Welcome to another edition of our Summer 2022 Education & Advocacy Internship newsletter! The synopses you’ll be reading this week were written by our fantastic cohort of interns as part of their program; we hope you enjoy!

The lead article this week, Electroacupuncture may improve sleep quality in patients with depression, is in the Therapies Currently Available category.

In this newsletter: Opportunities, Education, Sports, Cannabis & Psychedelics, Diagnostics, Therapies Currently Available, Therapies & Diagnostic Tools Under Research, Mental Health, Statistics, Youth, Women’s Health, & CTE & Neurodegeneration Issues.

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Aaron Banse, Amanda Cheney Zitting, Ania Hoang, Chad Foster, Elizabeth Zegarowicz, Fadhil Hussain, Kaori Hirano, Kira Kunzman, Padmini Konidena, Sarah Fink, & Shannon Glor.

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

Thursday, August 4, 12:00 pm PST: A free online class, Return to Driving and Work after TBI, will be presented by Dr. Jamie Ott, D.O., Hosted by the Brain Injury Alliance of Washington State. You did not need to be a WA State resident to attend. Register in advance.

The University of Michigan Concussion Center is providing a free online course and concussion training certification, providing “information for coaches, athletic trainers, parents, and athletes on the basics of concussion.” The course is open to all and provides a certificate of completion for those in Michigan. Note: you will be prompted to create an account before taking the course.

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.”

Education

MyBrainPacer: an app to promote individual recovery practices for mTBI patients

A recent article from Global News outlines the features and benefits of an app currently being developed by scientists at the Lawson Health Research Institute and St. Joseph’s Health Care London in Ontario, Canada. Currently only available in Canada, the app – called MyBrainPacer – is used to “track and organize brain activity” in people living with a mild traumatic brain injury (mTBI). It allows patients to track their daily activities such as “driving, grocery shopping, exercise and screen use” by implementing a point-tracking system. The points system aims to keep patients within a specific range of activity so that they don’t experience a flare-up of symptoms, whether later in the day or sometime in the following days.

As Lawson scientist Dalton Wolfe states, “The problem is that people sometimes overdo it and forget that they’re still in recovery…when they do, those terrible symptoms may last again for quite a long time, and it sets their recovery back.” As patients monitor the short- and long-term effects of particular daily activities on their energy levels, they can find “a personalized level of activity to promote individual recovery.”

MyBrainPacer app allows patients and their clinicians to work together to find healthy ways for the patients to orient their lives and most efficiently allot their energy. Because “the relationship of symptoms with activities…var[ies] over a large number of people,” clinicians can better understand how their particular patient responds to specific activities. This app is still in the developing stage and is currently only available in Canada. But hopefully, as scientists continue to refine and advance the features of this app, it will equip patients and clinicians with valuable tools to promote an emphasis on individual recovery.

Sports

MLS Player is the First in U.S. Pro Soccer to be diagnosed with CTE

While much of the talk around chronic traumatic encephalopathy (CTE) is associated with injuries from American football, it’s not just these football players who suffer from it. In 2020, former major league soccer player Scott Vermillion died at only 44 years old due to a mix of alcohol and prescription drug poisoning. Boston University CTE Center studied his brain, discovering that Scott had been suffering from CTE – a degenerative brain disease that causes memory loss, depression, aggressive or impulsive behavior, and often leads to premature death.

This diagnosis places Scott as the first professional soccer player in the U.S. with a public case of CTE and adds to the notion that this issue has gone inadequately addressed for far too long. A New York Times article described how Scott’s health, and the life of his wife & kids, had been impacted and eventually changed forever by soccer.

Although research is still emerging around CTE, there is no doubt that this is a serious diagnosis. Major League Soccer has specific policies to educate players, coaches, and officials. There is hope that a concussion substitute policy, where teams can have additional substitutes during a game to provide more time to evaluate potential brain injuries in players, will be officially implemented. According to the Major League Soccer Player Association, current substitution rules do not give medical professionals enough time to properly diagnose potential concussions.

In a press release, Concussion Legacy Foundation CEO Dr. Chris Nowinski stated, "A dementia crisis tied to repetitive heading has been discovered among professional soccer players in the United Kingdom, and the same revelation may not be far behind in the United States.” To learn more, see our resource on Neurodegenerative Disease.

Cannabis & Psychedelics

Psychedelics study shows promise for helping individuals with mental illness

An article by Abby Carney published in the University of Texas Alcalde discusses the upcoming launch of two “psychedelic treatment studies – one for victims of childhood abuse, and one focused on veterans with PTSD.” This study is based at the new Center for Psychedelic Research and Therapy at the University of Texas (UT), led by Charles B. Nemeroff and Greg Fonzo. Their research with veterans focuses on treating mental health disorders with psychedelics.

The study will combine a guided psychedelic experience with subsequent psychotherapy, with the idea that “the trip they take on psilocybin could create a safe space for the mind to interact with these traumatic memories,” according to the UT Alcalde article. Most of the symptoms experienced during PTSD overlap with TBI symptoms, which can lead to TBI being underdiagnosed.

The trauma veterans face is different in that “it’s very repeated, and oftentimes very chronic kinds of issues… And so there’s a lot of guilt, a lot of self-blame.” Nemeroff and Fonzo think this new therapy is helpful because the psychedelics “help to open it up to more traditional therapy methods like cognitive behavioral therapy.” During the psychedelic therapy, there will be someone in the room with the veteran throughout the experience, and “they’ll be listening to music, possibly talking about the things they’re seeing and feeling.” The use of psychedelics, therefore, may prove beneficial for overlapping symptoms related to PTSD and TBI that current treatments are not well suited to address.

The psilocybin may also “promote the growth of new nerve connections which allows for the enhancement of the brain’s capacity for change.” Since this form of therapy has been legalized within certain states, like Texas, UT’s new Center for Psychedelic Research and Therapy was developed and is the first of its kind. “The Center is bringing scientific rigor to a field that hasn’t always been taken seriously.” However, this treatment is not yet FDA-approved; more trials with thousands of subjects must be conducted first, along with the legalization of the use of psychedelics into federal law.

Diagnostics

Popup alert system reduces unnecessary CT scans on children

In an article in Health Imaging, Andrew J. Knighton points out that CT scans for pediatric patients are common practice despite "The risk of clinically important TBI (ciTBI) in pediatric patients with minor head trauma is less than 1%." Kingston states, "CT scans in high-risk groups are a necessary diagnostic tool, CT scans in the low-risk groups yield little diagnostic benefit and expose children to unnecessary radiation."

In his study, Knighton et al. studied the effectiveness of an alert system that provides a multimodal assessment (including the PECARN decision rule) that helps physicians decide if a CT is necessary to rule out a "clinically important" TBI. The use of the pop-up alert system resulted in a 4.6% increase in adherence to guidelines and an 8.8% decrease in CT scans. This computerized decision support system for physicians in general emergency departments will decrease uncertainty in clinicians' diagnoses and reduce the use of CT scans on children.

The study, published in the Annals of Emergency Medicine, was conducted in 21 emergency departments involving 12,670 pediatric head trauma patients and 339 clinicians. For the study's control group using standard care models, the clinician followed the proper guidelines 94.8% of the time and performed a CT scan 38.6 % of the time. Pop-up group clinicians' guideline adherence increased to 99.4%, and the amount of CT scans decreased to 29.8%. With this pop-up alert, the study authors found a "modest, yet safe, reduction in CT scans," meaning that children are less frequently exposed to unnecessary radiation.

Therapies Currently Available

Electroacupuncture may improve sleep quality in patients with depression

A recent study published in JAMA Network Open states that electroacupuncture is “an effective and safe alternative therapy for treating insomnia in patients with depression.” We are covering this research because, although it is not about concussion, insomnia and depression are also concussion symptoms. Electroacupuncture is a form of acupuncture that includes an electrical current passed between the needles.

Xuan Yin et al. write that, while cognitive behavioral therapy (CBT) is effective for managing chronic insomnia, CBT cannot be offered in China on a large scale due to “cultural difference and limited medical resources.” Because of this limitation, the “rates of antidepressant prescriptions continue to rise,” which is a problem because antidepressants may impede sleep or contribute to oversedation. Electroacupuncture is a viable alternative to CBT and antidepressants, as it significantly positively affects participants’ sleep quality, depression, insomnia, anxiety, and sleep time.

The study included 270 participants with insomnia-induced depression. The researchers randomly sorted them into three groups: electroacupuncture (EA), sham acupuncture (SA), and the control group. All three received standard care, which includes recommendations to exercise, eat well, manage stress levels, and adhere to any pre-existing prescribed medication regimen for the study’s duration. Participants were assessed using the Pittsburgh Sleep Quality Index (PSQI), Hamilton Depression Rating Scale (HDRS-17), Insomnia Severity Index (ISI), Self-rating Anxiety Scale, and sleep time (measured with an actigraph, a wearable device to measure time asleep). Researchers examined EA and SA participants for short-term and long-term improvements with these measures; neither the researchers nor participants were aware of whether participants were in the EA or SA group. Trained, qualified specialists administered the electroacupuncture treatments for 30 minutes, 3 days a week, for 8 weeks. There was follow-up with patients up to 32 weeks after the initial.

The researchers found a significant increase in sleep quality of EA participants through the PSQI and ISI, as well as a “greater reduction of severity of insomnia, depressive mood, and anxiety symptoms at the end of the intervention.” Although the study finds a significant reduction in depression levels after electroacupuncture, Yin et al. acknowledge that other studies find no such difference. They state that “such findings were hampered by flaws in study design, including short treatment duration and different acupoint prescriptions, as well as variable acupuncturists’ skills.” Also, much of the analyzed data was subjective or based on the patient’s opinion.

A MedPage Today article notes that a limitation of this study is that acupuncturists were not blinded to whether they were administering EA or SA. Overall, the study has promising implications for electroacupuncture as a potential treatment for patients suffering from both depression and insomnia.

Therapies & Diagnostic Tools Under Research

New sensor technology may assist in earlier diagnosis of concussion by tracking head movement

Researchers have designed a sensor capable of estimating head movements essential for predicting concussions. A study published in Scientific Research demonstrated that a sensor in the form of a patch attached to the neck could track the two primary types of head movement, angular acceleration and angular velocity, which are “two essential markers for predicting concussions.”

In an article published in Smithsonian Magazine, Nelson Sepúlveda, co-author of the study, stated that the intention of the patch was “to have wearable, untethered patches that can provide real-time information about the head and neck movement of the athlete.”

The current technology used to measure head impact exposure is the Head Impact Telemetry (HIT) system, composed of many sensors that are physically connected to a helmet. This new sensor is a single patch attached to the back of the neck and uses Ferro-Electret Nano-Generator (FENG) technology. This patch can be utilized in more situations since it only needs to be placed on the neck and doesn’t require a helmet. Another benefit of the patch that suggests it is an improvement from the HIT system is that it would stop the “potential of false readings from helmet sliding or peak angular acceleration.”

Understanding how the head moves will hopefully, as Nelson Sepúlveda stated in an article published by Science News, “lead to earlier diagnosis of concussions.” These sensor patches can provide current and accurate measurements of forces on the head in a variety of sports and may assist in sideline diagnoses of concussions during sport.

Mental Health

Prompt mental health interventions for occupation-related mTBI increase likelihood of returning to work sooner

A comprehensive study published in the Journal of the American College of Occupational and Environmental Medicine expands on how mental health intervention can help those suffering from lasting TBI symptoms. Over ten years, Natasha Nanwa et al. aimed to determine the impact of timing of mental health-related interventions in patients with occupation-related mTBI.

The findings were clear: those who received mental health care within the first three months of their mTBI were 12.6% more likely to return to work sooner than those who received mental health care more than three months since their mTBI. Among patients who received care for their mental health, “the early mental health intervention group had lower mean care costs (incremental difference of $1580) and shorter durations of disability,” and a smaller loss of earnings.

If this is the case, why are doctors not recommending patients to mental health care immediately after receiving an mTBI diagnosis? Nanwa et al. believe, according to an article in JD Supra, that doctors are hesitant to prescribe mental health treatment to concussion patients because of a fear of “over-medicalization” of psychological factors. The authors posit that, historically, prompt mental health referrals were only given to those with severe psychological distress, and it was presumed that their psychological distress was the cause of persistent symptoms and difficulty returning to work. This study, however, proved otherwise. Patients who received early mental health interventions had reduced health care costs and shorter durations away from work. This suggests that worker’s comp insurers would in fact save money by paying for mental health treatment following an mTBI diagnosis. Furthermore, mTBI patients would be able to return to an everyday, normal life faster.

Statistics

Trigger warning: Suicide

Also, note that the new Suicide & Crisis Hotline number has changed to 9-8-8.

Study finds Black, Hispanic, and mixed-race people with concussion history have the highest rate of suicide attempts among youth with a history of depression

A recent study by Shawn R. Eagle et al., published in JAMA Network Open, analyzed the associations of race, ethnicity, and concussion history with reported suicide attempt (SA) rates. The study used pre-existing data on 28,442 respondents to the US Youth Risk Behavior Surveillance System (YRBSS) from 2017-2019. Survey participants responded either yes or no to having a sport- or recreation-related concussion, having depression, or attempting suicide within the past 12 months. The survey also included demographic questions, such as race and ethnicity.

The racial disparity in health care, income, and availability of mental health resources is a known issue, so researchers looked to find how it might affect SA and how concussions tied in. The study found that Black, Hispanic, and multiracial populations with depression and concussion history were most at risk for SA.

A University of Pittsburgh press release about their study summarized the findings; “Among children who were depressed, concussion increased the risk for reporting a suicide attempt by 31%. If the child reported depression and concussion in the previous year, being Black, Hispanic or Latino, or multiracial enhanced risk for a suicide attempt by an additional 28%. Within that group, females had a 33% increased risk of a suicide attempt compared to males.”

The same press release laid out some other key findings: “Black, Hispanic/Latino, or multiracial youth with depression and past-year concussion history had 59% increased likelihood of suicide attempt. Being female within the Black, Hispanic/Latino or multiracial cohort was associated with 33% increased risk compared with males in that cohort.”

“Unfortunately, this study could not parse out the temporal relationships among concussion, depression, and suicide attempt. We therefore cannot determine causality among these variables.”

These findings suggest that care disparities are keeping youth of color, particularly females, from getting the help they need, leading to worse outcomes post-concussion. “Clinicians should consider how concussion and depression may uniquely influence suicide attempts based on race and ethnicity and biological sex.” Furthermore, the study shows that significant improvements need to be made in concussion care concerning patients’ mental health. Both these issues need to be addressed in the future for the sake of equity and to keep young kids safe.

Youth

Association between Age of First Concussion and Clinical/Cognitive Outcomes in Collegiate Athletes

A recent study published in Sports Medicine found no significant association between age of first concussion (AFC) and cognitive, psychological, and physical outcomes for collegiate athletes. Authors J. N. Moody et al. suggest that “sociodemographic disparities, pre-existing conditions, and sport type may impact clinical and cognitive outcomes” more than a collegiate athlete’s concussion history.

Despite finding a lack of association between AFC and clinical outcomes, the authors emphasize that “it is important to minimize the risk of concussion in youth sports to optimize brain development and future clinical outcomes... Concussions may be associated with adverse consequences later in life, including increased risk for neurodegenerative diseases, psychiatric symptoms, neurobehavioral symptoms, and cognitive decline.”

This study examined 4,267 contact, limited-contact, and non-contact college athletes as part of the CARE Consortium, a “30-site, multiyear study examining the natural history of concussions in NCAA athletes and USA Service Academy cadets.” Baseline assessments included taking participants’ history of sport- or non-sport-related mTBI. This assessment also included tests for postural stability, anxiety[-related] psychological distress, depressive psychological distress, visual memory, verbal memory, motor speed, reaction time, and “symptoms commonly associated with concussion.” To find a relationship between AFC and clinical outcomes, the authors used statistical analysis to adjust for concussion history, sport type, pre-existing conditions, and sociodemographic factors.

The study found that earlier AFC was associated with statistically significant slower reaction time and higher global and somatic psychological distress in women. Despite the results being statistically significant, the authors concluded that “these results are likely not clinically meaningful,” as every one-year increase in AFC in women was associated with less than .003 second change in reaction time and less than a 4% change in psychological distress scores. These changes are small enough that they have little practical clinical significance. The authors found no significant relationships between AFC and clinical outcomes among men. The authors found pre-existing conditions, sociodemographic factors, and sport type had a greater impact on clinical/cognitive outcomes than an athlete’s concussion history.

Further research is needed to examine if AFC has associations with clinically relevant consequences after young adulthood. Additionally, this study has limited generalizability due to its sample of only NCAA athletes, making further research essential to understanding the effects of AFC on clinical/cognitive outcomes.

Women’s Health

High concussion rates in girls’ youth rugby, prevention strategies for both boys and girls

An article in The Conversation states that in Canada and the U.K., girls’ youth rugby has one of the “highest concussion rates across all youth sports.” In this synopsis, we discuss a study that found high levels of injuries and concussions in girls’ youth rugby, an effort to remove compulsory contact rugby participation in U.K. schools, and a study of an intervention program to reduce musculoskeletal injury.

A study published in the Clinical Journal of Sport Medicine describes the mechanisms for injury and concussion rates in female high school rugby players. Isla J. Shill et al. conducted a two-year study with female high school rugby players (214 in the first year and 207 in the second year) from Calgary Senior High School Athletics Association 2018 and 2019 rugby competitions. Researchers defined injuries as “any injuries that resulted in time loss, inability to complete a session and/or requiring medical attention.” The study found 155 match injuries, with concussions the most common (40% of injuries). (add both injuries, concussions) The researchers determined that tackling “was the most frequent mechanism of concussion in matches.”

U.K. academics and the U.K. Concussion Legacy Foundation are calling for an end to compulsory contact rugby in state-funded secondary schools; contact rugby is “compulsory for 91 percent of boys and just over half of girls.” Non-contact rugby can still incorporate the benefits of the sport while placing the player’s welfare first.

As there have not yet been tackle bans in youth rugby, intervention programs can provide more accessible strategies for concussion prevention. A study by Michael D. Hislop et al., published in the British Journal of Sports Medicine, focused on reducing musculoskeletal injury and concussion risks. In the study, 3188 male players aged 14-18 randomly received either the intervention (preventive movement control exercises) or the control program. The researchers found that completing the intervention program three times a week reduced the risk of injury by 72% and concussions by 59%. Further work is required to observe the risk reduction effect in female athletes. Given the unpredictable nature of injuries, prevention allows for safer games, protecting the young players from injuries and concussions while also letting them enjoy the benefits of the sport.

CTE & Neurodegeneration Issues

Study finds association between APOEe4 and Chronic Traumatic Encephalopathy (CTE) severity

One of the most extensive studies of the APOE-CTE association has found that the APOEε4 genotype may increase the risk of CTE progression and severity. These findings, published in JAMA Neurology, may help scientists understand the mechanisms behind CTE and provide insights into the potential prevention and management of CTE.

The cross-sectional study sought to test the association between APOE genotype and CTE neuropathology. APOE codes for the primary cholesterol transporter in the brain. According to an article in Physician’s Weekly, the APOEε4 variant of this gene is “known to increase risk of other neurodegenerative diseases such as Alzheimer’s.” The study included 364 male brain donors exposed to repetitive head impacts (RHI) through contact sports or military service – 294 individuals diagnosed with CTE and 70 controls. The brain tissue from these donors was genotyped and neuropathologically evaluated, while informants (who knew the donors during life) were interviewed for retrospective clinical evaluations of these donors.

The study found significant associations between the APOEε4 genotype, CTE stage, and the amount of tau protein deposits in the frontal lobe of donors over the age of 65. The authors found no association in subjects younger than 65. The findings suggest that “APOEε4 likely has associations both with early and late pathology of CTE”. Among football players over the age of 65, the association size between CTE stage and APOEε4 status was similar to a previously found association between CTE stage and having played football for more than 7 years, suggesting that “APOEε4 may be particularly important for disease progression and severity.”

Understanding the effect that the APOEε4 genotype has on CTE progression can provide an idea of how the disease progresses, as well as potentially inform a “precision medicine approach to harm reduction, including guiding decisions regarding contact sport play and providing a target for therapies.”