Headache treatment algorithm; veterans’ adventure programs (5/27/21 newsletter)

May 27

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, Rainey Tilley, and Josh Wu.

Editors: Conor Gormally and Malayka Gormally.

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Opportunities

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

June 3, 6 pm PST: Brain Anatomy, presented by Robert Burke, DPT, hosted by the Brain Injury Alliance of WA State (BIAWA). Free; register in advance.

June 8, 6 pm EST: Whiplash and Spinal Cord Injuries, with Dr. Eric Massicotte, presented by the Canadian Concussion Centre. Free; register in advance.

June 10, 10:30 am PST: Modified Gentle Yoga for Brain Injury, hosted by BIAWA. Register in advance.

Education

Two new CDC initiatives; free online training for pediatric healthcare providers, and an injury prevention campaign for older adults

The CDC has a new, free online training for healthcare providers “to improve the care of your pediatric patients with mTBI,” with separate versions for clinicians, school health providers (such as school nurses), and allied health professionals. The goal of the HEADSUP to Healthcare Providers training is to provide “an overview of the evidence-based recommendations outlined in the CDC Pediatric mTBI Guideline and to equip healthcare providers with practical strategies to integrate these recommendations into clinical practice.” Those who complete the training receive 2 CEU credits through the American Academy of Pediatrics.

An article in the Oakdale Leader highlights the CDC launch of a national campaign, Still Going Strong, to help older adults “age without injury.” The campaign is geared towards adults 65 and older and their caregivers, plus information for healthcare providers. The campaign includes education for “common risk factors for brain injuries that happen after falls and motor vehicle accidents.” The campaign also includes simple steps to prevent injury and maintain independence. An article in The Advocate details the CDC tips for elders to prevent injuries from falls.

Sports

Concussion Spotters Will be at The World Cup

A recent article published in The Guardian states that the 2022 Fifa World Cup has announced a plan to use concussion spotters to identify potential brain injuries during World Cup games. This is unprecedented news for one of the most popular sporting events globally, yet it shows how far behind soccer governing bodies are in bettering player safety. Other sports like rugby and football already have concussion spotters in place, while the Fifa World Cup has lacked player safety procedures.

The games will also have video replays for the medical staff to review for concussions, stationed away from the team dugout to avoid distractions. FIFA trialed these new safety measures in their Club World Cup and is ready to put them into action to prioritize the safety and health of the players. This plan also detaches the health officials and concussion spotters from the heat of the moment or team biases, as they will be in separate spaces. While removing players from important soccer games will always remain a heart-wrenching task, creating a more objective environment for medical staff to watch for injuries protects the beautiful game in the long run.

Self-care

Brain injury support group in Teton Valley, Idaho; open to attendees from out of state

The Teton Valley News recently covered a brain injury support group established by Sarah Johnson and Kelly Sadauckas in Teton Valley, Idaho. Johnson (a brain injury survivor) and Sadaukas (a physical therapist who works with patients experiencing post-concussion syndrome) hope to bring more support to people experiencing the effects of brain injury. Resources like this one are vital, as “residents in rural states like Idaho are at a higher risk for TBI because of limited access to and availability of healthcare.”

In addition to this support group, Sadauckas states that she has seen growing awareness of concussions and brain injury in Teton Valley. She has received more referrals through patients reporting post-concussion-like symptoms at annual check-ups.

Although Johnson recognizes that the pandemic slowed the growth of the support group, one benefit of the online format is that geographical location is not a barrier to being part of the group. The group meets virtually (on Zoom) at 6 p.m. on the third Thursday of each month. The article mentions that you can email Johnson at tbidriggs@gmail.com to receive a meeting invite.

Therapies Currently Available

New study highlights the need for increase in post-traumatic headache research

A review article by Håkan Ashina, MD, et al. aims to establish a contemporary paradigm for post-traumatic headache (PTH) classification and treatment, and proposes a “treatment algorithm based on expert opinion due to the scarcity of data from clinical trials.” The review, published in Lancet Neurology, provides a “comprehensive overview of the classification, clinical characteristics, and management” of PTH.

In a Q&A with Healio, Ashina explains that the most common current treatment for acute, chronic, and persistent PTH involves acute and preventive medications developed for treating migraines and tension-type headaches – the two most common headache types that PTH can resemble. Because of the relative speed at which this kind of PTH can become chronic (weeks or months as opposed to years or decades with migraines), Ashina et al. classify TBI-induced PTH as a “highly disabling neurologic disorder.”

The authors assert the need for epidemiological studies to better-understand the prevalence of PTH at differing times in patients’ recovery from the original injury. These kinds of prospective studies are particularly vital, as “people with PTH often report other post-concussive symptoms as well, such as sleep disturbances, concentration difficulties, anxiety and depression.”

See Headaches and Headaches: Advanced Page (on our website) for descriptions and diagrams of the different headache types and treatment modalities.

Therapies Under Research

PolarCap with circulating cool fluid shows promising clinical results; company applies to FDA for approval

After the publication of promising clinical results in the journal Concussion, PolarCool, a Swedish medical device company, has "has submitted a 510(k) pre-market notification to the U.S. Food and Drug Administration (FDA) for the PolarCap® System," according to a press release. Martin Waleij, PolarCool Chairman of the Board, believes that "With this important FDA submission, we are paving the way for the first-ever sports-related TBI treatment model...our 510(k) submission is the first step in the FDA review process."

Anna Gard et al. studied 15 Swedish pro ice hockey teams; 29 players who suffered a concussion received immediate treatment with the portable cooling system, and 52 concussed players received standard concussion management. Players treated with the PolarCap system returned to play sooner (7 vs. 12.5 days) and were less likely to have an extended recovery (7% vs. 25% were out of play more than three weeks). Limitations of the study include that the selection of teams was not randomized, and the researchers did not have a way to include a sham treatment in the study.

According to the PolarCool website, "the PolarCap System is intended to reduce brain temperature to prevent or limit long term cognitive impairment after brain trauma." The website has a video animation of the product in use; "The cold circulating fluid enters the polar cap system and reduces the brain temperature. Cooling reduces the brain's metabolic demand; the procedure takes 45-60 minutes."

Veterans and Service Members

Nonprofit website helps veterans connect with free adventure programs

A nonprofit called US Vet Connect helps veterans connect with 175 unique, free adventure programs across the country geared towards helping service members. The mission of US Vet Connect is “to raise awareness for organizations that have a direct impact on veterans’ lives and to make it as user friendly as possible for the veterans to find their next adventure.”

US Vet Connect lists programs by type of adventure, and you can also search for programs near you using the map feature. For example, if you click on Equine-Horses, you’ll find equine therapies in 24 states, with links to each program.

The adventure categories include Archery, Art, ATV, Cycling, Equine-Horses, Fishing & On the Water, Golf & Disc Golf, Hiking & Mountaineering, Homesteading, Hunting & Shooting, Martial Arts, Motorcycles, Music, Retreats, Scuba Diving, Service Dogs, Winter Sports, and Yoga.

Mental Health

Study finds that about one-third of children struggle with mental health problems following a concussion

A review and meta-analysis conducted by Alice Gornall et al. found that roughly a third of children deal with mental health problems following a concussion. The review, published in the British Journal of Sports Medicine, examined 69 studies published between 1980 and 2020, including data from 89,114 children who sustained a concussion.

Among children who sustained a concussion, up to 36.7 percent experienced internalizing mental health problems such as anxiety and depression. Up to 20 percent experienced externalizing mental health problems such as aggression and hyperactivity. These rates were significantly higher than those of children who had not sustained a concussion.

Regarding the findings, one of the authors, Vicki Anderson, in an article for The Hill, suggested that “concussion may both precipitate and exacerbate mental health difficulties, impacting delayed recovery and psychosocial outcomes.” In turn, she stressed the importance of incorporating mental health assessment and intervention into concussion care, arguing that it “represents an opportunity to engage children and adolescents with mental health services to either prevent unnecessary problems emerging or to treat already existing issues.”

Youth

1 in 4 U.S. teenagers has had a concussion

In a study published in the Journal of the American Medical Association, researchers at the University of Michigan found that 1 in 4 adolescents self-reported at least one concussion in their lifetime in a 2020 survey. This new data marks a 20% increase from the authors’ previous (2016) study’s findings of at least one lifetime concussion in 1 in 5 adolescents. The results came from the 2016-2020 Monitoring The Future initiative that studied nearly 53,000 8th, 10th, and 12th graders. About half of the students were girls, 45% were white, 12% African American, 21% Hispanic, and 23% other (including Asian American, Native American or Alaska Native, and Native Hawaiin or Pacific Islander).

“Self-reported concussion did not increase among adolescents who did not participate in sports,” said co-author of the study Philip Veliz, assistant research professor at the U-M School of Nursing for Michigan News. “One reason that adolescents who participate in sports saw an increase in self-reported concussion could be due to greater awareness of these types of injuries within sporting contexts. This type of information among nonparticipants may be limited given that they are not participating in activities that are susceptible to these types of injuries.”

Veliz said that he was surprised by increased reporting among Hispanic, non-Hispanic other, and non-Hispanic Black youth despite these groups’ history of lower prevalence of self-reporting concussions than non-Hispanic white adolescents. The increase in concussion self-reporting for students who participate in competitive sports contrasts with 2012-2018 emergency department data that showed a decrease in sports and recreation-related traumatic brain injuries among youth. Veliz said more adolescents might be seeking care from health professionals who have appropriate diagnosis and management skills outside of the emergency department.

Women's Health

21 women write about the ramifications of concussion on their lives

A new book, Impact: Women Writing After Concussion, edited by Jane Cawthorne, will be published on September 15 and is currently available for pre-order. On her website, Jane Cawthorne writes:

“In Impact, 21 women writers consider the ramifications of concussion on their personal and professional lives. The anthology bears witness to the painstaking work that goes into redefining identity and regaining creative practice after a traumatic event. By sharing their complex, non-linear, and sometimes incomplete healing journeys, these women convey the magnitude of a disability which is often doubted, overlooked, and trivialized, in part because of its invisibility. Showcasing a diversity of women’s stories, Impact offers compassion and empathy to all readers and families healing from concussion and other types of trauma.”

Impact: Women Writing After Concussion was listed in “Forthcoming Titles in Science & Technology, 2021” on Choice, “a publishing unit of the Association of College and Research Libraries, a division of the American Library Association.”

CTE and Neurodegeneration

Some learning and cognition issues after repetitive impact could be treatable & not analogous to CTE process

An article in The Age, “It Gives Hope to Athletes,” discusses the positive implications of a study by Stephanie S. Sloley et al., published in Nature Communications. The study found that symptoms of repetitive head impacts, such as learning and memory impairment, may be linked to chronic synaptic adaptation (rather than CTE) and may one day be treatable with the use of specific drugs.

According to one of the study authors, Dr. Bevan Main, “We have identified a pathway by which non-damaging, but high-frequency brain impact blunts normal brain function and causes long-term problems with learning and memory. This pathway is independent of the main feature of CTE - the build-up of a protein called tau.”

In a press release by Georgetown University, senior investigator Mark Burns said that “Our goal was to understand how the brain changes in response to the low-level head impacts that many young football players, for example, are regularly experiencing.” The researchers found that while the synaptic pathways were intact, “the way that they communicated using glutamate was blunted, repressed...We believe that the brain is adapting to the repeated bursts of glutamate caused by high-frequency head impact, and dampens its normal response to glutamate, perhaps as a way to protect the neurons.”

When researchers gave the mice a drug (an FDA-approved Alzheimer’s medication) that blocks glutamate before exposing them to high-frequency mild head impacts, they did not develop synaptic adaptation or cognitive problems.