This week's lead article, Athletes with sport-related concussions have increased speech errors, is in the Diagnostics category.

In this newsletter: Opportunities, Pathophysiology, Diagnostics, Self-Care, Therapies Currently Available, Mental Health, Youth, and Women’s Health.

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Minhong Kim, Sravya Valiveti, Nancy Cullen, Aamy Woldesenbet, Melissa Brown, and Conor Gormally

Editors: Conor Gormally and Malayka Gormally

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Opportunities

Friday, April 21, 8 am PST: Critical Elements for Return to Learn After Concussion: A Review of the Current Landscape for Students Across Ages, presented by Katy O'Brien, Ph.D., CCC-SLP, and hosted by The Center on Brain Injury and Research Training. Register in advance.

Friday, April 28, 10:30 am EST: A free virtual speaker series, Does Repeated Brain Injury Lead to a Maladaptive Phenotype? Can we Untangle the Gordian Knot?, presented by Ross Zafonte, DO, and hosted by the University of Michigan Concussion Center. Register in advance.

Tuesday, May 2, 6 pm EST: When and Why to Consult a Social Worker, presented by Eden Dales, MSW, and hosted by the Canadian Concussion Center. Register in advance.

Researchers are seeking participants for an NIH-funded (NCCIH) K23 research study at Massachusetts General Hospital and Harvard Medical School, aiming to develop and test a program to prevent persistent concussion symptoms for young adults. There is no cost for participating, no medication, and no travel. Want to learn more? See our previous newsletter, or email MGHConcussionToolkit@partners.org.

Pathophysiology

Measuring acute thalamic functional integrity has the promise to identify those at risk for persistent symptoms

In a study published in Brain, Rebecca Woodrow et al. found that chronic postconcussive symptoms in mTBI patients may be partly driven by acute thalamic pathophysiology. The thalamus, an almond-shaped structure near the center of the brain, connects nerve fibers from all over the cerebral cortex. In this study of 108 mTBI patients (Glasgow Coma Scale of 13-15 and a normal CT), researchers used functional and structural magnetic resonance imaging (MRI) to measure acute changes in thalamic functional connectivity at a mean of 14 days post-injury. Functional connectivity refers to the similarity in brain signaling between distinct brain regions; this synchronous activation during various activities indicates that the regions are functionally connected.

Compared to 76 controls, the authors observed acute thalamic hyperconnectivity in mTBI patients. Specifically, mTBI patients had increased functional connectivity across 23 pairs of thalamic nuclei compared to controls. Connectivity across thalamic regions in mTBI patients consistently matched or outmatched functional connectivity in controls. Noting that 47% of the mTBI cohort had not fully recovered six months after injury, the researchers found that these acute functional MRI markers differentiated mTBI patients with chronic postconcussive symptoms within the mTBI cohort.

Along with establishing a connection between thalamic activity and chronic symptoms, the researchers investigated the neurochemical associations of hyperconnectivity. Most notably, they found a significant positive correlation between hyperconnectivity and noradrenergic transporter density. Consequently, noradrenergic transporter density may represent a marker of interest for hyperconnectivity due to injury co-occurring with chronic mTBI symptoms.

To compare their functional MRI markers to other potential diagnostic and prognostic tools, Woodrow et al. also measured levels of various blood biomarkers (NSE, S100B, GFAP, UCH-L1, NFL, and tau protein), finding no significant difference between mTBI patients and controls. They emphasize that the “absence of visible structural damage, neuropsychiatric disease, previous concussion, or these blood biomarkers in our poor outcome groups underlined the need for novel biomarkers to help prognosticate chronic outcome.”

Further, the 31.6% of the 108 patients (34) classified as experiencing postconcussive symptoms (and a total of 51 patients, 47.2% not fully recovered) at six months exemplify that “acute functional change and chronic symptomatology are found in even the ‘mildest’ form of mTBI.” The researchers hope that acute thalamic hyperconnectivity could offer a means of portending chronic symptomology in mTBI patients.

Diagnostics

Athletes with sport-related concussions have increased speech errors

A study by Sona Patel et al., published in Frontiers in Psychology, is the first research to show increases in speech error rates following sports-related concussion (SRC), which the authors believe may indicate cognitive dysfunction. By analyzing recordings of athletes performing speech and language tasks at baseline and after concussion, the authors coded events of 14 different error types into 6 categories to compare error rates pre- and post-injury. They found that, when re-testing within six days after a concussion, athletes had increased error rates, using more fillers (like “uh,” “err,” or “um”) and paused more frequently than at baseline.

The authors suggest that this pattern of errors is a “set of compensatory mechanisms” unique to concussion, compared to moderate and severe traumatic brain injury (TBI). Further, they believe that the athletes’ use of fillers, which maintain fluency of speech, may be a compensatory communication pattern only available to those with concussions, with moderate-to-severe TBI patients unable to use fillers to maintain fluency of speech after injury.

The authors posit that these errors are suggestive of inefficient linguistic planning and underlying cognitive dysfunction. They point out that these particular cognitive linguistic functions (memory, attention, and high-order executive function) “primarily occur in cortical regions [the brain’s surface gray matter] where axonal shearing and other trauma occur” in SRC. However, they believe that this “mild cortical level trauma” is not to a degree that would affect the areas associated with articulation errors. The authors summarize that the time fillers and pauses found in SRC and the overarching cognitive-linguistic dysfunction stem from neural “insult to cortical regions of the brain.”

Speech changes following moderate-to-severe TBI are better researched, but the researchers point out that speech changes following concussion have not received nearly the same attention. This is the first study to demonstrate quantitative and qualitative changes in speech following SRC and has multiple implications for both diagnosing concussions and bettering our understanding of the neural insult to the brain that concussions present.

Self-Care

New Zealand man with persisting symptoms after multiple concussions writes a children’s book written for his young daughter to help her understand

Shaan Caskey is a father of a four-year-old girl; he also has had multiple concussions throughout life, the first of which happened in 4th form (approximately 9th grade) and the last in 2011 (7 years before his daughter was born). In an article for the New Zealand online publication Stuff, Stephanie Ockhuysen explains that Caskey’s most consequential consistent symptom is fatigue. Caskey’s fatigue has “the biggest impact on [his] life”–significant enough that he had to leave his job. It is also substantial enough that sometimes when his daughter wants a playmate, he has to tell her he can’t do that for her.

To help explain to his daughter, Willow, why he can’t play, Caskey wrote a children’s book, Daddy Needs to Sleep Today. He wrote it from Willow’s perspective (what she sees of his symptoms), answering her questions throughout the book. Caskey self-published the book and, despite writing it specifically for Willow, Caskey anticipates others with brain injuries or those with a family member with a brain injury will also connect with the book and find it helpful. “It was designed to soften the blow of why they can’t play that day,” Caskey says; his wife reads it to Willow whenever he isn’t able to play with her, and she loves it.

Caskey’s persistent symptoms are substantial; he wrote the book for his daughter in a day but then had to rest for the next two days. He uses metaphors to describe his symptoms; to Caskey, his TBI is “like being drunk and hungover at the same time...it’s like going to bed and plugging your cellphone into charge and some days it could have been plugged in all night, but you still wake up flat.” Daddy Needs to Sleep Today can be bought online at The Underground Bookstore.

Therapies Currently Available

Novel innovation to aerobic exercise program for adolescents recovering from sports-related concussion

An article published in the Clinical Journal of Sports Medicine details a significant innovation; a new protocol for prescribing and implementing subsymptom threshold aerobic exercise programs for adolescents recovering from sports-related concussion (SRC) without requiring systematic graded exercise testing. Graduated exercise programs facilitate faster recovery from SRC and reduce the incidence of persistent post-concussive symptoms (PPCS). Authors Haley Chizuk et al. note that the requirement for formal exercise testing before prescribing an exercise program has been a barrier since many clinics do not have the equipment or time to do a formal exercise test. The authors emphasize that before starting an aerobic exercise plan, the patient should not have cardiovascular, vestibular, or musculoskeletal issues that could cause a problem.

The paper describes a safe, effective procedure for clinicians to prescribe an exercise program using a Heart Rate threshold (HRt) formula that takes into account the sex of the adolescent patient and days since injury–they found that the age of the adolescent was not a factor. The exercise program follows the FITT principle (frequency, intensity, type, and time). It provides a chart of suggested intensity (HRt) for male and female concussed adolescents from the first week through the fourth week of recovery; the patient uses an HR monitor (Apple Watch, Fit Bit, etc.) to adhere to the HRt. The chart provides 80% and 90% HRt ranges, as previous studies focused on meeting an 80% HRt, but the authors note that they have found 90% HRt to be safe and potentially more effective. The type of exercise should be aerobic, such as swimming, running, or walking, with a recommended frequency of 20 minutes per day, 5 to 6 days per week. In addition, regular modification of the exercise plan is necessary to improve effectiveness and adherence; the occurrence of PPCS symptoms (during the period of the exercise program) may also be grounds for further modification. If symptoms persist after four weeks, patients will require a multidisciplinary rehabilitative approach in addition to exercise.

In summary, this sports exercise program offers a promising approach to helping adolescents recover from SRC more quickly and potentially reduce PPCS incidence. By eliminating the need for graded exercise testing, this program could provide a more accessible and cost-effective solution for managing SRC recovery. Future studies should examine exercise prescriptions for different ages, fitness levels, and those experiencing PPCS, as well as compare the effectiveness of exercise interventions derived from graded exercise tests versus those guided by subjective symptom responses only.

Mental Health

Concussion is associated with increased risk of mental health issues, hospitalization, and self harm in youth

A recent journal article published in JAMA Network Open found that children and adolescents who sustain a concussion face an increased risk of mental health problems. Overall, children and adolescents who had sustained a concussion had a 40% higher risk of developing a mental health issue than children who had sustained an orthopedic injury.

Ultimately, the authors conclude that concussion is “associated with an increased risk of mental health issues, psychiatric hospitalization, and self-harm” among youth aged 5-18. The study authors recommend that providers assess patients’ mental health and note that pediatric concussion patients see improved outcomes when receiving mental health treatment alongside collaborative care.

In this retrospective study, authors Andrée-Anne Ledoux et al. examined ten years of medical data, resulting in a sample of 448,803 children (aged 5-18) who had sustained either a concussion or orthopedic injury. The authors compared rates of new mental health diagnoses between the 152,321 children diagnosed with a concussion and the comparison group of 296,482 children who had sustained an orthopedic injury. Children from both groups were matched by age and sex.

Since concussion can exacerbate pre-existing mental health issues and the team wished to study the rates of new mental health problems after a concussion, Ledoux et al. excluded individuals with mental health contact with the medical system in the year before their index (first) year in the study. Analysis revealed that the incidence rate of a new mental health diagnosis was 11,141 per 100,000 for children in the concussion injury group and 7,960 per 100,000 for children in the orthopedic injury group. One of the study’s limitations is that the authors could not adjust for factors that may increase the risk of mental health problems after a concussion, “such as family anxiety, the psychosocial consequences of postconcussion symptoms, coping skills, management protocol, and a sedentary lifestyle.”

Youth

COVID-19 pandemic has made it harder for students to get recommended concussion care

An article by Alexandra de Leon published on the Harborview Injury Prevention & Research Center (HIPRC) website notes that many students in the state of Washington who have suffered a concussion during the COVID-19 pandemic have not been receiving the recommended concussion care due to inadequate support or lack of accommodations available at their schools. Concussions in youth are a significant public health concern across the country; de Leon states that “as many as 7% of U.S. youth will have at least one concussion before age 18, according to a recent study from the U.S. Centers for Disease Control and Prevention.” Further, adolescents age 13-17 are at higher risk of not receiving the care they need following a concussion.

The article also sheds light on how long-term sequelae and persistent effects from a concussion have been going under-recognized or under-treated. According to Dr. Monica Vavilala, Director of HIPRC and a professor of anesthesiology and pain medicine at the University of Washington School of Medicine, “People used to think of concussions as being something different from a traumatic brain injury—that concussions were mild, no big deal and didn’t really require that much attention.”

The article calls for more vigilance at home with youth who have been experiencing lingering symptoms after a concussion, such as “headaches, fatigue, difficulty with concentration, and emotional problems such as anxiety and depression,” as persistent symptoms have a direct impact on their academic performance at school and may lead to lower grades. These factors highlight the need for parents to be cognizant of signs that their kids are experiencing debilitating or persistent symptoms after concussion––and to promptly seek medical attention instead of dismissing those signs. Recovery for kids with a concussion will be different for every case; the combination of symptoms will be unique and recovery time could vary anywhere from a few weeks to longer if the symptoms persist and are not properly addressed. The article emphasizes that prompt diagnosis and timely follow-up are essential to reduce symptom severity and risk of long-term psychological or cognitive harm.

Recently, some schools in Washington state have implemented a concussion return-to-learn program developed by the CDC that enables schools to make accommodations for their students. These accommodations include “physical and cognitive rest for several days after the injury and a gradual return to full academic activities based on a learning plan tailored to the individual student’s needs.”

A recent study by Dr. Vavilala et al. published in Future Medicine evaluated the implementation of concussion return-to-learn protocol and academic support structures at 21 Washington public high schools during the COVID-19 pandemic. Findings revealed that “1 in 4 schools made no program-based accommodations during this span and those that did still struggled to provide the recommended support.” Dr. Vavilala highlighted the need for evidence-based guidelines and proper resource allocation to schools to offer the appropriate guidance and accommodations needed to support their students with a concussion.

Dr. Vavilala notes that a “Return to Play” law currently exists in Washington state, which “requires athletes suspected of having a concussion to be evaluated by a medical professional, and be allowed to return to play only when deemed safe.” She hopes to work actively with state policymakers to ensure a return-to-learn law is passed soon.

Women’s Health

The creation and evaluation of the Brain Injury Screening Questionnaire IPV Module

A study in the Journal of Neurotrauma determined that a newly developed Brain Injury Screening Questionnaire IPV Module is a promising tool for identifying traumatic brain injury (TBI) in the context of intimate partner violence (IPV). This research from authors Dr. Kristen Dams-O’Connor et al. is significant for multiple reasons. Firstly, intimate partner violence is highly prevalent, with one in three women in the United States experiencing IPV in their lifetime. Secondly, physically violent partners often target vulnerable parts of the body, such as the head, neck, and face, which can cause a TBI, a brain injury (BI), or acquired brain injury (ABI) related to nonfatal strangulation (NFS).

Despite the wealth of new research about the connection between IPV and TBIs, survivors are often unaware of this connection, and healthcare providers frequently overlook it despite its prevalence and serious ramifications. On top of that, there is significant evidence that those with a history of IPV are more likely to report when asked directly about IPV-related experiences. Therefore, the researchers aimed to develop and evaluate a new tool, the Brain Injury Screening Questionnaire IPV Module.

There were two parts to the development and evaluation of the IPV Module. First, the researchers created the module using items from existing IPV and TBI screening tools and sought multiple rounds of feedback from different stakeholders. The result was a 7-item self-report questionnaire that asked about participants’ history of IPV-related injuries. The second step was to test out the efficacy of the module on participants. They added this questionnaire to another study about the Late Effects of TBI. The general results of this experiment, Dam-O’Connor et al. tell us, is that “specific cueing about IPV-related injuries appears to elicit more comprehensive reporting as compared to more general queries about violence or safety.”

The findings from this study are significant, as they expose a few critical issues of IPV with BI screening. Dam-O’Connor et al. describes how the “standard TBI screening tools are inadequate for identifying IPV-BI and structured cueing of IPV-related contexts yield greater reporting of both IPV- and non-IPV-related violent BI.” On top of that, even in settings that use the gold standard of TBI screening, IPV-related injuries go unnoticed. Therefore, incorporating this module is necessary to fully bring this “hidden epidemic” into the light and identify IPV survivors in need of care for TBI.