This week, our lead article, Great Podcast: managing your child’s concussion, is in the Therapies Currently Available category.

In this newsletter: Opportunities, Education, Pathophysiology, Therapies Currently Available, & Culture.

Writers: Josh Wu, Ella Webster, Malayka Gormally, and Myla Hightower

Editors: Malayka Gormally and Conor Gormally

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Opportunities

Friday, April 18, 4:30 pm PST: A free online poetry class, Unlocking Thought: Poetry as a Path to Healing Part 4, presented by Cynara Clarke, hosted by Brain Northwest.

Tuesday, April 22, 6 pm EST: A free webinar, Imaging in Concussion, presented by Dr. Andrea Para, and hosted by the Canadian Concussion Centre. Register in advance.

May 3-4 and May 17-18, 11am - 5:30pm PT: A 20-hour, online LoveYourBrain Yoga for Traumatic Brain Injury Training (Level 1). The course is sliding scale, with some scholarships available.

Tuesday, May 13, 3 pm EST: a webinar, Silent Struggles: Traumatic Brain Injuries and Mental Health in Law Enforcement, presented by Jaclyn Caccesse, PhD, hosted by the Brain Injury Association of America. Free for patients and families, $50 for CEU credit.

Education

A youth-athlete concussion education program improves knowledge but does not reduce demographic-related disparities in knowledge

A recent observational cohort study published in Exercise, Sport, and Movement examined the effectiveness of a 30-minute, school-based concussion education program for middle and high school athletes. The study highlighted persistent disparities in knowledge, attitudes, and perceptions related to concussion management, finding lower scores among youth with lower grades, students attending schools with a lower Child Opportunity Index (COI), and students in contact sports (which were preponderantly male athletes). James R. Wilkes et al. note that concussion education can promote athletes reporting a concussion to the coach and that concussion reporting “directly relates to [concussion] outcomes.”

These results suggest that, although educational interventions can enhance overall concussion awareness, they may not be sufficient to bridge existing gaps rooted in socioeconomic and contextual factors. The study underscores the need for more tailored and equitable educational strategies to ensure all student-athletes, regardless of background, have the necessary resources and understanding to effectively manage and report concussions.

The study involved middle and high school athletes from public schools in a suburban county in Pennsylvania. Participants completed surveys assessing their concussion-related knowledge, attitudes, and perceptions both before and after receiving concussion education. Researchers identified demographic-specific disparities in knowledge prior to concussion education and a gap in improvement in these same groups post-education. The findings revealed that, while all students showed improvements after receiving their concussion education, those participating in non-contact sports, at higher grade levels, and attending schools with higher Child Opportunity Index (COI) scores consistently outperformed their peers who were involved in contact sports, had lower grades, or attended lower COI schools. The results reveal an opportunity for targeted education to improve outcomes for athletes in contact sports, lower grade levels, or lower COI schools. The study authors theorize that the lower scores for contact athletes may be due to more males in contact sports and more females in non-contact sports. Previous research has found that females are more likely to report a concussion, and intent to report a concussion was one of the questions in the survey. Some limitations of the study included its reliance on self-reported survey data and its sampling of only students within a single suburban county, which may limit the generalizability of the findings.

These were the survey questions: How would you rate your understanding of concussion, I am able to explain what a concussion is, I am familiar with the signs and symptoms of a concussion, I would be able to know if I had a concussion, If I had symptoms of a concussion, I would pull myself out of a practice/game and let my coach know, I think reporting a concussion is important.

Pathophysiology

Blood-based biomarker NfL shows promise for diagnosis of prolonged pediatric mild traumatic brain injury

In a recent study published in Nature, Mayer et al. found that some blood-based biomarkers may better assess the acute phase of pediatric mild traumatic brain injury (pmTBI), while others may indicate prolonged injury. They isolated Neurofilament Light Chain (NfL) as a prominent marker for pmTBI because NfL was found to be statistically significant in the acute phase (~7 days post-injury) and in prolonged injury, up to 4 months after the event. While similar biomarkers are emerging for adult concussion diagnosis, pediatric brains are still developing, requiring specific diagnostic tools.

The study measured the GFAP, NfL, Tau, pTau181, and UCH-L1 protein levels in non-fasting plasma samples from 59 pmTBI patients and 41 healthy controls. Samples were taken at approximately 1 week post-injury and again after 4 months. NFL emerged as a promising marker as it exhibited statistically significantly increased levels at both time points, especially in patients with altered mental status. In contrast, UCH-L1, GFAP, and p-Tau181 were elevated only immediately post-concussion (one week sample) and decreased over time. Notably, post-concussive symptoms were more accurate than NfL in diagnostic accuracy in the acute period, but NfL provided better diagnostic accuracy at four months.

The current diagnostic labels for concussions and traumatic brain injuries, in general, are mild, moderate, and severe, with little precision and few objective measures dictating the difference between them. NfL was highlighted as a possible solution to this categorization, leading to better prognostic differentiation.

The study supports NfL as a potential sub-acute to early indicator of pmTBI, distinguishing it from more short-lived biomarkers like GFAP and UCH-L1. However, the authors acknowledge limitations, including variability in the timing of the first post-injury sample (7-10 days) and the small sample size. Further research is needed to validate NfL’s clinical utility and improve precision in pediatric mild traumatic brain injury (pmTBI) diagnosis and prognosis.

Therapies Currently Available

Great Podcast: managing your child’s concussion

What does a parent or caregiver need to know about concussion? How should a healthcare provider advise parents? We highly recommend the half-hour interview with pediatrician and concussion specialist Dr. Christina Master on the American Academy of Pediatrics “Healthy Children” podcast with host Edith Bracho-Sanchez. Dr. Master gives a parent-friendly explanation of how to recognize concussion symptoms and when an ER trip is necessary. She describes a concussion assessment, which should include a Visio-vestibular exam that includes tests for visual function and balance (watch this short video of the exam). Dr. Masters describes homework for the parents to care for their child.

“Try not to hit your head again anytime soon” because that can “make a bad situation worse.” No high-risk sport or recreational activity.
The first 2-3 days. No school, and activities (including physical and cognitive) should “be very low key to give the brain a chance to recover that brain energy.”
After 2-3 days, back to school and activities with support and adjustments. “If we can get kids back into their normal settings but with adjustments and modifications, that’s the best thing. Not having them with their friends in their school and with their normal activities, seems to be worse than getting back to those normal settings, just with a lot of support and a lot of adjustments.”
Adjustments include taking breaks, “not having too much pressure, letting them be involved to the extent that they can, but not having them overdo it.” Try to avoid your child exceeding their brain energy, which may trigger bad symptoms such as severe headache and dizziness. For these adjustments, work with your child’s school. (Concussion Alliance note: exacerbated symptoms are not indicative of a new injury as long as there is no new impact).
Seek care if your child has lingering symptoms; “we have ways of actively treating them to get back to their activities.”

Dr. Master uses the analogy of a cell phone battery: kids usually have a battery that is 100%, but after a concussion, “if they are lower than 100%, and they do an activity, they get even lower. So, the critical piece is that we don’t want to end up at zero on our battery. We should probably recharge the battery at 20%, and if we can do that regular recharging more frequently than we normally would, we can keep that brain battery in a good space.”

Culture

Social determinants of health affect geriatric rehab access after TBI

A study in The Journal of Head Trauma Rehabilitation reveals that neighborhood conditions can significantly influence whether older adults hospitalized for traumatic brain injury (TBI) receive outpatient or in-home rehabilitation services after they have been discharged, influencing how well they recover. Led by Dr. Monique Pappadis, the study found that social and structural factors of a patient's neighborhood affected whether a patient received outpatient or home health rehabilitation services. These neighborhood-based social determinants of health (contextual SDoH) included the ethnic and racial makeup of a neighborhood, the socioeconomic position of the neighborhood, and the residential context of the neighborhood (such as urban or rural areas, as well as access to transportation, healthcare, nutritious food, and community safety). According to a Wolters Kluwer press release, patients over 65 are at higher risk for adverse TBI outcomes, and "access to community-based rehabilitation services––delivered at home or in an outpatient facility––can have a major impact on recovery and functioning." Notably, 38% of the study population received no outpatient rehabilitation, which includes "physical therapy, occupational therapy, speech/language therapy, and behavioral health [e.g., psychology, neuropsychology, social work]." Dr. Pappadis and her team write that their findings demonstrate "the need to improve access to rehabilitation services for persons with TBI living in communities with greater social needs." In particular, "targeted interventions are required, especially for rural, Black, and Hispanic/Latino communities."

Using Medicare data from over 19,000 adults aged 66 and older hospitalized for TBI in Texas, the researchers examined how neighborhood characteristics influenced access to receiving a "first outpatient or home health rehabilitation visit" after discharge. In terms of outpatient rehab services, patients living in rural areas were 17% less likely to receive outpatient rehabilitation compared to those in urban settings. Similarly, individuals from neighborhoods with higher rates of uninsured residents were 22% less likely to access outpatient rehab, even after controlling for injury severity, age, and baseline health. Interestingly, those living in areas with severe housing problems were 34% more likely to receive outpatient rehab services, potentially reflecting a greater underlying need in those communities.

In terms of in-home rehab services, patients in neighborhoods with higher median incomes and neighborhoods with higher unemployment had lower rates of in-home rehab services. Additionally, "Patients who lived near grocery stores were more likely to have home health visits," according to a HealthDay article about the study (These neighborhoods had a higher Food Environment Index.)

The study authors note the complexities found in the study; for example, some neighborhood-based Social Determinants of Health "were associated with a decreased likelihood of an outpatient visit but an increased likelihood of a home health visit." Pappadis et al. note, "The intricate relationship between healthcare access and community socioeconomic factors necessitates sophisticated strategies to increase equity."

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