Faster recovery under current guidelines (2/18/21 newsletter)

Feb 18

Written By Concussion Alliance

Thank you for reading our Concussion Update newsletter; we appreciate your support.

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

Writers: Will Altaweel, Malayka Gormally, Tori Gray, Ming Shen, Emily Spain, Trinh Tieu, Alex Whitis, and Josh Wu.

Editors: Conor Gormally and Malayka Gormally.

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Upcoming opportunities

Friday, February 26: The Canadian Concussion Centre’s 8th Annual Concussion Research Symposium - virtual event. Full program and registration here. Topics: Exercise as a treatment for concussion and persistent symptoms, Tele-therapy treatment of persisting concussion-related mental health disorders, Headache treatment, Vestibular physiotherapy treatment for concussion, and more.

Education

Free CATT concussion management course for high-performance athletes

The Concussion Awareness Training Tool (CATT) has a new online concussion management course focusing on varsity-level athletes; the course is free, takes 30 minutes, and is provided in English and French. After a "self-assessment" pre-test, the information is provided in the form of short blocks of text, two-minute videos, quotes from athletes, and innovative interactive sections. The course emphasizes reporting a concussion and "teaches athletes how to support themselves or a teammate in the event of a concussion," according to an article in U Sports News. Associated with the course is a helpful Concussion Information Package for Athletes available in pdf format for downloading.

The course is a collaboration between the BC Injury Research and Prevention Unit at BC Children's Hospital and U Sports, "the national governing body of university sport in Canada, which represents 56 universities." Concussion Alliance highly recommends CATT online's up-to-date, interactive online courses.

Sports

Athletes are less likely to maintain their previous level of competition following a concussion

A study conducted by Fionn Büttner et al. found that adult amateur athletes who sustained a concussion were less likely than their healthy counterparts to have maintained their level of competition a year later. The study, published in the Journal of Science and Medicine in Sport, compared the outcomes of 50 concussed athletes (ages 16-38) to an age-, sex-, and activity-matched control group of 50 uninjured participants. A year after their initial assessment, 76% of non-concussed participants still participated in the same sport at the same level of competition, compared to 48% of athletes a year after their concussion. This difference was statistically significant.

For the concussed group, the median time for clearance to return to play was 13 days, and the median for “return to pre-injury level of sport competition” was 31 days. However, Büttner et al. believe that the drop off from 96% of athletes returning to their pre-injury level within 50 days to over 52% of them no longer playing at that level a year later is a valuable insight.

They argue that “concussed athletes who have pre-existing mental health problems, who fear re-injury, and/or who are concerned about the long-term consequences of concussion may be less likely to sustain their participation at their pre-injury level of sport competition if they do not receive the required social support.” Numerous physical, emotional, psychological, and social factors may hinder athletes’ ability to return to their pre-concussion level of competition. However, the study did not assess such factors. Nonetheless, the findings shed light on how concussions may restrict athletic performance in the long term.

Cannabis & Psychedelics

VA study on their clinicians’ knowledge and perspectives on cannabis for medical purposes

Researchers affiliated with the VA Portland Healthcare System conducted “A qualitative study of VHA clinicians’ knowledge and perspectives on cannabis for medical purposes.” They interviewed 14 Veterans Health Administration clinicians, transcribed the interviews, and analyzed the answers using qualitative thematic analysis. Authors Vivian A Christensen et al. note that the legalization of cannabis in many states had led to an increase in its use, including by veterans. Among the practitioners interviewed were those specializing in pain, PTSD, and mental health. “A small number (of clinicians) thought cannabis held promise as a treatment for certain medical conditions, such as chronic pain or posttraumatic stress disorder, while others were unsure.”

The study, published in Family Practice, found that clinicians expressed ambivalence about cannabis, inhibiting conversations with their patients about the topic. The clinicians cited concerns including: “discomfort with the lack of product standardization; lack of research examining the effectiveness and risks of cannabis use; unfamiliarity with pharmacology, formulations, and dosing of cannabis; and uncertainty regarding VHA policy.” The authors advise that “Educational materials about cannabis products, dose and harms would be helpful to (VA) clinicians.”

Diagnostics

New brain modeling approach links mild and moderate TBI forces and long-term damage

Researchers from Imperial London College published a study in Brain: A Journal of Neurology showing a clear link between mechanical forces acting on the brain during a TBI and the resulting long-term changes. The research combined a computational model of brain injury with experimental studies on rat brains.

The researchers previously built a computer model of the human head to predict long-term damage from TBI. The model focused on representing axons, or “white matter,” which plays a large role in networks altered in long-term damage. In the current study, they tested if the modeling approach could accurately predict the pattern of white matter damage in rats given mild and moderate brain injuries using a controlled cortical impact. The rats were assessed after several weeks, correlating to years of changes in the human brain.

The authors tracked the location and duration of mechanical forces linked to brain damage. They found that the effect of shear stresses on white matter helped predict the location of long-term damage. Because of the brain’s jelly-like consistency, being jolted and applying force causes shearing between adjacent parts within the brain.

“Different types of injuries will cause different kinds of shear,” said Dr. Mazdak Ghajari from the Dyson School of Design Engineering in a press release for Imperial London College News. “With this new model we can now more accurately predict which injuries will cause severe, long-term damage, and potentially avert it. For example, motorbike accidents involve a lot of rotational movement, which causes lots of shear. We are studying dozens of bike helmets to see which best protect against excess rotation.”

Researchers Cornelius K Donat et al. will continue to model different kinds of TBI within this framework to further the design of protective headgear and study whether repeated impacts from activities such as sports could lead to similar long-term brain injuries.

Self-care

Vaccination is vital for TBI patients at risk for neuroinflammatory COVID complications

The Brain Injury Association of America (BIAA) released an open letterindicating the importance of getting the COVID-19 vaccination for brain injury patients to protect themselves from developing more serious neuroinflammatory problems. Chronic neurological disorders such as brain injuries place individuals at an increased risk of developing complications due to COVID-19.

In an article on their organization’s website, BIAA National Medical Director Brent E. Masel, M.D. notes that traumatic brain injuries produce inflammatory processes in the brain that bring about chronic issues, leading to a significantly higher risk of negative complications to COVID-19, which has also been shown to cause neuroinflammatory symptoms.

The BIAA notes that while the vaccine can cause side effects such as arm soreness, headache, and fever, these symptoms are only transient and are part of the immune response needed to develop protection against COVID-19. There has been no evidence that the vaccine can worsen TBI symptoms. Gregory J. O’Shanick, the national medical director emeritus of BIAA, emphasizes that COVID-19 has caused “severe neurobehavioral disturbance, delirium, psychosis, and, sadly, deaths.” Therefore, it is important that TBI patients get vaccinated. Those who would like more information and resources may contact a brain injury specialist at BIAA by calling 1-800-444-6443.

Therapies Currently Available

Recovery times shorten when clinicians follow newest management guidelines

A retrospective review of medical records by John M. Neideceker, DO, ATC et al. found that updated guidelines for concussion management significantly reduced the duration of symptoms in middle and high school athletes with a first-time, sports-related concussion.

The authors looked at the medical records of youth (age 11-18) treated in 2011-2013 by one clinic. Based on the then-current guidelines, patients were advised “strict rest” until all concussion symptoms resolved – often referred to as “cocooning." A matching 2016-2018 patient cohort (from the same clinic) was treated based on the guidelines developed by the 5th Consensus in Concussion in Sport. These patients were advised “active rest,” defined as initiating “low intensity physical or cognitive activity at 24 to 48 hours” following their concussion.

For the 2016-2018 cohort, the clinician took a history of preexisting conditions including “migraines/frequent headaches, learning disability, visual problems, and mental health,” including those who self-reported these diagnoses. Patients received counseling and education to help develop realistic expectations for recovery trajectory and to prevent catastrophizing and heightened anxiety negatively affecting recovery.

Comparing the “strict rest” cohorts to the “active rest” plus education and counseling, the median duration of symptoms dropped from 28 days to 7 days in females and from 11 days to 5 days in males. “Recovery of concussion symptoms” three weeks out increased from 41.2% to 93.1% for females and 74.5% to 95.4% for males.

This retrospective review of medical records, published in Musculoskeletal Medicine and Pain, has limitations due to the lack of standardization of post-injury concussion evaluations and reliance on patients’ self-reporting symptoms. The authors conclude that “active rest,” recognizing preexisting conditions, and educating patients about recovery expectations can decrease symptom duration.

Therapies Being Researched

Mechanisms contributing to post-TBI inflammation, metformin a potential acute TBI medication

Traumatic brain injury can result in long-term neuroinflammation, which is associated with a host of detrimental outcomes. AMPK is an energy-sensing protein known to aid in the anti-inflammatory immune response following intracerebral hemorrhage (bleeding of the brain itself). In a study published in JCI Insight, Babak Baban et al. sought to elucidate AMPK’s anti-inflammation role in TBI cases.

Innate lymphoid cells, or ILCs, help orchestrate immune responses; two of the three ILC subtypes are pro-inflammatory. ILCs are always present, but all three subtypes elevate in moderate to severe TBI patients relative to control patients. This finding is based on analysis of cerebrospinal fluid in patients with severe TBI and mirrors their findings in mice.

After documenting that post-injury mice had reduced AMPK activation, researchers assessed whether metformin – a known AMPK activator and common diabetes drug – could “limit the deleterious aspects and promote the beneficial aspects of immune activation after acute brain injury.” Post-injury mice receiving metformin showed significantly greater AMPK activation, significantly reduced pro-inflammatory ILCs, and neurobehavioral improvements relative to placebo treatment mice (N=24).

While the study offers some insights into pro-inflammatory responses after TBI, issues remain. Metformin carries an associated risk of hypoglycemia, making the need for safer, more specific AMPK activators a priority. Additionally, the paper claims elevated ILCs in post-injury human dura without presenting a control group.

Veterans and Service Members

Free opportunity to try a CBT app for insomnia customized for military members with TBI

A clinical trial is enrolling 200 service members and veterans to test the efficacy of an online Cognitive Behavioral Therapy (CBT) app for insomnia that has been customized to be specific to military members. Research has found that Cognitive Behavioral Therapy is an effective treatment for insomnia; read more about this therapy on our website. Sleep Healthy Using the Internet (SHUTi) is the app that researchers have customized for this clinical trial. Similar CBT-i trials have proven to be effective and are recommended by Dr. Charles Czeisler, Professor of Sleep Medicine at Harvard Medical School. For civilians, this app is expensive and requires a prescription.

The use of the app will be free for participants who qualify for the study. All study-related activities will take place via telephone or the internet. No in-person visits are required. For more details, see our blog post, which includes the flyer for the clinical trial. To participate (or ask questions), contact the study via email at cnrm-ecbti@usuhs.edu, or call or text (301) 456-5474.

The clinical trial is being run by The Center for Neuroscience and Regenerative Medicine at the Uniformed Services University.

Mental Health

Concussion History associated with greater odds of suicidal ideation and suicide attempts in middle school students

A study published in Journal of Psychiatric Research analyzed the correlation between self-reported concussion history and middle school-aged students’ suicide risk factors. This study was one of the first studies to analyze middle school-aged students and how their concussion history affects their mental health.

Researchers used data from seven states to study the responses of 19,254 middle school students who took the 2017 Youth Behavior Risk Survey (YRBS). The survey included questions about whether the students had suffered a concussion and if they had thought about, planned, or tried to kill themselves — the “yes or no” phrasing of the questions aided in analyzing the data. To evaluate the data to understand the relationship between risk factors and previous concussion history, scientists used regression models to process all of each student’s various aspects.

The study found that previous concussion history and thoughts of suicide in middle school students could be closely related, similar to studies done with high school students. “Self-reported history of concussion was significantly associated with greater odds for history of suicidal ideation, planned suicide attempt, and past suicide attempt.” However, this study has restraints due to components such as emotional and life experiences that weren’t or can’t be incorporated into the logistical models.

Authors Dale D. Mantey, PhD, MPA et al. suggest that their study could help restructure intervention and support programs for students. In the Mental Health category of a previous newsletter edition, we highlighted a researcher who emphasized the need to add suicide prevention into multi-disciplinary care and support.

Youth

Melatonin prescription not associated with faster symptom recovery

A study found that youth diagnosed with a concussion who had “reported sleep disturbances within 14 days of injury” had more severe concussion symptoms than concussion patients who did not report sleep problems after injury. Melatonin prescriptions didn’t help those symptoms recover faster.

The study sample included 225 patients (age 8-18) who had been diagnosed with a concussion within two weeks of the injury. Study authors David R Howell et al. evaluated these patients within the first 14 days and assessed them again 15 to 35 days after the injury. The researchers measured symptom severity, headache severity, melatonin prescription, and change in symptom severity between the two visits.

Out of the 225 patients, 36% of them reported sleep problems while 64% did not. Those with sleep problems had greater severity of concussion symptoms across the two evaluations. However, there was no significant difference in symptoms between those who received a melatonin prescription and those who did not.

This study, published in Clinical Journal of Sports Medicine, highlights the correlation between sleep problems and worsening post-concussion symptoms. It also provided evidence that melatonin does not affect the worsening symptoms associated with sleep deprivation. However, future experiments should further investigate this study’s claims due to the measurements’ subjective nature.

Note: In a previous edition of this newsletter (in the Youth category), we covered a different study's finding that melatonin could improve sleep-related brain functions in children recovering from a concussion.

Women's Health

Why are women more at risk of injury from motor vehicle accidents? Women drive smaller cars & vehicle design based on male-body crash test dummies

A study by researchers from the Insurance Institute for Highway Safety found that women are twice as likely to experience a concussion in a car accident, perhaps due to the fact that they are more likely to drive smaller, lighter cars than men. The study was conducted by “a research group supported by auto insurers,” according to an article by ABCNews. This new study relates to a 2019 study and highlights the importance of accounting for both men and women in car-accident crash tests. It also points to the issue that crash-test dummies may not be accurately reflecting the bodies of the people driving the vehicles.

In 2019, Bloomberg CityLab published an article by Sarah Holder examining a connection between gender discrepancies in car accident injury severity. Holder presents findings from a study by Jason Forman et al. that found that “the odds of serious injury or death for female car-crash victims is 73 percent higher than for males.” In her article, Holder discusses the possible reasons for females’ higher risk, quoting Forman and other researchers who surmise that the higher risk may be connected to the low proportion of crash-test dummies that model the female body.