Fewer symptoms with collaborative care (4/29/21 newsletter)

May 1

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

Writers: Will Altaweel, Conor Gormally, Malayka Gormally, Emily Spain, Trinh Tieu, Rainey Tilley, 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; Clubhouse only works on iPhones. We now have a Concussion Alliance club in Clubhouse. Use this link to access the talk with Dr. Wexler and Julian Szieff. We will be recording the conversation and will include a link for the recording in our next newsletter.

Additional opportunities

May 4, 11 am PST: TangoStride, a dance-based walking class for people with mobility challenges, taught by Gabriela Condrea. Work on balance and posture while sitting or standing. Free and presented on Zoom by the Brain Injury Alliance of Washington State (BIAWA). Register in advance.

May 11, 3 pm PST: Free webinar about vestibular therapy with Shaleen Sulway, presented by the Canadian Concussion Centre. Register in advance.

May 12, 11 am PST: Storing the Stuff: Organizing Tips and Techniques, free Zoom class by Lauren Williams, Certified Professional Organizer. Presented by BIAWA; register in advance.

Education

Brain injury consulting program aims to help struggling students in PA and CO

BrainSTEPS (Strategies Teaching Educators, Parents, and Students) is a consulting program for schools to develop and implement educational plans for students (K-12) following a brain injury. The program addresses “any type of brain injury,” including concussions. It aims to build a bridge connecting the medical, rehabilitation, and education sectors with families. The original BrainSTEPS model was established in Pennsylvania in 2007 to address the cognitive, physical, socio-emotional, and behavioral impairments that impact students’ classroom performance.

In 2016, BrainSTEPS Colorado also implemented the program, which is considered “a national model for brain injury educational consulting.” The program comprises 30 statewide consulting teams that include education professionals, medical rehabilitation professionals, and family members.

Beyond providing brain injury presentations, BrainSTEPS teams consult with schools regarding identification, return-to-learn plans, intervention selection and implementation, long-term monitoring of students for any new symptoms, and other issues that professionals face in supporting students with brain injuries. Students in PA or CO can submit a referral to the BrainSTEPS Program on their website, where adults can become consultation team members.

Sports

TE Jordan Reed retires from the NFL after a career plagued with concussions

NFL tight end Jordan Reed is officially retiring after seven seasons, stating that his multiple concussions inhibit his ability to play at the necessary level of the league, according to an article in Yahoo! Sports. Reed has seven documented concussions across his career, with several others from his time at the University of Florida. He cites his last concussion, suffered during a preseason game, as the final factor in his decision to retire from football. The toll of concussions and ongoing symptoms like blurry vision made Reed realize that “something wasn’t right.”

Now, Reed plans to seek professional help and focus on life after football. In an interview with USA Today, Reed comments that unless the rules of the game evolved, he would not allow his son to play football “because it’s dangerous.” Although Reed allowed that he has no regrets about his football career, his decision to stop was motivated by a desire to stay healthy enough to be there for his family.

By doing this, Reed provides a valuable model to football players and athletes who have suffered multiple concussions. He promotes the idea that athletes need to acknowledge what life will be like after their athletic career ends and potentially stop playing to protect themselves.

Cannabis & Psychedelics

New psychedelic research division at UCSF

The University of California, San Francisco, recently formed a Neuroscape Psychedelics Division, with the aid of $6.4M in private funding, to advance psychedelics research, according to a UCSF press release. The goal of the new division is to “integrate cutting-edge neuroscience technology with psychedelics treatment” to improve understanding of how psychedelic therapy can be more personalized. The division plans to “focus on the contextual elements that shape a patient’s experience” before, during, and after treatment to deliver patients optimal treatment.

Although this research is not concussion-specific, many post-concussion individuals suffer from mental health issues, including depression, PTSD, and anxiety. Psychedelics may be a powerful clinical tool to help treat mental health conditions in patients with persistent post-concussion symptoms.

Diagnostics

In-vivo imaging of young athletes with PCS and repeated concussions shows increased tau aggregation and neuroinflammation

A Swedish-based study published in NeuroImage: Clinical used recently-developed positron emission tomography (PET) tau-tracers to evaluate neuroinflammation and tau aggregation in young, symptomatic athletes with repeated sports-related concussion (rSRC) or moderate-to-severe traumatic brain injuries (TBI). This is the first such study to examine such young athletes (mean age 25-27) in vivo.

Authors Niklas Marklund et al. evaluated 12 symptomatic athletes with at least three SRC who were anywhere from six months to a decade from their most recent concussion. The rSRC athletes all had relatively high SCAT3 and symptoms scores, and met the most recent diagnostic criteria for Post-Concussion Syndrome. Alongside this cohort, the authors included 9 healthy controls and 6 TBI patients.

The rSRC and TBI cohorts both “had increased tau aggregation and neuroinflammation/microglial activation,” and increased concentrations of neurofilament light chain (NF-L) levels. Both tau and NF-L levels have shown correlations with increased risk for neurodegenerative disease, though the nuances of these relationships are still under study. The breadth of the time range since injury supports the theory that repeated concussions can lead to “persistent pathology.” However, past autopsy findings of young athletes showed delayed tau aggregation, implying that a prolonged injury process is required for tau aggregation.

The rSRC and TBI cohorts were distinct in their levels of these markers. Particularly, rSRC subjects showed less neuroinflammation than TBI subjects, while TBI subjects showed evidence of widespread white matter injury on MRI not present in rSRC subjects. The authors suggested follow-up imaging to determine if the tau aggregation observed in their study is progressive and further study to help differentiate the number of injuries, injury severity, and time since last injury.

Self-care

Tips and tools for coping with fatigue after brain injury

Fatigue is a relatively common symptom after a concussion. Two nonprofits have information and tools to help cope.

Brainline recently highlighted the PaceMyDay app, part of a suite of four apps created by the nonprofit BEST (Brain Education Strategies Technology). The founder of BEST, Michelle Ranae Wild, explains in this video how PaceMyDay helps you monitor and adjust your energy consumption and “then adjust your actions so that you can avoid becoming run down or in physical pain.” In a second video, Kristi Kragthorpe explains how PaceMyDay has been helpful to her. The suite of BEST apps (which includes PaceMyDay) costs $14.99. For each app, you can access a free training video.

Headway has information about fatigue on their website, which we covered in the self-care section of our 10/1/20 newsletter. Also, we recommend Headway’s overview on fatigue, which includes tips on coping, tips for a good night’s sleep, and hormonal imbalances. If you are interested in further information about hormonal balances, see our interview with Dr. Tamara Wexler, and join us in Clubhouse on 4/30 for a discussion with Dr. Wexler (see the Opportunities section). Also, see our page on Cognitive Behavioral Therapy, which Headway suggests as a tool to address fatigue.

Although a somewhat older article, it’s worth reading Brainline’s interview with Concussion Alliance Professional Advisory Board member Dr. Nathan Zasler about fatigue after brain injury.

Therapies Currently Available

Study finds that compliance with aerobic exercise recommendations is important for concussion recovery and associated with fewer symptoms

A study conducted by David R. Howell et al. found that greater adherence to physicians’ aerobic exercise recommendations was associated with fewer post-concussion symptoms one month after the start of treatment. The study, published in The American Journal of Sports Medicine, included 37 participants (ages 14-21). The authors randomly assigned participants who either received a specific, individualized exercise prescription or were told to comply with the activity level recommended by their physician (standard-of-care). The group receiving individual aerobic exercise prescriptions were instructed to “exercise 5 d/wk, 20 min/d (100 min/wk), at a target heart rate based on an exercise test at the initial visit.”

There were no significant differences in symptom levels between the individualized intervention group and the standard-of-care group at all follow-up evaluations. The researchers reported low compliance in both groups and that “exercise volume was similar between groups.” However, the authors found that those who exercised for at least 100 minutes per week during the first month of the study reported significantly lower symptom scores than those who exercised for less than 100 minutes per week. Moreover, exercising for at least 160 minutes per week was associated with symptom resolution one month after the start of treatment.

Overall, these findings suggest that further research addressing compliance with aerobic exercise recommendations, rather than the specific recommendations themselves, may be crucial for improving post-concussion outcomes. Regarding limitations of the study, the authors note that “it is possible that participants who were feeling better were more likely to exercise more, rather than the exercise itself driving the reduction in symptom severity.”

Therapies Under Research

New understanding of SARM1, the key protein in axon degeneration, may inform therapeutic drug design

Axon degeneration is a natural “self-destruct” mechanism that axons enter when damaged by mechanical injury or disease. As such, it is a key pathological feature of mTBI, as well as other neurodegenerative diseases such as Alzheimer’s and ALS. Previous research has shown that the protein SARM1 acts as the central executioner of the axonal degeneration pathway, making it an attractive therapeutic drug target. However, more work was needed to fully understand SARM1’s structure.

A study by Matthew Figley et al., published in Neuron, set out to analyze SARM1 with a variety of structural, biochemical, biophysical, and cellular assays. They successfully discerned SARM1’s 3D structure with the techniques of x-ray crystallography and cryo-electron microscopy. The researchers also discovered that SARM1 is sensitive to the ratio of nicotinamide mononucleotide (NMN) to Nicotinamide adenine dinucleotide (NAD+). As the ratio of NMN to NAD+ increases, the SARM1 protein activates. They also report that SARM1’s three-dimensional structure changes when bound to NMN and that this binding is necessary for injury-induced axon destruction.

With a better understanding of the structure and function of SARM1, the research team hopes their findings will inform future therapeutic drug design.

Youth

“Fewer symptoms and better quality of life” with collaborative care

A study found that collaborative care was more effective than standard care for youth with persistent post-concussion symptoms. Carolyn A McCarty et al. enrolled 200 patients aged 11 to 18 who had been diagnosed with sports or recreation-related concussion within the past nine months and still had at least three symptoms persisting one month after injury. The authors randomly assigned half the group to six months of collaborative care, which involved “cognitive behavioral therapy and care management, delivered mostly through telehealth.” The other half of the group received usual care at specialty clinics.

At three months, the adolescents in collaborative care “reported significant improvements in Health Behavior Inventory scores compared with usual care.” At twelve months, those receiving collaborative care reported better quality of life, as measured by the Pediatric Quality of Life Inventory. There was no difference between the groups in terms of parent-reported outcomes of adolescent depression and anxiety. The study was published in JAMA Network Open.

Neurodegeneration Issues

Loss of consciousness head injuries (in middle age or younger) associated with reduced cognitive function and brain volume in aged population

A 2021 study by Sarah-Naomi James and colleagues analyzes the association between head injury aging, cerebral abnormalities, and subtle cognitive deficits (in dementia-free individuals) later in life. The authors recruited a sample size of 502 participants, aged 69-71 from the 1946 British Birth Cohort. From this cohort, 104 (21%) participants reported a head injury with loss of consciousness (LOC) throughout their life. The researchers categorized participants by whether they had experienced a LOC >15 years before the study (80 participants, 16%) or experienced a LOC at any point. The study protocol required that participants undergo a brain scan and cognitive testing to measure cerebral pathology and cognitive function, respectively.

As a cohort, participants who sustained a head injury with loss of consciousness displayed lower scores on cognitive tests when compared to participants who had not suffered a head injury during their lifetime. However, James and colleagues identified that when the head injury occurred influenced the injury’s effect on cognition. Specifically, the authors found that participants who had a head injury with LOC >15 years prior to the study, “when participants were aged 53 or younger,” demonstrated cognitive function that was less “than expected based on known predictors of later‐life cognition such as their childhood cognitive performance.” This decline in cognitive function manifested in measures of speed, motor skills, and attention. Those who experienced a LOC head within 15 years of the study did not demonstrate a decline in cognitive function.

Finally, while there was no indication of elevated amyloid-beta (Aβ) plaque build-up in participants who sustained a head injury with LOC, participants diagnosed with a head injury with LOC >15 years before the study displayed lower brain volume and worse microstructural integrity, which might partly explain the lower cognitive scores.

Overall, James and colleagues’ study results strongly suggest that LOC head injuries “aged 50’s or earlier” are associated with decreased cognitive function and reduced brain volume later in life. The authors note that “Growing research provides evidence that greater time since injury is associated with greater cognitive decline and older brain aging, suggesting that [head injury] accelerates brain atrophy and cognitive decline aging trajectories.” The study was published in Annals of Clinical and Translational Neurology.