Brain injury Covid-19 vaccine eligibility (3/18/21 newsletter)
We would like to acknowledge our volunteers and leadership team members who wrote for this newsletter:
Writers: Conor Gormally, Malayka Gormally, Mack Hancock, Micale Hunt, Caroline Saksena, Trinh Tieu, Rainey Tilley, Alex Whitis, and Josh Wu.
Editors: Conor Gormally and Malayka Gormally.
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Opportunities
Covid-19 vaccine eligibility for those with disabilities in some states
Washington state opened up COVID-19 vaccine eligibility to include people 16 years or older who have a disability that puts them at high risk for severe COVID-19 illness. You can call the Brain Injury Alliance of Washington State (BIAWA) Resource Line to talk through this new option. 877-982-4292.
Note: the Washington State Covid-19 Vaccine Phase Finder does not provide “brain injury” as an option to check, but it does give the option to select “I have a disability.” It appears that young people who check the box for disability are eligible for the vaccine.
California has also opened up eligibility to those with disabilities, according to an article in KTLA 5. Although brain injury is not specifically listed as an eligible condition, it appears that people who check a box for one of three general disability criteria are eligible for the vaccine. One of these criteria is that “getting COVID-19 will limit the person’s ability to receive ongoing care or services vital to well-being and survival.”
New webinar series
March 30, 6:00 - 7:00 pm EST: Imaging of Concussion with Dr. David Mikulis. The Canadain Concussion Centre is hosting biweekly webinars featuring experts on concussion treatment topics, including exercise therapy, treatments for dizziness & vertigo, headaches, vestibular therapy, and whiplash. The Zoom webinars are free, though you must register in advance.
Education
TeachAids launches Institute for Brain Research and Innovation
Health education-focused non-profit TeachAids launched the Institute for Brain Research and Innovation in January, as reported in Medical Plastics News. The Institute’s mission is to implement and evaluate tools to improve concussion reporting and understand concussive symptoms, severity, and side-effects. Dr. Daniel Daneshvar, the previous founding scientific advisor for TeachAids and current faculty at Harvard Medical School, was named the Institute’s director; he will lead researchers across the country in researching this topic. The Institute’s findings will be globally available in a CrashCourse program, which consists of various interactive educational materials such as brain fly-through videos on brain trauma for educating athletes on concussions.
“In many ways, the concept for the Institute has been part of the culture of TeachAids since the beginning,” Daneshvar said in a press release for The Stanford Daily. “The Institute simply aims to formalize the research arm that helped make CrashCourse such an effective program.” The Institute primarily serves as a gathering space for scientists, but TeachAids will also incorporate athletes’ and coaches’ perspectives into its work.
Sports
Controversial FDA approval of “Q-Collar” may protect athletes against repetitive sub-concussive hits but not from concussion or other TBI
The FDA just approved a non-prescription device called the Q-Collar, for “athletes aged 13 years and older during sports activities to aid in the protection of the brain from the effects associated with repetitive sub-concussive head impacts,” according to an FDA News Release.
The Q-Collar fits around the athlete’s neck and puts pressure on the jugular veins in the neck, elevating brain blood volume “to help reduce movement of the brain within the cranial space which may occur during head impacts. The device may reduce the occurrence of specific changes in the brain that are associated with brain injury,” according to the FDA. The theory is that the brain sloshes around less with the Q-collar, minimizing potential micro-injuries that come with repetitive sub-concussive impacts.
The FDA authorization includes a notice that “the Q-Collar hasn’t shown efficacy in preventing concussions or serious head injury,” according to an ABC News article. “‘It’s a troublesome FDA statement because it’s hard to know exactly what [the devices] do for the consumer,’ said David Putrino, PT, PhD, director of rehabilitation innovation and assistant professor of rehabilitation and human performance in the Mount Sinai Health System.”
The FDA clearance was based on research that “found changes in deep structures of the brain in 73% of participants in the no-collar group. However, 77% of the collar group participants showed no significant alterations in these same structures,” according to an ABC 7 Eyewitness News article.
Numerous professionals have raised concerns that the Q-Collar may do more harm than good. These worries include that it may give a false sense of security and that “somebody wearing this collar who sustains a brain injury resulting in elevated pressure inside the skull would be at much higher risk if neck veins remain compressed.”
Cannabis & Psychedelics
New study evaluates the effect of THC on repetitive subconcussive head impacts from soccer headings
Dr. Keisuke Kawata of Indiana University recently announced a new study to evaluate the effects of chronic cannabis (THC) use on the brain in response to repetitive subconcussive head impacts. Two groups of participants (long-term cannabis users and cannabis non-users) will perform twenty soccer headers in ten minutes. The researchers will evaluate participants’ cognitive function, ocular-motor function, autonomic function, and blood biomarker measurements.
Dr. Kawata hypothesizes that “repetitive subconcussive head impacts will impair cognitive function in worse memory, attention span, and visual and verbal problem solving [– and that] this impairment will be greater in the chronic cannabis use groups than [the] non-using group.” The researchers expect to complete this study in December of 2021.
Diagnostics
Higher rates of sleep apnea in those with Post-Concussion Syndrome: sleep study recommended for those with non-restorative sleep or waking up with headaches
Alexandra Santos et al. conducted a retrospective chart review study on 51 patients with post-concussion syndrome (PCS) who had been referred for a sleep study. Of the study’s patients, 78% were diagnosed with sleep apnea; their profiles did not match the typical sleep apnea profile. The study mentions that for those with traumatic brain injuries (across all levels of severity), the incidence for sleep apnea is 25% – compared to 6% in the general population. This research is likely the first to look specifically at PCS patients.
In the study, published in the Journal of Clinical Medicine, PCS patients with sleep apnea reported significantly more memory symptoms and had a “higher total symptom number.” For this group of PCS patients, sleep apnea incidence was roughly equivalent for males and females, and 72% were under 65. BMI was similar between those with and without sleep apnea. The study participants did not match the typical sleep apnea profile of overweight, older males.
Central sleep apnea is caused by disruption of the brain’s breathing regulation centers. These centers are part of the autonomic nervous system (ANS), often disrupted by concussion. The study authors suggest that “PCS patients are at higher risk for sleep apnea and sleep study should be considered if complaining of non-restorative sleep and/or waking up with headaches...The high number of sleep apnea diagnoses in the present study suggests that people with PCS are at high risk of sleep apnea and should routinely be investigated further for sleep-disordered breathing."
In her healio.com blogpost, Dorothy L. Hitchmoth, a former VA Hospital chief of optometry, urges eye specialist doctors to look for connections between sleep apnea and concussions. Sleep apnea is associated with a variety of ocular conditions and is more common in concussion patients.
Hitchmoth asserts that if a patient has floppy eyelid syndrome, ischemic optic neuropathy, generalized swelling of the optic nerve, or central serous retinopathy, eye specialists should ask about snoring and daytime sleepiness. Encourage patients who answer affirmatively to follow up with diagnosis and treatment for sleep apnea.
Therapies Currently Available
Study shows that early vestibular rehabilitation therapy helps athletes reduce symptoms and return to sports faster
Sage Journal recently published a retrospective cohort study done by Ranbir Ahluwalia et al. that discovered that vestibular rehabilitation therapy (VRT) within the first 30 days after a sports-related concussion (SRC) corresponds with a decrease in time in returning to sports and symptom resolution, but not in returning to school.
The study sample included 23 patients aged 5 to 23 years with SRC who initiated vestibular rehabilitation therapy (VRT) from January 2019 to December 2019. They were divided into an early VRT group and a late VRT group. The early group was given VRT ≤ 30 days post-injury, the late group was given VRT at >30 days post-injury. The late group took longer to return to play (median of 110 days compared to 31 days) and for symptoms to reside (median of 121.5 days vs 54 days). However, both groups took approximately the same to return to learn (median of 12 days vs 17.5 days). Unfortunately, these results are limited to the small sample size of 23 patients.
This study highlights the importance of early vestibular dysfunction screening and VRT to reduce symptoms and recovery time. Patients with concussions should ask clinicians to screen and initiate VRT within a month of the injury. Future prospective trials should be done with a larger sample size to corroborate these results or evaluate if earlier VRT would improve recovery time even more.
Note: See our page on Vestibular Therapy for more information and our Find Providers page to search for vestibular therapists in your area.
Therapies Being Researched
Inhibiting a component of the immune system after TBI may prevent degenerative neuroinflammatory response
Our immune systems play a vital role in keeping us healthy. However, thanks to a study by Alawieh et al. published in the Journal of Neuroscience, more and more evidence emerges that the immune system contributes to neurodegenerative problems following TBI. The present study investigated the molecular processes that initiate and sustain chronic neuroinflammation post-TBI. In doing so, a promising therapeutic target emerged.
The complement system* is an essential part of the innate immune system that augments the body’s ability to clear out damaged cells, attack pathogens, and promote inflammation. When experimental mice sustained brain injuries, the complement system, “specifically complement-mediated microglial phagocytosis** of synapses,” remained active up to three months later. Through opsonization***, the complement system signaled microglial cells in the immune system to degrade synapses throughout the brain. As such, this system contributed to a chronic neurodegenerative response.
Researchers inhibited the complement response in a group of mice post-injury, at which point the degenerative neuroinflammatory response was interrupted. Mice performed better on memory and spatial learning tasks, even after the complement system was no longer inhibited, until two months post-injury. This finding suggests that complement inhibition could be an effective therapeutic approach across acute and chronic timescales. In future studies, the researchers hope to explore the window of effective treatment by inhibiting complement at even later time points.
*Complement system: "The complement system, also known as complement cascade, is a part of the immune system that enhances (complements) the ability of antibodies and phagocytic cells to clear microbes and damaged cells from an organism, promote inflammation, and attack the pathogen’s cell membrane."
**Phagocytosis: "the process by which living cells called phagocytes ingest or engulf other cells or particles."
***Opsonization: "a process where opsonins bind to the surface of the antigen so that the antigen will be readily identified and engulfed by phagocytes for destruction."
Mental Health
Poor sleep quality after multiple concussions may increase risk for depression: suggestion for preventative sleep-interventions
Benjamin Brett, PhD et al. did a study to see if sleep quality is a “mechanistic pathway through which repeated concussion increases risk of depression later in life.” The multicenter study enrolled 58 former American collegiate football players who had discontinued sport approximately 15 years prior. The former athletes were given tests for depression and sleep quality, and their years of participation in football was also a variable taken into account.
The authors found that concussion history did predict sleep quality, and “sleep quality significantly predicted depressive symptom severity.” However, when they took into indirect effects, “concussion history did not predict depressive symptom severity.”
The study, published in The Journal of Head Trauma Rehabilitation, concludes that the findings “raise the possibility” that poor sleep quality, common after mTBI, may contribute to a greater risk of depression. The authors suggest that individuals with “multiple prior concussions” be given preventative, or “prophylactic” sleep-related interventions to reduce the risk of depression.
Youth
First week post-concussion: an increase in self-paced activity may not impact symptom resolution, but increased time in school may have a positive effect
A study by Jingzhen Yang et al., published in The Journal of Head Trauma Rehabilitation, used wearable devices to track physical and cognitive activity the first week after a concussion in youths. The authors enrolled 83 participants aged 11-17 within 72 hours of sustaining a concussion and then measured their step counts and cognitive activity in the first week following their injury. Participants followed a self-paced daily routine, completing a daily post-concussion symptom assessment.
Yang et al. found that every 2000 step increase in participants’ daily step count was associated with a 17% increase in the likelihood of early symptom resolution (asymptomatic before 28 days). However, this increase was not statistically significant when the authors controlled for covariates such as acute post-concussion symptom levels. They also found that every 60-minute increase in time spent at school was associated with a 14% higher chance of early symptom resolution; this association was still significant when the authors controlled for the same covariates.
The finding that increased time at school is associated with a higher chance of early symptom resolution is notable. That early physical activity post-injury does not positively impact concussion recovery appears to conflict with several recent studies. The other studies looked at youth given individualized, graduated, sub-symptom level exercise programs as early as the first week post-injury; these programs did improve recovery times and symptom load.
In this study, in which increased physical activity in the first week did not make a difference, the physical activity was self-paced, and “nearly half of daily physical activity was at a light intensity.” Concussion Alliance has recently covered related research in our 1/8/21 newsletter (under Therapies) and our Graduated Exercise Therapy page.
Women's Health
Female athletes may face higher risk of concussion and developing dementia
British MPs were warned last week that women and girls face double the risk of concussion and developing brain injuries from playing sport compared to their male counterparts, according to an article in The Guardian. Dr. Willie Stewart, a consultant neuropathologist at the University of Glasgow, noted growing concerns about the long-term consequences of these head injuries. While substantial research has gone into relationships between concussions and male sports at an elite level, that is not the case for female elite sport.
The disparity in research is problematic when considering the risk of sustaining a concussion in women’s soccer is roughly twice as high as it is in men’s. Not only are the risks of sustaining a concussion higher for female athletes, but female soccer players could also have a greater risk of dementia from heading the ball, according to an article in ITV News.
To close the gap between studies on male and female athletes, Dr. Michael Grey is running a project to monitor ex-footballers for early signs of dementia. While the study includes both male and female athletes, there are currently fewer female athletes signed up, which will make it difficult for the research team to adequately explore the effects of deteriorating brain health in women and the differences between men and women.
The research team is looking for former professional football players over 40 (either men and women). Amateur footballers and active non-footballers aged over 40 can also take part. The majority of testing will be done online at home. If you or someone you know may be eligible to participate, please visit www.scoresproject.org or email scoresproject@uae.ac.uk to learn more.
Executive Editor
Concussion Alliance Co-founder and Executive Director Malayka Gormally