(8/4/22 Newsletter) Study finds causal link between repeated head impacts and CTE

Welcome to the final 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 and will help us celebrate their fantastic work this summer!

The lead article this week, Study finds causal link between repeated head impacts and CTE, is in the CTE & Neurodegeneration Issues category.

In this newsletter: Opportunities, Sports, Pathophysiology, Diagnostics, Self-Care, Therapies & Diagnostic Tools Under Research, Veterans & Service Members, Mental Health, Statistics, Youth, Culture, & 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

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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 here.

Researchers are recruiting "current or former female athletes 18-45 yrs of age for a study assessing the relationship between menstrual cycle functioning & sports-related injuries." Your participation via an online survey will take 10 minutes total. The study is hosted by Icahn School of Medicine Sinai Research. Click here to take the survey.

Friday, August 19, 12:00 PST: A free online class, Budgeting on a Limited Income, will be presented by Scott Slater, a CPA and the Executive Director of the Brain Injury Alliance of Washingon State. You did not need to be a WA State resident to attend. Register here.

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 first 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."

Sports

Bodychecking experience does not reduce the rates of concussions and injuries

A study by Paul J. Eliason et al., published in the Canadian Medical Association Journal, showed that bodychecking experience did not protect youth hockey players against injuries and concussions. In fact, it found that players with more bodychecking experience had 2.5 times the rate of injury and concussions compared with those with less experience, with concussions being a third of those injuries. The results of this study support the removal of bodychecking in youth hockey.

Before this study, the prevailing wisdom in sport was that more practice meant more experience, which would reduce the risk of injury. For example, more bodychecking in hockey would reduce the rate of injuries and concussions. In 2013, Hockey Calgary banned bodychecking in hockey for youth under thirteen years old. The ban raised concerns about whether younger players would learn how to bodycheck, but this study provides evidence to the contrary.

The University of Calgary conducted this study in partnership with Hockey Canada, Hockey Calgary, and Hockey Edmonton. The researchers collected data from 941 hockey players aged 15-17 in Alberta over three playing seasons from 2015–2018. Researchers compared players with two or fewer years of bodychecking experience against those with three years or more and looked at the rate of injuries and concussions. The study showed that more bodychecking experience did not protect youth hockey players against injuries and concussions and strongly suggests that policies implemented to ban bodychecking resulted in reduced rates of injuries and concussions.

More research is needed to check for other factors that may affect the relationship between bodychecking experience and rates of injuries and concussions. Such variables include medical conditions, aggressiveness, and hitting experience. Regarding the findings, George Conroy, in an article for CBC, suggested that “those with more body experience are getting injured because they’re likely more aggressive and capable of inflicting harm in a game.” He stresses the importance of teaching how to practice proper checking to help reduce injuries.

Despite this latest study and the known risks from bodychecking, Kevin Kolbeka, executive director of Hockey Calgary, has yet to modify the sport and remove bodychecking in youth hockey.

Pathophysiology

Visio-vestibular deficit risks are higher based on four factors in youth concussions

A recent study published in the Journal of Neurotrauma found that adolescents’ risk of visio-vestibular abnormality depends on sex, age, concussion history, and the number of recovery days. Researchers Kristy B. Arbogast et al. researched these four risks individually, with the groups being male or female, 11-14 or 15-18 years old, 0 or 1+ previous concussions, and ≤ 28 or 29+ days for recovery. They found that visio-vestibular abnormalities are higher in females, those older than 14 years, those with one or more previous concussions, or those who spend longer than 28 days for concussion symptom recovery – compared to their respective cohorts.

Arbogast et al. also note that the abnormalities are common, suggesting that providers should target these symptoms for treatment. These abnormalities, commonly found after a concussion, involve problems with vision (eye focusing and eye coordination, for example) and the vestibular ocular reflex, which coordinates the movements of the head and the eyes to ensure stable vision. See our Visual Therapy and Vestibular Therapy pages for more information and treatment options.

The study utilized participants between 11-18 years of age in two groups: participants who sustained a concussion and healthy controls. Researchers used a visio-vestibular exam (VVE) to test for eye movement and gait in 9 exercises. Errors or symptom provocation during these exercises indicates visio-vestibular abnormalities. The researchers used the (self-reported) Post-Concussion Symptom Inventory (PCSI) or the PCSI Child (for children less than 13) to measure symptoms following the concussion. The authors monitored participants’ recovery trajectories over time using PCSI and VVE results, finding that the trajectory of symptom resolution “varies by age, sex, and concussion history.”

However, the study did have some limitations. The study involved predominantly white participants, and participants in the concussion group were from a “specialty care program [so it] may be biased towards those with prolonged recovery.” Doctors can implement the study’s findings to identify those at risk for a higher prevalence of symptoms and increased length of recovery and send them for early referral to a specialist.

Diagnostics

Eye-tracking in uninjured youth vs. those with acute or persistent post-concussion symptoms

Humans rely very heavily on their vision for many aspects of their lives, including reflexes, balance, and basic activities of daily living. Many concussion patients experience difficulty with eye tracking, which can manifest as trouble with balance, reading, and sometimes dizziness and headaches. A study by Divya Jain et al., published in the Journal of the American Academy of Optometry, compared vision differences in uninjured youth, youth with an acute concussion, and those with persistent post-concussion symptoms. Their findings indicate “a promising objective method that may potentially supplement current clinical assessments as a dynamic objective measure of vision and autonomic dysfunction.”

The study found that “thirteen eye tracking metrics were... significantly different between uninjured adolescents, and those with either acute or persistent concussion symptoms.” Jain et al. also found that partipants’ sex had a noticeable effect on the analysis of the patient’s eye tracking results. Of the 256 metrics applied, Jain found “significant differences between uninjured adolescents and those with concussions among female participants for twelve of thirteen metrics, but only in four of thirteen metrics among male participants.”

Working with 224 concussed adolescents and 180 uninjured adolescents ages 13-17, the study authors used 256 eye tracking metrics and a self-reported symptom severity test. Further work from this study could help “more comprehensively and objectively characterize deficits that may contribute to acute and persistent symptoms.”

Self-Care

Regaining your identity after Post-Concussion Syndrome

Many people with post-concussion syndrome (PCS) may feel like they have lost their identity. Symptoms of PCS may include headaches, dizziness, brain fog, emotional dysregulation, light and noise sensitivity, speech issues, and balance problems. These symptoms can be life-altering, causing a once-healthy individual to be unable to complete daily tasks such as going for a walk, socializing, or driving. Anna Leggett shares her story (published by CFG Law) of how she felt like she became a completely different person after a concussion. She states that she “just couldn’t seem to get back to being who I’d been.”

Since PCS is seemingly “invisible,” it causes many people to isolate themselves. This isolation may be due to feeling down or anxious, dealing with chronic pain, or even just the social pressures of judgment from peers. As part of Anna’s story, she shares some of the things she learned during her recovery to reclaim her identity.

Anna encourages her readers by saying, “It’s easy to fall into despair and hopelessness, but I want to encourage you that you can feel confident in who you are again.” With hard work, help from a counselor, and guidance from a neuropsychologist, Anna pieced together who she was and who she wanted to become.

Anna advises showing love towards the “new you.” Acknowledge your achievements and remember that you are doing the best you can. Paying attention to how you talk to yourself may feel like an insignificant step, but speaking to yourself in kind, encouraging words can make a difference during recovery. Finally, Anna reminds her readers to do everything they can to put themselves first during recovery. Sometimes it may be necessary to tell people “No.” Self-care is critical for recovery and gives the best chance of getting better and continuing to be the best version of yourself.

Although PCS may be a significant detour on your life map, you can frame it as an opportunity to work on developing yourself as a person. There are many books, videos, online courses, and other personal development resources which are free or inexpensive. The brain constantly creates new connections, which are influenced by our choices, experiences, habits, and what we are learning. Over time, it is possible to improve PCS symptoms and change behaviors. Anna ends her story by reflecting on the empathy that can be grown while battling PCS, saying, “Your experience gives you a different perspective on life and you will be able to use that to encourage, help and support other people.”

We recommend the following Concussion Alliance Resource pages: Overview of Self-Care, Mental Health, The Invisible Injury, Neuropsychologists, Cognitive Behavioral Therapy, and Prolonged Symptoms.

Therapies & Diagnostic Tools Under Research

New accessible blood test can show warning signs of neurodegeneration

Last year, researchers at King’s College London found that abnormally high levels of Neurofilament Light Chain (NfL) proteins in the blood could provide earlier warnings before clinical signs of neurodegeneration become definitive.

Neurofilament Light Chain (NfL) is a neurofilament type specific to neuronal damage from various causes. NfL has been widely studied in research settings, but until now, a test has not been available for doctors to use. A Labcorp press release explained that their new test may help with understanding if someone is experiencing neurodegeneration, potentially promoting the implementation of a “more effective and efficient [diagnosis and treatment] path.” This new test can be performed from a standard blood collection, making it accessible to people who may be at risk for or showing signs of neurodegeneration.

Labcorp official Dr. Joseph Volpe stated that the test can be used over time, in conjunction with treatment methods, to “indicate the effectiveness of medicines or therapies” on cognition and neurodegeneration. Using the NfL test to monitor a patient over time may also help develop treatments and facilitate medical understanding of how treatments affect people individually. This widely available test may allow doctors to see and verify if patients are experiencing neurodegeneration. To learn more about neurodegeneration, visit our page Neurodegenerative Diseases.

Veterans & Service Members

Cognitive Behavioral Therapy effective for headaches, PTSD in veterans

A study has found cognitive behavioral therapy (CBT) effective in helping veterans and service members reduce their post-traumatic headache (PTH) and post-traumatic stress disorder (PTSD) symptoms. PTH "is the most disabling complication of mild traumatic brain injury," according to study authors Donald D. McGeary et al.. Often, individuals with PTSD symptoms also have PTH, and there is no standardized therapy or treatment for those people with both conditions.

Using CBT to treat post-concussive symptoms is not a new treatment but an under-recognized one. Cognitive behavioral therapy (CBT) is a form of psychological therapy that works to change harmful thought patterns that could be causing depression, anxiety, or in this case, post-traumatic headaches and PTSD. This study, published in the JAMA Neurology Journal, found that the "CBT intervention successfully addressed headaches" for veteran service members and found significant positive results in those with PTSD.

The study authors performed a randomized clinical trial with 193 veterans who have served in combat with post-traumatic headaches and signs of PTSD. Headache-related disability was measured by the Headache Impact Test 6 (HIT-6), which has the following metrics: Little or no impact = HIT-6 score 49 or less. Some impact = HIT-6 score 50–55. Substantial impact = HIT-6 score 56–59. Severe impact = HIT-6 score ≥ 60. At baseline, participants in the CBT group scored an average of 66.1 points on the HIT-6 scale. Researchers found that those who received CBT, on average, improved their HIT-6 score by at least 2 points after the first treatment and by almost 3 points within the first six months.

To study the effects of CBT on veterans with PTSD, the researchers used a PCL-5 test to measure the severity of the patient's PTSD; the PCL-5 has a score range of 0-80 and a suggested PTSD threshold of 31-33. The study authors found a reduction of PTSD severity of at least 15 points on average in PCL-5 scores after just one session of CBT and almost a 20-point decrease after three months of treatment.

Mental Health

Collegiate athletes with previous concussions are subject to a greater possibility of mental health disabilities

Burns et al. conducted a study to assess the associations between self-reported mental health disability and baseline concussion measures in collegiate athletes. This research, published in the Journal of Clinical and Translational Research, concluded that “previous concussion history placed collegiate student-athletes at higher risk for mental health disability.” Both a history of a concussion and patients’ perception of their mental health result in a greater probability of a diagnosed mental health disability.

From student-athletes to retired athletes, research has found that concussions are reliable indicators of a greater likelihood of experiencing mental health disabilities. Unfortunately, reporting mental health problems is particularly challenging for athletes who face “stigma and pressure from coaches/teammates/fans.” For healthcare professionals, knowing that a patient who has a history of concussions may be more susceptible to developing mental health disabilities is critical for prompt referral to other appropriate healthcare professionals or treatments as necessary.

This study examined data from 333 student-athletes (ages 18 to 35), including complete health history information and Patient-reported outcome measures (PROMs). PROMs are “validated questionnaires to determine patient experiences and perception of their condition,” with the condition being the patient’s state of mental health. The questionnaire included evaluations assessing patients’ anxiety and depression with mental and physical components.

The results of this study align with findings from previous research on athletes with a history of concussions. A 2021 study by Hinds et al. in Sports Medicine concluded that there was a “higher prevalence of adverse mental health..in [elite rugby players] and in former athletes who reported a higher number of concussions.”

Statistics

Increases in childhood consumer-product-related TBIs, including concussions

A recent study published in the American Journal of Preventive Medicine tracked the long-term trends in childhood consumer-product-related traumatic brain injuries (CP-TBI). Mild, moderate, and severe TBI were all included, although the amount of mTBI (concussions) was likely underestimated. This study was the first to explore the long-term trends of CP-TBI in children, which landed over 6.2 million children in the emergency department between 2000-2019. CP-TBI includes TBIs related to sports and recreation (bicycling, football, basketball, soccer, longboarding, etc.) or contact with materials (walls and ceilings, flooring materials, bed frames, stairs, etc.).

The incidence rate increased from 4.5% in 2000 to 12.3% in 2019, with annual changes in incidence rates staying steady in females while declining in males. Some of the increase may be related to increased awareness of concussions, but more concentrated efforts to reduce CP-TBI are needed for school-aged girls. The study also suggests risk reduction measures, such as: “removing in-home, school, and playground surface hazards (e.g., uneven surfaces); improving lighting; and installing home safety devices (e.g., stairway handrails), along with the use of appropriate protective devices (e.g., properly fitting, high-quality helmets).”

This serial cross-sectional study used data from the 2000-2019 National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP), which monitors CP-related injuries presenting to participating emergency departments. Because only CP-TBI cases recorded at NEISS emergency departments are included, concussion incidence rates are likely underestimated. Some concussion patients may have entered the medical system through non-participating emergency departments, non-emergency medical providers, or never received medical care at all. It is important to note that most children with concussions enter the healthcare system through their primary care provider.

Youth

Need for earlier concussion identification in younger students and more comprehensive management in older students

A study by Katherine Price Snedaker et al., published in Brain Injury, looked at K-12 students with concussions and analyzed how sex, concussion history, and injury setting affected the time to get medical evaluation and what type of accommodations they received.

The study revealed several discrepancies in concussion management and recovery that need addressing. Based on these discrepancies, the authors create recommendations for shortening recovery times: concussions in elementary and middle school should be identified and evaluated sooner, and high schools should focus on more comprehensive concussion management and accommodation.

The study found that in the elementary and middle school (E/MS) group, more males had concussions, while in the high school (HS) group, more females had concussions. Also, the HS group generally received an evaluation faster but required more accommodations than the E/MS group. The study also compared those who had experienced school-related concussions (ScRC) and non-school-related concussions (NScRC). They found that students with NScRC were evaluated significantly later post-injury than students with ScRC.

Researchers surveyed participants from one school district from 2015-2019. The researchers noted that the study only relied on data from medical providers’ notes and didn’t do any monitoring itself. The study also didn’t account for the accommodations that students actually experienced in the classroom. In the future, a more in-depth look at the experience of students with concussion within the classroom could provide more insight.

Culture

185 Former professional and semi-professional rugby players file a lawsuit against rugby organizations

An article in Wales Online tackles the upcoming largest class-action lawsuit of its kind outside of the US on behalf of numerous professional and semi-professional union rugby players. The suit is against World Rugby, The Rugby Football Union (RFU), and the Welsh Rugby Union (WRU). Rylands Law represents the 185 semi-professional and professional rugby players in this lawsuit; these players are all in their 30s, 40s, or 50s. Former players are experiencing various neurological impairments, including early onset dementia, probable CTE, epilepsy, Parkinson’s, and motor neuron disease.

The claim is not for financial compensation but rather “to challenge the current perceptions of the governing bodies, to reach a point where they accept the connection between repetitive blows to the head and permanent neurological injury and to take steps to protect players and support those who are injured.” The claim also raises the issue of the organization’s alleged failure to provide adequate measures to inform, educate or warn the claimants about the risks of permanent brain damage. The players also claim that the organization did not take action to limit the amount of tackling in practice or games and did not the number of games per year.

Another article for Wales Online profiles Adam Hughes, a retired Welsh rugby player. At age 30, he confesses his struggle with brain damage. After only being retired for two years, Hughes cannot get his heart rate above average without having to sit in a dark room until his symptoms subside. Hughes said in the same interview that he cannot remember the rules of the game he has played his whole life, showing the devastating impacts that the game he loved so much has had on his quality of life.

The UK-based lawsuit is not the only class action lawsuit against rugby. The Irish Rugby Football Union (IRFU) faces a class action lawsuit in tandem with the UK-based legal proceedings, as reported in the Irish Times; Manus McClafferty is in charge of the case. Currently, they will not disclose more than that there are Irish rugby players involved. The IRFU has faced similar issues, so McClafferty and the players are waiting to see how the RFU lawsuit will pan out.

CTE & Neurodegeneration Issues

Study finds causal link between repeated head impacts and CTE

A study published in Frontiers in Neurology has found that repetitive head impacts (RHI) are a definitive cause of Chronic Traumatic Encephalopathy (CTE). RHI was defined as “the cumulative exposure to concussive and subconcussive events.” The study found that contact sport athletes were 68 times more likely to develop CTE compared to controls. This finding may have impacts throughout the sports world as, according to a Twitter thread by the lead author Dr. Chris Nowinski, CTE has been diagnosed in players from multiple contact sports – including football, rugby, soccer, and many more.

The research team, comprised of leading experts from various institutions across the world, used the Bradford Hill Criteria for Causation to conclude a cause-and-effect relationship between repetitive head impacts and CTE. The Bradford Hill Criteria “are among the most frequently cited metrics for evaluating causal inference in epidemiology.” According to the Frontiers article, current CTE literature “suggests an extremely high likelihood of a causal relationship . . . bolstered by the complete absence of evidence for plausible alternative hypotheses”.

The researchers acknowledge that the “link between RHI and CTE is imperfect” as “new science could change our perspective on causality.” However, this fact does mean nothing should be done. “Accepting the causal RHI/CTE link opens the door to actions that could dramatically reduce the burden of CTE moving forward while we await scientific advances.”

According to a tweet from Dr. Adam J. White, the analysis has had a reach of 4.5 billion within two days. The study’s findings put the onus on sports organizations worldwide (such as the NFL, FIFA, Rugby Football Union, and more) to acknowledge the link between RHI and CTE, thereby ensuring both their athletes and the public are not misled. Understanding the cause of CTE is monumental in preventing and managing CTE in anyone exposed to repetitive head impacts.

For additional information, we recommend this press release from the Concussion Legacy Foundation and this article from the Guardian.