Increased risk of criminal behavior after mTBI (6/1/23 Newsletter)
This week's lead article, Increased risk of criminal behavior after mTBI, is in the Culture category.
In this newsletter: Opportunities, Education, Cannabis & Psychedelics, Diagnostics, Therapies Currently Available, Culture, and CTE and Neurodegeneration Issues.
We appreciate the Concussion Alliance interns, staff, and Leadership Team members who created this edition:
Writers: Minhong Kim, Malayka Gormally, and Ian Scott.
Editors: Conor Gormally and Malayka Gormally
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Opportunities
Friday, June 9, 8 am PST: a free webinar, Now What? Setting your student up for success. Considerations for educators, clinicians and parents, presented by Gina Piccolini DeSalvo, Doctoral Candidate, hosted by The Center on Brain Injury Research and Training. Register in Advance.
Researchers are seeking study participants for an NIH-funded Epilepsy Research Program to better understand the incidence of post-traumatic epilepsy (PTE) following a traumatic brain injury (TBI) and to improve patient care and outcomes. Participant eligibility includes people with post-traumatic epilepsy with a military service record or their caregivers; people without military service may be considered. Participants will receive a modest consultant fee. If selected for an in-person meeting, reviewers will receive reimbursement for expenses associated with attending the meeting, including, if applicable, hotel, travel, and meal expenses. The research is being conducted by U.S. Army Medical Research and Development Command and the Congressionally Directed Medical Research Programs (CDMRP). Jill Addai, MSW, LSW at GDIT is in charge of recruiting study participants. For more information, email jill.addai2@gdit.com.
Education
A recent concussion is one of the factors in weapon carrying by U.S. high-school students
A study published in the American Journal of Preventive Medicine explores the connection between exposure to school violence and carrying a weapon on school property among U.S. high-school students. The authors found an association between carrying a weapon on school property and “being threatened/injured with a weapon at school, being bullied at school, being in a physical fight at school, missing school owing to safety concerns.” However, female students experiencing bullying did not carry weapons at an increased rate.
Surprisingly, both male and female students who had experienced a recent concussion were more likely to be involved in physical fights and carry weapons than students who had not experienced a recent concussion. The study authors advocate for early intervention for students, including “positive behavioral supports and inclusion of assessment and counseling around issues of conflict resolution, substance use, psychological and social functioning, and recent concussion.”
Researchers Richard Lowry et al. used data for 28,422 students from the 2017 and 2019 national Youth Risk Surveys. They found that 4.7% of male students carried a weapon within 30 days of taking the survey, compared to 1.8% of female students. Students who carry weapons at school are more likely to be male, have experienced school violence, and engaged in substance use. It is important to note that this study does not attempt to establish any causal links, and is simply investigating potential risk factors for carrying a weapon on school grounds. Future research is needed to verify and better understand the associations observed in this study.
Cannabis & Psychedelics
Study of psilocybin for veterans with PTSD; preparation for WA state legalization of psilocybin-facilitated mental health treatment
A small-scale study through the University of Washington will explore the therapeutic use of psilocybin, the active ingredient in psychedelic mushrooms. This trial will involve 30 to 40 military veterans and first responders who have post-traumatic stress disorder and alcohol use disorder, two disorders often linked together. The participants for the study will be recruited through community interest groups that have fostered relationships with the participants, according to a UW Medicine press release.
This study is in response to Senate Bill 5263, recently signed by Washington Governor Jay Inslee, which governs the use of psilocybin for medical and recreational use. The bill's directive is to start treating people by January 1st, 2025. Psilocybin is under-researched and a novel area of psychotherapy, so this study is part of the year-and-a-half effort before the start of 2025 to develop infrastructure surrounding psilocybin-facilitated treatment and to determine if it is a viable treatment for mental health. There are many other medical trials exploring how psilocybin can be used to treat other disorders, such as depression, anxiety, and substance abuse.
The study will be performed in a controlled environment with psychotherapy before and after the psychedelic experience. During the psychedelic experience, the participants will be accompanied by two trained therapists. The group will be split in two, with half of the participants receiving a placebo. After the study, those receiving the placebo treatment will have the option to receive the psilocybin treatment.
Dr. Nathan Sackett, an addiction psychologist at the University of Washington heading the study, notes, "if your story is that you're depressed or that you have trauma or that you need to use alcohol or substances, it gets very difficult to step out of that story." He hopes that using psilocybin in a therapeutic setting will allow people to step out of their heads and question the validity of the story they tell themselves.
Diagnostics
New definition and diagnostic criteria for mild TBI
“Visual Representation of the American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury.”
A new standard for defining and diagnosing mild TBI has been developed by the ACRM Mild Traumatic Brain Injury Task Force, led by Silverberg and Iverson; it is an update of the American Congress of Rehabilitation Medicine (ACRM) diagnostic criteria, which influences research and clinical care and has not been updated since 1993. Since its publication in 1993, numerous criteria for defining and diagnosing mild TBI have proliferated, leading to difficulty harmonizing findings of different research studies and inconsistency in patient care and insurance coverage. For example, a study applied 17 definitions of mild TBI to 11,907 pediatric cases in an emergency department; the proportion of the patients that met the criteria for mild TBI ranged from 7% to 99%, depending on the definition.
The new ACRM Diagnostic Criteria, published in Archives of Physical Medicine and Rehabilitation, includes seven criteria, including the determination that the terms ‘concussion’ and ‘mild TBI’ may be used interchangeably. One new criterion broadens the possible mechanisms of mild TBI to include “forces generated from blast or explosion,” thereby including military and first responder mild TBI. It no longer uses the word ‘accident’ to describe the injury event because assault and intimate partner violence are recognized causes of mild TBI. Several criteria more clearly define signs and symptoms of mild TBI and address clinical findings in an acute clinical examination, including cognitive impairment, balance impairment, and oculomotor impairment, or “symptom provocation in response to vestibular-oculomotor challenge on acute clinical examination.”
Also new is the inclusion of laboratory findings such as elevated blood biomarker(s) and neuroimaging to rule out the need for surgical interventions. You can read the specifics of the new criteria in a downloadable 74-page document in Appendix. Supplementary materials.
According to a press release by the University of British Columbia, Dr. Noah Silverberg and Dr. Grant Iverson will be working towards widespread adoption of the new ACRM criteria.
Therapies Currently Available
Physical therapy interventions aid recovery for concussed adolescent and young adult athletes
A systematic review published in the International Journal of Sports Physical Therapy investigated the efficacy of physical therapy in treating concussed adolescent and young adult athletes.
Authors Kylie Art et al. examined eight randomized control trials for this review. Four studies used aerobic intervention for the treatment groups, which included exercises such as stationary bike workouts and walking/jogging on the treadmill. The remaining four studies used multimodal intervention for the treatment groups, which included treatments such as vestibular rehabilitation techniques, cervical spine physical therapy interventions, motion exercises, submaximal aerobic training, and light coordination.
The researchers found that these physical therapy interventions, like aerobic exercise and multimodal intervention, allowed for a “quicker symptom recovery and return to sport than traditional treatment of physical and cognitive rest” for concussed adolescent and young adult athletes. They add that none of the eight reviewed studies showed significant adverse effects from early physical therapy interventions, indicating the efficacy and the safety of this approach in treating patients post-concussion.
However, one limitation of this systematic review is that all eight studies examined used relatively small sample sizes (ranging from 15 to 118 participants). Further research may be needed to validate these findings.
Culture
Increased risk of criminal behavior after mTBI, especially for males and for multiple mTBI
A New Zealand study found that people who have experienced a single mild TBI had an “increased risk of criminal behavior.” Based on their data set, men with a single mild TBI, compared to an orthopedic injury control group, had 29% more violent crime charges and 20% more convictions. Rates for violent charges and convictions for men with multiple mild TBIs were more than double that of orthopedic controls, “suggesting a cumulative effect.” They had more violent crime charges (57% compared to 24%, an increase of 137.5%) and more convictions (34% compared to 14%, a rise of 142.86%).
The researchers Alice Theadom et al. found that there was no increased risk of criminal activity after one mild TBI for women, but there was an increased risk for violent charges and offenses for women with more than one mild TBI. No link was found to other offenses, such as drug, fraud, or traffic offenses. The study, published in Frontiers in Psychiatry, used data from a New Zealand health and justice records databases, with 6,606 mTBI cases and 15,771 matched orthopedic controls. Patients over 16 years of age were included in the study; the comparison group was matched for “age, gender, ethnicity, socioeconomic status and previous criminal charges” to control for other individual demographic variables’ potential impact on results.
In a media release from the Auckland University of Technology, Alice Theadom, PhD, said that their study shows that even one mild TBI can “influence behavior across a person’s lifetime.” She hypothesized that a mild TBI could create cognitive and emotional difficulties, including difficulty processing information, making decisions quickly, irritability, and impulsivity–which can escalate the risk of a violent response in a challenging situation. The relationship between mild TBI and violent offenses is highly complex; Dr. Theadom notes that “It is likely a mild TBI exacerbates other risk factors such as mental health difficulties, drug and alcohol [abuse], and social deprivation by reducing people’s ability to cope, make good decisions, and manage emotional reactions to events.” The researchers note that one limitation of the study is that it included only those patients who had been medically diagnosed with an mTBI, while many individuals make not seek diagnosis due to “restricted access to transport, lack of awareness, cost or fear of repercussion.”
CTE and Neurodegeneration Issues
Four former U.S. pro soccer players diagnosed with severe CTE
Four former professional soccer players were found to have chronic traumatic encephalopathy (CTE), marking the first diagnoses of the degenerative brain disease among players of the North American Soccer League (NASL), a precursor to Major League Soccer, which disbanded in 1985. According to an article by Jimmy Golen for AP News, all four players, Jimmy Conway, Jimmy Gabriel, Franny Pantuosco, and Terry Fryat, were diagnosed posthumously with the most severe stage of CTE.
Valerie Fryatt said her husband had several diagnosed concussions, but he also was a skilled and "prolific header of the ball." CTE researchers believe repeated sub-concussive blows to the head, such as heading the ball in soccer, may cause CTE. Notably, the National Institutes of Health (NIH) determined in December 2022 that CTE "is caused in part" by repeated traumatic brain injuries–although subconcussive impacts are not defined as a traumatic brain injury.
A press release by Concussion Legacy Foundation gives the background of each former player, who ranged in age from 64 to 80 when they passed and were subsequently diagnosed with CTE. Dr. Ann McKee, Director of the Boston University CTE Center and UNITE Brain Bank, where the men's brains were diagnosed, stated, "We've found CTE in soccer players, young and old, non-professional and professional. There needs to be greater emphasis on reducing or eliminating heading during soccer, as heading is a major source of concussions and the repetitive nonconcussive injuries that cause CTE." The AP News article notes that CTE diagnoses of former soccer players are expected to increase now that those who began playing the sport as children are reaching old age.