Brain Structure Changes (6/25/20 newsletter)

Jul 4

We are excited to announce that Concussion Alliance is hosting a 10-week summer internship for undergraduates, and the interns and mentors in the program have written this newsletter! All of the writers are students or alumni from Carleton College.

Contributors this week:

Editors: Conor Gormally and Malayka Gormally.
Contributors: Will Altaweel, Cassidy Bins, Eloïse Cowan, Trevor Hughes, Hannah Kennicott, Elena Morales-Grahl, Caroline Saksena, Srishti (Shelly) Seth, and Elliot Yim.

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Covid-19

Delays in returns to consciousness for COVID patients taken off ventilators leads to fear of potential brain damage caused by the virus

Despite expectations that COVID patients would wake up within a day once taken off ventilators, according to a recent Washington Post article, some patients are taking weeks to wake up. A study published in Jama Neurology, focusing on hospitalizations in Wuhan, China, cites that 14.8% of a sample of patients with COVID had “impaired consciousness” after the removal of ventilators. In an article published in Neurocritical Care, Edward J. Needham et al. describe how the neurological effects of this “impaired consciousness” can range from fatigue, mild memory lapses, and some mental fog, to severe cognitive dysfunction requiring lengthy rehabilitation.

A related study in the New England Journal of Medicine found that 12 months after “adults [suffered] with respiratory failure or shock in the ICU...34 percent had symptoms equivalent to those typically seen in patients with moderate traumatic brain injury."

The reasons for this “impaired consciousness” are not well understood, but neurologist Nicholas Schiff mentions (in the Washington Post article) the possibilities of strokes. However, there are no signs of strokes in many of these patients. COVID-19 virus particles could also potentially be crossing the blood-brain barrier and attacking brain tissue, although there is only a single case report demonstrating this in the Journal of Medical Virology. Schiff acknowledges that much more research is needed to understand how and why patients are taking so long to recover after ventilator usage and notes neurological rehabilitation units will likely be faced with a significant challenge soon.

Oregon House approves bill to support students experiencing a concussion

The Oregon House recently passed legislation that will support students who are experiencing concussion or other traumatic brain injury, according to an article from KTVZ News. Concussions can induce cognitive impairments and learning difficulties that persist for months after the incident itself, and this bill aims to support students during this time. The bill, House Bill 4140, requires the Oregon Department of Education to produce a form that “outlines the academic accommodations available to students experiencing a concussion” or brain injury. House Bill 4140 is a tremendous step to establishing a formalized concussion support system in the public education system. The bill now moves to the Oregon Senate.

Sports

A culturally tailored bicycle safety intervention may increase helmet use among youth

A study conducted by Leticia M. Ryan, MD, MPH, et al. found that a culturally tailored, youth-targeted bicycle safety intervention may increase helmet use among urban youth. The researchers recruited 20 youth (ages 8-15) and their parent/guardian; 80% of the youth “reported not owning or wearing a helmet.” The intervention included a free bike helmet and fitting demonstration, a parent guidance document, and a video that compared using helmets to protect heads with using phone cases to protect phones.

Of the 20 youth, 12 responded at the one-month follow up; five reported that they had ridden a bike during that month. Of those five youth, 100% reported “always” wearing their helmet, compared to none of them having reported wearing a helmet prior to the intervention.

While the increase in helmet use is promising, it was not statistically significant. Moreover, the study, published in Health Promotion Practice, had a high attrition rate; only 25% of the participants were able to report on their helmet use in the one-month follow-up. To address the limitations of the study, future researchers might re-examine the intervention with a larger sample size to verify that it increases helmet use among urban youth.

Importantly, Ryan et al. suggest that the intervention could help reduce the risk of brain injury from a bike accident. In a press release from Johns Hopkins Medicine, lead author Dr. Ryan emphasized the value of this research, stating that "For families in low income and minority communities, programs that inform about helmet safety measures [are] crucial."

Changes in athlete brain structure and function even in absence of concussion

Kathryn Y. Manning, PhD, et al. published an article in Neurology that followed female athletes who play contact (rugby) and noncontact (rowing and swimming) sports to characterize brain microstructure and function during the on- and off-season. As summarized in a press release by the American Academy of Neurology, even if the athletes playing contact sports did not sustain diagnosed concussions, they experienced structural and functional changes in the brain, measured by diffusion and resting-state fMRI. Researchers identified changes in neural networks in those playing contact sports.

The researchers believe that “more research is needed to understand what these changes may mean and to what extent they reflect how the brain compensates for the injuries, repairs itself or degenerates so we can better understand the long-term health effects of playing a contact sport.”

Cannabis

Professional hockey players advocate for CBD as a treatment for traumatic brain injuries

An increase in the number of predatory hits in the NHL has renewed concerns about players sustaining traumatic brain injuries (TBI). Former NHL player Riley Cote voiced his support of cannabidiol (CBD) for professional athletes as both a preventative and rehabilitative treatment in an interview with the Toronto Observer.

Martin Lee of Project CBD, a California-based nonprofit that advocates for CBD use, said in the Observer article that “CBD has delivered impressive neuroprotective results in preclinical experiments. Pioneering medical scientists recognize that CBD can convey potent, long-lasting neuroprotection if given as much as 12 hours after the onset of a head injury.” He believes that a remedy combining CBD and THC would be an ideal therapeutic candidate to treat athletes and others with TBIs. However, most medical research and clinical trials into CBD as a neuroprotectant or concussion treatment are still in the early stages; you can read more on Concussion Alliance’s page CBD and Cannabis Research.

Cote, alongside many other current NHL players, hopes that sports organizations and medical staff will provide CBD to players in the next year or two.

Diagnostics

Study finds altered information flow in brains of adolescent athletes with concussions

White matter damage as the result of concussion may pose a unique risk to adolescents’ developing brains. A study by Dionissios T. Hristopulos et al. published in Frontiers in Human Neuroscience found evidence of structural re-routing of information flow in the brains of adolescent males with concussions.

The researchers monitored functional connectivity in the brain via electroencephalogram (EEG) signals to understand how information flow in the adolescent brain changes within one week of concussion. They recruited 32 male adolescent athletes with no prior history of concussion and 21 male adolescent athletes with sport-related concussions; each athlete sat with his eyes closed for 5 minutes while researchers collected resting-state EEG data. They identified four different “detour” pathways present in adolescents with concussions, which differentiated them from the healthy control group.

Earlier studies have found concussion-induced hyperconnectivity, but this new study is the first to demonstrate “the formation of re-routing patterns via an effective connectivity analysis.”

The present study is limited in its small sample size, lack of longitudinal data collection, and reliance on the participation of male athletes only. However, the study presents a promising step toward developing a diagnostic tool that may identify particular “detours” in brain pathways as evidence of concussion.

Therapies

Combining translingual neurostimulation and physical therapy could be effective against mild-to-moderate TBI problems related to balance

New research published in Neuromodulation Technology at the Neural Interfaceshows promising results for translingual neurostimulation (TLNS), a non-invasive brain stimulation method. Researchers Alain Ptito, PhD, et al. found that combining TLNS and physical therapy (PT) was an effective treatment for patients with a “chronic balance deficit” after a mild-to-moderate traumatic brain injury (mmTBI). The researchers examined 122 participants who had experienced a plateau phase in recovery after a mmTBI and subsequent PT over two years.

The study used a combination of PT with either high-frequency pulse (HFP) TLNS or low-frequency pulse (LFP) TLNS, and found that both frequencies had significant effects on participants’ balance, fall frequency, and sleep quality. Patients in both treatment groups had better scores for both composite SOT (sensory organization test) and dynamic gait index (DGI), indicating significant improvements in posture and balance.

The study is partially limited by its predominately female sample. However, its results indicate the potential for future research related to mmTBI patients who are plateauing after conventional PT.

Growth hormone replacement decreases fatigue and alters brain structure and connectivity, but effects may not last beyond treatment

Traver Wright et al. published a study in the Journal of Neurotraumainvestigating the effects of growth hormone (GH) replacement on fatigue, brain morphometry, and connectivity. Eighteen subjects with a history of mild TBI, fatigue, and insufficient GH secretion received GH replacement for nine months.

The patients improved in subjective measures of fatigue, sleep disturbances, anxiety, and perception of effort while exercising. Researchers were able to measure improvements in resting energy expenditure, body composition, and metabolic measures of fatigue, though the latter’s efficacy requires more analysis due to experimental limits.

Following GH replacement, MRI scans revealed strengthened neural connectivity in specific regions of the brain associated with sensorimotor, motor, and executive functioning skills. With regard to symptoms, the researchers noted that “after discontinuing GH treatment, patients tend to exhibit a gradual return of symptoms over approximately 3 months.”

Further research is needed to trace the interplay between GH treatment, exercise regime, and changes in fatigue and the brain. Introducing MRI scanning to assess post GH replacement in mTBI patients allows for a comparison of brain structure with patient function that will improve understanding of how GH may provide fatigue relief after TBI. While a promising treatment for symptoms, the authors emphasize that “this treatment does not cure the underlying condition as the symptoms return when treatment has ended.”

Veterans and Service Members

Dementia risk increased with TBI in Veterans

A study by Kimberly Peterson, MS, et al., published in The Journal of Head Trauma Rehabilitation, found that the prevalence of dementia in veterans is similar to that of the general population. However, dementia risk is significantly higher in those who have experienced TBI. An article in HCP Live mentions that this study has limitations in accounting for additional variables related to the nature of combat, but it does corroborate previous studies that found a relationship between TBI and dementia.

Mental Health

Adults with a concussion history found to be three times more likely to develop depression

Depression is a potential concussion symptom that can persist for months after the initial injury. A recent analysis by Sarah C. Hellewell in Frontiers in Neurology expands on the exact nature of this relationship. After conducting a thorough review of all recently published studies examining depression in adults who are “at least six months post [concussive] injury,” Dr. Hellewell concluded that individuals experiencing a concussion are “three times more likely to experience depression” than those without a concussion history. In addition, Dr. Hellewell revealed that this increased risk of depression onset persists for decades after the incident. Future studies are needed to replicate this finding and find measures to reduce this risk.

Statistics

The long-term impact of mTBI on the elderly population

Researchers from KU Leuven University in Belgium recently presented work seeking to reevaluate the diagnosis procedure of mild Traumatic Brain Injury (mTBI) in the elderly. The study, a poster presentation at the Frontiers in Traumatic Brain Injury online conference on June 16th, questions the current understanding of brain injury cases in patients over 65. R.A. Gavrila Laic et al. argue that an mTBI diagnosis is not sufficient to cover other physiological and psychosocial impairments that may arise following a concussion. Instead, their work suggests that long-term impacts include loss of cognitive or motor function, depression, epilepsy, and a higher probability of suffering from neurodegenerative diseases such as dementia or Parkinson’s disease. Further investigation should be undertaken to study the impact of TBI on the elderly and associations with other conditions.

Youth

One in 20 pediatric emergency department patients have head injuries

Head injuries, including traumatic brain injury (TBI), are common in pediatric emergency visits. A retrospective analysis by Ryan et al. found that one in twenty children who visit pediatric emergency departments has sustained a head injury. The authors examined activity in three pediatric emergency departments (PEDs) around Dublin, Ireland, from 2014 to 2015 using several search terms, including “head injury” and “intracranial bleed.” Head injury was among the diagnoses in 5.9% of all visits to the analyzed PEDs. Falls were the most common cause of head injuries (45.5%), and sports only accounted for 12.2% of head injuries. Preschool children also dominated presentations of all head injuries (45%). The study was published in the Irish Medical Journal.

Women's Health

Black women’s experience with brain injury and IPV/DV

Dr. Pappadis, a TBI researcher who was a guest speaker for our 2020 Education & Advocacy Internship, suggests this 30-minute documentary “Cultural Humility: People, Principles and Practices” as “a way to approach our clients with an openness, willingness and love.” The documentary is by Vivian Chávez, and makes use of “music, interviews, archival footage, and images of community, nature and dance to explain what Cultural Humility is and why we need it.”

Culture

Writer Mike Abrams compares NFL to a plantation citing handling of concussions

In a Miami Herald article, writer Mike Abrams equates the NFL to a modern-day plantation, citing the many ways that the NFL exploits its black players (who make up over 70% of the league) while disregarding their health and humanity. His primary evidence for this claim is the NFL’s historic mishandling of concussions. When the NFL created their Traumatic Brain Injury Committee, a doctor with no experience handling head injuries, Dr. Elliot J. Pellman, was named chairman. Committee member Dr. Ira Casson also appeared before Congress (2010), denying any link between repeated head impacts and brain injury. It wasn’t until former players filed a class-action suit that the NFL publicly acknowledged the linkage.

As Abram says, “by 2012, the multibillion-dollar NFL committed all of $30 million to support medical research into this issue. Wow! Players really mattered to this group.” Abrams describes how the lack of guaranteed contracts, short careers, and little pay (compared to the worth of the company) in no way justifies the extremely high risk of injury, especially injuries to the brain.