Kari Fraser was out for a trail run on Mount Sanitas, in Boulder, Colorado, in the winter of 2015 when she slipped on some ice and knocked her head. The impact resulted in a black eye, a severe headache, and a concussion. Fraser, who was 53 at the time, went to the ER and was told she’d be OK, but she didn’t know what to expect when she left the hospital. For months after her visit, she had an extreme sensitivity to loud noises that made her “almost violently irritable,” she told me, and she couldn’t run downhill without feeling a painful shaking sensation in her brain. “I wasn’t given any information about what my recovery might look like,” she says.

Fraser’s experience isn’t unique. Most people who crack their helmet in a bike accident or ding their head while climbing want to know the severity of their injury and what to expect during recovery. Currently, answers to those questions can be frustratingly imprecise. But that could change as researchers turn to biomarkers—substances found in the blood that can alert doctors to what’s happening in the body—to improve diagnosis and learn more about how the body recovers.

The number of serious head and neck injuries in extreme sports is on the rise, yet doctors are still working on ways to measure and quantify what happens in the brain when someone sustains a concussion. There’s no bloodwork and no imaging tests available—doctors make a diagnosis based on patient history and clinical evaluation, looking for signs of concussion such as dizziness and headaches. But many of these symptoms can be caused by other factors, according to Breton Asken, a neuropsychology fellow at the University of California at San Francisco. And while an MRI or CT scan can reveal life-­threatening swelling or bleeding in the brain, a scan that appears normal doesn’t mean you don’t have a concussion, says Linda Papa, an emergency physician at Orlando Regional Medical Center and a concussion researcher. What’s more, CT scans are expensive and expose patients to a hefty dose of radiation. MRIs, while more detailed, are even costlier, and it can take a while to get results.

This is why researchers are turning to biomarkers, hoping to find a better way to assess the severity of head injuries. With simple blood analysis, doctors may be able to make a clear diagnosis and identify patients who can be spared a CT scan or an MRI. In 2018, the FDA approved a new blood test that could help with the latter, although it’s not yet widely available. The test looks for two brain proteins that can indicate damage to brain tissues: ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP).  in 2019, Papa and her colleagues measured UCH-L1 and GFAP levels in more than 700 trauma patients. They found that patients with no head trauma had the lowest levels of these biomarkers; those who’d hit their heads but weren’t diagnosed with concussion had higher levels, and those who’d sustained concussions had the highest of all. Of the two proteins, GFAP was the most useful for distinguishing among the three groups. UHC-L1 also rose with orthopedic wounds, suggesting that it isn’t specific enough to isolate head trauma.

While these are promising findings, researchers caution that concussion injuries­— and the damage they can cause to the brain—are so varied and complex that multiple markers are necessary to provide an accurate diagnosis and track patient recovery. In January, Michael McCrea, a neuropsychologist at the Medical College of Wisconsin, and his colleagues published in JAMA Network Open looking at GFAP, UCH-L1, and other biomarkers specifically in relation to sports concussions. The team compared blood samples from more than 250 concussed college athletes with samples from non-concussed athletes in contact sports, and with a control group of athletes who didn’t play contact sports or have concussions. Similar to previous studies, they found that athletes with concussions had elevated levels of GFAP one or two days after injury, and in some cases longer than that. Levels of UCH-L1 also went up in athletes who had concussions.

Biomarkers like GFAP may also help doctors identify previously undetected injuries. Some knocks to the brain don’t produce noticeable symptoms but cause damage to neurons and tissue that can diminish brain function, especially if someone experiences multiple head injuries. A test that recognizes subconcussive injuries—those that don’t produce symptoms—would be game-­changing, says Adnan Hirad, an M.D. and a Ph.D. candidate at the University of Rochester who studies brain injuries in football players. In the NFL, for example, trainers could make sure that players who need more recovery time after a hit don’t return to the game until they’ve healed.

Another challenge for doctors, says Amaal Starling, a neurologist at the Mayo Clinic, is to separate concussion sufferers likely to make a complete recovery after a little rest (the vast majority) from those who will need extra time and treatment. On that front, researchers are looking at two additional biomarkers, IL-6 and IL-1RA, that show promise in identifying injuries that may require a longer recovery period. A blood test for these could prevent athletes from returning to risky sports too soon and receiving another blow to the head. Studies have also shown that after a concussion, risk of musculoskeletal injuries rises twofold, perhaps due to small remaining deficits in the nervous system, according to Thomas Buckley, a concussion researcher at the University of Delaware. If these deficits impair balance or delay reaction times, the result could be a sprained ankle or torn ACL. And while people with head injuries might worry about chronic traumatic encephalopathy—the neurodegenerative disease making headlines in connection with former NFL players—the science seems pretty clear that CTE results from repeated hits, not a single event, Hirad says.

Researchers caution that studies on biomarkers are new and inconclusive. A simple blood test to detect concussion or identify athletes who need extra recovery time is years away, if it ever arrives. In the meantime, if you receive a head injury, your best bet is to use extreme caution and see a doctor. And before jumping back into your sport, listen to your body. Like Kari Fraser, it will likely tell you if you need more rest.

Get Smart

A knock on the noggin doesn’t always lead to a concussion. Here’s a rundown of important facts related to head injuries.

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Sometimes called a mild traumatic brain injury. A diagnosis considers the patient’s medical history and whether they show symptoms like headaches, dizziness, and slowed reaction times.

Traumatic Brain Injury (Moderate or Severe)

The seriousness of a TBI is determined by one or more diagnostic tests. If a person is unconscious or mentally out of it for 30 minutes to 24 hours, it’s a moderate case. More than 24 hours indicates a severe injury.

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A crack in your cranium that may or may not break the skin. Look for clear discharge from the nose or ears, bruises around the eyes or behind the ears, and blood in the eardrums. If the fracture injured the brain, symptoms such as seizures, vomiting, and confusion may develop.

CTE

Neurodegenerative disease associated with memory loss, mood disorders like depression, and cognitive decline. A definitive diagnosis can be made only by examining the brain post-mortem.

Epidural Hematoma

When blood pools between the brain and the skull. Symptoms may appear soon after the injury and include headaches,vomiting, and seizures.

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Terry Laughlin could make anyone fall in love with swimming.

He talked about his sport as if it were art, like poetry or dance. The that he developed over his 45-year coaching career didn’t just hone swimmers’ technique; it also encouraged a way of thinking, an approach to life, whose basic principle was to move in harmony with the water, rather than fight it.

Other coaches counsel their swimmers to focus on pulling and kicking. Laughlin, on the other hand, contended that the shape of the body moving through the water was even more important. He’d noticed that swimmers who held a sleek profile during push off traveled farther and faster, with less effort than those who moved less aerodynamically. He wasn’t the first coach to pick up on this, but he was the one to popularize an approach to swimming that capitalized on it.

Laughlin called this approach “vessel-shaping,” a term he picked up in the late 1980s from Bill Boomer, then swim coach at the University of Rochester. Boomer’s mantra, which also became Laughlin’s, was that “the shape of the vessel matters more than the size of the engine.” He thought a swimmer could make greater gains by reducing drag than by increasing propulsion.

Laughlin began his coaching career in the early 1970s at the U.S. Merchant Marine Academy in Kings Point, New York. In 1989, after more than a decade of coaching college and club teams and producing 24 national champions, he founded the Total Immersion swim program to work with his most receptive and grateful audience: “adult-onset swimmers,” as he called them—people who’d taken up the sport in adulthood without any background or experience.

“His teaching methods opened up a whole new world to runners and cyclists who wanted to become triathletes,” says Ann Svenson, registrar for the .

In 1996, Laughlin published his philosophy of vessel-shaping and mindful practice in the book . Sales were steady, and two decades after that first edition came out, the book’s 2004 update is Amazon’s number one top-seller in swimming titles. The Total Immersion swim clinics, which grew into a small empire of classes and licensed coaches, have reached thousands and thousands of people.   

That’s quite an accomplishment for someone whose swimming abilities as a kid growing up on Long Island were so mediocre that he was cut from his grammar school swim team. After two summers spent accumulating laps in pursuit of the Red Cross 50-Mile swim badge, he managed to make his high school swim team. He eventually won a swimming scholarship to St. John’s University in New York. Yet his achievements at the time failed to meet his aspirations, and he concluded that he lacked talent and was unlikely to ever improve much.

So he started coaching. By observing his athletes through underwater cameras and through long discussions with Boomer, he soon became convinced that he could make amazing improvements to performance simply by tweaking technique. That discovery opened up a new world of possibilities to him, and for the rest of his life, he was driven by a passion to share that epiphany with other would-be swimmers.

Total Immersion was mindfulness and focus, practiced in the water. Despite his program’s popularity, Laughlin never became one of those slick, marketing pros. What mattered to him was spreading and expanding upon the ideas. It was only the behind-the-scenes work of his wife, Alice, that kept the Total Immersion business viable. She took care of the bank accounts, management, and other details so that Laughlin could be what his daughter Fiona calls, “the twinkle-toed positive free-spirit legend that everyone loves.”

There’s an old adage that those who can’t do, teach. But Laughlin recognized that teaching and doing are two different aptitudes. It wasn’t merely doing that made him a better swimmer: it was focused practice and attention. It was learning. He believed anyone could learn to swim better and more efficiently, and people who took up the Total Immersion approach regularly called it life-changing.

It was life-changing for Laughlin, too. In 2006, he set national records in the one- and two-mile open water cable swims, and was named to that year’s USMS Long Distance All Star team. Over the years, he continued to swim competitively and to do “bucket list swims,” like the one from Corsica to Sardinia he completed in 2015. He sought joy and purpose in the water. “Since I entered my 60s, my racing goals have been to transform a race into a game or work of art,” Laughlin once told the small discussion group where I got to know him.

I’d first met Laughlin in person at the Stanford pool, on a cold, dark morning last fall. I was writing a book about exercise recovery, and he’d invited me to attend a practice at the university. He had opinions about training that he shared freely, with both me and Stanford coach Greg Meehan. Some of his strong views could have come across as criticisms, but that’s not how Laughlin delivered them. His manner was firm, but gentle. He was confident in his ideas.

Laughlin died October 20 of complications from the metastatic prostate cancer. He was 66 and had been living with cancer for two years. He’s survived by his wife Alice, three daughters—Fiona, Carrie and Betsy—and numerous extended family members. He approached cancer like he approached swimming and life. “The more external turbulence I encounter, the more inner calm I must cultivate,” he told his family.

“His influence is far-reaching, and will continue,” says David Barra, co-founder of New York Open Water and a longtime friend. “He made swimming accessible to everyone with a methodical approach that enabled practitioners to monitor their progress precisely and incrementally, but ultimately the goal was always to experience the joy of swimming.”   

In the hospital a week before he died, Laughlin’s daughter Carrie asked him to reflect on what he’d learned during his 45-year career. “Everything that I’ve practiced and taught has prepared me for this crisis moment in my life,” he said. A stroke had landed him in the hospital, and he used the mindfulness techniques he’d developed to teach himself to drink again after the stroke hampered his ability to swallow. “My focal points for drinking are: sip; exhale; relax; swallow; repeat,” he said. He treated those sips of water like repeats in the pool—complete with rest intervals.

Laughlin remained optimistic to the end. His relentless positivity, along with his sense of humor and love of baseball, were his defining features, says his sister, Moira Laughlin. Shortly before he died, he told a joke about two friends who had a pact. The first of them to die would return to tell the other whether there was baseball in heaven. So the first guy dies, and he appears to his friend. The good news, he says, is that there’s baseball in heaven. The bad news is that you’re pitching tomorrow.

“He thought that joke was so hilarious,” Fiona told me. “It was the last time I saw him laugh.”

A few days after he died, I received an email from Laughlin’s account. It was an announcement of his death, sent by his family, and like every other Terry Laughlin email, it was signed with a 1990s-era ascii image depicting a swimmer and a tagline that suddenly seemed like a perfect epitaph.

“May your laps be as happy as mine.”

is lead science writer at FiveThirtyEight. Her book about exercise recovery will be published next year by W.W. Norton.

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