Are "normal" recovery timelines too short? (3/19/20 newsletter)

Mar 20

We are pleased to have Carleton College students and alumni working with Concussion Alliance. Contributors this week:

Editor: Conor Gormally and Malayka Gormally.
Contributors: Conor Gormally, Julian Szieff, Zachary Touqan, and Malayka Gormally.

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Education

Free university-level online course on concussion prevention, detection, and management For the second year, the University of Calgary joins with Université Laval to offer a free Massive Online Open Course (MOOC) with “the goal of improving concussion prevention, detection and management,” according to UCalgary News. The MOOC is a “non-credited university-level course accessible to everyone” that does not have any prerequisite requirements but does provide a certificate upon completion of the course and passing the exams. Last year, the course had 8,591 participants, including the Executive Director of Concussion Alliance, who highly recommends it. The MOOC is open for registration; the course runs from April 1 - May 25, 2020. You can do the work at your own pace, and you can start after the April 1 date, but you must finish the course by May 25.

Students will “learn from a variety of videos of experts in their fields, including researchers, community partners, health-care professionals, policy-makers, athletes and sport and recreation representatives, many of whose research helped shape the International Consensus Statement on Concussion in Sport.” Titled “Demystifying Concussion 101,” the course is created for a range of participants; healthcare professionals as well as coaches, teachers, and parents. An optional segment assists participants in developing a concussion protocol for their particular sport or community setting. Students can also interact with the course leader Kathryn Schenider, PT, PhD, who was an author on the most recent International Consensus Statement on Concussion in Sport.

Sports

More concussions go undiagnosed at high schools without athletic trainers

An analysis by InvestigateWest, a nonprofit online watchdog journal with a focus on public policy, has found gaps in both concussion diagnosis and proper treatment between Oregon schools with and without athletic trainers. Schools with athletic trainers screened more students and, mirroring other studies across the country, were more able to identify concussions and reduce injury rates. The difference is especially stark in football where, over the last two years in Oregon, InvestigateWest found that 566 concussions were reported at schools with athletic trainers compared to the only 34 reported at schools without trainers. The burden falls hardest on small and small-budget schools who cannot afford to hire athletic trainers. While there should be a trainer at every high school, the budget constraints on education make this goal challenging.

David Kracke is Oregon’s Brain Injury Advocate Coordinator; he is currently studying the legislation put into place by Hawaii to fund athletic trainers as well as other ways to further support schools without athletic trainers. He, and the article’s other interviewees, are hopeful that increased funding and better training for coaches and athletes will improve the number of youth athletes being diagnosed and treated during high school sports.

Cannabis

Australian healthcare company to test new cannabinoid formula for head trauma

A clinical trial is planned to study the effectiveness of IHL-216A, a novel cannabinoid, in protecting the brain against the primary mechanisms that cause cell death and other neurological dysfunction following head trauma. Impression Healthcare, an Australian medical cannabis company, has designed randomized controlled human clinical trials that will use a 99% pure Cannabidiol isolate, in line with standards set by the World (and Australian) Anti-Doping Authority, according to an article in SMALL CAPS.

The human trials are set to take place with a group of up to 50 Australian MMA fighters who “receive head knocks and show symptoms of moderate to severe head concussions,” which will be measured with FitGuard concussive measuring mouthguards, according to The Market Herald. The SMALL CAPS article describes the parameters of the trial: participants will complete baseline neurocognitive tests, which will be repeated throughout the study in both the experiment and placebo groups, in addition to EEG and blood biomarker assessments.

Diagnostics

New tau biomarker found in 50% of veterans with mTBI history

As researchers try to understand the link between repetitive mTBI and CTE, they are looking into the role of tau, the protein found in neurofibrillary tangles in CTE. Researchers Dara L. Dickstein et al. from the VA and Mount Sinai School of Medicine published a study in Molecular Psychiatry using a tau binding ligand (a radioactive molecule) to evaluate differences between ten veterans and seven healthy controls. The researchers selected veterans with at least one mTBI and a history of behavioral issues. No differences in brain volume or neurofilament light (NfL) chain protein levels were found between groups; NfL chain protein is a blood biomarker in plasma, elevated levels of which are often found in TBI patients. Still, five of the ten veterans had increased p-tau neurofibrillary tangles in several areas of the brain, as indicated by the tau binding ligand.

While the researchers did not find NfL differences between veterans and controls, they did find NfL differences between the 50% of veterans with increased tau binding and those with baseline levels of tau retention. The small sample size likely limits the significance of this difference; a much larger sample is needed to determine if NfL could be a CTE blood biomarker. These researchers are hoping these results will provide more evidence into how or if TBI builds into CTE.

Therapies

For those concussion patients who can’t do sub-symptom level aerobic exercise: what should they do?

The relatively new consensus that concussion patients should return to sub-symptom aerobic exercise after approximately 48 hours of rest is based on the groundbreaking research by Dr. John Leddy, Dr. Barry Willer, and their team at the University at Buffalo. This understanding runs counter to earlier prevailing recommendations that called for concussion patients to “cocoon” and rest until all symptoms subsided.

The Buffalo team focused their research on college and high school athletes, some of whom were prescribed individualized, progressive programs of aerobic exercise below the level that exacerbated symptoms. According to an article on the University of Buffalo website, one study found that “Patients who followed the aerobic exercise program took on average 13 days to recover while those in the control group, who performed stretching exercises, took 17 days. In addition, fewer patients in the exercise program took longer than four weeks to recover than did patients in the control group.”

But how does this understanding apply to non-athletes: those for whom aerobic exercise is foreign, or are physically unable due to age or disease process, or are young children? This question came up at a panel session led by Dr. John Leddy and Dr. Barry Willer at the 7th North American Brain Injury Society Annual Conference (NABIS) last month. The question was posed by Emily Squier MA, LCSW, a combat/polytrauma case manager at the Captain James A. Lovell Federal Health Care Center. Squier works with veterans who have multiple injuries and are unable to do aerobic exercise. After a discussion, the consensus amongst the audience of concussion professionals and the members of the panel was that after 48 hours of rest, adult concussion patients unable to do aerobic exercise would benefit from whatever physical activities they can perform, such as walks in their neighborhood. Children who have suffered a concussion would benefit from simple physical activities such as playing in the park.

Concussion Alliance co-founders Malayka & Conor Gormally attended the NABIS conference and this presentation. See also our blog post on several related studies, including those of Dr. Leddy and Dr. Willer, concerning physical activity as a therapy for concussion.

Veterans

VA blog highlights free privately funded multidisciplinary care institute at University of Colorado

The U.S. Department of Veterans Affairs VAntage Point blog features a recent post about the Marcus Institute for Brain Health (MIBH). The blog post clarifies that the program is primarily focused on Veterans with lingering neurological problems, symptoms, and psychological health problems following a mild to moderate TBI, but is also open to civilians with similar profiles. Located at the University of Colorado Anschutz Medical Campus, each program participant and one family member are hosted and fed on campus while the intake and treatment processes happen. The initial evaluation takes 3-4 days, at the end of which the institute’s clinicians decide whether or not the patient is eligible for its 3-week program.

If eligible, the patient will then undergo a three-week personalized, multidisciplinary treatment plan. As far as available treatments, the institute lists cognitive (speech-language) therapy, physical therapy, and counseling & psychological services, as well as a mix of complementary & alternative therapies including “acupuncture/acupressure, therapeutic massage, mindfulness training, yoga, canine therapy, equine therapy, [and] art therapy.” You can begin the application for the MIBH program here.

Mental Health

Canadian concussion researcher says suicide prevention should always be considered as part of multidisciplinary care and support

A news article from the Canadian Broadcasting Corporation highlights the increased prevalence and risk of suicide in concussion patients and those suffering with persistent post-concussion symptoms. According to Canadian Concussion Centre director Dr. Charles Tator, concussion experts are "always worried about it because we do know that some people do commit suicide after suffering from this." Beyond the mental health and mood changes that often occur as a result of a concussion, Dr. Tator's research highlights an increase in post-injury impulsivity, which increases the risk for transition from suicidal thought/ideation to an actual attempt.

Dr. Tator's proposed solution is more comprehensive, multidisciplinary care, as "Concussion is in itself a team sport. It's not just the [medical doctor], but it's the social worker. It's the occupational therapists, the physiotherapist...". However, the family of a suicide victim who was suffering from severe persistent post-concussion symptoms in Canada says they heard no mention of multidisciplinary care from their daughter's health care providers. Advocacy groups like the Manitoba Brain Injury Association often have to step in and help concussion patients navigate the healthcare system to get the care they need.

Statistics

NZ Sports concussion clinic study finds fewer than half of patients recovered in two weeks

A New Zealand study, published in the Clinical Journal of Sport Medicine, tracked all the patients in a two-year period at a “dedicated, fully funded community–based sports concussion clinic in Auckland, New Zealand.” The authors, Stephen Kara MBChB, FRNZCGP, et al., found that only 45% of the clinic’s patients (all with sports-related mTBI) were clinically recovered after two weeks of care during this period.

At the clinic, both diagnosis and treatment programs were in line with the most current standards of concussion care. Patients would first undergo a thorough concussion evaluation, including “age-appropriate” SCAT-5 testing, physical evaluation of the intracranial nerve and peripheral nervous system, vestibular and cervical assessment, and testing of the autonomic nervous system. The clinic’s initial recovery program focused on in-clinic patient education, and then a brief (24-48 hour) rest period followed by a semi-personalized program of gradually increasing mental and physical exertion guided by symptom aggravation. Cervical and vestibular physiotherapy were also prescribed at the initial assessment or in follow-up visits as-needed.

Even with a high standard of informed, multidisciplinary assessment and care at a dedicated concussion clinic, most of the 594 patients in the study were not clinically recovered within two weeks, and only 77% had recovered by four weeks. These 594 patients ranged in age from 7 to 64 (with an average of 20.2) and were 77% male. The most recent International Consensus Statement on Concussion in Sport defines the “expected time frames” for concussion recovery as 10-14 days for adults and 4 weeks for children. Given that the average time to assessment in-clinic was 8.7 days from the injury, the fact that only 45% of patients were clinically recovered two weeks from assessment is even more concerning, as these patients were (on average) actually three weeks out from their injury. Further, the authors found a statistically significant correlation between delays in visiting the clinic and recovery time; a 7-day increase in time to assessment was predictive of a 15% increase in recovery time.

Women's Health

Females may experience more frequent and severe concussions than males...why?

An article published by the BBC discusses some of the research into why females face a higher risk of sustaining concussions and potentially suffer worse and longer-lasting, post-concussion symptoms than their male counterparts. Tracy Covassin, a leading researcher in the potential differences between female and male concussions, found in her analysis of the National Collegiate Athletic Association’s injury records that female players were almost twice as likely to sustain a concussion as male players of the same sport. Women are also more likely to report headaches, difficulty focusing, mood swings, and general mental fatigue as post-concussion symptoms. Females also tend to require longer to recover, with one study of 266 adolescents finding that females take 76 days on average to recover from concussions while males take 50 days on average.

Three main theories have been proposed to explain the sex-linked differences in concussion frequency and severity. The first suggests that females having 30% thinner necks on average when compared to males; having a less muscular neck gives the athlete a less stable base, allowing for more head movement on impact and a higher risk of brain injury. The second theory suggests that the female brain may have “slightly faster metabolisms than male ones, with greater blood flow to the head;” when glucose and oxygen become limited due to the injury, the net result could be more harmful to females than males.

Finally, some evidence suggests that the operative reason is related to female sex hormones, with more severe and frequent concussions potentially linked to fluctuations in progesterone levels during certain time frames of the menstrual cycle. These separate theories may not be mutually exclusive, as more evidence may suggest all three hypotheses play a role in the differences between how males and females deal with concussions and post-concussion symptoms.

An additional new theory is that structural differences in female axons may put women at higher risk, see our article under Women’s Health in our 10/17/19 newsletter.

Culture

Netflix docuseries “Cheer” may normalize dangerous athletic environment

The popular Netflix docuseries “Cheer,” about a small college’s competitive cheer squad, has inspired numerous opinion pieces warning of the dangers of cheerleading and specifically the heedlessness of the Navarro College coach in terms of injuries, including and especially with regards to concussions. “The series tells one of the oldest, darkest stories in American sports—of athletes with no pay and little support breaking their bodies again and again, all for the greater glory of an authority figure they dare not question,” according to The Atlantic.

“As a former cheerleading coach, I’m worried Netflix’s Cheer normalized a lack of safety,” is the headline in Inews; the article quotes MacKenzie “Sherbs” Sherman, a flyer for the Navarro College cheerleading squad, who says she has been “concussed five times.” The Atlantic article highlights a 2007 study, published in Pediatrics, that found that “cheerleading has accounted for approximately 66% of all catastrophic injuries in high school girl athletes over the past 25 years.” A 12news article refers to another study (published in Pediatrics) that “shows high school cheerleaders have the second-highest rate of concussion in practice, only behind football.” Concussion Alliance has covered this cheerleading in two blog posts: Why cheerleaders are receiving worse concussion care than other athletes, and Former UC Berkeley cheerleader files a lawsuit calling for better safety measures for cheerleaders.