Psilocybin/CBD trial for concussion (4/30/20 newsletter)

Apr 30

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

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

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See the COVID-19 section of our website for a comprehensive list of recommended resources. Our first recommendation remains Coronavirus.gov, from The Centers for Disease Control (CDC).

Education

Remote learning poses special challenges for college students and faculty with concussions

An article in The Williams Record, the independent student newspaper of Williams College, quotes both students and professors who find the extended screen time required for online education exacerbates persistent post-concussion symptoms or causes symptoms from an earlier concussion to “resurface.” The Williams College Office of Accessible Education is working to make concussion-friendly adjustments to the courses of affected students. Professor of History Karen Merrill takes frequent breaks from her screen and tries to “work [away from] the computer whenever possible.” Merrill “likes to let her students know about the challenges she faces because ‘There are a lot of students on campus who [have had] concussions… and there can be really profound effects in terms of how you work, especially online.’”

Sports

Research recommends new starting stance in football to reduce hits to the head by 40%

Researchers from Purdue University and Stanford University have published novel findings concerning the reduction of head injuries in North American football depending on starting stance in the Clinical Journal of Sport Medicine. Taylor A. Lee, BS, et al. used video footage and sensors to evaluate how head acceleration events (HAEs) varied in frequency and distribution based on player position, starting stance, and play type. Regardless of play type, offensive line players starting in a “down stance” suffered HAEs more frequently (40% more often) than players in an “up stance.” This research creates some precedent for future rule changes in football, to reduce the number of full-contact practices and HAEs, especially for offensive and defensive linemen. The researchers claim that these crucial changes would not affect gameplay.

One of the study authors, Paul Auerbach, MD, MS, gave hope that changes were soon to come. In an article in Orthopedics This Week, he states that “it seemed logical that if something could be done to lessen the number of potentially injurious blows to the heads of the linemen, that this would be desired by people who care about making the game safer.”

Cannabis

Study: combined cannabidiol (CBD) and psilocybin pill for mTBI with PTSD

In addition to an ongoing five-year study of a cannabidiol (CBD) pill for mTBI, Dr. Michael Hoffer (University of Miami’s Miller School of Medicine) will be the lead investigator for new research combining cannabidiol and psilocybin for the treatment of mTBI with PTSD or stand-alone PTSD. “Up to 40% of people impacted by mTBI [or TBI] also suffer from PTSD,” according to a University of Miami press release. Dr. Hoffer notes that “As a result, they’re disabled not just by the sequelae of the head injury, which can be dizziness, hearing disorders, memory issues, and headaches, but also [by] posttraumatic stress symptoms that complicate the disability after the head injury.”

Regarding his long-standing research into cannabidiol, Dr. Hoffer says that “CBD has the potential to treat the sequelae of traumatic brain injury, including hearing loss, balance disorders, memory and other cognitive issues. It has the ability to treat these disorders and prevent them from becoming significant issues after the concussion.” This new study began in February 2020, and includes “preclinical studies and eventual human clinical trials,” with the goal of developing a cannabidiol-psilocybin prescription medication.

Dr. Hoffer notes that “Since mTBI associated with PTSD is a combination disorder that affects more than 10 million individuals per year and has no proven medical treatment, our novel combination of medicines could be a breakthrough in treating these indications.” Both studies have been funded by Tassili Life Sciences Corp., which was recently acquired by Champignon Brands Inc, according to a press release. Concussion Alliance has recently posted the summary of an interview with Dr. Hoffer regarding his research on a cannabidiol-based pill.

Diagnostics

Study shows potential for objective diagnostic biomarkers in sports-related concussion patients

In a study involving high school and collegiate athletes, conducted by Dr. Timothy B Meier et al., specific protein markers in the body showed signs of potential to distinguish between concussed athletes and control groups. By collecting pre-injury baseline blood samples from participants and comparing those samples to blood collected within six hours and then 24-48 hours post-injury, the study's authors found drastically elevated levels of all but two of the proteins studied during the early acute phase post-injury, with one of the two outliers showing particularly high levels in cases where the concussed lost consciousness or suffered from amnesia post-injury. While still early to make any definitive claims, the studied proteins show potential as a more objective diagnostic criterion than symptoms alone and may prove useful for identifying and treating concussed athletes accurately and quickly. The study was published in Annals of Neurology.

Therapies

Aerobic exercise at home may be a valuable treatment for sports-related concussions

An article, published in the Clinical Journal of Sport Medicine and authored by Itai Bezherano et al., offers three potential methods of aerobic exercise prescription after a sports-related concussion, depending on the equipment available and circumstances of each particular case. The study notes that the most recent Consensus Statement on Concussion in Sport “now recommends a brief period of relative rest (24-48 hours) followed by a gradual return to activity.”

The first option involves a graded exertion test, either the Buffalo Concussion Treadmill Test (BCTT) or the Buffalo Concussion Bike Test (BCBT), performed by the patient in the clinic, followed by the use of a heart-rate monitor during their at-home exercise routine. The BCTT and BCBT are stress tests designed to assess the level of exercise that a patient’s autonomic nervous system can tolerate before their symptoms worsen. These tests yield a maximum sub-symptom heart rate, which the patient reaches and maintains in their exercise program using the heart monitor.

The second option also involves an in-clinic BCTT or BCBT stress test. However, if the patient does not have access to a heart rate monitor, Beznerano suggests the prescribing physician calculate the appropriate workload and speed, tailoring those variables to the patient’s at-home exercise routine.

The third option is for those clinicians who do not use the stress test, or for the patient who is physically unable to do the stress test. This option does require the patient to have a heart-rate monitor. Because there is no ability to determine a target heart-rate using the stress tests, a prescribed exercise regimen needs to begin conservatively and progress slowly to ensure the safety of the patient. While some physicians may be reluctant to prescribe exercise to those suffering from concussion, the results from research in this area have begun to change the paradigm regarding exercise therapy for concussion patients.

#StayHome Tools

Live group meditation, new apps, and telehealth neurology for concussions

The use of meditation apps has surged in the past month, according to an article in The Washington Post. The need for connection has spurred the popularity of live meditation classes, led by an instructor and sometimes a celebrity guest, with options for live commenting and Q&A after the session. Ten Percent Happier offers a free “Live guided meditation + a virtual break from social distancing. Every weekday at 3 pm Eastern.”

In our last newsletter, we discussed the health gamification app SuperBetter. The software company has just added a “Stay Strong in the Pandemic“ powerpack, which has activities to “help players increase mental, social, emotional, and physical resilience while following the World Health Organization and CDC guidance to slow the spread of the virus.”

For our Canadian readers, the Toronto Sun featured Dr. Evan Lewis, a neurologist who does telehealth for concussions, which allows him to expedite care and circumvent the typical “six to eight months to see a specialist.” Dr. Lewis founded the Neurology Centre of Toronto, which has a comprehensive concussion care team.

Veterans

The National Intrepid Center of Excellence (NICoE) celebrates ten years

Located at Walter Reed National Military Medical Center in Maryland, the NICoE is a clinical program designed to help service members with traumatic brain injuries and psychological health conditions. Their programs focus on a holistic view of health, often incorporating psychological and spiritual elements, as well as the patient's family into their care. Their programs range from outpatient treatment to a four week intensive. The outpatient clinic provides full TBI care, a Brain Fitness Center includes computer training to train the brain, and they offer the Veterans Crisis Line. The crisis line is open to any current or former service member.

Mental Health

Cognitive Behavioral Therapy (CBT) adapted for cognitive impairments

Cognitive-behavioral therapy (CBT) is recommended for concussion patients with “persistent mood or behavioral issues” in the most recent Consensus Statement on Concussion in Sport. But how well does CBT work if persistent symptoms include cognitive challenges? Related research by Jennie Ponsford, PhD, et al. studied how a modified version of CBT worked for moderate and severe TBI patients. The study found that CBT-ABI, a version of CBT “adapted to accommodate cognitive impairments” in acquired brain injury patients, successfully reduced anxiety and depression relative to controls. Adaptations to CBT included “incorporating simplified concepts, concrete behavioral examples, pictorial handouts and cues, and considerable repetition, as well as booster sessions.”

The authors found greater anxiety symptom reduction in those who had higher baseline anxiety and older study participants who may have “brought greater motivation and wealth of experience in order to challenge unhelpful thoughts and apply alternative strategies to overcome them.” Greater depression symptom reduction was associated with higher baseline depression, longer time since injury, and higher expectancy for change. The study was published in The Journal of Head Trauma Rehabilitation.

Statistics

New research suggests diffusion MRI may predict re-injury

A multi-institutional study published in Frontiers in Neurology investigated if Diffusion Tensor Imaging (DTI) MRI was a good predictor of re-injury for concussion patients. DTI is an MRI technique that examines cell integrity in the brain by measuring the movement of water in and out of the neurons. This study focused specifically on the brain's white matter, which is constructed of axons, the component of neurons that sends the signal onto the next neuron. By examining the integrity of these axons with DTI-MRI, scientists can understand if the cell membranes are more or less permeable to water. This study examined the corpus callosum, the connection between the two halves of the brain made entirely of white matter.

The authors, Benjamin L. Brett et al., found that of the 82 athletes they studied, the athletes whose corpus callosum white matter became more permeable one week after injury were at a higher risk for re-injury in the next year. This correlation was not present 24-48 hours after injury but was present at one week after injury. Compared to the population which did not suffer a second injury, the re-injured athletes had a higher water permeability in their white matter at one week. This finding is significant because past research has shown that, while abnormalities in the permeability of neurons are consistently present after a concussion, other studies have found both increases and decreases and have measured different brain regions.

While this study's sample size (82 athletes, 69 control patents) was substantial, further research is needed to confirm these results. One of the limitations to DTI-MRI is the need for MRI scans and the need for additional computer interpretation of the DTI data (which is not widely available). However, this research group is still hoping to develop DTI-MRI as a measure of risk for re-injury. They believe that after concussions, a subset of athletes may "experience a perturbation in white matter integrity that is associated with a more prolonged period of risk for repeat injury or overall increased susceptibility." If healthcare providers can warn that subset's members of this increased risk after their concussion, their increased risk for re-injury could be significantly mitigated.

Culture

Can cumulative trauma be a work-related injury?

A recent article published by New Zealand’s Newshub shed light on Constable Matt Davis’s fight to get cumulative trauma recognized as a work-related injury. His struggle with the Accident Compensation Corporation (ACC) stems from his experience with trauma after working as a policeman for 17 years. Davis was “diagnosed with a mild-trauma brain injury and concussion,” leading to PTSD, depression, and suicidal thoughts.

The ACC’s current legislation does not consider cumulative or repeated trauma as sufficient grounds for compensation. However, there is hope of coming change as Davis’s position has begun to receive support. The president of the Police Association, Chris Cahill, states, “the fact that [cumulative trauma] isn’t already recognized says there’s some blockages so we just want to make sure that we’ve got the right research to clear those blockages.” In response, Davis has started a petition to change ACC legislation to recognize the dangers he and other emergency service workers face while on the job and mental consequences that can result.