VR Brain Fly-Through (7/23/20 newsletter)

Jul 23

We are in week six of the 10-week Concussion Alliance summer internship; the interns, mentors, and one of our volunteers 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, Conor Gormally, Malayka Gormally, Trevor Hughes, Elena Morales-Grahl, Hannah Kennicott, Caroline Saksena, Srishti (Shelly) Seth, Trinh Tieu, and Elliot Yim.

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Education

VR Brain Fly-Through from Teachaids

Nonprofit organization TeachAids released a new video and virtual reality aid called Brain Fly-Through, which marks the launch of their CrashCourse Multi-Sport Concussion Education series. The video features world mountain biking champion Kate Courtney narrating her own experience with concussions and highlighting the importance of reporting them immediately. The video and VR (available on Oculus Rift) is notable for superb visualizations of different brain structures. The technology and visuals were created by Stanford University’s Neurosurgical Simulation and Virtual Reality Center, according to TeachAids.org. In September 2018, TeachAids first launched a CrashCourse concussion education film focused on football. Following its success, the organization has collaborated with 17 national governing bodies of the US Olympic and Paralympic Committee to launch the new multi-sport series. Concussion Alliance is a TeachAids partner.

“It was an honor to participate in this Crashcourse production. I’ve been waiting for the right opportunity to share my personal experiences, with the hope of helping others,” Courtney said in VeloNews.

Sports

Retired rugby players report more injuries than retired non-contact athletes - concussions the most prevalent

In an article in The Conversation, professor Karen Hind discusses her recent research, published in Sports Medicine, concerning rugby players’ risk of injury. Hind and her team investigated 189 rugby players, both elite and amateur, and 65 non-contact sports retired athletes.

The researchers found that retired rugby players were “two to seven times more likely to report experiencing an injury” than non-contact sport retirees. Both amateur and elite rugby players had significantly higher numbers of injuries per season than non-contact athletes (0.9 and 1.6 respectively, versus 0.2). Concussions were the most prevalent injury; 81% of elite players and 76% of amateur players reported suffering at least one concussion during their careers. Additionally, retired rugby players were significantly more likely than retired non-contact athletes to “report long-term impact from an injury,” with concussion and neck injury among those that continued to affect players beyond their retirement.

This study highlights the prevalence of injuries in contact sports. Hind emphasizes that injury recovery resources should be more accessible to retired athletes, as well as current players.

Cannabis

Rise of cannabis use in chronic pain patients

Research published in Advances in Therapy sheds new light on cannabis use in specific patient populations. Vwaire Orhurhu et al. found an increase in cannabis use in hospital in-patients struggling with chronic pain from 2011 to 2015. Drawing from the National Inpatient Sample (NIS), the researchers identified 10.3 million chronic pain patients, of whom 247,949 used cannabis during that time period.

The study identified several trends within both the general pool of patients and subgroups. In general, the number of cannabis users increased from 33,189 in 2011 to 72,115 in 2015. The researchers also observed upwards trends in women, patients with particularly low annual incomes, patients between 45 and 64 years of age, and tobacco use disorder patients. Conversely, the prevalence of opioid use disorder patients using cannabis decreased over the sample period.

The study is limited by the lack of certain details provided by the NIS database. However, its results indicate a significant upward trend of increased cannabis use in chronic pain patients. Although the study is not about concussion patients, chronic pain is a common persistent post-concussion symptom.

Diagnostics

NfL biomarker study points to long-term problems from concussions

Whoops! Although it may not look like it, there is, in fact, a Diagnostics section in this newsletter! However, this particular research has such crucial findings that we wanted to break it down in greater depth than we usually do for this format. We don't want to disrupt the flow of your reading, so we put the Diagnostics article at the bottom of this newsletter.

Self-care

Free online yoga classes for those affected by TBI

LoveYourBrain, a nonprofit that seeks to encourage a positive, community-based approach to head injury prevention and healing, is currently offering free virtual yoga classes for those affected by TBI. Classes are organized by types of poses (standing, chair, and floor) and range from 20 to 55 minutes.

Therapies currently available

Defense and Veterans Brain Injury Center releases improved post-concussion sleep recommendations - for patients and clinicians

The Defense and Veterans Brain Injury Center (DVBIC) announced new guidelines for clinicians, plus tips for healthy sleep after a concussion (mTBI) in an article by the Military Health System. Timely intervention against concussion-related sleep issues can significantly aid recovery by protecting against the deteriorating cycle of chronic sleep problems and worsened symptoms.

DVBIC’s new Clinical Recommendations, Management of Sleep Disturbances Following Concussion/mTBI: Guidance for Primary Care Management in Deployed and Non-Deployed Settings are also applicable to clinicians in non-military settings.

DVBIC developed a fact sheet for people experiencing post-concussion sleep disturbances. While targeted at service members and veterans recovering from a concussion, anyone facing sleep disturbances may find it valuable. Healthy sleep practices include limiting screen time, caffeine, alcohol, exercise, and naps all close to bedtime, as well as making a comfortable bedroom environment. Controlling these stimuli, alongside focusing on relaxation or mindfulness may encourage sleep.

The fact sheet also lists free sleep-health apps and a web resource on sleep, which can help a person who’s sustained a concussion keep track of their sleep patterns and adopt positive sleep habits to support their recovery.

Therapies under research

Silymarin (from Milk Thistle) may prevent cognitive decline following concussion in male mice

A study conducted by Ghaffar Shokouhi et al. found that the neuroprotective agent silymarin may effectively treat cognitive decline following concussion in male mice. In the study, published in Life Sciences, 96 mice (10-11 weeks old, 50% male, 50% female) were divided into four groups. The researchers induced concussions in two groups and treated one group with silymarin, a naturally occurring neuroprotective agent extracted from Milk Thistle. The other two groups remained uninjured, and one of those two received silymarin treatment.

Compared to the untreated injured group, the concussed male mice that received silymarin demonstrated improved working memory, recognition memory, and spatial memory. The researchers found positive changes in the hippocampi (a brain region associated with memory) of the injured male mice who received silymarin. The mice had decreased TNF-α and glutamate levels, which are elevated by a concussion, and increases in BDNF concentration, which is lowered by a concussion. These changes suggest that silymarin may prevent memory decline by decreasing neuroinflammation and neurotoxicity, as well as increasing neuron growth and synaptic plasticity.

For concussion-induced female mice, silymarin did not improve memory performance on any of the measurement tasks, nor did it alter TNF-α, glutamate, and BDNF levels in the hippocampus. Further research is needed to determine what contributes to sex differences in the effects of silymarin. Moreover, additional research should aim to examine whether the benefits of silymarin translate to humans.

Veterans and Service Members

Blast-related mTBI associated with higher incidence of headache and PTSD, and higher costs

A longitudinal study by Dr. Dismuke-Greer et al. compared veterans who sustained blast-related (BR) and non-blast-related (NBR) mTBI. These researchers looked at differences in diagnoses, symptoms, health services utilization, and costs between the BR and NBR groups. Veterans in the BR group were more likely to have more combat exposure and had higher incidences of headaches and PTSD than the NBR group. They also had increased numbers of VHA (Veterans Health Administration) visits and higher outpatient costs. The authors pose that these findings suggest the need for an interdisciplinary care team for veterans in the BR group, as they are “complex patients.” The study was published in Archives of Physical Medicine and Rehabilitation.

Mental Health

Concussion expert discusses limitations of recent study correlating brain injuries with greater depressive symptoms and cognitive impairments

In our last newsletter, Concussion Alliance covered a study published in Neurology reporting that patients with a history of traumatic brain injury (TBI) or repetitive head impacts (RHI) had higher depression scores and cognitive deficits than adults without this same history. A recent interview with Dr. Steve Erickson of Banner University Medicine discusses several methodological limitations of the study. Dr. Erickson explains that in the study, the researchers group all forms of TBI together (mild, moderate, severe) in their analysis, limiting their findings’ validity.

Dr. Erickson agrees that moderate and severe TBIs present “long term sequelae including persistent cognitive deficits and psychiatric illness.” However, he suggests it is a stretch to say that “multiple episodes of mild TBI results in cognitive deficits later in life” without baseline cognitive testing for each participant. For future research, Dr. Erickson recommends that studies separate mild TBIs from moderate or severe in their analysis. He also advises that studies should document the number of brain injuries, timing/spacing of these injuries, and the age that these injuries were sustained for each participant to further improve their accuracy.

Statistics

Reduction in youth sport-related TBIs associated with decline of youth football participation

The US Center for Disease Control and Prevention published in their Morbidity and Mortality Weekly Report that the rate of emergency visits for youth contact sports-related TBI (including concussions) decreased 32% from 2012 to 2018. Most the decline in the “latter part of the study period was predominantly the result of a decline in ED [emergency room] visits related to football” related TBIs.

The report's authors attribute much of the decline during the study period to the 24% decline in the number of players in youth football programs since 2010, along with increased restrictions regarding tackling and contact in football programs, as highlighted in a CNN article about the study. However, the CDC report's authors acknowledge that the decreased percentage of ER visits could be an underestimate, as people may not seek medical assistance for their injuries and because the report only looks at youth patients.

Youth

The youth opportunity foundation creates council that will focus on traumatic brain injury in the juvenile justice system

The non-profit Youth Opportunity Foundation (YOF) recently created a Clinical and Scientific Advisory Council that will primarily focus on traumatic brain injury (TBI) in the juvenile justice system. This council will consist of experts in brain injury, the juvenile justice system, and education. YOF focuses on forming partnerships and research that help at-risk youth in Indianapolis.

According to an article in the Daily Herald, “Children and teens who suffer a TBI, including severe or repeated concussions, are nearly 20 times more likely to interact with the juvenile justice system or be admitted to a psychiatric hospital due to criminal conduct disorder.” Research also shows that TBI history increases the likelihood of criminal activity. The article points out that TBI can cause impairments in impulse control and decision making, providing reasoning for how TBI may increase the probability of criminal behavior. A better understanding of TBI in at-risk youth may be vital for helping these young people cope with their problems and become successful adults.

Women's Health

Writer A.H. Reaume shares how developing persistent post-concussion symptoms affected her ability and willingness to have children

In an article in The Guardian Why I don’t have a child: my brain injury complicates my choice, A.H. Reaume writes about her idea at the age of 10 that she may not want to have children. Reaume explains that despite her uncertainty, her ability to choose was taken away by a concussion she sustained when she dropped a weight on her head at the gym. At two years post-injury and accepting that she would have persistent post-concussion symptoms, such as fatigue and difficulty thinking, Reaume decided to enjoy life on her terms.

Reaume points out that many of her disabled friends have chosen to have kids and done so successfully, but she is content with how her life has turned out. She finishes the article by describing how even though she will never have kids, she has created a family that will always be with her.

Culture

Disparities in subspecialty concussion care for Hispanic youth

Access to adequate medical care is not a reality for all concussion patients. In a study published in the Journal of Racial and Ethnic Health Disparities, M. Copley et al. identified “disparities in subspecialty concussion care for Hispanic youth, as well as for individuals with limited English proficiency (LEP) and non-private insurance.” Clinicians should take steps to reduce such disparities -- for example, by providing interpreters for families with LEP.

CTE and Neurodegeneration Issues

Magnetic Resonance Spectroscopy (MRS) appears as a promising tool for detecting neurodegeneration following brain injuries

A recent analysis by Dr. Amande Eisele et al. in Neurogenerative Diseasesindicates that magnetic resonance spectroscopy (MRS) could be a possible method of observing brain metabolism changes in adults following a single mTBI. In a meta-analysis of four studies and a systematic review of two others, the authors found consistent changes in levels of two brain metabolites: N-Acetyl-Aspartate (NAA), which is a marker of neuronal integrity, and glutamate (Glu), a marker for disturbed brain metabolism.

In all four studies in the meta-analysis, patients displayed a "moderate decline" in NAA concentrations, and two studies reported increased Glu concentrations. However, Dr. Eisele et al. found no significant concentration changes for any other biomarkers that they were looking at. The authors explain that while MRS may effectively detect dysfunction in brain metabolism, the evidence of this following mTBI is "scarce" and that further research is also needed to elucidate whether NAA or Glu are effective biomarker predictors of TBI-induced neurodegeneration via MRS technology.

Diagnostics

NfL biomarker study points to long-term problems from concussions

In a study of 358 participants across two distinct cohorts (including healthy controls) enrolled from 2011-2019, Pashtun Shahim et al. found that the biomarker Neurofilament Light (NfL) "shows promise as a biomarker for acute and repetitive sports-related concussion and patients with subacute and chronic TBI." The researchers' objective was to determine if NfL measured in serum (blood) was as effective a biomarker as NfL measured in cerebrospinal fluid (extracted via spinal tap). In confirming that these two are closely correlated, the authors made numerous other findings that may affect concussion and TBI diagnosis and prognosis. The researchers' findings, published in Neurology,extended to acute concussions, persistent post-concussion symptoms, and repetitive concussions.

Regarding a single concussion, "concentrations in mTBIs were elevated for up to five years after injury... suggesting that a single mTBI may result in long term axonal degeneration that can be detected with serum NfL." The researchers found that increased NfL concentrations may persist and even rise beyond the acute stage. "In the [six-participant] subset of acute concussed players who developed persistent [symptoms], and agreed to undergo longitudinal assessments, we observed an increase in serum NfL over the months or years after concussion in all except one player who could RTP [return to play] within three months."

In the study cohort of TBI patients recruited from a US-based clinic, NfL concentrations "measured during the chronic post-injury period [were] associated with the likely rate of brain atrophy" observed with MRI. These chronic post-injury NfL levels were also associated with progression of traumatic axonal injury (TAI), measured via Diffusion Tensor Imaging. Additionally, increased NfL concentrations were associated with reductions in the volume of white matter, grey matter, and the corpus callosum.

"In the subset of players with persistent [symptoms]" who the researchers were able to follow over time, "serum NfL increased over the months and years after concussion, suggesting that repetitive head trauma may cause long-term axonal degeneration." This and many of the authors' other findings "add support to the existing hypotheses that TAI may be an underlying mechanism for persistent [symptoms] following repetitive concussions and serum NfL is a sensitive biochemical marker for assessing TAI either acutely or in the months or years after injury."

The researchers listed six study limitations, three of which were related to challenges in collecting data over time. However, the potential for NfL to help concussion patients and providers is massive. NfL concentrations were able to distinguish mild, moderate, and severe TBI patients from healthy controls, and differentiate moderate vs. mild and severe vs. moderate TBI in patients. Further, NfL serum concentrations were correlated with the number of concussions, symptom severity, time for RTP in acute concussions, and duration of persistent concussion symptoms. Particularly because cerebrospinal fluid is difficult and dangerous to extract, NfL concentrations measured from blood have the potential to be a vital and accessible screening tool to identify patients who may need additional care.