New Return-to-Learn Program 7/29/21 newsletter

Aug 12

We are honored that Conor Gormally's oral presentation about our internship is part of the Poster Session for the 2021 World Congress on Brain Injury which is currently in session. This is the second to last week of our summer 2021 Concussion Education & Advocacy Internship Program.

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, Aamy Woldesenbet, and Elizabeth Zhou.

Editors: Conor Gormally and Malayka Gormally.

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Opportunities

August 2, 11:00 am PST: Attend a free, virtual class Deepening Resilience hosted by the Brain Injury Alliance of Washington. “By increasing personal resilience, you can respond with more skills to the challenges in your life." Register in advance.

August 13, 12:00 pm PST: A free, virtual class Post-traumatic Headache (Headache after Brain Injury), will be presented by physicians from the University of Washington Headache Clinic. The class is hosted by the Brain Injury Alliance of WA State. Register in advance.

Education

Return-to-Learn: A Utah school districts protocol to help students post-concussion

An article published in the Salt Lake Tribune shares how a Utah school district developed a new program to help students experiencing academic challenges after a concussion. The Alpine School District partnered with Intermountain Healthcare to create a new Return-to-Learn program. When recovering from a concussion, students can feel as though they are on their own. Under this new protocol, the student is monitored for five key academic benchmarks during a gradual return to school instead of being thrown directly back into a full course load.

“Watching my son struggle highlighted for me the need to create a comprehensive program that would help teachers, parents and students with the learning challenges that come with concussion,”

-Mickell Bos, Alpine School District assistant principal

Mickell’s son Nathan had suffered three concussions in three years. After the third, he began to struggle with his academics, and his mother saw this firsthand. After seeing Nathan struggle, it became a priority for Mickell to make it easier for all of her students to return to the classroom after a concussion. As the first Utah school district to implement the Return-to-Learn protocol, Mickell is hopeful that other schools will adopt this Return-to-Learn protocol so no student will have to suffer the way her son did.

Sports

World Rugby introduces an independent panel of concussion consultants to oversee return-to-play decisions

An article by international news agency Agence France-Presse reports that World Rugby has introduced an independent panel of consultants to oversee return-to-play decisions for all competitions at the elite level. Governing body World Rugby will institute an Independent Concussion Consultants panel (ICC) to review cases where a concussed player faces expectations to return to play ten days or fewer after their concussion. In addition, the ICC panel will review the cases of specific players who are considered high risk. Players are considered high risk if they have sustained one concussion in the previous three months, more than two concussions in the previous twelve months, or more than five concussions in their career.

Other independent panels of concussion consultants have already found success at former Rugby World Cups. World Rugby Chief Medical Officer Dr. Eanna Falvey explains that the use of the ICC panel “completely recognises and supports the need to ensure an individualised player approach based on risk, rather than an arbitrary stand down time.” The ICC will begin to operate across the international level this month.

Cannabis & Psychedelics

New legislation in Seattle will decriminalize psychedelic drugs such as mushrooms

Members of the Seattle City Council are considering new legislation that would decriminalize psychedelic drugs, such as psilocybin mushrooms. A KIRO7article explains that the council members are concurrently asking a newly-established drug and recovery task force to consider expanding the decriminalization decision across Washington State. The main reason behind the council members’ proposal is the rise in research indicating that psychedelics can be an effective medicinal treatment for patients with mental health disorders such as drug addiction, depression, and PTSD. In addition, “This is an important and emerging area of treatment for traumatic brain injury,” said Councilmember Teresa Mosqueda.

Councilmembers Andrew Lewis and Lisa Herbold have written a letter to request the new Overdose Emergency and Innovative Recovery (OEIR) task force to consider working on “recommendations to liberalize policy on entheogens at the state and local level” (psychedelics are also referred to as entheogens). The letter was signed by seven out of nine members of the Seattle City Council.

Concurrently, Councilmembers Sawant and Lewis are trying to make the legal change happen in Seattle first. Sawant stated that the council could not completely legalize psychedelics but that the city council could effectively decriminalize the drugs by making them the lowest priority for police. The councilmembers also reviewed other ongoing research regarding the medical effectiveness of psychedelic compounds like psilocybin, found in certain mushrooms, can have on the brain.

Self-care

Tips and tricks to help manage taste & smell difficulties following a brain injury

Changes in taste and smell are common for patients who have experienced a severe traumatic brain injury (TBI) but can also occur with “minor head injuries,” such as concussion. Because of this, patients might experience difficulties and setbacks with eating and general appetite and struggle with maintaining a healthy, nutritious diet. UK brain injury association Headway recently published an article with tips to help individuals dealing with dramatic changes in appetite due to a TBI. Below are the five methods to help cope with appetite changes due to TBIs – check out the original article to read more about specific examples.

Making meals more interesting (either trying a new recipe, participating in more social meals, or making the dish itself more visually appealing)
Ensuring a varied and nutritious diet
Avoid using too much salt
Mindful drinking (using water to get rid of unwanted tastes, limiting caffeine intake)
Limiting alcohol consumption

Therapies Currently Available

Optometrists may play vital role in post-concussion rehab

An article in Optometry Times addressed the widespread absence of vision therapy in post-concussive rehab. Based on a study referenced by the author, as many as 90% of patients with a traumatic brain injury experience symptoms relating to visual dysfunction. Given the interconnected nature of the eye and the brain, the author believes that vision therapy may lead to better outcomes in patients undergoing concussion rehab.

A pioneer in what may lead to a paradigm shift in concussion diagnosis and treatment, the author James Deom, OD, MPH, is one of several neuro-optometrists working to educate healthcare providers in his area about the benefits of vision therapy for concussion patients. He holds the belief that “optimal benefits from physical and occupation therapy cannot be achieved if patients have underlying untreated deficits in their vision and/or eye movement.”

Within his office, Dr. Deom conducts vestibular ocular motor screening on concussion patients to help determine symptomatology. He is also using the relatively new RightEye device in his clinic, which allows him to monitor patient progress through the device’s infrared eye-tracking technology. Vision therapy may prove to be a vital component in the effort to improve concussion treatment.

Mental Health

Concussion symptoms compounded with psychological trauma take longer to resolve

An article published by Defence Visual Information Distribution Service suggests that those who experienced psychological trauma while they sustained a concussion have a greater risk of lasting symptoms. If concussive symptoms resulting from a traumatic event linger for over four weeks, clinical psychologist Dr. Marjorie Campbell asserts that “‘the psychological part of it needs to be tended to.’”

While most individuals recover from concussions within about three weeks, research has found that anywhere from 10-50% develop persistent post-concussion symptoms. Campell argues that psychological trauma could contribute to this lack of recovery if the person sustained the injury from a distressing experience like combat or a car accident. She notes that headaches, depression, anxiety, irritability, fatigue, dizziness, and sensitivity to light and sound occur more in those who sustained concussions and “psychological trauma at the same time” than those whose concussions were unrelated to a traumatic event.

Providers should evaluate the physical and psychological components of brain injury in tandem. TBI researchers must incorporate psychological health in their studies to get a fuller picture of the injury and its consequences.

Youth

Study found long-term detrimental effects to children’s executive functioning after TBI

A study published in the JAMA Network Open mapped executive function (EF) recovery trajectories in children who had suffered a mild-to-severe traumatic brain injury. EFs include self-regulation skills such as attention control, managing frustration, assessing consequences, and future planning. These skills may be disrupted by all ranges of TBI, especially among children and young adults still developing these skills. In this study, researchers used the Behavior Rating Inventory of Executive function (BRIEF) and BRIEF–preschool to measure EF on the Emotional Control, Inhibit, Working Memory, and Plan-Organize subscales. Working with a cohort of 559 children, researchers Heather T. Keenan, MDCM, PhD, et al. conducted a 3-year longitudinal study that found that children’s EFs worsened sharply from baseline during the 12 months after injury, alongside a secondary worsening between 24 and 36 months.

In an interview with Healio News, Dr. Keenan said, “Understanding how TBI influences the developmental trajectory of EF in children injured in different developmental periods is critically important to allow targeted intervention for behavior regulation and metacognitive skills.” Her study showed that some children worsen after an initial recovery plateau, indicating that additional EF assessments will be necessary long after conventional assumptions. As Dr. Keenan said, “Results further suggest that children with TBI may struggle over time as tasks become more complex, leading to a need for reassessment and different supports to improve participation in the school, home and community.”

Women's Health

Females are more susceptible to concussions than males and tend to experience them with greater severity

A recent study, published in the American Journal of Sports Medicine, found that female athletes have a higher risk of being concussed and scoring higher on the severity scale for concussion compared to their male counterparts. However, both female and male athletes recovered from concussions at similar rates. This field of research is still relatively young and requires more exploration of the impact of sex differences in concussion severity, recovery, and risk of sustaining multiple concussions. However, this information is helpful for healthcare providers to educate athletes on the relative risk of concussions in their respective sports and determine ways to reduce the risk. The study finding may also inform rehabilitation practices.

The study authors evaluated 11,563 baseline ImPACT tests conducted on athletes between 2009 to 2019; the average athlete was 15 years of age, and 34% of the sample were female. Healthcare professionals followed a standardized protocol and determined that a concussion injury was present in the athlete if “at least 2 of the 5 ImPACT composite scores (e.g., verbal memory, reaction time) deviated more than 80% from baseline” composite scores. Researchers calculated the post-injury severity index by comparing baseline and post-concussion composite scores. An article published in Sports Medicine Research explains that the researchers “had enough sample data to define ‘recovery’ as the time when someone had no more than 1 composite score that deviated” from the baseline score.

Researchers concluded that “female athletes had better verbal memory, processing speed, and reaction time but reported more symptoms of concussion and had lower visual memory.” In addition, “Females had a 62% higher odds of concussion compared to males and reported greater post-injury severity. The higher post-injury severity index was primarily from poor processing speeds and more symptom reporting. Based on ImPACT scores, females recovered slightly slower than males” – this is possibly due to confounding variables (e.g., initial severity score, age, comorbidities, disabilities).

Females reported more symptoms, especially post-concussion migraine and mental health concerns such as anxiety and depression, “which are treatable with therapy or therapeutic agents.” Using these preliminary findings, healthcare providers can create individualized treatment plans for specific athletes and educate female athletes that they are at higher risk of concussions with more severe symptoms than men. Additionally, clinicians “should monitor patients for migraine symptoms and neuropsychiatric problems to enable more individualized treatment approaches to rehab.”

Culture

The struggle of receiving disability insurance for a TBI

In a first-person piece from her website TBI to 100 Miles, Kristin discusses her struggle with getting social security disability insurance (SSDI) after receiving a traumatic brain injury (TBI). Concussion Alliance would like to clarify that Kristin suffered a concussion (mTBI) and now has extensive, persistent symptoms, according to her bio and her blog post about the bike crash that caused her injury. When she first applied for SSDI, Kristin had to wait ten months to hear back from a state agency, and the agency denied her insurance claim. During this time, she was receiving back pay—money someone receives when they aren’t working their job—but she had to use 25% of it to pay for an SSDI attorney. She also had to pay $1000 out of pocket to receive “neuropsychological and functional capacity evaluations” because her lawyer told her that she would need them to improve her appeal.

After 18 more months, Kristin was denied SSDI again. This time the reasoning was clearer – Kristin could still run after her concussion. While some concussion patients struggle with physical activity after injury, others’ symptoms may manifest primarily or exclusively in other domains (cognitive, behavioral, hormonal, etc.). (Kristen attributed a lot of her improvement during recovery to her running). She proceeded to file another appeal regarding her insurance claim, this time at the federal court level. Five years after she filed her initial appeal, a judge ruled in favor of her case.

Kristin’s blog post also includes specifics about applying for Social Security Disability and “a brief summary of the questions used to determine if you are disabled.” Kristin’s story not only speaks to the shortcomings of the United States’ healthcare system but is also an indication of the lack of recognition TBIs get as life-altering conditions.