Multimodal treatment speeds recovery, return to sport

In this newsletter: Opportunities, Education, Sports, Diagnostics, Veterans & Service Members, Therapies Currently Available, and Therapies Under Research.

The lead article, Patients with persistent symptoms 3x more likely to return to sport in 8 weeks with multimodal therapies, is in the Therapies Currently Available category.

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

Writers: Alyssa Schaechinger, Conor Gormally, & Malayka Gormally

Editors: Conor Gormally and Malayka Gormally.

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Opportunities

Currently enrolling for January 16, 2022 start-date: Concussion Corner Academy, a 12-week course providing CEUs for physical therapists and athletic trainers. The program faculty are leaders in the concussion field; Concussion Alliance highly recommends this course for healthcare professionals.

November 17, 11 am PST: Strengthening Relationships Through Effective Communication. Produced by BIAWA; register in advance.

November 23, 4:30 pm PST: Brain Anatomy and common symptoms following brain injury. Produced by BIWA; register in advance.

December 7, 7:00 pm EST: free Love Your Brain Interactive Virtual Open House for clinicians, TBI advocates, and patients.

Education

“The Nocebo Effect”: The potential negative impacts of improper post-concussion protocol

A recent article from William Allsetter of 5280 magazine describes how researchers are identifying a ‘nocebo effect’ with regard to concussion. Like the placebo effect, the nocebo effect results in a patient having symptoms of a concussion long after their injury due to an improper post-concussion protocol.

Allsetter’s article is in reference to The Nocebo Effect and Pediatric Concussion, published in Human Kinetics Journals. Michael Kirkwood, David Howell et al. describe the nocebo effect and its implications for concussion management including how providers can “Prevent, Lessen and Eliminate Nocebo Effects.” Concussion Alliance highly recommends this thoughtful discussion about how to talk with concussion patients, including choosing terms carefully and being “thoughtful about messaging, both explicit and implicit.”

In the 5280 magazine article, Dr. Howell suggests that if patients exercise more regularly following an initial short period of rest, exercise will reduce their recovery time. Doctors previously thought that the best method to recover from a concussion was to rest in a dark room until symptoms subside. This idea has been replaced by research that shows the positive impacts of exercise in concussion patients following a day or two of rest following the initial injury. However, there are still many doctors that prescribe extended periods of rest to concussion patients. These extended periods of isolation can lead to depression and anxiety in patients, which then project themselves as concussion symptoms. Overall, it is essential to encourage concussion patients to gradually return to activity, as this helps eliminate ‘nocebo effect’ symptoms and allows for a quicker overall recovery.

Sports

Differences in concussion between college students and intercollegiate athletes

A study by Melissa Anderson et al., published in Archives of Physical Medicine and Rehabilitation, evaluated concussion mechanisms, health history, and clinical outcomes in college students and intercollegiate athletes. Based on their findings, Anderson et al. believe that greater attention and care should be given to concussion recognition and treatment in recreational sports and that “future research should further explore factors moderating symptom presence and return to daily activities among college students to better understand and augment concussion recovery.”

The authors found that, after a concussion, “general college students presented with a greater number of concussion symptoms and worse balance performance than athletes.” In contrast, “college students produced better CNT [neurocognitive testing] scores for five domains while athletes only performed better for one CNT domain score acutely following concussion. The college students in our study presented with a greater proportion of ADHD, anxiety, depression, and migraine history than is typically reported in other, college- student literature.”

Anderson et al. used data from 179 college students and 49 athletes evaluated acutely (<7 days post-injury) between Fall 2016 and Spring 2020. Participants self-reported their injury mechanism and health history “(e.g., loss of consciousness, amnesia, headache/migraine history, LD, ADHD, concussion history, anxiety, and depression)” and completed clinical assessments in this acute period. Clinical assessments included Balance Error Scoring System (BESS) to measure balance, a 22-item symptom checklist from the Sport Concussion Assessment Tool (SCAT3) to assess symptoms, and the CNS Vital Signs assessment to examine the neurocognitive status of patients, covering a “range of mental processes from simple motor performance, attention, memory, to executive functions.”

The authors found that “among students, 24% reported sustaining a concussion while participating in recreational sports and 27% of impacts occurred to the back of the head.” They also found that college students with a history of headaches reported greater symptom severity, and 33% of students reported a previous concussion history.

Diagnostics

Provisional patent for concussion diagnostic using urine-metabolite analysis

Researchers from the University of Lethbridge and the University of Calgary have developed a test for concussions based on urine metabolites. The study, published in Frontiers in Neurology, found that “metabolite signatures can accurately reflect central nervous system inflammation and neuronal injury.” According to an article in CTV News by Sean Marks, the diagnostic tool has been approved for a provisional patent. This patent will allow researchers Zachary Wanner et al. to “run tests on a much wider group of people to determine certain parameters for age, gender and even different neurological conditions.”

For their study, the researchers recruited “423 Canadian national team athletes, national development athletes, and amateur ice hockey players,” all-male and aged 12-16, and monitored them throughout a season. During the season, 40 players sustained a sports-related concussion (SRC), and 26 provided the urine samples within the 24-72 hour window after sustaining their concussion. All participants provided a urine non-concussed urine sample at the beginning of the season, along with a patient history including “previous head injuries, description of recovery from previous head injuries, neurological conditions, medications, sport participation, and biographical information.”

From their analysis of differences between the players’ non-concussed and concussed urine samples, the researchers found a panel of 18 urine metabolites that classified SRC with 81.6% accuracy. Further, “three specific metabolites significantly correlated with increased symptom burden and prolonged return to sport.” According to the CTV News article, the researchers believe that these metabolic biomarkers could also help create specialized recovery plans and monitor recovery processes for those with concussion. In the article, researcher Tony Montina said that clinicians could “look for changes in levels to tell us how well a therapy is working, allowing for targeted therapeutics to speed up the recovery process for athletes.”

Veterans & Service Members

Two studies for veterans with concussion history dealing with insomnia

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.

Sleep study for veterans with sleep issues and concussion history

The Sleepless Warriors At-Home study is recruiting veterans age 21+ who have served in the military for at least 180 days, have trouble sleeping, and have a concussion history.

“Participants are randomly assigned to one of two therapies that are specifically focused on sleep. Both are short-term, structured treatments that teach different skills and techniques aimed at improving insomnia symptoms. The specific skills you learn will depend on which therapy you are assigned.”

“In both treatments, you’ll meet online with a therapist once a week for approximately 1 hour to discuss your difficulties with sleep. The techniques they teach you will be tailored to your personal circumstances.”

The study involves nine teletherapy appointments and one follow-up appointment after six months. The study also offers compensation for each visit, up to a total of $325. Follow this link to the study page if you’re interested in participating; the study page has a link to a survey to determine if you are eligible to participate. You can also call (650) 446-3373 for more information.

Therapies Currently Available

Patients with persistent symptoms 3x more likely to return to sport in 8 weeks with multimodal therapies

Patients with persistent post-concussion symptoms returned to sport significantly faster if they received individually tailored multimodal treatments, including cervical, vestibular, and oculomotor therapy. In a systematic review and meta-analysis, authors Susan A Reid et al. found that “concussed individuals with persistent symptoms were 3 times more likely to have returned to sport in 8 weeks” if they received multimodal interventions tailored to their presenting symptoms.

The authors included eight randomized controlled trials included in their analysis, with the aim of evaluating the effect of “subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies on days to recovery/return to activity, symptom scores,” etc. Subthreshold aerobic activity had a small to moderate effect on symptom scores but did not reduce the days to recovery in patients with acute or persistent post-concussion symptoms. There was only limited evidence for stand-alone treatments (cervical, vestibular, oculomotor therapies). The study was published in the British Journal of Sports Medicine.

Concussion Alliance supports a multidisciplinary treatment for persistent post-concussion symptoms. This study’s finding on subsymptom aerobic exercise conflicts with results from other studies that have found it shortens recovery time. See our previous newsletters and blog posts here, here, and here.

Therapies Under Research

Concussion produces hearing problems in 15-20%, rhythm-based therapy may help

A fascinating NPR article by Jon Hamilton discusses how hearing is negatively affected after a concussion, sometimes long-term, and explores a potential treatment modality. Nina Kraus, professor of neurobiology at Northwestern University, says that "about 15% to 20% of concussions cause persistent sound-processing difficulties," particularly in hearing speech in a noisy environment. Also, their lab has found that concussion can also produce hypersensitivity to noise. Kraus runs the lab Brainvolts, and she recently published the book Of Sound Mind: How Our Brain Constructs a Meaningful Sonic World, which has a chapter on concussion.

Kraus and her team are currently running an NIH-funded study testing and following 500 Division I athletes for five years. They are finding that, after a concussion, athletes are missing all kinds of details of sound. Kraus is exploring rhythm therapy for those with lingering symptoms related to hearing.

Kraus wrote an editorial for The Hearing Journal discussing the "digital music medicine intervention" provided by Interactive Metronome (IM). Her editorial details her theory of why and how the IM intervention is effective, explaining that IM is a rhythm-based treatment that "requires only to clap or tap a foot along with a beat and respond to accompanying feedback."

A randomized control trial found that "The addition of IM therapy to [standard rehabilitation care] appears to have a positive effect on neuropsychological outcomes for soldiers who have sustained mild-to-moderate TBI and have persistent cognitive complaints after the period for expected recovery has passed."

In a brief interview with KCBS radio, Kraus says, "If people are still experiencing difficulty understanding speech, especially in noisy places, [our lab] can see that their brain is processing sound without some of the very very crucial details in sound that we need in order to make sense of it."