(sounds of soccer game in background) - [Female Athlete] She kicks it.

It's coming right for me.

And I went up, and then (sounds of soccer game in background) I got hit in the face and I fell down.

And the next thing I remember is just like being on the ground.

♪ (ominous music) ♪ - [Male Athlete] I felt almost slow motion, like my brain wasn't processing everything like it should be.

Yeah, I didn't get laid out.

It wasn't a big, huge hit.

♪ - [Female Athlete] My eye was, like, swollen.

My head was throbbing.

♪ It wasn't my first concussion so I knew there was a really good chance I had another one.

♪ - [Doctor] Your brain is really, you know it's exquisitely wired.

I mean, there's connections that go everywhere.

They're not designed to withstand that type of force.

♪ - [Trainer] You know, if you're confused or you're like feeling really slowed down, that's a symptom of a concussion.

- [Doctor] And then you get swelling, then you get inflammation, and all those things are conditions that should never exist in the brain.

I don't think people realize what a devastating injury it can be.

♪ (sports up tempo music) ♪ - [Narrator] Concussion.

They can happen in any sport.

(crowd cheers) They can happen at any age.

-[Woman] How many of you guys have ever had a concussion?

Whoa.

Four out of seven.

- [Narrator] It's one of the most difficult injuries to diagnose and treat.

- [Man] It's not black and white.

It's very gray.

- [Woman] The tests aren't as good as we'd like them to be.

[Narrator] Two scientists in Montana believe their research can lead to a more definitive test to assess brain injury and healing.

- [Man] It's really a change in how you view the health of your brain.

- [Narrator] The search for solutions will lead to surprises.

- [Man] I'll be damned.

♪ (music climaxes) ♪ - [Announcer] Production support for this program was provided by The Greater Montana Foundation, encouraging communication on issues, trends and values of importance to Montanans.

And by viewers like you who are friends of Montana PBS.

Thank you.

♪ (cheerful music) ♪ - [Woman] A lot of times the passion for sports to play has to do with feeling a part of a team.

(team cheer) - It's what you want, you want it more than anything else, is to just play.

♪ - [Male student] Being on that field underneath those lights is a different feeling, really.

(Cheering) ♪ (rousing music) ♪ - [Quarterback] HUT!

♪ (game sounds and cheering) ♪ (game sounds and cheering) - [Announcer on Field] Three, two, one.

(Horn sounds!)

- [Mark Plakorus] You invest everything, and it's just a lot of emotion involved in it, so when you get it taken away from ya', it's indescribable what it feels like.

- [Trainer] Bend your arm, did you get smacked?

- [Trainer] Can you straighten your legs?

- [Trainer] Just hurt in the front of your head?

- [Athlete] Yeah.

(crying) - [Trainer] Did it pop?

- [Female trainer] There's a lot of pressure and it's something that all athletic trainers deal with.

- [Male trainer] I mean, that's the toughest part of the job.

- [Trainer] Can you hold it on your own?

- [Athlete] Yeah.

- [Narrator] The emotionally charged atmosphere of sports makes assessing injuries tough.

Head injuries are particularly difficult.

Better information is needed.

(tape ripping) An experiment is underway.

(team chanting and clapping) - Set.

Hit, hit.

(ball being kicked) - [Narrator] It actually started before the first whistle.

♪ (music begins) ♪ -[J.C. Weida] Hey, how we doin'?

- [Narrator] University of Montana head athletic trainer, J.C. Weida, has been with the department for more than 20 years.

- [J.C.] Neck, back, shoulders, arms, elbows all good.

- [Narrator] He's gathering important medical histories for student athletes.

- [J.C.] Okay, then left knee, you broke your wrist, but no surgery?

- [Narrator] He's seen the changing landscape with concussions in sports.

- So in the 90's, concussions were thought of as a toughness issue, and so people were thinking that they should play with a concussion.

Had a concussion, how many?

- Athlete Two?

Three?

- [J.C.] Two?

- There's some people at the University of Montana that were accepted into a grant to do a study based on blood proteins in concussions or head injuries.

If it's okay with you, you gotta sign another sheet, do another quick thing, they'll just take a little bit extra blood and check that blood protein, looking for that protein.

- [Narrator] He's asking members of the football team and women's soccer team to volunteer to give an anonymous blood sample.

♪ The scientists running the experiment are Dr. Sarj Patel and Dr. Tom Rau.

♪ - [Dr. Tom Rau] I think we're on the right track.

- [Narrator] The scientists are taking these samples to begin a search.

(car traveling) The goal of the experiment is to see if there could be information in human blood to tell us about injury and recovery of the brain.

(elevator dings) Sarj is carrying the potential to unlock a whole new area of advancement in the treatment of traumatic brain injuries.

♪ (music ends) ♪ At first glance, they might appear to be the most unlikely duo.

♪ - [Dr. Tom Rau] He and I are very, very different.

He's more like, he comes out of the U.K. and is going (mumbles) high brow, and I'm more like Montana hick.

- [Dr. Sarj Patel] That's all him.

I would never say that.

(laughing) - [Dr .Rau] But whatever, take your time.

I realize senior citizens need a lot of time for their eyes to adjust.

I give him crap all the time.

- [Dr .Patel] He's very easy to pick on, I'm not gonna lie.

Did you cave?

- [Dr .Rau] No, I didn't cave.

- [Dr .Patel] Did you change the numbers from yesterday?

- [Dr .Rau] No, I didn't change the numbers.

- [Dr .Patel] Just checking man.

([Dr .Rau] laughing) - Do you see how he (...) talks to me?

(laughing) Right, he's always trying to kill me, I'm always, like, running around, trying to get away from him.

He's laying traps, snakes, alligators, stuff like that.

- Keep him on his toes.

- Yeah, it does, it does.

- [Dr .Rau] It's a weird relationship because he and I are always kind of competing with each other, and it keeps us both running.

- [Dr .Patel] We're very equal partners in the work.

I couldn't do these studies without him and he couldn't do them without me.

- [Narrator] Scientifically, they're a perfect match for the project.

Dr. Tom Rau earned his PhD in neuroscience, specializing in brain injury.

He was working on a research project in his area of expertise.

(doors open) Dr. Sarj Patel approached him with a request.

Sarj has a strong background in molecular biology and he wanted to combine his research question with Tom's work in traumatic brain injury, or TBI.

- [Dr. Rau] 'Cause in the past I think a lot of people have operated in one field or the other, so they've said, you know, TBI produces these changes, but we can't tell what's happening at a molecular level because they haven't partnered with a molecular biologist to work out those mechanisms.

And, really, what's happening is molecular.

I mean, it's happening at a very, very small level.

- [Narrator] This particularly applies to mild traumatic brain injuries, where the changes are so small and so subtle, they don't appear in most neural imaging.

The statistics are also difficult to see.

Concussions are under-reported, but the Center for Disease Control estimates nearly four million people suffer a concussion in the United States each year.

- [Dr. Rau] One of the most difficult parts of the whole concussion testing, the majority of people do heal normally.

You've got a small subset of that group, small but significant, that aren't healing correctly.

- [Dr. Patel] You know, we can do a lot of research and sometimes you wonder what the importance of studying a particular protein or a particular mechanism is.

- [Dr. Rau] You know once you get invested in something like that and you see how the injury affects peoples lives, I think it's hard to not get invested in that project and trying to solve a part of it.

- You make these discoveries that can have an impact on the human population, not just here in the States but in the whole world.

- [Narrator] Their project started with a conversation in the hallway and a modest grant.

But they needed more funding.

They applied for the GE, NFL Head Health Challenge that's addressing the growing concern with concussions.

Their's was one of 16 winning proposals, selected from an international pool of entries.

They were awarded $300,000 and one year to show progress.

They're off to a good start, collecting samples and designing tests, but the calendar is turning quickly.

They have seven months left to get results and qualify for the GE, NFL final round award of $500,000.

Their jobs and the project hang in the balance.

- I think we're on the right track, but that pressure's always there, it's always there.

You know that you have seven months of salary left then you're done.

You know, and if we're done then the whole thing just shuts down and that's it.

Box it up and walk away.

- I mean, I worry about not having the funding.

I worry about the fact that, you know, what's my family gonna do if nothing comes of this project.

(family eating) - [Amanda Patel] It's very scary, especially when you have kids and a house and a family, and you don't how much longer they're gonna have funding.

- I knew we'd see it eventually.

- [Dr. Rau]You know, it's a huge stress on everyone in your life, you know, your family.

If I don't get another grant next June, or next May, I'm outta work, you know, and then I don't know what we're gonna do.

When this grant came in, I was basically like 25 days away from being unemployed.

- [Narrator] This is the life of a research professor in science, bring in the grant money, or they're out of work.

Publish or perish.

The clock is ticking.

The deadlines are approaching, and the need for their research is growing.

(music ends) (soccer game sounds) - [Trainer] It is a physical game, you know.

It's not a non-contact sport like people think it is.

(soccer game sounds) ♪ (dramatic music) ♪ (soccer game sounds) ♪ (dramatic music) ♪ - [Narrator] While heading the ball receives the attention, the most common cause of concussions in women's soccer remains player-to-player contact.

Unfortunately, for University of Montana red-shirt freshman, Payton Agnew, she fit that profile.

An elbow to the face forced her out of the game.

The school's concussion protocol started as soon as she left the field.

-[Trainer] You nauseous?

-[Payton] A little bit, yeah.

-[Trainer] Headache, headache worse?

Yeah.

-[Payton] I really just wanted to stay on the field it wasn't gonna happen, I knew I had to come off.

-[Trainer] Let go sit over here.

-[Payton] I mean more than anything, I wanted to stay.

- [Narrator] The University of Montana uses a seven step protocol for diagnosis and return to play.

In a best case recovery, the athlete would complete one step each day, as long as they remain symptom-free.

Payton is removed from the game and given a sideline assessment.

-[Trainer] What other symptoms do you have right now?

-[Payton] Dizzy, and it's just throbbing.

-[Trainer] 'Kay - [Narrator] University of Montana soccer trainer, Melanie Dalpais, is in her sixth year.

She's using the Standardized Concussion Assessment Tool, or SCAT3.

-[Melanie] Can you backwards from a hundred by sevens for me?

-[Payton] 100, 93, 86?

-[Melanie] The biggest thing for me is talking to them, seeing what their responses are.

And, yeah, the SCAT3.

it's a predetermined conversation.

-[Melanie] How bad is your headache on a scale of zero to six?

-[Payton] Like a four.

- They use questions that they have shown to either, mimic or not mimic concussion-related symptoms.

So the SCAT3 and doing that test is part of my determining factor.

Okay, bring your head forward.

Okay, and back.

Pressure?

-[Payton] Forward, backward.

-[Melanie] Okay.

It's less for me about her answers and more to how she answers.

And more if I see normal Payton or if I see some things that are a little bit off.

-[Melanie] We're gonna track.

You ready?

-[Payton] It hurts.

-[Melanie] That hurts?

What about this way?

-[Payton] I couldn't follow that finger.

It made my headache....

I was being stabbed with a knife trying to track that finger the first time.

I mean, I could not do it to save my life.

- [Narrator] Based on symptoms and testing, Melanie determined Payton had a concussion.

but Melanie says the protocol still lacks a certainty other injury testing provides.

-[Melanie] You know, my top two injuries are an ACL tear or a concussion.

In a knee, I can do the test.

I can physically do a test that shows that their knee is now much better than it was before.

But when it comes to concussions, we don't really know what's going on because the studies haven't been done yet.

- [Narrator] The other key factor was history, and Payton has a history.

This has her fifth diagnosed concussion playing soccer.

The first three were during her teenage years in San Diego.

Whether it was high school or a club team, they basically had no concussion protocol.

- [Payton] When it came to getting hurt, you just kinda dealt with it on your own and it was all up to you, so I can't really say I took the proper steps to recovery just 'cause I didn't know what they were, I didn't have anyone to tell me.

- We never took her to a doctor to have her assessed as being, okay, this is a concussion, only because she didn't wanna miss out on games.

So what probably should have happened, didn't.

-[Ron Agnew] You're always concerned that if you make a bad decision as a parent, then, I mean, there could be repercussions, you know, years from now, so you try to measure that and you wanna err on the side of caution.

But we don't know what being cautious is when it comes to concussions.

(soccer game sounds) - [Narrator] It's a dilemma many families face when dealing with a head injury.

This time, Payton will follow the university's protocol.

There are only three weeks left in the season and she desperately wants to get back on the field.

(football being kicked) No two head injuries are the same, and this brings a different case.

When we last saw Missoula High School junior, Bridger Skillicorn, he had taken himself out of the game.

He didn't suffer one major blow, like Payton, or even briefly lose consciousness.

One possible reason for leaving the game may have been the cumulative toll of what's know as sub concussive hits.

♪ (dramatic music) ♪ ♪ (dramatic music) ♪ ♪ - [Dr. Rau] How many sub concussive hits can you have before it equals one concussion?

♪ - [Narrator] Instead of thinking of one big hit, ♪ there is a growing concern over the repeated blows from games and practices where the athlete does not lose consciousness.

♪ - [Dr. Rau] So does that mean that their head's not being damaged?

Or does just that mean that they can withstand a lot of impact without losing consciousness.

- [Narrator] Bridger is six feet four inches and 260 pounds and puts in work on both the offensive and defensive lines.

(football sounds) By the third quarter, the 17-year-old knew something wasn't quite right and he came over to talk to his trainer, Paul Capp.

-[Bridger] I don't know.

-[Paul] You feel like your feet are bothering you?

-[Bridger] Not like...

I feel like too slow, like, I don't know, I don't know.

I don't know how to explain it.

- Immediately, just talking with him, he wasn't normal like he usually is.

- I just wasn't feeling myself.

I was feeling really slowed down, really, really confused.

Like, it took me a long time to process and they'd play call and it'd take me a really long time to process what I'm about to do.

-[Paul] Lights seem a little brighter?

Seem louder than usual here.

-[Paul] Little bit.

-[Paul] Can you hear everything, though?

-[Paul] Yeah.

- [Narrator] Paul Capp is in his second year as Missoula Hellgate High School Athletic Trainer.

He's also using the SCAT3 protocol, asking a series of questions.

-[Paul] What half is it?

- [Narrator] Checking symptoms.

-[Paul] Nauseous, anything like that?

- [Narrator] And testing vision and balance.

-[Paul] Okay, look straight ahead.

You know with other injuries, with the tests that we have and MRI's and tools like that, we have very black and white ways of determining where an athlete is at with that injury.

With concussions, we have nothing even close to that.

-[Paul] You okay, Jacobson?

- Yeah, I'm fine.

-[Paul] You sure?

- Yeah.

-[Paul]Good.

-[Bridger]I know it sounds like a lot more emotional when I had my concussion, but I just remember so angry and sad about it.

I was just crying.

I look back, it's kinda, it's not funny, but it is kinda funny at the same time now.

Like that's something that I'd never do normally.

- Feel okay?

You look a little pale.

Pissed off a little bit?

- After the game when we seen him, it was just like, wow, that's a concussion.

'Cause it was pretty obvious, you know he doesn't remember...

I don't even think he remembers talking to us after the game, honestly.

- [Narrator] Bridger also played youth sports.

This will be his second diagnosed concussion.

(cheering) Now he follows a similar path to Payton, trying to safely return to play.

This is the phase where the scientists hope to help.

(Piano music) - [Narrator]Deep in the university building's basement, scientists took the first steps toward a major advancement in the study of concussions.

Dr. Tom Rau's expertise with injury models intersected with Dr. Sarj Patel's work in molecular biology.

- [Dr. Rau] So it's really kind of a complex measure of how well they're remembering where the negative reinforcement is.

- [Narrator] Using rats, they were trying to track the behavior of a particular protein during a traumatic brain injury, or TBI.

- [Dr. Rau] We knew that in our animal model of TBI that a key protein was disappearing throughout the brain, and that protein plays a large role in the health of the brain, so we knew that the loss of that protein was crucial.

- You know, I've been studying this protein for a very long time, sort of had an idea of how it behaves, we've studied some of the mechanisms.

Usually it goes up, and for some reason in traumatic brain injury it was disappearing, so that was very intriguing to us.

- [Narrator] The protein, identified as system xc, helps in the process of protecting cells in the brain.

Following the traumatic brain injury, that protein was disappearing.

The scientists started looking for answers on a molecular level.

♪ Inside a cell, the DNA provides a template to make ribonucleic acid, or RNA.

♪ A certain type of RNA then produces important proteins.

♪ - [Dr. Rau] Under normal circumstances the RNA are taking information from your DNA, your genetic blueprint and are making new proteins.

♪ But micro-RNA's actually come in and stop that process, so these proteins aren't being produced.

They're obviously very, very potent, they're very, very powerful.

- [Narrator] These scientists think the micro-RNA's could hold the key.

♪ Because of some of their properties, these even tinier molecules can move freely from the brain in to the bloodstream.

♪ Their presence in blood could reveal critical information.

♪ The hypothesis?

High levels of specific micro-RNA's in the blood could indicate an ongoing brain injury.

It would be a major breakthrough in the field.

A new way to get information about the brain without an invasive procedure.

It would simply require a blood test.

- [Dr. Rau] So if an individual had a traumatic brain injury, we could go in, we could draw their blood and measure the micro-RNA's to say, you know, yes, these are elevated.

You're not safe to go back and play.

You're not safe to do any of these activities until these micro-RNA's come back to a normal level.

That would indicate that this protein we've been studying is coming back to normal levels, your brain is recovered, it's safe for you to go back and play.

- [Narrator] It would be a powerful diagnostic tool to add to the current protocol.

After the athlete is removed from the game, a blood sample would be taken.

Once they progressed through the protocol, another blood test would be given to see if levels returned to normal before resuming full-contact practice and play.

Before that could happen, the scientists had to take a huge step.

Their hypothesis was based on animals and they needed to see if it applied to humans.

-[J.C.] You need to relax.

There you go.

- [Narrator] They partnered with the University of Montana's Athletic Department and head trainer, J.C. Weida.

- Blood and blood proteins, which is a different direction than anybody else is looking at.

They get a grant, and they obviously need subjects.

I can be a middle person in helping to attain those subjects.

- [Narrator] J.C. helped get football players and women's soccer players to volunteer and give a blood sample.

By the end of the year, Dr. Sarj Patel was packing up 90 samples.

They included athletes and non-athletes, some had a concussion history, some did not.

He'll send them all to a lab for analysis.

-[Dr. Patel] We're eager to see what's gonna come out of this.

You know, I'm excited.

Nervous, but excited, too.

- [Narrator] It will take months before they know if this container unlocks any answers.

(door closes) - [Researcher] I'm cutting them thin just gives us the ability, then, under the microscope to see.

- [Narrator] The other members of the research team try to push the science forward.

The research is expensive and the funding is running out.

Their jobs are also on the line.

- [Dr Rau] But I don't know what you guys, - [Narrator] Tom and Sarj shift their focus to raising money.

With little financial support from the university, they search for more funding.

- [Person on phone] I think it might be a bit early for that, right, correct me if I'm wrong.

- [Narrator] Conference calls with outside companies, writing grant proposals and writing more grant proposals.

-[Dr Rau] There's so much potential money on the line.

To walk away now and go back to testing piss and poop when we could have 500k coming in.

So it's hard to, as you get closer to that drop dead date, you know that all the work that you put in could end, you know, and if there's no funding for it that's where it goes, it just dies.

That's a hard thing to swallow sometimes, especially when you're so invested in what you're doing.

You can't run science that way.

You can't run a career that way.

That's the reality of it and that's what I signed up for, but at some point you're also like, I signed up for this but this wasn't a permanent sign up.

You know, I didn't sign up til, what am I going to be 95 years old, okay, Sarj, let's write another grant and hopefully we won't be unemployed shortly.

And, you know, at some point you gotta come to reality and be like, this is completely unstable.

(soft music) - [Narrator] They get the word that results from their first samples will be emailed to them, In traumatic brain injury research in humans, no one has ever detected these specific molecules related to the injury.

With little time and money, they have no margin for error.

♪ -[Dr. Rau] If we don't see anything, that's less than desirable.

(laughing) That's more of, I'm sad, than happy.

- [Dr. Patal] But we don't know, right?

- Yeah, we don't know.

- That's the whole point.

-[Dr. Rau] Yeah, you don't know.

But it's a lotta work to get to this point to figure out in 30 seconds if you're right or wrong.

If it's wrong, I'm gonna be out on a window ledge.

♪ I'll be damned.

♪ - So comparing to control, that one went up twofold, - Holy (...).

- that one went up twofold, that one went up threefold.

- (laughing) Yes, yes, yes, yes.

- [Narrator] The results showed they detected specific molecules related to human brain injury.

- J. Yeah, yeah, yeah, yeah, yeah.

That went up fourfold.

(laughing) - Well, we got a few.

-[Dr. Rau] That was really exciting, that they were there, that they were detectable, that we could actually see them.

The second part was that we found patterns in that.

- [Narrator] The patterns dealt with three main groups.

Those who reported never having a concussion, they had almost no detection of these micro-RNA's.

The next group suffered a concussion, but had no lingering symptoms.

They had low levels, a good sign of a healthy recovery.

The final group, about 20% of the participants, suffered a concussion and reported lingering symptoms.

Every one of those people showed elevated levels of these specific micro-RNA's.

A positive step towards possibly identifying those who need help in recovery.

-[Dr. Rau] It's encouraging.

It's encouraging because those are individuals that may have a long term process going on that need to be studied very carefully and watched very carefully.

- [Narrator] What did these high micro-RNA levels indicate when it comes to how the brain works?

(beeping) The researchers used an old children's game to test the participants working memory.

Everyone took the test several times in a row.

Both groups, those who did not suffer a concussion and those who did, scored well on the first tests.

They immediately took the test again, and the group that reported a concussion and had lingering symptoms, showed a drop in their scores.

By the third time taking the test, those with a concussion and lingering symptoms had significantly lower scores.

- [Dr. Rau] What we think is happening is that those individuals are susceptible to fatigue, to memory fatigue.

Their brains haven't healed completely and they don't have the same capacity to remember things and that leads to dysfunction in their lives.

- [Narrator] These powerful molecules, the micro-RNA's, now open the door to even bigger questions.

- [Dr. Patel] Well, we're trying to get a better handle on now is, with the very presence of these things, how long do those changes last.

If these molecules are disappearing, do these proteins return.

You know, are you repairing.

-[Dr. Rau] What I can't tell you is that if those micro-RNA's are elevated and they go out and get another injury, will that injury be more severe?

Will they have that second injury syndrome?

We don't know that yet.

- [Narrator] The science will have to wait.

The deadline is almost here.

- You don't got any time and you don't got any money.

You don't have any time.

By the time you get it put in, we're done.

- I know.

- [Narrator] The project won't move forward until they get more funding.

(TV on in background) ♪ - [Payton] I'm not allowed to go to class.

I'm not allowed to go to practice.

I shouldn't watch TV or look at the screens.

I shouldn't drive.

I should just lay at my house and do nothing.

♪ I mean, that's how people go insane, it's like torture.

♪ I'll admit it, throughout the day I was watching TV, ♪ and once it got to eight, 8:30, I couldn't do it.

I couldn't focus on the TV, I couldn't handle the light and I remember texting Nora, being like, I can't do this.

♪ And it's not even like you can fall asleep 'cause your brain doesn't shut off.

♪ - [Narrator] Payton Agnew is trying to follow the return-to-play protocol.

She wants to get her life back to a normal routine.

After resting, her symptoms improved and she tried to start catching up on class work.

- [Payton] I went to class, and it was on the third floor and I walked the stairs but I always do that, and I just got really sick during history.

So then I had to step out after we took our quiz and I just sat in the bathroom with my eyes covered for like 20 minutes.

- [Narrator] It's a setback, but Payton's self-reporting is the main window into her condition.

A few days later, her symptoms improve again and she's ready to try the next step of a light aerobic workout.

- If at any point you start to feel bad or any of your symptoms come back-- - So like worse than I did when I came in here?

- Yeah.

But you felt okay, right?

- Okay, yeah.

(laughs) - Two minutes in.

- God.

This is the worst.

Can't I just run?

- No.

(exercise bike humming) - Okay, so like what extent am I not supposed, like, am I supposed to stop.

- Do you feel bad?

- Not bad, but like getting worse.

- Stop.

(gasping in disgust) - But I don't wanna do it again.

(gasping in disgust again) Okay, now what.

- We're done for today.

- [Payton] I hate biking.

I hate it.

I wanted to pass so bad.

I knew I wasn't going to.

Uh, dammit.

- [Narrator] Another setback delays her return to the field.

Payton still gave honest feedback.

Self-reporting is key, but it's also part of the problem.

- [Payton] All I have to say is, "No, I don't have a headache," to be on the field.

That's it at this point, 'cause everything I'm doing is like, as long as I say I feel good, I feel fine, I'm cleared.

But at the same time you can't do that 'cause it's just, it's so dangerous, but you want to and you don't want to at the same time.

- [Trainer] Nausea or vomiting?

- Three.

- [Narrator] It's not quite that simple for Payton to get back on the field.

- [Physical Therapist] Well, I'm sorry to hear you have a concussion.

- [Narrator] Payton was referred to a local physical therapist who was using balance testing and vision testing, - [Physical Therapist] That's much better.

- [Narrator] to reduce the reliance on self-reporting.

Back at the university, perhaps the most common tool for schools and sports teams is a computerized test that Payton knows well, The Immediate Post-Concussion Assessment and Cognitive Testing.

ImPACT is a computer exam that checks skills such as memory, pattern recognition and reaction time.

A person takes a test when healthy to establish a baseline, and then takes additional exams after a concussion to track any differences.

ImPACT is the most widely used concussion evaluation system in the United States, and that just might be the problem.

- [Melanie] I mean, they're doing this on middle school and junior high kids.

At 11 and 12 years old they're starting to take this ImPACT test.

Well, by the time they're 18 to 22 in college, they're gonna know, they're gonna have it memorized.

And yeah, they change the test every year, and yeah, they change the style, and yeah, there's five different versions of the test.

But when you interview an athlete or when you talk to them after the test, there's a learning curve.

They know what to expect and so when they know what to expect, the results are skewed.

- [Payton] You can train yourself to memorize what's given, so it's not a problem.

'Cause, I mean, I do have conversations with people about, oh, well what words did you get and what images did you get and how did you do this and that.

There's a learning curve.

Period.

(laughs) - [Narrator] Bridger won't be taking the ImPACT test as part of his return-to-play protocol.

His trainer, Paul Capp, says his high school athletes discovered a different tactic taking the test.

- [Paul] I was talking about how I didn't think that necessarily.

the baseline tests were very good, I thought that the kids were either not trying to perform well on it or they were intentionally not doing very well on it.

So I just wasn't feeling like I was getting very good baseline tests to even help me make a accurate decision on where they're at based on their post-concussion test.

- [Narrator] The ImPACT test was never intended to be a sole determining factor with concussions.

Healthcare professionals and scientists agree there will not be one single test to deal with head injuries.

The next combination of tests needs to provide more definitive information.

- [Melanie] We can see that there's improvement and we can see that symptoms are being relieved, but it's hard at this point because there's no solid evidence to show us that we've healed them.

(clap, "hut") - [Narrator] The uncertainty is just as hard on the athletes.

It's been 10 days since his injury and Bridger still has lingering symptoms and can't practice.

- [Paul] I know, it sucks.

- [Bridger] I just have the worst headaches of my life.

Really, really, really bad.

- [Narrator] It's taking longer than he thought, but there's no set timeline for head injuries.

Bridger's friend, Ronnie Chavez, received a concussion in the same game.

Now he's back at practice and will play on Friday night.

♪ - [Bridger]It was pretty frustrating in seeing Ronnie getting back, you know, it was pretty frustrating because I felt like, you know, I was letting my teammates down a little bit, but I needed to take care of my concussion.

(soccer ball bouncing) - [Payton] Well, you don't feel like a part of the team when you're out.

You don't.

You feel like an outsider.

♪ It's really hard, just emotionally, ♪ to just handle mentally.

♪ - [Melanie] There's no point in you going.

- [Payton] But I feel guilty if I don't go.

- [Melanie] You have a concussion.

- [Payton] It doesn't stop the guilt.

- [Melanie] It's not like your teammates, I mean, teammates want you to get better, so if that means not going to practice is going to make you better, you shouldn't feel guilty for trying to make yourself better and get yourself back out on the field so you can play.

♪ - [Payton] It's like the angel and the devil on your shoulder.

You can't choose which one you want more because, well, in the long run it's your head but right now your whole life is getting back on the field.

♪ It's so hard.

It's so hard.

(sighs) And I'm, I don't even know what to say, it just sucks.

(laughs) It just sucks.

- [Narrator] The stress takes its toll on everyone.

Coaches, parents, players, trainers.

Everyone wants more certainty that just doesn't exist.

Paul Capp experienced that during a rivalry game.

His sophomore player, with a concussion history, came to the sideline holding his head.

♪ - [Paul Hey, you're not going back in until your checked, so.

Four, nine and three.

Say them backwards.

- [Darren] Four, nine and three.

Say them backwards.

Nine, three, four, three.

I don't (...) (...) you, Paul.

- [Paul] No.

- [Darren] I'm fine.

- [Paul] So it's definitely in doubt about whether he had one.

Four, two, seven, one.

- [Darren] One, two, four, (...), seven was the first one, yeah.

Seven, four, two, one, so.

I don't (...) know.

- [Paul] Okay, no, no, no.

You're not going in this half.

Call me whatever name he wanted to call me, he was out.

- [Darren] I'm fine, I don't have one.

- [Paul] Then why are you wincing?

-[Player] I'm not.

- [Paul] Everyone says you need to go check on Darren, he's over there wincing, he's over there grabbing his head.

- [Coach] Chill.

- [Darren] I don't know what it is about it, it just really set me off and I just could not contain myself.

I wanted to go in so bad.

-[Paul] No, I'm not risking it.

I know there's something, - (...) - I know that there's something wrong with you.

- [Darren] Everything's (...) fine with me.

I'm (...) pissed.

- [Paul] Do I view this as him being really angry because of this missed block or do I view this as him being really angry as, like, a result of a personality change from a possible head injury.

(mumbling) - [Paul] You're not.

You're done.

I'm gonna send you to the locker room if you keep arguing with me, Darren - [Darren] I was not givin' in to til the very end.

- [Paul] You're not acting like yourself.

You're acting like what you act like when you get a concussion and you're all defiant about things.

You've had three of 'em around me so I kinda know what I'm dealing with.

You're down 53, quit arguing with me.

Oh, my God.

(sideline sounds) I honestly don't think he had a concussion.

I told him that after the game and once he was calmed down.

- [Darren] I wish he woulda let me play, but I can see where he's coming from, 'cause, it's like, I feel like if I was in his shoes and I had a kid that was had several concussions before and concussions are pretty serious.

- [Paul] It's always difficult to tell somebody they're not gonna play in the game.

'Cause you don't get that many opportunities as a high school kid.

It's just draining because it's not straightforward.

Nothing is straightforward.

It's not black and white, it's very gray.

(cheering) - [Narrator] It turns out, all that uncertainty also applies to the scientists.

(game sounds) ♪ (dramatic music starts) ♪ - [Dr. Patel] Thank you gentlemen for coming out to Montana to hopefully get an idea a little bit of some of the work we've been doing.

I know you have the progress report.

- [Dr. Rau] And so these are the things that we've done with the money you've given us in the year time frame.

- [Narrator] The scientists are making their final presentations to a group from General Electric, who flew to Montana for a site visit.

The GE reps, along with the NFL, are evaluating all 16 Head Health Challenge projects to determine the final awards.

- [Dr. Patel] The size of the state, the rural, one of the things that we did really well was really show how much bang we got for every buck.

Parents wanna know, parents really wanna know what their kids, - [Narrator] Tom and Sarj presented their promising early results to the GE representatives.

They hope it will show them they deserve to be among the six projects selected for final round funding.

An award worth half a million dollars to each group.

- I think for GE and the NFL, what we're looking to find is what uniquely will they be able to bring to the table and continue to advance if they were to receive the final award.

And I think that's going to be very difficult because I think each one of them have presented really exciting potential future work.

So our work's cut out for us.

I mean, I think we're gonna have a hard time choosing, but that's what we want.

We want a hard time choosing.

(small group of voices) - [Dr. Rau] They're hard to read.

You know, I don't really know.

I don't really know.

It's really hard to tell what their thoughts were.

- [Dr. Patel] You know, they said they had 16 really good projects.

That's why our research, to help understand and diagnose-- - [Dr. Rau] Well, we've got 29 days til we're unemployed.

29 days til we're completely out of money.

We're gonna take this act on the road.

We've both got straw hats, he can play the ukulele.

I can dance, yeah.

- Poorly, - Poor, yeah, poorly.

They actually throw money to have me stop dancing, but yeah, we're outta money in about 30 days.

(music ends) (Football game sounds) - [Narrator] While the research and funding wait, small Montana schools have their own challenges.

(band playing) In places like Alberton, Augusta, and Drummond, they try to care for student athletes on a limited budget.

(players cheering) Most smaller schools, like the Class C Simms Tigers, contract with a nearby clinic to have a trainer at games, and maybe one weekday visit.

Morgan Umphres works for a Great Falls clinic that provides athletic trainer outreach for small schools in the area.

-[Morgan] Get him off.

Get Kuskey off.

- [Kuskey] We're good, we're good.

-[Morgan] Hey, you sure.

- [Kuskey] Yeah.

-[Morgan] Why'd you stand like that?

- [Kuskey] Hurt my head a little bit but we're good.

-[Morgan] What quarter is it?

- [Kuskey] Fourth.

-[Morgan] How much time is left?

- [Kuskey] Probably about six, five minutes.

Oh, (...).

(laughs) -[Morgan] 'Kay.

Stand on your right foot.

Stand on your left foot.

Feel nauseous, like you gotta puke at all?

How's your headache now?

- [Kuskey] It's fine.

-[Morgan] Scale a zero to 10.

- [Kuskey] Zero.

- -[Morgan] You sure?

- [Kuskey]Yeah, -[Morgan] Kay.

I feel like you're just getting tired.

-[Morgan] If I wasn't a hundred percent sure that he didn't have a concussion I wouldn't a sent him back in.

(coach yelling at players) - [Narrator] In this case, Morgan determined the player did not have a concussion.

However, when a player is diagnosed, it can be tricky to enforce the protocol as their part time trainer.

(player grunting) -[Morgan] How do you know that they're being compliant if I can't even see 'em on a daily basis.

It's hard to manage.

There's a lot of emailing that goes on between me and the AD's and the coach to make sure that that athlete stays outta practice during the week and make sure that they follow the progression, the return-to-play progression.

(game sounds) So just report anything, okay.

- [Kuskey] Oh, I will.

-[Morgan] Be honest.

- [Kuskey] Yeah.

- [Narrator] Small budgets and small staffs won't be going away anytime soon in Montana schools.

They might have an even greater need for a simple scientific assessment of head injuries.

-[Morgan] Any diagnostic tools that you can get, they come in and get a blood draw along with a doctors eval and stuff, it'd just be one more step in that doctor's visit to return to play.

- [QB calling play] Swing left, big 24 dive, halfback swing pass left on one.

Ready?

- [All] Break.

- [Hut Hut!]

(players hitting) - [Narrator] The greatest need might be with the youngest athletes.

- [Coach] Ready, go.

(players hitting) - [Coach] To high, Rory.

(whistle blows) - [Joe] I like to tackle kids.

That was fun.

(laughing) Just to kinda wreck whatever they were doin'.

(people cheering at game) - [Narrator] In a variety of sports, there are young people with bodies and brains that are still developing.

These fifth graders are having fun playing tackle football.

They're part of the next generation of players that have heard a thing or two about concussions.

- [Joe] It's when your brain hits your skull and when you have, like, a motion in your head where it bounces back and forth in your head.

And you get bruised and pass out, or you have to take a day off from school.

(laughs) - [Narrator] Joe Weida might know a little more than most fifth graders when it comes to concussions.

Maybe he gets it from his dad.

- [J.C.] Good job, Joe.

J.C. Weida is the head trainer at the University of Montana, and helped facilitate the science experiment with concussions.

- [J.C.] And obviously I'm hypersensitive to it.

I talked about it with my family, my wife, my kids.

I don't think concussions are the boogie man.

I do think that how you process those things and how you deal with it can make huge differences.

- [Trainer] Are you dizzy still?

- [Player] Yes.

-[Trainer] He definitely has a concussion but I'm gonna check him out for more just to make sure there's not anymore symptoms.

It might be smarter, just for your own health and safety, if you don't play so you don't get hit and make it worse.

Does that make sense?

- [Player] Yes, but I don't want to do that.

(trainer laughing) - [Narrator] It's a rare sight to see an athletic trainer at a youth sports event.

Most often, parents and players are on their own.

Christine Howard is working for the Missoula Youth Football League.

- [Two way radio] Can I get you to field two?

- [Narrator] She has to cover four fields at once.

She says concussion awareness is on the rise, but everyone needs better information.

- [Christine] So that's the tricky part sometimes.

It's good that people know about it, but it almost can be bad at times when they think they know everything and they don't.

- [Narrator] At every level, youth sports, high school and college, - [Trainer] So you wanna be able to play next weekend, too?

- [Narrator] Most healthcare professionals are trying to use best practices and follow current protocol for head injuries.

- [Trainer] Do you have anything else going on?

Is it just your eye?

- [Player] It's just my eye.

- [Trainer] Any ringing in your ears?

- [Narrator] But for some athletic trainers working in the field, there is the lingering question.

Is it enough?

- [Player] I don't feel bad or anything.

- The thing with concussions is we think that we're measuring.

We think that we know what we're doing.

We think that we're healing.

But there's no...

The tests aren't as good as we'd like them to be.

- I don't even know if we're halfway, as far as having all the tools we need to do a good job as far as detecting them, and making sure that kids are returning to play at a time that's the best.

- [Dr. Fritz] What's been going on, how do you feel?

- [Payton] Good.

Yeah, I practiced today.

- [Dr. Fritz] What did you do at practice?

- [Payton] All of it.

- [Dr. Fritz] And how did it feel?

- [Payton] Good.

- [Dr. Fritz] Excellent.

- [Narrator] After three weeks of appointments and testing, Payton is ready for a definitive answer about returning to play.

- [Payton] Since, like, the week after I got hurt, so, I don't know, it's been a couple of weeks.

- [Narrator] She's meeting with University of Montana team physician, Dr. Carla Fritz, who will make the final call.

- [Dr. Fritz] Everything looks good.

- [Payton] Yay!

- [Dr. Fritz] Keep doing your exercises.

- [Payton] Yes I kno.

- [Dr. Fritz] Again, brace yourself.

Try not run into people.

Again, I know it's a contact sport, let's try not to get you knocked out in our first game of the conference.

- [Payton] I'll do what I can.

- [Dr. Fritz] Good.

Thanks for coming in.

- [Payton] Yep.

(locker room sounds) - [Narrator] The team doctor cleared Payton, but she did not play in her team's final game of the season.

(soccer game sounds) She returned to practice.

Payton has the entire off-season to think about a recovery that's more than just physical.

- [Payton] It's just hard to go back and put yourself in the same situations that you get hurt in.

During practice, it scares me and I don't necessarily think it's worth it, but during a game, that's what I'm best at.

I'm tall, I jump, I'm pretty good in the air.

You just gotta go for it every time and hope for the best.

(cheering) - [Narrator] Bridger was also cleared after three weeks, and he got to play again that same season.

His trainer worked with a local doctor during the process.

But Bridger's got an even bigger decision ahead.

His senior year of high school is approaching, and he needs to decide if that will include football.

(football game sounds) - [Don] I think there's a lot of things that weigh on his mind and I think it makes him anxious and nervous.

A couple more concussions and then what a I do?

- [Bridger] We've talked about it, I mean, we've talked about how many is it gonna take for me, like, if I get three or four, I mean, at some point you have to call it good.

You can't take anymore.

- [Don] I think that we worry about it, but we don't dwell on it, either.

We know that if it's something that he loves to do, it's always been Bridger's decision to do football or not to do football.

- [Narrator] It won't be an easy decision for Bridger, and he's not the only one who's looking towards an uncertain future.

♪ (suspenseful music starts) ♪ - [Dr. Patel] There's been plenty of times, numerous times, I mean we were very close to calling it quits.

We both had our own reasons.

- [Dr. Rau] I had boxes in my office ready to pack up because we were two weeks from being completely out of money.

♪ - [Dr. Patel] Basically we got the call from GE and the NFL.

I've gotta be honest, it was really nervous.

- [Dr. Rau] I was hoping, but I didn't know, I obviously had no idea if we were gonna get it or not.

- [Dr. Patel] He started talking and then he was just like, Ah, I'm not gonna drag this out, just wanna congratulate you.

It was a relief.

- [Dr. Rau] I was like, what, what are you talking about?

And then, yeah, so we get the GE, NFL, the money's out.

I was like, you're kidding.

- [Dr. Patel It was big weight lifted off the shoulders to know that, you know, we had some more time.

- [Dr. Rau] They said they were impressed with our drive and our motivation and the fact that we really wanted to get something done.

And I think that really helped out.

♪ - [UM President Royce Engstrom] It's a transformation day for the Montana University system, as it embarks upon a systematic strengthening of research.

- [Governor Steve Bullock] And the time to invest in research of tomorrow is now.

- [Narrator] This event marked another funding success for the scientists.

- [Dr. Patel] So hopefully have economic impact for the state.

- [Narrator] In addition to the GE, NFL award, they received an even larger grant through the university system with funds provided by the state legislature.

They now have nearly $3,000,000 to move the research forward over the next few years, and there's much work to be done.

They need more subjects and a larger sample size to validate their early blood work.

They want to partner with other researchers to develop a panel of tests, including balance and vision, to combine with their blood test for a more thorough view of traumatic brain injury and recovery.

Their future plans are finally taking shape.

♪ (The Star Spangled Banner) ♪ - [Narrator] It's a new season for high school football.

This is Bridger Skillicorn's senior year.

(player shouting at team mates) After a lot of thought, he made his decision.

- [Bridger] Yeah, I talked to my parents and a lot of my good friends and grandparents and everything about it, and I tried to get everybody's opinion, and I ended up choosing not to play.

(teacher speaking in background) - [Narrator] Bridger said he wanted to concentrate on his schoolwork and get ready to pursue his college major in Wildlife Biology.

He said the concussion wasn't the biggest factor in his decision, but it played a part.

- [Bridger] It's just better for me, I just think to not risk it.

- [Game announcer] Substitutions for both teams, first in for the Grizzlies, number 16, Payton Agnew.

- [Narrator] It's also a new season for Payton Agnew.

She's back and playing well during her sophomore year.

Just like Bridger, she made her decision with the support of everyone around her.

- [Rod] I wanna see her play, I want her to play because I know she enjoys playing.

And I think she's happiest when she is involved with a team and playing soccer.

I hate to see that taken away from her.

- [Barbara] We just seemed to be getting over one hurdle and there's another one, so she has to tell us, I can't tell her.

(cheering) - [Payton] I know that I can only take about one or two more times.

I'm fully aware of what could happen to me if I do get another one or if I get a really severe one.

Or if I get another and try to come back, I mean I know all, I know all the consequences.

♪ (dramatic music starts) ♪ - [Narrator] But does anyone really know all the consequences when it comes to head injuries?

There's so much unknown about the human brain, injury and recovery.

When will new research and new information get to the people who need it most.

The answer, like a concussion, is not simple.

- [Dr. Patel] We made some really good progress, but to really get to where we gonna go, there are a lotta hurdles there.

- [Narrator] They have years of research ahead.

Their pursuit of a patent for their work will be difficult in the United States.

And going through FDA approval will be a long and expensive process.

It might not be athletes of this age, but instead athletes of this age, who will ultimately benefit from their work.

- [Dr. Patel] You know, I really wanna see something tangible really come outta this research, you know.

In that, want it to affect somebody's life.

- [Dr. Rau] You realize that it has use and it has potential, and if it does all work out, it'd be great.

You know, if what we have validates, we will push it.

We will push it forward no matter what happens.

And try and get it into the clinic.

And hopefully it doesn't take a decade.

♪ (dramatic music) ♪ ♪ ♪ (music ends - [Narrator] Production support for this program was provided by The Greater Montana Foundation, encouraging communication on issues, trends and values of importance to Montanans.

And by viewer like you who are friends of Montana PBS.

Thank you.