Racial disparities in concussions (10/1/20 newsletter)

Oct 1

Contributors this week:

Contributors: Will Altaweel, Malayka Gormally, Trevor Hughes, Hannah Kennicott, Elena Morales-Grahl, Caroline Saksena, Srishti (Shelly) Seth, Julian Szieff, and Elliot Yim.
Editors: Conor Gormally and Malayka Gormally.

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Webinars, courses, galas

Registration is now open for a free online concussion course hosted by the University of Calgary and Université Laval. “The seven-week course is open to those who are interested in preventing, detecting and managing concussions. Do the course at your own pace, but you must complete it by Novovember 23, 2020.” Registration is open until Oct 19. Concussion Alliance staff took this course in 2019 and highly recommend it. A University of Calgary press release gives additional information about the course.

10/7/20: Modified Gentle Yoga for Brain Injury combines mindfulness-based stress reduction (such as breathing exercises) and gentle yoga, geared to the beginner. Free, advance registration is required. 10:30 - 11:30 am PST.

10/7/30: The Concussion Legacy Foundation annual gala (now online) will focus on mental health and feature renowned guest speaker and author Malcolm Gladwell. Tickets are free for veterans and active-duty military, and for concussion and PCS families, there is a “suggested donation of $30 or whatever you are able to manage at this time.” Advance registration is required. 7:00 - 8:00 pm EST.

10/8/20: Tips for Optimal Recovery From Brain Injury led by Dr. Michal Turner. Free, advance registration is required. 10:00 - 11:00 am PST.

10/14/20: ABC’s of Problem Solving and Reconnecting to Your Goals After a Brain Injury - Part 1. Free, advance registration is required. 11:00 am - 12:30 pm PST.

Education

New web page on What Happens to Your Brain When You Get a Concussion

This summer, Concussion Alliance interns Elena Morales-Grahl and Caroline Saksena created two web pages on What Happens to Your Brain When You Get a Concussion. By translating current research understanding into accessible words and pictures, these web pages aim to help individuals make sense of their experiences and find reassurance that they’re not alone.

The primary What Happens to Your Brain web page provides an overview of how a concussion impacts your brain, and the Deeper Dive web page explains the process in more detail for readers that crave a deeper understanding of the injury. Each page integrates the field’s current knowledge with resources for additional learning.

In developing their pages, Elena and Caroline prioritized accuracy and accessibility. Reading highly regarded literature on brain injury, consulting with doctors and scientists in the field, and meeting with people who’ve had concussions all informed their design process. These new web pages include text, diagrams, and external resources to provide a clear and accurate explanation of what a concussion looks like in the brain. Caroline and Elena hope that anyone interested in learning more about concussions can understand their web pages, regardless of a science background.

Caroline brought a unique perspective to the project as someone who’s had two concussions and has sought information and understanding about her brain injuries for years. “I included words and knowledge that have helped me heal. These pages are a resource I wish were available to me when I was recovering from my concussions.” Both Caroline and Elena appreciate the value of understanding one’s injury, and how that understanding can build toward validation of experiences, healing, and confidence advocating in medical or therapy settings.

Through their pages, the pair hopes that patients, caretakers, and friends can better understand what’s going on during recovery from a concussion and learn the best ways to support the people they care about through a concussion.

Sports

Two former NFL players sue the NFL for racial discrimination when handling concussion settlement claims

Najeh Davenport and Kevin Henry, two former Black NFL players, have filed a lawsuit against the NFL accusing the organization of racially discriminating against Black players in their concussion settlement claims. Summarized in an article from the Milwaukee Journal Sentinel, the lawsuit cites that the NFL evaluates players’ claims using “race-normed standards,” which assume that Black players have lower baseline cognitive functioning than White players. The lawsuit argues that observed differences in neurological damage tests are not as drastic for Black players as White players because of these standards. As a result, Black players qualify for benefits less often.

Independent neurological exams found that Davenport qualified for benefits. Despite these results, NFL appealed by conducting their own “race-normed” exam, concluding that “Davenport suffered no cognitive impairments, and should not receive any payout under the settlement.” Cy Smith, the lead attorney for this lawsuit, said, “The NFL’s administration of the settlement created a ‘Black’ door and a ‘White’ door for benefits, in which former players with identical test scores get different treatment — solely on the basis of race.”

“The lawsuit asks a judge to declare [that] the current practice violates the Black players’ rights to equal protection, stop its use, and pay damages to the affected retirees for pain, suffering and humiliation, as well as punitive damages.”

Cannabis

Dangerous vaping additives and thickeners expose the risks of unregulated cannabis markets

The CDC has been closely monitoring the data behind E-cigarette and Vaping-related Lung Injuries (EVALI). According to an article by Project CBD, research in 2020 has found that these injuries likely result from several sources, including synthetic cannabinoids, thickeners, and additives, most notably vitamin E acetate, a thickener identified by the CDC as the most likely culprit. While the mechanism of injury and specific vaping source for EVALI has been debated, the presence of lung tissue damage resulting from vaping has led to 68 deaths and 3,000 hospitalizations by February 2020. The symptoms experienced by those with EVALI are remarkably similar to COVID-19, including acute respiratory distress following immune system dysregulation from a cytokine storm.

New research from Yale University by Dr. Abigail Friedman has shed light on potential reasons behind the increase in cases of EVALI. Her study, published in the journal Addiction, finds that areas with higher vaping and marijuana use rates were associated with fewer EVALI cases. Dr. Friedman suggests that “well-established markets may have crowded-out use of riskier, informally sourced e-liquids.” These findings are backed up by the facts discussed in the Yale press release for Dr. Friedman’s study.

“Indeed, the five earliest states to legalize recreational marijuana—Alaska, California, Colorado, Oregon, and Washington—all had less than one EVALI case per 100,000 residents aged 12 to 64. None of the highest EVALI-prevalence states—Utah, North Dakota, Minnesota, Delaware, and Indiana—allowed recreational marijuana use.”

The statewide lack of marijuana regulation and legalization may be leading smokers and cannabis seekers to dangerous and deceitful alternatives. This research suggests that better regulation of cannabis products is sorely needed, especially in states without well-established vaping markets.

Diagnostics

Measurements of eye responses to light are promising as concussion diagnostic tool

A study by Dr. Christina Master et al. revealed that pupillary light reflex metrics--how the pupil responds to light--can help diagnose and monitor concussions. Pupillary light reflex metrics are quantitative, objective measurements that can not be hidden or controlled by patients. A Children’s Hospital of Philadelphia press release explains that the metrics are obtained with a relatively small, hand-held pupillometer device, which was part of the technique's appeal to researchers. The study evaluated 98 concussed and 134 non-concussed athletes (ages 12-18) at a suburban private school.

The authors discovered that eight of the nine metrics used to measure eye responses correlated with concussion status: maximum and minimum pupillary diameter, percentage constriction, peak and average constriction velocity, peak and average dilation velocity, and time to 75% pupillary redilation. The only insignificant metric was latency, the pupil response time to light. The study was published in JAMA Ophthalmology.

Self-care

Tips for managing excessive fatigue related to concussions

The U.K. nonprofit Headway has published a series of articles about fatigue after brain injury and how to manage it. In 2019, Headway surveyed 3,166 brain injury survivors and found that “87% of respondents feel that fatigue has a negative impact on their life.” In an article about the survey, Headway notes that “fatigue--or excessive tiredness...is the most commonly cited effect of brain injury reported by the 11,000 callers to our helpline last year.” The article, “Early warning signs of brain injury fatigue,” lists physical signs (e.g., increased pain), communication problems, and mood changes as early warning signs. If recognized, these warning signs can allow “people to take steps to rest and in many cases lessen its [fatigue’s] impact.”

Another article, “Try these 8 ways to cope with fatigue after brain injury,” has suggestions for managing your emotions, pacing yourself throughout the day, sleep hygiene, exercise, nutrition and hydration, medication, modifying your environment, and cognitive (thinking) strategies. The information draws from a more in-depth booklet, Managing fatigue after brain injury (PDF).

Of note, one of the recommendations for managing mood is cognitive-behavioral therapy (CBT), and Concussion Alliance has a new web page about CBT for concussions, including the use of free CBT apps.

Free meditation resource

UCLA Mindful has guided meditations on its app (iTunes / Google Play), audio meditations on its website, and a weekly live Mindful Awareness podcast.

Therapies currently available from providers

Concussion Alliance creates a new web page outlining how cognitive behavioral therapy (CBT) can treat persistent post-concussive symptoms

This summer, Concussion Alliance interns Elliot Yim and Will Altaweel created a new web page on Cognitive Behavioral Therapy (CBT). The web page discusses CBT, a type of psychotherapy that aims to change harmful thought patterns, and addresses how the therapy can treat persistent post-concussive symptoms.

The page outlines several key things: what it’s like to go to a cognitive-behavioral therapist, the numerous symptoms that CBT can treat (e.g., anxiety, depression, and insomnia), and how to access a therapist that practices CBT. The web page draws from empirical research to support CBT’s effectiveness and includes patient and provider testimonials.

It is important to note that if you are a concussion patient considering seeking out CBT, the 5th international consensus on concussion in sport recommends CBT as part of a collaborative approach to treating persistent post-concussive symptoms. Other treatments, such as physical therapy or a graduated exercise program, are essential for targeting symptoms that cannot be addressed by CBT.

Therapies under research

New stem cell phase 1 clinical trial approved for mTBI patients

In a press release, the American CryoStem Corporation announced that the FDA had approved a phase 1 clinical trial to research the treatment of Post-Concussion Syndrome (PCS) with stem cells. This clinical trial will utilize adipose (fatty) tissue-derived stem cells from the patient, administered intravenously at differing dosing levels. The study will be recruiting 20 patients with an athletic or military background with a confirmed PCS diagnosis from at least three mTBI injuries with unresolved symptoms.

While the press release does not discuss how stem cells might help, a study by Dr. Alison E. Willing on the mechanism of stem cell effect on mTBI, published in the CNS Neuroscience & Therapeutics Journal, theorizes about these mechanisms. The stem cells specified in this phase 1 clinical trial have been “shown to penetrate the BBB [blood-brain barrier], migrate to the site of injury, and secrete several growth factors” while modulating inflammation. In animal models, administration of these stem cells improves muscle and neurological outcomes. There are two hypotheses for the basis for this improvement. These stem cells may differentiate into neuronal or glial cells and support recovery, but there has been no definitive evidence of stem cells differentiating into brain tissue. The second hypothesis suggests that these stem cells may influence inflammation and hormonal changes at the injury site.

This clinical trial will examine if this stem cell treatment is safe and effective in humans with mTBI, with the intent to publish data in 2021.

Veterans and Service Members

Blood biomarkers for cognitive impairment and TBI in older veterans

Dr. Carrie B. Peltz et al. published a study in Neurology that examined blood biomarkers of TBI and cognitive impairment in veterans. The study cohort included 155 older veterans (mean age 79) with and without TBI and/or cognitive impairment, living in retirement homes. Blood biomarkers differed within the four groups. In veterans with a TBI history, the authors identified several CNS-enriched exosomal biomarkers as significantly associated with cognitive impairment, including p-tau, NfL, IL-6, and TNF-α. Factors to be considered include the inherent difficulty in distant (in the past) TBI reporting and in distinguishing the etiology of cognitive impairment in those with TBI.

Mental Health

Research points to two prominent drivers of anxiety's effect on post-concussion symptoms

Anxiety plays a significant role in post-concussion syndrome. Researchers previously have found that anxiety is associated with mood symptoms and post-concussion symptom burden. Research released in Psychosomatics by Dr. Jonathan Greenburg suggests that two specific behaviors may drive the connection between anxiety and post-concussion symptoms. The first behavior, catastrophizing, is marked by a tendency to exaggerate the severity of an event or experience when describing it. The second behavior, limiting behavior, is defined as an aversion to engaging in activities. Researchers had 57 patients complete questionnaires regarding their post-concussion symptoms, anxiety, and the prevalence of these two behaviors.

Patients who reported higher levels of catastrophization and limiting behaviors were more likely to have both higher levels of anxiety and higher symptom burdens. The presence of limiting behaviors was a more common feature of post-concussion patients. Two of this study's limitations are its small sample size and that it does not track pre-injury levels of anxiety or these two behaviors. Despite these limitations, this study suggests that further research into anxiety's effect on concussion patients and better therapies to address patients' anxiety is needed.

Statistics

In Canada, the incidence of youth sport-related concussions rises sharply and then levels off

The incidence of sport-related concussions for youth aged 12-19 in Canada rose two-and-a-half fold from 2005/6 to 2013/14. However, these incidence numbers stabilized between 2013/14 and 2017/18. Researchers Dr. Kevin Gordon et al. conclude that “In Canada, the annual incidence rates of reported sport-related concussions or other brain injuries is changing and may reflect improved reporting and recognition.” The study, published in the Clinical Journal of Sport Medicine, used two-decades worth of serial data from the annual Canadian Community Health Survey.

It is worth noting that “approximately 1 in 450 Canadians 12 years and older report sport-related concussions or other brain injuries as their most significant injury associated with disability” in 2017/18. This percentage translates to 221 people per 100,000.

Youth

Concussion training for youth sports coaches in the U.S. and Canada

Canada
The governing organization for school sports in British Columbia (BC School Sports) has mandated that all supervisors of secondary school sports complete the online “Coach Course” produced by the Concussion Awareness Training Tool (CATT), according to a press release by BC Children’s Hospital. The 45-minute Coach Course, which includes a completion certificate, provides information on recognizing symptoms and information coaches need “to provide evidence-based care for their athletes who have sustained a concussion.”

The goal of the new mandate is that “every head coach, assistant coach, manager, teacher-sponsor and student-manager will complete concussion education online so they can better care for more than 70,000 youth at the more than 450 public and independent secondary schools that are members of BC School Sports.” Concussion Alliance highly recommends the CATT online training tools as an educational resource.

United States
A study published in the Journal of Safety Research looked at sports officials’ and athletic trainers’ “concussion-related knowledge, attitudes, and behavioral intentions” before and after taking the free CDC’s HEADS UP online concussion training course. Study participants included 9,864 sports officials and 3,463 athletic trainers. Researchers Jill Daugherty et al. gave participants tests before and after they took the HEAD UP course, including “13 knowledge questions and 7 behavioral and attitude questions.”

The results showed that “sports officials’ and athletic trainers’ concussion knowledge, attitudes, and behavioral intentions improved immediately following completion of the CDC HEADS UP online training.” Many of the improvements in knowledge and attitudes will have practical significance. For example, after the HEADS UP training, an additional 21% of the study participants knew that “athletes who are removed from play because of a possible concussion should return to play only after they are back to their regular school activities.”

Women's Health

First documentary film to focus on the epidemic of brain injuries from domestic violence premieres at Boston Film Festival

A groundbreaking film This Hits Home: The Traumatic Impact of Domestic Violence, directed and produced by Sydney Scotia, had its world premiere last weekend at the (remote) Boston Film Festival. This feature-length documentary “reveals the invisible and silent epidemic of permanent traumatic brain injury in women devastated by domestic violence.” You can view a trailer on the film’s website, which includes information that “one in four American women will be knocked out, beaten or victimized by severe violence from a partner in their lifetime.”

Included in the documentary are interviews with world-renowned experts, such as Harvard researcher Dr. Eve Valera (a Concussion Alliance professional advisory board member), and Boston University researcher Dr. Ann McKee, who studies CTE. The film includes “intimate and compelling stories of courageous women,” and the perspectives of people who work to support survivors of domestic violence. The film was supported by the National Football League Players Association (NFLPA) and the American Brain Foundation (ABF). FilmDaily published an article about Sydney Scotia and the making of the film.

Culture

Black high school athletes have a lower incidence of concussion-reporting, putting them at increased risk

A study published in the Journal of Racial And Ethnic Disparities compared concussion-reporting behaviors between Black and White high school athletes. This study is the first to look at how race affects concussion-reporting in high school athletes, and the authors stress that “Athletes who fail to report concussion symptoms, intentionally or not, place themselves at risk for a prolonged recovery at best, and catastrophic injury at worst.”

Researchers Jessica Wallace et al. administered a 10-minute paper survey to 577 high school athletes from seven Title I schools and seven non-Title I schools. Title 1 schools have a high student poverty rate, lower funding, and are less likely to have a full-time athletic trainer (AT). The term bell-ringer was included in the survey to “determine athletes’ perception of the seriousness in terminology and to assess when a possible concussion may have occurred.” The study results showed that “a larger proportion of Black athletes who experienced bell-ringers and concussions did not report them to an authoritative figure compared with White athletes.”

“Specifically, 18% of Black athletes reported less concussions in games, almost one-third of Black athletes reported less concussions in practice, and 15% reported less bell-ringers in games than White athletes. However, a greater proportion of White athletes knew of a teammate who did not report a concussion to an authoritative figure, and also recalled experiencing bell-ringers and concussions more frequently than Black athletes.”

In the discussion portion of the study, the authors note that in general, “Black athletes represented a higher proportion of Title I school attendance,” which held in this study, as “Black athletes in our sample had less access to an AT compared with White athletes.” Previous research has shown that “the absence of an AT in a school has been linked to lower concussion knowledge,” and less understanding of concussion symptoms. In broader terms, the “Lack of access to an AT likely intensifies this complex problem as researchers have shown that Black athletes are 40% less likely to report to the emergency department for a sport-related head injury and are less likely to be diagnosed with a concussion compared with White athletes.”

Concussion Alliance has previously covered racial disparities in ED visits. Research shows that vastly more concussions are reported in schools with ATs compared to schools that don’t have ATs.