Light therapy improves brain structure in case study (10/15/20 newsletter)

Oct 19

Thank you for reading our Concussion Update newsletter, we appreciate your support.

We would like to acknowledge our contributors this week:

Writers: Will Altaweel, Eloïse Cowan, Malayka Gormally, Mack Hancock, Galen Moller, Srishti (Shelly) Seth, Julian Szieff, Trinh Tieu, and Elliot Yim.
Editors: Conor Gormally and Malayka Gormally.

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Education

Workshop

10/22/20: A 90-minute Concussion Management Workshop for professionals will be hosted by SportMedBC next Thursday. The workshop features “best practices on sport-related concussions” including sport risk factors, management techniques, and a review of assessment tools. “A certificate of completion will be issued. This course is approved for BCRPA, CMTBC, and NCCP Continuing Education Credits.” The fee is $15 and registration is required.

A new book, Concussion: Traumatic Brain Injury from Head to Tail

A new book by Dr. Kester J Nedd at the University of Miami Miller School of Medicine highlights concussion patients’ stories to show what happens to the brain after an injury and how it responds. The author brings his experience as a concussion traumatic brain injury specialist at the Design Neuroscience Center in Miami to a needed discussion of improving concussion understanding and treatment. Dr. Nedd points out the limitations in our current treatment, answers some of the field’s most challenging questions, and proposes a new evaluation method called the Brain Hierarchical Evaluation and Treatment (BHET) method. This book, written for patients and providers alike, presents a bridge between our research understanding and current clinical practices.

Sports

Quality of life in ice hockey players retired due to concussions

Concussions in the sporting world have become a key point of discussion over recent years. Too often now, concussions are ending sporting careers and creating lifelong challenges. In the game of ice hockey, high speeds very often result in high impact collisions. With so many players having to retire due to concussions, their quality of life following their career is often of great concern.

A recent study published in Concussion looked at 76 former male and female ice hockey players who decided to retire from the game due to concussions. The majority of these former players cited the possibility of more concussions and the risks that would bring as the reason for their retirement. Anna Gard et al. investigated post-concussion symptom burden, which varied greatly among participants. They found that hockey players who retired because of significant post-concussion symptoms had a lower quality of life than a population sample, while players who retired due to fear of future concussions did not have a lower quality of life.

The authors also found that players who displayed a broader range of symptoms suffered more than those who suffered only a few symptoms. The majority of retired players, however, had worse emotional health in comparison with norms. It is no surprise that many hockey players struggle with post-concussion syndrome following their careers, as hockey is a fast-paced sport that features frequent collisions.

Cannabis

Italian study shows a reduction in prescription medications dispensed after the legalization of CBD from marijuana

The United States’ cannabis policies vary enormously from state to state, and research around CBD and cannabis is slowly growing. In Italy, between January 2016 and February 2018, light cannabis was slowly legalized for public consumption province by province. Light cannabis refers to a cannabis flower product high in cannabidiol (CBD) that does not produce “psychotropic effects (0.2-0.6% THC).”

A study by Vincenzo Carrieri et al., published in the Journal of Health Economics, examines the effect of legalization on prescription medication sales. They limited the drugs they studied to “drugs dispensed by the Italian NHS containing active ingredients used to treat symptoms for which marijuana can also provide relief or, at least, relaxant effects.” These include “opioids, anxiolytics, hypnotics and sedatives, anti-migraines, anti-epileptics, anti-psychotics, and anti-depressives.”

Examining over 2,000 data points of prescription medication sales, month by month, and province by province, the study found an average reduction of 1.6% in prescription medications dispensed. This trend was highest for anti-anxiety (11.4% reduction) and sedatives (10% reduction) and lowest for seizure medications (1.5% reduction), antidepressants (1.2% reduction), opioids (1.2% reduction), and migraine medication (1% reduction). The authors propose that this effect is consistent with a ’self-medication’ model, where patients experiment with alternative treatments then switch over to those treatments permanently.

This model of ‘self-medication’ offers the patient choices but has the potential for risk. In particular, a transition to self-medication with light cannabis is risky for those patients on medications like antidepressants and seizure prescriptions, which require consistent monitored usage. Regardless of intent, patients seek out, test, and occasionally substitute light cannabis for sedatives and anti-anxiety medication. The efficacy of this alternative medication calls for further research and improved cannabis policy.

Diagnostics

mTBI patients with acute neck pain are at greater risk for incomplete recoveries and have more severe post-traumatic complaints

Recent studies have suggested that neck pain immediately after an mTBI could be a predictive factor for incomplete recovery. In an article published in BMC Neurology, researchers Sophie M. Coffeng et al. further outline this predictor by analyzing how neck pain affects post-traumatic complaints and functional recovery in patients with mTBI. They also looked for other injury and demographic characteristics of patients with acute neck pain to facilitate earlier intervention.

Their data came from 156 mTBI patients with acute neck pain and 766 patients without acute neck pain admitted to the emergency department in three different level-1 trauma centers from 2013-2015. Patients with acute neck pain were more often female, significantly younger, and indicated more acute complaints than subjects without neck pain. They had fewer external head wounds and were more likely to have been in car accidents, suggesting “high-energy low-impact trauma mechanisms.”

In follow-up questionnaires two weeks and six months post-injury, these patients had higher quantities, frequencies, and severities of post-traumatic complaints. They were more likely to have incomplete recovery at six months than patients without neck pain. 225 subjects did not reply to these follow-ups, and 156 only responded to the 2-week questionnaire. The researchers acknowledge that this loss in follow-up could bias their results towards more negative outcomes. Still, they argue that this dropout is typical of other mTBI follow-up studies and facilitates the comparison of their results with similar research.

Self-care

An overview of self-care

We’ve updated our web page Overview of Self-care, which has brief summaries of tips to help concussion patients with sleep, exercise, nutrition, sensory sensitivity, and emotional wellness. We discuss free apps for cognitive behavior therapy, night shift modes for your phone, the latest exercise guidelines after concussion, anti-inflammatory foods, screen time, earplugs, apps for meditation, and support groups.

Therapies

In a case study, transcranial photobiomodulation improved brain structures and neuropsychological test scores

Two recent research studies investigated photobiomodulation for concussions. In our blog post, we discuss the case study of a 23-year old professional hockey player who reported headaches, mild anxiety, difficulty concentrating, and inability to pay attention, likely due to six concussions. The study by Linda L. Chao et al., published in Frontiers in Neurology, found that an 8-week treatment of home-use light therapy improved brain structure and function(measured by MRI scans) and neuropsychological test scores. After the treatment period, improvements included “increased brain volumes, improved functional connectivity, increased cerebral perfusion, and improvements on neuropsychological test scores.” The study used Vielight light therapy devices, which are FDA classified as “General Wellness” devices and are commercially available.

“Concussions in Ice Hockey -- Moving Toward Objective Diagnoses and Point-of-Care Treatment: A review,” published in Current Sports Medicine Reports, cites transcranial light as one of the “most promising point-of-care treatment options for sport-related concussions, specifically those in ice hockey.” The report details that the delivery of red and near-infrared light to the scalp penetrates the subjacent cortical brain regions. Light therapy improves the electron transport chain’s function, which “may increase mitochondrial membrane potential, increasing oxygen consumption, glucose metabolism, and ATP production” in the brain. The authors, Sarah C. Pender et al., note that “Human trials are limited to case reports of patients treated for postconcussion syndrome.”

A clinical trial of photobiomodulation for persistent post-concussion symptoms is recruiting study participants. Read our blog post or reply to this email for more information.

Veterans and Service Members

Veterans’ seizures may be due in part to past TBI; therapies for nonepileptic seizures

Task and Purpose published an article, “Why is this happening? -- Mysterious seizures haunt Marines a decade after deployment.” The article considers potential factors for increased seizures after the Iraq and Afghanistan wars, including exposure to toxins and mild traumatic brain injuries caused by exposure to blasts from improvised explosive devices (IEDs). A 2017 study found that “troops with a traumatic brain injury or post-traumatic stress (PTS) diagnosis were three to four times more likely to have a seizure.” For those troops diagnosed with both TBI and PTS, “the risk [for seizures] rose to two or three times more.”

The increases in mTBIs may be associated with the rise in psychogenic nonepileptic seizures (PNES), based on an association found in a 2015 study. The Task and Purpose article discusses two types of seizures: epileptic seizures related to “physical injuries [which] cause electrical activity in the brain that sparks the seizures,” and seizure-like PNES episodes.

According to the Epilepsy Foundation, PNES “may look like epileptic seizures but are not epileptic and instead are caused by psychological factors,” and “The only reliable test to positively make the diagnosis of PNES is video EEG monitoring.” This type of seizure is often misdiagnosed and does not respond to medication, but “may respond better to therapy,” such as cognitive-behavioral therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR). Some of the marines profiled in the Task and Purpose article were using self-care methods such as CBD products, medical marijuana, and an anti-inflammatory diet. The Task and Purpose article mentions a "small 2017 study [that] found that 13 of 16 veterans who received prolonged exposure therapy to treat their PTS stopped having [PNES] seizures."

Mental Health

Brain injury can lead to damaged executive functioning

Headway, a UK-based charity, discusses the detrimental effects of brain injury on executive functions. Executive functions are vital to daily life and activities, and “executive dysfunction” refers to their impairment. According to Headway, executive dysfunction manifests in emotional, behavioral, and cognitive difficulties. These may include struggles with motivation, vacillating between moods, and difficulty processing new information. Headway provides a list of signs of executive dysfunction. The foundation also recommends that patients struggling with symptoms should talk with their doctor and potentially seek more specialized care.

Statistics

Long-term effects from concussions are seen decades after injury

Researchers from the Brain Aging and Behavior Section of the National Institute on Aging have been studying the long-term effects of mild traumatic brain injuries (mTBI). Danielle June et al. tracked structural changes with MRI and PET scans and cognitive changes with neuropsychological tests with patients over 20 years. Their study analyzed data from the Baltimore Longitudinal Study of Aging, including 51 older participants who had a concussion 20 years ago alongside 150 control participants without a previous concussion.

MRI and PET scans showed that patients who had sustained a concussion had white matter damage in their frontal lobes, temporal lobes, and hippocampus in their initial scan - the damage remained in subsequent visits. Additionally, these damaged lobes showed detectable differences in brain activity. Although imaging was noticeably different in patients who had sustained a concussion in the past, “there were no significant differences between the groups regarding neuropsychological performance.” This difference in results indicates that previously concussed patients’ brains may have adapted for the structural damage and perform just as well cognitively. The researchers plan to explore this finding in future studies.

The researchers acknowledged the limitation that these data came from the patient's self-reported histories, which may include more severe forms of TBI. Additionally, the researchers note that this study did not have a large sample size and should be replicated with more patient data. The study was published in Neuroimage.

Youth

Diagnosis and outcome differ between assault and sports-related concussions in youth

Researchers presented a study comparing the medical treatment of children and youth who experienced assault-related concussions (ARC) versus sports and recreation-related concussions (SRC) at the virtual American Academy of Pediatrics (AAP) National Conference. Daniel J. Corwin et al. performed a retrospective chart review from 2012 to 2014, examining patient data from 124 children and adolescents ages 8 to 18, with even numbers of ARC and SRC patients. The review included comparisons of demographics, details from their initial medical care visit, and patient outcome data.

“We focus a lot on sports-related concussion, and that’s very important, but unless we recognize [that] a child who presents to the emergency department after assault could have a concussion, they are much less likely to be screened for certain concussion aspects,” said Dr. Margaret Means of Children’s Hospital of Philadelphia to Medscape Medical News.

The authors found that patients with ARC were more likely to be Black, publicly insured, and receive significantly less visio-vestibular testing (recommended for accurate concussion diagnosis) at their initial visit compared to SRC patients. During recovery, the two groups did not differ in the total number of reported physical, cognitive, emotional, and sleep-related symptoms. However, over twice as many ARC patients reported a decline in school grades compared to SRC patients.

“The decline in grades in this group suggests it takes longer for children to become asymptomatic from concussion related to an assault,” said Dr. Means. “We need to investigate that further to hopefully address that difference and help kids to not experience that decline in grades.” The study suggests an under-diagnosis of concussions in assault patients, and highlights the need for further examination in larger populations.

Women's Health

A new online course trains frontline workers to help survivors of brain injury caused by intimate partner violence

A new version of the Concussion Awareness Training Tools (CATT) is now available to train frontline workers to detect brain injury in women who have experienced intimate partner violence (IPV). This free online course will equip shelter staff with the knowledge and resources to recognize brain injury signs and provide women with the support they need. This 45-minute, interactive, video-based course can be found in both English in French on the CATT website.

Principal researcher Paul Van Dokelaar states, in a UBC press release, that “brain injury is a prominent, and largely invisible, injury among survivors of intimate partner violence for which frontline staff at women’s shelters have typically received minimal, if any training.” Indeed, one in three women suffers from IPV, which increases the likelihood that they have sustained a brain injury. In the case of a concussion, it is crucial to get immediate help, both to relieve pain and other symptoms and to try to avoid long-term consequences. However, concussions in IPV survivors are often overlooked or misdiagnosed.

The University of British Columbia and the Kelowna Women’s Shelter built this resource as part of a partnership that also launched the Supporting Survivors of Abuse and Brain Injury through Research (SOAR) program. SOAR provides evidence-based tools to increase awareness and information for women’s support workers about the brain injury-IPV correlation.

Culture

Concussions may impair driving performance, even after symptom resolution

A study conducted by Landon B. Lempke et al. found that concussions may impair driving performance, even in asymptomatic patients. The study, published in the Journal of Sport and Health Science, compared the driving performance of 14 asymptomatic individuals who had sustained a concussion (15.9 days post-concussion on average) to 14 matched controls.

The researchers assessed driving performance by measuring participants' composite reaction times in three simulated scenarios: approaching a stoplight, evading another vehicle, and stopping for a pedestrian. Relative to the control group, reaction times for the asymptomatic concussed group were 292.86 ms slower on average—a statistically significant difference.

The study also examined computerized neurocognitive testing (CNT) as a potential proxy for driving performance. However, there was no correlation between participants' CNT scores and reaction times when driving, suggesting that CNT is not a valid proxy for assessing whether a concussion patient can return to driving. Given the demonstrated link between concussions and impaired driving performance, future research should aim to determine a valid method of assessing whether concussion patients can safely return to driving.

Additional information about this study can be found in our August 20 newsletter. Concussion Alliance reported on the presentation of this research at a conference before its publishing in a peer-reviewed journal.