Immune cell treatment (11/12/20 newsletter)

Nov 12

We would like to acknowledge our contributors this week:

Writers: Conor Gormally, Malayka Gormally, Mack Hancock , Galen Moller, Srishti (Shelly) Seth, Julian Szieff, and Trinh Tieu.

Editors: Conor Gormally and Malayka Gormally.

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Education

Well-written concussion education for middle and high school students

Science News for Students has published a well-written article, “Many student athletes face risk of concussions that heal slowly.” The article uses an engaging style, perfect for middle and high school students, to explain what a concussion is, discuss recent research, and detail which sports pose the highest risk for concussions. The article emphasizes that “On average, high-school athletes with concussion take about one month to return to play,” and that girls, as well as athletes with a previous concussion, take longer to recover.

Sports

Canadian health charity provides resources for safer hockey

Parachute is a Canadian national charity dedicated to reducing and preventing injury through evidence-based advocacy and education. Parachute’s Smart Hockey program integrates concussion tools and resources to help prevent and recognize concussions in hockey.

The program provides six main tools and resources:

Educational guides for coaches, trainers, safety personnel, and players.
The Concussion Recognition Tool (CRT5), which aids in concussion recognition and immediate concussion management.
Return-to-Play strategies and programs.
Personal concussion records for players.
Tools to help create a concussion-safe environment for players, including “STOP” patches on the back of jerseys and harsher penalties for dangerous interactions between players.
Advocacy for safe play, including on-ice tips to assist in preventing concussion.

Cannabis

Landmark study of CBD for former hockey players hopes to finish data collection this year

According to an article in Green Entrepreneur, Canadian researchers Dr. Amin Kassam and Dr. Richard Rovin hope to conclude their randomized, double-blind study testing CBD’s impact on concussion-related health issues this year. This study is part of a 2019 agreement between the NHL Alumni Association and the cannabis company Canopy Growth.

The study involves around 100 retired NHL players living in Canada, where cannabis is legal at the federal level. In a TSN article from 2019, Dr. Kassam specified that the study’s subjects would undergo high-resolution MRI and diffusion-tensor imaging (DTI), as well as emotional, psychological, memory, oculomotor, vestibular, and blood testing for biomarkers before and after the study. The participants will also complete health and medication questionnaires to give researchers a broader view of their health. In the randomized, double-blinded treatment segment of the study, approximately 80% of athletes would take CBD capsules twice weekly, while the other 20% take a placebo.

Dr. Kassam hopes that this study will add formally measured scientific evidence to the wealth of anecdotes from former athletes using CBD to help mitigate pain, anxiety, and depression.

Diagnostics

Potential new biomarker for traumatic brain injury to begin testing in human trials

Concussion research continues to search for a quantified test or marker of brain injury. A breakthrough in this area could allow for better diagnosis, treatment verification, and recovery analysis. Researchers from Massachusetts General Hospital and Harvard Medical School have found a new biomarker that shows promise.

Published in the Journal of Cerebral Blood Flow & Metabolism, this research from Nicolas J Guehl et al. focuses on a marker that labels neural damage to the myelin, the sheath of material around axons. When the myelin sheath is damaged, molecules on the axon’s surface become exposed. This new biomarker acts as a tracer, binding to these exposed molecules and making the damage visible on a PET scan. This myelin damage occurs in traumatic brain injury, and research with this biomarker in Rheus’s monkeys found that it could identify TBIs suffered three years prior.

While this study’s sample size is limited, and it has not been translated to humans yet, the possibility of a biomarker that can evaluate brain injury is exciting. The researchers plan to start human trials within the next month or two, according to a press release in The Harvard Crimson.

Self-care

CEFALY, a nerve stimulator for migraine headaches, now available without prescription

Headache patients can now purchase the CEFALY trigeminal nerve stimulator online without a prescription. The United States Food and Drug Administration (FDA) cleared the CEFALY DUAL “as an over-the-counter product for the acute and preventative treatment of migraine headaches in adults (18 years and older),” according to a press release by CEFALY. Use of the CEFALY device for post-traumatic headaches (PTH) in concussion patients was discussed in a presentation chaired by Nathan Zasler, MD, a leading expert on PTH, at the 2017 International Brain Injury Association Conference.

Headache is the most common symptom after traumatic brain injury (TBI). According to a 2020 study by Jordan Vanderende et al., the most common type of PTH is “migraine or probable migraine (49%), followed by tension type (37%) and unclassifiable.” Patients are “managed according to the primary headache type their PTH symptoms most closely resemble.” This study also found that “more than half of patients will continue to experience significant and potentially disabling headache symptoms 1 year following mTBI.”

The CEFALY DUAL is available for $399 (special offer) on the CEFALY website. There is a 100% money-back 60-day guarantee and financing options. While some leading clinicians are using CEFALY with patients, Concussion Alliance is not aware of any research on the use of CEFALY for post-concussion headaches.

Therapies Currently Available

Interprofessional concussion management model shows potential for reducing Return to Learn and Return to Play times

The management of concussion clinics is a complex and evolving field, and the concept of interprofessional concussion management is growing in popularity. Recent research, published in Physical Therapy in Sport, highlighted data from their switch to an interprofessional concussion management model (IPM) for college athletes on eight varsity sports teams. Shannon Kenrick-Rochon et al. evaluated changes in return to learn (RTL) and return to play (RTP) times and found that both decreased when the clinic switched to the interprofessional model. The IPM model consists of a core team of three to five professionals that refers to additional specialists as needed.

While their data involves only 30 patients over two years, they also found that increased communication, improved experience, and focus on protocols clearly benefited providers and preliminarily showed effectiveness in treatment.

While more broad and longitudinal research is needed to shed light on interprofessional concussion management's effectiveness, early findings show that collaboration has enormous potential. Refining and validating an effective and appropriate multi-modal diagnostic and treatment plan for patients would allow for proper regulations and medical guidelines to be better-implemented in emergency rooms and concussion clinics.

Therapies Being Researched

New-found immune cell may promote cellular healing from neurological diseases, including TBI

A study published in Nature Immunology discovered a new immune cell that could potentially treat currently incurable neurological diseases such as traumatic brain injuries (TBIs), spine injuries, strokes, and multiple sclerosis. Dr. Andrew Sas et al. found a new cell, classified closest to a granulocyte (white blood cell), in a mouse model. In a press release posted by The Lantern, Dr. Sas explains that this cell “releases a substance that stimulates nerve cell growth and allows damaged nerve fiber to regenerate.”

Researchers describe this cell as an immature version of a neutrophil cell (which helps the body fight off infection) that expresses specific markers associated with the healing process.

This new cell functioned differently, as it helped protect the damaged nerve cells and drove nerve fiber growth in the mouse model. Researchers used an antibody to block the activity of already present neutrophil cells, which can “stunt the recovery process,” allowing production of the new immune cell as a substitute.

The researchers hope to inject this cell in patients with TBIs, leading to new treatments for those who have neurological diseases or feel lasting effects from TBIs.

Veterans and Service Members

New approaches to behavioral health for veterans

As part of their Veterans Day section, the Fayetteville Observer shared some new programs and treatments to help veterans with PTSD and traumatic brain injuries. They spoke with Dr. Michael West, the deputy installation director of Psychological Health for Fort Bragg. Dr. West says that these new behavioral health programs are designed to help service members “become more resilient rather than simply strive for recovery.” They are also using evidence-based treatments and including the soldiers’ families in their treatments.

Also at Fort Bragg is the Intrepid Spirit Center, which uses “a holistic, multidisciplinary approach to better determine the cause of persistent post-concussive symptoms.” This approach to care, called “whole health” is included in the regimens of several other veteran health centers in the North Carolina and Virginia region. Christina Vair, director for Whole Health for Salisbury, says veterans who participate in the whole health approach have a “three-fold reduction in opiate medications.” Vair says they are trying to integrate the model of care into the VA, but have received some push back from “more traditional” physicians.

Concussion Alliance thanks our military service members and veterans for their courage and sacrifice.

Mental Health

Personality may not impact the rate of head injury in sports

The biology of concussions is often the focus of research, but less often is the spotlight turned onto the concussion patient’s personality. Psychological measures can help improve the strategies we can take to reduce head injury prevalence, especially among athletes. New research from Dr. Cara Levitch et al. examined if personality traits correlate with the frequency of head impacts in amateur soccer players.

This study, published in the Clinical Journal of Sport Medicine, surveyed 307 players using questionnaires to determine personality characteristics and frequency of head impacts, both intentional (heading) and unintentional. The authors found no correlation between personality traits and the frequency of head impacts. While more objective measures than self-reporting surveys are needed to validate this study, this research could help guide steps for decreasing the frequency of head impacts. Experts should tailor strategies to reduce the prevalence of concussions towards teaching all participants how to play safely, rather than correcting those who take more risks.

Statistics

Prospective study finds personal factors may be predictors of PCS

A prospective study by Toril Skandsen et al. applied a biopsychosocial model to explore how pre-injury personal factors could help identify mild TBI and concussion patients at greater risk for developing persistent symptoms. The study, a journal pre-proof for publication in an upcoming edition of Archives of Physical Medicine and Rehabilitation, evaluated 378 patients aged 16-59 and two control groups: 82 trauma controls with minor orthopedic injuries and 81 age and gender-matched community controls with no relevant injury history.

The authors found that women were more likely to have persistent symptoms than men. They also found that reduced or part-time employment, bodily pain, headaches, “poor sleep quality, symptoms of ADHD, a tendency toward neuroticism, and lower resilience” had predictive power for patients developing persistent symptoms.

The authors acknowledged several limitations in their study, including self-reporting of pre-injury personal factors after injury, potential confounding factors regarding the predictive power of employment status, and the relatively low number of patients with complicated mild TBI and PCS. However, their results indicate the potential prognostic power of personal factors in assessing risk for persistent symptoms. Concussion Alliance believes that this approach could help many concussion patients who develop persistent symptoms but fall through cracks in the medical system.

Youth

Rural pediatricians’ experience with mTBIs and CDC guidelines

A recent study by Daugherty et al., published in The Journal of Rural Health, examined rural primary care providers’ experiences with and usages of the CDC’s pediatric mTBI guidelines. In 2018, the Centers for Disease Control and Prevention (CDC) released a set of evidence-based guidelines on pediatric mTBI to educate health care providers on best practices regarding mTBI diagnosis, prognosis, and management or treatment. Because rural patients have higher rates of mTBI and limited access to care, the CDC guidelines are a particularly important tool for rural health care providers.

Researchers conducted nine interviews with pediatric rural health care providers from all U.S. regions. The interviewees reported that common causes of mTBI included sports and all-terrain vehicles. Although guideline recommendations were helpful and feasible, interviewees reported barriers to implementation, such as lack of access to specialists for further treatment. Providers suggested implementing customized information for rural health care providers in both print and digital formats to help with the adoption of the guidelines.

Women's Health

Focus on women and brain injury: new edition of Brain Injury Professional Magazine

Women Vs. Brain Injury is the focus of the most recent edition of the Brain Injury Professional Magazine, the official publication of the International Brain Injury Association and the North American Brain Injury Society. The entire edition is excellent, with articles by leading researchers and clinicians in the field, including:

“Exercise in Concussed Females” (John Leddy, MD and Barry Willer, PhD)
“Factors Affecting Recovery Trajectories in Pediatric Female Concussion” (Christina L. Master, MD and Natasha Desai, MD)
“Traumatic Brain Injury Among Female Veterans” (Maheen Mausoof Adamson, PhD and Odette A. Harris, MD, MPH)
“Refocusing Care in Girls with Post-concussion Syndrome” (Nick Reed, MScOT, PhD)
“Women with Brain Injury: Past, Present, and Future” (Katherine Price Snedaker, LCSW)

The entire magazine issue is available online in a magazine format here. Concussion Alliance thanks guest editor Katherine Snedaker (founder of PinkConcussions.org) for listing our Concussion Update newsletter in the “Useful Resources” section of this edition.

Culture

Flying likely safe after a concussion

A cohort study of NCAA athletes and military cadets found that “flying within 72 hours of concussion did not show greater symptoms, prolonged symptom recovery, or delayed return to activity or school.” Additionally, time zones crossed, total hours traveled, or time from injury to flight did not affect time to symptom recovery, time to return to learn or play, or headache severity scores. Authors Tara L. Sharma, DO, et al. conclude that “these findings may be reassuring to patients, coaches, and athletic trainers.”

The study hoped to address concerns that “Hypobaric hypoxemia, such as that encountered during air travel, could also exacerbate concussion-related symptoms and prolong recovery.” Published in JAMA Network Open, this study was conducted by the National Collegiate Association (NCAA) and the US Department of Defense Concussion Assessment, Research, and Education Consortium. The study looked at two large cohorts of NCAA athletes and military cadets, from August 2014 to September 2018, comparing those who flew after suffering a concussion with those who did not travel by air.

There are several limitations to this study, including the fact that a “limited number of athletes flew within a few hours of their concussion,” the median number of hours on the plane was only two hours, and only a few athletes crossed three or more time zones. The authors suggest flying within six hours of injury and long-haul flights as areas worthy of future research.

In particular, the authors mention that, in another study, “increased neuroinflammatory markers were found in mice exposed to hypobaric conditions 3 hours after mild TBI, but delayed exposure (24 hours after injury) showed no deleterious effects.” While they did not find disparities in recovery times or symptoms severity, “there may be changes at a molecular level in athletes who flew closer to their injury.” The authors suggest conducting future studies using biomarkers to look for this effect.