Improving how we treat veterans with mTBI (11/14/19 newsletter)

Nov 19

We are pleased to have Carleton College students and alumni interning with Concussion Alliance. Intern contributors this week:

Editor: Galen Moller
Contributors: Eloïse Cowan, Conor Gormally, Galen Moller, Katie Taylor, and Warren Situ.

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Education

New Canadian policy on concussion provides recommendations for key audiences

A news report from the Concussion Awareness Training Tool shared a new Canadian policy on concussion, created by the Canadian Medical Association, College of Family Physicians of Canada, and the Canadian Academy of Sport and Exercise Medicine. The joint set of policy recommendations is designed to promote awareness of concussions outside of sport and improve management and treatment procedures for key target audiences.

The policy summary includes recommendations for physicians; medical colleges; athletes in contact/collision sports, and parents of minors in such sports; people who sustain a head injury outside of organized sports; employers; governmental regulatory bodies; and other groups. These recommendations aim to curb injury minimization and other mindsets or misperceptions that “perpetuate, and contribute to, toxic cultural dynamics within sporting, leisure, and work environments.”

Online program on “Acquired Brain Injuries in the Elderly Population” on November 20th.

The Brain Injury Association of New York State is presenting an online professional development session that will focus on the “particular care considerations” necessary when an elderly person acquires a brain injury after a fall. Presenter Benjamin Seidel is a “board-certified physiatrist with sub-specialty certification in brain injury medicine as well as electrodiagnostics.” The online session will take place on November 20th from 1 to 2 PM. The registration fee is $25 for members and $30 for non-members.

Sports

“The Aerial program helps kids head the soccer ball safely” is now available as a blog post

Cannabis

Breakthrough identification of vitamin E acetate in lung injuries

In its ongoing efforts to identify the cause of the numerous cases of E-cigarette or vaping product-use-associated lung injury (EVALI), the CDC has had a breakthrough. Last Friday, in the Morbidity and Mortality Weekly Report, they announced that they’d collected and examined fluid samples from the lungs of 29 EVALI patients, and they detected vitamin E acetate in all 29 samples. This provides evidence of vitamin E acetate at the primary site of injury among EVALI patients, which is consistent with past tests that found vitamin E acetate in samples of the products used by EVALI patients.

Vitamin E acetate is the first and only potential toxicant of concern found at levels detectable to their test. “Other diluents and additives of concern (e.g., plant oils, MCT oil, petroleum distillates, and diluent terpenes)” were not detected in the lung fluid samples. THC was detected in 23 of 28 samples tested, including the samples from three patients who said they did not use THC products. Nicotine metabolites were detected in 16 of 26 samples. Their findings support past advice from the CDC that people should avoid using e-cigarettes or vaping products—especially if they come from somewhere other than a dispensary, as these can have any number of unknown ingredients.

Diagnostics

What we know about post-traumatic headaches

Post-traumatic headache (PTH) accompanied by light sensitivity is the most common symptom of post-concussion syndrome (PCS). PTH is defined as a secondary headache disorder that can manifest as different sets of symptoms that resemble those of primary headache disorders, such as migraines, tension headaches, and migraine-like cluster headaches. Physicians often treat PTH symptoms in the same way they would treat the symptoms of primary headache disorders, but this is partly because we do not fully understand the physiological mechanisms of PTH and light sensitivity.

A narrative review by Christopher Mares et al., published in The Canadian Journal of Neurological Sciences, summarized by Neurology Advisor, describes our current knowledge about PTH and light sensitivity after mTBI, to help guide further research and provide better care for these symptoms. According to the review, potential PTH mechanisms include inflammation, cortical spreading depolarization, excess glutamate, autoimmune factors, electrolyte abnormalities, and hormone dysregulation. The article demonstrates that concussion symptoms often have many possible causes, and more research from multiple disciplines can be very helpful.

Therapies

New mobile app being developed to help manage concussion recovery through graded exercise

Michael Hutchison, assistant professor at the University of Toronto’s Faculty of Kinesiology & Physical Education, has developed a mobile app that provides users with personalized and graded aerobic exercise to help manage their recovery from concussions. In a news release from the university, he explained that the inspiration for the app came from the pervasive “lack of awareness and education regarding the initial medical management of concussion,” along with the fact that physicians’ infrequent availability often leaves patients “to navigate and manage their symptoms without having the required knowledge or skills to do so.” The app, named RHEA, will utilize machine-learning algorithms to develop a personalized exercise program for its user, providing a more self-involved way to recover.

Hutchison expects to have RHEA available on Apple and Android phones in the new year. There are even plans to eventually develop the app for helping individuals manage other health conditions like PTSD, anxiety, and depression.

Research on the PoNS treatment for balance deficit due to mTBI

The journal Brain Injury published an abstract (#800), which was accepted by the IBIA’s 13th World Congress, concerning research on a Portable Neuromodulation Stimulator (PoNS) which delivers translingual neurostimulation (TLNS). This device uses stimulation of the trigeminal and facial cranial nerves to improve chronic balance loss due to neurotrauma. This particular study aimed to determine the effectiveness of the PoNS device combined with targeted exercise. Authors Mitchell Tyler et al. found that TLNS delivered with the PoNS device led to fewer falls and improvements in balance with both high- and low-frequency stimulations.

The PoNS device currently holds regulatory approval in Canada, where it is in use in a number of clinics, according to the Helius Medical Technologies website. The Weekly Concussion Update previously discussed the FDA’s rejection of the PoNS device in April 2019. In October 2019, Helius Medical Technologies announced the company was working with the FDA and is planning a new study based on the FDA’s request for research that “demonstrates the benefit of PoNS Treatment compared to physical therapy alone.”

Veterans

Pentagon plans to expand transitional healthcare program for veterans with TBI

According to an article in Al-Monitor, the Defense Department plans to expand its inTransition program to provide treatment for military veterans suffering from brain trauma. Since concussions and traumatic brain injuries have become a pressing military health concern of the twenty-first century, the Departments of Defense and Veteran Affairs are devoting more resources to improving recognition and treatment of this issue. This makes leaders in veteran affairs organizations cautiously optimistic for the future of these types of programs.

Many brain injuries are caused in combat by sophisticated explosive devices, but brain injuries are also caused in training by shoulder-fired weapons. While the Pentagon has made progress in diagnosing both types of head injuries, experts still believe that the number of concussions remains undercounted.

The inTransition program is a free, confidential program that is available to all military service members, regardless of length of service or discharge status. Information about enrolling in the inTransition program is on the Psychological Health Center of Excellence website.

Mental Health

The sensory-emotional connection of PTSD after mTBI

According to an article published in Scientific Reports, mTBI is a “significant predictor of PTSD following deployment.” UCLA researchers Ann Hoffman et al. wanted to determine if this relationship comes from the fact that TBI events in combat are often emotionally traumatizing, or if it’s because concussions injure the brain in a way that makes it more vulnerable to developing PTSD. To test this, they put rats with and without fluid percussion injury (FPI, an mTBI-like injury) through a typical fear-learning experiment, where the rats were taught to associate the sound of white noise with the pain of foot-shocks. Compared to the control group, the FPI rats displayed more fear when they were first exposed to the white noise, without any footshocks. In a UCLA news release, senior author Micheal Fanselow said it was as though “the noise itself became scary to them, even though it wasn’t much noise. They treated it almost like a shock.” They also showed greater contextual fear when they were left alone in the space where they’d been frightened.

The rats with FPI also had more activity in their amygdalas—an area of the brain associated with auditory fear processing. They also seemed to be processing the sounds more with their thalamus than their auditory cortex. Since the thalamus is less evolved, it provides a very simplistic representation of sound. Their results suggest that mTBI may make neutral sensory inputs upsetting, and increase reactivity in areas of the brain responsible for fear responses.

Statistics

New machine-based learning techniques can reveal patterns in sports-concussion recovery

An article in Science Daily highlighted innovations in statistics and computer science that could serve concussion recovery. Researchers from Florida Atlantic University’s College of Engineering and Computer Science have been using machine learning and modeling to predict concussion recovery times. The researchers are still developing algorithms and acquiring a more efficient model. However, machine-based learning could soon offer clinical decision support for physicians as well as helping concussion sufferers in planning accommodations.

The study from Medicine & Science in Sports and Exercise, led by Dr. Michael F. Bergeron, details how symptoms such as insomnia, balance, and difficulty concentrating can be used to create models with predictive values. These data are obtained from datasets of three years of concussion recovery data from high-school athletes as well as an original dataset of contact sports-related injuries in both males and females.

Women's Health

“The concussion gender gap in youth sports” is now available as a blog post.

Culture

Seattle Opera to present a new chamber opera about returning home from war

KUOW reports that “The Falling and the Rising,” a new chamber opera about returning home from war, will premiere on November 15th at the Seattle Opera. Its story revolves around a woman returning from service overseas after suffering a TBI. “She’s put into an induced coma, where she interacts with many of her battle buddies who give her guidance and get her back to an awakened state,” says playwright and librettist Jerre Dye, who created the opera with composer Zach Redler.

The opera was inspired by interviews with more than 30 active and veteran service members and will feature the U.S. Army Field Band. It is a major collaborative work involving military veterans from local arts organization Path With Art, and other organizations across the Puget Sound region, who want to use this classic artform to shine a light on a contemporary societal issue. Tickets are available through November 24th.