Medications for concussion (9/3/20 newsletter)

Sep 3

Contributors this week:

Editors: Conor Gormally and Malayka Gormally.
Contributors: Conor Gormally, Malayka Gormally, Micalie Hunt, Hannah Kennicott, and Trinh Tieu.

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Education

Self-care webinar, TBI research topics webinar

A free webinar will focus on “basic self-care practices: sleeping, eating regularly, deciding when to say “no” and when to say ‘yes.’” The webinar, intended to promote “enjoyable social interaction” and “reduce emotional dis-regulation,” is facilitated by Maria Dalbotten, Brain Injury Survivor, LMHC. Date: Monday, September 14, 11 am to 12:00 pm, PDT. Register in advance.

The Current Topics in TBI: Wednesday Speaker Series, hosted by the University of Kentucky, provides free, one-hour presentations on various TBI-related research topics, followed by a Q&A session. The presenters range from renowned experts to graduate students from around the world. September 9th is “Next generation protein biomarkers in TBI,”’ presented by Denes Agoston of the Uniformed Services University Health Services.

Wednesday, 8 pm GMT / 3 pm EST / 12 pm PDT  Speaker List
Webinar link: bit.ly/TBIzoom   Zoom ID: 771734358 Password: TBI

Training for educators who have students struggling with concussion symptoms

A 10-hour online course “In the Classroom after Concussion: Best Practices for Student Success,” provides information, strategies, and resources for educators who may have students struggling in the classroom due to a concussion. The course is designed for “Classroom teachers, special educators, school psychologists, counselors, therapists, and administrators.” A University of Oregon press release notes that “if a student’s injury causes them to persistently struggle in the classroom or ... leaves the student little time to catch up, they may be at risk for academic failure or an altered life trajectory.”

Offered by the nationally recognized Center on Brain Injury Research and Training at the University of Oregon, the curriculum was “proving effective with educators in a multi-state study.” You can take the training for free, pay $40 for ten Professional Development Units, or pay $120 for one Continuing Education Unit. The curriculum includes 21 lessons, each taking approximately 15 minutes to complete, plus interviews with educators.

Sports

How concussion education in coaches and parents impacts their knowledge, beliefs, and behaviors

A recent study conducted by Amanda Black et al. examined whether there is an association between the concussion education of parents and coaches of youth hockey and their beliefs and behaviors. In other words, does education translate into significant changes in how adults approach concussion prevention, identification, and treatment? Interestingly, coach and parent education did impact knowledge but was not significantly associated with particular beliefs or behaviors, like removing youth athletes from play or taking athletes with suspected concussions to physicians. The study was published in BMJ Open.

Cannabis

Literature review highlights evidence that cannabinoids can “alleviate” inflammation in the nervous system

In a review article published in the British Journal of Pharmacology, Meagan Mckenna et al. discuss the evidence regarding cannabinoid control of neurogenic inflammation and the “neuropharmacological processes” involved in alleviating this inflammation. The authors address three kinds of cannabinoids: endocannabinoids created and released by the body, synthetic cannabinoids produced in labs, and naturally occurring phytocannabinoids from the cannabis plant.

While the article limits its discussion of evidence to arthritis, asthma, and migraine treatment, the authors highlight that “many chronic inflammatory diseases have a neurogenic component.” Cannabinoids can inhibit several pro-inflammatory processes in the nervous system, alleviating neurogenic inflammation. Concussion Alliance would like to specify that in concussion, neuroinflammation is often part of the injury’s presentation.

Diagnostics

Biomarkers predictive of recovery times in college athletes

Dr. Cassandra Pattinson et al. published a diagnostic study in JAMA that identified biomarkers in 127 college athletes that could serve as predictors for return-to-sport times following concussions. The researchers performed blood testing at several time points, including preseason (baseline), 0-21 hours post-injury, 24 to 48 hours post-injury, at symptom resolution, and seven days after full return to sport. Higher total tau protein 24 to 48 hours post-injury and higher glial fibrillary acidic protein (GFAP) 0 to 21 hours post-injury were promising indicators of longer recovery times.

Levels of neurofilament light chain (Nf-L), a protein recognized for its potential use as a biomarker for Alzheimer’s and Parkinson’s, were tested but not found to be significantly correlated with recovery times. Identifying biomarkers like tau and GFAP could aid in flagging athletes who may have longer recovery times or need rehabilitative treatment.

Self-care

Concussion Alliance is excited to promote an updated Emotional Wellness page!

Concussion Alliance Summer Intern Cassidy Bins created an updated version of our Emotional Wellness page as one of her projects this summer. The page has information on meditation and deep breathing, cognitive behavioral therapy, support groups, and apps for staying on track with self-care.

Good intent, poor outcome: What not to say to someone with a brain injury

If you’ve experienced a brain injury, you might have also heard many comments from well-meaning friends, family members, and strangers that made you uncomfortable. If you know someone who has experienced a brain injury, you may have made one of those awkward comments. A new article from Headway: the brain injury association outlines a list of ten of the most common remarks people make to individuals with a brain injury and explains why these phrases might be doing more harm than good.

From “I know what you mean… I’ve got a terrible memory too!” to the infamous “you should be back to normal by now,” and the always irritating “chin up - there’s always someone worse off,” individuals dealing with brain injuries have likely heard them all before. If you are dealing with a brain injury, knowing that others also deal with insensitive comments may help you identify what is bothering you and help you speak up for yourself.

Therapies currently available from providers

Migraine medication reduces migraine-like post-traumatic headache by 51% in case series with mTBI patients

Treatment with the migraine medication erenumab reduced, by 51.1%, the post-traumatic headache (PTH) of 5 women who developed migraine-like chronic PTH after mTBI. This research, published in Brain Injury, is the first to study erenumab as a PTH therapy. The patients, who had been experiencing PTH for an average of 32 months, had been treated with botulinum toxin and oral medications but still had an "average patient-rated headache intensity" of 86/100."

After self-administering erenumab monthly for an average of 3 1/2 months, three patients reported a 45-60% decrease in the intensity of their PTH. Despite not rating headache intensity at follow-up, the other two patients mentioned qualitative improvements. "All five patients were able to reduce the dose and/or discontinue the use of other headache prophylactic medications, including TCAs, gabapentin, and botulinum toxin."

Researchers Jordan VanderEnde et al. explain that PTH is the most common aftereffect of mTBI, "affecting up to 90% of this patient population." "More than half of patients will continue to experience significant and potentially disabling headache symptoms one year following mTBI." There are different types of PTH that mTBI patients may experience, and erenumab's mechanism is tailored explicitly to targeting migraine pathology.

The study mentions several limitations, including selection bias, which is unavoidable in case studies. Three of the five women developed constipation, a much greater rate than other, albeit larger, studies of erenumab, which found a rate of constipation of 4% and a 1% rate of severe side effects.

Therapies under research

Interviews with Oxeia CEO & CSO: Phase 2 clinical trials for concussion medication

This month, Oxeia Biopharmaceuticals will be launching Phase 2 trials of their drug treatment for concussion, OXE-103, a synthetic form of the hormone ghrelin. Overseen by a neurologist experienced in treating patients with persistent concussion symptoms, the trial will enroll 40 patients with significant concussion symptoms within 28-days of injury. The aim is to test the ability of OXE-103 to reduce concussion symptom burden over the study period.

We’ve published two interviews, one with Oxeia CEO Michael Wyand, and a second with Oxeia Co-Founder and Chief Scientific Officer Vishal Bansal. Mr. Wyand discusses the challenges of being the first potential drug for concussion to go through the FDA review process, how the trial will measure whether OXE-103 helps concussion patients, the history of Oxeia, and more. Dr. Vishal details why OXE-103 has an advantage over other types of treatments under research. He also talks about the neuro molecular mechanism of ghrelin in the brain, ghrelin and the blood-brain barrier, and details about the clinical trial.

Veterans and Service Members

Free webinars on traumatic brain injury for the veterans’ community

Shasta College is hosting two free webinars led by a Defense and Veterans Brain Injury Center certified brain injury specialist; the webinars are open to participants throughout the United States. The webinars are designed for “community partners working with veterans, service members or dependents who have had a traumatic brain injury or concussion or at risk of obtaining one, clinical staff and caregivers, veterans, student veterans, service members, educational staff and VA and DOD employees.” Webinar dates:
Wednesday, September 16, 8 am - 9 am, PST
Thursday, September 17, 3 pm - 4 pm, PST

To register, email Veterans Service Coordinator James Konopitski at jkonopitski@shastacollege.edu. Don’t delay in registering, as “seating” is limited.

Underdiagnosing of TBI in British military

An article by Sean Rayment in the Mirror reveals thousands of British soldiers who served in Iraq and Afghanistan may be suffering from untreated TBI. Reportedly, there has been a severe, widespread misdiagnosis of PTSD and underdiagnosis of TBI in the British military, believed to be a result of a lack of post-combat TBI screening by the British military.

Mental Health

Managing mental health symptoms and concussion

Concussion Awareness Training Tool (CATT) has released a document with strategies to address mental health challenges during concussion recovery. Techniques include physical activity (as tolerated), deep breathing exercises, meditation, and memory aids; the document goes into detail about each strategy and gives step-by-step instructions and examples.

Given that COVID-19 has heavily impacted mental health nationwide, these strategies may be more critical now than ever before. CATT has also released a COVID-19 specific article with tips on managing concussion symptoms during the pandemic. The article includes sections on screen time, sensory sensitivity (loud noises, bright lights, and crowded households), regulating mental health, and managing energy levels - providing several strategies under each section.

Statistics

Sleep-wake disturbances and fatigue last at least a year in 33% of mTBI patients

Researchers Simen Berg Saksvik et al. recruited 378 mTBI patients (with matched control patients) from two emergency departments in Norway. They found that “Patients with mTBI consistently reported higher rates of having problems with sleep need, poor sleep quality, excessive daytime sleepiness, and fatigue” than the control groups, including patients with orthopedic injuries. “In patients with mTBI who experienced sleep-wake disturbances and fatigue 2 weeks after injury, around half still had problems at 3 months and approximately one third” still had problems at 12 months.

“In fact, as many as 53% of mTBI patients who experienced sleep-wake disturbance or fatigue at 2 weeks after injury in the present study had persisting problems that lasted 3 months or longer.” The study was published in the Journal of Neurotrauma.

In a press release, Berg Saksvik mentioned that the researchers “found that problems like an increased need for sleep, poor sleep quality, daytime drowsiness and fatigue occurred much more often and lasted longer after concussions than after other types of injuries.” He emphasized that “Sleep problems are often associated with issues like poor memory, concentration difficulties, depression and anxiety. Treating sleep problems as early as possible after a concussion may help slow down or prevent the development of such problems.”

Youth

Melatonin may improve sleep-related symptoms in concussed children

A recent study published in the Journal of Neurotrauma by Kartik Iyer et al. revealed that melatonin could improve sleep-related brain functions in children recovering from a concussion. This double-blinded, placebo-controlled study involved 62 concussed children who were randomly given either 3mg or 10mg of sublingual melatonin or a placebo during the 4-week clinical trial. Researchers evaluated MRIs and Post-Concussion Symptom Inventory scores before and after treatment.

Children who received melatonin experienced significant improvement in brain regions essential for sleep control and cognition, and these changes “were correlated with improvement in subjective and objective sleep parameters.” Researchers identified “dosage-related modulations of functional connectivity and structure in defined brain networks.” This means that improvements increased as the dosage increased (placebo, 3 mg, 10 mg).

“The results suggest melatonin, when taken by children with concussion, compensated for normal brain functions that may have been interrupted due to injury,” said Child Health Research Center’s Dr. Iyer in a press release by Medical Xpress.

However, the researchers believe that solving sleep problems is only one part of the recovery process. Dr. Iyer mentions that “not all children made a full recovery from concussion just by taking melatonin.” The authors found that “Even though increases in brain functions and gray matter corresponded with decreases in sleep disturbance and fatigue, the supplement didn’t resolve other common concussion symptoms such as memory problems, anxiety and depression.”

Women's Health

Study finds high rates of head impact & strangulation, low rates of medical treatment in IPV survivors

A recent study published in Violence Against Women examines possible brain injury rates among survivors of intimate partner violence (IPV). IPV is a preventable public health epidemic that elevates individuals' risk to receive a head, neck, or face injury, potentially resulting in a traumatic brain injury. The study's participants were 171 female IPV survivors, 19 years and older, who completed a HELP Brain Injury screening to estimate the rate of women at risk for a brain injury.

Of the 171 women screened, 91% indicated they had been hit in the head or strangled, and 31% reported that it had happened more than six times in their life. Disturbingly, only 35% of the women who were hit in the head or strangled received medical treatment, even though 64% reported losing consciousness or experienced a period of being dazed and confused.

Authors Shireen S. Rajaram et al. conclude that organizations that serve IPV survivors should screen for brain injury to refer TBI patients to neurorehabilitation services, which could significantly improve their quality of life. Additionally, organizations should implement education/training programs to address the intersection between IPV and brain injury and develop referral protocols for support services. For more information, see our new website section for Partner-Inflicted Brain Injury, created by summer intern Trevor Hughes.

Culture

Gender identity should be considered and expanded on in research and clinical treatment of neurotrauma

A review article by Katherine R Giordano et al. published in the Journal of Neurotrauma examines the “current clinical literature investigating sex differences after TBI.” However, after analyzing this literature, the authors focus on “differences within contemporary gender categories.” They suggest that “binary categories of male and female are not sufficient to guide clinical decisions for neurotrauma.”

The authors consider the results of several studies that investigated the impact of gender identity on TBI outcomes through several social and medical lenses. Using these studies as a framework, Giordano et al. level a critique of both research practices and healthcare delivery processes that leaves patients who do not identify as cisgender [out] in the cold. “The onus lies with biomedical research and health care delivery to understand the patient and where they come from in order to treat them. This includes consideration of non-binary sex and non-binary gender.“

Progress in this area is particularly vital, as “Transgender and gender non-conforming individuals are affected by violence at higher rates compared to cisgender individuals due to anti-transgender stigma and discrimination in society.” Also, these stigmas can also affect the social relationships, support systems, and emotional security of non-cisgender concussion patients, all of which can further impact their outcomes and recoveries.

Concussions are a highly heterogeneous injury, and those who treat persistent symptoms should provide individualized care. However, “Despite the incidence of TBI in gender non-conforming populations, healthcare delivery and treatment have not been personalized for these patients.“