This week's lead article, Medical marijuana decreases migraine length, frequency, severity, and disability level in patients, is in the Cannabis & Psychedelics category.

In this newsletter: Opportunities, Education, Sports, Cannabis & Psychedelics, Pathophysiology, Self Care, Therapies Currently Available, Mental Health, Youth, and CTE & Neurodegeneration Issues.

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Nancy Cullen, Lori Mae Yvette Calibuso Acob, Minhong Kim, Josh Wu, Jemsy Mathew, Conor Gormally, and Malayka Gormally

Editors: Conor Gormally and Malayka Gormally

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Opportunities

Friday, January 27, 8-9 am PST: a free online webinar, Traumatic Brain Injury in Preschool Children, presented by Brenda Eagan-Johnson, DEd, and hosted by The Center on Brain Injury Research and Training. Register in advance.

Tuesday, February 7, 6-7 pm EST: free online webinar Neuropsychological Assessment in Persisting Concussion Symptoms: How Brain Injury Affects Thinking, presented by Dr. David Gold and hosted by the Canadian Concussion Center. Register in advance.

Thursday, February 16, 11 am - 1 pm EST: a free online education event, TBI Across the Lifespan, which will explore “clinical best practices for prevention, assessment, and treatment of mild TBI, also known as concussion, for military dependents. This event will cover pediatric treatments ages 0-12 and adolescent to adult treatment ages 12 and up.” The program is presented by the Traumatic Brain Injury Center of Excellence, but you do not need to be associated with the military to attend.

Female athletes wanted for a short online research survey. Researchers at Mount Sinai Icahn School of Medicine are working to understand menstrual cycle functioning in athletes who have experienced a sports-related concussion or orthopedic injury. Take the survey here.

Athlete participants wanted for a 1 hr Zoom interview with researchers at Simon Fraser University investigating sport-related concussion. Participants must have sustained a sport-related concussion in the past year. Contact Kyle Bergh, kyle_bergh@sfu.ca, 604-989-7887.

Education

Early return to school (within 0-2 days) associated with lower symptom burden at 2 weeks, especially for those with worse acute concussion symptoms

Findings from a study published in JAMA Network Open Pediatrics suggest that extended absence from school is associated with higher symptom burden and may slow recovery in students with a concussion. Jen Christensen writes in CNN Health, "for kids ages 8 to 18 who were recovering from a concussion, an early return to school, in two days or fewer, was associated with children experiencing fewer symptoms 14 days after their injury." An early return to school (RTS) was defined as missing 0 to 2 days, excluding weekends.

Surprisingly, youth aged 8-18 "with higher initial symptoms who returned to school early had a lower symptom burden at day 14," according to researchers Christopher G. Vaughan et al. For children 5-7 years, there was no association of early RTS with less symptom burden at 14 days. The study included 1630 children (15-18 years) recruited from 9 Canadian emergency departments within 48 hours of their concussion. The researchers suggest that the efficacy of an early RTS may be due to the following:

the benefits of socialization
reduced stress from not missing too much school
maintaining or returning to a normal sleep-wake schedule
returning to light-to-moderate physical activity (e.g., gym class and recreational activities)

For additional information on RTS, see our resources Your child or adolescent was just diagnosed with a concussion. What do you do now?, and Pediatric Concussions.

Sports

Dr. Chris Nowinski reflects on NFL football player Damar Hamlin’s cardiac arrest

In an opinion article published in The New York Times, Dr. Chris Nowinski reflects on the outpouring of support for Damar Hamlin, a National Football League (NFL) player who suffered cardiac arrest during a Monday Night Football game. “I am encouraged by the outpouring of support for Hamlin, a talented player and a role model, and for his family,” says Dr. Nowinski, a former college football player and neuroscientist who directs the nonprofit organization Concussion Legacy Foundation.

Dr. Nowinski laments that while so much medical and cultural attention has focused on this single case of cardiac arrest, there has been a lack of awareness of two chronic medical conditions that pose the greatest danger to players: chronic heart disease and the long-term effects of traumatic brain injuries. Take chronic heart disease. NFL players are at an increased risk of developing chronic heart disease because of the “football weight” they gain. “Young former NFL players, mostly linemen, die from heart attacks or heart disease nearly every year,” says Dr. Nowinski. A 2019 research study found that NFL players were 2.5 times as likely to die from a cardiac cause as MLB players. Or consider the long-term effects of traumatic brain injuries. Dr. Nowinski highlights that former NFL players in their 50s are “ten times as likely to be diagnosed with dementia as the general population.” NFL players are “3.5 times as likely to die of Parkinson’s disease as Major League Baseball players.” Further, at least 10 percent of NFL players could develop chronic traumatic encephalopathy (CTE).

Experts have speculated that commotio cordis, a lethal condition that occurs when heart rhythm becomes disrupted due to a chest impact, may have caused Damar Hamlin’s cardiac arrest. Dr. Nowinski adds, “in football, where players wear lots of padding, an event like this is so rare at the NFL level that it probably won’t occur again in our lifetimes.”

Dr. Nowinski concludes, “Damar Hamlin deserves every ounce of our attention, support and respect after putting himself at risk for our entertainment. Let’s keep talking about him, his family, his teammates, his city and the fans who have rallied behind him and all the positives that he has inspired and represents, including the preciousness of life — even the parts of it that are not captured on camera.”

Cannabis & Psychedelics

Medical marijuana decreases migraine length, frequency, severity, and disability level in patients

A systematic review by Mingma L. Sherpa et al. explored the safety and efficacy of medical marijuana in treating migraine headaches: the study was published in Cureus. Migraine-like headaches are the most common type of headache experienced by concussion patients. After screening 1646 articles, the authors determined that nine articles were relevant and of high-enough quality to include in the review. The nine studies all included participants aged 18-60 diagnosed with migraines who received medical marijuana. Sherpa et al. found that “that medical marijuana has a significant clinical response by reducing the length and frequency of migraines.”

One study, in particular, found that patients experienced decreased migraine severity regardless of the concentration of THC (a psychoactive component of marijuana) or CBD (a non-psychoactive compound). The same study found that “regardless of dosage, cannabis preparation, flower, or concentration, severity was also decreased.” Another study found that medical marijuana users reported “significantly less migraine disability” and used prescription opioids and triptans at lower rates. Yet another study found that medical marijuana use “was 51% more effective than non-cannabis drugs for reducing migraines.” The authors found no severe adverse effects in any of the nine studies, concluding that, beyond showing encouraging results for its therapeutic effects, its use is well-tolerated with fewer side effects than other migraine treatments.

Pathophysiology

Diagnosable and Treatable: Benign paroxysmal positional vertigo after concussion

In a case study published in Cureus, Dr. Khalid Bashir et al. demonstrated that benign paroxysmal positional vertigo (BPPV) is a treatable, common cause of dizziness in pediatric patients with concussion. In this study, two concussed rugby players were tested using the Dix-Hallpike test and treated using the Epley maneuver, resulting in complete relief of their symptoms. The authors note, “In one study, almost 30% of pediatric patients developed BPPV following concussion.” Concernedly, “clinicians who typically manage BPPV patients are pediatricians, ED physicians, and family physicians who may have little or no experience with BPPV, which may lead to delays in diagnosis and treatment and may prolong concussion recovery.” The authors encourage providers to be trained in the evaluation and management of BPPV to expedite diagnosis and hasten recovery.

The authors shared two cases of male rugby players, aged 15 and 16, who were diagnosed with BPPV after a concussion diagnosed in an emergency department. Both developed vertigo, a sudden sensation that the room was spinning, and vomiting. The players experienced these symptoms for about five to six hours before returning to the emergency department for further evaluation, where they were diagnosed with posterior canal BPPV. Posterior canal BPPV is the most common subtype of BPPV that occurs when calcium “crystals” begin to float freely in our ear canals, sending confusing messages to our brains and causing dizziness. Luckily, posterior canal BPPV can be easily diagnosed with a Dix-Hallpike test and treated with bedside canalith repositioning maneuvers such as the Epley maneuver. After a six-to-eight-week follow-up, both players reported no recurrence of their vertigo or vomiting symptoms.

The Dix-Hallpike test involves the patient sitting up and the provider turning their head 45 degrees to one side. Keeping the head at a 45-degree angle, the provider guides the patient down, watching for rapid, involuntary eye movements, which is a sign of dizziness and BPPV. The Epley maneuver is a series of head movements intended to put those calcium “crystals” back in place, reducing the symptoms of vertigo.

Although the study is limited by its small number of case studies, they present an urgent need for physicians to be trained in efficiently diagnosing and treating patients with BPPV, which is a treatable common cause of dizziness in pediatric patients with concussion. Dr. Bashir and his team encourage providers to be trained in the evaluation and management of BPPV to expedite diagnosis and hasten recovery.

Although the study is limited by its small number of case studies, they present an urgent need for physicians to be trained in efficiently diagnosing and treating patients with BPPV.

Self Care

One woman’s story about natural remedies she used for persistent post-concussive symptoms

In an opinion piece published by CFG Law, Anna Leggett describes her experience with persistent post-concussive symptoms, mainly headaches, and the natural remedies that helped her relieve them. She had daily headaches for a year and a half, and she took strong prescription painkillers for the first few months post-concussion. She then wanted to go off them and had to find alternative remedies, which she did by looking for advice from multiple different avenues. Her final suggestions, though, are not one specific remedy that worked, but instead, that “a multi-pronged approach” is necessary, on top of patience and persistence, since it will take time before experiencing reduced pain, as well as time to try multiple remedies. (Note that “Frequent use of medications can cause medication overuse headaches”–see our resource on Headaches. For additional information, see our resources Complementary and Alternative Treatments and Overview of Self-Care).

Ms. Leggett found that headache diaries, CBD oil, essential oils, vitamins and supplements, and changing her diet are a few of the remedies that worked well for her. She also learned to emphasize self-care to manage stress levels, which helped a lot in the reduction of the frequency and intensity of her headaches. Headache diaries were a crucial part of her recovery because even though they didn’t provide care in the ways that remedies do, they made her able to see patterns in her headaches and see from past entries whether her headaches were actually getting better over time. Headache diaries are also great because they’re free – you can look them up on google and find multiple templates, and Ms. Leggett even shares the specific one she used in her article.

As Ms. Leggett says, this is from her personal experience and shouldn’t be taken as medical advice; instead, you should talk to your doctor about treatment options and keep them informed of the natural remedies you want to try. She shows that recovery from persistent post-concussive symptoms is possible, but it takes time, effort, and, most especially, taking care of yourself.

Therapies Currently Available

Vestibular rehabilitation found useful for RTS, dizziness, gait, and quality of life after concussion

What is the effectiveness of vestibular rehabilitation after concussion? Erasmo Galeno et al. did a systematic review of randomized control trials to assess the efficacy of vestibular rehabilitation (VR) for mTBI-related impairments such as "vertigo, dizziness, balance, gait disorders double or blurry vision, and others." Seven studies met the inclusion criteria, and the authors concluded that "VR seems useful to reduce symptoms in patients with concussion." Limitations include the heterogeneity of the studies and, for several VR outcomes, the lack of information on the efficacy of the VR treatment in the long term due to study designs.

Published in the journal Healthcare, some of the outcomes of VR compared to a control group (no VR) are as follows:

VR in the acute phase of concussion resulted in Return to Sport which was 2.91 to 3.9 times faster than the control group.
In the short term, VR could reduce the gait impairment of patients.
VR treatment groups scored a mean of almost 7 points lower on the dizziness handicap inventory compared to control groups in the short term. "VR seems to be a valid approach for the management of patients suffering from dizziness after concussive trauma."
In terms of quality of life, VR had a significant effect, with "a mean [quality of life score] score 6.5 points higher compared to the control group."

For further information, see our resource on Vestibular Therapy.

Mental Health

Brain fog at higher rates in mTBI patients–also correlated with depression

With all the talk of brain fog and Long Covid, it is interesting to see a study that found that brain fog was higher in patients with symptomatic mild TBI than in healthy controls and that brain fog in these patients correlates with depression. Published in Research in Nursing & Health, researchers Tyler Bell et al. found that brain fog was higher in “symptomatic mild TBI and moderate-to-severe TBI compared with healthy controls.” The authors also found “greater depressive symptoms in symptomatic mild TBI,” measured by the Profile of Moods Scale. Brain fog correlated with worse cognitive function for those with moderate-to-severe TBI but not those with symptomatic mild TBI.

One limitation of the study was that it was relatively small, involving 15 participants with symptomatic mTBI, 15 with moderate-to-severe TBI, and 16 healthy controls. Nevertheless, the authors conclude that “Brain fog appears to reflect challenges in recovery, including depressive symptoms and worse cognitive function. Screening for brain fog might be worthwhile in people with brain injuries.”

See our resource on Cognitive Rehabilitation Therapy, a type of rehab that has been shown to help “clear Covid-related brain fog.” Regarding depression, see our resources, The Invisible Injury, Mental Health, Cognitive Behavioral Therapy, and Overview of Self-Care.

Youth

How a concussion changed one college student’s academic experience

The article “Navigating a Temporary Disability: How a Sports Concussion Impacted My Academic Experience” is a personal account of Sarah Densham’s experience after sustaining a sports-related concussion. This article, published by the for-profit Best Colleges website, is an informative, worthwhile first-person account, although we have comments on the information provided. We recommend our College Students resource for those interested in this topic.

At dive practice, Sarah remembers violently smacking her head on the water, followed by the immediate sensation of pain echoing throughout her head. She describes her post-concussion life as a “new reality,” with new physical and cognitive symptoms manifesting as a result of the injury–such as headaches, fatigue, and difficulty concentrating. Sarah details the challenges of balancing the demands of schoolwork with the need for rest and recovery after a concussion. She explains that while it is essential to rest and give the brain time to heal, it can also be problematic to miss classes and fall behind in coursework. This disruption of “normal” life led to emotional distress, including feelings of isolation and frustration with the limitations her symptoms imposed on her academic and social life.

Regarding rest, current guidelines recommend resting for up to 48 hours after the injury and then gradually increasing activity. Research shows that complete rest long-term can delay recovery and may contribute to persistent symptoms. See our Guidelines to Recovery resource.

Sarah also mentions the challenges of communicating with the professors and classmates about the injury and the accommodations they need. Navigating a school’s accommodations process for students with temporary disabilities can be difficult for students unfamiliar with the process and unsure of what resources are available. Sarah reminds us about the importance of self-advocacy, seeking support from friends and family, and being patient with the healing process.

In our College Students resource, see the sections on Return to Learn, Accommodations, Self-Advocacy, Social Life, and Peers.

In the end, Sarah recovered from her concussion in three weeks. However, she was not the same person she was before her concussion. Headaches, lapses in concentration, and arduous studying sessions all intermittently plague her life. But the drawbacks of her concussion inadvertently revealed a newfound appreciation for the silent struggles that everyone goes through. Sarah’s main takeaways from her concussion are that asking others for a shoulder to lean on is a sign of strength and that life is more precious than an exam grade or sports accomplishment–so strive for a healthy one.

Headaches, trouble with concentration, and trouble with studying (including reading books and use of screens) are common persistent post-concussive symptoms (PPCS). For more information, see our resources Seek Treatment for Persistent Symptoms, Prolonged Symptoms of Concussion, Medical and Rehabilitative Treatments, Complimentary and Alternative Treatments, and Overview of Self-Care.

CTE & Neurodegeneration Issues

Pro Soccer players: around age of 65, early signs of cognitive dysfunction

An ongoing U.K. study finds that by age 65, professional football (soccer) players are more likely to have poorer brain health than non-players. Researchers at the University of East Anglia, Norwich, England, are conducting a study called Screening Cognitive Outcomes after Repetitive Head Impact Exposure—or SCORES—to investigate changes in the cognitive health of athletes as they age. Lead researcher Dr. Michael Grey told BBC that the team found “early signs of cognitive dysfunction” that appear long before memory problems or conditions like dementia become apparent. “‘The participants are being monitored for changing brain health over time, so we will hopefully follow our cohort of former footballers for the rest of their lives,’ Dr Grey said. ‘This will give us a really clear picture of the potential damage caused by heading the ball.’”

The researchers monitored a group of more than 75 former elite football players over age 40 with no dementia diagnosis and active non-footballers. They observed that, compared with the non-footballers, the professional footballers had improved brain health in their forties. However, after age sixty-five, professional footballers showed “early warning signs for deteriorating brain health,” such as worsening reaction time, executive function, and spatial navigation. Their results confirm that regular exercise associated with playing football improves brain health, but the adverse effects of contact sport also begin to appear after age sixty-five.

Currently, in its third phase, the study is testing participants from across the United Kingdom and is still recruiting study participants. The ongoing longitudinal study aims to better understand the risk of neurodegeneration in football players by monitoring their cohort of footballers for the rest of their lives. The researchers hope that as the study progresses, their collected data will serve as a vital tool for future research into predicting the risk of brain degeneration.