Meditation and yoga improve symptoms (12/10/20 newsletter)

Dec 12

We would like to acknowledge our volunteers and our December intern cohort who wrote for this newsletter:

Writers: Rachel Block, Eloïse Cowan, Miriam Freedman, Tori Gray, Arthur Onwumere, Kailey Smith, Emily Spain, Maya Strike, Josh Wu, and Elliot Yim.

Editors: Conor Gormally and Malayka Gormally.

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Education

Recruiting parents to participate on behalf of their children in a groundbreaking Return to Learn research study

A research study will evaluate the effectiveness of a newly developed national Return to Learn program, which provides “guidance for high school students who have suffered a concussion and are returning to the academic classroom.” While there is a nationwide Return to Play protocol, no such guidance exists for Return to Learn. The study, led by Monica Vavilala, MD, at the Harborview Injury Prevention and Research Center (HIPRC) at the University of Washington, is currently enrolling participants through June 1st, 2021. The study is funded by the Centers for Disease Control and Prevention (CDC).

Participants in the study will be provided “structure and guidance around successfully returning students to academics after a concussion” and will be “financially compensated for the 5-week study.” Contact rtluw@UW.edu for additional information.

Eligibility: Parents with a student who:

is a high school student (age 14-19)
was diagnosed with a concussion in the past two months
the trauma (concussion) did not result in an acute hospital stay longer than 48 hours
the student attends an in-person, online, or hybrid school environment.

See our blog post to download flyers about the study in English and Spanish.

Sports

Recommendations to increase concussive symptom disclosure: NCAA and Department of Defense

A consensus statement developed in a meeting co-organized by the NCAA and Department of Defense summarized recommendations to increase early and honest symptom disclosure. Both institutions have “goal-focused social environments that may encourage individuals to ‘participate through’ concussion symptoms” despite the risk of further brain injury.

The institutions identified 17 “useful and feasible” recommendations for college athletic departments and military leaders to implement. These recommendations encouraged education and process changes at multiple levels: individuals, coaches and leaders, team or unit environments, and at the organizational level. The multilevel approach emphasized that localized and targeted concussion education “can create and sustain local cultures supportive of concussion disclosure,” which will be more effective than a single approach to concussion education.

Despite the recommendations’ focus on college athletics and the military, the information can also be useful in youth and high school sports. The meeting took place in June 2019 and the consensus statement was published in the British Journal of Sports Medicine.

Cannabis & Psychedelics

Professional athletes use psychedelic medicines to heal brain injury symptoms

An HBO segment features interviews of four former professional athletes and two experts on psychedelic research about psychedelics' potential to heal brain injuries.

The segment opened with the story of Daniel Carcillo, a two-time Stanley Cup champion who experienced headaches, light-sensitivity, slurred speech, insomnia, depression, brain fog, and additional brain injury symptoms after a twelve-year professional hockey career and seven diagnosed concussions. After years of little to no improvement using conventional medicine and psychotherapy, Carcillo traveled to Peru and took ayahuasca, which contains the psychedelic compound DMT. Immediately after the psychedelic treatment, Carcillo stopped experiencing many of his brain injury symptoms, enough to consider himself healed. The other three former professional athletes interviewed in the segment had similar experiences.

The segment also included interviews from psychedelic experts Rick Doblin, Ph.D.and Dr. Robin Carhart-Harris on the clinical evidence supporting the players' anecdotes of recovery. Doblin explained that psychedelics increase brain activity and neuroplasticity, leading to the rewiring of neural pathways that last beyond the treatment course. He also claimed on a Ted Talk that "psychedelics, when used wisely, have the potential to help heal us, to help inspire us and perhaps even to help save us." Despite the early encouraging news, significantly more research is needed on psychedelics' benefits to brain injury patients.

Diagnostics

Sensorimotor impairments detected in concussed amateur athletes after clearance to return to sport

Fionn Büttner and colleagues conducted a prospective, longitudinal study to test sensorimotor impairments in amateur athletes following a sports-related concussion. The researchers recruited participants from a hospital emergency department over 20 months. To be eligible, concussed participants had to be amateur athletes between ages 16 and 38 who sustained a concussion during a game or practice. The researchers compared fifty concussed participants to a control group of fifty non-concussed participants.

The study, published in Physical Therapy in Sport, assessed the concussed participants within one week following their injury, after clearance to return to their sport, and two weeks after returning to their sport. Control participants were also assessed three times: at an initial assessment and again at two and then four weeks after.

The researchers used two tests to measure sensorimotor impairments: the Star Excursion Balance Test (SBET) and the Multiple Hop Test (MHT). The SBET requires participants to do single-leg squats and touch a pattern of dots on the floor with their non-weight-bearing leg. In the MHT, participants hop and try to land stably on ten numbered markers.

Interestingly, the researchers found no difference between the concussed and the control group on the SBET. Despite no statistically significant difference between concussion and control groups on this more static test, the researchers note that “...sensorimotor impairments may be present when athletes return to more dynamic, complex environments such as sport.”

During the more-dynamic MHT, the concussed group showed significantly more corrective postural strategies, or movements to maintain balance, than the control group one week after their concussion and upon clearance to return to their sport. Two weeks following approval to return to their sport, there were no significant differences between the two groups. These results suggest sensorimotor impairments caused by concussions are associated with maintaining posture and balance and can manifest in gait and posture changes.

However, since the researchers found these balance and postural differences in the MHT only, this particular test is a more appropriate and useful diagnostic tool for concussion than the SBET. The authors noted that they could not collect pre-injury data for their concussed participants and could not measure differences across different sports.

Self-care

First meta-analysis shows yoga, mindfulness, and meditation-based interventions improve symptoms of mild traumatic brain injury

The first systematic review and meta-analysis on yoga, mindfulness, and meditation in concussion patients shows promising results for treating the symptoms of a mild traumatic brain injury (mTBI). The analysis, by Rebecca Acabchuck et al., included 20 different studies focused on yoga, meditation, or mindfulness interventions for people suffering from mTBI. The authors found significant improvements in concussion symptoms including mental health, physical health, cognitive performance, and self-related processing in the participants who engaged in the target activities, compared to the controls. mTBI patients treated with these interventions showed the most improvement in depression scores and fatigue compared to controls.

The authors mention some limitations in the studies (a lack of randomization, blinding, and recording of adverse events), but the promising results highlight the need for further research in how meditation, yoga, and mindfulness-based interventions can improve symptoms of mTBI. The meta-analysis was published by the International Association of Applied Psychology.

During the pandemic, concussion patients are looking for new resources that they can access while social distancing. Your donationsupports this newsletter and our Education and Advocacy Internship Program. This December, interns are updating our Medication and CBD pages, adding pages on Mental Health and Post-concussion Headaches, and building our social media program.

Therapies Currently Available

CBT can improve sleep and other symptoms in individuals with mild-to-severe traumatic brain injury

A scoping review published in Brain Injury sheds light on the use of cognitive-behavioral therapy (CBT) for treating insomnia in people with a traumatic brain injury (TBI). Sleep disturbances, and particularly insomnia, are among the most common complaints in individuals with TBI. Authors Rebecca Ludwig et al. performed a literature evaluation to determine whether CBT and CBT-I (CBT specifically designed for insomnia) effectively reduced sleep disturbances and combated insomnia.

The researchers found five articles that met the inclusion criteria: one case report, two case series, and two randomized control trials. Three studies investigated CBT-I, while two studies investigated CBT. A case study by Ouellet & Morin (2004) found that a participant who underwent CBT-I after a moderate TBI showed decreased sleep latency (time to fall asleep), reduced time spent awake after initially falling asleep, and increased sleep efficiency. The participant also reported reduced fatigue and dysfunctional beliefs about sleep.

In a 2007 study, Ouellet & Morin investigated eleven individuals with mild to severe TBI who underwent CBT-I with similar results, but with the notable addition of significant decreases in depression and anxiety scores. Lu et al. (2016) provided CBT-I to three individuals with mild to severe TBI, finding reductions in insomnia severity, anxiety, depression, and fatigue.

Nguyen et al. (2017) conducted a randomized controlled study for 24 individuals with mild to severe TBI, finding greater improvement in sleep quality, fatigue, and depression in the CBT group. Finally, in a study by Theadom et al. (2018), 24 participants with mild to moderate TBI underwent an online CBT program for sleep disturbance or a control educational program in which the CBT group showed more improved sleep quality compared to the control group.

The scoping review authors concluded that CBT or CBT-I could improve sleep quality and alleviate insomnia, anxiety, depression, and fatigue in individuals with TBI. The scoping review is limited by its studies’ small number of participants, the small number of randomized control trials, and variability in the number of sessions and delivery (i.e., in-person versus online). The authors propose that a randomized control trial using CBT-I to treat individuals with TBI could provide the answer to some of these questions. Read more about CBT for concussions on our website.

Therapies Being Researched

Estrogen has anti-neuroinflammatory benefits following TBI in male rats

A study by Jin Wang et al. in the journal Molecular Neurobiology examined the role the hormone estrogen plays in decreasing neuroinflammation caused by traumatic brain injuries (TBI). TBIs consist of the initial injury (caused by the physical impact and subsequent neuronal damage) and secondary injuries, including neuroinflammation and cell death. This study focuses on a treatment that may address the secondary injury.

The study consisted of 90 male rats divided randomly into three groups. One group received a TBI and no hormone administration; a second group received a TBI and administration of the estrogen hormone estradiol 2 (E2) for three days following the TBI; the third (control) group did not receive a TBI or E2.

To measure the effectiveness of E2 in decreasing neuroinflammation following TBI, the researchers measured for three cellular markers of neuroinflammation and neuronal damage: astrocytes, microglia, and cytokines. The TBI+E2 rats displayed fewer activations of microglia and astrocytes than TBI-only rats. Thus, TBI+E2 rats showed a decreased neuroinflammatory response compare to TBI-only rats because they had significantly less activation of astrocytes and microglia and less expression of cytokines.

These results expand on past human and animal studies that find estrogen to be anti-neuroinflammatory. Namely, this research suggests that the administration of the estrogen E2 following a TBI decreases markers of neuroinflammation. The results are promising, as they indicate the potential for E2 as a therapy to reduce the effects of neuroinflammation following a TBI. However, the researchers used exclusively male rats. Therefore, there is no indication of the efficacy of E2 on neuroinflammation caused by a TBI in female rats, where circulating estrogen levels could interfere with the effects of administered E2.

Veterans and Service Members

Veterans suffering from depression and concussion symptoms could turn to magnetic brain stimulation for help

A promising treatment technology, repetitive transcranial magnetic stimulation (rTMS), could aid veterans with persistent post-concussive symptoms, depression, and post-traumatic stress disorder (PTSD), according to a press release from Wolters Kluwer Health. rTMS is currently employed in the treatment of major depressive disorder by targeting specific areas of the brain with magnetic stimulation. However, a review published in the Journal of Head Trauma and Rehabilitation indicates that rTMS treatment could potentially be expanded to treat symptoms caused by concussions in military personnel.

Nearly 350,000 veterans have been diagnosed with a form of traumatic brain injury (TBI) since 2000, according to the Defense and Veterans Brain Injury Center (DVBIC). Veterans are at high risk for concussion during training and deployment. Most of the brain injuries suffered by veterans are concussions. While they are deemed mild traumatic brain injuries (mTBIs), concussions lead to comorbidities such as cognitive impairment, depression, and suicidal ideation. It is also important to note that concussions in service members cannot be compared to those in athletes or civilians; their causes (often blast-injuries) and consequences are unique and often more nefarious.

Currently, little support exists for veterans with TBIs. There are no FDA-approved medications or specialized treatments for neuropsychiatric and neurocognitive symptoms. rTMS is a non-invasive method that could remedy the need for new therapies that treat such symptoms.

However “there remains a paucity of conclusive data for which rTMS protocols may be optimal for patients with specific combinations of symptoms. The physiological and psychological impact of concussion (especially in military populations) poses unique challenges that likely require individualized precision at the level of protocol and targeting.” Though no adverse consequences were found, “smarter clinical trials” are needed to fine-tune the settings of the device before it is optimized for military concussions.

Mental Health

Depressive symptoms in high school athletes following a concussion might be temporary

A prospective, longitudinal study carried out by Erin Hammer et al. examined the effect of sports-related concussions on measures of depression in high school athletes. Published in Sports Health, the study utilized concussion symptom evaluations and PHQ-9 assessments (a highly sensitive and specific test for detecting major depression in adolescents). These preseason baseline tests were then compared to the same tests given 24-72 hours after concussion onset; a week later (before athletes' return to play), and then at three months, six months, and twelve months after the recorded onset of their sports-related concussion.

Contrary to previous research suggesting an increased risk of depression with a history of concussions, this study found that mood worsened slightly in the week after sustaining a concussion but returned to baseline when the athlete returned to play and remained at this level for at least 12 months. The large sample size and diverse population make these results generalizable to the typical high school athlete.

Furthermore, the prospective nature of the experimental design reduces potential recall biases. Limitations to the study may include the risk of athletes manipulating baseline test results and minimizing their symptoms after the concussion event, due to their motivation to return to play as quickly as possible.

In general, the study presents relatively strong evidence that “Sport-related concussion did not worsen longitudinal measures of depressed mood in this cohort of high school athletes.” However, clinicians should be attentive to complications resulting from prolonged post-concussion symptoms, a history of multiple concussions, or prior occurrence of major depression.

Statistics

Two genes linked to higher risk of concussion

A prospective study published online ahead of print in Medicine & Science in Sports & Exercise found genetic markers that may indicate a higher risk for concussion. The study, conducted by Stuart K. Kim et al., looked at the genotypes of two different cohorts: the Kaiser Permanente Research Board (KPRB) cohort of 83,414 patients and the United Kingdom (UK) Biobank cohort of 212,122 patients. Concussion cases were identified in the KPRB cohort using clinical diagnoses and in the UK Biobank using primary care data. There were 3,170 cases of concussion in the KPRB cohort (leaving 80,244 individuals as the control group) and 894 individuals with concussions in the UK Biobank group (211,228 controls).

The authors found two single nucleotide polymorphisms (SNPs) that showed significant genome-wide associations with concussions, which they believe could function as biomarkers to identify an increased risk of concussion. These SNPs are located in the SPATA5 and PLXNA4 genes.

The authors do recognize that there are limitations to their research. There is a possibility that these concussions could have been poorly documented. They also only included individuals of European descent, so there is a possibility that these gene mutations could have a different effect on other ethnicities. Lastly, the level of significance of the PLXNA4 gene was low, so further research and testing are necessary. However, this is among the first studies to show evidence for genetic markers of increased concussion risk that could potentially screen athletes, soldiers, and others in high impact situations to improve safety for those more prone to concussions.

Youth

Children may have altered melatonin and cortisol levels following an mTBI, leading to changes in sleep and stress

A study published in Sports Medicine and Health Science recently found that children in the acute (immediate) phase of an mTBI may have altered melatonin and cortisol metabolism. The study, conducted by Arthur Maerlender et al., involved 11 participants, averaged age 12, who recently received an mTBI. They also included an additional 9 matched control volunteers of similar ages who were not injured.

Results indicated that the injured group took more time to fall asleep and experienced higher levels of fatigue. The injured group also demonstrated a statistically significant correlation between the time taken to fall asleep and stress levels. Melatonin is a hormone that helps with sleep. The authors measured melatonin levels at each subject's bedtime and found that the injured group had lower melatonin levels than controls.

Cortisol is a hormone that increases stress levels. Levels of cortisol were measured at each subject's bedtime (T1) and wake-up time (T2) as well as 30 minutes after waking up (T3). From T1 to T2, cortisol levels increased more for the injured group compared to the control group. From T2 to T3, when well-regulated systems have the highest cortisol, cortisol levels for the injured group increased less than the control group.

These findings, which are consistent with studies in adults, suggest that mTBI in the acute phase alters cortisol metabolism in a way that disrupts sleep. The research also suggests that melatonin plays a vital role in sleep changes after an mTBI. Post-concussive stress may trigger the observed modifications in cortisol and melatonin metabolism. Due to the small sample size, further research is needed to allow for more robust inferences. Despite this shortcoming, the study provides crucial information about how children's stress and sleep are affected by mTBI.

Women's Health

Women’s sports: the harsh reality that concussions can bring

Concussions have become a high-profile issue in men’s sports over the last few years. However, while female athletes are more likely to experience a concussion than their male counterparts, they are still fighting for visibility and improved care. In a feature story for ESPN, Assistant Editor Brittany Mitchell tells her personal story of struggling with concussions and speaks with Dr. Rowena Mobbs of Macquarie University’s National Repetitive Head Trauma Research Group.

While most female athletes are given a concussion protocol, there is no guarantee that that protocol will prevent potential long-term impairment for some patients. According to studies in the Orthopedic Journal of Sports Medicine, female athletes are twice as likely as men to experience a concussion. They are also more likely to have longer-lasting and stronger symptoms than men. Dr. Mobbs told ESPN, “three times as many women compared to men suffer chronic migraines, an issue that can be exacerbated by a concussion, while the anatomical differences between men and women around the head and neck may also play a role.”

These symptoms can worsen if the protocol isn’t taken seriously. Dr. Mobbs told ESPN, “Symptoms of a concussion do not necessarily indicate the degree of trouble in the brain.” In her personal story, she grew impatient and started playing earlier than she should have, resulting in her hitting her head yet again. If athletes return too early to their sport without properly being cleared to do so, they can further hinder their recovery.

Beyond the brain’s increased vulnerability during the recovery period, many concussion patients have issues with decision-making, balance, vision processing, and delayed reaction times that could increase their risk to themselves and other players. If athletes are injured again during this period, as Mitchell was, they risk long-term effects on their brains, physical health, and cognitive abilities.

In the article, Mitchell speaks to former professional women’s soccer player Natasha Prior, who retired at 21 due to the cumulative impact of repeated concussions throughout her playing career. Prior speaks on the wide-ranging physical symptoms that she experienced from her last concussion as a professional athlete but emphasized the depression that she experienced as a result of the injury. Prior said her depression “felt chemical” and was exacerbated by the pressure put on her by her team to return to play too soon.

Culture

US government workers’ concussion-like “Havana Syndrome” may have been caused by microwave radiation

An article from NBC News recently explained that “Havana Syndrome” was most likely caused by microwave radiation. In 2016, several diplomats and state department workers stationed in Havana, Cuba “heard strange noises” and then suffered symptoms similar to those of a concussion. The U.S. government tried to handle the situation and allegedly helped the victims transfer and get care, calling what they experienced “Havana Syndrome.”

Two years later, in Guangzhou, China, similar phenomena occurred. The U.S government filed the symptoms as “health incidents,” forcing most victims to use unpaid leave and sick days to cover their time recovering. There have been multiple incidents that fit this same description all over Europe and Asia.

Now, almost four years later, the National Academies of Sciences has released a report claiming that microwave radiation is the cause of these mysterious symptoms. How the State Department workers and Diplomats were exposed to these microwaves is still unclear. Congress has yet to acknowledge these attacks’ existence, but various members of the Senate’s Foreign Relations and Armed Services Committees are speaking up on behalf of these victims.

Neurodegeneration Issues

New study shows that soccer players are still “heading” toward brain damage

In 2019, Dr. Daniel Mackey and his research associates in Scotland conducted the most extensive study on neurodegenerative disease mortality among former soccer players. They found that mortality rates from neurodegenerative diseases like dementia or Alzheimers are about two to three times higher in professional soccer players than people from the general population.

More recently, an article in Newsbreak reviewed a new study performed by news organization Mail on Sunday that documents a smaller subset of Stewart’s original study. The population of this new study contained 475 first-team (1965-66 season) soccer players from England’s top division. Of that group, 189 people have died, and 79 (42%) of those people died of neurodegenerative illnesses or conditions potentially associated with a traumatic brain injury like Alzheimer’s, dementia, or Parkinson’s disease.

The probability of a regular British man dying with neurodegenerative conditions is about 13%, making a professional soccer player’s chance of dying three to four times higher than average. Furthermore, at least 25 of the remaining players reported they currently have dementia.

The correlation between soccer and neurodegenerative illnesses is frighteningly apparent. This data signifies the need for change in a sport that has hardly taken any steps to address this problem. Players, coaches, and caregivers should be more attentive to repetitive hits to the head to prevent or diminish the potential of brain damage.