COVID-19 and TBI (5/13/21 newsletter)

May 20

Written By Concussion Alliance

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

Writers: Will Altaweel, Conor Gormally, Malayka Gormally, Mack Hancock, Trinh Tieu, and Elliot Yim.

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

COVID-19 and You, and other events

May 18, 6:30 pm EST: Attend a free, virtual brain injury-friendly merengue dance class hosted by the Brain Injury Society of Toronto. Register in advance; click on "Latin Night with BIST."

May 19, 1 pm PST: Covid 19 & You: The Neurologic, Cognitive and Social Effects of Covid-19, a free educational webinar on "the effects of COVID-19 and how they relate to TBI." The presentation will also “explore the neurological, cognitive, and social effects of COVID-19, as well as vaccine safety, concerns, and benefits.” The webinar, hosted by the Brain Injury Alliance of WA State, will feature Dr. Aaron Bunnell, Assistant Professor, Department of Rehabilitation Medicine, University of Washington (UW). Dr. Bunnell is the founder of the Post-COVID Rehabilitation and Recovery Clinic at UW. Register in advance.

May 21, 8:30 am to 4:15 pm PST: Childhood Brain Injury: Best Practices in Return to School, a free virtual conference. See our Education section for more information.

May 25, 3 pm PST: Free webinar about headaches with Dr. Marie Slegr, presented by the Canadian Concussion Centre. Register in advance.

June 2-3: Brain Injury Canada Conference: Navigating the Landscape of Brain Injury. A two-day conference for health care providers. The two-day conference costs $119.

Education

Return to School virtual conference

A free virtual conference, Childhood Brain Injury: Best Practices in Return to School, will be held on Friday, May 21. The Center on Brain Injury Research and Training will host the conference; the center is affiliated with the Department of Psychology at the University of Oregon. The conference runs from 8:30 am to 4:15 pm PST and includes presentations and breakout discussion rooms. The conference brochure has speaker bios; register in advance.

Presentations include:

Creating a Successful Support Network at School for Students with Brain Injury
CDC Perspective: Gaps in School Services and Strategies for Improvement
Teacher Panel: Perspectives from the Front Line
Longitudinal Qualitative Study on Return to School: Implications for School Services
Best Practices in Return to School
Return to School Models that Show Promise
Evaluation of RTS models: Brain STEPS and Central Oregon TBI models

Sports

Study finds that brain abnormalities may persist beyond symptom resolution following a sports-related concussion

A study conducted by David K. Wright et al. found that white matter changes persisted beyond symptom resolution in athletes who sustained a sports-related concussion (SRC). The study, published in Cerebral Cortex, included 30 participants. The authors compared diffusion-weighted magnetic resonance imaging (dMRI) scans of 14 athletes who sustained an SRC with 16 age and education-matched control participants. Participants received a dMRI 24-48 hours following the concussion and another dMRI two weeks later.

Relative to control participants, athletes who sustained an SRC showed significant differences in several measures of white matter fiber bundles, including increased fiber density, increased fractional anisotropy, and decreased apparent diffusion coefficients. These differences were still evident in the second dMRI scan, even though most SRC participants were no longer symptomatic and received clearance to return to play.

The authors note “sex-specific differences, with male SRC athletes having significantly greater white matter disruption compared with female SRC athletes.”

These persistent differences suggest that brain abnormalities resulting from an SRC may last beyond the resolution of symptoms. This finding may have important implications for concussion care, particularly regarding return-to-play timelines.

Diagnostics

Visio-vestibular examinations improve concussion detection in adolescent athletes

The Minds Matter Concussion Program research team at Children’s Hospital of Philadelphia (CHOP) conducted a series of studies that evaluated the use of Visio-Vestibular Examination (VVE) to diagnose concussions and manage treatment. According to a CHOP press release, the studies conducted in the past few years build on previous research showing that children who receive a VVE in their initial evaluation are more likely to receive a concussion diagnosis, leading to improved outcomes.

The Visio-Vestibular Examination (VVE) is a battery of clinical assessments used to support the diagnosis of concussions. The different exams identify visual and vestibular deficits that can indicate a concussion after a head injury. The team's most recent study, published in the Clinical Journal of Sports Medicine, examined 69 adolescent athletes with concussions and 69 without from a suburban high school and academic pediatric tertiary care center.

The researchers aimed to determine the optimal number of repetitions required in the saccades and gaze stability test to find a significant difference between the two groups. By increasing the number of test repetitions, they created a more demanding or rigorous task that could more clearly and accurately detect visio-vestibular deficits in concussed youth. The findings suggest that a higher threshold level of 20 repetitions of the test enables clinicians to more accurately diagnose youth concussions in settings beyond sports medicine.

Self-care

Supplements for the preventative management of epilepsy caused by mTBI

Research is finding that mild traumatic brain injury increases the risk for epilepsy, especially in females. For those who do have post-concussion epilepsy, prophylactic, or preventative management of epilepsy may include taking magnesium oxide and Vitamin B2 (Riboflavin). These are the two supplements listed, with dosing information and precautions, under Prophylactic Migraine Medications (page 89) in the Veterans Affairs / Department of Defence Guideline for Management of Concussion-Mild Traumatic Brain Injury.

Therapies Currently Available

Subthreshold aerobic activity is beneficial in the chronic phase post-concussion, as well as the acute phase

Kathryn M. Carter et al. performed a systematic review and meta-analysis of current research on active rehabilitation for concussion management and recovery. The analysis, published online ahead of print in Medicine & Science in Sports & Exercise, examined 23 articles that studied “a total of 2547 concussed participants aged 8-53 (49% females, 50% males).” Of these studies, 14 looked at children and adolescents, while 8 focused on adults. The study participants also varied in the time since injury, with Carter et al. including articles with patients in both acute (<2 weeks) and chronic (>2 weeks) phases of concussion.

While Concussion Alliance has previously reported on systematic review and meta-analyses of the effectiveness of exercise and activity on acute concussion, this article found large, positive, statistically significant effects, “indicating that every study showed improved concussion symptom scores with a physical activity intervention.” The positivity and statistical significance of this effect were true for sport-related and non-sport-related concussion, in both acute and chronic phases.

This meta-analysis is groundbreaking in identifying that “subthreshold aerobic activity is beneficial for [post-concussion symptom] recovery regardless of the time since injury (≤ 2 weeks or > 2 weeks post-injury),” and that “the potential benefits of physical activity are not limited to a particular sub-population of concussion patients or by the symptom assessment tool.” While the authors mention several limitations in performing a systematic analysis across studies with different structures and interventions, they identified that “subthreshold aerobic activity may be the best mode of physical activity to prescribe for PCS recovery.” See our page on Graduated Exercise Therapy for more information.

Mental Health

TBI changes sensory sensitivity, which may lead to TBI-PTSD comorbidity

Research published in Scientific Reports sheds new light on the relationship between traumatic brain injury (TBI) and PTSD. Researchers Hoffman et al. found evidence that increased sensory sensitivity after TBI may lead to TBI-PTSD comorbidity. The researchers used rat models of brain and emotional trauma.

The study found “an interaction between auditory sensitivity after TBI and fear conditioning.” Further, fluid percussion injury (FPI, an experimental model of TBI) “makes white noise in and of itself aversive.” Animals that were given an FPI and then exposed to 75 dB of white noise exhibited phonophobia characteristics. When the white noise was paired with electric shocks, “fear is robustly enhanced.”

The authors investigated “how the injured brain responds differently to white noise.” In terms of brain region activity, exposure to white noise after an FPI in animals caused increased activity in the amygdala (which processes fear and pain) and decreased activity in the hippocampus (which plays a role in learning and memory).

Overall, the study contributes to research aiming to elucidate the “neurobiological interactions between comorbid TBI and PTSD.” Note that the study did not clarify what level of TBI (or FPI) the rats were given; presumably, the injury was a moderate to severe TBI.

Statistics

Increasing knowledge of concussion induced balance deficits in community-dwelling adults

A Toronto concussion study by Michelle Sweeny et al. performed a cross-sectional analysis of balance deficits following acute concussion in older adults not living in nursing homes. Balance deficits are often impaired following a concussion, increasing the difficulty of engaging in activities of daily living. Sweeny et al. note that this analysis is critical due to differences in "socioeconomic status, level of education, mechanism of injury, and recovery trajectory," leading to difficulties in analyzing acute concussions in this population.

Balance and dizziness are common symptoms associated with acute concussion patients. Instrumental measures can be helpful in further analyzing the origin of the balance problem and the mechanisms involved. Several instrumental techniques are used to measure balance in acute concussion patients, including the Balance Error Scoring System (BESS). This type of test can identify the "physical manifestation" of balance-related symptoms. Another technique used is the "characteristics of the force-plate derived center-of-pressure” (COP), which classifies balance issues.

The study was able to see increased errors in the BESS measurements of acute concussion patients, as well as deficits of the COP during quiet standing. When comparing the results of the BESS and CHOP tests, the authors found that the "measures do not align with self-reported balance symptoms." With this in mind, symptoms reported by the patients should not be the only tool used to diagnose or determine balance deficits. The optimal way to diagnose patients is to use self-reported symptoms along with more measurable diagnostics. The study was published in Brain Injury.

Women's Health

Female adolescent soccer players have almost double the concussion risk of males

Abigail C. Bretzin et al. researched injury outcomes in adolescent soccer players from Michigan by gender, mechanism of injury, injury management, and outcome. The study found that adolescent girls had 1.88 times the risk of sports-related concussion (SRC) of boys and that the mechanism for the injury was different between girls and boys.

There were three key takeaway points from this study that was published in JAMA Open Network. The higher incidence of SCR in girls than in boys is in line with previous research findings that female high school soccer players have approximately a 60% to 80% higher risk of concussion than boys. (See this 2020 study and this 2018 study.) Secondly, the mechanism of concussion most commonly reported by boys was a collision with other players, whereas girls reported it to be a collision with an object (such as the ball or goal post).

The third takeaway is in differences in the manner of concussion management. In most cases, “boys had a 54% greater odds of immediate removal from play” than girls. This difference may be attributed to the concussion mechanism; a possible concussion from direct contact with another player is more evident than one due to a collision with an object. The study also found that girls take an average of about two days longer than boys to return to play.

This study gives weight to the fact that a sex-related difference exists for the risk of concussions – more research needs to investigate why female athletes seem to possess a higher risk. An article in the BBC News highlighted the higher risk to girls and reported that the UK has stopped introducing heading a football until after age eleven.

Lead study author Dr. Willie Stewart commented that “we need to think less about collisions and more about contact because girls are told to sit out less than boys.” One other intriguing fact from this study was that the presence of an athletic trainer led to a threefold higher likelihood of recognizing a concussion and removing the player from the game. Young athletes, especially girls, will highly benefit from these considerations and ideally have better average outcomes than they currently experience.