Happy holiday season! This is our final Concussion Update newsletter of the year!

This week our newsletter synopses are all written by our December 2022 Interns! We’re again featuring the call for study participants from the Center for Neuroscience and Regenerative Medicine again.

This week's lead article, Boswellia serrata extract found to have cognitive benefits for traumatic brain injury patients, is in the Self Care category.

In this newsletter: Special Feature: Opportunities, Cannabis & Psychedelics, Diagnostics, Self Care, Therapies Currently Available, Veterans & Service Members, Mental Health, Youth, Women’s Health, and Culture.

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Beckett Schafer, Catie Marvin, Coral Outwater, Jemsy Mathew, John Garay Hernandez, Lexi Kingma, Nancy Cullen, Shira Dubin, & Sonia Shah

Editors: Conor Gormally and Malayka Gormally

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

Special Feature: Opportunities

Are you a service member or veteran struggling with symptoms of depression? Do you have a history of TBIs, including concussion? You may want to participate in a new clinical trial of an app for depression that uses cognitive behavioral therapy (CBT); the researchers designed this app specifically for the military community. CBT is effective and recommended for depression, but it can be challenging to access a CBT provider, thus the trial of delivering CBT therapy via an app.

Study participants will be provided with the CBT app and will work with the researchers remotely. The time commitment is 30–60 minutes per week for 16 weeks. There are no in-person visits so you can join the study from any location. You may find your depressive symptoms reduced, “but there is no guarantee you will benefit from this study.” There is no financial compensation for being part of the study.

If you’d like to learn more about CBT and depression, please read our Cognitive Behavioral Therapy and Mental Health pages.

Concussion Alliance has worked with this research group from the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University several times. We found the team great to work with, and the study’s Principal Investigator, David Brody, MD, PhD, is esteemed in the concussion research space.

To learn more, contact the study team:

Call or text 301.461.4322 or email CNRM-D@usuhs.edu.

Looking for youth study participants: researchers at Nationwide Children’s Hospital are “Looking for Youth Athletes Who Stopped Contact Sports After Concussion” to take “to complete a few short online surveys and a 30-min phone or video interview.”

Podcast episode now available: Dr. Julie Stamm gives a “Concussion Concerns” talk on the Athletic Training Chat podcast. Dr. Stamm is the author of The Brain on Youth Sports, and she has been a guest speaker for our internship program.

Cannabis & Psychedelics

Study finds CBD reduces anxiety and pain, improves sleep

Empirical evidence regarding CBD (cannabidiol derived from hemp) products’ medical effectiveness is limited. Some studies suggest CBD has beneficial therapeutic anxiolytic (management of anxiety), analgesic (management of pain), and anti-inflammatory properties. For example, observational studies, such as a 2021 study, have suggested that CBD improves symptoms of anxiety, insomnia, and pain, as well as self-reported quality of life.

Published in 2022 by Integrative Medicine Reports, Jessica Londeree Saleska and colleagues probed this question in their The Radicle Science Advancing CBD Education and Science (ACES) study, which tested the therapeutic effectiveness of orally ingested CBD products. After analyzing the resulting data, Saleska et al. stated, “The safety of CBD products in this study is consistent with previous clinical research. CBD proves [to have an effect] with apparent safety when taken daily over a similar period.” Among the experimental group, 46.6% of the participants reported improvements in anxiety, 47.9% in sleep disturbance, and 35.2% in pain. These findings add to existing data suggesting CBD products can assist in managing anxiety, sleep disturbance, and pain symptoms.

The ACES study assigned 2816 pre-screened participants to a study group given a 28-day CBD product intake regimen. Individuals in the study group were randomly given one of 13 CBD products. The participants were then arranged and observed based on their levels of health, which researchers measured during the screening process. Thereafter, the study group was instructed to use the CBD product based on the label instructions, according to health provider advice and personal preference. Participants also completed an online survey once a week for the duration of the study, which measured well-being, anxiety, sleep disturbance, and pain symptoms.

After the 28-day regimen, the analyzed data found that the study group significantly improved in anxiety, sleep disturbance, and pain domains. Roughly 9.5% of participants reported experiencing side effects, “the most common of which were gas/flatulence (1.6%), headache (1.4%), diarrhea (1.2%), and bloating (1.2%)”. No other side effects were reported. According to ACES, these results were not impacted by whether the CBD products were marketed as Isolate, Full, or Broad spectrum.

It is worth noting, however, that Saleska et al. acknowledge this ACES study did have limitations. For one, ACES notes that ‘about one in five participants reported using another cannabinoid product during the study,’ despite the researchers instructing them not to. On top of this, ACES did not anticipate the possible impact that placebo or expectancy bias may have had on these results. Saleska thus emphasizes that future studies must implement the same experimental procedure with a double-blinded placebo control to reaffirm this study’s findings. That said, Saleska and associates view this study as evidence that CBD is a valuable conjunct to therapies that manage anxiety, sleep disturbance, and pain symptoms.

Diagnostics

History of undiagnosed concussions linked to worse neurocognitive outcomes and symptom severity.

In a recent study of nearly 30,000 college athletes and military cadets, researchers found that students with at least one undiagnosed concussion had more severe symptoms and performed worse on neurological tests compared to students with no history of concussion and those with diagnosed concussions. Robert C. Lynall et al. state in The American Journal of Sports Medicine that “it is possible that undiagnosed, and therefore untreated, concussions lead to subtle lingering symptoms that persist beyond clinical concussion recovery.”

According to the authors, “These findings add to a growing body of literature suggesting that early concussion diagnosis, often facilitated by honest and timely care seeking by the injured individual, is critical to maximize recovery and increase positive health outcomes after the concussion.” The study’s authors suggest a broad intervention targeted to athletes, coaches and parents, clinicians, and those considering becoming military members.

The data source for this study was the Concussion Assessment, Research, and Education Consortium. Researchers separated participants into three groups: those with no history of concussion (77% of participants), those who have had one or more concussions–all of which were diagnosed–(17.8%), and those who have had at least one undiagnosed concussion (5.3%). Participants self-reported symptoms using a symptom checklist (SCAT3) and symptom inventory (BSI-18) and took neurocognition, mental status, and balance tests.

Those with at least one undiagnosed concussion had significantly greater symptom scores on the checklist and the inventory than the other two groups. On the other hand, participants with diagnosed concussion history did not seem to differ from participants with no history of concussion in terms of symptoms. While their self-reported symptoms did not vary, those with a history of diagnosed concussion performed worse than those without concussion on two examinations: a test of spatial processing and visuospatial working memory and a test of reaction time. By comparison, those whose concussions went untreated performed significantly worse on six tests but better on two. The researchers found no differences in mental status or balance between any of the groups. However, the results were somewhat inconsistent depending on which test participants took, even among tests intended to measure the same type of cognition. Researchers believe this inconsistency is due to the inherent differences between each type of test. Additionally, while researchers controlled for sex and sport type, they did not control for attention disorders and age, which could have potentially impacted the results.

Self Care

Boswellia serrata extract found to have cognitive benefits for traumatic brain injury patients

A recent study published in Brain Injury has found that the extract from Boswellia serrata—a tree native to India, Northern Africa, and the Middle East—improves cognitive functions in traumatic brain injury (TBI) patients. The study’s patient population included those with mild, moderate, and severe TBIs, which were categorized based on the Glasgow coma scale (GCS), brain imaging, post-traumatic amnesia (PTA), and loss of consciousness (LOC). The pilot placebo-controlled clinical trial was conducted by researchers Meshkat et al. at the Tehran University of Medical Sciences, Tehran, Iran. Their findings may lead to the inclusion of Boswellia as a supplemental treatment for TBI.

Researchers took a baseline evaluation of participant cognitive function using three tests: the Rey Auditory Verbal Learning Test-Recognition Test (RAVLT), the Digit Symbol Substitution Test (DSST), and the trail-making test part B (TMT-B). Meshkat et al. randomly assigned patients to either a Boswellia (active) or a placebo (control) group. The active group received 400 mg capsules of Boswellia thrice a day, while the placebo group received capsules of identical size and color. After three months of the treatment, participants retook the three cognitive tests.

Researchers observed that, after three months, cognitive functions improved significantly in the Boswellia group compared to the placebo group across all three cognitive assessment tests. Additionally, there were no serious signs or symptoms of adverse events or toxicity alerts. The researchers are hopeful that their findings will lead to the potential usage of Boswellia extract in TBI treatments. “We anticipate that a Boswellia formulation enriched for BAs [Boswellic acids] such as Strowell™ could be used as an adjunctive and supportive treatment to improve outcomes and recovery of patients with TBI,” they said.

Therapies Currently Available

Multidisciplinary care at concussion clinics is ideal–but clinics are hard to find and afford

In an article on ABC News Australia, Haylee Gleeson outlines the process and care she received at a concussion clinic. Like too many other concussion patients, when Ms. Gleeson had a concussion, she was in pain, confused, and given minimal direction on where to get help for her symptoms. After several weeks of being told by her general practitioner to just "keep resting" for her persisting symptoms, she stumbled upon a concussion clinic with a team of specialists: a neuropsychologist (psychologist with a specialization in the brain and behavior), physiotherapist (physical therapist), behavioral optometrists (see the section on neuro-optometrists in Vision Therapy), occupational therapist (help with everyday activities), a rehab physician (physiatrist), and more.

This multidisciplinary therapy approach works well because different specialists can help with various symptoms. The team that helped Ms. Gleeson uses target therapy, which initially focuses on alleviating patients' most severe symptoms. Some researchers believe symptoms are linked, so this method of targeting the worst symptoms can also help alleviate some of the other symptoms.

The article also articulated difficulties finding and affording concussion clinics in Australia–similar to those in the United States. Ms. Gleeson acknowledges that she's one of the lucky ones–many people don't find a clinic as easily as she did, if at all. Many people struggle with their injury's invisibility and the lack of readily available care. Even for those who do find the clinic, there are still the issues that it is not easy, quick, or cheap – she has been a patient for over a year, and it is still hard work to improve. And for those who need the help the most – like those who still can't work well after their injury – they can't afford the clinic, and even those with insurance can only get a few sessions covered.

Ms. Gleeson's article exemplifies the difficulties of persistent post-concussion symptoms but also shows some cause for celebration and hope for a future of better care. As Professor Olver, medical director of rehabilitation at Epworth HealthCare and chair of rehabilitation at Monash University, tells Ms. Gleeson, most patients can make a full recovery–or at the very least, significant improvements. And other researchers at Monash University are studying multidisciplinary concussion treatment plans that will help create the groundwork for more concussion clinics.

Content Warning: Synopsis includes accounts of suicide.

Veterans & Service Members

Traumatic Brain Injury is a culprit for rising suicide rates among veterans

The gunshot intended to end Daniel Williams’ own life ultimately killed a police officer responding to Williams’ wife’s call for help. While in Iraq, Army Specialist Williams sustained a blast traumatic brain injury from an IED explosion that also took his friend’s life. Left with physical and psychological damage exacerbated by a delay in mental health care, Williams attempted to join the 30,177 other active and retired US service members who had taken their lives since 2001. Three years later, he was diagnosed with a TBI. After seeking help through medicine and therapy, he is now involved with the National Alliance on Mental Health and chairs the National Veterans and Military Council. Williams is helping Alabama veterans find “renewed hope and purpose,” according to an article by Patricia Kime and Rebecca Kheel in the online publication Military.

Since the Persian Gulf War and 9/11, veterans have returned from service with diagnosed and undiagnosed TBIs of all severities, including mild TBI (mTBIs). A 76% increase in the veteran suicide rate over just twelve years, from 2005 to 2017, motivated scientists to examine the relationship between mTBIs and suicide among active duty and retired service members. Some research attributes this increase in suicide correlated to TBIs to changes in battle strategy, such as the implementation of remote explosives and the improvement of battle-side medicine–which result in more service members surviving their TBIs and needing care.

With veteran suicide rates on the rise, researchers have begun to intensively examine general populations against populations that have endured a TBI. A 2018 Danish study concluded that, of 34,500 general population deaths, TBI patients demonstrated a suicide rate twice as high as those without TBIs. More recently, this past February, epidemiologist Jeffrey Howard concluded that Veterans suffering from a TBI are at risk for not only suicide but death by other accidents such as homicide. According to neurologist Dr. Warren Lux, “even those with mild [brain] injuries” undergo “neurochemical changes and troublesome deficits.” Regarding those with moderate and severe TBIs, Dr. Lux is concerned about the loss of the “ability to monitor themselves” and “the ability to understand consequences” due to damage in the frontal lobe.

Cognitive impairment might contribute to increased suicidal ideation of service members who suffered more than one TBI. Veterans with multiple TBIs, deployed in Iraq and Afghanistan, admitted to suicidal ideation twice as much as those with one or no diagnosed TBIs in a 2018 study. Given that 2.3% of service members experience an additional TBI each year promoting TBI awareness and assisting active and retired service members to seek help is crucial.

While frontline TBIs are common, 80% of service member TBIs are sustained away from deployment and are caused by training accidents and injuries. The prominence of TBI-related suicide among veteran populations is a significant concern for researchers, service members, and their families. In a second article and upcoming third article addressing rising veteran suicide rates, Kime and Kheel argue there is a demand to amend the military’s treatment plan for their TBI patients.

Mental Health

Does there need to be a shift from medication being prescribed as a treatment pattern following a traumatic brain injury?

A recent study by Madeline R. Marks et al. aimed to examine the treatment patterns for anxiety and post-traumatic stress disorder (PTSD) following a traumatic brain injury. Anxiety and PTSD are mental health conditions that can follow a traumatic brain injury (TBI) and profoundly impact an individual's recovery. The authors found that individuals diagnosed with anxiety or PTSD were more likely to be prescribed drugs rather than psychotherapy (talk therapy). The study, published in the Journal of Neuropsychiatry and Clinical Neurosciences, used a sample of 207,354 adults from administrative claims data.

The researchers found that of those diagnosed with anxiety, 76.2% were prescribed medication, whereas only 19.1% received psychotherapy. For those diagnosed with PTSD, 75.2% were prescribed medication, while 36.0% received psychotherapy. According to an article in PsyPost, the researchers are concerned about their findings "since psychotherapy is regarded as a first-line treatment for both PTSD and anxiety disorders and one that does not carry the risk of unfavorable medication interactions." Lead author Madeline Marks suggests that the "results from our study raised the importance of access to mental health care and evidence-based treatments for anxiety and PTSD post-TBI."

While the study is limited by not considering that some participants had pre-existing, it still highlights the importance of improving care for individuals and training medical providers to be more aware of the mental health effects of TBI. (See the Concussion Alliance resources Cognitive Behavioral Therapy, Mental Health, The Invisible Injury, and Post-Traumatic Stress Disorder.)

Youth

Concussions in Children Affect Long-Term School Performance

A recent cohort study published in the Journal of Science and Medicine in Sport (R. Lystad et al.) studied children 18 or under hospitalized for concussions in New South Wales, Australia, tracking their test scores and graduation rates post-concussion. The study found that this cohort of pediatric concussion patients had a significantly increased risk of not achieving the national minimum standard (NMS) in literacy and numeracy, as well as not completing high school. Understanding the connections between concussions and academic performance may help educators provide proper assistance and care for students returning to school post-concussion.

The study found that children and adolescents hospitalized with a concussion had a 30% higher risk of not achieving the NMS for numeracy and a 40% higher risk of not achieving the NMS for literacy. Furthermore, adolescents hospitalized with concussion had a 64% higher risk of not completing high school year eleven (junior year) and a 75% higher risk of not completing high school year twelve (senior year).

The study consisted of a population-based cohort study of youth 18 or under hospitalized with a concussion from 2005-2018 in New South Wales, Australia. The cohorts of concussed youth were matched by age, sex, and postcode to account for confounding variables. The authors measured literacy and numeracy NMS and graduation rates among each cohort compared to peers who had not sustained concussions in the same period. The study followed 1,049 concussed students for grade three, 1,035 for grade five,932 for grade seven,689 for grade nine, 1,445 for high school year ten, 1,366 for high school year eleven, and 1,182 for high school year twelve.

Identifying the connection between concussion history and challenges in school proves the importance of academic support systems for concussed students. Further research is needed to understand what support systems can best assist concussed students in their return to school and overall performance.

Women’s Health

Victims of domestic abuse are 12 times more likely to suffer a TBI than athletes or veterans

An article from the University of Montreal, by Béatrice St-Cyr-Leroux, discusses research that finds that women who are repeatedly choked or struck in the head due to domestic violence are 11 to 12 times more likely to suffer a traumatic brain injury (TBI) than athletes or veterans. Despite this, their injuries usually go undiagnosed and untreated.

Unlike athletes, who have a straightforward and established rehabilitation process, these women often do not have the space or resources to recover safely. Many of these women do not get treatment, and when they do, their TBI symptoms may be overshadowed by their psychological symptoms. Carolina Bottari, a professor and researcher at the University of Montreal, states, “It’s absurd when you compare these victims to athletes, who have clear protocols for dealing with head injuries sustained while playing sports. Women who are victims of domestic violence aren’t even seen by a doctor.” TBIs may also make it difficult for a woman to testify in court or leave her partner due to symptoms of confusion and difficulty with memory.

Bottari believes the key to giving these women the resources they need lies in educating the people who work with them daily, “such as shelter personnel, the police, and the legal community,” and increasing communication between these disciplines. Examples include giving shelter workers information that can help them identify the symptoms of TBI, raising awareness to help doctors know to look for TBIs related to domestic violence, and educating police to recognize when a woman should go to the hospital. Another important aspect is creating an environment of trust and respect so women feel encouraged to talk about their experiences. For more information, see our resource, Partner-Inflicted Brain Injuries.

Bottari summarizes the issue and looks to the future, “In short, there is a great deal of awareness-raising that needs to be done about this widespread problem, and it has to be approached in a holistic, long-term manner, since some of the after-effects may be irreparable.”

Culture

Does race impact the prevalence and type of concussion sustained by adults in the United States?

A study by Lempke et al. focused on adult patients visiting emergency departments (ED) for concussions, investigating the relationship between race/ethnicity, the number of concussion ED visits, the mode of injury (sports, motor vehicle accidents, falls, etc.), and the use of CT scan during a visit. Published in Frontiers in Neurology, the study’s data analysis showed no significant differences in race/ethnicity and the likelihood of visiting the ED for concussions. However, “relative to sports-related injuries,” Black patients had a higher likelihood of sustaining concussions through motor vehicle collisions and “other injuries” than non-Hispanic White patients. “Relative to sports-related injuries,” Asian, multiracial, or other race patients (treated as one category in analysis) had a lower probability of sustaining concussions through falls or “other” compared to non-Hispanic White patients.

Regarding CT scan usage, Hispanic patients had a 48% lower chance of receiving a CT scan than non-Hispanic White patients. A CT scan cannot diagnose a concussion but can rule out more severe neurotraumatic injuries. Not undergoing a CT avoids radiation exposure, but more severe trauma may go undiagnosed.

The study examined 884 people aged 20-45 out of 62,841 adult emergency department visits. Upon arrival at the emergency department, participants filled out a questionnaire that included race. The authors divided participants into four racial categories: “non-Hispanic White, non-Hispanic Asian, non-Hispanic Black or African American, Hispanic/Latinx, and non-Hispanic multiracial or another race.”

It is important to note that these findings may not apply to adolescents or adults over age 45. Additionally, “49–89% of concussions are estimated to be missed and not diagnosed in the ED” because concussion is a clinical diagnosis (diagnosed by symptoms and signs that may be challenging to differentiate from symptoms and signs of other injuries), so the data may not be fully representative.

Researchers advise that “future work should continue examining the complex biopsychosocial relationships surrounding concussions to ensure equitable healthcare access and delivery.”