Treat sleep disorders after TBI to reduce dementia risk (7/1/21 newsletter)

Jul 1

We are almost finished with the third week of our summer 2021 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.

This is the second of five newsletters that 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 who wrote for this newsletter:

Writers: Clovis Wong, Karina Suwal, Meena Shanmugam, Alex Widman, Alyssa Schaechinger, Han Nguyen, Bethany Lazo, Calder Stenn, and Aamy Woldesenbet.

Editors: Conor Gormally and Malayka Gormally.

These are the nine interns who wrote this newsletter.

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Note: the synopsis concerning “Treat sleep disorders after TBI to prevent dementia risk” is in the last category, “CTE and Neurodegeneration.”

Sports

Concussions may increase risk of subsequent injury among high school athletes

Researchers led by Julie C. Wilson completed a study suggesting recent concussions may increase high school athletes' risk for subsequent injuries in the same season. The study evaluated 1364 male high school students who sustained two injuries over a single athletic season through an online database. All of the high school students participated in collision sports. Of the initial injuries, 686 were lower extremity injuries; 417 were upper extremity injuries; 261 were concussions.

Wilson et al. found that if an athlete’s first injury was a concussion, they had a higher risk of getting a concussion as a second, subsequent injury than an athlete whose first injury was to a lower extremity. In addition, they found that both a concussion and a lower extremity injury as a first injury increased the risk of subsequent lower extremity injuries. However, there was no statistically significant difference in risk added between the first injury concussion group and the first injury lower extremity group. While the researchers noted that high school athlete data are limited, the study suggests an association between a recent concussion and an increased risk for subsequent injury in the same sports season. The study was published in the Journal of Science and Medicine in Sport.

Cannabis & Psychedelics

Can psilocybin be as effective as Lexapro in treating depression?

In an article from his website, Canadian-American physician Peter Attia, host of The Peter Attia Drive podcast, discusses the results of a psilocybin-based depression study conducted by the Centre for Psychedelic Research at Imperial College London. In the study published in The New England Journal of Medicine, the research institute compared the effectiveness of psilocybin to Lexapro, a common SSRI (selective serotonin reuptake inhibitor), in treating depression. The study’s 59 participants were split into two groups; one received two doses of 25 mg psilocybin pills taken three weeks apart during therapy sessions, while the other received Lexapro for six weeks.

The researchers told both groups that “they would receive an undisclosed amount of psilocybin” to set equivalent expectations in both groups. The Lexapro group was given a sub-therapeutic dose of psilocybin (1 mg) every time the psilocybin group received a 25 mg dose. The institution also gave both groups an equal amount of in-person psychotherapy during the trial.

To evaluate the severity of depression in test subjects during the study, the Centre for Psychedelic Research used a survey called a 16-item Quick Inventory of Depressive Symptomatology–Self Report (QIDS-SR-16). The research institute enrolled study participants who scored in the moderate to severe levels of depression on an initial QIDS-SR-16. By the end of the study, the researchers found that the psilocybin group’s QIDS depression severity scores decreased more than their Lexapro counterparts. However, the difference between the two groups’ decreased scores was not statistically significant – the psilocybin group’s end scores only decreased by two points more than the Lexapro group on average (out of a total range of 27).

Robin Carhart-Harris, PhD et al. conclude that the Lexapro and psilocybin treatments in this experiment were “equally effective.” While Attia points to some limitations in this study—such as small sample size, the effectiveness of the QIDS point system, and expectation bias—he still believes it to have some clinical significance indicating the potential for psilocybin as an alternative to Lexapro for treating depression. Depression is relatively common among concussion patients, as symptoms and especially persistent symptoms can induce a depression disorder or exacerbate pre-existing depression.

Self-care

Coping with post-brain injury depression: helpful tips for emotional recovery

A recent article from Headway: the brain injury association shared ten tips for dealing with post-brain injury depression. Depression is common following a TBI of any degree and may be part of the recovery process for post-concussion patients. It is hard enough for patients to deal with many mTBI physical symptoms; adding in mental and emotional symptoms can make the recovery journey even more complex. Patients can use the tips mentioned in the article to make progress in their emotional recovery, which can ultimately aid in their physical recovery. Many of the tips mentioned in the article could be considered general health tips: exercise, seek support from friends and family, and engage in fun activities when able. However, some tips required a more in-depth explanation.

Identifying the cause of patients’ depression can be difficult as it may result from chemical changes in the brain following injury, the grief of missing out on activities due to the injury, or various other factors. Reaching out to a medical professional can help identify the cause, which will make it easier to start the emotional recovery process.

Depression following a TBI or any other cause can lead to suicidal thoughts, which may not go away independently. It can be challenging to do, but it is essential to talk to someone about those feelings. You can reach out to many organizations for help, such as the National Suicide Prevention Lifeline, which can be reached at 800-273-8255.

Therapies Currently Available

Contradicting studies on whether rest impedes concussion symptom recovery

A research paper published in Academic Emergency Medicine found a lack of evidence that prescribing light exercise prevents post-concussion symptoms more than standard rest instructions for Emergency Department patients with acute concussions. In this paper, Catherine E. Varner et al. directed a randomized trial comparing 367 mTBI patients aged 18-64. Control group participants were instructed to gradually return to exercise following symptom resolution, while experimental group participants were prescribed 30 minutes of daily light exercise. After 30 days, researchers administered the Rivermead Post-concussion Symptoms Questionnaire (RPQ); RPQ results showed no significant difference in median change of RPQ scores among the two groups.

This paper’s results contradict many other study findings that strict rest beyond the 24-48 hour acute phase of concussion negatively affects post-concussion symptom recovery. For example, a consensus statement developed by the Team Physician Consensus Conference (TPCC) published in the British Journal of Sports Medicine upholds that strict rest after a sports-related concussion slows recovery and increases the probability of prolonged symptoms. This consensus statement references the 5th international conference in concussion in sport and a 2015 research paper – published by Danny G. Thomas et al. in Pediatrics – that performed a randomized controlled trial of 88 patients aged 11-22. The 2015 study consisted of a control group prescribed one-to-two days’ rest followed by a stepwise return to activity, and an experimental group prescribed strict rest for five days. After 10 days, the experimental group (prescripted strict rest for five days) reported statistically significantly more post-concussive symptoms and slower symptom resolution, which runs counter to the Varner et al. research.

When looking at the contradicting results of these studies, it is essential to recognize differing experimental definitions and methods. While the experimental group in Varner et al.’s study was prescribed 30 minutes of daily light exercise, the experimental group in Thomas et al.’s study was prescribed five days of strict rest. The two research papers defined “standard care” differently, as either rest or light activity relative to strict rest. Additionally, definitions of exercise or activity following concussion are not uniform and can be a hidden confounding factor in evaluating the results of studies in this area.

While Varner et al.’s results did not find that daily light exercise improved post-concussion symptoms, these results do not directly contradict previous findings that extended strict rest may be detrimental to recovery. Nevertheless, these conflicting study results highlight the need for more research about the role of rest in post-concussion symptom recovery and more uniform terminology surrounding standard concussion care within research.

Statistics

Head injury with loss of consciousness associated with chronic disability

A study published in Neurology established links between head injury with loss of consciousness (LOC) and chronic disability. The authors concluded that of individuals with a history of head injury with LOC, 47.4% “had some disability in at least one area of functioning,” compared to 38.6% in the control group, according to an American Academy of Neurology press release. This finding showed a statistically significant association between head injury with LOC and disability.

Andrea L.C. Schneider, MD, PhD et al. conducted a cross-sectional analysis of data from a 2011 - 2014 National Health and Nutrition Examination Survey (NHANES), choosing individuals 40 years or older, with a mean age of 58. Among the 7,390 in the analysis, 16% had a head injury with loss of consciousness from self-report.

The NHANES survey asked participants to describe their ability to conduct a set of daily tasks, including their ability to eat and dress. In addition, grip strength was measured to note any arm-related disability, a marker of cerebellum dysfunction. Finally, the survey participants were asked about disabilities that impact their capacity to complete work-related tasks, such as impairments related to physical and emotional functionality.

Dr. Sneider emphasized the importance of this study, saying, “The substantial burden of disability suggests that research into how to better care for and improve the functioning of people with concussions over the long term should be a priority for both public health and for planning for individuals.” According to an article in Helio, the study’s scope was limited by a lack of inclusion of vulnerable populations in stressful settings, such as the military, nursing facilities, and prisons.

Youth

Study finds less than 1/6th of Irish children get a medical assessment before return to play

A recent study conducted by Mac Suibhne et al. identifies the failure to adhere to return to play (RTP) protocols in children in Ireland, a high percentage of whom sustain a concussion during sports and return to play without medical review. Only nine (15.79%) out of 57 patients underwent medical assessment prior to returning to play. Despite being advised on RTP protocols at discharge from the Emergency Department, 48 patients (84.2%) “returned to play without a medical assessment” including seven children (13.72%) who reported returning to play earlier due to continued pressure from their coaches and teammates. The performance following RTP of 25 (43.86%) patients was simultaneously impacted owing to intermittent headaches, dizziness, and fatigue.

The commitment to RTP guidelines is a fundamental contribution to concussion management in the pediatric population to facilitate successful sports return without symptom exacerbation. Children are suggested to take an immediate short period of physical and cognitive rest of 1 to 2 days before gradually initiating sports activities aligning with RTP protocols to enhance the recovery process. As concussion symptoms might persist or not resolve spontaneously, children require professional medical assessment before going back to play. This research, published in The Irish Medical Journal, reveals the reality of Irish pediatric trauma and exposes the lack of appropriate healthcare provision to patients diagnosed with concussion. Concussion Alliance wants to point out that second impact syndrome (which can be disabling or fatal) is also a risk of returning to play without medical review.

Women's Health

Brain injury contributes to cognitive-motor deficits in women affected by intimate partner violence

A study by Naomi Maldonado-Rodriguez et al. published in the Journal of Neurotrauma found that psychopathologies and brain injury sustained from intimate partner violence (IPV) can lead to deficits in cognitive-motor function. IPV impacts one in three women worldwide and often results in brain injury (BI).

The researchers recruited 40 women exposed to IPV from a local women’s shelter to participate in a sensorimotor task. Participants used moveable robotic arms to hit predetermined target shapes while avoiding other distractor shapes. Women who had experienced more than 10 BIs, more severe BIs, or loss of consciousness or amnesia following an IPV-related BI hit fewer targets than those with less frequent or severe BIs. Survivors of more severe BIs also had slower hand movement.

This study accounts for psychopathological comorbidities like depression, anxiety, and PTSD as consequences of IPV. In particular, depression and PTSD influenced the number of distractor shapes hit and the object processing rate of participants. These findings suggest that brain injuries compounded by mental illness may worsen cognitive-motor function in those with a history of IPV. However, this study was limited by its use of a small, relatively homogeneous sample.

The impact of IPV-related brain injury and psychopathologies could explain why abuse survivors might find it challenging to make planning decisions related to their safety. Understanding these injuries’ impact on brain function may “help explain some of the behaviors historically attributed to faults in character” in women who experience IPV.

CTE and Neurodegeneration

Contribution of sleep disorders to dementia incidence following traumatic brain injury: A decade-long retrospective study

A study by Tatyana Mollayeva et al. aims to find a connection between sleep disorders and dementia risk in patients with traumatic brain injuries (TBI) of all severities. The study, published in Sleep, studied a cohort of adults admitted to the emergency department or acute care hospital between May 2003 and April 2013 and who had no prior history of dementia; the researchers followed the participants until May 2016.

Of the 712,708 patients in the study, 59% were male, with a median cohort age of 44 years. At a median follow-up time of 52 months, 4.6% had developed dementia. Controlling for participant age, sex, income level, TBI severity, and comorbidities, “diagnosed sleep disorder was a significant predictor of incident dementia.” After the results were stratified by sex, the relationship between sleep disorder and dementia was statistically significant in both males and females.

The authors concluded “sleep disorders were independently associated with dementia onset,” and patients with TBI should be screened for sleep disorders as part of their regular treatment plan. “Hidden” sleep disorders could potentially cause a cascade of debilitating effects in patients with and recovering from TBI, and these adverse effects could increase with age.