The synapses sort of get overloaded with neurotransmitters. That is information that's coming in from another neuron and they just flood the system. And so the ability for neurons at the cellular level to communicate with each other breaks down. And as they break down, then we begin to see changes occurring in what's called calcium channels, basically the way that the potassium calcium channels, the way that the nervous system, the brain tissue propagates an electrical signal through the brain. That mechanism breaks down. And ultimately at the end of all this, you'll see a red area over on the right side of the slide. What happens there is that difference in potential in the axon that's carrying information away from one neuron towards another. That basically loses its ability to differentiate and move a charge along it, signal to the next cell. And so what happens is it swells and when it swells, it actually bursts. And so you can have destruction of the neuron at a whole bunch of levels from the nucleus of the neuron out to the axon. And that's at the cellular level. The brain as you know is composed of gray and white matter. The gray matter is over on the top layers of the brains called the cortical surface of the neocortex. And then most of the brain is made up of white matter, which is connective tissue, which basically you can think of as train tracks for moving information from one brain area to the next. And normally an adult then information is moving about 250 feet a second, which is a lot faster than I can run. A lot of the disruption with more severe head injuries seems to occur in those white matter areas. The two pictures below that top picture, that's just a cutaway of the center of the brain, those are showing what's called diffuser tensor images of the brain. And they're showing you these white matter tracks in the brain, these highways that carry information from that gray matter on the top of the brain to other gray matter areas and to gray matter areas within the brain like the thalamus, where a number of other operations are occurring. Well those can get disrupted as well. This is the picture on the upper right is a picture of somebody with a moderate head injury. And the green and red are radiations that are connecting, basically there is a white matter connecting the neocortex that's going to run through the middle of the brain, the corpus close them up to the other hemisphere. And the green area, those pathways are pretty much intact. But on the left side, the red area, only partial number of those fibers remain intact. And as far as we know, at this point, those fibers don't grow back. So that can be a pretty major disruption in the ability of the brain to interconnect and move information from one brain area to the next. If you have a concussion, your chance of having a second concussion increases. And that's what this slide from Kirkowitz basically is showing is you have some percentage of athletes have a concussion and then there is a recurring rate. If you have one concussion likelihood of having a second, it actually increases. And then having a third and fourth, those also increase as well. I think the field first became aware of this in motorcycle accidents, because it turns out if you don't wear a helmet, or frankly in some cases depending on the insult with a helmet, that if a person was released from care and went back to riding a motorcycle, there was a much shorter period of time before they would experience another head injury, and then that would occur in the third instance, perhaps even further. And at that point, usually the individual wasn't able to return. There are a couple of significant syndromes that we should be concerned about. You probably have heard of post-concussive syndrome. This is just where concussion symptoms, these symptoms that I just listed briefly earlier, that these will persist for, again, several weeks, perhaps several months, sometimes out to a year. More serious concern is what's called the secondary concussive syndrome. This is where you've experienced a concussion, still are showing symptoms, and then the individual experiences a second concussion. And there's actually a risk of death in that case, although the percentage is very, I've seen them as high as 4%. That just underscores the importance of being able to identify athletes or anyone who has a concussion, making sure that they're at least minimally getting rest and then not returning to play or not returning to their normal level of activities until those symptoms have disappeared. There are a number of challenges that currently face us, and these are certainly what we're working with in the Center for Brain Biology and Behavior, and actually very excitingly across the country. A major change we've seen that's occurred in the last year has been movement towards very large studies involving multiple institutions and multiple laboratories. And the reason for that is we had many scientists have sort of a lone ranger approach to science, where each lab is doing its own thing. But if you're trying to accumulate a history of concussion and track people in the long term, that at any one school gives you a very small number of concussions to study, which means it may take you 8 or 10 years as one of the studies I'll talk about in a moment did to get some idea about the incidence of concussion and whether differences between males and females in concussion risk and so on. But by lots of schools putting together sharing resources, combining their data, then you can get, you know, 1,000 test cases done in a relatively short period of time. And that's something that Art Mirlander really is trying to help us organize here at Center for Brain Biology and Behavior, and also with our partnership with the Nebraska Light Performance Laboratory. We're also pursuing that quite aggressively. So the search, the key thing everybody's after are biomarkers. What is some objective measure that tells us a concussion has really occurred, and that's what we don't have at present. We still rely heavily on symptoms, but again, symptoms are unreliable in terms of telling you how long it can take somebody to recover from concussion, or in fact maybe even the severity of the concussion. Just lots of individual differences. We still have very little information about long term recovery from concussion, so a lot of the studies that are currently underway are looking at trying to track athletes and non-athletes, seeing how long they take to recover. Are there any milestones they go through? At what point can they return to not just athletic competition, but also academic competition? After all here at all of our institutions in the Big Ten, I believe, and throughout the great conferences, these are students who are athletes. And so they're there to develop careers for skills for the rest of their lives. And so you want to ensure that they have a great opportunity for that. Developing treatments is another issue. We have no clinical trials that tell us what treatments are most effective. Sleep is what's recommended or not doing activities. But the question is, what do you do if you're not supposed to do anything? Who of you in here, if you're told don't do anything for 24 hours a day for one week, two weeks, three weeks, is going to remain sane? You're always going to be doing something and that can put a strain on your system. The best advice that we have at this point is you can do some things, but they should not be things that are going to attack you. And if you begin to feel like your headache is getting severe or you're beginning to feel fatigued, as Art was saying the other day, to somebody back off. And if you're feeling these symptoms occurring after 15 minutes and only study for 10 minutes. And if that's okay, then you can maybe gradually increase it over time. But we're still feeling our way. We have no real scientific data. So when a physician recommends rest, they're recommending it based on common practice. Again, not on the basis of any research data. It's not their fault. We as researchers aren't giving them the appropriate data. But with a rise in public consciousness, that's clearly stimulated the research community to pay more attention to the issue. And so now we're seeing a real advanced and active move in that direction. So treatments is another issue. And then also when does recovery occur? How do we know if a person is back to the way they used to be? Oddly enough, we didn't use to test athletes prior to the start of the season. We knew how they would behave before getting a concussion. So all of our measures of whether they recovered or not is whether the athlete basically said they felt okay, or whether they were performing what people might consider a normal level. But that might not be a normal level for that particular individual. Maybe they had more potential. Maybe they started at a higher point. And so their behavior is being reduced and really need more time to recover. So those are the four major challenges that are going to direct research in my opinion for the next decade. A few things, there is some really great research coming out over the last few years. There is a nice longitudinal study by Lincoln that was published recently. And among other things, Lincoln looked at this business about concussion incidents in males and females. And one of the things she noted is that if you look at comparison of females playing comparable sports to men, then the rates of concussion are actually higher in females than in males. Overall, you're looking at incidents in some sports where they're like ice hockey is going to be higher in men than women. We don't tend to have a lot of female football teams. So that's meant to have more of a lock on that. In terms of repeat concussions, again, if you have a concussion, there's a chance of increased concussion. But if you look at these figures and virtually all the areas, females tend to have a significantly higher concussion rates in males. Roughly about two, studies vary between about two and 2.6 times concussion rate for females over males in same sports. That's a great question. A lot of the referrals are by trainers and of course the individual would be very... All of you who are married or have a significant other, females that is, may note that males in general are a little recalcitrant about seeing physicians. Does that take anybody by surprise? But that could definitely be another factor. It also depends on the training skills of the trainers, what they've been trained to recognize and so on. Generally across the Lincoln studies, they've shown an increase in reporting of concussion that could be due to awareness, better training that trainers are receiving in terms of concussion identification. But generally, again, the rates are higher for females than for males. As you might suspect, the mechanism for concussions is a bit different. Males more in terms of direct contact with other individuals. Females, it's more in terms of contact with the playing surface hitting the ground than to player-player contact. This is a movie that's actually over in real time, about 7 tenths of a second. What you're doing is you're looking at electrical activity that's recorded over the scalp using an electrode net that's got 256 electrodes in it. And that adult is simply hearing a speech syllable, bah. I'll change the story as we get closer to Christmas and we'll move to bah humbug. But basically, the point of this is there's a lot of electrical activity going on a very, very short period of time. Even processing just very, very simple kinds of information. And it's not just involving one area of the brain. If you note, you see electrical activity moving from the top of the head, that's the top of the picture, towards the back, towards the sides. These different colors reflect different positive negative voltages that we can record at the scalp. So a lot of very rapid information moving. Again, that information is moving around 250 feet per second. Obviously, if you have conduction problems, that's going to slow down the processing. Talk to somebody with multiple sclerosis where the slowdown is about 50 milliseconds. 20th of a second, that produces very marked disruptions in our behaviors. We also, as tools in the Center for Brain Biology and Behavior, do have the MRI system. It's a standard Skyra MRI, 17,000 pounds. So nobody's going to walk away with it. But we can, we have a very unique protocol here in that we can actually record brain images using that brain imaging equipment. At the same time, we're measuring the brain's electrical activity. And very few sites around the world have that capability. So we can look at not just what brain areas are being activated or disrupted from, let's say, a concussion, but also a change in the order in which the areas are activated as well as timing. And we think the ordering and the timing tell us information about how the brain reorganizes itself as a function of the brain injury. Here's some data from athletes we've tested here at UNL. It's a simple what's called a working memory task. And so you're seeing a single number at a time. And that number goes away and next number appears. And all the individual has to do is say, well, they see a number is whether it matched the number that occurred two positions earlier. Sort of like in a way of, you know, somebody gives you a phone number, remember, and then distracts you by asking a question and you got to keep that number in memory while you're doing something else. Well, in athletes without any history of concussion in the last one to two years, what we see on the left side here, if you're looking at the match and the mismatch conditions, matches where they see a five and say, yeah, that occurred two spaces earlier. And yeah, that's correct or a mismatch. No, it was a three that occurred earlier, so it's not a match. But what we see is very clear difference in the brain electrical pattern between those two circumstances for somebody without a recent one to two year head injury. However, those athletes experiencing a head injury one to two years prior at basically 200 milliseconds where we should be seeing a difference. We're not seeing it. We don't see it, frankly, for another 200 milliseconds. So we're seeing a slowdown of roughly about four times what you see in multiple sclerosis. That's a pretty scary. Now, behaviorally, these guys are performing fine. So again, you know, the brain's able to compensate. It's reorganizing itself to deal with and they're able to function. But if we put a stopwatch on them or we're using pretty high tech stuff to pick up on those differences, clearly there are differences in the way they're processing information. Just another slide from another population of athletes. And again, the red and the blue lines, these are off of different electrode sites across the scalp. But the blue line reflects those individuals who basically don't have a prior head injury. And the red line is those that did experience an injury. And so there's a difference in the brain electrical activity and something quite different is happening in the brain. In a case study we published a couple of years ago, we were working with a lady who basically had fallen. Had a very significant concussion, maybe bordered on a moderate head injury. But the upshot of it was is the world to her appeared to be at an angle, 30 degrees off-center. And so when she'd stand up, she would see the room as being like this and so she'd compensate and she'd fall over. But another curious thing about this is that she was stuttering as a function of this injury. And stuttering would be 10 attempts to say a word. So she could not return to her job because she couldn't stand. She was confined to a wheelchair because otherwise she'd fall over repeatedly and get more head injuries and then essentially could not converse. Very talented individual, had great skills, traveled around the country and so on, just limited. We did a very simple task with her. We had her look at that reversing checkerboard up there, reverses it at one second, intervals. And that's a task that should only involve the occipital lobe of the brain. And it's a very simple task. She didn't have to do anything, just look at it. And ophthalmologists with this syndrome, this visual shift syndrome, have known about it for a couple of decades. And the intervention is simply to fit the individual with a set of prisms in their glasses. And so what it does is it corrects the world, makes it right up again. And so when you put those on, she can now walk without falling over. But the weird thing was she could also now talk without a stutter. And so the ophthalmologists knew about the visual correction, but nobody knew about why she stopped stuttering. And that's something we discovered and got a nice award for that and so on. What we found is that with her brain, when we did not have the prisms on, those areas marked in green are all the areas that were activated in her brain, including large sections of the left temporal lobe, which is just right above my hand here, which is heavily involved usually in language perception, but also frontal lobe is also heavily involved in language production articulation and so on. You put the lenses on, actually that involves 17 different brain areas. You put the lenses on and the only area now that's activated are the visual areas marked in yellow, which are the areas that should have been activated. So this woman has permanent brain injury, fairly significant, but just by putting the lenses on, she now can return to work, she no longer stutters. And it turns out what the problem was is her vestibular system was great. So her semi-canals in her ears were saying, yeah, you're upright. Her visual system was saying, no, no, you're not upright, you're at an angle. And so the brain was basically trying to figure out how does it solve this basic sensory conflict and putting the lenses on corrected the visual distortion. And that removed the conflict and so now she can walk and see the world, but now she's no longer using the language areas to try and help her stand up straight and reconcile that difference between information. So that's the kind of things that we can get out with these kinds of tools. This actually has introduced a new type of therapy that I now have colleagues pursuing where you can take people with certain types of brain damage, we think. And even though they're permanently disabled, by changing the visual input and the auditory input or sensory input, they actually can now return to normal behavioral function. And if that really works out, then that'll be something really quite exciting. This is a graphic representation of our model of how things work in terms of concussion. We're the only ones at this stage that actually have a model. We think in terms of normal development, what happens as you're learning something, you involve lots of different brain areas. And as you might suspect, if you have lots of brain areas involved, this can take time for information to move through all of those. And gradually over time, as you learn, you have fewer and fewer brain areas being involved and the speed between those areas gets faster. And so eventually you're down here where you have just very few areas and the order in which the areas are activated is pretty automatic. So we can process things very quickly. Remember when you were trying to learn to type? I'd never learned how to type. But for those of you who had better skills, you were honey and pecking and now you're at a point, in theory at least, where you don't have to look at all the keys all the time and you can move and it's not as much of an effort. That's that difference in moving from lots of areas that are involved, a lot of time involved in processing to just a few areas where you have more automatic processing occurring. We think what happens with concussion is the brain loses part of the network. So what the frontal lobes do, anytime you have a head injury, frontal lobes get heavily, massively involved in helping to restructure the brain. Front lobes get involved and it basically is looking for other ways to help the brain communicate. And in some cases that may lead to new pathways being used or even some other areas that maybe weren't primary areas engaged in that process. Now we note about some of this phenomena, bits and pieces and literature going back to the 1940s to a guy by the name of Hebb, Don Hebb. He used to be at McGill University. So this is one of the models we're using to guide our research and look at you know, pre versus post concussion and recovery from concussion to see if these networks have changed significantly and what areas involve, how stable are those changes between individuals and do they offer us information about better ways to do intervention. So imagine you could monitor online with these kinds of brain imaging techniques whether your intervention is working or not. And the techniques like with the electrophysiology are not that expensive and they're also portable. Future research, we see multi-trade, multi-site research going on, Big Ten, NCAA, Ivy League which were a part of that collaboration. And basically we're studying lots of things from at the same time in the same athletes. Getting health histories, looking at genetic risk, balanced vestibular ocular control, GATE, GATE is disrupted with a concussion, doing neuropsychological testing, reasoning, memory sorts of tasks, of course using different kinds of brain imaging. Again, these are involving large scale multi-site studies and then also importantly standardization across sites. Art and I did a questionnaire for the Big Ten Ivy League recently and got back the results and we were surprised to find across the two conferences relatively few laboratories are using the same measures. So high probably of all the measures being used about maybe 90% or not common measures and even of those 10% that are there, 10% on maybe some subsets but not all laboratories. So that's another thing we think we have to do is do a better job at standardizing research across centers. Finally, these are some of our major initiatives that we're currently involved in. Here at UNL Athletics and the R&B have both given us permission to move ahead to recruit former UNL athletes at all ages. You've all heard about chronic traumatic encephalopathy, the possibility that early concussions may accelerate the onset of things like Alzheimer's disease. And so this is an opportunity to both provide a service to our former athletes but also to gather information to see if there is something really systematic where athletes who suffered multiple concussions at different stages of their college pro-careers and so on versus others do in fact show earlier signs of cognitive impairment. We're also part of a 15-institution NCAA Department of Defense grant and we're testing all athletes across all sports. We have permission from athletics to try to recruit all 620 athletes here across all sports in our studies. And then ART heads up a Big 10 Ivy League grant initiative that has a heavy emphasis on brain imaging. I've covered a number of things here but this is really only a small part of this. We have this great collaboration with Judy Bernfield's group and the Nebraska Athletic Performance Center. We've got phenomenal talent within the Center for Brain Biology and Behavior. Scott Stoltenberg is doing exciting things in genetics and looking at a possibility of genetic risk and how concussion might alter. You know maybe things even related perhaps to expected lifespan in terms of damage. Julie Honecker out of Communication Disorders Special Ed is looking at balance, oculomotor control. So a number of different disciplines, I think we have about 9 different disciplines at present within the center of colleagues from different disciplines working together to try and solve these very critical questions that really can affect us all. How does all this relate to you in terms of not being athletes? The vast majority of concussions are not athletic, it's only a very small proportion. So these immediately relate to concussions due to car injury, falling off bicycles, playing sports around the house, hitting your head on a cabinet, hitting your head getting in and out of doors, all sorts of things falling. So all these things are directly germane to everyday life. And with that we're actually trying to mark it a helmet for a mice. We're looking to see if that will work out here. We have time for questions so please raise your hand and I'll bring you the microphone. And please say your name too. My name is Tim Gay. Are we to conclude from the Lincoln study that football is the safest sport? I guess one thing is that makes football a target for concussion studies is just a large number of people there in there. But all things being equal, just the concussion incident seems to be higher in general for women across sports. But concussion certainly has a high number of concussions, yeah. Although last year I think Lonnie Albers, who's the team physician, reported 2%. I'm sorry, only two cases of concussion which we thought was interesting. Oftentimes within the Big Ten rates seem to be somewhere around 25 football concussions per year. It's just that you tend to get slammed into the mat. I think that's where you got the surface contact stuff when you take the individual down. And yeah, I think they're... I'm Charles Marietta. I'm actually with Environmental Health and Safety here on campus. Thank you for your informative talk and your data. My question is, is there any stem cell research or therapy that's being pursued as far as repairing brain tissue after injury? We certainly see that research going on in terms of animal research. And I think there is some human research going. But things are still pretty primitive. I mean, people are doing, we read about a study just recently where they were taking some nerve tissue from one part of the body and using it to try and resection spinal cord for spinal cord severed patients. So that looks to be very optimal, very exciting possibilities. Ultimately, we're not really sure exactly how the brain's dealing with the concussion that occurs. Clearly, there's lots of things that are happening at the micro level. And the issue is how to deal with that. There's a lot of glucose delivery immediately after a concussion, which is important for a nutrient, providing nutrients to the cell. Within seconds, it just plummets. And so the cells that are being injured or traumatized aren't getting appropriate nutrients. Blood pressure and blood supply also drops, probably as a protective measure to keep minimized bleeds. But that's then not going to deliver more oxygen and glucose to the affected areas that will slow down and recover you with suspect. We just are setting up to do a set of studies looking at heart-brain interactions. Nobody's looked at that in terms of the concussion models. So we're wondering if we can get a better handle on that mechanism. It might be that the heart and the brain have some different priorities at some point. And maybe one might be able to tweak those to maximize or minimize brain damage and maybe minimize symptoms. But that's all speculation. You all realize having a PHD up front and giving them a microphone is tantamount to long-term torture. If a person has a blow to the head and loses consciousness, do you assume they have had a concussion? And the second part of that is if does the length of unconsciousness have anything to do with the severity of the concussion? Great questions. I don't really know the answer to the second one. Our assumption certainly is if you're unconscious then something irregular has happened to the brain and that you've had a concussion. And that is one of the signs that we rely on to determine whether one has occurred. So the answer would in theory be yes to both of those. But that's where we need to go. Dennis, what are the similarities and differences between sport-related concussions and traumatic brain injuries in the battlefield? Well, in terms of at least talking to Colonel Hack and looking at the literature that's out there, if there's a concussion that's sustained, so this again is mild traumatic brain injury, then there don't seem to be any real practical differences between them. If you're dealing with shockwave sorts of effects, blast waves, so there's an explosion and before you get hit by the debris, you get hit by the shockwave. That shockwave basically sets up high frequency vibration that works its way through brain tissue. Just a radical guess would be that's probably not good for the brain. So that would be different than, say, a rotational type of stress on the brain from a football. But then they also get hit by debris and they get hit by other things that then can produce other kinds of injuries so it would make it more complicated. What little we still know about that is a lot of animal studies. Although the military now is in the field equipping their, our personnel with basically shockwave detectors to tell them, and we found out that people firing howitzers, they're getting beat by shockwaves all the time. So now they're beginning to talk about better protective gear. And yeah. I don't have any information on, supposedly they're supposed to be subconcussive. But, you know, there are different risks. But I just don't know that literature so I'm not going to be much help. That's a great question. I'll look into it. Bob Kelly. My daughter three years ago was hit in the back of the head with a volleyball serve and suffered a concussion. And she's still taking headache medicine and a slight antidepressant. Any thoughts on what the, or long term is? So depression is another one of these things that goes along with concussion. That's another symptom. You know, I guess what one tries to do the concussion meds are one thing, but maybe looking at other things and the behavior that might change. Oftentimes people with concussion report that if they're trying to work on something, they feel okay for a while and then they start having headaches. And the advice I've heard, I think I've alluded to art earlier, is to basically back off. So stop before, so if you develop a headache after 15 minutes of doing something, take a rest and then maybe do it for 10 minutes before. And then over time expand it, but always back off from the level that you're feeling the headache. Now she's having chronic headaches, and this is a whole other issue to deal with. And I don't know that anybody's really come up with a reasonable way. I assume you had her to see a neurologist. So it might be we could talk about that afterwards. Art may have something to add on that perhaps. Doug Rinks, I want to know what your thoughts are on the use of psychotic eye movements and sideline testing for onset of concussions? Certainly that's one of those markers is a research area that's burgeoning. People are looking at that, ability to track. Yeah, so that's certainly one of these things that's easy to test. Balance is another thing that can be used on the sideline. We're actually, we've done, we published one paper with using electrophysiology on the sideline. It's not feasible to do it now because it takes an hour to analyze the data. Coaches and trainers aren't going to wait an hour, but we think within a couple of years we can get it down to five minutes or so. But there are a number of things, quick tests. The impact can be administered, SCAT 3 on the sideline, those are quick tests. The problem with using those kinds of tests rather than something that's measuring physiology, motor tracking, eye tracking balance is that players sometimes are advised by more senior players not to perform very well before the season starts on impact pre-concussion or pre-play screening so that if they do get dinged during the game their score won't be so low that they'll get pulled out of the game. So again, that's why we're hunting for a biomarker is something that you can measure independent to the individual to give you an objective measure whether a concussion has actually occurred or not. Our training of trainers is highly varied. Medical schools not trained physicians on head injury. There's no set of curriculum in med schools. We actually have formed a committee in the Big Ten Ivy League working with a committee with a bunch of med school deans. We're building an 11-week curriculum basically so that physicians will have training to then appropriately diagnose and recommend intervention for people who do suffer concussions or moderate to severe head injuries. So it's a user's market. You always check out your dentist to make sure they're certified and they know what they're talking about. You always have to talk to your physician to make sure they've got some official training and head injury and aren't just relying on the popular press just like you'd want to make sure that I know something about what I'm talking about if I'm teaching the class that my students sign up for, some of whom are here. They told me they came for the talk but I notice they're eating pizza as well. Dr. Mulfiz, how does stress, so we know stress impacts the brain. So over long term, how could stress magnify the effects of a concussion? The short answer would be yes, it does. But stress sort of magnifies everything. So it does play a factor and certainly if you aren't performing at the level you want to perform at, that's going to be very stressful. Especially you have high achieving students, you look at the college kids, high school kids who want to do well and now they can't perform, maybe sometimes teachers don't make allowances, most often they do. That does place a lot of extra stress on the individual and the best thing parents can do is have discussions with teachers and also with their child to do accommodation to minimize that stress. But that's only going to bring out things like headaches and so on. We have time for a couple more questions, there's one question here and perhaps we'll take one or two more. This might be an extreme, my name is Pat Boyle by the way, this might be an extreme example but why, I would assume that when someone like Muhammad Ali got hit, the damage was immediate. Why did it take so many years for some of those symptoms to show up? There could be big individual differences. If you look at their articles coming out in terms of chronic traumatic encephalopathy, they're showing signs of brain deterioration within six months of boxers starting to box. So with some individuals at least, that kind of pretty insidious brain death is occurring pretty quickly. Again there are individual differences so one individual could do well and sustain many hits, another one and now they've got chronic headaches and other symptoms that persist for a long period of time. We don't know really any of that. It's an inadequate answer but it's the best I can do. Dennis, thank you for your comments. My name is Richard Byron, like the person over here, I have a son that has had multiple concussions and most of the sports you listed in your study and one of the things we found and we're actually recommended by some folks here and in the community about going through neurofeedback and using that as a treatment. Can you talk about results that you're seeing because that's really the only thing that helped my son's headache and his sleep patterns? I think this is an emerging area and again one I'm not particularly familiar with. Also there's not a lot published on it yet, that's the other critical issue. So I think as more of this gets out, people do more experimentation. We have controls to compare the results to then probably have a better idea. Again, thank you for the talk. Could you comment on maybe the other side of the equation? What can we do to prevent concussions more than just dealing with the after effects? That's a great question. What can we do to prevent concussions? Helmets don't seem to be the end all. Helmets protect you from skull fractures and a lot of people are working on helmets to do other things that might somehow take away some of the impact, some of the rotational forces and so on reduce G factors. There are probably some simple things. Soccer is an interesting sport. If you look at the number of headers in practice in soccer, men's or women, I think I saw a paper, there's on average about 250 headers during the course of a week and during the average game there's about five to six headers. Now I don't know how many of you have dealt with the soccer ball. Those suckers are really heavy. I would suspect you could be just as effective in terms of practicing headers with a very light ball as opposed to a really heavy solid one. That might be one area. I think Tim and I were at a congressional hearing back in April, I guess. There are people that are selling little bands, all sorts of paraphernalia that supposedly reduces concussion by 30%. There's no data to support that, they're just ripping off the public. It's one of the things that concussion, the Congress has to do is put some constraints on people selling these things. I've had some manufacturers come in with wanting us to test things that basically are little rubber things that fit under a helmet, which don't look like they're going to reduce rotation at all. They're interested in getting data on that, but it's not always clear that, given just the physics of it, and I rely on Tim for the physics, that that's going to make a difference. Rule changes clearly are going to be a factor of the NFL, NCA have already tried to reduce some of those, some discussion about doing away with kickoff returns, that's where a lot of these concussion instances occur. I think Tim's pointed out that if you, some of the linemen you see with the big collars on, if you immobilize the helmet, you don't have rotation, you don't jiggle the head around, and so that's a good way to reduce concussions or eliminate. On the other hand, you're running backs and quarterbacks and so on, tight ends, they want to move their head, so that removes that. I had once suggested, we had the President and Vice President of Rydell visiting one time, and I had suggested them of putting cameras in the, immobilize the head, but putting cameras in. And I said, what kind of running back would not want to know how close the guy behind him is? I thought that was a great idea. He was way too polite to laugh, thank you. But that might be another thing, bringing technology. I was talking to Tom Osborn about that, and I said, the technology is really cheap to implement. And he said, not if you put in the football helmet. And so maybe some people with bigger budgets would benefit from that, but obviously lots of schools. We need to change the way we rate helmets. There's this five star rating that basically is looking more straight line sorts of forces rather than these rotational forces that we think are playing more significant role in concussion. And that five star system has been in play for decades and probably needs to be updated. Well, it does need to be updated. So there are some things maybe with equipment. I think Tim was pointing out that players these days use fewer and fewer pads. They want to go lightweight, so they're getting more injuries. So making them pad up more might be a reasonable thing. But again, at a gross level it may be that some rule changes would perhaps help. We see better officiating going on. So officials would be more aggressive about calling plays that are more likely to result in concussion. The NFL moved to having spotters in the stadium that clearly is helping trainers identify whether a concussion has occurred, because even if the player won't admit it or doesn't realize it. Can you imagine talking to a seven-year-old saying, were you unconscious? You don't have a clue. I remember talking to Tom Osborn at one point. He said he was injured at the end, got a concussion at the end of the second quarter. And I guess this is when he was with the Giants. And he doesn't recall playing the third and fourth quarters at all. And he had to watch the game films days afterwards to see how he did. Those are concussions. You can see the event you have passion. And when you are good and you're working on something hot, important, good things happen. So that was a great presentation. Please join me in thanking...