National Concussion Awareness Day plus Tua Tagovailoa’s Concussion and Elevated Risks (9/19/24 Internship Newsletter)
In this newsletter: Opportunities, National Concussion Awareness Day, Sports, Diagnostics, Therapies Currently Available, Youth, and Women’s Health.
We appreciate the Concussion Alliance interns and staff who created this edition:
Writers: Jeffrey Kong, Ella Webster, Sam Gossard, Sneha Bansal, Kaitlyn Chen, and Malayka Gormally (staff).
Editors: Malayka Gormally and Conor Gormally
Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.
Opportunities
Tuesday, September 24, 6:00 EST: a free webinar, Treatment of Post-Concussion Symptoms Related to Screens at Work, School or Play, presented by Dr. Charles Tator (Neurosurgeon) and hosted by the Canadian Concussion Centre. Register in advance.
Wednesday, October 2, 6 pm EST: a virtual program, I am Worthy of Rest: Yoga Nidra for Sleep after Brain Injury, presented by Ramsey Pearce and hosted by LoveYourBrain. Register in advance; tickets are on a sliding scale, including free.
Thursday, October 10, 3 pm EST: a remote webinar for providers, Memory and other Cognitive Deficits After TBI and Rehabilitation, presented by Nancy D. Chiaravalloti, Ph.D and hosted by the Brain Injury Association of America. Register in advance; the fee is $50, 1 ACBIS CEU
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 then scroll down) to learn more about the study (by North Texas Traumatic Brain Model Systems) including eligibility, and who to contact.
National Concussion Awareness Day is September 20th
Patient Flyer: Navigating Your Recovery. Click here or on the flyer to download the two-sided PDF.
This Friday is National Concussion Awareness Day! It's so important to spread awareness because concussions are an invisible and misunderstood global health epidemic.
Most people don't know that traumatic brain injuries (~80% of which are concussions) are eight times more common than breast cancer, AIDS, multiple sclerosis, and spinal cord injury combined. Despite this, most people and their doctors are still operating on outdated advice for concussion recovery.
To help educate people on Concussion Awareness Day, Concussion Alliance has produced this flyer on managing concussions and when to see healthcare providers. Please click here or on the image to download the flyer.
Concussion Awareness Now resources:
Friday, September 20, 2 pm EST: a free remote program, the National Concussion Awareness Day Champion Rally, hosted by the Concussion Awareness Network (CAN). Learn more about the rally and register here. You can also download educational materials from CAN to share.
For social media participation for National Concussion Awareness Day: take a selfie in front of a fill-in-able sign (Version 1 or Version 2) to display on social media and use the hashtags #StartTheConversation, #ConcussionConversation, and #ConcussionAwarenessNow!, and tag CAN (Facebook, Instagram, or LinkedIn) and Concussion Alliance (Twitter, Facebook, Instagram, or LinkedIn).
Sports
Tua Tagovailoa’s Concussion and Elevated Risks
After Miami Dolphins quarterback Tua Tagovailoa sustained a third concussion over the last seasons, the national conversation returned to the question of whether Tua should retire, and whether Tua has a heightened risk of CTE (more on CTE below). CTE is not the only issue here; there are negative implications for multiple concussions. Recent research indicates that sustaining multiple concussions can contribute to:
Higher prevalence of mild cognitive impairment and dementia (2023 study of former NFL players, higher prevalence associated with 10+ concussions)
Higher levels of tau in the cerebrospinal fluid; tau dysfunction is associated with several neurodegenerative diseases, including Alzheimer’s (2019 study of professional athletes)
Greater risk of suicidal ideation, planning, and attempts (2023 study of high school students)
Heightened cognitive, sleep, and neuropsychiatric symptoms (2023 study of adolescents)
Elevated levels of inflammation in the brain (2023 study of adult athletes with PPCS)
Negative effects on heart activity, and brain oxygen levels due to neuro-autonomic cardiovascular dysfunction (ongoing research of adults)
Disruption of the brain’s default mode network (DMN), which could increase the risk of long-term cognitive issues (2021 abstract presentation of a study of adolescents and young adults)
This image is from the New York Times article, Collective Force of Head Hits, Not Just the Number of Them, Increases Odds of C.T.E.
Let’s talk about CTE and Tua’s situation; the understanding of this disease has been substantially informed by a 2023 study published in Nature Communications. Tua has been playing tackle football for 18 years, since at least age eight in Pop Warner leagues, which puts him at an elevated risk for CTE, regardless of the number of concussions he has sustained. However, as a quarterback, his risk is lower than players with similar long careers in higher contact positions like defensive linemen. The New York Times explained the study well, noting that “The best predictor of brain disease later in life, the study found, was the cumulative force of the head hits absorbed by the players over the course of their careers, not the number of diagnosed concussions.”
Starting tackle football (or contact sports) at a young age increases the number of years an individual is exposed to repetitive nonconcussive head impacts, which is a driver of CTE. The other driver of CTE risk is the number of nonconcussive hits per season; the quarterback, running back, and defensive lineman positions were compared, with the quarterback position sustaining the least nonconcussive hits per season. The risk was multiple times higher for running backs, and especially defensive linemen, who take the most hits. The study also found that concussions were not correlated to CTE risk. For more information see our Concussion Update Newsletter synopsis on this study.
Head contacts are infrequently penalized in youth basketball games
A study published in the Clinical Journal of Sports Medicine compared the rates and mechanisms of head contact and suspected concussions in two different divisions of boys and girls youth basketball, raising significant concerns for safety in these games. Using video software, Fehr et al. reviewed and analyzed basketball games from 24 boys’ and 24 girls’ U16-U18 Canadian club basketball teams (12 games each in higher-level ‘Division 1’ and lower-level ‘Division 2’ tournaments). They looked for moments where there was head contact (HC) and suspected concussion incidents.
One unexpected finding of this study is the lack of fouls called for head contacts during the game, despite contact to the head being illegal in basketball. This issue was worse in the Division 2 tournaments. In Division 1, defensive players were called for a foul under 20% of the time when offensive players sustained a head contact (19.7% in boys games and 19.5% in girls), while in Division 2 games, that number was closer to 10% (8.8% in boys games 12.2% in girls). These findings led researchers to conclude that implementing greater referee rule enforcement and training for contact violations may help prevent head contact and concussions in youth basketball. The authors note that “the small proportion of fouls called for moderate and severe [head] contacts is concerning,” whereas milder head contacts may be hard for a referee to spot without video replay. They also note that enforcement of these rules may not be as effective as in football or soccer “due to characteristics of match play and injury patterns.”
In their video review, it was found that in Division 1, the Head Contact rates did not differ between boys and girls (20 vs. 18 per game on average), while in Division 2, boys had somewhat higher rates of Head Contact than girls (21 vs. 16). The rates of suspected concussion did not differ to a degree that was statistically significant between boys and girls, but the researchers note a need for more research in this area, as their findings conflict those of previous studies that found greater injury rates among girls basketball games.
While this study is a good start, further research, and studies may be needed to grow and expand on the ideas addressed in this observational study. Fehr et al. state that “...there is limited research assessing illegal activity that goes unpenalized in competition.” Some limiting factors were a lack of footage for all games and not all concussions being immediately reported.
Diagnostics
IL6 and other blood-based biomarkers indicate the potential for non-CT detection of intracranial injuries in pediatric mTBI
In this prospective multi-centric cohort study published in Frontiers, Chiollaz et al. found evidence of a potential blood-based biomarker for detecting intracranial injury in pediatric mild traumatic brain injury (mTBI). This could reduce the need for CT scans and lengthy emergency department (ED) stays. Over two and a half years, researchers in Switzerland tested blood samples of 285 pediatric mTBI patients for inflammatory markers IL6, IL8, and IL10 and found promising trends for further exploration of IL6.
The study involved pediatric mTBI patients who visited pediatric emergency departments in Switzerland. They were divided into three groups: those who received CT and intracranial injury was observed (14), those who received a CT and no intracranial injury was observed (48), and those who did not receive a CT but remained in ED for observation (223). 74 healthy children were used as controls for comparison. CT scans pose a risk of cancer due to the patient being exposed to ionizing radiation. Still, they are considered necessary in the case of a possible intracranial injury because of the lack of clinically available biomarkers.
All study participants had their blood drawn within 6-24 hours of the injury. Researchers found that levels of IL6 and IL10 were elevated in all mTBI patients compared to controls, but IL6, in particular, was significantly increased in mTBI patients with an intracranial injury found via CT. IL6 had a specificity of 48% for identifying patients without intracranial injury and showed 100% sensitivity in excluding all patients with an intracranial injury, indicating its possible future use in avoiding unnecessary CT scans. While IL8 levels were elevated in patients who received a CT scan, it did not help distinguish an intracranial injury.
The authors noted a limitation of blood-based markers as they are present in the blood after any cellular damage, not just brain injury, which may result in a false-positive intracranial injury diagnosis. Since study participants ranged from 1 month to 16 years, age correlation was monitored within the control group, noting that IL6 slightly increased with age and IL10 decreased with age.
Although IL6 is a promising biomarker, the researchers emphasized that more studies are needed before IL6, or any blood-based biomarker, can be used for pediatric mTBI in clinical settings.
Therapies Currently Available
CBT-I treatment in concussion patients improves insomnia symptoms
In a preliminary randomized wait-list control study published in the Journal of Head Trauma Rehabilitation, researchers found that concussion patients' insomnia symptoms improved with cognitive behavioral therapy for insomnia (CBT-I) treatment. The CBT-I was provided at an academic institution via Zoom (teleconference). Participants were eligible if they scored ten or higher on the Insomnia Severity Index (indicating clinically diagnosed insomnia), were 18–64 years old, and were at least four weeks post-concussion. Study authors Rebecca Ludwig et al. found that 63% were below the threshold for clinically diagnosed insomnia at the end of CBT-I intervention. CBT-I (Cognitive behavioral therapy for insomnia) has been considered the gold standard for insomnia, but the researchers note there is limited evidence on CBT-I for individuals with concussion. (To learn more see, our resources Cognitive Behavioral Therapy, Sleep and Sleep Problems, and our section on Sleep in our Self-Care resource.)
Interestingly, the participants who reported improvement in insomnia symptoms also had improved post-concussion symptoms, as well as improvement in anxiety and depression. The study recommends that CBT-I should also be considered for the treatment of post-concussive symptoms in the presence of insomnia. Post-concussive symptoms are likely exacerbated by limited sleep, which makes CBT-I effective for post-concussive symptoms and insomnia when both are present.
Researchers placed the 32 participants in the study into either a group that started CBT-I immediately after baseline data was collected or a group that waited six weeks to start treatment after the baseline. Both groups were given questionnaires at baseline and three times over 18 weeks on insomnia, post-concussion symptoms, anxiety, and depression.
Researchers found significant improvements in both experiment groups for post-concussion symptoms, anxiety, and depression. Also, following the 18-week study, 63% of participants ended up with below a ten on the Insomnia Severity Index, which is below the threshold for clinically diagnosed insomnia.
The findings of this study indicate that CBT-I is an effective treatment to improve sleep problems associated with post-concussive symptoms. The researchers acknowledge that this study had a limited amount of participants (32), and 81% of participants were female, making gender generalizability a problem. Future research should focus on tracking sleep time with CBT-I treatment and include different study designs.
Youth
Why do you athletes downplay or not report their concussion symptoms? A new model to answer this question
A recent study published in Psychology of Sport and Exercise examines the reasons why youth athletes often under-report concussion symptoms, including a strong desire to continue playing and their perceptions of stigma around reporting, and presents strategies for changing the culture around concussion disclosure. The study focused on 17 youth athletes aged 12 to 18 participating in various sports. It employed qualitative methods, including interviews and surveys, to gather insights about their attitudes toward concussions and the factors influencing their decisions to report or conceal symptoms. Kaleigh Pennock et al. developed the first-ever model of “youth sport-related concussion under-reporting” that reveals various dimensions contributing to high-risk conditions for under-reporting, which may result in players hiding their symptoms temporarily or indefinitely.
Dr. Alison Doherty (who is affiliated with the research team) explains in a YouTube video that additional factors in underreporting include players who are unsure about their symptoms or severity and coaches hesitating “to remove athletes due to similar uncertainty about the injury.” This hesitation puts athletes at risk of additional harm, including longer recovery times. The study and video also include strategies to develop a “culture of self-reporting and removal from play.” (We provide detailed information from this video later in this article.) Their findings underscore the need for better communication and education regarding concussion awareness in youth sports.
Dr. Kaleigh Pennock, one of the study’s authors, also co-authored an article in The Conversation that provides an excellent overview of the study, which described the various factors that cause youth athletes to under-report their symptoms, emphasizing that these factors can be “personal, social and cultural.”
The researchers suggest that enhancing awareness and understanding of concussion symptoms among young athletes could lead to more accurate concussion reporting and improved safety measures. The implications of these findings extend beyond individual athletes. By fostering an environment that encourages open discussions about concussion symptoms, coaches, parents, and sports organizations can help mitigate the risks associated with undiagnosed concussions. An article written by the Concussion in Youth Sport Research Team led by Dr. Alison Doherty and published by the Sport Information Resource Centre suggests evidence-informed strategies for change that would support “a culture of self-reporting and removal from play.”
Dr. Alison Doherty, who is affiliated with the research team, explains the findings of the study in the 6-minute YouTube video. Factors or influences preventing youth athletes from reporting:
They are “unsure about the symptoms or severity.” Because concussion symptoms are nonspecific, they may wonder if their symptoms are caused by something else, such as dehydration, or rationalize that the injury “is not that bad.”
They don’t want to be removed from the game; this is, especially if it is an important game. This desire clouds their judgment.
They perceive “strong social pressure not to speak up” to not let their team, coach, or parent down. This pressure increases with important games.
They are influenced by sports culture to “‘tough it out’” and don’t want to be perceived as weak.
Dr. Doherty explains factors that prevent coaches from pulling a player from a game. Coaches are less likely to pull an athlete from a game if:
They are “uncertain about the symptoms, and they lack confidence identifying a concussion.”
They rely on observation and input from the player, which is compromised due to the factors listed above.
Dr. Doherty and the research team developed guidance for a “multi-pronged” to encourage concussion reporting and removal from play. She emphasizes creating an “athlete-centered” team culture that prioritizes player development, well-being, and best effort, in which the player feels comfortable speaking up about a possible concussion. Strategies to accomplish this include:
Concussion education that focuses on the restraining influences listed above.
“Repeated messaging throughout the year from multiple sources,” including videos, discussion of athletes’ personal experiences, and role-playing scenarios.
Education that frames reporting as a positive thing that will shorten recovery time, thus helping the athlete and the team, and does not signal “the collapse of the athlete’s status on the team.”
Education countering the sports norms of ‘toughing it out’ and ‘playing through pain’ and confronts messaging that applauds these damaging cultural norms.
The study does have limitations, including a reliance on self-reported data, which may introduce bias. Additionally, the small sample size may not fully represent the diverse experiences of all youth athletes across different sports and regions.
See our Concussion in Youth Sports resource on research about sports-related concussions and concussion issues specific to sports.
Women’s Health
Females, military personnel, and especially female military personnel report higher total postconcussive symptoms
A recent study published in The Clinical Neuropsychologist found that females reported higher total postconcussive symptoms compared to males and that military personnel reported higher total symptoms than the civilian population. Additionally, there was an interaction effect such that female military personnel reported higher total symptoms than either of the two groups (non-military females and non-female military personnel). In addition to the findings for total post-concussion symptoms, the team found similar patterns for “somatic, cognitive, and affective [mood or mental] symptom domains.“ Data was gathered using the FITBIR Informatics System, a database of TBI research. They included six studies totaling 9890 participants ranging in age from 16 to 84, with 32% of participants being female.
These findings imply that different treatment options may be required for women and for those who have sustained concussions in different environments, such as in the military. The authors of the study say, “Ultimately, more research with higher female representation is needed so that appropriate treatments and interventions can be delivered.”’
This need for research is critical because, historically, there has been an underrepresentation of women in concussion research across sports, military, and civilian contexts. Consequently, the majority of knowledge on concussions and their treatments is based on research conducted on males. Although this study uncovers differences in symptom reporting in concussions between males and females, the next step is to understand why these differences exist in order to determine if differing treatments are necessary. The variance in symptom reporting could be due to different socialization techniques (women may be more likely to report their symptoms), differences in the presentation of symptoms, and differences by sex and population (military, civilian sports) in objective cognitive functioning or how that functioning is measured. Additional potential factors for sex differences may be biological factors such as hormonal systems, neural architecture, muscle or biomechanical systems, or a combination of both these factors.
When conducting research on women, it is also essential to include underrepresented groups within that demographic, such as IPV survivors. The data in this study likely did not include sufficient data from this demographic due to underreporting. However, acknowledging and considering these groups in future research studies is crucial.