Concussion education during stay-at-home (4/16/20 newsletter)

Apr 16

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

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

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Our regular Concussion Update newsletter, plus COVID-19 information.

Special Category: COVID-19

See the COVID-19 section of our website for a comprehensive list of recommended resources.

Education

Free webinars for concussion patients during the pandemic

The Concussion Legacy Foundation has free webinars for concussion patients during the pandemic: Q&A on concussions and Post-Concussion Syndrome (4 pm EST today), plus previous webinars Managing Post-Concussion Syndrome in the Time of Coronavirus and Coping with Suspected CTE During the COVID-19 Pandemic.

Concussion Journal Club, next Zoom meeting is April 23

Dr. Tad Seifert has organized the Concussion Journal Club, which is open to anyone to participate. Dr. Siefert @neurodoctad creates a Twitter poll to select which article to discuss. Participants meet via Zoom conference, with the lead author of the article sometimes moderating the discussion. Email Dr. Siefert for a Zoom invitation, Tad.Seifert@nortonhealthcare.org.

Professional conference on concussion management via webinar

The nonprofit The Center Foundation will host a professional education conference on concussion management, Brain Trust 2020, via webinar on May 1-2.

Sports

Canadian review of persistent concussion symptoms from bicycle accidents finds longer symptom duration than comparable collision sports persistent symptoms

Researchers from the University of Toronto and the Canadian Concussion Centre at Toronto Western Hospital conducted a retrospective review of 28 adults who had been referred to the Centre for treatment of post-concussion syndrome (PCS) resulting from a concussion sustained while bicycling. The patients in the study had a mean recovery time of 23.7 months, but, at the time of the last follow-up, 82.1% of the patients had not yet recovered. The authors, Connor Moore et al., also noted that patients with a history of concussions had significantly longer mean durations of PCS symptoms than those with no prior concussions. They also found that patients with PCS from bicycle concussions had a greater mean duration…[of symptoms] (23.7 months) than a comparison group of patients with PCS due to [concussion from] collision sports (16.1 months).” The study was published in BMJ Open Sport & Exercise Medicine.

Cannabis

The University of Miami requests cannabis users fill out a survey about their usage during COVID-19

The University of Miami has asked for people to help them by completing a quick online survey about cannabis usage and health during the coronavirus outbreak. Those who use medical cannabis are more likely to be in an at-risk population for coronavirus with underlying chronic medical conditions such as auto-immune disorders. They are hoping to examine details of cannabis use, general health parameters, and the role of cannabis in this time.

Researchers from the University of Miami are requesting that everyone take the quiz. Even if you aren’t a medical cannabis user, the data will be vital to understanding how cannabis is used and is affecting people during the stay at home period. The survey takes less than 5 minutes and is very easy to use.

Diagnostics

NCAA and CARE Consortium find concussed athletes have elevated levels of biomarkers associated with TBI

The National Collegiate Athletic Association (NCAA) and the US Department of Defense Concussion Assessment, Research, and Education (CARE) Consortium recently conducted a three-year, “multicenter, prospective, case-control study” of NCAA athletes. Of the 504 participants (264 concussion patients and 244 contact and non-contact sport controls), the concussion patients and contact sport controls had blood analysis done during their preseason, and all participants underwent baseline testing and follow-up procedures throughout their seasons.

The goal of the study was to determine whether four blood biomarkers used in TBI research could identify less severe sports-related concussions in collegiate athletes. Two biomarkers, GFAP & UCH-L1, are FDA-cleared for “clinical use in identifying the presence of underlying intracranial injury after more severe TBI.” Another two, NF-L and tau, are being used in TBI diagnosis research.

The study results indicate the potential for blood biomarkers to diagnose less severe brain trauma. The athletes showed significant elevations, during the acute post-injury period, of “GFAP, UCH-L1, and tau levels compared with preseason baseline levels, and [compared] with two groups of control athletes.” The levels were less elevated than those found in moderate to severe TBI patients in other studies. The authors argue that these biomarkers showed a “modest ability” to differentiate concussed athletes from controls. The study, led by Michael McCrea, PhD, ABPP, was published in JAMA Network Open.

Therapies

Physical therapy associations sponsor first clinical practice guidelines for concussion evaluation & treatment by physical therapists

The Academy of Orthopaedic Physical Therapy and the American Physical Therapy Association have funded the creation of a set of Clinical Practice Guidelines for Physical Therapy Evaluation and Treatment After Concussion. The guidelines, published in the Journal of Orthopaedic & Sports Physical Therapy, represent a paradigm shift in concussion treatment. Physical therapists now have access to what is effectively a “current best practices” document detailing guidance (with scores for degree of recommendation and level of evidence) and recommendations for three components of the care process, outlined below.

“(1) a process for determining appropriateness of physical therapy concussive event examination, (2) physical therapy examination and evaluation processes for patients who have experienced a concussive event, and (3) developing and implementing a physical therapy plan of care for patients who have experienced a concussive event.”

#StayHome Tools

Trouble sleeping? An excellent, free app to help with sleep, using cognitive behavioral therapy

CBT-i Coach is a cognitive behavioral therapy (CBT) app developed by the U.S. Department of Veterans Affairs. Cognitive Behavioral Therapy apps were found to be effective in combating insomnia in a 2017 study. The study also concluded that CBT apps “likely [have] benefits beyond sleep to mental health and well-being.” NPR has an excellent article (Oct 8, 2018) about CBT apps for insomnia, in which several sleep doctors recommend the CBT-i Coach. Download the app for free on iTunes and Google Play.

How physical therapists are using telehealth for concussion patients

Due to the pandemic, physical therapy via telehealth is now available from many providers nationwide, with many insurance plans covering it. This is good news for concussion patients who are isolated at home, as physical therapists are qualified to deliver many of the concussion treatments (such as vestibular and exertional therapy) recommended in the most recent International Consensus on Concussion in Sport. In a blog post, we interview Justin H Ho PT, DPT, CSCS, about how he adjusts his practice for telehealth concussion patients, and his plans to make telehealth a platform to promote earlier access to healthcare and rehab after a concussion. In another blog post, we interview Joe Mahon PT, DPT, SCS about his concussion treatments via telehealth; Joe is offering free PT sessions while shelter in place orders are in effect.

Also: Free meditations, calming music, and sleep stories from the Calm app; Mental health tips for quarantine, by Dr. Eileen Feliciano.

Veterans

Troops and TBI: The silent, misunderstood cloud over our soldiers

Members of the armed forces suffer injuries of every kind during their service; this is no different for head trauma and TBI. But, what may be different is how a lack of concrete testing and treatment is affecting injured troops. Perhaps in comparison to stories of lost limbs and lost lives, injuries with less clear external markers (such as concussions and TBI) can appear to be less severe. This perspective is reinforced by military culture’s emphasis on fortitude and the ability to push through pain, regardless of the risks, according to an article in Military.com. Director of the Brain Injury of America Association, Dr. Brent Masel, stresses that “TBI is by no means a minor injury.”

In the past, it was not unusual to have a patient suffering from mild TBI told to sit in a dark room and avoid unnecessary brain strain. Dr. Jamshid Ghajar, president of the Brain Trauma Foundation, points to published literature that finds “early exercise after a concussion speeds recovery.” Further, seclusion in a dark room only serves to isolate patients and inadvertently extend recovery times. Instead, like any injured patient, Ghajar suggests that it is more productive to identify the symptoms and begin therapy soon after injury. Dr. David Cifu, a Virginia Commonwealth University Health professor, further suggests immediately addressing all symptoms, including mental ones such as anxiety or depression, while also proving the kind of rehabilitation recommended by Dr. Ghajar.

Mental Health

Mental health distress related to or made worse by the pandemic; free resources

A recent poll by the American Psychiatric Association found that 36% of Americans say the pandemic has had a “serious impact on their mental health,” according to Forbes. An article in Military, Let’s Avoid a Second Crisis in the Wake of COVID-19, discusses the pandemic-related stresses on individuals, especially those “suffering from post-traumatic stress or traumatic brain injury.”

Many healthcare providers have made the transition to telehealth, so if you have insurance, we suggest making an appointment for mental healthcare via video conference.

Disaster Distress Helpline: call 1-800-985-5990 or text TalkWithUs to 66746 (or “Hablanos” for Spanish to 66746) to connect with a trained crisis counselor. The Disaster Distress Line is run by the Substance Abuse and Mental Health Services Administration. It is a source of support for people dealing with the pandemic, including health issues, unemployment, grief, and uncertainty. The helpline is free and provides 24/7, 365-day-a-year crisis counseling.

An extensive list of free mental health support services is provided by WHILE AT HOME.

Statistics

New research shows the need for increased hormonal dysfunction screening in concussion patients with persistent symptoms

Two new studies have come out with compelling evidence, further linking hormonal dysfunction with concussions. The first study from researchers at the University of Edinburgh, published in the Journal of Neurotrauma, conducted a statistical group analysis of 29 studies examining endocrine dysfunction in TBI patients. With data from over 2000 patients, the researchers found that 12 months post-TBI, between 32-34% of patients with persistent symptoms had an endocrine dysfunction. This population included all degrees of TBI severity and, while the percentage of endocrine dysfunction was lower for mild TBI (concussion), the correlation persisted.

The second study from the University of Arizona and collaborators, published in Frontiers in Neurology, reviewed cases of TBI and endocrine dysfunction in Arizona children. They found that patients with a childhood TBI were three times as likely to be diagnosed with an endocrine dysfunction as patients without a childhood history of TBI. Both of these studies add to the recommendation that providers use preventative screening for endocrine disorders, especially with patients with persistent symptoms. The author of this section, Julian Szieff, has written an in-depth blog post on this subject for our website.

Women's Health

Increase in intimate partner violence (and concussions) during stay-at-home orders

There has been a sharp rise in domestic violence due to stay-at-home or lockdown orders throughout the world, according to an article in The New York Times. Research has uncovered a high incidence of concussions in survivors of intimate partner violence (IPV).

Resources:
National Domestic Violence hotline offers telephone or live chat support. "Our advocates are available 24/7 at 1-800-799-SAFE (7233) in more than 200 languages. All calls are free and confidential."

The National Network to End Domestic Violence (NNEDV) has an extensive list of resources for survivors, LGBTQ survivors, youth/children, older adults, survivors with HIV, immigrant survivors, and resources for survivors in different languages. There is also information for domestic violence (DV) coalitions, DV shelter programs, and women’s shelters.

Culture

People are sleeping more during the pandemic, and that’s a good thing

An article in Forbes by Concussion Alliance professional advisory board member Nicole Fisher highlights the importance of sleep, particularly during this period. Sleep is a time when vital processes such as cell/muscle repair, immune system bolstering, memory encoding, hormone regulation, and flushing of toxins from the brain. Long-term sleep loss is associated with obesity, depression, risk-taking behavior, and increased memory loss (in those with Alzheimer's). With the impact of COVID-19 on our lives, prioritizing our health and being kind to ourselves has become even more vital, and sleep is a crucial part of that.