Birth control pills as an RX for female concussion? (6/10/21 newsletter)

Jun 12

We are excited to announce that our summer 2021 Concussion Education & Advocacy Internship Program is starting next week! The interns are excited to write for the next edition of this newsletter.

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 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

June 7–July 30: A free MOOC (Massive Open Online course), Understanding Traumatic Brain Injury will address mild, moderate, and severe TBI. The course is produced by the University of Tasmania and requires approximately two hours per week; they provide a certificate at completion.

June 21, 10:30 am PST: Strength-Based and Person-Centered Goal Setting, a free online class by Anita Chin, Certified Life Coach. Presented by the Brain Injury Alliance of WA State (BIAWA); register in advance.

June 22, 1 pm PST: Navigating Grief and Loss in Your Relationship pt 2, a free online class by Peach Jack, MA. Presented by BIAWA; register in advance.

June 22, 6 pm EST: Journey to Recovery, with Dr. Apameh Tarazi, presented by the Canadian Concussion Centre. Free; register in advance.

Education

Updated pediatric concussion guidelines for healthcare professionals

The Living Guideline For Diagnosing and Managing Pediatric Concussion, produced by a team of professionals in Ontario under the auspices of the Ontario Neurotrauma Foundation, provides healthcare providers with up-to-date and comprehensive information regarding initial medical assessment and follow-up, managing concussion symptoms, and biomarkers. The guidelines are written for healthcare professionals, but the group also recommends that parents bring the guidelines to the attention of their child’s healthcare provider. A study by Paniccia et al. published in the Journal of Concussion reevaluated these guidelines to inform the 2020 update.

Using the Appraisal Guidelines for Research and Evaluation II (AGREE II) evaluation tool and a survey, the researchers updated the previous clinical practice guidelines to reflect new developments in science and promote their implementation by pediatricians. The current study employed the integrated knowledge transition (iKT) approach, so participants composed of researchers, physicians, allied health professionals, policymakers, educators, and knowledge translation experts were recruited for their experience and expertise.

Results showed that appraisers scored or rated editorial independence and scope and purpose domains the highest, indicating high quality for the existing guidelines. However, applicability was the lowest domain, suggesting further updates and revisions need to be made to clarify who should use the tools provided and how to interpret their results. Overall, the study evaluating the 2014 guidelines identified areas that needed improvement, shared and informed decisions about the content and format, and targeted content, clinical questions, and dissemination strategies that are key to clinical uptake.

The ONF’s guidelines have since been updated in 2020 and can be found online. The website includes a “Summary of New Evidence” that was incorporated into the updated guidelines.

Sports

Study finds that white college athletes have greater concussion symptom knowledge than their black peers

A study conducted by Jessica Wallace et al. found that White college athletes have greater knowledge of concussion symptoms than Black college athletes. The study, published in the Journal of Head Trauma Rehabilitation, included 768 NCAA athletes (82.6% White, 17.4% Black) who completed a scale measuring their concussion symptom knowledge.

On average, White athletes scored 1.8 points higher than Black athletes on the scale, indicating that White athletes have significantly more knowledge of concussion symptoms than their Black counterparts. White athletes were more likely than Black athletes to cite a school-based professional and the NCAA as a source of concussion information. In contrast, Black athletes were more likely than White athletes to cite referees as a source of concussion information.

Although the NCAA requires concussion education for all athletes, the disparity in concussion symptom knowledge between White and Black athletes nonetheless highlights the need for strategies that can help ensure equitable access to concussion education.

Self-care

Yoga, meditation, and mindfulness help depression, fatigue, more in chronic mTBI

Rebecca L. Acabchuk et al. performed “the first systematic review and meta-analysis of meditation, yoga, and mindfulness-based interventions for [mild traumatic brain injury] rehabilitation to evaluate the extent to which these interventions impact biopsychosocial outcomes related to chronic mTBI." The review, published in Applied Psychology: Health and Well-Being, includes 20 unique studies, totaling 539 participants. Only two studies included adolescent participants, with the others focusing on adults (mean age = 43). The duration of interventions varied significantly, from a single ten-minute mindfulness exercise to 32 weeks of regular interventions.

Interventions included "meditation (95%), breathing practices (90%), yoga (65%), and additional physical activity (35%)... including walking (k = 6), sport (k = 1), and QiGong movements (k = 1). When reported (k = 14), vigor level ranged from mild (k = 11) to varied (k = 3).” The authors found stronger pre/post-treatment effects when the studies had a control group, but treatment groups across all studies showed measurable improvements in mental health, cognitive performance, physical health, and self-appraised quality of life. Upon more in-depth statistical modeling, treatment group subjects only statistically significantly outperformed control subjects with regard to depression, fatigue, and general mental health categories.

The authors also highlight several limitations with the studies reviewed. Only one study intentionally recruited for repeated mTBI, which is associated with “greater symptom severity and duration.” None of the studies included looked specifically at adolescents, despite concerns about chronic mTBI in that population. Many of the studies also relied on self-reported improvements without object physiological measures or imaging analyses. None of the studies looked at subjects’ sleep, and only 25% of the studies included long-term follow-up.

The authors argue that their systematic review and meta-analysis show the ability of meditation, yoga, and mindfulness-based interventions to generate multifaceted improvements in the lives of people dealing with chronic mTBI. The authors hope that this review drives further research that addresses the aforementioned limitations and includes a more rigorous study of this treatments’ potential mechanistic pathways.

Therapies Currently Available

Physical therapy improves symptoms regardless of time since concussion

Physical therapy improved post-concussion symptoms regardless of "time elapsed between concussion and physical therapy" or months spent in treatment. The study, published in the Journal of Concussion, involved a retrospective chart review of 202 concussion patients referred to physical therapy. The patients were grouped based on the days (0-14, 15-30, 31-60, 61-120, or 121-365) between their concussion and commencing physical therapy and months spent in treatment (1-4). Researchers reviewed pre-and-post-treatment patients' scores on the Sport Concussion Assessment Tool (SCAT) plus testing for convergence insufficiency (vision), dizziness, balance, and others.

"Improvements were similar for all patients receiving post-concussive physical therapy, regardless of time between injury and treatment onset, and regardless of time spent in treatment." The study authors Rosemarie S Moser et al. suggest that the findings "may have implications for clinical decision-making and for third party payers' coverage of post-concussion treatment." Limitations of the study include lack of randomization and convenience sample and the fact that the research was retrospective.

Therapies Under Research

Promising preliminary results: photobiomodulation for persistent symptoms following a history of repetitive head impacts (also call for study participants)

An article in Desert News discussed ongoing clinical trials of photobiomodulation (PBM) to treat persistent symptoms following a history of repetitive head impacts–and the tragic story of a retired football player who did not make it into the study. The Department of Neurology at the University of Utah School of Medicine is running a series of clinical trials using the Vielight headset device to deliver near-infrared light to the brain every other day for 20 minutes.

Dr. Larry Carr, a former BYU football linebacker, participated in a PBM case study and experienced life-changing improvements (both subjective and objective) after suffering from CTE-like symptoms. Dr. Carr approached Dr. David Tate (a clinical neuropsychologist of international renown and co-director of the University of Utah’s Traumatic Brain Injury and Concussion Center), who launched a clinical trial of ex-collision athletes. The results for the first thirteen athletes showed “encouraging preliminary results,” which Dr. Tate recently presented to the Harvard neuroimaging faculty.

The study is recruiting an additional 50 ex-collisions athletes for the trial, which involves two trips to Salt Lake City for initial and then final testing after eight weeks, with an option to continue treatment long term. While focused on athletes, study participants also include a professional stuntman and a “woman who was the victim of domestic abuse.”

The researchers plan several additional studies, including “a study this upcoming football season involving 40 current BYU players,” to see if PBM can prevent “CTE-like damage.”

For more information, read our interview with Dr. Carr and our article on PBM. To inquire about participating in the study, contact Dr. Carr, 805-795-2452 or lrc067@hotmail.com.

Youth

New tool helps physicians and parents assess very young children for concussion

A study investigated the validity of a unique observational tool to assess for a concussion in infants, toddlers, and preschoolers; the device is designed for use in emergency departments and urban pediatric hospitals. Researchers Dominique Dupont, BSc et al., studied the tool Report on Early Childhood Traumatic Injury Observations & Symptoms (REACTIONS) that documents 17 postconcussive symptoms. Parents complete the assessment either in the acute, subacute, or persistent phase after mTBI.

A University of Montreal press release explains that "Pediatric traumatic brain injury (TBI) is particularly prevalent in toddlers; they're more likely to be injured because they have a lower sense of danger and are still developing physically. But parents and clinicians have trouble detecting symptoms of trauma, given the toddler's limited verbal skills."

University of Montreal neuropsychology professor Miriam Beauchamp, the study's principal author, developed the REACTIONS tool. The article notes that "post-concussion symptoms can easily be confused with behaviors typical of this developmental period."

The REACTIONS questionnaire "explains how symptoms can manifest in a young child" and asks questions about signs that parents can observe, such as increased comfort-seeking behavior or regression in behavior, such as loss of being potty-trained or no longer sleeping through the night. The study was published in the Journal of Head Trauma Rehabilitation.

Updated pediatric concussion guidelines for healthcare professionals. See our Education section (at the top of this newsletter) for information about the pediatric concussion guidelines.

Women's Health

Will birth control pills (progesterone) someday be prescribed for female athletes at risk for concussion, or who have suffered a concussion?

A preliminary study raises the intriguing possibility that prescribing progesterone (such as birth control pills) to female athletes at risk for a concussion or for those who have suffered a concussion may reduce the severity of symptoms. The study by Yufen Chen et al., published in the Journal of Neurotrauma, compared 30 female collegiate club athletes 3-10 days after an mTBI with a matched control group.

A Northwestern University press release interviewed Amy Herrold, PhD, one of the study authors. "Our findings suggest being in the luteal phase (right after ovulation) of the menstrual cycle when progesterone is highest — or being on contraceptives, which artificially increase progesterone — may mean athletes won't have as severe symptoms when they have a concussion injury...Clinicians also may want to evaluate wider use of hormonal contraceptives that raise progesterone levels for athletes who are at risk for incurring a concussion or mild TBI as there could be potential for neuroprotection."

The study is the first to reveal that "the physiological reason for the neural protection is increased blood flow to the brain [particularly in the left middle temporal gyrus] as a result of higher levels of progesterone." They discovered "a significant three-way relationship among progesterone, cerebral blood flow, and perceived stress score." Higher progesterone levels were associated with a lower (more normal) perceived stress score and higher (more normal) cerebral blood flow.

The researchers conclude that "These findings support a hypothesis for progesterone having a neuroprotective role after concussion" and they plan to do a larger study to see if the results can be replicated.

Culture

Prep football star and college recruit’s multiple concussions, and his battle with mental health

Bryce Gowdy, a Georgia Tech football recruit, planned to escape the homelessness that his family suffered from and become a Division 1 college football player at Georgia Tech. Unfortunately, this day would never come, due to Bryce’s battle with mental illness, according to a Washington Post article. The last message Bryce Gowdy sent on his phone was to his girlfriend, expressing how “stuck” he felt.

After leaving for a quick task and favor for his mother, Bryce found his way to nearby train tracks and took his own life. Although Bryce was buried before an autopsy was able to be done to determine if he was suffering from Chronic Traumatic Encephalopathy, Bryce was diagnosed with multiple concussions. While recovering from his first concussion at 11 years old, he developed depression; Byrce expressed to his mom that he did not “see the point in living anymore.” With Bryce’s mom having experienced mental illness herself, she immediately put Bryce into therapy in hopes of improving his mental state.

Bryce’s second diagnosed concussion (his mom suspects others) came during football training following his commitment to Georgia Tech. Bryce had immediate visible signs of a concussion following a hit to the head, including dizziness and instability. Bryce expressed his fear to his mom regarding his head trauma and having to start his senior football season but would not make this fear known to anyone else. Following this concussion, more visible signs of mental change consumed Bryce, including erratic behavior as well as anger over minor events; his mom said “he was definitely suicidal in the final month of his life.” The family had fallen into homelessness, the stress of which was likely a factor.

The erratic behavior was not normal for Bryce – following his death, these events made clear that he was suffering beyond what anyone should ever have to as a teen.

CTE and Neurodegeneration

Similar Neurodegeneration patterns between mild traumatic brain injuries and Alzheimer’s Disease

GeroScience recently published a study done by Kenneth A. Rostowsky & Andrei Irimia on the similarities of cognitive impairment between mild traumatic brain injury (mTBI) and Alzheimer’s (AD). This study discovered statistical similarities between subjects in a chronic stage of mTBI and AD as evidenced by the neurodegeneration of white matter and gray matter.

The study’s sample consisted of 33 mTBI subjects between 47-83 years old with clinical proof of chronic symptoms of mTBI and no history of dementia or other neurological diseases, 66 AD patients selected between the ages of 55-92 years old, and 81 healthy controls with no abnormal brain conditions ranging between 55-87 years. These participants were recruited by healthcare professionals “who had treated them as outpatients and who had referred them for further neurocognitive assessment, neurological treatment, and/or neuroimaging.”

The researchers tested the groups’ cortical thickness, mean fractional anisotropy, and cognitive abilities to determine the similarities of white matter and gray matter in their subjects’ brains. A low cortical thickness (cortical thinning) implies a degradation of gray matter in the brain, and low fractional anisotropy levels indicate damage to the white matter. The results showed that there were significant similarities in cortical thinning between mTBI and AD, mean fractional anisotropy in both mTBI and AD, and significantly different cortical thickness and mean fractional anisotropy between mTBI and AD.

However, the association between mTBI and AD does not imply causation. Furthermore, pre-existing medical conditions in geriatric patients could complicate the isolation of variables in the neurodegeneration of gray matter and white matter in the brain. Due to the older age of the patients in this study, the results may not apply to the young generation suffering from mTBI with chronic symptoms. Future studies should attempt to build upon this study and compare the neurological and neuropsychological consequences of mTBI and AD to further elucidate this relationship.