This week’s lead article, University of Calgary Finds Link Between Teen Concussions and Dating Violence, is in the Youth category.

In this newsletter: Opportunities, Sports, Pathophysiology, Self-Care, Statistics, and Youth.

We appreciate the Concussion Alliance volunteers and staff who created this edition:
Writers: Ella Webster, Sravya Valiveti, Camilla Smith-Donald, Sneha Bansal, and Yvette Calibuso Acob.

Editors: Malayka Gormally and Conor Gormally

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Opportunities

Friday, October 25, 8 am PST: a free webinar, Return To Learn at the College Level and High School Level, presented by Concussion Alliance Advisory Board Member Allyssa Memmini, Ph.D., LAT, ATC, and Steven Broglio PhD, ATC. Hosted by The Center on Brain Injury Research and Training; register in advance.

Tuesday, November 5, 6 pm EST: a free webinar, Anxiety, Depression & PTSD: Before and After Concussion, presented by Dr. Abe Snaiderman (Neuropsychiatrist) and hosted by the Canadian Concussion Centre. Register in advance.

Wednesday, November 13, 6 pm EST: a webinar, Balancing Self and Other: Caring Relationships after Brain Injury, presented by Jonathan Prescott, founder of Wise Caregiving and ordained student of Zen Master Thich Nhat Han, hosted by LoveYourBrain. Self-selecting ticket fees range from free to $50.

Tuesday, November 19, 6 pm EST: a free webinar, Drugs for Neuropsychiatric Symptoms of Concussion, presented by Dr. Abe Snaiderman (Neuropsychiatrist) and hosted by the Canadian Concussion Centre. Register in advance.

Participate in a study of telehealth treatment: Researchers are recruiting people with TBI to participate in a telehealth-based healthy lifestyle intervention; participants can live anywhere in the U.S. Eligibility requirements include 18-80 years of age, at least 6 months post TBI, etc. Click here (and scroll down) to learn more about the study (by North Texas Traumatic Brain Model Systems), including eligibility and who to contact.

Sports

NFL protective changes must be implemented at all levels of football to reduce or prevent the risk of CTE

In this article from The Brink, Doug Most interviews researchers from Boston University’s renowned Chronic Traumatic Encephalopathy (CTE) Center, who point out that while the NFL has taken steps to reduce concussion risk for their players, they believe that meaningfully reducing CTE risk requires implementation of these changes across all age levels of football. Taking it one step further, the Concussion Legacy Foundation (affiliated with the Boston CTE Center) advises, based on recent research, that parents do not “let children play tackle football until they are 14 years old.“

Starting 30 years ago, the NFL has been slowly making changes to reduce their players’ risk of brain injury, including new rules, new equipment, and stiffer penalties. However, Michael Alosco and other experts at Boston University argue that these changes are insufficient as they don’t extend to youth, high school, or even college football.

In 2023, researchers Daniel Daneshvar et al. at Boston University found that CTE “is not caused by isolated incidents of concussions, but rather by smaller repetitive blows [repetitive non-concussive head impacts] to the head that accumulate over months and years.” Their findings highlight the harm that comes just from playing tackle football, with the BU study stating that CTE risk doubles every 2.6 years of playing tackle football––whether or not a concussion occurs. Based on these studies, the researchers conclude that the younger a player starts tackle football, the more years of repetitive non-concussive head impacts they accumulate, increasing the risk of CTE.

While the decision to enroll children in tackle football often rests with parents, the NFL’s national influence could play a key role in shifting how the game is played at younger levels. Chris Nowinski, co-founder and president of the Concussion Legacy Foundation, stresses the ethical responsibility of the NFL to protect future generations of players. Even with the precautionary safety measures, delaying the introduction of tackle football and promoting flag football are considered the most effective preventative measures against CTE.

Pathophysiology

Even mild TBI history linked to detectable changes in neuroimaging, poor sleep quality, and greater depressive symptoms

In a recent study published in JAMA Neurology, a remote history of TBI was correlated with cerebral microbleeds, an imaging marker that may suggest vascular pathology in patients with TBI. The study evaluated a cohort of 617 middle-aged healthy participants with no previous cognitive impairments; of participants who had a history of TBI, 94% of these TBI histories were mild (concussion), and 6% were moderate or severe. Specifically, Audrey Low et al. examined the association between vascular pathological changes linked to TBI (such as cerebral microbleeds) and associated clinical outcomes. This study also assessed the impact of vascular risk factors–small vessel disease markers associated with cardiovascular disease risk–and how they correlate with TBI history.

The authors found that participants with a history of even one TBI event had a higher rate of cerebral microbleeds compared to those patients without prior TBI history. They also found a dose-response relationship, where a higher number of TBI events was associated with more cerebral microbleeds. Cerebral microbleeds were found to be associated with prior TBI and greater age but did not have an association with cardiovascular disease risk. A history of even one TBI event was also correlated to gait disturbances, worse depressive symptoms, sleep quality changes, and cognitive impairments––specifically memory and language, but not attention.

This study analyzed data from the PREVENT Dementia Program to investigate if a remote history of TBI, particularly mild TBI, is a contributing factor for later-life dementia and neurodegeneration. Overall, this study highlighted that TBI-driven observable changes on brain imaging were associated with clinical outcomes such as depressive symptoms, gait and sleep quality changes, and some measures of cognitive impairments. The study also established that cerebral microbleeds could arise from and may be a consequence of prior TBI. Further, a history of TBI, even mild TBI, may have an underlying vascular pathophysiological mechanism link that could place otherwise healthy middle-aged patients at higher risk for dementia and neurodegeneration.

Self-Care

More time exercising post-concussion correlated with better sleep

A recent study in The Journal of Head Trauma Rehabilitation found that, for adolescents, exercising for more than 150 minutes per week after concussion was correlated with improved sleep. Many experience sleep problems post-concussion, which can hinder recovery and compound other post-concussion symptoms by, for example, increasing difficulties with daytime cognitive function. Post-concussion exercise is already known to have benefits for many aspects of concussion recovery, but this study aimed to determine whether there is a correlation between post-concussion exercise and sleep. David R. Howell et al. compared sleep quality in a group of adolescent concussion patients over the course of a month. Those who exercised more than 150 minutes per week showed significantly greater sleep improvement than those who exercised less than 150 minutes weekly.

To determine whether post-concussion exercise and sleep are correlated, researchers monitored the weekly exercise of 36 adolescents for a 1-month period post-concussion. Participants were not directed on how much to exercise. Instead, researchers used wristbands to measure how much activity they undertook on their own and, with the resulting data, divided participants into two groups: those who had exercised more than 150 minutes per week and those who exercised 150 minutes per week or less. Participants’ quality of sleep was measured at enrollment (on average, 8 days post-concussion) and after one month, using the Pittsburgh Sleep Quality Index (PSQI), which combines several self-reported factors, such as subjective sleep quality, sleep duration, and sleep disturbances, to determine a holistic score of sleep quality. Those who exercised more than 150 minutes per week post-concussion showed “significantly greater median PSQI rating improvements” with a large effect size compared to the cohort who exercised less than 150 minutes. Notably, there were no significant differences in the initial sleep quality ratings or concussion symptom severity ratings between those who, after one month, had exercised more or less than 150 minutes per week.

Though sleep quality and time exercising were clearly correlated, there is not enough information to determine causation. In any case, it is clear that both sleep and exercise are critical to concussion recovery.

Statistics

History of TBI (including concussion) is associated with increased risk of stroke, intracerebral hemorrhage

A new study published in the Journal of the American Heart Association examined the risk of stroke after traumatic brain injury (TBI) in young adults. The study, conducted in South Korea, looked at a population of over one million young adults aged 18 to 49 years old, using matched cohorts with and without a TBI history; of those with a TBI history, 82% had experienced a mild TBI (concussion). Choi et al. found that those with a history of concussion were nearly twice as likely to have a stroke and were nearly twice as likely to have an intracerebral hemorrhage compared to those without any history of TBI. (Patients with a moderate or severe TBI had an almost 5-fold risk of stroke and more than a 9-fold risk of intracerebral hemorrhage.) These higher risks remained even after accounting for common stroke risk factors like high blood pressure and obesity. The study also showed that the risk of stroke continues for years after the injury, even for people who had a concussion. An article in JAHA notes that “Nevertheless, the risk is still relatively very low for those with concussion (mild TBI) who make up the vast majority of patients with TBI.”

Despite the study’s limitations in the lack of generalizability to groups outside of the Korean population, this study supports previous findings, which show that the increased stroke risk after TBI affects all types of strokes and can last for years. (In both cohorts, the most common stroke subtype was ischemic stroke.) The study authors urge clinicians to take a more comprehensive approach to secondary stroke prevention through regular health checkups and proactive management of stroke risk factors. Ultimately, healthcare professionals should be vigilant about the possibility of stroke in younger patients with a history of TBI.

Youth

University of Calgary Finds Link Between Teen Concussions and Dating Violence

A study from the University of Calgary, published in the Journal of Adolescent Health, has uncovered a significant association between teen dating violence and concussions. The research indicates that adolescents with a history of concussion are 3.1 times more likely to report having experienced physical dating violence and 3.4 times more likely to report having experienced sexual dating violence compared to adolescents without concussion histories. Additionally, girls and nonbinary youth “who experienced any victimization had significantly higher odds of any concussion” compared to girls and nonbinary youth who had not experienced victimization. These findings emphasize the need for screening for dating violence in adolescents who have suffered concussions, plus the need for system-wide support and awareness programs for teens.

The researchers analyzed data from over 3,000 adolescents aged 14-16 (9th and 10th graders) in Alberta, Canada. Utilizing data from the 2014 Canadian Community Health Survey, researchers examined the prevalence of dating violence among adolescents with and without concussion histories. They controlled for factors like age, sex, and household income to ensure robust results. The association between teen dating violence and increased odds of concussion remained strong even after accounting for other risk factors.

An article published by Livewire Calgary clarified that teen violence includes “physical, sexual, psychological and/or stalking aggression in dating or sexual relationships among adolescents. These behaviours may happen in person between dating partners or electronically and online, such as on social media platforms.”

Dr. Kathryn Schneider, the senior author of this study, remarked, “This is the first study to show an association between concussion and dating violence in adolescents. It’s crucial that we consider the broader impacts of concussion on adolescent health and well-being.” Dr. Schneider emphasized the importance of these findings for healthcare providers: “This research underscores the need for comprehensive care following a concussion, including screening for potential mental health and behavioral issues.”

In the article, journalist Paula Tran also discusses Canadian youth dating violence statistics, noting that “45 per cent of teens surveyed said they experienced dating violence since they turned 15.” Despite these high numbers, resources for teen dating violence survivors are lacking, with one suggestion to embed resources and awareness programs in schools and other locations where youth gather.

Despite its valuable insights, the study has limitations. Its cross-sectional design prevents establishing causality, and it relied on self-reported data, which may be biased. Future research should focus on longitudinal studies to clarify the relationship between concussions and dating violence and explore interventions to support affected adolescents.

For more information, visit the Concussion Among Adolescents webpage.

Girls and non-binary youth had a significantly higher risk of concussion if they had experienced dating violence, according to the study.

“I think a lot of people see dating relationships in adolescents as short, which they generally are, and therefore not important. But that part’s not true. They do really matter for well-being. They can promote positive well-being but unfortunately, when they include violence and aggression, can be linked to poor outcomes,” Exner-Cortens told LWC in an interview.