PT via telehealth for concussion care (4/2/20 newsletter)

Apr 3

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, Hannah Kennicott, and Malayka Gormally.

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

Special Category: COVID-19

See our new COVID-19 page on our website for recommended COVID-19 resources.

Education

#stayhome, take an online course on concussion prevention, detection, and management

Most of our readers are probably following #stayhome orders, so it may be an excellent time to take the University of Calgary’s free Massive Online Open Course on Concussions (MOOC). 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, with the “the goal of improving concussion prevention, detection, and management,” according to UCalgary News. 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. For more information, see our previous newsletter.

Sports

Delayed Olympics a setback for trial of concussion substitutes in soccer

At the end of February, the International Football Association Board (IFAB) agreed to create a trial protocol for concussion substitutes to be instituted at the 2020 Tokyo Olympics, according to an article in The Independent. However, the delay of the event due to the COVID-19 pandemic also put on hold the first official action by FIFA to protect player safety; previous safety measures for concussion are under consideration by specific leagues or national footballing associations, rather than the sport’s governing body (FIFA).

While the trials were set to be a concrete step forward towards treating concussions appropriately, Headway Foundation executive Peter McCabe criticized the measures for not affecting one of the most crucial aspects of concussion safety: diagnosis time. The IFAB did not indicate that its trials would include a change from the current three-minute diagnosis window, which is not a sufficient amount of time to diagnose a concussion. The official Sports Concussion Assessment Tool - 5th Edition (SCAT-5), which is supported by FIFA, explicitly states on the test that it cannot be performed in less than 10 minutes.

Cannabis

THC content in most cannabis purchases is higher than research-based recommendations for pain

A recent study published in PLOS One by researchers from UNC and Wake Forest University mapped the potency of medical and recreational cannabis sold via dispensaries’ online stores. Mary Catherine Cash et al. found that medical cannabis often had similar THC and CBD concentrations to recreational cannabis, with most THC concentrations being greater than 15%. Consulting prior research, the study authors point out that these concentrations, “seem unsuitable for medicinal purposes, particularly for patients with chronic neuropathic pain.”

Crucially, they refer to findings in another study that show that cannabis with THC concentrations over 10% is less likely to provide the same pain relief and occasionally increases subjective pain sensations. Additionally, cannabis strains with concentrations over 10% are more likely to cause “adverse effects,” including feeling high, anxiety, and long term outcomes such as increased risk for psychiatric disorders and memory impairment. The risk factor associated with higher potency cannabis is compounded by the fact that these more concentrated strains often have less CBD, a higher concentration of which could alleviate some of the adverse effects of cannabis usage. Lastly, the risk of dependence on cannabis increases as users are exposed to high THC use. The researchers recommend that people looking for neuropathic pain relief purchase cannabis products that contain less than 10% THC and a non-trivial percentage of CBD.

Diagnostics

Early data shows persistent deficits of dynamic balance in concussion patients

A group of researchers from the University of Georgia investigated whether recreational athletes with a concussion history experience lasting balance problems. In their preliminary study, published online (ahead of print) in the Journal of Athletic Training, Robert Lynall et al. compared single-legged hop and single-leg squat performance in 15 recreational athletes with a concussion history against a matched group of healthy controls. The concussion group ranged in time since injury from 28 to 432 days, with an average of 126 days.

While the authors found no difference in measures for single-leg squat and dominant leg single-legged hop, they did find that the concussion history group had a statistically significant difference in time to stabilization for the non-dominant single-legged hop. The athletes with a history of concussion were, on average, 0.35 seconds slower to stabilize themselves when hopping down from a box onto their non-dominant leg than the healthy controls. This result suggests that small but essential balance problems may persist long beyond clinical recovery and return to play. The sample size of this study is far too small to draw more robust conclusions. Still, the authors believe that the dynamic single-legged hop is worth researching further to determine its value as a diagnostic and prognostic tool.

Therapies

Biodegradable nanoparticles may distract white blood cells that would otherwise increase brain swelling after TBI

A study authored by Jack Kessler, MD, investigates the effects of introducing immunomodulatory nanoparticles into mice suffering from TBI. The results, published in Neurology Today, suggest that this treatment could potentially limit swelling in the brains of head trauma victims and reduce damage to the brain. While this treatment does not affect damage already caused by TBI, the ability to intervene and lessen the potential for further damage would be a massive benefit if human trials prove effective.

The nanoparticles, created out of biodegradable materials also used in sutures, are meant to distract the body’s natural immune response to trauma. By introducing an inert foreign invader, large white blood cells will prioritize these nanoparticles rather than reaching the brain and causing further swelling. Currently, the only remedy to extreme swelling in the brain is a craniotomy, or the surgical opening of the skull, to relieve pressure on the brain. While more studies are required to measure the effectiveness of this treatment in humans, this treatment introduces the idea of a fast-acting emergency intervention that could reduce overall damage from TBI.

#StayHome Tools

Physical therapists offering concussion care via telehealth

We interviewed two physical therapists, Joe Mahon DPT, SCS and Justin Ho PT, DPT, CSCS, who are incorporating telemedicine into their work with concussion patients. We will be publishing their interviews soon. In the meantime, Joe Mahon is offering free physical therapy sessions via telehealth for concussion patients while shelter in place orders are in effect, contact him via his website. Justin Ho, a contributor to Concussion Alliance, works for Lake Washington Physical Therapy, which is offering telehealth PT that is covered by most insurance companies. They also offer a cash rate if insurance does not cover. To reach Justin, send an email to the attention of Justin Ho. Both physical therapists will meet with patients for an initial consult, but will not move on to treatment unless the patient has been seen by a physician.

Veterans

Repeated subconcussive forces from blast waves could damage brain pathways related to fear, increase susceptibility to PTSD.

Explosions and blast waves are nothing new on the battlefield, and the effects of heavy blasts on soldiers are well-understood, according to an article in The National Interest. However, the research is not nearly as extensive for smaller, repeated exposure to a sub-concussive force like those from shoulder-mounted rocket launchers, wall-breaching explosives, and other commonplace military weapons and equipment. A report by Molly M. Simmons et al., and released by the nonprofit RAND Corporation, shows no military-wide data on the topic despite the current assessment that repeated exposure to subconcussive force can potentially lead to problems associated with PTSD.

One potential explanation, synthesized from data collected through animal trials, suggests that repeated subconcussive force to the head could damage pathways responsible for regulating situational fear. Damage to those pathways could leave the victim more susceptible to PTSD or PTSD-like symptoms in the future.

Mental Health

Online tools: licensed therapists and free chatbots

There are online options both for talk therapy with a licensed therapist and for helping people in crisis, according to an article in Vox. Online therapy companies TalkSpace and BetterHelp are experiencing increasing use, as is the nonprofit, volunteer-based Crisis Text Line. There are also artificial intelligence chat tools for mental health, such as Woebot, a free app that provides cognitive behavioral therapy (CBT), which is one of the therapies advocated for concussions by the International Consensus on Concussion in Sport. A study of Woebot published in JMIR Publications found “Conversational agents appear to be a feasible, engaging, and effective way to deliver CBT.” Wysa, another chatbot, is promising that during the pandemic “AI chat, and tool packs for anxiety and isolation support will remain free.”

SuperBetter’s mental health resiliency app tackles COVID-1

The continued expansion of technology into our lives has fostered new possibilities for apps for therapy and medicine. SuperBetter tries to improve mental health using a technique called gamification, a strategy using incentives, and a step by step process to make accomplishing tasks easier. Through a combination of rewards for completing small tasks like drinking a full glass of water in the morning and scientific and perspective-altering advice, the app fosters mental health resilience. Through teaching users how to be kinder to themselves and reward positive behaviors, these new habits become self-reinforcing. SuperBetter advertises itself as a resource for helping those struggling with anxiety, depression, stress, and concussion recovery. Their resources also include free bonus features, which are designed to help those recovering from concussion as well.

Now their designers are expanding to include a free app that gives daily rewards specific to coronavirus with virtual scavenger-hunts and social elements to foster more robust social connections. SuperBetter is focused on helping with coronavirus related anxiety and has had a 40% increase in usage time this past week. Importantly, as the creator of Superbetter, and a concussion patient herself, Jane McGonigal says, “The game isn’t therapy, and shouldn’t be used in place of therapy.”

Statistics

Mild TBI patients have headaches more often, with greater severity, and a higher impact on daily life than patients with moderate to severe TBIs.

Dr. Amit Akirov published an article on the website Neurology Advisor that reviews the relationships between TBI severity and headache characteristics. Headache characteristics were considered from two professional perspectives: symptom-based specialists, like neurologists and primary care providers, and headache specialists. In the study, 33% of patients with moderate-to-severe TBI and 58% of those with mild TBI had a new or worse headache at 12 months post-injury. Additionally, headaches in those with mild TBI had more severe impacts on daily function. Migraines were also more common in those with mild TBI compared to moderate-to-severe TBI. The article summarizes results found in a recent study by Hoffman et al., published by The American Academy of Physical Medicine and Rehabilitation.

Women's Health

Intimate partner violence likely to rise due to COVID-19; survivors will face limited options and resources

An article in ProPublica highlights accounts from desperate human services workers whose ability to care for their patients is severely limited. A section of the article is dedicated to Intimate Partner Violence (IPV), which we feel is essential to highlight given the reported rate of TBI in IPV survivors of 30-74%. The concerns highlighted in the article focus on two main factors: IPV victims who are stuck in close quarters with their abuser may feel even more trapped, and they may avoid hospitals or health care services for fear of exposure to the virus.

While it is particularly challenging to help IPV survivors during this time, we would like to share a Reddit post, written by a Crisis Counselor, that has a list of resources for IPV victims.

An article in CNN details concerns about increased domestic violence due to lockdowns, and some measures being taken in France, Spain, Italy, and Australia to assist survivors of IPV.

Culture

How to adjust to crisis

Living with a concussion or persistent post-concussion symptoms is stressful enough, and now the strains of social distancing are added to that. Concussion patients often face pressure to be more productive than they can be, or more productive than is suitable for their recovery process. The COVID-19 shutdowns exacerbate this problem. An article by Aisha S. Ahmad, Why You Should Ignore All that Coronavirus-Inspired Productivity Pressure, published in The Chronicle of Higher Education, is particularly useful. Ahmad shares her experiences of adapting to crisis, and these are her recommendations:

Stage 1 - Security (the first few days or weeks): Ahmed recommends that “you should make ample room to allow for a mental adjustment.” She adds, “No sane person feels good during a global disaster, so be grateful for the discomfort of your sanity. At this stage, “focus on food, family, friends, and maybe fitness.” Stage 2 - The Mental Shift: After establishing your security, Ahmed says that you will be more stable, and “your brain can and will reset to new crisis conditions, and your ability to do higher-level work will resume.” She adds, “However, do not rush or prejudge your mental shift, especially if you have never experienced a disaster before.” Stage 3 - Embrace the New Normal: “On the other side of this shift, your wonderful, creative, resilient brain will be waiting for you,” Ahmed says, and “Things will start to feel more natural.”