Nature for concussion symptoms (8/6/20 newsletter)

Aug 6

We are in week eight of the 10-week Concussion Alliance summer internship; the interns, mentors, and two of our volunteers have written this newsletter!

Contributors this week:

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

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Education

Two free webinars: Strategies for Sleep after Brain Injury, and Changing Your Mind

Strategies for Sleep after Brain Injury will “discuss how and why your sleep can be disrupted and offer several tools to help improve sleep.” Healthcare providers from UW Medicine will facilitate this free webinar. Wednesday, August 12th, from 10:30 - 11:30 AM, PST. You must register in advance to attend.

Changing Your Mind, a webinar by Certified Life Coach Anita Chin, will focus on helping to reframe your perspective away from negative thoughts and towards a sense of possibilities. Thursday, August 13th from 1:00 - 2:00 PM, PST. You must register in advance to attend. Both webinars are provided by the Brain Injury Alliance of Washington.

Sports

Most youth football players have helmets that don’t fit right, posing risk for more severe and long-lasting symptoms

A press release announced new research presented at the National Athletic Trainers’ Association (NATA) Virtual Clinical Symposia & AT Expo. The research found that 74% of youth football helmets did not meet all the proper fitting criteria. The study looked at 273 youth (7-12 years old) football players in recreational youth football leagues and evaluated their helmets on a checklist of 13 measures. If the helmet failed to meet at least one of the checklist criteria, it would be classified as improperly fitted. The press release notes that “Improper fit is a critical risk factor for increased concussion symptoms and duration.”

Lead study author Susan Yeargin, Ph.D., suggests that the helmets may not be snug fitting due to the misconception that kids need room to grow into their helmets. In an article in Everyday Health, Dr. Yeargen adds that a helmet “should fit at the time of purchase.” The top reasons for improper fit were: chin strap did not equally fit on both sides of the face (46% of cases), the face mask slipped up and down (36% of cases), and lack of snugness on all sides (26% of cases).

Helmets should fit properly to reduce the risk of having more - and more persistent - concussions symptoms, as previous studies have found. The study will be published in the Journal of Athletic Training later this year.

Cannabis

Cannabis flower may act as an effective pain reliever for migraines and headaches

To read this synopsis, please see our blog post.

Diagnostics

Do measurements of clinical reaction times cause athletes to return to sport too soon?

A recent study conducted by Landon Lempke et al. assessed whether clinical measures of reaction time were correlated with functional reaction time, a distinction that has vast implications for postconcussion management. Clinical reaction times are measured through tests such as the Stroop Task (a cognitive task used to measure attention and reaction time) or the drop stick task. In contrast, functional reaction times are measured through one’s gait, jump landing, etc. Generally, clinical reaction times are used to assess postconcussion performance with the assumption that they are essentially equivalent to the reaction times required for athletics.

In a sample of 41 healthy participants, the authors compared participants’ clinical and functional response times under both single and dual-task conditions. Single-task conditions only measured motion, while dual-task conditions included movement while doing a cognitive task -- subtracting by 6’s and 7’s. The authors note that “Sport activities simultaneously require considerable cognitive activity during full-body movements, but traditional postconcussion clinical assessments do not challenge motor and cognitive skills simultaneously.”

The study found that Stroop Task reaction times did not correlate with any measure of functional reaction time, “suggesting that sport-like reaction time is not being assessed after concussion.” Overall, reaction times in dual-task conditions were significantly slower than those in single-task conditions.

The clinical reaction times being measured (i.e., finger and hand movement) do not assess the full range of functional reaction times (e.g., jumping and balancing on one leg). Nor do clinical reaction times measure the combination of movement and cognition. The authors suggest that “Functional and dual-task reaction times assessments may add clinical value and warrant further exploration after concussion.” The study was published in Medicine & Science In Sports & Exercise.

Self-care

Beneficial effects of natural environments on people with mTBI symptoms

Writing for Life Matters, journalist Sarah Allely recounts how nature helped her recover from a mild traumatic brain injury. After a car knocked her off her bike, she found herself struggling with symptoms that prevented her from functioning in her professional and home life. Notably, she found herself unusually sensitive to the stimuli of urban life and socialization. However, Allely eventually discovered that sounds of nature helped with recurring headaches, and that being in “the natural environment” aided with anxiety and depression.

Allely had since created a podcast called Brain on Nature. She converses with experts in this emerging field that aims to investigate how nature affects people’s brains. David Sayer, professor at the University of Utah, says that “our increased screen time has led to more multi-tasking, and the combination puts a strain on our brains.” Avik Basu, an environmental psychologist at the University of Michigan, says that even “simple ways of interacting with nature” such as having plants in the house or having natural views outside one’s window can be beneficial.

You can listen to Allely’s podcast to hear about her story in more detail.

Therapies currently available

In-depth webinar on physical therapy as treatment for PCS

The Concussion Legacy Foundation recently hosted a webinar, How Physical Therapy Can Treat Post-Concussion Syndrome. Guest speaker Noah Bond first shared his story of dealing with PCS for over four years and how physical therapy was significant in his recovery. Then Linsday Walston, PT, DPT, NCS, OCS, and neurologic residency director and education coordinator at PT Solutions Physical Therapy, presented specific ways that physical therapy helps patients. She explained misconceptions around PCS treatment, shared a timeline of how physical therapy can ease symptoms of PCS, and highlighted how different types of physical therapy can treat specific symptoms.

For additional information, read our blog post detailing the importance of telehealth and vestibular therapy with Sara Gallagher.

Therapies under research

Increase in 5-HT2AR autoantibodies following TBI may provide insight into treatment of neurodegenerative diseases

A better understanding of the relationship between traumatic brain injury (TBI) and neurotoxic 5-hydroxytryptamine 2A receptor (5-HT2AR) autoantibodies may speed the development of pharmacological treatments for neurodegenerative diseases. According to an article in TechLink, 5-HT2AR is “typically found in specific brain regions involved in cognition, perception, and mood,” and is associated with “neurodegenerative diseases such as Alzheimer’s and dementia, as well as obesity, stroke, and major depressive disorder.”

In a Department of Veterans Affairs study published in the Journal of Endocrinology and Diabetes, researchers Mark Zimering et al. found that “nearly two-thirds of traumatic brain injured-patients harbored 5-HT2AR autoantibodies in their circulation.” Researchers tested for neurotoxicity in the plasma of veterans with TBI. They propose an association between neurodegeneration and an increase in 5-HT2AR autoantibodies following TBI.

Among the study limitations are that it included only middle-aged and older men, and it did not differentiate severity of TBI. More research is needed to determine 5-HT2AR’s potential role as a ”useful biomarker in identifying a subset of TBI at increased risk for late neurodegeneration.” On a hopeful note, clinicians are already using several FDA-approved medications to target 5-HT2AR autoantibodies for treatment of "diabetic painful neuropathy, major depression, schizophrenia, and Parkinson’s disease-related hallucinations.”

Veterans and Service Members

Daily drinking in veterans associated with TBI

A recent study by Andrew S. London et al. found that veterans with TBI are more likely than nonveterans to be current, daily drinkers (at least one alcoholic beverage every day for the past 30 days). Interestingly, veterans without TBI are less likely than nonveterans to be current, daily drinkers. Psychiatric disorders were also associated with higher incidences of daily drinking. The authors propose that future studies consider daily drinking as a possible form of self-medication, as well as binge drinking or other substance abuse.

The researchers express concern that “Daily self-medicating with alcohol may serve as a substitute for receipt of health services, which may increase some veterans’ risk for unmet needs for military service-related health care and alcohol problems.” The study was a Research Brief published by the Lerner Center for Public Health Promotion at Syracuse University.

Mental Health

Nearly 40% of police officers found to have experienced a traumatic brain injury and severe post-concussion symptoms

A pilot study of 54 U.K. police officers published in the Journal of Psychiatric and Mental Health Nursing found that 40% of officers had experienced a mild traumatic brain injury (mTBI), compared to 12% in the general population. Nicholas Smith et al. found that the 21 officers in the study who self-reported an mTBI “displayed higher numbers of ongoing post-concussion symptoms”- specifically greater severity of PTSD, depression, and drinking as a coping mechanism.

Because of the wide variety of complex decisions officers make daily, Dr. Smith believes “police officers should be screened for TBIs” to ensure these decisions are being made without any emotional deficits. Further research investigating “injuries in the police population” with larger sample sizes is needed to confirm the high prevalence of mTBIs and associated mental health difficulties among police officers.

Statistics

Study finds structural (but no cognitive) changes long after concussion

In this exploratory study published in NeuroImage, Danielle June et al. used imaging and cognitive testing to measure changes in brain structure and cognition long after a concussive event.

The study used several types of scans and neurocognitive testing on a group of study participants who had experienced a mild TBI an average of twenty years prior to the study. Using structural MRI, the study found that individuals who experienced a concussive event showed statistically significant brain volume reductions in their hippocampus and temporal white matter compared to a control group. The study also used Diffusion Tensor Imaging (DTI) to look at white matter microstructure and found significantly more axonal diffusion in people who had previously suffered one or more concussions. These findings suggest that neurodegenerative volume loss occurs from a concussive event and that axonal microstructure may be impaired long after.

Additionally, the use of PET scans demonstrated that energy usage was significantly higher in the subjects who had previously suffered from a concussion when compared to the control group, suggesting further long-term structural changes.

June et al. found no significant differences concerning cognitive testing, but suggest that concussion patients may compensate for axon damage and reduced brain size with the increase in energy usage seen in the study's PET scans.

Due to the relatively small sample size, reliance on self-reported history, and low variation in the subject pool (majority educated, white, male), further research is needed to find whether these results are generalizable to a broader population.

Youth

Alarming effects of anabolic steroid use -- as well as the effects of repetitive mTBI -- in adolescent rats, but no findings of cumulative effects

With the prevalence of anabolic steroid (synthetic testosterone) use among young athletes who also often suffer repetitive mild traumatic brain injuries (mTBI), it is essential to understand how this use may impact mTBI recovery. In a study published in Brain Sciences, Jason Tabor et al. used adolescent rats to test the effects of anabolic steroids on post-concussive symptoms, brain structure, and hormones.

Researchers found increases in depressive symptoms in the steroid-use group, as well as short-term memory impairments, decreases in brain region size, and changes in mRNA transcription. The group with repetitive mTBI (and no steroids) showed impaired performance in behavioral activity tests. The researchers found no cumulative effects of anabolic steroid use and repetitive mTBI. In other words, they did not find that the combination of repetitive mTBI and anabolic steroids resulted in additional adverse effects.

The scientists point to a need for more sensitive measures as a possible reason why they found no cumulative effects of repetitive mTBI and anabolic steroids. It is also possible that the study did not measure enough regions of the brain. This study does demonstrate the adverse effects of anabolic steroids in young rat brains, and as young athletes continue to use this hormone, a need for further research in this area is necessary. The study also “corroborates previous results that repetitive mTBI negatively impacts neurodevelopment.”

Women's Health

Concussion may increase the risk of early menopause

A study conducted by Melissa Biscardi found that concussion may increase the risk of early menopause. The study, a master’s thesis at the University of Toronto, included ten premenopausal women (ages 25-50) who had sustained a concussion one or more years before their recruitment for the study.

Principally, the study examined the women’s Anti-mullerian hormone (AMH) levels, which is a proxy for ovarian reserve and menopausal timing. Among the sample, 50% of women had less than ideal AMH levels for their age. This percentage is higher than that of the general population, suggesting that concussion may accelerate reproductive aging.

In addition, the women in the study scored higher on the Menopause Rating Scale (MRS) than the general population, indicating that they experienced more symptoms associated with menopause.

The study lacks statistical power due to the small sample size; future studies should aim to include a larger sample to enhance the findings’ generalizability. Nonetheless, this research suggests that it is essential to monitor the reproductive health of women following a concussion.

Culture

Members of parliament encourage government to screen victims of domestic abuse, including incarcerated women, for traumatic brain injuries

According to the National Coalition Against Domestic Violence, millions of women are victims of domestic abuse each year. An article in NR Times reports that U.K. Labour MP Chris Bryant recently proposed an amendment that these women should undergo mandatory screenings for traumatic brain injuries. Bryant argued these screenings should take place “within two weeks” following the submission of either a domestic abuse protection notice or a domestic abuse charge against an alleged perpetrator.

To a similar end, Chris Bryant also proposed an amendment that prisons should screen female prisoners for TBI within two weeks of starting their sentence. Bryant insisted that current prisoners who have suffered domestic violence should also undergo this same screening process. Bryant’s goal is to ensure that inmates affected by TBIs can receive the necessary neurorehabilitation to help them “understand their condition...and lead a fuller life.” To support his claims, Bryant cited a screening program by the Disabilities Trust that found “real benefits in terms of preventing reoffending” by getting these diagnoses.

Despite support for both amendments by other parliament members and numerous charities, the House of Commons tabled both of Bryant’s proposals. However, because Bryant believes there was a misunderstanding, the minister has promised him a meeting before the bill goes to the House of Lords in late August.

Neurodegeneration Issues

Sledding athletes' brain-rattling rides, crashes, and "sled head" brain damage may be a factor in athletes taking their lives

A New York Times article illuminates an emerging pattern of suicide among sledding athletes. Current and retired sliding sport athletes, especially in bobsled and skeleton, report battling chronic headaches, sensitivity to bright lights and loud noises, forgetfulness, and psychological problems. The small size of the sliding community makes the prevalence of these symptoms, suicides, and early deaths even more concerning.

Physics professor, and Canadian skeleton athlete, Alexis Morris chose to put an accelerometer on his helmet and launch his body down the world's fastest track. The run, with the sled hitting speeds of 70-80 mph, is considered routine on that track; the accelerometer registered as high as 84.5 g-forces in the twisting corners. In addition to the head rattling, Morris's neck tired near the end of the run, resulting in his helmet grounding into the ice a few times.

Enduring routine crashes, impacts to the head, brain-rattling vibrations, and strong gravitational acceleration forces leave sliding athletes with headaches, exhaustion, and brain fog so often that they have a word for this problem: "sled head." Normalizing concussive-like symptoms with an off-hand term troubles brain experts because, as Morris admits, "you get sucked into thinking it's not a big deal." It reduces the recognition, in these communities, of brain injury as a severe issue. Distressed in his final days before his suicide, Olympic bobsledder Adam Wood told his wife: "You just don't even have an idea that you are destroying your life."