New athletic safety requirements (12/12/19 newsletter)

Dec 15

We are pleased to have Carleton College students and alumni interning with Concussion Alliance. Intern contributors this week:

Editor: Galen Moller
Contributors: Olivia Collis, Kenta Hikino, Hannah Kennicott, Evie Kortanek, Ben Preiss, Katie Taylor, and Trinh Tieu

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Education

Athletes and concussions: communication is key for every coach

The International Concussion Society created a guide to help coaches build a team environment that is conducive to player safety. One of their first recommendations is to educate athletes and parents about the common signs, symptoms, and myths of concussions. Athletes do not always know when to speak to an adult about a possible injury or if it is serious enough to merit concern. Parents can also influence an athlete’s perceptions of injury severity, and whether they should keep playing, so keeping both groups informed about concussions is key to preventing them. Additionally, coaches should work with parents and players to encourage fair play, as the CDC reports that 25% of concussions in high school athletes occur as a result of illegal or overly aggressive play.

Athletes need to know that their health and safety are a top priority, and they should never fear their coach’s reaction if they come forward with an injury. Coaches should establish a culture that encourages open communication, in which athletes will not worry about letting down their teammates or losing their place on the team if they report a concussion. Even though sports center around competition and fun, coaches are at the heart of ensuring the health and physical well-being of their athletes. An educated and supported team is a safer team.

Concussions and youth sports: a list of tools for staying informed and aware

In a recent USA TODAY article, author Nancy Armour provides some tips for making informed decisions about concussions and youth sports. She advocates for an understanding of the recommendations for your child’s sport, such as the fact that research strongly discourages playing tackle football before the age of 14, or the minimum age requirements for body-checking in hockey and heading the ball in soccer. It is important to ask your child’s coach and league organizers about their rules for practice, to make sure they are following these guidelines.

She also advises readers to be wary of conflicts of interest implicit in published studies about contact sports and head trauma. Readers should always consider the potential motivations of whoever funded the study and question research that runs contrary to accepted science. Finally, Armour recommends that you make sure your child wears certified protective equipment during practice and games and understands the importance of being up-front about injuries.

Sports

German soccer implements new neurophysiological screenings for the season

Deutsche Welle reports that Germany’s top division of professional soccer, the Bundesliga, has implemented new measures to address player concussions for the 2019-2020 season under the orders of the German Football League (DFL). All professional soccer players in Germany are now required to partake in the Sports Concussion Assessment Tool’s (SCAT) baseline screening. Though the evaluation requires more than 10 minutes, it allows team physiotherapists to examine thoroughly and correctly diagnose players with head injuries. The DFL’s mandate comes after four high-profile incidents of player head injuries in the Bundesliga last season. Experts on sports medicine seem to unanimously agree that the risk for concussions in soccer should be taken seriously, and these new screenings are a step in the right direction. However, there are additional improvements to be made.

“Baseline screening is not suited to sideline tests,” said Daniel Golz of the Society for Sports Neuropsychology, and doctors are only allowed three minutes to check on injured players during games. To make the most of these three minutes, the Bundesliga has implemented procedures like viewing video replays of the injury in slow motion on tablets. Being able to observe the mechanism of a head injury gives doctors more information. Ideas of temporary substitutions to allow team doctors more time to examine the injury during the game or using “neutral doctors” to avoid conflicts of interest are not part of the discussion but have been floated around. According to Katrin Hemschemeier, a researcher for the Federal Institute of Sports Science at the University of Paderborn, "professional leagues in the United States such as the NFL, NHL, and NBA are the examples to follow,” as they have “baseline screenings, protocols and a series of tests,” and specialize their screenings to each sport.

Texas requires soft-shell helmets for touch football players

Although both touch and flag football are promoted by the NFL, among other groups, “as safer ways to teach young players about the game,” embedded within their fabric are concussion risks that are often overlooked. A New York Times article published in August describes how the Texas State 7on7 Organization became “the first statewide group in the country to require that all of its players wear soft-shell helmets,” after a player in Arlington, TX, sustained a severe head injury during a practice for his high school’s 7-on-7 touch football team.

Injuries in touch and flag football have contributed to a growing awareness that even in the ‘safest’ contact sports, measures that reduce concussion risk and prioritize player safety are still imperative. Manufacturers of soft-shell helmets have seen a “surge in orders from sports administrators, coaches and parents trying to prevent head injuries.” While no helmet can completely prevent concussions, their “shock-absorbing padding can reduce the risk of a concussion by decreasing the force of a blow to the head.” Stefan Duma, an engineering professor who oversees helmet testing at Virginia Tech, says this new mandate will “spur the development of more sophisticated headgear and their adoption in other sports.” See the Virginia Tech Flag Football Helmet Ratings.

Cannabis

Yale announces Connecticut’s first research study in medical marijuana

Yale recently announced its plans to launch Connecticut’s first-ever research study into medical marijuana, news12 Connecticut reports. While the exact parameters of the study are unknown, Dr. Rajita Sinha, of Yale’s School of Medicine, says the research will look into how medical marijuana works, for whom it works, and what kind of doses are appropriate. Connecticut legalized research into medical marijuana three years ago, but Yale’s study is the first of its kind to be approved and funded.

Partnering with Yale for the study is CTPharma, an in-state medical grower. While CTPharma’s stated goal for the study is looking into medical marijuana’s potential to relieve pain and stress, some research as shown that cannabis and its components may aid concussion recovery (see our article on CBD and Cannabis Research). More medical research and accurate information can only mean good things for those with mTBI.

Diagnostics

Adolescent and adult athletes show blood-brain barrier damage even without concussion symptoms

The primary role of the blood-brain barrier is to maintain a stable and healthy environment within the brain by letting vital nutrients and hormones in, while keeping harmful substances that may be present in the blood, such as bacteria or toxins, out. If it is damaged, it can become more porous and let in more harmful substances. A study published in the Journal of Neurotrauma by Eoin O’Keeffe et al. examined the integrity of the blood-brain barrier in professional mixed martial arts fighters and adolescent rugby players—both high-risk populations for concussions.
The athletes were tested pre-fight or pre-season and again post-match or post-season. The researchers measured blood-brain barrier damage using an MRI protocol developed at Ben-Gurion University, a blood test for specific biomarkers indicating brain damage, and a mouthguard with sensors tracking movement developed at Stanford University.

Ten out of 19 adolescent rugby players showed signs of damage to the blood-brain barrier at the end of the season, according to Science Daily. The amount of blood-brain barrier damage seen with the MRI correlated to the detected movement from the mouthguard sensors. All injuries detected were lower than the current threshold for mild head trauma. The study indicates that even mild trauma can lead to a leaky blood-brain barrier. Professor, Alon Friedman, M.D., Ph.D., a member of the research team, says they hope their study “can help better detect a significant brain injury that may occur after what seems to be a 'mild TBI' among amateur and professional athletes."

Therapies

A “team approach” to concussion care

Dr. Jeffrey Bazarian of the University of Rochester recently published an article in The Journal of Head Trauma Rehabilitation that reviews the potential of an interprofessional approach to treating concussions. Concussion patients pursue healthcare providers with a wide variety of specialties, including sports medicine, neurology, and family medicine. One model of concussion care is a team approach in which multidisciplinary collaboration and coordination maximize the diversity of the knowledge of providers interacting with a patient. The article acknowledges gaps in current research, including what the most efficient model of an interdisciplinary clinic is and how this model may differ for the outcomes of athletes and nonathletes.

Veterans

Department of Defense funds $1.1 million grant for mTBI diagnostic tool development

Science & Enterprise reports that medical device company Medicortex Finland Oy received a $1.1 million grant from the U.S. Department of Defense (DoD) to fund their fast TBI diagnostic kit. The company is working to develop a tool that can quickly diagnose suspected mTBIs by detecting biomarkers—specific proteins and enzymes that appear in the bloodstream that indicate brain damage.

Previous research by Medicortex resulted in a hand-held concussion test kit named “ProbTBI” that could be administered by Army medics or sports team trainers, without the need for specialized equipment. It tests bodily fluids for 12 biomarkers that appear soon after someone experiences a TBI. Medicortex founder and CEO Adrian Harel stated in BusinessWire that the grant “will enable us to strengthen our research team and expand our translational programs from the clinical sample collection to a prototype kit.” The grant was awarded through the DoD’s Combat Casualty Care Research Program, which supports diagnostics with the potential to reduce mortality and illness caused by injuries on the battlefield.

Mental Health

Implications of a common pathophysiology and symptomatology between TBI and PTSD

In a study published by Current Neurology and Neuroscience Reports, Rebecca C. Hendrickson et al. note that symptoms previously thought to be specific to either traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD) are increasingly observed in both disorders. For example, flashbacks and avoidance of trauma-related cues have repeatedly been observed following TBI, while sensory sensitivity and vestibular dysfunction have been found in PTSD. The authors also highlight findings that PTSD involves “alterations in many of the core physiologic systems known to be affected by a TBI.” Specifically, the researchers cite similar changes in the regulation of neurotransmitter, neuroendocrine, and immune-mediated stress response systems in PTSD and TBI.

They note substantial implications of these findings for future research and clinical care. They emphasize symptom rating scales for PTSD and TBI may not be specific. They also encourage future studies to determine whether physiological changes observed in either disorder “have the potential to be elicited by both a traumatic stressor and a CNS [central nervous system] injury.” For clinical care of patients with either TBI or PTSD, the researchers recommend drawing on treatment tools for both disorders, especially in cases with treatment-resistant symptoms. While TBI and PTSD are highly comorbid and share some pathophysiological elements, their separation is critical if we are to work with just one in the lab and the clinic.

Statistics

Cellphone-related head and neck injuries account for 9,000 ER visits each year

MinnPost reported on a study published in JAMA Otolaryngology-Head & Neck Surgery that found that more than 9,000 Americans end up in hospital emergency departments each year due to cell phone-related head and neck injuries. The study, by Roman Povolotskiy et al., also found that the frequency of these types of incidents increased significantly after the release of the iPhone in 2007. The researchers analyzed data collected by about 100 hospital emergency departments across the U.S. between 1998 and 2017. The data contained detailed “narratives” of the causes of the injuries seen in those departments, including the use (or misuse) of cellphones.

While the majority of the injuries were lacerations or bruises, 18% of the patients were diagnosed with an “internal organ injury,” which the researchers assumed were mild traumatic brain injuries, “given that most patients were discharged and not admitted for treatment.” They point out that these patients’ injuries should be taken seriously, as, “the symptoms of post-concussion syndrome can vary in severity from mild (headache, nausea, or fatigue) to severe (memory problems, emotional ability, or depression.” The researchers advise that “such patients must receive close follow-up care after they leave the hospital.”

Women's Health

Brain donation initiative to increase female brain injury research

A recent article published by The Telegraph discusses how Dr. Willie Stewart of the Glasgow Brain Injury Research Group is working to encourage female athletes in the UK to donate their brains for traumatic brain injury (TBI) research. Dr. Stewart, whose research demonstrated a link between male professional soccer and dementia, emphasizes that “sex differences have not been adequately explored” in understanding outcomes of brain injury. While chronic traumatic encephalopathy (CTE), a degenerative brain disease associated with repeated sub-concussive hits, has been linked to dementia in men, there are only two recorded cases of the disease in women. Increased concussion vulnerability and prolonged post-concussion recovery times in women demonstrate a need for female brain injury research, as noted in another recent article published by The Telegraph.

By collecting brain donations from female athletes, Dr. Stewart hopes to increase our understanding of how women are affected by brain injury and investigate potential sex differences in the development of neurological diseases from TBI, including CTE.

Culture

Culture of risk, comradery, and athleticism

In a recent article published by The New Yorker, Nick Paumgarten discusses the culture behind contact sports and their relationship with concussions. Playing in his masters' hockey league, he sustained three concussions in a year and subsequently suffered from post-concussion syndrome. These head injuries put him out of work for an extended period, causing him to consider early retirement. Paumgarten ponders the culture and attitudes present in contact sports that put both his and his son’s teams at such a heightened risk for head injuries.

His recreational hockey league fostered a community based around respect for the “unquantifiable quality of grit and attention to detail” allegedly possessed by valuable players. In describing his team, Paumgarten stated, “Hockey, it needs to be said, brings out the dickishness in us all. It may even require it.” While this was written in an endearing tone, it also introduces a valid concept: could this competitive nature be both emotionally enriching and physically harmful for players? In the author’s experience, participants and parents recognize and acknowledge concussions with increasing frequency. However, there is still work to do in athletic communities to ensure proper treatment of head injuries.