Happy September! We have another excellent newsletter for you this week, courtesy of our volunteer writers.

We’re thrilled to announce that Concussion Alliance will be presenting a poster at the upcoming International Brain Injury Association 2022 Joint Conference on Brain Injury entitled Patient and Provider Reflections on Improving Care for Persistent Post-Concussion Symptoms. The conference runs September 21-24 in New York.

The lead article this week, Almost 75% of Emergency Department concussion patients don’t recover at 2 weeks, is in the Diagnostics category.

In this newsletter: Opportunities, Education, Sports, Pathophysiology, Diagnostics, Therapies & Diagnostic Tools Under Research, Statistics, Women’s Health, & Culture.

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Kira Kunzman, Minhong Kim, Shelly Seth, Sravya Valiveti, Lori Mae Yvette Calibuso Acob, Padmini Konidena, and Melissa Sodko

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

Tuesday, September 13, 6 pm EST: A free online webinar, Intro to Concussions by Dr. Charles Tator, including a presentation and a Q&A session. Hosted by the Canadian Concussion Centre. Register in advance for the webinar series.

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."

Education

Only 15% of medical students in Scotland receive concussion education–92% want it

A study on concussion education for medical students in Scotland, published in Brain Injury, found a disparity between current levels of concussion education and the "desire and importance placed on concussion education by the medical students." Authors Christopher G Gervis et al. identified that "knowledge gaps exist in managing and preventing sports-related concussion."

The survey, comprising 23 questions, was distributed in Oct 2020 to Scotland medical students in Years 3-6, of which 200 (8%) students responded. The average knowledge score was 87.3% for symptoms and 31% for concussion management. 15% shared that they received some concussion education in medical school, and 92.5% expressed interest in being educated on concussion management while in medical school.

Other results suggested that "15% of participants knew that headgear has no role in preventing concussions and one participant correctly identified the minimum ‘return to sport’ timeframes for adults and children."

Previous research showed deficiencies associated with concussion education knowledge amongst medical students. By assessing the current knowledge levels of students in Scotland medical schools, this survey highlighted a future need for improving concussion education and teaching in medical schools to keep medical students and the physician workforce informed.

Sports

Football Association of England ban on youth heading–commentary

The Football Association of England (FA) announced a trial ban on heading for some players 12 years old and younger; a commentary about the ban by distinguished researchers Willie Stewart and Alan Carson was published in Nature Reviews Neurology. The trial ban, which runs the 2022-23 season, was put into place after former athletes voiced concerns about younger players risking traumatic brain injuries (TBI) and long-term neurodegeneration such as chronic traumatic encephalopathy (CTE), a progressive brain disease attributed to repeated head impacts over time that is only diagnosable by autopsy. Drs. Stewart and Carson acknowledge that this ban is a positive outcome but advocate that more restrictions must be implemented to protect younger players.

US Club Soccer implemented a heading ban for players under the age of 11 in 2016. Additionally, the ban specified that players 12 or 13 years old are limited to 30 minutes of heading training per week.

If the trial is successful, the FA will apply to the International Football Association Board for permission to remove heading for all players 12 and under for the 2023-24 season. These limitations of sub-concussive hits will benefit younger athletes, hopefully reducing their risk of neurodegenerative diseases as they age.

Pathophysiology

Concussion history produces subtly elevated symptom severity in college athletes

Current literature shows that young athletes with a history of concussion experience greater symptom severity. However, Benjamin Brett et al. raise the question of how true this association is when accounting for confounding factors–such as demographics, sleep quality, and personality traits. They also sought to determine whether greater symptom severity and psychological distress are associated primarily with previous concussion injuries or with a “response to injury in general.”

Their study, published in the Journal of Head Trauma Rehabilitation, concluded that collegiate athletes with a concussion history did experience “subtle elevations in symptom severity” and psychological distress regardless of their demographics, sleep quality, and personality traits. The authors also concluded that increased symptoms are not associated with previous orthopedic injuries but rather a history of concussion.

To assess these relationships, Brett et al. conducted a cross-sectional study on 106 collegiate athletes (33 female and 73 male) between 18 and 26 who were involved in sports between December 2017 and March 2020. Athletes who used neuroactive medications or had a self-reported diagnosis of neurodevelopmental conditions, such as ADHD, were excluded. The authors also excluded individuals with a previous moderate or severe TBI, problematic alcohol or substance use, or a diagnosed concussion within the past six months. For a measure of general injury, the authors used previous orthopedic injuries, including fractures, ligament tears or sprain, joint dislocations, and muscle injuries.

Limitations of this study include the lack of generalizability to groups outside of the collegiate age. The authors also acknowledge that although they accounted for demographics as a confounding factor, their overall sample was limited in ethnoracial representation. However, Brett et al. remain hopeful that these findings will encourage clinicians to consider the etiology of symptoms when treating athletes rather than relying on medical, lifestyle, and personality factors. The team is also hopeful that their findings will advance clinician knowledge of early detection of which athletes are at greater risk of adverse outcomes.

Diagnostics

Almost 75% of Emergency Department concussion patients aren’t recovered at 2 weeks

A study published in the Journal of the American Medicine Association found that 73% of concussion patients presenting to Emergency Departments (EDs) reported incomplete recovery at two weeks, and 56% reported incomplete recovery at six months post-injury. Participants with incomplete recovery at 2 weeks were more likely to have incomplete recovery at 6 months. “Most participants with incomplete recovery reported that they had not returned to baseline or preinjury life.”

The study’s findings support the need for a better system of care for patients with mild TBI by bridging care from the ED. Emergency department clinicians need to be cognizant of the risk of incomplete recovery for patients with mild TBI. Authors Debbie Y. Madhck conclude that “The findings of this study suggest that ED clinicians should recommend 2-week follow-up visits for these patients [concussion patients] to identify those with incomplete recovery and to facilitate their rehabilitation.”

The research team analyzed participants enrolled between 2014 and 2018 in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study (TRACK-TBI), conducted in EDs at eighteen Level 1 trauma centers in urban areas. Of the 2697 participants enrolled in TRACK-TBI, 991 had a Glasgow Coma Scale (GCS) score of 15, and negative head computed tomography (CT), meeting the definition of mild TBI, or concussion.

Outcomes from the study include the Glasgow Outcome Scale-Extended (GOS-E) score, stratified according to functional recovery (GOS-E score, 8) vs. incomplete recovery (GOS-E score, <8) at 2 weeks and 6 months post-injury. An additional outcome identified the severity of mild TBI-related symptoms assessed by the Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score. When comparing 2-week and 6-month RPQ scores, those with incomplete recovery at 2 weeks were more likely to have incomplete recovery at 6 months.

Therapies & Diagnostic Tools Under Research

FIFA World Cup: diagnosing a concussion with virtual reality

The FIFA World Cup is the most-watched sporting event in the world, captivating more than half the world’s population with four weeks of world-class soccer. To protect players’ brain health, FIFA has unveiled its most comprehensive concussion protocol yet for the 2022 World Cup hosted in Qatar. This protocol includes permitting concussion substitutes “regardless of how many of the usual five subs have been made,” according to an article in The Sydney Morning Herald.

This World Cup is the first major tournament to incorporate a virtual reality-based concussion assessment system called NeuroFlex, which consists of a laptop, a VR headset, and analysis software. When a player sustains a suspected head trauma, team doctors will use the NeuroFlex system to help diagnose a concussion. The 8-minute-long NeuroFlex test tracks a player’s eye and head position as they perform simple tasks. These tasks focus on assessing ocular motor functions — the eye’s ability to focus on an object of interest — to evaluate brain health.

NeuroFlex may bring more objectivity to the somewhat subjective process of diagnosing a concussion during live sports matches. “Right now, the data that the medical teams rely on is very subjective – waving of a finger, a couple of balance tests, maybe a couple of cognitive tests,” says NeuroFlex executive director Grenville Thynne. “This (NeuroFlex) takes out subjectivity ... there’s a lot of data that is given to the team doc in order to make his decision.”

Statistics

One third of children experience persistent post-concussive symptoms

A review published in The Journal of Pediatrics found that approximately one-third of children with a concussion experience persistent post-concussive symptoms (PPCS). Leah Chadwick et al. performed a systematic review and meta-analysis that explored the proportion of children with PPCS along with the potential moderators of PPCS prevalence. The researchers found that “The prevalence of PPCS was higher in older and female children who presented for care at concussion clinics,” and higher in more recently published studies due to increasing knowledge and awareness about concussions.

The researchers examined 13 studies published between 2005 and 2020, totaling data from 5,307 participants. Within the studies, heterogeneity was significant, and as a result, the authors explored potential moderators. The risk of PPCS was “1.168 times higher for a 1-year increase in age; boys were 0.949 times likely as girls to have PPCS and point of care showed a 3.256 times higher risk of PPCS in specialized concussion clinics than in EDs”.

The authors also identified a limitation of the study in the lack of standardization in the definition of PPCS, which poses a challenge that may result in an over/underestimate of the proportion of children experiencing PPCS.

Chadwick stated, “Public health campaigns and clinical training to raise awareness of PPCS and moderators that increase or decrease its prevalence, may help reduce the negative consequences of persistent symptoms after concussion.”

Women’s Health

Mandatory headgear protects high school female lacrosse players

According to a study published in the British Journal of Sports Medicine, the risk of experiencing a concussion injury is significantly lower for high school female lacrosse players in states that require protective headgear compared to states that do not require protective headgear. Although girls’ lacrosse is not considered a contact sport, concussions can occur in various ways: ball or stick impacts with players’ heads, falls, and unintentional player contact.

Study authors Daniel C Herman et al. found that “states not mandating lacrosse headgear had a 59% greater overall incidence of concussion than those required to wear headgear.” These findings suggest that headgear should be mandatory to maximize the safety of lacrosse players.

The authors compared concussion incidence rates from high school girls teams in Florida, a state that requires lacrosse headgear, to high schools in 31 states without lacrosse headgear requirements. During the 2019 and 2021 seasons, there were 141 documented concussions–25 in the Florida group and 114 in the states without headgear mandates. Not only were concussion rates significantly higher for the nonmandatory headgear group compared to the mandatory headgear group, but there was also an observed “74% greater incidence of concussion…during gameplay in states not mandating headgear.”

Mandatory headgear consists of a lightweight, soft shell. While some argue that mandating headgear will encourage players to partake in more risky and aggressive playing behavior, the data from this study argues that headgear is essential for protecting the health and safety of high school girls’ lacrosse players.

Culture

Traumatic brain injury increases the risk of experiencing housing insecurity by 74%

A recent study in Social Sciences found that individuals with a traumatic brain injury (TBI) are at a higher risk of homelessness. The reverse is also true: being homeless could be a risk factor for TBI. Stephanie Chassman et al. performed a study with 115 participants by asking them whether their first TBI occurred before or after becoming homeless. They found around three-quarters (74%) of the participants sustained a TBI before becoming homeless.

However, counterintuitively, they discovered that the individuals in the group who had sustained a TBI prior to experiencing homelessness were “less likely to have experienced housing instability due to a mental health issue or concern,” suggesting that other TBI-related factors could result in homelessness.

Some of the TBIs sustained likely included concussions, as the screening tool included “a ‘multiple’ TBI event, defined as ‘a period where three or more blows to the head caused altered consciousness.’”

TBI and homelessness appear to be connected because a person sustaining a TBI may be unable to work or work the same hours or lose social support, which could negatively influence their housing security. In the reverse scenario, a person experiencing housing insecurity could be more prone to TBI due to an increased risk of assault and substance abuse.

Some of the TBIs sustained likely included concussions, as the screening tool included “a ‘multiple’ TBI event, defined as ‘a period where three or more blows to the head caused altered consciousness.’”

TBI and homelessness are associated with many issues, such as job loss, mental health problems, lack of insurance, intimate partner violence, and more. These issues are highly complex, and there is difficulty in determining causation. Because of the issue’s complexity, impact on people’s lives, and the lack of existing research, there is a critical need for further investigation of the relationship between housing insecurity and TBI.