Exercise therapy for concussions (9/17/20 newsletter)

Sep 17

Still from video by Dr. Barry Willer about the Buffalo Concussion Treadmill Test, State University of New York at Buffalo

Contributors this week:

Will Altaweel, Conor Gormally, Malayka Gormally, Trevor Hughes, Hannah Kennicott, Srishti (Shelly) Seth, Julian Szieff, and Trinh Tieu.
Editors: Conor Gormally and Malayka Gormally.

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Education

Webinars, some in recognition of National Concussion Awareness Day, September 18

9/18/20: Athlete stress and traumatic brain injuries, a Facebook livestream, produced by the nonprofit OneMind and hosted by Olympic Gymnast Laurie Hernandez. The episode includes an interview with Dr. Geoffrey Manley, Chief of Neurosurgery at San Francisco General Hospital and Lead Investigator of the TRACK-TBI research study. Go to the OneMind Facebook page on Friday. 12:00 PST / 3:00 pm EST

9/23/20: Virtual Panel Discussion on the Neuroscience of Brain Injury, presented by NYU Langone Neuroscience Institute and Concussion Center. Four experts “will provide research-based information about the pathophysiology of concussion as well as assessment and management techniques.” Attendees can submit questions in advance of registration. 2:00 pm PST / 5:00 EST

9/23 and 9/30: Current Topics in TBI: Wednesday Speaker Series. Webinar link: bit.ly/TBIzoom (Password: TBI) 12 pm PST / 3 pm EST

9/30/20: A Self-advocacy webinar hosted by the Brain Injury Alliance of Washington state. “Having a visible or invisible disability inevitably leads...people make incorrect assumptions about you...how do you defend yourself against something that’s only been implied?...we’ll seek to answer these questions and discuss strategies.” Required registration in advance. 1:00 pm PST / 4:00 pm EST

Sports

Youth football may not be correlated with worse concussion outcomes in college players

An article in MedPage Today summarized a recent study by Dr. Jaclyn B. Caccese et al. that found college football players who played tackle football as children weren't at increased risk for prolonged or worsened concussion symptoms. Participants' estimated age of first exposure to football was not associated with longer symptom recovery, worse balance, more elevated psychological distress, or worse cognitive performance post-concussion. The null hypothesis study was published in Neurology. The MedPage Today article notes that the jury may still be out regarding how youth sports affects long-term outcomes-- for instance, a 2015 study found greater cognitive impairment in NFL players who played tackle football before age 12.

Cannabis

Severe brain-injured patients fared better if they had marijuana in their system

A study, published in the Journal of Surgical Research, reviewed hospital records for 4849 adults admitted for severe traumatic brain injury at two regional trauma centers from 2014 to 2018. The researchers divided the patients into two cohorts. One cohort of 1,373 patients had THC (tetrahydrocannabinol, the psychoactive component of marijuana) in their system, and no other drug. The other patient cohort did not have THC in their system when they were injured. The cohort of THC-positive patients spent less time in the hospital, fewer days on a ventilator, and fewer days in an intensive care unit than the cohort without THC in their system.

Researchers Sharven Taghavi MD, MS, MPH, et al. conclude that marijuana “may provide some improvement in outcomes in patients with traumatic brain injury and those that are more severely injured...The mechanism behind this finding needs further evaluation.” Concussion Alliance would like to point out that there are significant differences between a severe TBI and a concussion (or mTBI), so it is unknown how this study's findings may relate to concussion patients.

Diagnostics

Brain swelling from TBI may cause lymphatic vessel damage and explain long-term effects

A recent study by Ashley C. Bolte et al., published in Nature Communications, found that traumatic brain injuries (TBI) can cause swelling that prevents the brain from removing harmful toxins and debris, potentially increasing the risk for Alzheimer’s disease, dementia, and other neurodegenerative problems. The researchers used mouse models to gain a new understanding of how TBI, even when mild, causes swelling and pressure against lymphatic vessels “that can last out to at least one month post-injury.” They found that this pressure on these vessels causes serious and long-lasting impairment of the brain’s ability to purge toxins, which may help explain why TBI can have long-term effects.

“This provides some of the best evidence yet that if you haven’t recovered from a brain injury and you get hit in the head again, you’re going to have even more severe consequences,” according to study co-author John Lukens in a University of Virginia Health System press release. “This reinforces the idea that you have to give people an opportunity to heal. And if you don’t, you’re putting yourself at a much higher risk for long-term consequences that you might not see in a year but could see in a couple of decades.”

The study suggests that people with pre-existing difficulties with brain drainage, "from prior concussions or naturally," are more likely to suffer much more significant TBI consequences. However, in the press release, Dr. Lukens stated that emerging imaging technology might help doctors identify those most at risk for these severe consequences. One day, they could rejuvenate the impaired lymphatic vessels with drugs to improve patients’ outcomes and possibly delay or prevent these significant consequences.

Self-care

Managing Concussion Symptoms During Covid-19

If you’ve sustained a concussion during COVID-19 or are still feeling symptoms, these can be challenging times. More work than ever is on screens, and stress has increased for many. These challenges can slow recovery and exacerbate symptoms, but luckily there are many easy ways to manage recovery. CATT Online has put together a handy resource for helping concussion patients manage their screen time, crowded households, mental health, and energy levels.

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Therapies currently available from providers

New web page on Graduated Exercise Therapy

Concussion Alliance Summer Intern Srishti (Shelly) Seth created a web page for Graduated Exercise Therapy as one of her projects this summer. Graduated Exercise Therapy is a type of rehab therapy for concussion patients that uses a gradual return to physical activity in stages to reduce concussion symptoms. Based on a 2020 study that explains how to conduct the Buffalo Concussion Treadmill Test (BCTT), the web page outlines different options for patients to receive this treatment.

Patients can work with providers who can administer the BCTT, utilize a physical therapist to design a personalized regimen, or use a heart rate monitor to create their own routine following guidelines from Dr. John Leddy and Dr. Barry Willer of the State University of New York at Buffalo. Our new page's description of the last option, an at-home exercise routine, may be the most useful, especially during the COVID-19 pandemic, providing in-depth instructions in addition to a visual graphic explaining the process.

This web page also provides exercise options for groups of people who are unable to do aerobic exercise, as well as research supporting that aerobic exercise is a beneficial treatment to reduce concussion symptoms.

Therapies under research

A unique collaboration makes use of supercomputers to analyze stem cell treatment for TBI

Researchers in the University of Texas system are utilizing a unique partnership with the Texas Advanced Computing Center (TACC) to further their research on stem cells to treat brain injury by using supercomputers for data analysis. While the treatment research is in clinical phase 2 trials, the proposed mechanism of action is that the stem cells (developed from the patient's bone marrow) dampen the immune response, which often causes additional cell death and blood-brain barrier breakdown.

Jenifer Juranek, Ph.D., uses MRI analysis with a specific focus on diffusion MRI examining the flow of blood, water, and cerebrospinal fluid in the brain, according to the University of Texas at Austin press release. This analysis produces an enormous amount of raw data, normally 1 gigabyte per data set, with over 200 data sets making up each scan. To handle this analysis, Juranek is collaborating with the TACC through the University of Texas Research Cyberinfrastructure. This collaboration has streamlined and expanded the analysis Juranek can do, including new brain swelling analysis.

This research focuses on evaluating severe TBI in the context of stem cell treatments. Their results will inform not only our understanding of TBI but will open up new avenues for research and analysis. According to Juranek, "If medical research wants to continue to make advances, they need to pair themselves with [supercomputer groups]. The information that we're gathering is so massive that in order to analyze it properly, you've got to have access to these kinds of resources."

Veterans and Service Members

Diversion from jail to probation and social service programs for veterans with TBI

St. James Plaindealer reports that Minnesota state recently approved the Veterans Restorative Justice Act, which favors probation and social service programs over jail time for high-risk veterans who plead guilty to less serious offenses. Crimes committed due to the influence of TBI, PTSD, service-connected sexual trauma, a substance abuse disorder, or a mental health condition may qualify.

Mental Health

Invisible Injury web page sheds light on why concussion patients often feel alone in the recovery process

This summer, Concussion Alliance intern Will Altaweel revised and expanded our website’s Invisible Injury web page. The web page aims to explore how concussions’ invisibility—that there is no external evidence of the injury—can adversely affect the recovery process.

In examining the problem of invisibility, the web page focuses on three things:

Reasons that people with persistent post-concussive symptoms (PPCS) feel alone.
Some of the factors that prevent effective treatment for PPCS.
Ways in which we can make concussion patients feel more visible.

Each section draws from empirical studies and includes anecdotes from two Concussion Alliance community members who have experienced PPCS.

An overarching theme that the web page highlights is the lack of knowledge about PPCS, both among the medical community and other members of concussion patients’ support systems. For instance, a 2015 poll found that 70% of those polled did not know that there are treatments for a concussion. Accordingly, the web page addresses the importance of education for increasing awareness of PPCS so that concussion patients can receive more meaningful and beneficial support in the recovery process.

Statistics

College athletes experience difficulties acquiring new motor skills more than one year after their concussion

A study published in Neurorehabilitation and Neural Repair looked at 56 college student-athletes’ capacity to acquire new motor skills. Researchers stratified the participants into three groups: no history of concussion, acute-state concussion (<2 weeks post-injury), and “chronic-state concussion” (> 1-year post-injury). The classification of “chronic-state concussion” only characterized athletes’ time since injury, not chronic symptoms.

Researchers Gabriela Cantarero et al. found that both acute and “chronic-state concussion” student-athletes had “deficits in their abilities to acquire new motor skills.” These deficits did not show up in either self-reporting of symptoms by the athletes or on basic neurological tests. Additionally, athletes with “higher numbers of previous concussions (regardless of the time since injury) correlated with more severe behavioral and neurophysiological motor impairments.” In particular, athletes “with a higher number of prior concussions showed poorer retention” of new motor skills learned over several days.

This study’s limitations include limited female participants and reliance on self-reporting of symptoms and concussion history. The study authors suggest that “Our results indicate the need to develop early interventions to reduce the long-term effects of repeated concussions.”

Youth

A pediatric emergency room doctor explains how to get kids to wear their helmets

Nkeiruka Orajiaka is a Pediatric Emergency Room Doctor at Nationwide Children’s Hospital in Columbus, Ohio; she has some useful background and advice for parents. In her article for MSN Lifestyle, Dr. Orajiaka reports that over 50% of children don’t wear helmets while on skateboards or scooters, 18% of children never wear a helmet when riding a bike, and that wearing a helmet can prevent up to 88% of head injuries.

Dr. Orajiaka offers eight suggestions for getting children to wear helmets. From tips about finding the right helmet to things that parents can do to set themselves up for success, having the ‘helmet conversation’ with children can save lives and prevent head injuries.

Women's Health

Concussion Alliance presents new web page on partner-inflicted brain injuries

This past summer, Concussion Alliance intern Trevor Hughes researched, designed, and wrote a web page on partner-inflicted brain injuries. The web page highlights the plight of the nearly 3.5 million American women who experience a mild traumatic brain injury from intimate partner violence each year. The page explores this epidemic by providing a five-step guide to recognizing, understanding, and advocating for those affected by intimate partner violence-related brain injuries. Each section is highly interactive and features graphics, videos, quotes, and the works of over 20 researchers. The page concludes with actionable steps that readers can take to help victims of partner-inflicted brain injuries right now. Please go check it out!

Culture

General practitioners, employers, and coworkers influence return-to-work success

A study examined facilitators and barriers to return-to-work (RTW) through in-depth interviews with “22 adults with mTBI at 2–5 years post-injury” who have experienced persistent post-concussion symptoms (PCS). Heidi Jeannet Graff et al. recruited interviewees from “an interdisciplinary outpatient concussion clinic in Denmark treating approximately 100 patients with persistent PCS annually.”

The interviewees described a successful RTW as “dependent on the collaboration and support of the employer,” which often did not occur. Workplace culture, the understanding of employers and coworkers, and flexibility regarding work hours were all critical factors that the interviewees highlighted. However, “The participants often felt obligated to quickly increase working hours, even if they continued to experience symptom-associated work disability.” Other participants struggled to successfully pass off or restructure assignments and responsibilities, especially in workplaces with “high demands, high workload, and high expectations from managers.”

The authors also asked participants about their experiences with their general practitioners, who in Denmark are primarily responsible for information, treatment, referrals, and coordination in the post-acute phase of concussion. However, “only two participants described [facilitating factors] related to the general practitioner; the remaining participants emphasized barriers to RTW.” When it came to helping patients with persistent PCS, who often require the most help from professionals in coordinating treatment and rehabilitation, the authors found that general practitioners fell short in multiple areas.

“When symptoms became persistent and the illness trajectory became prolonged, general practitioners failed to provide guidance on [the] course of disease, symptom duration, or treatment and rehabilitation opportunities, or advice on how to cope with symptoms, causing social isolation and long-term sickness absence. General practitioners lacked knowledge on referral opportunities to, for example, interdisciplinary specialized rehabilitation and vocational rehabilitation, leaving the patient to act as gatekeeper for their own treatment and having to seek advice elsewhere. The participants lacked individually tailored guidance on the extent of rest, the use of computers and smartphones, and how to structure a gradual RTW; these were questions that remained unanswered.” The study was published in Neuropsychological Rehabilitation.