New test for risk of delayed recovery in youth athletes (10/14/21 newsletter)

In this newsletter: Opportunities, Covid-19, Education, Sports, Diagnostics, Therapies Currently Available, Veterans & Service Members, Mental Health, Statistics, Youth, and CTE & Neurodegeneration Issues.

The lead article, New test for risk of delayed recovery in youth, is in the Youth category.

We appreciate the volunteers and leadership team members who created this edition:

Writers: Minhong Kim, Nox Zand, Shelly Seth, Josh Wu, Conor Gormally, & Malayka Gormally

Editors: Conor Gormally and Malayka Gormally.

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Opportunities

October 21, 3:30 pm EST: Long-Term Health Effects of Concussion: A Panel Discussion, hosted by the University of Michigan Concussion Center.

October 28, 4 pm EST: John Leddy, MD, discusses the role of exercise in diagnosis & treatment of concussion and “the Physiology of Concussion with respect to the Autonomic Nervous System and Cerebral Blood Flow Regulation.” Presented by University of Michigan Concussion Center; register in advance.

Covid-19

COVID-19 long-haulers self-advocate for holistic research

An article in The Atlantic discusses increased visibility of long-COVID symptoms and concurrent invalidation of those living with the condition. Academic researchers have only recently started investigating the symptoms of long-COVID. At the same time, long-haulers emphasize that some of these studies may not present a holistic picture of what they experience. The Patient-Led Research Collaborative, a collective of long-haulers, asserts that academics try to fit long-COVID symptoms into existing schemas instead of correctly treating it as a novel phenomenon.

The Collaborative’s current research interests include comparisons between long-COVID and myalgic encephalomyelitis/chronic fatigue syndrome, along with questioning whether or not long-COVID is an autoimmune condition triggered by COVID-19. The Patient-Led Research Collaborative independently completed a survey of symptoms that felt important to those experiencing them and are often neglected by academic researchers, such as menstrual complications and neurological symptoms. The Patient-Led Research Collaborative is also currently advocating for patients before Congress and is working to bridge the gap to become more involved in academic research surrounding their condition.

Education

You-CAN educates and advocates for Canadian youth

A concussion peer-support program for Canadian high school students, Youth Concussion Awareness Network (You-CAN), is a "school-based peer-led intervention to improve concussion reporting and social support" developed in response to the growing rate of concussions amongst Canadians ages 12-17. This intervention is an ongoing cluster randomized trial developed and run by Dr. Nick Reed et al. of Oak Concussion Lab (Toronto, Canada); the project is co-led by Parachute Canada.

You-CAN is being trialed in "Three high schools from six randomly selected Canadian school boards." The program will provide peer-facilitated emotional support to youth who have recently suffered a concussion and educate fellow students about concussions. The You-CAN program includes the creation of Concussion Councils within each school; the councils meet regularly, share information and provide resources, and host an annual "week-long" concussion awareness campaign," according to a blog post from the Sports Information Resource Centre (SIRC).

Sports

Upcoming study will determine effectiveness of header training in VR for soccer players

In an upcoming study, researchers at Manchester Metropolitan University (UK) will compare real-life heading training with virtual reality (VR) heading training for soccer players. If the VR training is commensurate with real-life training, it could help reduce subconcussive impacts from heading – which the FIELD study has recently shown are correlated with an increase in neurodegenerative disease in professional players.

In an article in The Independent, researcher Dr. Greg Wood posits that “At the moment, coaches are caught between needing to teach the skills of heading but also being constrained in how much they can do because of the potential dangers, which is why VR could be a solution as you can teach the skill without the impact. But the important question for us is can VR actually improve the skills of a player in a real world setting?"

The researchers will use Player 22 software created by Rezzil, utilizing the Oculus Quest 2 platform (VR Goggles). The study will have a control group, a VR group, and a ‘real life’ group; each group will be a mixed-gender group of 15 people. All groups will be tested for their heading accuracy at baseline and again after 7 to 10 days. In the interim, the control group will do nothing, the VR group will do heading training with VR goggles, and the ‘real life’ group will do real-life heading training. “The hope will be that the VR training proves to be at least as effective, if not more effective, than the real-life training.”

Diagnostics

Researchers uncover secondary damage to mouse brain cells responsible for managing sensory information flow to the brain

A research article in Science found that mild brain injury in mice causes an immune response that triggers neuroinflammation both at the injury and in a vulnerable secondary region of the brain. Researchers Stephanie S. Holden et al. may have found a potential explanation for one cause of persistent concussion symptoms while also discovering an effective intervention.

Following a mild brain injury to the brain’s outermost layer (the cerebral cortex), there is a secondary injury to the thalamus, a region deep in the brain responsible for relaying sensory information to the cortex for processing. The researchers found that this secondary injury is caused by increased levels of the immune molecule C1q, which marks an immune response that generates neuroinflammation.

In particular, the brain cells within the thalamus responsible for modulating the flow of information through that region were uniquely sensitive to damage from neuroinflammation caused by C1q. Further, these flow-control cells didn’t recover from that damage in the same way other brain cells in the thalamus and cortex did. This lack of recovery is worrisome because damage to these particular cells impairs the thalamus’s ability to regulate the flow of sensory information to the cortex. Concussion Alliance theorizes that damage to these cells may contribute to common concussion symptoms like headache, light and sound sensitivity, and fatigue.

The authors discovered that blocking C1q expression in the brain following that injury counteracted neuron loss, chronic inflammation, and disruption of sleep spindles (associated with epilepsy development) in all regions but particularly within the vulnerable cells in the thalamus. Concussion Alliance notes that there is some incidence of development of epilepsy after concussion, which could be due to damage in these particular cells.

Therapies Currently Available

Twenty minutes of daily subsymptom aerobic exercise speeds recovery in adolescent athletes

In a randomized controlled clinical trial published in The Lancet Child & Adolescent Health, researchers John Leddy et al. found that subsymptom aerobic exercise reduced median recovery time, increased the likelihood of recovery within four weeks, and reduced the risk of persistent post-concussive symptoms by 48% in a cohort of adolescent athletes. Their study expanded from a 2019 study by recruiting from two hospital-affiliated concussion clinics, Children’s Hospital of Philadelphia and Boston Children’s Hospital, in addition to their original University of Buffalo concussion clinics.

The trial included 118 adolescents aged 13-18 who presented within ten days of injury. The researchers randomly split subjects into two groups where 61 were prescribed 20 minutes of daily subsymptom aerobic exercise treatment, and 57 received prescribed stretching designed not to elevate heart rate. Instead of self-reporting, subjects wore heart-rate monitors that allowed researchers to accurately determine whether subjects followed instructions, while the subjects adhered to their prescriptions at home for four weeks after injury.

Leddy et al. found that the median time to recovery was 14 days in exercise treatment and 19 days in stretching treatment and that this difference was statistically significant. Further, those that followed instructions or exceeded the 20 min/day prescription at home (tracked with heart monitors) recovered faster than those who didn’t consistently meet the prescribed time within the exercise treatment group. In an article in UBNow, co-author Dr. Barry Willer pointed out that “This finding is important because delayed recovery comes with substantial cost to adolescents, including academic difficulties, risk for depression and reduced quality of life.”

The authors also found that the prescribed exercise benefitted all athletes, regardless of gender. The UBNow article mentions that, according to other investigations, this approach may work for adults with non-sport concussion but isn’t as effective and results aren’t as rapid as with adolescents or athletes; the treatment also often needs to be paired with other therapies. First author Dr. John Leddy noted in the UBNow article that “by contrast, this kind of sub-symptom aerobic exercise approach is often the only treatment that adolescent athletes need.”

Concussion Alliance has written extensively about the University of Buffalo’s work with subsymptom aerobic exercise treatment in this 2020 blog post and on our page on Graduated Exercise Therapy.

Veterans & Service Members

September 28 - November 16: four consecutive free online Awareness Training Programs for college faculty/staff on supporting Veterans and Military students. Session 4 covers TBI.

Clinical Trial for veterans and active-duty military members with Insomnia

A current study is enrolling service members and veterans to test the efficacy of an online Cognitive Behavioral Therapy app for insomnia (SHUTi), customized specifically for military members. The study is totally online and remote; contact the study team by emailing cnrm-ecbti@usuhs.edu or call or text (301)456-5474 to learn more.

Mental Health

Young nordic skier experiences mental health issues following concussion

An article in a local Colorado news report recounted the story of Bennett Gamber, a young nordic skier poised to join the Olympic team before two concussions altered the trajectory of his life. He had just recovered from his first concussion when he got his second. He was optimistic about his recovery, as his first concussion resolved within a couple of months. However, his optimism was misplaced; months passed with nagging symptoms of anxiety and irritability as his stress levels skyrocketed. Little things started to bother him more than usual and he couldn’t partake in his favorite activities. After seeking medical help, his doctor prescribed antidepressants, which slowly improved his mood. Starting college also helped Bennett take control of his life, as it provided structure and assignments to engage him. He now sees a neurologist to help monitor his symptoms, but he reports feeling a lot happier than before.

This story represents a personal account of the finding that about one-third of youth experience behavioral health symptoms following a concussion. The awareness surrounding concussions has increased as concussion numbers rise in children’s athletics. Stricter laws and regulations have been put into place to prevent adolescents from returning to activity before they are physically and mentally prepared. However, laws and regulations regarding the aftermath of a concussion do not prevent the accompanying mental health problems, highlighting the importance of seeking help to deal with mental health disorders that may stem from or be exacerbated by the injury. Mental health disorders are often missed in physical examinations, which adds to the importance of finding a licensed practitioner to guide concussion patients in navigating their mental health.

Statistics

Influence of insurance type on rate and type of initial concussion visits in youth

Concussion screening and treatment are more accessible to those who have private insurance rather than publicly insured individuals. However, given the prevalence and increased awareness of concussions, especially among youth, it is imperative to look into how treatments differ among insurance types.

A study by Radlicz et al., published in BMC Public Health, looked into differences in the rate and type of concussion visit, as well as the time of the concussion to the initial visit among publicly and privately insured individuals. The authors looked at 4,955 concussion cases over five years. They found that the rate of concussion visits was higher in privately insured individuals than for publicly insured individuals. Additionally, privately insured individuals had a greater proportion of visits to sports medicine clinics and a lower proportion of visits to the ED/urgent care. The time from the injury to the initial visit decreased throughout the study for both privately and publicly insured individuals, with a greater decrease in publicly insured individuals.

These findings suggest that those with private insurance are more likely to seek care from a sports-related clinic rather than urgent care. The authors note that sports-related injuries are the most common form of reported concussions among youth, meaning that differences in insurance type can correlate with treatment specificity, recovery times, and efficacy in treatments. Limitations to this study include lack of a diverse racial population and slight underrepresentation of publicly insured participants.

Youth

New, brief exam allows physicians to assess risk of delayed recovery, speeding referral to specialized treatment

In a study that could be a game-changer in youth concussion management, researchers Mohammad Nadir Haider et al. validated a previously developed, 10-minute exam for risk of delayed concussion recovery. This exam allows non-specialist medical providers (such as primary care doctors) to predict, with 85% accuracy and within ten days of injury, which children and adolescents are at risk for Persistent Post-Concussive Symptoms (PPCS).

Current guidelines classify children and adolescents as experiencing delayed recovery if symptoms persist beyond four weeks; delayed recovery can occur in up to 30% of cases and will require care from a specialized, multidisciplinary team. In a University at Buffalo press release, Dr. Haider said: “The current standard of practice is to wait and see for the first four weeks. But our research and other studies have shown that in children and adolescents, delayed treatment can lead to a higher risk of persistent impairments with poor outcomes.”

The Buffalo Concussion Physical Examination (BCPE) incorporates “physician exam techniques that every clinician already has,” according to Dr. Haider. The exam factors in the number of previous concussions, lightheadedness and dizziness when standing up, vestibular ocular reflex (balance and vision issues), and scores on the tandem gait test, among other factors. The BCPE exam generates a Risk of Delayed Recovery (RDR) score that categorizes the patient as low-risk, medium-risk, or high-risk.

Dr. Haider plans to create an app that will deliver the RDR score. The study was published in the British Journal of Sports Medicine.

CTE & Neurodegeneration Issues

NIH grant awarded to Boston University CTE Center to investigate repetitive head impact

The Boston University CTE center was awarded 2.3 million by the National Institutes of Health (NIH) to investigate the relationship between repetitive head impacts from contact sports and damage to the brain’s white matter and vascular system.

The grant will fund the research project SAVE, the Study of the Axonal and Vascular Effects from Repetitive Head Impacts. Led by Dr. Michael L. Alosco, associate professor of neurology at Boston University, SAVE aims to help researchers understand how damage to the brain’s white matter and vascular system affects “cognitive function, mood and behavior, and dementia.” Project SAVE will recruit 200 athletes and 100 matched controls.

“This study has the potential to revolutionize our understanding of the complex changes found in the brains of individuals exposed to repetitive head impacts,” said Dr. Alosco.