Police deliver concussions at protests (6/11/20 newsletter)

Jun 15

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

Editor: Malayka Gormally.
Contributors: Eloïse Cowan, Conor Gormally, Malayka Gormally, Micale Hunt, Hannah Kennicott, Julian Szieff, and Zachary Touqan.

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Concussion Alliance wholeheartedly supports the George Floyd protests and the Black Lives Matter movement. Systemic racism and inequality affect every aspect of American life, including concussion diagnosis and treatment. While we have previously addressed the role of racial, socioeconomic, and gender disparities in concussion outcomes, we recognize that we need to do more. We will be devoting a portion of our summer internship program to address this issue more systematically and make a concerted effort to break down barriers to concussion education. Please also see the Culture section of this newsletter, which focuses on concussions suffered due to violent police responses to protests.

Education

Webinar: How Physical Therapy Can Help with Post-Concussion Syndrome

The webinar, “How Physical Therapy Can Help with Post-Concussion Syndrome,” is today (June 11) at 4 pm EST. You must register in advance, and the host, Concussion Legacy Foundation (CLF), will send you a link. The guest speaker is Dr. Lindsay Walston, Neurologic Residency Director at PT Solutions Physical Therapy. The next CLF webinar is July 9.

Interview: how to disclose a disability during the employment process

The June 19 meeting of a remote support group will feature an interview with Jeanette Silva, “a job coach for individuals with disabilities. Ms. Silva will share information about how to disclose a disability during the employment process.” The Virtual Brain Injury Support Group Gathering is hosted by the Brain Injury Alliance of Washington State; you must register to attend the meeting, which is 1-2 pm PST.

Sports

Interview: No Game for Boys to Play

On the 13th episode of The End of Sport podcast, hosts conversed with author Kathleen Bachynski about the risks associated with football in the US and questioned its legitimacy as a popular sport. Bachynski recently found success in her Atlantic article “Youth Football Is a Moral Abdication” and her book No Game for Boys to Play, which won the 2020 North American Society for Sport History Book Award.

Repetitive low-grade head trauma linked to changes in neuromotor function

Researchers at Curtin University, led by Associate Professor Ryu Takechi, have found that rats that receive long term exposure to repetitive, low-grade head trauma experience a decrease in motor function. The study, published in Frontiers of Neurology, investigated the effects of repetitive sub-concussive cranial impacts (head trauma not severe enough to result in a concussion) on rats over a 2-week and a 12-week period. Rats in the 2-week group showed no significant differences when compared to control.

When made to walk across 3cm, 2cm, and 1cm wide beams and compared to a control group, rats that experienced trauma over a 12-week period were found to have statistically significant increases in foot-slips on the 1cm beam, with no statistically significant differences detected in the wider beam tests. The researchers make note that the narrower beams are considered to be more sensitive tests.

Most studies investigating the effects of head trauma on animal subjects focus on more severe injury levels. This study was designed to model something akin to the types of seemingly low-grade, repetitive trauma that certain athletes may experience, such as soccer players heading the ball, according to an article in Medical Express. Further, this study suggests a positive correlation between long term exposure to sub-concussive trauma and motor dysfunction, illuminating the need for further testing and study into the effects of seemingly innocuous impacts to the head in athletes.

Cannabis

Cannabis use may alleviate PTSD symptoms in the short term

While the focus of this study was solely on individuals with PTSD, many concussion patients, especially veterans, develop PTSD along with or as a result of a concussion. Researchers Emily LaFrance et al. utilized data from “404 medical cannabis users who self-identified as having PTSD,” acquired from the medical cannabis tracking app StrainPrint. Users establish baseline conditions and symptoms, along with their severities, and use the app to track the effects of particular doses and strains of medical cannabis on those symptoms. The researchers analyzed 11,797 data points, recorded from their sample over 31 months, containing self-recorded impacts on “intrusive thoughts, flashbacks, irritability, and/or anxiety” as well as information on the user’s gender, dosage, and strain inhaled.

LaFrance et al. found that medical cannabis use, on average, reduced all PTSD symptoms by “more than 50% immediately after use,” and was effective in reducing symptoms in over 90% of sessions. The researchers found, however, that there was a high variance in the effectiveness of this reduction between individuals. Additionally, baseline PTSD symptom scores did not decrease over time. Furthermore, the doses used, particularly to treat anxiety, increased over time. The researchers believe that, while cannabis use may provide relief for PTSD symptoms, it alone is likely not a “long-term remedy for the disorder,” and drug tolerance points towards the need to increase dosage over time to maintain symptom alleviation. The study was published in the Journal of Affective Disorders.

Diagnostics

Prognostic biomarkers for assessing the risk of complications, particularly after three or more concussions

A recent study conducted by Dr. Guedes et al. of the National Institute of Nursing Research identified several biomarkers that can aid in predicting an individual's complications following concussion, according to an article in Physician's Weekly. High plasma and exosome levels of the structural protein neurofilament light (NfL) as well as two cytokines associated with inflammation, tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6), were found to be predictors of long-term concussion-related complications, including PTSD and depression. The study participants, both veterans and service members, “were enrolled in the Chronic Effects of Neurotrauma Consortium (CENC), a multicenter observational study of the long-term effects of mild TBI," according to an NIH press release.

According to an American Academy of Neurology press release, neurofilament light is "a nerve protein that can be detected in the blood when nerve cells are injured or die." For all of the participants in the study, their most recent concussion was at least seven years in the past. Despite the length time since their last concussion, the study found that "The average blood levels of neurofilament light were 33% higher in those with three or more concussions than those who had never had a concussion." Study author Kimbra L. Kenny, MD, states that "Our study found there's great potential for this protein to predict the problems people with concussions may experience years after their injuries."

The researchers conclude that "Our results suggest a possible neuroinflammatory and axonal disruptive basis for symptoms that persist years after mTBI, especially repetitive." The study was published in Neurology.

Therapies

New treatment parameters may show efficacy of Hyperbaric Oxygen Treatment for mild TBI

Hyperbaric oxygen treatment (HBOT) as a treatment for mild TBI has been controversial due to mixed evidence, high cost, and relative inaccessibility of treatment. In the treatment of severe TBI, there has been more evidence of its potential to help patients; however, for mTBI, there has been a reticence to advise its use before other therapies with proven efficacy, especially due to its high cost. However, with 70% of veterans with TBI still receiving treatment four years later, the need for more effective therapies and some concerns around the standardization of HBOT research has pushed researchers to continue examining HBOT.

Researchers at Louisiana State University Health Sciences Center and Tulane School of Medicine recently published in the journal of Medical Gas Researchtheir results from a study funded by U.S. Army Medical Research examining the efficacy of HBOT. Using a randomized controlled study of 50 patients and a specific treatment paradigm (150 kPa for 1 hour, 5 days a week, over 8 weeks) showing previous efficacy, researchers tried to eliminate design differences, placebo effects, and dosage differences. Their results showed a statistically significant multi-domain improvement in patients whose persistent post-concussive symptoms have lasted over 4 years.

Patients experienced improvements in "postconcussion symptoms, cognitive variables (memory, cognition/speed of information processing), and behavioral/emotional problems (anxiety, depression, PTSD symptoms, sleep, and quality of life) compared to a randomly assigned Control Group. "Researchers emphasize that this efficacy, despite a delay from TBI to treatment, is encouraging for patients who are still suffering.” Follow-ups at 3 months showed a continued abatement of symptoms.

This study, by Paul G Harch et al., is limited by its small sample size, the lack of double-blinding (the researchers knowing who was getting treatment), and a potential placebo effect. However, the newfound specificity of treatment parameters and revaluation of the research to focus on the specific pressure of 150 kPa for 1 hour, 5 days a week for 8 weeks, should yield a new focus for continued research. If more research can replicate their impactful long-term results for a larger population of mild TBI patients, then this therapy may warrant more attention as a recommended therapy for mTBI patients. Especially interesting in this article is the authors' discussion of the errors in standardization in HBOT mTBI research.

Veterans

Association between inflammatory biomarker interleukin-6 and acute concussion in military personnel

A study conducted by researchers Katie A. Edwards et al. investigated the concentration of three blood-based inflammatory proteins (IL-6, IL-10, and TNFa) in military personnel immediately following a concussive experience and 24 hours later. When compared to a healthy control, levels of IL-10 and TNFa were not significantly different in the concussed. However, during the acute phase of concussion (within eight hours of receiving a concussive impact of blast wave), participants showed statistically significant concentrations of interleukin-6 (IL-6) in their blood samples, indicating the potential for IL-6's use as a biomarker of concussion in the acute phase after receiving brain trauma.

Further, the researchers suggest the potential for continued study into their findings to examine "underlying biological pathways to mitigate inflammation and improve outcomes," and to look into further connections between the fluctuations of inflammatory protein concentrations and the symptoms experienced following a concussion. The study was published in BMC Neurology.

Paid research participation opportunity for veterans (remote)

The Eisenhower Center in Michigan has a call for veterans to be paid study participants by answering two sets of questionnaires. Researchers are looking for veterans "who are currently experiencing some difficulties" and who "may have received previous treatment or may currently be receiving individual or group treatment." The research team is studying the effectiveness of a 30-day residential treatment. The call for study participants is for veterans who will serve as the "control group" who are not in a residential program. Study participants will receive financial compensation in the form of gift cards. Detailed information can be found in this letter to the veteran community, and this flyer describing the call for study participants.

Mental Health

Social support during youth concussion recovery - see our blog post.

Statistics

The incidence of reported concussions in high school athletes continues to rise

Researchers from Northwestern University's Feinberg School of Medicine have released a new study evaluating the rate of reported concussion across 100 high schools in the United States. As compared to 2010-2014, the years 2015-2017 showed an increase in the annual reported concussion rate. The new data shows a continued gender disparity with girls reporting a significantly higher concussion rate than boys in gender-matched sports.

In a press release by the American Academy of Orthopaedic Surgeons, lead author Dr. Wellington Hsu expressed surprise at the continued increase in concussion rate, saying "with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however, because we've studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out."

Researchers plan to continue evaluating youth concussion to understand if this increased reporting is due to increased prevalence, increased awareness, or increased reporting by youth. Researchers hope that their research "will lead to stronger implementation of targeted preventative measures such as rule changes, protective headgear, and contact avoidance."

Women's Health

One pandemic may hide another: The dangers of intimate partner violence during Covid-19

EClinicalMedicine, an open access clinical journal published by The Lancet, recently published a letter to the editor that speaks out against two “pandemics” having deleterious effects on women: Covid-19 and intimate partner violence (IPV). The author Eve Valera, PhD, highlights that since COVID-19 has enforced lockdowns, accounts of IPV and its consequences, including traumatic brain injuries (TBIs), have increased. Due to efforts to mitigate the virus, victims may fear the consequence of trying to escape a violent home or may not be able to escape at all.

Though severe intimate partner violence impacts one in four women, they often do not receive proper or immediate healthcare when concussions occur. Misdiagnoses are frequent because concussion symptoms such as anxiety, depression, or difficulty sleeping are written off as a psychological stress response to abuse rather than physiological trauma.

In hopes of remediating these dangers, Valera asserts that “all clinicians need to be aware of this in order to ensure optimal interventions and avoid additional harm.” She recommends that medical practitioners run efficient screens for IPV related TBI by inquiring about injuries that may have occurred. They should offer proper and immediate interventions, possibly referring them to a neurologist, and provide women with information on the various symptoms that can be indicative of TBIs. She warns, “if we do not act now, we risk facing yet another pandemic of women who are struggling to live with the effects of likely undiagnosed TBIs.”

Note: Valera’s letter to the editor is listed under “Correspondence” on the EClinicalMedicine website. Dr. Valera is a Concussion Alliance Advisory Board Member.

Culture

Concussion incidence from police crackdowns of Geroge Floyd protests likely underreported

“We are going to have an uptick in concussions & moderate/severe Brain injuries ON TOP of ↑ COVID cases,” tweeted Jessica Schwartz, PT, DPT, CSCS, and host of Concussion Corner Podcast, on June 2nd. “If you’re in a #GeorgeFloydProtest, please see assistance for your medical needs.” A significant number of protestors have suffered concussions, moderate/severe brain injuries, or have lost an eye (and likely suffered a concussion) due to brutal police crackdowns of protestors. Those suffering brain injuries include protesters in Minneapolis, Brooklyn, the Bronx, NY, Buffalo, NY, Chicago, San Diego, Detroit, and Sacramento.

The LA Times published an article, “By firing rubber bullets at protesters, police risk killing, blinding or maiming them,” referencing a 2017 study, published in BMJ Open, that found that “3% of people hit by rubber bullets died of the injury. Fifteen percent of the 1,984 people studied were permanently injured by the rubber bullets, also known as ‘kinetic impact projectiles.’”

Also, numerous videos show police hitting protestors on the head with kicks, punches, batons, and shields, as well as shoving protestors to the ground so they hit their head, hitting them with cars, and running over them with horses. Protestors have spoken to reporters about their quandary of wanting to continue to protest while suffering from debilitating concussion symptoms.

Protesters who return to protesting with an acute concussion risk suffering a second concussion that precipitates persistent post-concussion symptoms, or in the worst case, second-impact syndrome. Concussion Alliance recognizes how vital these protests are, but also wishes to remind protesters that their long-term health is important, and they can contribute to the movement in other ways while they recover from their concussion.