Graded cervical (neck) manual therapy may reduce risk of persistent symptoms for patients with neck pain (4/28/22 Newsletter)

The application cycle for our Summer 2022 Education & Advocacy Internship is open! It runs June 13 – August 5 and is open to undergraduate students. Our program is remote and open to any students who are interested and able to attend our synchronous meetings. For more information about the program and how to apply, go to our Internship Program page

In this newsletter: Opportunities, Cannabis & Psychedelics, Pathophysiology, Diagnostics, Self-Care, Therapies Currently Available, Veterans & Service Members, Mental Health, Statistics, Women’s Health, and CTE & Neurodegeneration Issues.

The lead article this week, Graded cervical (neck) manual therapy may reduce risk of persistent symptoms for patients with neck pain, is in the Pathophysiology category.

We appreciate the Concussion Alliance Volunteers who created this edition:

Writers: Claire Holmes, Aaron Banse, Sravya Valiveti, Aamy Woldesenbet, Henry Petrini & Conor Gormally

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

Friday, April 29, 6-8 pm EST: free virtual event via Zoom, Concussion Annual Public Forum: Concussions in the Home and Workplace, including Falls and Interpersonal Violence: Prevention and Treatment. Register in advance.

Wednesday, May 4, 2 pm PST: free online class, Getting Organized with Brain Injury, presented by the Brain Injury Alliance of WA State. You don’t need to be a resident of WA state to attend. Register in advance.

Tuesday, May 10, 6 pm EST: free webinar, Legal/Legislation/Guideline Issues with Dr. Charles Tator and Mr. Patrick Brown, LLB. Produced by the Canadian Concussion Centre, sign up here.

Be part of a study on brain health and head impacts from sport: The Head Impact and Trauma Surveillance Study (HITTS) is recruiting study participants who will take a fully online, annual survey. "Anyone age 40 or older who played soccer or tackle football at any level (youth, high school, college, or pro/elite) can enroll."

Cannabis & Psychedelics

Podcast episode on psychedelics

We recommend this engaging interview with UCLA psychiatrist and psychedelic expert Walter Dunn, MD, on the UCLA Steve Tisch BrainSPORT Podcast Episode 9A: Psychedelics - How they work and comparing them to current treatments. The conversation ranges from defining psychedelics, the history of psychedelics (Cary Grant said that psychedelic-assisted therapy changed his life), to how psychedelics work in the brain. The talk is not specifically about traumatic brain injury, but we’ve transcribed the portion of the conversation addressing veterans with a history of TBI and PTSD, see below.

Dr. Daniel Adel Rafie (minute 27):

I think it [psychedelics-assisted therapy] is really striking in the context of PTSD. At our program [Operation Mend], we deal with a lot of patients who have a history of TBI and PTSD secondary to a terrible event that happened in Afghanistan or Iraq. What happens is, even trying to address that event, in someone with severe PTSD, they can’t go there. It causes a dissociative episode or it causes them to flip out and have an emotional response. You can’t actually address it–it seems like there is this huge wall up that you can’t get past. And I always thought that psychedelics would be a potential tool to be able to either climb over that wall and be able to address it without having those episodes or those experiences.

Walter Dunn, MD:

That is an excellent point. That kind of highlights why we have been able to move so quickly, why we’ve been able to maintain this steady pace and energy toward potential implementation, is really the veterans. It has to be acknowledged that a huge driving force behind making these compounds available are the veterans coming back from Iraq and Afghanistan. Because our standard treatments, they have been effective, but again, a large proportion of them it has not worked for. There have been a lot of veterans who have gone outside the U.S. to experience these compounds and they’ve been helpful, and so there’s a lot of energy and many organizations working behind the scenes talking to the major players, people in the FDA, people in the state legislatures, about how can we make these available here in the United States, “legally.”

I think their situation, in terms of the intensity of the emotion from those traumas they experienced, yes, for a lot of them, the activation energy there is too high to address with traditional therapies, but with the help of psychedelics, specifically, what has been most promising, actually, has been MDMA, has allowed them to open up about it, talk about it [in therapy]. It is from that process where they are able to see their trauma from a different perspective and associate a different emotional range with it. Typically it was about fear, anger, but under the influence of MDMA, they are able to recount their experience but feel love and compassion and empathy, and realize that the experience, or the memory of the experience doesn’t have to be all negative. Look, the content is negative, but if I can see it from a different perspective, perhaps I can live with it from a different angle.”

Pathophysiology

Graded cervical (neck) manual therapy may reduce risk of persistent symptoms for patients with neck pain

Please see our blog post to read this synopsis.

Diagnostics

After vigorous exercise, SCAT scores may be inaccurate due to non-injured athletes reporting fatigue and neck pain

A team at Rutgers University compared after-game scores on the Sport Concussion Assessment Tool (SCAT) for rugby players who had sustained a blow to the head and those who did not. Those who suffered a head injury reported 26 symptoms on average, while the non-injured rugby players reported an average of nine.

Stephanie Iring et al. point out that the on-field SCAT assessment may be “overestimating the condition and wrongly identifying symptoms like fatigue and neck pain caused from intense exercise and not a brain injury,” according to a press release. Those with a head injury were more likely to report headaches and “not feeling right,” so these symptoms may be a ‘stronger indicator of concussion in players who have just finished an intense game.”

Other symptoms more common to concussion players (compared to simply fatigued players) were “cognitive-sensory effects, emotional-affective symptoms and hypersensitivity.” The study was presented at the American Physiological Society annual meeting in April. “The researchers suggested further studies are needed to examine how these components can be used along with current physiological measures to better assess a concussion in athletes.”

Self-Care

(Not concussion-specific) Excellent resources on mindfulness and mediation

We recommend this series of resources from Dr. Peter Attia on mindfulness and meditation. This resource page includes a series of audio clips from Dr. Attia’s interview podcast series ‘The Peter Attia Drive Podcast.’

Dr. Attia obtained his medical degree from Stanford University, trained at Johns Hopkins Hospital – where he won several prestigious awards – and has been mentored by leading clinicians and scientists.

Though these resources are not specific to patients with concussion, concussions and particularly persistent symptoms can cause or worsen existing mental health conditions, such as depression, anxiety, and PTSD. See additional resources for mediation in this blog post, on our Emotional Wellness page, and in our resources on Mental Health.

Therapies Currently Available

Veterans with chronic headaches interested in complementary and integrative medicine provided by the VHA

Please see our blog post to read this synopsis.

Veterans & Service Members

Help steer research through virtual meetings in Ohio, Texas, North Carolina, and Florida – Mind Over Matter: A Veteran-driven Roadmap to Research on Traumatic Brain Injury

The input from mTBI and their caregivers will be used to develop a M.O.M. Roadmap for Research on TBI featuring PCOR topics and CER questions that matter most to veterans which will be translated into a publicly accessible resource. Virtual meetings will be taking place in the states of Florida, Ohio, South Carolina, and Texas lasting up to one hour and will run monthly through May 2023. As a token of appreciation for participation, the veteran and/or community stakeholder will receive a $10 gift card, a $10 meal card, and a challenge coin.

If you are interested in participating in the project and would like more information, please contact the Project Manager, S. Juliana Moreno (fau_smoreno@health.fau.edu).

Mental Health

Review finds consistent associations between persistent symptoms and anxiety and depression, more consistent study methodology needed

A scoping review in Frontiers in Neurology explores the research on mental health outcomes for adult and adolescent patients dealing with persistent post-concussion symptoms (PPCS) lasting 4+ weeks from injury. From the 25 studies that met inclusion criteria, researchers Elena Sheldrake et al. found a common trend: “a higher association of symptoms of anxiety, symptoms of depression, or ‘other’ mood disorders in those with higher PPCS scores.”

Additionally, “most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.” They argue that their findings highlight the critical importance of interdisciplinary treatment that includes mental health interventions for patients with PPCS.

The included studies primarily studied anxiety, depression, or both anxiety and depression, “with minimal coverage on other emotional outcomes common to PPCS such as stress, irritability, aggression, or frustration.” Within the domains the studies covered, anxiety and depression commonly occurred in pediatric and adult populations. Hospitalization, greater PPCS symptom burden, and delayed symptom resolution were associated with significantly worse anxiety and depression.

However, the authors note that it can be challenging to identify the cause of symptoms that can occur as part of either PPCS or anxiety and depression, as there is some symptom overlap between these conditions. Further, only a few studies included history-taking of personal or family mental health diagnoses.

The primary participant group across the 25 studies were outpatients who’d visited a hospital/ED or TBI clinic, though the authors mention a lack of data on pediatrics. None of the 25 studies included a patient under the age of 8, and only 6 of the 25 focused on pediatric outcomes. They also cite a lack of data on geriatrics; only one of the 25 focused on geriatric populations, even though they are at high risk for concussions due to falls and complications from underlying or pre-existing conditions. The majority (17) of the studies focused exclusively on adults aged 19-60.

Overall, the authors found some difficulty in drawing conclusions due to differences in definitions, evaluation techniques, and other procedural and methodological details among the studies they reviewed. They argue that the high variation of study methodology supports “the call for common data elements in TBI research, such as those outlined by the National Institute of Neurological Disorders and Stroke, which aims to standardize and unify data collection studies related to TBI to increase efficiency and efficacy.”