Spring 2016 CONCUSSION: A NATIONAL CHALLENGE The BRIDGE LINKING ENGINEERING AND SOCIETY A Multidisciplinary Approach to Concussion Management — Jay L. Alberts Can Serum Brain Proteins Aid in Concussion Identification? — Jeffrey J. Bazarian Opportunities for Prevention of Athletic Concussion on the Playing Field — Robert C. Cantu TBI Clinical Trials: Past, Present, and Future — Dallas C. Hack Concussion and the NCAA: Report from the Chief Medical Officer — Brian W. Hainline Research to Understand Explosion-Related Injuries in Military Personnel — S. Krisztian Kovacs Emerging Insight from Human and Animal Studies about the Biomechanics of Concussion — Susan S. Margulies Association between Repetitive Head Impacts and Development of Chronic Traumatic Encephalopathy — Ann C. McKee Preventing Concussions in Motor Vehicle Crashes — Jeffrey P. Michael Military TBI: Is It the Same as Civilian TBI? — Daniel P. Perl Computational Models of Impact and Blast Force Effects on the Brain: Scaling of Animal Injury Models and Prediction of Human TBI — Raúl A. Radovitzky, James Q. Zheng, and Thomas F. Budinger Impaired Olfaction and Other Indicators of Neurological Damage Due to Mild TBI Associated with Combat — Robert L. Ruff Neuromechanics and Pathophysiology of Diffuse Axonal Injury in Concussion — Douglas H. Smith Medical Imaging to Recharacterize Concussion for Improved Diagnosis in Asymptomatic Athletes — Thomas M. Talavage The mission of the National Academy of Engineering is to advance the well-being of the nation by promoting a vibrant engineering profession and by marshalling the expertise and insights of eminent engineers to provide independent advice to the federal government on matters involving engineering and technology. The BRIDGE NATIONAL ACADEMY OF ENGINEERING Charles O. Holliday, Jr., Chair C. D. Mote, Jr., President Corale L. Brierley, Vice President Thomas F. Budinger, Home Secretary Ruth A. David, Foreign Secretary Martin B. Sherwin, Treasurer Editor in Chief: Ronald M. Latanision Managing Editor: Cameron H. Fletcher Production Assistant: Penelope Gibbs The Bridge (ISSN 0737-6278) is published quarterly by the National Aca d emy of Engineering, 2101 Constitution Avenue NW, Washington, DC 20418. Periodicals postage paid at Washington, DC. Vol. 46, No. 1, Spring 2016 Postmaster: Send address changes to The Bridge, 2101 Constitution Avenue NW, Washington, DC 20418. Papers are presented in The Bridge on the basis of general interest and time- liness. They reflect the views of the authors and not necessarily the position of the National Academy of Engineering. The Bridge is printed on recycled paper. C © 2016 by the National Academy of Sciences. All rights reserved. A complete copy of The Bridge is available in PDF format at www.nae.edu/TheBridge. Some of the articles in this issue are also avail- able as HTML documents and may contain links to related sources of information, multimedia files, or other content. The Volume 46, Number 1 • Spring 2016 BRIDGE LINKING ENGINEERING AND SOCIETY Editors’ Notes 3 Concussion: Status and Next Steps P. Hunter Peckham and Thomas F. Budinger 5 An Overview of Concussion: History and Needed Research Thomas F. Budinger Features 23 A Multidisciplinary Approach to Concussion Management Jay L. Alberts Effective care of concussion requires the coordination of both clinical resources and handoffs between providers. 26 Can Serum Brain Proteins Aid in Concussion Identification? Jeffrey J. Bazarian In the near future it may be possible to diagnose concussion with a simple blood test. 31 Opportunities for Prevention of Athletic Concussion on the Playing Field Robert C. Cantu Rule changes, neck strengthening, and education can all help reduce the risk of concussion on the playing field. 34 TBI Clinical Trials: Past, Present, and Future Dallas C. Hack Regulatory science is inadequate, but is a reflection of the state of the more general science in the field of TBI. 39 Concussion and the NCAA: Report from the Chief Medical Officer Brian W. Hainline Risk of concussion cannot be eliminated from sports. But safety can be improved through increasingly better informed decisions. 44 Research to Understand Explosion-Related Injuries in Military Personnel S. Krisztian Kovacs Controlled, reproducible interdisciplinary research is critical to improve understanding of traumatic brain injury. 49 Emerging Insight from Human and Animal Studies about the Biomechanics of Concussion Susan S. Margulies Research is needed to better understand the biomechanics of concussion and enhance injury prevention, safety equipment design, rules of play, treatments, and interventions. (continued on next page) 56 Association between Repetitive Head Impacts 79 Neuromechanics and Pathophysiology of and Development of Chronic Traumatic Diffuse Axonal Injury in Concussion Encephalopathy Douglas H. Smith Ann C. McKee Our research on concussion-induced axonal injury Intense research efforts are under way to identify may lead to identification of biomarkers that enable biomarkers to detect and monitor chronic traumatic noninvasive diagnosis and treatment. encephalopathy during life. 85 Medical Imaging to Recharacterize Concussion 61 Preventing Concussions in Motor Vehicle for Improved Diagnosis in Asymptomatic Crashes Athletes Jeffrey P. Michael Thomas M. Talavage Federal safety standards and technological advances The lack of symptoms or clinically diagnosable are helping to reduce concussion and other injuries dysfunction does not guarantee that an athlete is associated with motor vehicle crashes. healthy. 65 Military TBI: Is It the Same as Civilian TBI? 91 An Interview with . Daniel P. Perl Tom Scholz An IED blast wave would seem to cause a unique form of TBI, but the data needed to make such a NAE News and Notes determination are scarce. 98 Class of 2016 Elected 69 Computational Models of Impact and Blast 103 NAE Newsmakers Force Effects on the Brain: Scaling of Animal Injury Models and Prediction of Human TBI 105 News from the Center for Engineering Ethics Raúl A. Radovitzky, James Q. Zheng, and and Society Thomas F. Budinger 106 Mirzayan Fellows Join Program Office Simulations can be used to translate the results of 107 The IOM Is Now the Health and Medicine animal studies to human injury risk curves and guide Division the design of protective gear. 108 Message from NAE Vice President Corale 76 Impaired Olfaction and Other Indicators Brierley of Neurological Damage Due to Mild TBI 111 2015 Honor Roll of Donors Associated with Combat 124 In Memoriam Robert L. Ruff 126 Calendar of Meetings and Events Olfaction deficits and PTSD severity are correlated with both concussion and loss of consciousness. The National Academy of Sciences was established in 1863 by an emy of Sciences to advise the nation on medical and health issues. Act of Congress, signed by President Lincoln, as a private, nongov- Members are elected by their peers for distinguished contributions to ernmental institution to advise the nation on issues related to science medicine and health. Dr. Victor J. Dzau is president. and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objec- The National Academy of Engineering was established in 1964 tive analysis and advice to the nation and conduct other activities under the charter of the National Academy of Sciences to bring the to solve complex problems and inform public policy decisions. The practices of engineering to advising the nation. Members are elected Academies also encourage education and research, recognize out- by their peers for extraordinary contributions to engineering. Dr. C. D. standing contributions to knowledge, and increase public understand- Mote, Jr., is president. ing in matters of science, engineering, and medicine. The National Academy of Medicine (formerly the Institute of Medicine) Learn more about the National Academies of Sciences, Engineering, was established in 1970 under the charter of the National Acad- and Medicine at www.national-academies.org. 3 Editors’ Note The information in this issue can enhance under- standing of the nature and mechanisms of concus- P. Hunter Peckham (NAE) is Donnell sion. Years of experimental studies, initially focused on Institute Professor of Biomedical vehicle collisions, have evolved from crash simulations, Engineering & Orthopaedics and animal experiments, tissue biophysics, and computer Distinguished University Professor, simulations to investigations of physical parameters Institute for Functional Restoration, of head impact through instrumented helmets, objec- Case Western Reserve University, tive measures of cognitive function changes before and and codirector, MetroHealth after sports engagement, and noninvasive imaging (e.g., Rehabilitation Institute. functional magnetic resonance imaging, fMRI). Over the last 10 years the neuropathology associated Thomas F. Budinger (NAE) is with symptoms of brain dysfunction has been revealed. professor emeritus of bioengineer- Fortunately, these pathology diagnoses, at first done ing and electrical engineering and through postmortem assessments, can now be made by imaging methods (e.g., positron emission tomography, computer science, University of PET) in living athletes, veterans, and crash victims. California, Berkeley, and radiology, This information can be used to address a national University of California Medical problem