This week's lead article, Early intervention vestibular therapy linked to shorter recovery times, is in the Therapies Currently Available category.

In this newsletter: Opportunities, Education, Pathophysiology, Self Care, Therapies Currently Available, Therapies & Diagnostic Tools Under Research, Veterans and Service Members, and Youth.

This is the second newsletter of our Summer 2023 Concussion Education & Advocacy Internship! This week, the second half of our undergraduate intern cohort was able to demonstrate their newly gained science writing abilities.

We appreciate the Concussion Alliance interns and staff members who created this edition:
Writers: Fiona Liberge, Mackenzie Keesor, Keya Mookencherry, Kira Kunzman, Zach Napora, Maya Chawla, and Philis Fonkem

Editors: Kira Kunzman, Conor Gormally, and Malayka Gormally

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Opportunities

Wednesday, July 19, 12:00 pm PST: a free webinar, How Sensory Sensitivities Impact Relationships & Mood, presented by Maria Dalbotten, a mental health therapist and a TBI survivor. Hosted by the Brain Injury Alliance of WA State and open to the public. Register in advance.

If you missed the webinar, a recording of CLF Presents: New Research on CTE Risk & Prevention is now available.

Researchers at Massachusetts General Hospital and Harvard Medical School are offering a free program to help optimize recovery from a recent concussion.

Who can participate? Ages 18-35 years old; have a concussion from the previous 10 weeks; English fluency.

What does it involve? Participate in 4 virtual sessions (45 minutes each); The sessions will take place from the comfort of your own home using secure live-video; Complete 3 sets of questionnaires online through secure link about your emotional functioning and concussion symptoms.

Participants can receive up to $90 for participating in the program and answering questionnaires. No cost, no medication and no travel. Want to learn more? Email MGHConcussionToolkit@partners.org

Education

College students have limited concussion knowledge, colleges should allocate resources to students’ sources

Research by Stephen J. Heck et al., published in Future Medicine, found sex differences in how college students learned about concussions, where they wanted to learn about concussions in the future, and their existing concussion knowledge. The authors hoped to contribute to literature exploring concussion knowledge among college students; their results demonstrate the need for better health education. Lack of education about concussions can cause delays in identification, reporting, and treatment, which can negatively impact recovery times, academic work, and sport participation. Heck et al. also emphasize their goal of capturing the range of media through which a non-athlete specific sub-population of college students are educated.

From a survey given to a random sample of 208 college students, the authors concluded that students of both sexes demonstrated a limited understanding of the symptoms, consequences, and appropriate management of concussions–though females scored slightly higher. However, these students relied on similar sources of information, including healthcare professionals, coaches, and the Internet.

Heck et al. also found that education cannot be forced on students, concluding that meeting them where they are is the best tactic to provide necessary resources. They found that health educators, health centers, and campus peer educators are best positioned to deliver information. The authors suggest that colleges and universities allocate resources appropriately to account for students’ preferences.

Information regarding symptom identification and the risk of continuing activities is essential for college students (both athletes and non-athletes), and researchers should continue to explore the perspectives of all of their students.

Pathophysiology

Prolonged microglial activation observed beyond clinical recovery following concussion in collegiate athletes

A study published in Frontiers in Neurology found persisting microglial activation in concussed college athletes after they had been cleared for play based on their clinical recoveries. Microglia are the “immune cells of the central nervous system” and play a role in brain homeostasis; after a brain injury, microglia activate to promote pro- and anti-inflammatory responses and “influence synaptic remodeling and white matter recovery with brain injury.” This study by Neumann et al. compared collegiate athletes with concussions (five male and three female) and healthy collegiate students (five male and five female).

After the concussed athletes reported being symptom-free, they “progressed through a standardized graded exercise protocol prior to medical clearance for an unrestricted return to play by a physician.” Nevertheless, MRI and PET scans revealed persisting microglial activation, providing evidence of “incongruence between clinical and physiological recovery.” The researchers note that it is not conclusive whether the persisting microglial activation is part of a normal pro-inflammatory response as the body combats an injury or “onset of an anti-inflammatory chronic pathology,” something which future studies will hopefully help determine.

After clinical recovery, collegiate athletes are typically allowed unrestricted return-to-play (uRTP). Neumann et al. collected data in the collegiate athlete group at three time points: a baseline assessment prior to participating in sport, a second visit within 24 hours of their concussion, and a third visit after receiving uRTP instructions. The healthy, physically active students group had not done a baseline assessment and only participated in the second and third visits; they had no known head injuries during the experiment. During the second and third visits, all participants completed a “multidimensional battery of tests,” including mood, sleep, and neurocognitive assessments; a blood draw for DNA testing; and a brain MRI and PET.

Despite being cleared clinically with uRTP, findings for the group of concussed collegiate athletes consistently demonstrated persistent microglial activation. The researchers were motivated because of the increasing understanding that physiological concussion recovery persists beyond what can be identified by the current methodology for clinical evaluation. New physiological measures have helped advance researchers’ understanding of concussion-related neuroinflammation and how microglial activation could potentially function as an indicator. This study serves as a vital first step in understanding central microglial activation associated with concussion and what changes occur beyond “clinical recovery.”sis

Self Care

Physical fitness linked to physiological and psychological benefits for all ages

A literature review from Frontiers in Behavioral Neuroscience analyzed the effects of physical exercise on brain resilience, concluding that exercise has both physiological and psychological benefits. Expressly, they point to the role of exercise in delaying the onset of stress-related disorders and reducing the decline of cognition and physical abilities that occurs during normal aging. Researchers Arida and Texeira-Machado studied the benefits of physical activity over different stages of life (prenatal, childhood and adolescence, adulthood, and aging) and its impact on neurological disorders such as Parkinson’s Disease (PD), epilepsy, and strokes.

The research suggests that people who engage in physical fitness may find themselves more able to be cognitively resilient to depression, anxiety, and stress during youth and adulthood, as well as neurological disorders later on. Examining neurobiological mechanisms across all life stages, the authors found that “exercise positively influences brain and cognitive reserve by multiple pathways.”

Although this article does not directly link physical fitness benefits to concussion, we believe this information is relevant because physiological and psychological health is critical to the process of concussion recovery and maintaining wellness following that process.

A literature search resulted in 12 studies exploring the connection between physical fitness and brain resilience and 114 studies that provided information regarding different life stages and neurological conditions. While the summation of data suggests that “aerobic fitness [is] one of the best indicators of resilience,” the most effective dose parameters of exercise (e.g., intensity, type, and duration) are still further areas to explore, as many studies generate inconsistent results due to varying measures of activity.

This literature review emphasizes the importance of maintaining good physical fitness throughout life to support physiological and psychological health. Notably, physical exercise was positively linked to attenuating neurological disorder progression. Building a solid cognitive reserve can “prepare the brain to be more resilient to cognitive impairment, dementia, and consequently Alzheimer’s pathology,” most likely through promoting brain plasticity.

Therapies Currently Available

Early intervention vestibular therapy linked to shorter recovery times

A study published in Cureus found a relationship between the timing at which athletes with concussions received vestibular therapy and their time to return to play. In this retrospective study, Benjamin Ferry et al. found that athletes aged 12-25 who received vestibular therapy ~eight days after their initial injury returned to play faster than those who faced delays in accessing treatment. According to the study authors, “Including vestibular therapy in a multidisciplinary approach to concussion treatment may reduce the time for recovery and get athletes back playing their sports earlier.” This study found that expediting the introduction of vestibular rehabilitation increased its effectiveness.

The study authors found that for every one-day increase in time from injury to initial vestibular therapy, the mean time from injury to return to play (RTP) increased by one day. They also found other things that delayed return to play, including having a higher symptom score at initial evaluation, higher dizziness index score, and being female.

Researchers looked at patient charts from The Sports Medicine Concussion Clinic at Duke University over a five-year period. They used the charts from 282 athletes aged 12-25 who experienced sports-related concussions and tested positive for vestibular dysfunction (53.3% female and 46.7% male). Ferry et al. analyzed the relationship between the time of injury, the time of the initial vestibular therapy visit, and the date of the patient’s return to play. They also did a second analysis with patients who had significant dizziness at their initial vestibular therapy appointment–measured with the dizziness handicap index score–to evaluate the relationship of significant initial dizziness with time from injury to return to sport.

More research is needed to investigate the impact of early intervention vestibular therapy outcomes for patients outside the 12-25 age range. Future research should target the optimal time for initiation of vestibular therapy, duration of therapy, and frequency of therapy.

Therapies & Diagnostic Tools Under Research

Safety and feasibility of a telehealth-compatible graded exertion test for concussion care

The shift towards virtual healthcare over the COVID-19 pandemic sparked the development of a telehealth-friendly graded exertion test (GXT) named the MOVE (MOntreal Virtual Exertion) protocol. The safety and feasibility of this cost-effective, no-equipment test was evaluated in a study published by Dr. Liz Teel et al. in the Journal of Neurotrauma. Children in the subacute stage of concussion (approx. 31.5 days post-injury) and healthy controls completed the entire MOVE test with no adverse events. A remote GXT has great potential to expand the accessibility of individualized subsymptom threshold aerobic exercise prescriptions for concussion patients.

The MOVE protocol is a seven-stage sequence of progressively intense bodyweight exercises that can be administered over a telehealth platform. The MOVE protocol’s fixed number of stages makes it more time-effective than the Buffalo Concussion Treadmill Test (BCTT), for example, which is a continuously increasing “ramp-incremental” exercise test that stops when the patient reaches exhaustion. The final MOVE stage representing the highest exercise intensity is burpees, but under the guidance of the Montreal Children’s Hospital Concussion Clinic, burpees were substituted for high-knee running in the concussion group to reduce vestibular strain and simplify the movement pattern. 15 of the 30 concussed participants performed the MOVE protocol, and the other 15 performed the BCTT for comparison to current best practices. While all concussed participants completing the MOVE were monitored by a licensed physiotherapist out of caution, the test was delivered over video conferencing by a researcher in another room, staged as a bona fide simulation of telehealth.

Aerobic exercise programs are becoming a widely used tool in concussion rehabilitation, and it is currently considered the primary recommendation for care. To design an exercise program suited to the patient’s individual physiology, a graduated exercise test is conducted to establish a target intensity for the patient; the patient’s maximum sub-symptom heart rate was the target intensity in this study. However, the recently released 6th Consensus Statement on Concussion in Sport suggests identifying a heart rate threshold (HRt) at which the patient experiences no more than mild symptoms rather than being completely subsymptomatic. The target exercise intensity can be progressed throughout the course of rehabilitation.

The use of the MOVE GXT as a basis for developing exercise prescriptions has yet to be evaluated in practice, though the results of this study are encouraging. Further research should also focus on investigating whether this test is tolerable for patients in acute stages of concussion, as well as trialing a fully unsupervised administration of the test for children. Overall, this feasibility trial holds promise for the MOVE as a safe modality for graded exertion testing in telehealth environments, and is certainly an advancement in overcoming barriers to concussion care.

Veterans & Service Members

High risk for suicide, drug, and opioid OD deaths among service members with mTBI history who racially identify as ‘Other’

A study published in The Journal of Head Trauma Rehabilitation highlights the significance of understanding the impact of racial and ethnic disparities to develop targeted prevention and intervention strategies in “suicide, drug and opioid-related overdose death” rates for at-risk populations–such as military service members diagnosed with mild traumatic brain injury (mTBI) during their service. Researchers Nazanin Bahraini et al. studied “military personnel receiving care within the Military Health System” from 1999-2019. While Bahraini et al. note that the “overall suicide rate for veterans is 1.5 times the rate for civilians,” their study found that the suicide rate for military service members with a history of mTBI was more than double the suicide rate for service members without (81 suicides compared to 38.67 suicides per 100 000 person-years).

The study also highlighted the specific risk faced by military members with mTBI who self-identified as “Other” for race/ethnicity status. A press release by Wolters Kluwer Health emphasizes that “rates of all three causes of death were highest in the “Other” racial/ethnic category." The study authors explain that this category is “often selected by minoritized individuals who do not identify with any of the standard categories (e.g., multiracial).” The study found that “adjusting for age, suicide rates for those classified as Other were up to 5 times that of other racial/ethnic groups for suicide, and up to 11 and 3.5 times that of other race/ethnicity groups for drug and opioid overdose death, respectively.”

One driver for this disparity may be that minorities serve in disproportionately high numbers in lower-ranking positions such as “in the infantry or in positions that are generally associated with higher rates of injuries and casualties, perhaps increasing risk for TBI.” The researchers identified that military members identifying as Other “were more likely to serve in lower-ranking positions which has been associated with lower socioeconomic status and other social determinants that could in part be contributing to higher suicide and overdose mortality rates observed in this group.” The Wolter Kluwer Health press release notes that those with a mTBI are more likely to be prescribed opioids and to have other risk factors, creating a perfect storm; among “among military members with mTBI, over two-thirds of drug-overdose deaths involved an opioid.”

The research highlights the urgent need to bring awareness and to help find preventive strategies and measures to build support systems that consider the specific needs of diverse populations within the military, particularly racial and ethnic minority military members with mTBI. Tailored prevention initiatives focus on creating programs or trained professionals equipped to support individuals in crisis based on their specific needs and background, whether through communication or treatments needed for that individual.

Addressing these disparities and implementing targeted interventions may improve the well-being and reduce mortality rates among military service members and, by extension, tragedy or trauma for their loved ones.

Youth

Why Returning to Physical Activity is Important for Concussion Recovery: Rest No Longer Identified as Useful for Concussion Recovery

While providers have historically prescribed rest to concussion patients as a method for recovery, research and guidelines since 2016 have emphasized that returning to activity is essential and leads to better patient outcomes. A meta-analysis by Rochelle Chauhan et al. published in Pediatrics examined the effectiveness of physical and social activity in concussion recovery for youth. Chauhan et al. concluded that physical activity-related interventions decreased symptoms in youth with concussions in both the number and severity of symptoms. Concussion symptoms were split into four categories; emotional, physical, cognitive, and sleep-related.

The authors also evaluated the impact of active recovery on Quality of Life (QoL). QoL is characterized by school life, mental health, physical health, and participation in activities. However, the study did not find a statistically significant relationship between concussion patients who completed physical activity-related interventions and their QoL. In order to address QoL in youth, further research (specifically social activity-related interventions) needs to be conducted and analyzed.

Chauhan et al. focused this meta-analysis on youth and only included studies conducted with only children 0-18 or where over 50% of the sample size was 0-18. The article identified this as a limitation and a factor altering the generalizability of the results found in the report.