Physical activity after concussion (1/8/21 newsletter)

Jan 8

We would like to acknowledge our volunteers and leadership team members who wrote for this newsletter:

Writers: Will Altaweel, Eloïse Cowan, Malayka Gormally, Galen Moller, Shelly Seth, Emily Spain, Maya Strike, Rainey Tilley, Alex Whitis, and Josh Wu.

Editors: Conor Gormally and Malayka Gormally.

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Education

Sign up for SOAR Project’s free, online event on partner-inflicted brain injuries

Join Supporting Survivors of Abuse and Brain Injury through Research (SOAR) for workshops, panel discussions, and presentations on February 24th and 25th. SOAR is a research partnership that increases awareness and education concerning partner-inflicted brain injuries. Currently, 1 in 3 women experiences intimate partner violence (IPV) in their lifetime. Of those, 92% are likely to have received a brain injury upon impact. As SOAR states, brain injuries perpetrated by a romantic or sexual partner are an often-invisible public health crisis. Their “Moving Ahead” conference will showcase the latest findings, training, and educational tools gathered to aid survivors.

Notably, Dr. Eve Valera (who is on the Concussion Alliance professional advisory board) and author Rachel Louise Snyder will be keynote speakers. With this innovative event, they seek to “put knowledge of brain injury in intimate partner violence in practice.” For more information regarding partner-inflicted brain injuries, visit this page on the Concussion Alliance website.

Sports

Elevated tau levels in NCAA athletes with delayed return-to-sport

A study published in JAMA Network Open examined the association between three plasma biomarkers and concussion recovery length of NCAA student-athletes. Biomarkers may potentially aid clinical evaluation of concussion prognosis, as well as return to school and activity decisions.

This prospective study included 127 NCAA male and female student-athletes who experienced a sport-related concussion. Three plasma biomarkers - total tau protein, glial fibrillary acidic protein [GFAP], and neurofilament light chain protein [Nf-L] - were collected at baseline (during preseason), 0-21 hours post-injury, 24-48 hours post-injury, time of symptom resolution, and 7 days after return-to-sport. The study compared participants who returned to sport in less than 14 days with participants who took longer than 14 days to return to sport.

Consistent with prior studies, this study found that participants who took longer than 14 days to return to sport had significantly higher total tau protein at 24-48 hours post-injury and at time of symptom resolution. Total tau levels were not significantly different seven days after return-to-sport. In contrast, the participants who returned to sport after 14 days had significantly lower levels of GFAP 0-21 hours after injury. Different levels of Nf-L were not significant between the groups. The need for more research on all three plasma biomarkers remains.

Cannabis & Psychedelics

Psilocybin on track for medical use for mental health treatment and to alleviate mTBI symptoms

The 2020 election in November saw significant victories for the medical use of psychedelic mushrooms, according to an article in Fast Company. The District of Columbia voted to legalize the drug psilocybin, the hallucinogenic component of mushrooms. Additionally, Oregon voted to decriminalize drugs as a part of an initiative to encourage rehabilitative care rather than pressing criminal charges and preventing a way for individuals to overcome addiction.

These votes could encourage further research into psilocybin’s medical benefits, such as its use to treat drug-resistant depression, addiction, and PTSD. The FDA funded some research for the medical benefits of different psychedelics in 2019. These legal changes will bring scientists one step closer to challenging the negative stigma surrounding psychedelic drugs.

Psychedelics such as psilocybin may have promising benefits in relieving mTBI symptoms. Former NHL player Daniel Carcillo has used psilocybin to alleviate symptoms of the repeated head trauma that he endured during his career. We covered Daniel Carcillo’s story in a previous newsletter edition, and recommend the HBO video about his story.

These drugs may aid in medical treatments for countless individuals struggling with mental health and symptoms of mTBI. Decriminalizing psilocybin will influence how extensively researchers will explore its benefits, potentially changing the timeline for the possible introduction of psychedelic-based concussion treatments.

Diagnostics

Head Position and Posturography: A Novel Biomarker to Diagnose PCS

Researchers, led by Dr. Frederick Robert Carrick, have discovered that tilted head positions (head positions off the neutral plane) can distinguish subjects with post-concussive syndrome (PCS) from healthy subjects. The study, published in Brain Sciences, investigated a standard postural test, the Clinical Test of Sensory Integration in Balance (mCTSIB), with the addition of different head positions in 575 PCS patients and 60 healthy subjects.

In the standard mCTSIB test, the patient holds their head in a neutral position. Carrick and his team found that if PCS patients, while being tested with the mCTSIB, held their head turned to the right, to the left, flexed, or extended, their mCTSIB scores were much worse. However, for the normal healthy subjects, holding their head off the neutral plane did not worsen their mCTSIB scores.

The findings demonstrate that, for PCS patients, head position changes can compromise postural stability scores, indicating that the current standard of testing needs to be updated. The study also identified that head positions off the neutral plane may serve to diagnose PCS in patients more accurately. Researchers can, in the future, create and implement an extension of the mCTSIB that accounts for different head movements.

Self-care

10 ways to cope with depression after brain injury

The U.K. nonprofit Headway published a useful article, 10 ways to cope with depression after brain injury. Talking with others, avoiding isolation, engaging in activities, identifying contributing factors to your depression, and making a ‘soothe box’ are some of the suggestions. Concussion Alliance has resources that can help you implement many of the article’s additional recommendations, such as

seek support (Where to find online support, and Social support during youth concussion recovery)
exercise (Aerobic exercise as therapy and Graduated Exercise Therapy)
educate yourself about the effects of brain injury (What Happens to Your Brain When You Get a Concussion, the Deeper Dive, The Invisible Injury, and Mental Health)
Use wellbeing techniques (Emotional Wellness)
Be healthy (Overview of Self-care)

Therapies Currently Available

Gradually increasing to moderate-level exercise after a concussion produces best outcomes

A systematic review of current research on exercise after concussion by Barbara Baker et al. focused on what types and intensities of exercise are effective to promote concussion recovery. In all studies reviewed, an individualized exercise program reduced time to recovery, the number or intensity of symptoms, or the number of persistent symptoms.

The review, published in Human Kinetics Journals, identified that stationary cycling, treadmill, walking, and swimming improved patient outcomes. The review authors also found that moderate exercise intensity “had superior outcomes” to low-intensity exercise. However, the study patients began with low-intensity exercise and increased intensity in a gradual manner that did not exacerbate their symptoms or worsened their symptoms only slightly.

Intense exercise did not produce adverse effects, but the patients worked up to the intensity very gradually. The authors warn that “Overly strenuous physical and cognitive exertion exacerbate symptoms, decrease neurocognitive performance, and increase the risk of secondary injury.” The authors recommend working with a therapist (PT) to implement an individualized exercise mode prescription.

We have an article on Graduated Exercise Therapy, based on one of the research studies (Leddy et al.) in this systematic review. The article includes working with a PT and how to implement this type of exercise on your own.

Note: stationary cycling may be most appropriate for patients with balance issues or dizziness.

Therapies Being Researched

Light-activated nanocages may help safely deliver therapeutic drugs in future

Studies have indicated that the amino acid Cyclosporine A (CsA) can reduce brain lesion volume and axonal injury in rat TBI models. However, in clinical trials, CsA has also been associated with adverse reactions, such as renal failure. The authors of a new study hope that patients suffering from a TBI or complicated mTBI can eventually be treated with CsA even when the precise location of the damage is unknown - and within the first hour of injury. Their study, published in Molecular Pharmaceutics, suggests that light-sensitive nanocages could reduce the adverse effects of CsA, and deliver treatment “without the need to know the exact location of the TBI lesion.”

Black et al. developed a delivery technique using a nanocage composed of cyanine. While linked to the nanocage, CsA is inactive. Exposure to near-infrared light causes a photolytic “opening” of the nanocage, at which point CsA exits the nanocage. They confirmed that this photolysis is light-dependent in vitro [in a test tube, culture dish, or elsewhere outside a living organism], although CsA wasn’t efficiently liberated from the linker component.

The nanocage-linker-CsA complex was also tested in vivo using a rat TBI model. Rats were anesthetized and received controlled cortical injuries followed by continuous intravenous infusion of the nanocage-linker-CsA complex. Rats received either near-infrared light photoactivation on the head (experimental) or no photoactivation (control). Rats receiving photoactivation had significantly higher plasma levels of CsA-linker, suggesting initiation of the photolytic reaction. However, the assays failed to detect active CsA in either group.

While this study is a promising step towards safe CsA administration, there’s still work ahead. Future studies should explore the requirements for CsA to dissociate from linker components efficiently. Others should investigate if CsA retains neuroprotective properties when administered with this method, as well as potential toxicities of linker-CsA.

Veterans and Service Members

Veterans with substance abuse disorder and PTSD benefit when they’re treated concurrently

For post-911 veterans who have a substance use disorder and PTSD, a studyfound that treatment is most effective when the substance abuse (drugs or alcohol) and PTSD are addressed concurrently, rather than requiring the veteran to abstain from substance abuse before treating their PTSD. The RAND Corporation identified the best treatment as “Concurrent Treatment for PTSD and Substance Use Disorder Using Prolonged Exposure; Seeking Safety; and integrated cognitive behavioral therapy.” Naltrexone and antidepressants may also be promising treatments.

A RAND Review article describes the VA as having developed “gold-standard treatments” for veterans with substance abuse and PTSD. Yet the Rand study found “few providers who closely follow” the VA treatment protocols, possibly in part due to financial considerations.

In addition, veterans may not pursue care because of fear of career harm, financial costs, or lack of transportation, among many other reasons. The study lists recommended changes for providers, and we hope this information helps veterans advocate for themselves. The study was done in collaboration with the nonprofit Wounded Warrior Project, which provides free programs and services for veterans.

Mental Health

Neuroimaging may help predict the onset of PTSD following mTBI

A recent press release summarized a study by Dr. Murray Stein and colleagues, published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. The study followed mild traumatic brain injury (mTBI) patients over six months to test the relationship between mTBI and Post-Traumatic Stress Disorder (PTSD). Like mTBI, PTSD is associated with mood and cognition changes. Dr. Stein and his colleagues were concerned with utilizing neuroimaging to identify potential brain biomarkers for PTSD in individuals diagnosed with mTBI.

The authors’ intention was to see if MRI scans at two weeks post-injury were predictive of PTSD. Using data from TRACK-TBI for 428 mTBI patients, the authors compared MRI findings for the patients to assessments for probable PTSD three and six months following the injury. At three months, 18% of the participants had probable PTSD, while 16% had probable PTSD at six months.

Upon examining the MRIs, the authors found that decreased volume of specific brain regions predicted PTSD three months after the injury. Specifically, they identified the cingulate cortex, the superior frontal cortex, and the insula as regions that predicted PTSD onset three months post-mTBI. These regions are associated with arousal and emotional regulation, which are factors in the symptomatology of PTSD. Interestingly, the MRI neuroimaging markers did not have predictive power for PTSD at six months post-mTBI.

These findings by Dr. Stein and colleagues suggest that mTBI is associated with the development of PTSD, especially if certain brain regions demonstrate a lower-than-average volume. However, it is unclear if the participants already had decreased brain volume in these regions or if the mTBI precipitated a decrease in volume.

Statistics

College football players underestimate their risk of concussion by 43% to 63%, and the longer they play, the more they misestimate

This study of 296 current college football players used a questionnaire that asked athletes to estimate their risk of a concussion or other injury for the upcoming season. The questionnaire also asked how many times they had a concussion or other injury in the previous season. Using two types of analytic strategies, researchers Christine M. Baugh et al. found that college football players underestimated their concussion risk by either 43% or 63%. Also, some non-freshman athletes “significantly underestimated their risks compared with first-year athletes.”

The study, published in JAMA Network Open, points out that one-third of the athletes self-reported that they had suffered a concussion in the previous season, for a mean of 43 concussions per team in the study. This figure is much higher than a recent epidemiological study which found 5 or 6 concussions per team based on concussions officially reported by each team.

Athletes, particularly young men, commonly underestimate health risks. However, in a University of Colorado press release, the study authors note that the “risks college football athletes face may be more severe or debilitating.” The athletes’ underestimation of risk “raises questions of informed consent and how much risk should be acceptable in the context of the game.”

Although the study doesn’t mention younger athletes, the possibility that high school football players may not have an accurate estimation of their concussion and injury risk is problematic.

Youth

Study finds that exercising soon after a concussion may have positive effects

A study conducted by Julie Wilson et al. found that children and adolescents who engaged in physical activity within the first three weeks following a concussion had better outcomes than those who did not engage in physical activity. The study, published in the Journal of Clinical and Translational Research, included 575 pediatric patients (ages 8-18) whose outcomes were measured during an evaluation within three weeks of sustaining a concussion. Within the sample, 12% of these patients had engaged in physical activity before the evaluation.

Relative to patients who did not engage in physical activity before the evaluation, patients who exercised had significantly fewer symptoms, better postural control, and shorter recovery times.

Due to the study’s design, the researchers could not determine whether early physical activity caused improved sample outcomes. Thus, future studies should establish causality. Nonetheless, the findings suggest that clinicians should consider implementing structured early-exercise programs to promote post-concussion recovery.

Women's Health

Female athletes show greater changes after Peer Concussion Education Program

A study conducted by Meredith Kneavel et al. and published in Health Education & Behavior found that female athletes “showed significantly greater changes” in response to a Peer Concussion Education Program (PCEP). The study aimed to investigate the effect of gender differences after a PCEP. The study included 60 NCAA teams with 1,100 male student-athletes and 511 female student-athletes, where 30 teams in the experimental group received the PCEP, and the other 30 did not.

In addition to concussion education, the PCEP included assessments of symptom knowledge, return-to-play knowledge, reporting behavior, and attitudes toward reporting. After the PCEP, both male and female participants showed improvement in each of these measures compared to the control group. Additionally, women showed significantly better improvement than men in their return-to-play knowledge, their intention to report their concussion or a teammate’s concussion, and their attitude toward themselves and their teammates regarding concussions. Women were also more likely than men to discuss concussions with teammates, trainers, and peers.

These results suggest that women have greater rates of change in understanding some critical components of a PCEP in a group environment. The results also emphasize the importance of education for increasing the recognition and reporting of concussions. Although the data relied on self-assessments, it still presents strong evidence for gender differences in how individuals learn from a PCEP in group environments.

Culture

Illustrator Ananya Rao Middleton shares her experience with two invisible illnesses

A blog post from Krysalis Neuro Occupational Therapy shares illustrator and chronic illness activist Ananya Rao Middleton’s story. According to Ananya, her illustration career began in October 2018, when she sustained a mild traumatic brain injury and developed persistent symptoms. She was fatigued, sensitive to light, and dizzy, yet doctors told her to go home and rest. So she took six months off from work and started painting to express her feelings and take her mind off her symptoms. Her art gained attention for its vibrant colors and depictions of how women experience chronic illness, racism, and sexism.

In October 2019, after visiting a concussion specialist, Ananya was diagnosed with multiple sclerosis, which may have preceded the brain injury or triggered by it. With guidance from a neurologist and the TBI community, she has learned symptom management and how to take care of her brain. She continues illustrating, and her art was featured in the BBC’s Body Positive Campaign, Parliament’s Disability History Month, and the United Nations’ International Day for People with Disabilities.

MIddleton says, “What I’m trying to do at the moment is link my own experiences as someone with chronic illnesses with the illustration work I put out into the world.” Her work can be found on her website, Instagram, Twitter, and Facebook.