A young Robert De Niro, his face battered and bruised by too many rounds in the boxing ring, glares at you from a wall in Christopher Giza’s office. The famous image from 1980’s Raging Bull seems an appropriate choice for Giza, a UCLA professor of pediatric neurology and neurosurgery who has spent most of his medical career helping patients suffering from head injuries.
Three years ago, Giza established the BrainSPORT (Sports concussion, Prevention, Outreach, Research and Treatment) Program to provide multidisciplinary, research-based treatment for sports concussions in young athletes. Last year, BrainSPORT — housed within the Department of Neurosurgery at the UCLA David Geffen School of Medicine — received a huge boost from philanthropist Steve Tisch, co-owner of the New York Giants and an Academy Award–winning film producer (Forrest Gump, Risky Business).
Tisch’s $10-million pledge, Giza says, has enabled the newly renamed UCLA Steve Tisch BrainSPORT Program to secure its programmatic goals. BrainSPORT has hired its first program manager, set up its third concussion clinic (the Steve Tisch Clinic), welcomed its first two endowed fellows and appointed three associate directors.
“We hear a lot about traumatic brain injury and sports concussions in professional and collegiate athletes, and, of course, as an NFL owner, this is of particular concern to me,” says Tisch, whose interest in neurosurgery began in 2004, when his father was diagnosed with a malignant brain tumor. “But we hear a lot less about pediatric traumatic brain injury, and it is the single greatest cause of death and disability among children and young adults in the United States. I look forward to a day when the issues facing some adult former athletes as a result of head injuries and concussions no longer exist because of the work being done at UCLA and their focus on young people.”
Inside a Concussion
A concussion is essentially a brain-movement injury, Giza explains. The brain “floats” in fluid in the skull. “When the head or the skull accelerates or decelerates rapidly, the brain, which is kind of like firm Jell-O, moves and twists and kind of bounces around in there,” he says. “And, just like Jell-O on a plate, when one part shifts in relation to the other, the connections that go from one part of the brain to another get stretched or damaged.”
There is no hole in the brain, nor is there bruising or blood, Giza says. “The function of the brain is damaged, but mostly intact. We know that for the most part, with time, those biological processes can repair themselves. And most people do get better from an individual concussion.”
Giza credits the lab work of his colleague and mentor, David Hovda, with leading to the discovery that a person who suffers a single concussion will get better over time, if the brain is given time to recover. In fact, Hovda — who first came to UCLA as a postdoc in 1985 — won an NIH grant in 1990 to create the UCLA Brain Injury Research Center (BIRC), of which BrainSPORT is an offshoot. He is the BIRC’s first and only director.
“The treatment of brain injuries and concussions really has changed only in terms of management and recognition,” Hovda says. “The problem was that there were many organizations like the National Football League and the National Hockey League and the military and others that just didn’t realize what concussions were and how you would recognize them. Over the last 10 years, that has changed significantly.”
This, too, can be credited to Hovda, who has spent a lot of time over the last two decades talking to members of the World Boxing Council and the National Football League and appearing before the Joint Chiefs of Staff at the Pentagon to help them understand concussions.
“Each of these [organizations] was in a state of denial. Concussion was a ‘psychological’ problem; it wasn’t a neuroscience problem,” says Hovda, who was given the Strength of the Nation Award from the U.S. Army for his efforts on behalf of military personnel. “But because of our imaging, we were able to show them a picture of what a human concussion looked like, and this changed the real culture about what concussion was. Now, in the United States, there are laws.”
One of these is the Lystedt Law (2009), named after junior high school football player Zackery Lystedt, who was permanently disabled after sustaining a concussion and prematurely returning to the game. Now, Hovda says, concussion protocols exist. If players are suspected of having a concussion, they are removed from play, diagnosed and not allowed to return to the field until they are cleared by a certified health-care provider.
Educating the Masses
Besides treating patients, BrainSPORT has an equally important mission: to teach young athletes and their parents how to recognize the signs and symptoms of concussion. According to Giza, after an athlete takes a big hit, the brain goes into a state of energy crisis and doesn’t function properly, prompting outward signs and symptoms that are able to be seen.
“Less than 10 percent of clinically diagnosed concussions involve loss of consciousness,” Giza says. “The other 90 percent have headaches, light sensitivity, nausea, vomiting, incoordination, disorientation, slowed reflexes, slowed thinking. And when the brain is in this energy crisis, it’s just biologically more vulnerable to another injury. So if you get a second injury, and you’re already kind of teetering energetically, it could really tip you over into taking much longer to get better.”
For those parents who are interested in knowing which sports have the highest rates of concussion, Giza keeps a list. He places boxing, mixed martial arts and cage fighting at the top, although these sports do not publish injury reports. These are followed by high-risk sports such as tackle football, rugby, boys’ lacrosse, and boys’ and girls’ ice hockey. At intermediate risk are contact sports such as soccer, basketball and water polo. (These sports differ from “collision” sports, in which hitting each other is part of the game. In “contact” sports, hitting each other is incidental to the game.) Finally, the low-risk sports include baseball, softball, track and field, and swimming, although Giza says he sees concussions in these sports, too.
What may come as a surprise is that the rate of concussions for women soccer players is higher than that for the men. UCLA Women’s Head Soccer Coach Amanda Cromwell suggests that it might be due to women’s lack of core body strength or even a lack of stability in the neck muscles, although she didn’t find that to be true of her own team. “We’re actually below the national average [in number of concussions],” she says.
In Cromwell’s three years as UCLA’s head coach, her teams have had six concussions. “It’s part of the game,” she says, matter-of-factly. “It’s like any injury. Just as with any contact sport, especially a sport with a ball that’s moving at high velocity. You have contact with the ground, other heads, potentially the goalpost. So there are many incidents that could take place or cause a head injury.”
The 15 core members of Giza’s BrainSPORT team work closely with several other groups, including the Brain Injury Research Center, the Division of Pediatric Neurology at Mattel Children’s Hospital UCLA, the Division of Neuropsychology at the Semel Institute for Neuroscience and Human Behavior, and the Sports Medicine Program in the Department of Family Medicine.
John DiFiori, chief of the Division of Sports Medicine and head team physician for UCLA Athletics, has joined Giza in leading the university’s participation in the Grand Alliance initiative, launched last year by the NCAA and the Department of Defense. Called the most comprehensive study of concussion and head-impact exposure ever conducted, the three-year, $30-million effort aims to enroll 37,000 student-athletes. Participants receive an extensive preseason evaluation for concussion and are monitored in the event of an injury. So far, the Grand Alliance has conducted between 7,500 and 10,000 baseline assessments and has logged in more than 300 concussions.
Chosen for its multidisciplinary expertise in the care of concussions, particularly in imaging, UCLA was one of three original institutions in the study’s Advanced Research Core, according to DiFiori. UCLA has two sports participating in the Advanced Research Core — football and men’s and women’s soccer. Participation, which is voluntary, involves blood draws (to look for serum biomarkers, or blood proteins) and multimodal MRI scans.
“These are not your routine MRIs,” DiFiori says. “These are MRIs that detect microstructural injury in the brain, metabolic disturbance in the brain and brain activation. This is cutting-edge stuff.”
Football players have the added option of wearing helmet sensors that measure the forces that their heads (and, theoretically, their brains) are feeling. The study also includes a Clinical Study Core that involves all UCLA athletes, who have undergone clinical baseline testing and will be monitored all year for concussions.
Giza says, “We don’t know all the answers, and we’re still really at the beginning of understanding this. But if there’s one message I want spread, it’s ‘Protect your brain.’ You only get one of them. And if you suspect that your athlete has had a concussion, sit ’em out. It’s a recoverable injury, if you identify and treat it properly.”
David Eisenberg: Head and Heart
Athletes in contact sports, such as football and boxing, where brain injuries are common, are particularly susceptible to such neurodegenerative disorders as Alzheimer’s and Parkinson’s diseases and various other dementias, says UCLA Professor David Eisenberg. These so-called amyloid diseases are the focus of Eisenberg’s research. The diseases are caused by proteins that aggregate into fibers.
Part of what Eisenberg studies is the tau protein, found in Alzheimer’s and chronic traumatic encephalopathy (CTE), which also afflicts athletes. “It’s believed that concussions suffered by athletes and others can aggregate tau into the amyloid state and cause this neurodegenerative disease,” he says. “So by studying tau and its formation of amyloid fibers, we’re also studying Alzheimer’s, CTE and numerous other dementias.”
Eisenberg, who teaches biochemistry and molecular biology, chose to study amyloid diseases because, as a scientist, he wanted to contribute to the improvement of human health. His father, a pediatrician, had hoped his son would come into his medical practice. But his dad “was just so good at what he did, there was no way I could ever equal his concern [for] and attention to children,” Eisenberg says. “So I went into science, having been convinced by my undergraduate supervisor that you could do as much for human health by working in biochemistry as by being a doctor.”
Eisenberg came to UCLA in 1969, with degrees from Harvard and Oxford and postdoctoral studies at Princeton and Caltech. He was eager to work with Paul Boyer, founding director of UCLA’s Molecular Biology Institute. Now the Paul D. Boyer Professor of Biochemistry and Molecular Biology and a Howard Hughes Medical Institute investigator, Eisenberg first worked as a structural biologist, studying proteins and how they interact and bind to one another.
Then he looked around for a field where he could use the tools he had to make a contribution to improving human health, and found amyloid diseases.
The ultimate goal of the research, of course, is to find treatments and cures. To that end, Eisenberg and his team already have “learned to design inhibitors of the formation of these amyloid aggregates. We hope these inhibitors can be made into drugs.” — Sandy Siegel ’72