The Stanford Concussion and Brain Performance Center is at the cutting edge of concussion diagnosis and rehabilitation, with eye-tracking technology and a treatment protocol combining exercise and recovery.
Established in 2014, the Center aims to improve treatment of traumatic brain injuries (TBIs).
The Center complements a Department of Defense-funded consortium led by Stanford called the Brain Trauma Evidence-based Consortium (B-TEC). Created the same year as the Center, the B-TEC seeks to develop an evidence-based definition for concussion and proper diagnosis.
“There are over 3.1 million concussions that happen in this country any year,” said Scott Anderson, director of athletic training at Stanford. “It’s an epidemic. People don’t realize it.”
“The area has been poorly studied and people don’t really understand what the symptoms or what the clinical presentation of concussion actually is,” he said.
At the forefront of diagnosis and treatment for athletes
Anderson and the rest of Stanford’s Athletic Department worked closely with Jamshid Ghajar, clinical professor of neurosurgery and director of the Center, to develop a protocol for diagnosis and treatment of student athletes. Ghajar is also head of the B-TEC and president of the Brain Trauma Foundation, a nationwide organization that works to improve the care of traumatic brain injury patients.
Ghajar and a team of neuroscientists refined a patented portable eye-tracking technology called EYE-SYNC, which measures attention focus and recognizes unique signals indicating concussion.
Stanford athletes who think they may have a concussion immediately take the eye-tracking test, in which they watch a small circle move on a screen while the device monitors their eye movement. The device can also pick up on sleep deprivation and attention-deficit disorder.
“To my knowledge, the only places in the world right now that are using eye-tracking to detect concussions are Stanford University and the military,” Anderson said.
Before they can begin training, all student athletes must complete a baseline concussion test that can be used for comparison later to assess their medical condition. Baseline testing has become a standard requirement in university athletic programs across the country.
But today’s eye-tracking technology has made baseline testing somewhat of an extra precaution, because the eye-tracking device can detect concussions in just 30 seconds.
Ghajar, who treats patients at the Center in addition to conducting research, said he thinks that baseline testing will soon switch over to surveillance testing — monitoring athletes not to see if they have returned to baseline performance but to make sure they are in safe condition to be able to train and compete.
After the eye test, athletes suspected of having a concussion undergo two additional series of tests to rule out other injuries or conditions, such as whiplash, that are often misdiagnosed as concussion.
One series of tests evaluates functioning of the vestibular system, which monitors orientation of the body with respect to gravity and can be impaired by damage to the inner ear. These tests involve balancing exercises such as reading from a paper while walking forward.
Another series of tests consists of more traditional exercises that evaluate memory and cognitive function, testing athletes’ ability to recite sequences backwards and identify their location and the date.
The combination of these tests with the eye-tracking technology creates a particularly exhaustive approach to diagnosis.
Following diagnosis, Stanford immediately exercises concussed athletes on a cardio-based exercise machine in order to reestablish circadian rhythms and restore sleep cycles that aid healing. Ghajar said that long periods of rest actually impede recovery.
Anderson estimated that in the most favorable conditions, athletes following the treatment plan and passing regular testing throughout the recovery process could recover in five to six days.
Ghajar supported this estimate, saying that 90 percent of concussion cases treated at the Center recover within a week. Athletes recover even sooner, he said, often in three to four days.
Brian Rossi ’18, a wrestler who recently underwent concussion diagnosis and treatment, said he believes he has had many diagnosed and undiagnosed concussions throughout his career. According to both Ghajar and a 2014 NCAA concussion study, wrestlers are at the highest risk for concussions in NCAA sports.
Rossi noted that in his high school wrestling experience, doctors and coaches would not allow players to return to practice until they reached their normal baseline levels. At Stanford, he said, trainers immediately but gradually ease athletes into training, instead of telling athletes to cut all exercise until they are completely symptom free.
“I would say Stanford is more aggressive in their treatment,” said Rossi, who was cleared for competition about a week after initial testing.
In addition to treating TBIs, the Center is conducting the largest long-term study on concussions in the United States.
This study, launched in 2011 and funded by the Department of Defense, seeks to redefine concussions and develop a new brain trauma classification system for effective diagnostics and therapeutics. It examines 5,000 soldiers and 5,000 civilians and athletes from all over the country, including at Stanford. Researchers plan to publish results this fall.
A dilemma in collegiate sports
The Concussion and Brain Performance Center was founded amid heightened national discussion in medicine and the media about the consequences of concussions.
In 2011 and 2012 respectively, the suicides of NFL safety Dave Duerson and NFL linebacker Tiaina “Junior” Seau drew national attention to the lasting brain damage that can result from concussions sustained on the field. Analysis of Duerson and Seau’s brains revealed that both had chronic traumatic encephalopathy (CTE), a serious neurodegenerative disease.
But concussion controversy extends beyond the NFL, and athletes attested to the prevalence of concussions in high-contact college sports.
“I think in my eight-year football career, I’ve probably had 15 to 20 concussions,” wrote Anthony Wilkerson ’14, a former Stanford running back, in an email. “Fifteen or 20 times where in your head you think, ‘What did I just do? What did I just hit? I need a minute to gather. Ah, my head is pounding. Just go back to the huddle and do what’s necessary to get this win.’”
Anderson said that just in one quarter, the Stanford football team can average around 20 new concussion cases.
A number of national programs have arisen to address concussions in high-contact sports. For example, every football coach in the U.S. must now be Heads Up Football-certified to teach players to reduce dangerous contact by not using their heads to hit.
Stanford football player Peter Kalambayi ’17 also said that concussion detection has become a much greater priority in recent years.
“In the past it was more lenient in terms of diagnosing the concussion,” he said.
However, Wilkerson said that high-contact sports will always put athletes at risk.
“As we’ve moved forward, the approach to TBIs have changed immensely for the good but they will never be where they need to be as long as football is football,” he wrote. “Playing football expedites the process of cognitive decline.”
“Dr. Bennett Omalu, the first to publish findings of chronic traumatic encephalopathy in football players, made that clear to me when I asked him via email if there was anything we could do about concussions in football,” Wilkerson added. “He simply said ‘stop playing.’”
Still, in a sport like football where concussions are so commonplace that players often refer to minor unreported concussions as “getting your bell rung,” many players — like Kalambayi, who aspires to a career in the NFL — say they fully understand and accept the risks of playing.
“When you put on your football helmet, there’s a warning sticker on the inside that says ‘Football is a dangerous sport. May result in serious injuries,’” Kalambayi said. “You see that the first time you play football when you’re like 10 years old.”
“Every player knows they are going to get concussed at some point — it’s just a matter of how severe your concussion is going to be,” he said. “Everybody that plays football has kind of accepted it.”
When asked about the potentially serious long-term complications of playing high contact sports like football, wrestling and ice hockey in a university setting, Ghajar emphasized that he and the other doctors at the Center are very careful about patients who do not recover quickly, and for whom it may no longer be safe to continue playing contact sports.
Ghajar said that CTE is not sufficiently understood at this point to determine early on whether someone may be at risk for developing it. He also noted that, in addition to contact sports, sleep deprivation can be a large risk factor for injuries of all types, including brain injuries.
Ghajar added that student athletes come to universities mainly to study. He said that activities that could interfere with that, such as sports that may cause brain injury, should take less of a priority.
But ultimately, the decision to put oneself at risk for TBI by playing contact sports is a personal one.
“There’s only so much that the staff can do,” Wilkerson wrote. “Players have to look at themselves in the mirror and ask, ‘Is it really worth it?’ And if it’s worth it to you to sacrifice for your team, then so be it. You play at your own risk.”
For some former players like Wilkerson, love of a high contact sport and the allure of a professional career are not worth the risk of sustaining serious brain damage.
Wilkerson has not played football since graduating in 2014. After graduation, he helped start a company called BrainGear that makes a daily brain supplement.
“My experience at Stanford drastically changed my thoughts and opinions of football and brain injuries,” Wilkerson said. “I would never play again… All the research I did, all the lives that acted as examples before me, and my passions lying elsewhere, were enough to change everything.”
Contact Sandra Ortellado at sortella ‘at’ stanford.edu.