Get Kids' Vision Checked (4/15/21 newsletter

Apr 20

Written By Concussion Alliance

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

Writers: Will Altaweel, Malayka Gormally, Julian Szieff, 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.

Opportunities

Hosted by Concussion Alliance

April 30, 11 am PST, Dr. Tamara Wexler (MD, PhD, Neuro-endocrinologist) and Julian Szieff will be hosting a Clubhouse talk about pituitary hormone dysfunction after concussion. This talk will involve short presentations by Dr. Wexler and several question and answer segments. Contact us if you are interested in a Clubhouse invitation - we have a limited number of invitations available. We now have a Concussion Alliance club in Clubhouse. Use this link to access the talk with Dr. Wexler and Julian Szieff.

Additional Opportunities

April 22, 5:00 pm - 6:00 pm PST, Accessing Research: A Quick Guide, free Zoom program. Presented by the BIAWA. Register in advance.

April 27, 3 pm - 4 pm PST, Dizziness and Vertigo with Dr. John Rutka, presented by the Canadian Concussion Centre Webinar Series. Free, register in advance.

April 28, 10:00 am - 11:00 am PST, Resolving Inner Conflict: Move from Self-Doubt to Self-Acceptance, free Zoom program. Presented by the BIAWA. Register in advance.

Sports

Soccer’s First Attempt at Concussion Substitutions

The American soccer league (Major League Soccer) will be adopting a flawed new concussion substitution trial program introduced in December by the international soccer governing body (IFAB) for the 2021 season. Soccer leagues throughout the world have the option of adopting this trial program. While this is an important first step to addressing the prevalence of soccer concussions, concussion groups such as Headway UK have criticized this trial as continuing the flaws of current policies. While allowing for two concussion-specific substitutions, this trial does not allow for the required ten minutes (as established by the 2017 Concussion in Sport Group) to evaluate a player for returning to the field of play.

We have already seen this flaw in the English Premier League’s trial of the program when Issa Diop returned to play after a two-minute evaluation following a head impact before being substituted at half-time. George Chiampas (chief medical officer for US soccer), responding to a question about evaluation, said that “[United States] medical leaders [were] not selected for the IFAB FIFA committee. [We are] utilizing the options offered.” The importance of concussion substitutions should not be understated as players need to be removed from play for evaluation and treatment. Still, this trial fails players because it does not allow for a proper concussion assessment, one of the most critical elements of concussion prevention in sports.

Cannabis & Psychedelics

Survey on CBD use for anxiety, sleep problems, and stress

Researchers Julie Moltke & Chandni Hindocha recently conducted a study to garner a greater understanding of the patterns of use, dosage levels, and self-perceived effects of CBD.

The experiment consisted of sending a 20-minute survey to 387 current or past-CBD users. The survey included questions about demographics, CBD use, reasons for use, and effects on anxiety, sleep, and stress. The sample contained a majority of females (61.2%) and a wide range of ages (between 25 and 54 years old), primarily based in the UK (77.4%). “Fifty-four percent reported using less than 50 mg CBD daily,” a relatively low dose. The findings of the survey discovered that the top 4 reasons for using CBD were self-perceived anxiety (42.6%), sleep problems (42.5%), stress (37%), and general health and wellbeing (37%).

Further research should expand on this study’s results to understand how low doses of CBD, “representative of the general user,” might impact stress, sleep, and anxiety. In regards to concussions, this study captures some of the symptoms of concussions like anxiety, stress, and sleep problems. By illustrating that low-dose CBD can help alleviate these symptoms, it reinforces the idea that CBD may have beneficial effects for treating concussions. The study was published in the Journal of Cannabis Research.

Diagnostics

Advanced MRI reveals neuroanatomical changes associated with concussion

A study conducted by Sophie Richter et al. found that mTBI was associated with several neuroanatomical changes, including decreased white matter volume. The study, published in JAMA Network Open, included 81 mTBI patients (ages 14-85, 70% male) whose outcomes were compared with 104 control participants. All participants had two advanced MRI scans (using diffusion tensor imaging) to measure any neuroanatomical changes; one within 72 hours post-concussion and the other 2-3 weeks post-concussion.

Relative to control participants, mTBI patients’ white matter volume decreased between the two MRI scans to a statistically significant degree. While mTBI patients had, on average, 231.5 cm³ white matter in the first MRI, they had, on average, 229.8 cm³ white matter in the second MRI. In addition, the MRIs revealed statistically significant increases in ventricular volume and circumferential cerebrospinal fluid volume between the first and second scans for mTBI patients.

The authors note that “The evolution of diffusion tensor imaging (DTI) findings between scans was categorized into 3 phenotypes: progressive injury, minimal change, and pseudonormalization...we have, for the first time to our knowledge, parsed MRI and DTI changes in mTBI by deriving clinically plausible imaging phenotypes that were associated with symptom trajectories.”

Because these neuroanatomical changes indicate potentially progressive pathology in some of the patients, the study’s findings show that advanced MRI (using clinically available technology) may allow medical providers to identify which concussion patients are likely to have worse outcomes.

Self-care

Ways to cope with depression after a brain injury

See our blog post about this topic.

Therapies Currently Available

Meta-analysis finds multiple therapies effective for increasing quality of life in concussion patients

Researchers found that problem-solving therapy, cognitive behavioral therapy, and additional specialized interdisciplinary rehabilitation were effective for adults who have prolonged symptoms after mTBI and those at risk for prolonged symptoms. Markia C Möller et al. performed a systematic review and meta-analysis of randomized controlled trials and non-randomized controlled studies published from 2000 to 2019, identifying nine studies that fit their parameters.

The authors found that problem-solving therapy and cognitive behavioral therapy “reduce residual symptoms, improve psychological functioning, decrease depression, increase activity and participation, and improve quality of life, compared with usual care.” Their analysis also suggested that “specialized interdisciplinary rehabilitation reduces residual symptoms.” The study was published in the Journal of Rehabilitation Medicine.

Therapies Under Research

Dietary supplements may reduce neuroinflammation, though study’s conclusions are not statistically significant

A study by Elise Black et al. claims that dietary supplementation could help combat the adverse effects of mild TBI in rats. The research, published in Translational Neuroscience, aimed to join the growing body of literature showing that omega-3 polyunsaturated fatty acids (O3FAs) and cannabidiol (CBD) may help reduce detrimental effects associated with mTBI.

The researchers investigated two dietary supplements. Supplement A was O3FA-rich; Supplement B contained CBD with lower levels of O3FAs. Rats received supplementation for 30 days before TBI exposure. A week after impact, rats were euthanized; researchers quantified neuroinflammation levels by measuring two distinct biomarkers, GFAP and CD68. Non-supplemented mTBI rats tended to have elevated levels of both neuroinflammation markers relative to non-supplemented, uninjured rats. These trends were reversed in mTBI rats receiving Supplement A but not in those receiving Supplement B. However, these trends were not statistically significant.

The authors argue that since the trends were consistent across two markers quantified in different ways, the observed effects are real. They also suggest that working with mTBI “hinders efforts to reach…statistical significance,” and their protocol might result in statistical significance if applied to smaller rats.

Taken alone, findings lacking statistical significance are not convincing. Furthermore, this study was funded by Trident Brands Inc., which manufactures the investigated supplements. However, given the growing body of literature that O3FAs may help reduce harmful TBI sequelae, it’s possible a future study could achieve statistical significance.

Veterans and Service Members

Veterans with TBI are 41% more likely to develop a sleep disorder

In an average follow-up of five years after injury, veterans with a TBI are “41% more likely to develop any sleep disorder” than age-matched veterans without a TBI. These sleep disorders include sleep apnea, insomnia, hypersomnia, and sleep movement disorders. Authors Yue Leng et al. found the association with sleep disorders was more robust for mild traumatic brain injuries and was not affected by the presence of PTSD.

The cohort study, published in Neurology, included all patients diagnosed with a TBI in the Veterans Health Administration system over a period of four years: 98,709 veterans with TBI. These patients were age-matched with an equal number of veterans without TBI. The authors note that “Improved prevention and long-term management strategies for sleep are needed for veterans with TBI.”

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 a 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.

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.

Youth

Study finds 70% of adolescent participants had at least one oculomotor dysfunction diagnosis following a concussion

A study found that in a 4 to 12 week period after a concussion, 70% of adolescents had at least one oculomotor diagnosis, and 47% had more than one. These findings were based on a comprehensive oculomotor examination performed by an optometrist. In addition, the vision screening performed by a physician (rather than an optometrist) detected the various vision problems only 43% to 63% of the time, depending on which type of assessment the physician used.

The study, published in Vision Research, enrolled 113 youth aged 11-17 and assessed them for vision dysfunction 4 to 12 weeks after their concussion diagnosis. Vergence disorders (particularly convergence insufficiency) and accommodative disorders were the most common diagnosis. The authors Mitchell Scheiman et al. note that “The results of this study provide additional evidence that vision problems are common in adolescents with persistent concussion symptoms.”

Due to the underperformance of physician-delivered screening in identifying oculomotor dysfunction, the authors suggest that “adolescents with post-concussion symptoms lasting more than 4 weeks post injury receive a comprehensive oculomotor examination.”

Note that specialized optometrists conduct these comprehensive oculomotor exams. Read more about oculomotor exams, specialized optometrists (and how to find one), and vision therapy on our Vision Therapy page.

Women's Health

At 12 months after an mTBI, women have more severe symptoms than men

A study of 2000 patients with mTBI found that at 12 months after injury, “the severity of cognitive and somatic symptoms on the Rivermead Post Concussion Symptoms Questionnaire” was significantly worse for women than for men. When comparing females of different ages, women aged 35 to 49 had “more severe somatic PCS after mTBI than women aged 17 to 34 years or older than 50 years,” although this finding is preliminary.

Harvey S. Levin, PhD, et al. compared the mTBI patients to a control group made up of 299 patients with orthopedic trauma. Because of the use of a control group, the authors suggest that “the higher propensity of women to experience prolonged mTBI recovery may not be a consequence of sex differences in preinjury symptoms or reporting biases. Furthermore, these difference may not be the result of the nonspecific effects of trauma; rather, the sex differences may be a direct result of differences in susceptibility to brain injury symptoms.”

They note that women in their study had more severe symptoms despite having milder acute injuries, lower rates of CT pathology findings, lower rates of prior TBI, and higher educational rates, all of which should have made them less vulnerable to TBI-related symptoms. The study was published in JAMA Open Network.