Welcome back to our regularly scheduled Concussion Update newsletters. On August 5th, we wrapped up our Summer 2022 Education & Advocacy Internship! Thank you to everyone who supported our interns by attending the showcases (you can view Part 1 and Part 2 on Youtube), checking out their project pages (more about that below), and reading their newsletter synopses.

We’re back to volunteer-written synopses and are thrilled to have our volunteers returning to continue their excellent work in bringing the latest in concussion news and research to you.

Also in this newsletter are five special synopses of the projects that our interns completed as part of their service learning with us this summer. You’ll find those below the regular categories; we are so proud of the work that these interns have done this summer.

This week we are featuring our many new Opportunities and our five new and updated website resource pages.

In this newsletter: Opportunities, Education, Sports, Pathophysiology, Veterans, Mental Health, Youth, & Culture.

New resource pages: Women & Girls, College Students, Vision Therapy, Vestibular Therapy, Long-Covid

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Fadhil Hussain, Kira Kunzman, Minhong Kim, Shelly Seth, Melissa Brown, & Caroline Saksena (new resource synopses by Conor Gormally)

Editors: Conor Gormally and Malayka Gormally

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Opportunities

The University of Michigan Concussion Center is offering 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 first prompted to create an account before taking the course.

For school professionals: a free, online course, The Concussion Awareness Training Tool (CATT), for school professionals and administrators to provide "the information they need to take an evidence-based approach in responding to and managing concussion." Estimated time: 45 minutes.

Wednesday, September 28, 9 am - 4 pm, MST: A free online symposium hosted by the University of Calgary, including morning programs on concussion prevention and a concussion panel discussion. Register in advance.

Thursday, September 29, 4:00 pm EST: A free online presentation, Tackling the Mechanisms and Aftermath of Concussion, with Dough Smith, MD, of the University of Pennsylvania. This speaker series is hosted by the Concussion Center of the University of Michigan. Register in advance.

Free, 7-part eLearning series for professionals on Partner-Inflicted Brain Injuries – the course is for "professionals working with domestic violence victims to better understand brain injury and how it can impact the people you work with." The Ohio Domestic Violence Network produces the course; go to their Online Learning Portal, which will require that you sign up for a free account (be sure to check your inbox for an activation link). Once you are in the portal, this new course is 49th out of 49, so click through to the fifth page of course listings.

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."

Through September 3: The Concussion Corner Academy is now enrolling for their fall online live and hybrid courses for physical therapists, occupational therapists, and athletic trainers, with concussion-specific training provided by internationally recognized experts. Enrollment form.

Education

TBI and PTSD Law Enforcement Training Act: Teaching First Responders How to Approach Brain Injury and PTSD

The Senate passed a bipartisan bill named the TBI and PTSD Law Enforcement Training Act and sent it to President Joe Biden’s desk, according to an 11Alive News report. This bill–proposed by Georgia Senator Jon Ossoff and Iowa Senator Chuck Grassley–will ensure that first responders and crisis intervention teams are trained to handle cases involving PTSD, traumatic brain injury (TBI), or acquired brain injury (such as from a stroke). The bill tasks several federal agencies to develop best practices for law enforcement and other first responders on recognizing signs of TBI and PTSD, interacting with individuals with these conditions, and employing newly-developed crisis intervention training tools for those with TBI and PTSD. Furthermore, this act would require the Centers for Disease Control and Prevention (CDC) to research occurrences of TBIs in the line of duty among law enforcement and first responders.

A Congressional Budget Office publication estimates that, if passed, the act “would cost $203 million over the 2023-2027 period, and $67 million after 2027.” The bill would use this money to inform, train, and equip first responders to competently handle scenarios involving individuals suffering from TBI and PTSD. The training tools would include “information on the conditions and symptoms,” “information on how to recognize persons who have a traumatic brain injury, an acquired brain injury, or post-traumatic stress disorder,” and “techniques to interact with [these] persons.” A more informed community of first responders can create better, faster support for people with TBI and PTSD in crisis.

Sports

NFL teams trial Guardian Caps during the preseason in an effort to improve player safety

NFL players have been wearing helmet caps through this preseason for player safety and research, according to an article from APNews. The Guardian Cap is a 12-oz padded shell that goes over a player’s existing helmet. The NFL states that–based on laboratory studies–there is at least a 10% reduction in the severity of impact when one player in a collision is wearing a Guardian Cap and at least 20% if both players wear them.

Reaction to the Guardian Caps has been mixed. Notably, the co-founder and CEO of the Concussion Legacy Foundation, Dr. Chris Nowinski, is not convinced of the impact it will have on long-term health. According to an article in The News-Herald, he stated, “adding weight to a helmet can make things worse for the brain when it comes to rotational impacts. Adding size to the helmet does the same thing. It’s very difficult to recreate this in a lab. We aren’t sure if this will be a net positive or a net negative.”

Offensive linemen, defensive linemen, linebackers, and tight ends were required to wear the Guardian caps during 14 padded practices through Week 2 of the preseason, which ended Monday, August 22nd. The NFL’s chief medical officer, Dr. Allen Sills, told The Associated Press, “The league will analyze data from the training camp practices and review the feedback it gathers from all 32 teams to see what impact the shells actually had on reducing head trauma and to inform future health and safety efforts.”

According to an article published in the Santa Cruz Sentinel just after the first week of the preseason, New York Jets head coach Robert Saleh was also skeptical. “I do think because of the soft blow, it’s kind of lending the players to use their heads a little bit more.” The same article noted that NFL agent Leigh Steinberg “isn’t surprised about the pushback as it pertains to leading with the head... ‘that’s been the argument all the way since they gave up leather helmets,’ Steinberg said. ‘It’s been a consistent theme. I don’t think it’s anything but helpful. Does it solve the concussion problem? No. But is it a positive? Yes.’”

NFL head coaches Kyle Shanahan, Sean McVay, and Mike Tomlin also spoke positively of the Guardian Caps. Tomlin, a member of the NFL competition committee, has made the caps mandatory for all positions at Steelers practices. After this preseason’s trial period, the NFL plans to review the data and feedback around the Guardian Cap’s usage. Head coach and competition committee member Ron Rivera stated, “if this comes out and it really helps reduce it, then I imagine we will continue.”

Pathophysiology

Reduced functional connectivity measured 72 hours after mTBI predicts chronic pain at 12 months

A study published in the Annals of Neurology found that the level of functional connectivity (FC) of two brain regions (when measured within 72 hours after an mTBI) can predict a “transition to long-term chronic pain.” Comparing individuals with chronic pain at twelve months to those who were considered recovered at 12 months, those with chronic pain had reduced functional connectivity between these two brain regions at 72 hours after their mTBI. The authors note that these findings could potentially be a vital biomarker in identifying which patients are more likely to develop chronic pain after an mTBI, which can influence interventions and treatments early on.

Study authors Bosak et al. analyzed fMRI data from 105 patients who sustained an mTBI due to a car accident. After 12 months, researchers classified patients into a chronic pain group (n=44) and a recovery group (n=61) and compared their functional connectivity (FC) maps (from the fMRI taken 72 hours post-injury), which show interactions between different regions in the brain.

The authors found differences in two major brain regions, the nucleus accumbens (NAc) and the periaqueductal gray matter (PAG). The NAc is involved in reward- and aversion-based learning, and the PAG is involved in receiving pain pathways from the senses; interactions involving these two regions are involved in chronic pain symptoms.

Researchers found that the chronic pain group showed reduced FC, or fewer interactions, between the NAc and a region in the primary motor cortex. Additionally, the chronic pain group had less FC between the PAG and the primary somatosensory cortex, which is responsible for processing sensory information. The recovery group showed increased FC for the NAc and PAG with the rostral anterior cingulate cortex (rACC), which is responsible for integrating emotion and cognition.

Connectivity has also been an essential component of a separate study published in Neuroimage: Clinical; this study showed a relationship between poor sleep quality and white matter integrity.

Researchers acknowledge that this study is limited by not including a group of healthy individuals to compare fMRIs and FC scores as well as moving while the fMRI is conducted.

Veterans

Call for service members and veterans to try a cognitive behavioral therapy app to help with depression

Cognitive behavioral therapy is effective for depression– “CBT is the #1 recommended treatment for depression but in-person CBT isn’t always feasible,” according to the Center for Neuroscience and Regenerative Medicine (CNRM) at the Uniformed Services University. CNRM is calling for study participants for their online study of a cognitive behavioral therapy (CBT) app for “service members and veterans who have a history of head injuries and who are currently experiencing symptoms of depression.”

The study aims to determine if a digital therapeutic intervention (an app) is effective. The time commitment is 30-60 min/week for 16 weeks. To learn more, contact the CNRM study team: call or text 301-461-4322 or email CNRM-D@usuhs.edu. Learn about CBT on our Cognitive Behavioral Therapy treatment page.

Mental Health

Multiple studies indicate an association between mTBIs and depression

In a study of 9428 adults diagnosed with mTBI, 23% of patients were diagnosed with a mood disorder in the following 12 months, compared to 14% of controls. Affective disorders include “depressive, anxiety, and adjustment disorders,” according to the study published in PM&R. Authors Richard L. Delmonico et al. recommend early screening for affective disorders to proactively decrease barriers to rehabilitation.

Three other studies encompassing youth athletes, college athletes, and retired NFL players found that concussions increased risk of mental illness. Canadian children diagnosed with concussions underwent screening for depression (Children’s Depression Inventory-2, or CHI-2). Similar to a previous study in adults, 22% of these children experienced depressive symptoms. Intriguingly, these same children also scored higher in the post-concussive symptom inventory (PCSI) than those children who experienced no depressive symptoms.

Mirroring the two findings above, another study discovered a 20% increase in depression in post-concussive collegiate athletes compared to a baseline test. Researchers found that only 5% of the control group increased in the Beck Depression Inventory-Fast Screen compared to their baseline test. The authors discussed a need for research into why certain athletes experience fewer postconcussion depressive symptoms since this could indicate methods for preventing these symptoms in others.

Researchers found that amongst 30 retired NFL players, a significant correlation existed between self-reported lifetime concussions and depressive symptom severity (as measured by the Beck Depression Inventory-II). Intriguingly, when the symptoms were analyzed using a three-factor model that included affective (mood), cognitive (mind), and somatic (body; appetite, energy, sleep), only the cognitive depressive symptoms were significantly related to concussions.

For more information, please read Dr. Elizabeth Sandel’s article discussing the studies, what depression can look like, and a few reasons why TBIs increase the probability of developing depression.

Youth

Evaluating for concussion? Also check for post-concussive orthostatic tachycardia

In a retrospective review of 268 mTBI patients aged 8 to 25 (average age 16), Pearson et al. found that 7% exhibited orthostatic tachycardia (OT). Published in Child Neurology Open, this review by researchers at the UCLA Easton Clinic for the Brain highlighted the absence of a telltale clinical profile for OT. The authors suggest clinicians consider screening for OT when evaluating patients with a suspected concussion.

OT is defined by an increase in heart rate (≥ 40 bpm for those ≤ 19 years old and ≥ 30 bpm for those >19) when a patient moves between supine and standing positions, and there is also a lack of orthostatic hypotension (blood pressure drop when standing up or sitting down suddenly).

In the study title, the authors emphasize that “Post-Concussive Orthostatic Tachycardia [OT] is Distinct from Postural Orthostatic Tachycardia Syndrome (POTS) in Children and Adolescents.” While POTS is more prevalent in adolescent females, this retrospective review found that post-concussive OT is not–OT was equally prevalent across the sexes and ages studied.

Of the 19 patients (7%) who had OT, 15 had a “history of prior concussion,” but all other examined demographics, injury characteristics, and medical history were insignificant predictors of OT. Due to the overlapping symptom profiles between POTS and concussion, OT and non-OT patients reported similar symptoms. However, those with mTBI and OT reported more drowsiness.

Identifying OT before deciding on a course of medication management and graded exercise program is essential. Some commonly used medications may worsen OT, and graded exercise protocols may need to be adjusted. Additionally, clinicians can recommend targeted interventions such as “increasing hydration and salt intake, compression garments, graded exercise programs, pharmacotherapy, and behavioral therapies” to patients with post-concussive OT.

Culture

Historians believe TBI could explain King Henry VIII’s tyrant behavior

Once considered a wise, intelligent, and generous king during his youth, King Henry VIII transformed into an erratic, moody, and hot-tempered tyrant in his later years. He executed 57,000 people — including his royal wives, friends, advisors, and political dissidents — more than any other English monarch.

In a study published in the Journal of Clinical Neuroscience, a team of neurologists hypothesizes that King Henry VIII’s despotic behavior could be attributed to multiple head injuries from engaging in dangerous sports. Muhammad Qaiser Ikram et al. contend that King Henry VIII’s repeated head trauma could have caused diffuse axonal injury (a form of traumatic brain injury), resulting in significant psychological change. The researchers conclude that “it is entirely plausible, though perhaps not provable, that repeated traumatic brain injury led to changes in Henry’s personality.”

Historians have previously proposed that King Henry VIII’s dramatic personality change could have been due to diabetes, hypothyroidism, McLeod syndrome, or other conditions. Yet the traumatic brain injury hypothesis does fit with history, as King Henry VIII participated in dangerous activities such as wrestling, jousting, riding, and hawking, which subjected him to repeated head trauma. Four recorded instances are “thought to have contributed to his neurological deterioration:” A collision into the ground during a wrestling match with Francis I of France, a lance hit to the face in a jousting match, a fall into a ditch during pole vaulting, and a dangerous fall off a horse.

Summer 2022 Internship Project Synopses

Women & Girls

Summer 2022 Interns Amanda Cheney Zitting and Shannon Glor updated our ‘Populations’ page on Concussion in Women & Girls for their primary internship project. The first section covers outcomes, symptoms, and diagnosis that highlights the lack of inclusion of female participants in research, representing only 20% of study participants in “guiding current clinical care for sport-related concussion.” They discuss how sex-based symptoms and physiological differences can influence how women experience concussion –as well as the additional role of gender-related societal factors. Also included are fantastic sections on comparative mental health risk and the issue of brain injury in intimate partner violence.

The page wraps up with two innovative new sections. The first section is for caretakers and includes passages on the burden of caretaking and age-specific recommendations for taking care of children or parents. The page’s ‘Resources’ section includes a passage on ‘How to advocate for yourself in doctor’s appointments and avoid medical gaslighting.

In creating the page, Amanda and Shannon performed an in-depth literature review, updated existing sections of the page, and added new sections. Amanda and Shannon worked with Elizabeth Sandel, MD, who served as a mentor and reviewed their work.

College Students

Summer 2022 Interns Kira Kunzman and Kaori Hirano created a new ‘Populations’ page on Concussion in College Students for their primary internship project. They performed a comprehensive review of the research as a basis for building their resource on how concussions impact college students. This webpage resource covers what symptoms students are more likely to have, how being in college can affect the experience of having a concussion, and what recovery and accommodations strategies may be needed. This is a much-need resource, as college students suffer concussions at a higher rate than the general population average.

Kaori and Kira developed a novel ‘Return to Learn’ plan specifically for college students, partially adapted from Parachute’s Canadian Guideline on Concussion in Sport and the US Air Force Academy’s Return-to-Learn plan. The resource also includes a section on self-advocacy and a section for educators on how they can properly support their students –supported by brand-new Concussion Alliance accommodation guides for students and educators.

Critically, this resource page includes sections on how to navigate college social life with a concussion and sections on how peers can have a positive impact on fellow students with a concussion. A concussion can be an incredibly isolating injury, especially if college students feel like those around them don’t understand or believe what’s happening to them. The page includes sections for peers, club and sports captains, and residential advisors. These resources are critical to changing how concussions are viewed and how seriously they’re taken by college students across the country.

Vision Therapy

Summer 2022 Interns Elizabeth Zegarowicz and Aaron Banse updated our ‘Treatments’ page on Vision Therapy for their primary internship project. Vision therapy is one of our most important treatment pages, as 60-80% of concussion patients deal with some form of vision dysfunction – although it often resolves on its own within a month.

After highlighting signs and symptoms associated with visual dysfunction after concussion, the resource page covers treatment options in a new section that addresses affordability and different kinds of care providers, including a breakdown of the difference between neuro-optometrists and physical therapists with a specialty in vision issues. The resource addresses what a comprehensive eye exam should look like so concussion patients know that the exam they’re getting is what they need. This updated page includes some helpful self-care tips and resources, as well as an excellent breakdown of how concussion impacts the visual system.

Elizabeth and Aaron performed an in-depth literature review to ensure that the updated page reflects the most current research and evidence available and worked with leaders in the field to incorporate their professional insights.

Vestibular Therapy

Summer 2022 Interns Ania Hoang and Sarah Fink updated our ‘Treatments’ page on Vestibular Therapy for their internship project. While many patients understand that dizziness is a common symptom of concussion, vestibular system dysfunction can manifest in many other, subtler ways that patients or primary care providers might not recognize. While most patients’ vestibular symptoms resolve within roughly three weeks, many others will need active rehabilitation for issues they made not have recognized as vestibular dysfunction.

The resource starts with signs, symptoms, and explanations of what it may feel like to have vestibular dysfunction to help our website visitors determine if this information may be relevant. From there, the treatment page outlines what vestibular therapy is, why patients should consider it, what patients can expect from vestibular exams, and what tools therapists might use. The resource includes search tools to find providers, examples of other balance exercises that patients may find helpful, and an excellent breakdown of ‘the science behind the symptoms.’

Ania and Sarah performed an extensive literature review to ensure that the updated page reflects the most current research and evidence available, additionally including patient perspectives from a vestibular rehabilitation clinic and the Concussion Story Wall.

Long-Covid

Summer 2022 Intens Padmini Konidena and Chad Foster created a new ‘About Concussions’ resource page on Long-Covid. While not strictly about concussion, “both long-Covid and concussions involve similar symptoms such as brain fog, trouble concentrating, fatigue, and more. They also result in inflammatory processes that may cause harm beyond the time frame of the initial illness or brain injury. In both, researchers are finding the elevation of the same biomarkers (markers of bodily injury).”

The resource first outlines the basics of long-Covid, including common symptoms, proposed causes, and risk factors. Studies have found over 200 symptoms of long-Covid, and the proposed causes are still being researched, so this resource aims to help patients who don’t understand what they’re feeling and why. The webpage also dives into long-Covid and the brain and the similarities between long-Covid symptoms and persistent post-concussion symptoms, both in presentation and in neuropathology. Finally, the resource goes into potential treatments for long-Covid, pointing patients to therapies and long-Covid rehabilitation clinics that may be able to help them.

Padmini and Chad performed an in-depth literature review to ensure that the updated page reflects the most current research and evidence available and worked with long-Covid and concussion researchers from the University of Denver to incorporate their professional insights.