Hormone Replacement Therapy (3/4/21 Newsletter)

Mar 4

Discussing hormonal dysfunction after concussion; an interview with Dr. Tamara Wexler

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

Writers: Will Altaweel, Malayka Gormally, Mack Hancock, Micale Hunt, Emily Spain, Julian Szieff, Trinh Tieu, Rainey Tilley, and Josh Wu.

Editor: Malayka Gormally.

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Opportunities

March 9th, 1:00-2:00 pm. Mindfulness after Brain Injury, free Zoom class. Presented by BIAWA. Register in advance.

March 10th, 11:00 am - 12:30 pm PST. Self-advocacy (for those with an invisible injury); free Zoom class. Presented by BIAWA. Register in advance.

Education

You-CAN intervention aims to improve concussion reporting and social support in Canadian high schools

Researchers at the OAK Concussion Lab (University of Toronto) are evaluating a program called the Youth Concussion Awareness Network (You-CAN) as an intervention to improve concussion reporting and social support among high-school-aged youth. According to the study protocol published in BMC Public Health, the longitudinal study planned will use a cluster randomized trial design; sampling will be done at "three high schools from six randomly selected Candian school boards." The three schools will be randomly assigned to participate for one school year as:

(1) a control

(2) in the You-CAN intervention, led by the school staff

(3) in You-Can intervention, led by the school staff and research team

Participating in You-CAN entails creating a Concussion Council at the school, which will deliver a concussion awareness program and participate in an online showcase with other participating schools. The third school, led by school staff and the research team, will also have monthly calls with the research team. A survey will be administered at the beginning and end of the school year for all three schools, and schools participating in the You-CAN program will complete exit interviews with their Concussion Councils and other school staff.

The data from the study will measure how effective a school-based and peer-led concussion program is at increasing concussion knowledge, attitudes, subjective norms, perceived behavioral control, intent to report a concussion, and intent to provide social support to a peer. It will also provide information about the You-CAN program's implementation and acceptability by high school students and staff.

The lab is currently recruiting Canadian high schools to participate in the program. For details, schools can email you.can@utoronto.ca.

Oak Concussion Lab is also recruiting Canadian teenagers experiencing concussion symptoms for more than two weeks for a study “exploring a telerehabilitation approach to active rehabilitation for youth with concussion.” Recruitment ends March 15. Contact oaktelerehab@utoronto.ca or (416) 946-3273.

Sports

Long-Term influence of concussion on cardio-autonomic function in adolescent hockey players

Concussion may negatively influence cardiovascular function and the autonomic nervous system, including alteration in heart rate variability (HRV). HRV is the difference in time intervals between heartbeats; in a healthy heart, the heart rate varies in response to sleep, exercise, stress, etc. Reduced HRV is a marker of autonomic dysfunction or dysautonomia; the variability in heart rate response to stimulus is decreased.

In concussion patients, dysfunction in HRV most commonly emerges during a physical challenge, such as the final steps of the return-to-sport progression. This topic was studied by Allyssa K. Memmini et al. and published in the Journal of Athletic Training. Thirty-three male athletes participating in Midget-AAA hockey were divided based on concussion history into the following groups: no concussion history, one concussion, or two or more concussions.

The study’s findings suggest that more than one previous concussion may be associated with a greater risk for long-term dysautonomia, specifically, decreased HRV versus those without prior concussions or one concussion. The athletes who had sustained two or more concussions demonstrated increased time to physiological recovery after moderate aerobic exercise compared with the group who had sustained only one concussion and the healthy control group.

The study concluded that athletes with a history of more than one concussion warrant continued monitoring by sports medicine clinicians due to their potentially elevated risk of long-term dysautonomia.

Diagnostics

Clinicians now can objectively assess for concussion with the Concussion Index and BrainScope

The results of research by Jeffrey J. Brazarian et al., published in JAMA Network Open, provide validation of their previously developed Concussion Index. This machine-learning biomarker will help clinicians assesses the “likelihood and severity of concussive brain injury” and return-to-play decisions, according to an article in Yahoo! finance. The Concussion Index uses machine learning to quantify qEEG readings and assessments of neurocognitive performance and vestibular symptoms.

The Concussion Index testing can be delivered in 20 minutes in a clinic or ED setting. The delivery device, BrainScope, is made of two parts: what looks like a hair net of EEG pickups (one-time use) attached to a handheld device. In addition to quantifying the EEG results, the handheld Brainscope One Information Hub delivers the neurocognitive and vestibular/ocular function tests. A video produced by BrainScope for ED physicians provides a useful look at the device and its application; the devices will be marketed to physicians starting this month.

The study by Bazaraian et al. was a diagnostic cohort study involving 207 athletes with a concussion and 373 matched athletes without a concussion, in collaboration with ten clinical sites affiliated with US universities and high schools. The study participants were assessed with the qEEG, neurocognitive testing, and vestibular symptom inventories “within 72 hours of injury, at return to play, and 45 days after return to play.” Out of the Concussion Index range of 1-100, a score ≤70 “indicates it is likely the individual has a concussion, and >70 indicates it is likely the individual does not have a concussion.”

The authors found that the “Concussion Index accurately discriminated between athlete controls without concussion and athletes with concussion.” When the concussed athletes were clinically cleared to return to play, their Concussion Index had increased (improved) and was “in the range of “90% of control athletes without concussion, consistent with recovery.” Of note, those study participants with a concussion who experienced a prolonged return-to-play trajectory “had a significantly lower Concussion Index at day 0 compared with those with quick recovery.”

Self-care

Coping with five concussions: an interview with Ian Scott

Imagine living through five concussions before you even start college. This is the reality of Ian Scott, a freshman at Carleton College, who talks about his experience in this blog post. Although he might not seem any different compared to other people, he is perpetually battling the aftermath of his five concussions.

Ian cites his strong support system of family members and friends for helping him overcome the emotional struggle of five concussions. Surrounding himself with people that empathized with his situation let him know he felt cared for and he wasn’t battling with his concussion symptoms alone. As his symptoms recede, Ian also began to organize his life with respect to his concussed brain: he always wears a helmet when biking, he avoids sports/activities with a high risk of concussions, he uses a Cefaly device to battle headaches, and he prioritizes getting lots of rest. Read more about Ian’s story and his self-care strategies on our blog post.

Therapies Currently Available

Discussing hormonal dysfunction after concussion; an interview with Dr. Tamara Wexler

We interviewed Dr. Tamara Wexler, MD, PhD, about hormonal dysfunction after a concussion in our new blog post. Dr. Wexler is an endocrinologist specializing in neuroendocrinology and the treatment and study of hormone dysfunction following traumatic brain injury.

In this interview, Dr. Wexler discusses how hormonal dysfunction can affect patients and how to determine if a patient needs hormonal testing and/or replacement. Additionally, she discusses the advances in concussion endocrine research and treatment she hopes to see develop in the near future. Dr. Wexler serves as a Clinical Associate Professor at the NYU Langone Medical Center.

Therapies Being Researched

New research grant for exploring the effect of virtual reality-based rehabilitation for children experiencing TBI

Jaibin Shen, an assistant professor of psychology at UMass Lowell, recently earned a grant from the National Institutes of Health to research the possibility of using virtual reality simulation as a rehabilitation strategy for children experiencing traumatic brain injury (TBI). The three-year study aims to explore if interaction with a computer-generated artificial environment will enhance patients’ cognitive skills.

This study follows a successful pilot study by Shen that “supported the feasibility and safety of the virtual reality-based intervention” for children with a TBI. Although Shen focuses his research on TBI and not mTBI, some virtual reality-based rehabilitation strategies may also prove beneficial for children experiencing concussions. The announcement of the grant was made on the UMASS Lowell website.

Veterans and Service Members

Call for study participants near San Diego – veterans with mTBI history, headaches, and neck pain

The VA San Diego is calling for research participants to study the causes of headaches and neck pain in veterans with mild traumatic brain injury. According to an article in The San Diego Union-Tribune, eligible participants are veterans age 18-55 with a history of TBI.

Study participants need to be local to San Diego, as participation includes:

An MRI scan of the brain and neck
Measures of sensitivity to pain
An interview about TBI and headache history

Participation takes two hours, and study participants receive $50. Call study coordinator Tiana McMann at (858) 255-1670.

Mental Health

Certain factors heighten the risk for the development or exacerbation of mental illness following a concussion

Concussions are associated with physical and emotional trauma. An article by Angus Merry, published in the Queens University Journal, examines this association. Throughout this article, Merry focuses on the functional effects of concussions which influence treatment and post-concussion outcomes. Namely, since providers cannot diagnose concussions via brain imaging, the assessment and treatment of symptoms rely on patient communication.

Relying on patient communication is more complicated than one might think, as concussion symptoms range from “common symptoms,” such as headache or dizziness, to less well-known symptoms, such as reduced sleep, lack of concentration, and worsening depression and anxiety (especially in patients who have these preexisting conditions prior to having a concussion).

In the article, Merry cites a 2019 study by Murray B. Stein and colleagues. They found that mild traumatic brain injury (mTBI) is associated with worsening of preexisting mental health conditions and the onset of new mental illness. The participant pool consisted of 1155 patients with mTBI and 230 patients with orthopedic trauma injuries (not traumatic brain injuries); the study followed these patients from 2014-2018. They found that mTBI patients were at a significantly higher risk of developing Post-Traumatic Stress Disorder (PTSD) and/or major depressive disorder (MDD) following injury than patients who had only a non-head orthopedic injury.

Risk factors associated with developing PTSD six months after an mTBI were fewer years in school, being Black, self-reported psychiatric history, and injury resulting from an assault. Aside from an injury caused by assault, these risk factors were also associated with the probable development of MDD. Stein and colleagues concluded that a patient’s mental health history, education, race/ethnicity, and cause of the injury should influence how providers assess concussed patients; these factors are associated with the development of PTSD and/or MDD following injury. Thus, Merry’s article and Stein and colleagues’ study highlight the importance of understanding concussions are associated with the exacerbation of present mental illness or the development of mental illness.

Youth

Study finds that collaborative care is beneficial for adolescents with persistent post-concussive symptoms

A study conducted by Carolyn McCarty et al. found that among adolescents with persistent post-concussive symptoms, those who received collaborative care experienced greater relief than those who received usual care. The study, published in JAMA Network Open, included 200 participants (ages 11-18) who were randomly assigned to receive usual care or collaborative care, which included cognitive behavioral therapy, care management, and enhanced medical consultation over the course of six months.

A year after the start of treatment, the average Health Behavior Inventory score of the collaborative care group was 4.1 points lower than that of the usual care group, indicating that participants who received collaborative care had significantly fewer persistent post-concussive symptoms. In addition, the average Pediatric Quality of Life Inventory score of the collaborative care group was 4.7 points higher than that of the usual care group, indicating that participants who received collaborative care reported a significantly higher quality of life a year after the start of treatment. There were no differences between groups in anxiety and depressive symptoms throughout the treatment period.

Of note, the study’s sample was primarily comprised of White, high socioeconomic status adolescents. Because less privileged adolescents may face more barriers to receiving specialized concussion care, the findings may not be generalizable.

Women's Health

Oculomotor and vestibular concussion symptoms differ for male and female patients three weeks post-injury

Female pediatric patients are more likely to experience oculomotor and vestibular dysfunction than their male counterparts following concussion, according to a recent article published in Physical Therapy in Sport. In order to examine the difference between male and female patients, 197 female and 381 male pediatric patients within three weeks of their concussion were evaluated at a sports medicine clinic. The patients completed Balance Error Scoring System (BESS), tandem gait, gaze stability, and near point of convergence (NPC) tests. A higher proportion of female patients had abnormal NPC tests, gaze stability, and tandem gait tests compared to their male counterparts. Even when adjusting for other variables, Margot Gray et al. found an association between female sex and increased odds of abnormal results for both NPC tests and tandem gait tests.

Culture

Former NFL star Vincent Jackson's brain to be donated to CTE research

The family of former NFL star Vincent Jackson is donating his brain to scientists at Boston University studying CTE, according to an article in People. Jackson was a wide receiver who played for the San Diego Chargers and Tampa Bay Buccaneers before retiring in 2018 at age 38. Although the cause of death is still being investigated, Jackson's family believes that he suffered from chronic alcoholism and CTE. The research team at the Boston University CTE Center will analyze Jackson's brain to determine if he had CTE.

A 2017 study by Boston University found that 110 out of 111 deceased NFL players' brains had the disease, likely due to repetitive head impacts. The sample of 111 brains is based on those who chose to donate their brain (or their loved one's) for CTE diagnosis. Therefore, the high percentage of CTE found in the study may not represent the rate of possible CTE in former NFL players; this is a subject of ongoing discussion and research.