International Soccer Tournament Still Not Following Concussion Protocol (6/24/21 newsletter)

Jun 24

We are almost finished with the second week of our summer 2021 Concussion Education & Advocacy Internship Program! This year, our internship cohort consists of 18(!!) interns from 5(!!) different colleges, four in the US and one in Ireland. Because our cohort is larger this year, we'll be changing our newsletter for the next six weeks.

The next five newsletters will be released weekly to give all of our interns more opportunities to write. Half of the cohort has written synopses for this week's newsletters, and the other half is writing for next week's newsletter. Our interns are excited to start writing for our wonderful audience!

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

Writers: Lori Mae Yvette Calibuso Acob, Melissa Brown, Julia Brzac, Nathan Campbell, Emma Chin, Christine Hau, Wyatt Hill, Chelsea Ryan, and Elizabeth Zhao.

Editors: Conor Gormally and Malayka Gormally.

Pictured: These nine interns wrote this newsletter. Thank you!

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, produced by the University of Tasmania, will address mild, moderate, and severe TBI. The course requires approximately two hours per week; they provide a certificate at completion.

Sports

Benjamin Pavard’s recent injury sparks criticism of French Team and UEFA for not following new concussion charter

The Union of European Football Associations (UEFA) has recently made international headlines due to an incident in a June 15 match between France and Germany. Officials stopped the game in the 59th minute after French player Benjamin Pavard suffered an apparent brain injury from colliding with another player. However, after examination by medical staff, he returned to play two minutes later and remained in for the rest of the match. According to an article by The Athletic, French team doctors reported that Pavard did not lose consciousness, contradicting Pavard’s post-match interview, in which he stated he was “a little knocked out for 10 to 15 seconds.” (Concussion Alliance would like to note that fewer than 10% of concussions result in loss of consciousness.)

As The Guardian reported in a recent article, this occurred just less than a week after the 24 participating teams agreed upon a “concussion charter” that would improve and standardize protocols and baseline testing for players. Now, this agreement, as well as the UEFA and the French team, are under intense scrutiny following the incident. According to an SB Nation article, much of the fault lies with the league and its officials. Peter McGabe, CEO of Headway (a brain injury charity), opined that the referee might have worsened the situation, stating, “It appeared that the referee was attempting to speed up the medical team and usher them and the player off the pitch, rather than allowing them the time they needed to assess the seriousness of the injury.”

Additionally, FIFPRO, the international players union, condemned the decision to allow Pavard to continue to play and stated that the UEFA did not follow its own new concussion charter guidelines during the incident.

Fortunately, Pavard appears to be recovering well. He has been training with the rest of the French squad and is questionable to return for their next game.

Cannabis & Psychedelics

Phase II trials begin assessing new cannabidiol-based medication’s effectiveness in treating symptoms of PTSD and TBI

Galveston Daily News republished a press release that ANANDA Scientific Inc. and NYU Grossman School of Medicine began a clinical trial for the drug Nantheia. Nantheia is a cannabidiol-based medication with a proprietary delivery technology that enhances its effectiveness and shelf-life. These trials assess Nantheia’s effects on neurocognitive impairment in patients with Post-Traumatic Stress Disorder (PTSD) and those with both PTSD and traumatic brain injury (TBI) diagnoses. PTSD, which has associated neurocognitive impairment, has a US lifetime prevalence of 1.3–12.2%, with higher rates in populations with military combat experience. Additionally, 35% of veterans with combat experience have been diagnosed with TBI, often comorbid with PTSD.

PTSD, mild TBI, and TBI may result in neurocognitive impairment, for which there is no consistently effective medication. These Phase II trials operate under double-blind, randomized, placebo-controlled conditions with a sample of 120 patients, 50% of which have a history of both PTSD and mild TBI.

Diagnostics

Diffusion tensor imaging (DTI) proves a reliable biomarker in predicting cognitive impairment in patients with a history of concussions

A study conducted by Angelica C. Gonzalez et al. identified an association between diffusion tensor imaging (DTI) findings and Montreal Cognitive Assessment (MoCA) scores amongst patients with a history of concussion and persistent cognitive symptoms.

After analyzing the MoCA scores of fifty-three patients (19 females), researchers discovered that patients with low MoCA scores also had abnormal DTI variables of fractional anisotropy (FA) and mean diffusivity (MD).

The abnormally low FA values in the right frontal regions and high MD values in the right temporal regions reflect a “loss of integrity” in the right frontotemporal area of the brain. This region “has several brain structures that are critical for cognitive function,” including memory, attention, and visuospatial functions

DTI is an MRI technique that measures the motion of water within the brain’s white matter microstructure. The FA value measures the direction of water diffusion, telling us the degree of connectivity in the brain. MD measures the mean motion of water, helping to detect changes in white matter. The authors point out that their “DTI analysis reflects white as well as gray matter changes, as opposed to most previous studies that have analyzed only white matter changes.”

An important limitation of this study is other cognitive risk factors such as hypertension, hyperlipidemia, and diabetes. These factors are known to change white matter and may have played a role in the low MoCA scores. However, the study included young patients who didn’t have these risk factors, yet they experienced the same abnormal DTI values.

We anticipate that this research will increase our understanding of cognitive changes following a concussion and the possibilities of new interventions. The study was published in Frontiers in Neurology.

Self-care

Music therapy may improve executive functioning and reduce stress in traumatic brain injury patients

An article published by Krysalis Neuro Occupational Therapy points to music as a potential therapy aiding brain injury rehabilitation. The article quotes Anaya, who suffered a mild traumatic brain injury and is now a brain injury activist. Anaya found that listening to singing bowls helped. “There’s something about the low rumble and circular tones that I found very soothing and rhythmic...They certainly helped me to focus, calm my nervous system and sleep better!”

A systematic review and meta-analysis found that three months of music therapy significantly improved executive functioning in patients with traumatic brain injuries (TBIs) and increased grey matter volume, as measured using magnetic resonance imaging.

The significance of music therapy in alleviating TBI symptoms may also relate to stress. As framed by Saoirse Finn and Daisy Fancourt in a study published in Progress in Brain Research, “thirteen of 33 biomarkers tested were reported to change in response to listening to music. The most commonly analyzed biomarker was the stress hormone cortisol, with half of clinical studies demonstrating a stress-reducing effect of music listening. Blood glucose was [lowered] in response to music listening. Many of the other biomarkers analyzed are also part of biological stress pathways, which suggests that the primary way by which music listening affects us biologically is via modulations of stress response.”

While these studies aren’t specific to mild TBI, Concussion Alliance recognizes these findings may be relevant and of interest to our audience.

Therapies Under Research

Combination treatment administered in the ER linked to improved headache pain ratings

The standard of care in the ER is to provide a diagnosis of concussion and discharge the patient without treatment. A study published in Neurology found that patients who come into the ER with a post-traumatic headache within ten days of experiencing a head trauma benefitted from an IV of 20mg metoclopramide (a dopamine antagonist commonly used to treat nausea and vomiting) and 25mg diphenhydramine (an antihistamine). This treatment is known to work for migraines and tension headaches.

Benjamin W. Friedman et al. selected 160 patients, with 81 in the treatment group and 79 given an IV placebo. These groups were randomly assigned. Patients rated their initial pain level (1-10) before the injection and again an hour after receiving the injection. The placebo group had a mean improvement of 3.8, whereas the treatment group improved by a score of 5.2. The treatment group also reported residual benefits of the IV for post-concussion symptoms.

Side effects of this treatment were drowsiness, akathisia (inability to sit still), dizziness, diarrhea, and post-concussion symptoms. 43% of the treatment group and 28% of the placebo group reported these side effects. Friedman plans to continue working on this by determining the optimal dose and length of treatment to have long-term relief beyond just the emergency room.

Mental Health

Psychedelics may alleviate psychiatric disorders caused or exacerbated by concussion

Once deemed a dangerous substance, psychedelics are gaining mainstream acceptance as a potential treatment for psychiatric disorders, many of which can occur alongside or as a result of concussion and TBI. A recent article from the journal Nature describes the successes in alleviating symptoms when psychiatric patients incorporate psychedelics in their treatment plans.

A study published in JAMA Psychiatry reported that 71% of individuals with a major depressive disorder who took psilocybin saw more than half of their symptoms reduced. The participants reported “dreamlike states, intensifying sensory perception, and memories like pop-ups.” This altered state of consciousness allows individuals to escape from rigid thought patterns such as all-or-nothing thinking or learned helplessness, which are common to many psychiatric disorders and often felt by concussion patients struggling with persistent symptoms.

Beyond their psychological impact, psychedelics also bring biological benefits that can improve psychiatric symptoms. Like many antidepressants, psychedelics can affect serotonin receptors, which typically bind serotonin – a significant neurotransmitter that affects mood.

Additionally, researchers have postulated that psychedelics can induce neuroplasticity by increasing neuron stimulation. This biological mechanism is still a theory but shows consistency in the symptoms reported. Despite such promising results, participant bias, difficulties with reliable placebo controls, risks for dependency, and other limitations become barriers to conduct quality research.

Still, psychedelics have shown enough promise to be worthy of further study. In the future, researchers are hopeful that the decriminalization of psychedelic use will aid both research and the incidence of its therapeutic use for treating psychiatric disorders.

For concussion patients, both the injury itself and persisting symptoms can cause or exacerbate psychiatric disorders. Psychedelic-based therapy (with a qualified professional) may emerge as an available treatment within the next few years.

Youth

Headache and headache type could indicate longer concussion recovery time

A cohort study published in JAMA Open Network investigated whether the outcomes of posttraumatic headaches (PTH) after youth concussions are associated with a migraine phenotype. Posttraumatic headaches (PTH) are the most common acute and persistent symptom of concussion. The study authors found that PTH with a migraine phenotype is “associated with persistent symptoms following concussion compared with nonmigraine PTH or no PTH.”

PTH is “a new or significantly worsened head pain attributed to a head injury.” The researchers classified PTH as a migraine phenotype (PTH-M) based on reported moderate to severe intensity, as well as reported nausea compared to baseline or presence of both photophobia and phonophobia (sensitivity to light and noise). PTH was classified as nonmigraine (PTH-NM) if it did not meet the criteria for migraine headache.

The study analyzed data collected from Four Corners Youth Consortium(4CYC), a collaboration of three academic institutions specializing in concussion care. From the 4CYC registry, 81 participants age 5 to 18 years old with 286 total concussions were selected for the study. The analyzed data consisted of participants’ demographic characteristics, their symptoms three months and six months after injury, and the results of their Postconcussion Symptom Inventory, which includes an indication of PTH and if migraine features are present.

Joshua Kamins et al. found that patients with any PTH – migraine or nonmigraine – were more likely to have a prolonged recovery than those without PTH. Patients with PTH-M were significantly likely to take longer to recover (median 95 days) than patients in the PTH-NM group (median 70 days). Patients without PTH had a median recovery of 44 days. There was no significant sex-related difference within each PTH group, which suggests that a higher risk for migraine PTH in females may contribute to observed sex differences in persistent symptom incidence. The researchers conclude that PTH phenotyping may improve prediction of recovery for youths with concussion and also improve treatment, “as there are evidence-based treatments for migraine that could potentially improve” outcomes and manage headaches.

Women's Health

No sex-based differences found in sport-related concussion recovery of athletes in comparable collegiate sports

Recent research by Dr. Christina L. Master et al. suggests no differences in sports-related concussion (SRC) recovery for male and female athletes between comparable collegiate sports. The study included athletes from 30 colleges and universities across the United States, totaling 1071 concussions occurring in sports with both single-sex men’s and women’s divisions.

The researchers found no differences in recovery from a concussion at the Division I level of play, regardless of biological sex-based differences in risk factors for potentially longer SRC recovery. However, female athletes in Division II and III sports did experience longer SRC recovery times than their male counterparts, which may indicate the significance of non-biological factors such as unequal access to athletic training and sports medicine care. The study is from the NCAA-U.S. Department of Defense Concussion Assessment, Research, and Education Consortium and was published in the British Journal of Sports Medicine.

CTE and Neurodegeneration

Dementia risk increase as a result of just one head injury

U.S. News has reported that an individual's likelihood of developing dementia is increased by a staggering 25% after the first head injury. Subsequently, every further head injury increases their overall risk for dementia, according to a studypublished in the journal Alzheimer's & Dementia.

This prospective cohort study by Andrea, L.C. Schneider et al. analyzed 25 years of data on over 14,000 individuals enrolled in the Atherosclerosis Risk in Communities (ARIC) Study. The participants' mean age was 54 at baseline, and 24% had a reported head injury. Hospital records were also used to allow for missed information regarding the head injuries.

The researchers found that one previous head injury increased dementia risk by 25%. Participants who sustained two or more brain injuries were twice as likely to develop dementia within 25 years after the injury.

The study authors state that dementia is often used as an 'umbrella term' for a group of neurodegenerative diseases such as Alzheimer's, Parkinson's, Huntington's Disease, Vascular Dementia, and more. All these diseases cause difficulties with memory, cognitive task performance, thought-management, and logical thought sequences.

The results of this study align with research with mice conducted by Schwab et al., who noted that mild traumatic head injury can cause a change in gene expression related to brain aging, progressive decline, and toxic protein buildup – which have been linked to dementia.

The authors of both studies acknowledge that brain changes in the case of an injury may occur and cause persistent symptoms or cell degeneration (both associated with dementia risk). It is clear that more research is needed in this domain to understand how brain injuries may lead to dementia and how best to decrease the risk for those with a history of brain injuries.

Concussion Alliance would like to note that the study does not specify that patients were diagnosed with a brain injury, but rather looked at self-reported head injuries. While brain injuries can occur as a result of a head injury, not all head injuries also involve brain injuries, and a brain injury can occur without a head injury taking place. Additionally, the study does not differentiate between levels of brain injury; mild (concussion), moderate, and severe.