This week’s lead articles: World Mental Health Day is in the Mental Health category, and Brett Favre’s Parkinson’s diagnosis is in the Culture category.

In this newsletter: Opportunities, Sports, Therapies Currently Available, Therapies & Diagnostic Tools Under Research, Mental Health, Youth, and Culture.

We appreciate the Concussion Alliance volunteers and staff who created this edition:
Writers: Ella Webster, Fadhil Hussain, Aamy Woldesenbet, Joey Peters, and Malayka Gormally (staff).

Editors: Malayka Gormally and Conor Gormally

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Opportunities

Thursday, October 17, 3 pm EDT: a webinar, Post-Traumatic Headache: Concepts, Caveats, and Controversies, presented by internationally renowned PTH expert and Concussion Alliance Advisory Board Member Nathan Zasler, MD, and hosted by the Brain Injury Association of America. Register in advance; the fee is $50, 1 ACBIS CEU.

Tuesday, October 22, 6 pm EDT: a free webinar, Strategies for Mental Health, presented by Dr. Lesley Ruttan, Neuropsychologist, and hosted by the Canadian Concussion Centre. Register in advance.

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 scroll down) to learn more about the study (by North Texas Traumatic Brain Model Systems), including eligibility and who to contact.

Recordings of excellent recent webinars

Did you miss some of the Canadian Concussion Centre’s recent webinars? Below are the video recordings and related slide decks.

Concussions in Older Adults presented by Dr. Carmela Tartaglia. Video Link. Slide Deck.

Treatment of Post Concussion Symptoms Related to Screens at Work, School or Play, presented by Dr. Charles Tator. Video Link. Slide Deck.

Sports

Evidence backing the medical device, Q-collar, is being questioned, and further investigation is needed

In this article from The Chronicle of Higher Education, journalist Stephanie Lee highlights concerns raised by outside researchers over the accuracy of the studies supporting the Q-collar, a sports device designed by Q30 Innovations to help protect the brain. The Q-collar, worn around the neck, was approved by the FDA “to aid in the protection of the brain from effects associated with repetitive sub-concussive head impacts.” (The FDA specified that t he Q-collar does not prevent concussion or “long-term cognitive function deficits” and that the device has some risks; see our blog posts here and here.)

Many professional athletes have endorsed the Q-collar, trusting the claims made by the company that the Q-collar is “The only equipment proven to help protect the brain.” However, at least six studies (all funded by the company) have faced criticism. While some of the study authors have claimed they plan to correct the data, outside researchers Mu Yang from Columbia University Medical Center and James Smoliga from Tufts University remain unconvinced; in the Chronicle article, they point to a “pervasive pattern” of errors in the studies supporting the Q-collar. Smoglia is concerned about the Q-collar “‘lowering the perception of the risk…so now people are not making informed decisions.’”

The Q-collar works by applying light pressure to the jugular vein, increasing blood volume in the skull, which theoretically reduces brain movement during sudden impacts. David Smith, the device’s inventor, originally hoped it would prevent concussions, though the FDA did not approve such a claim.

Much of the initial support for the device came from brain scan images of high school football players, which showed significant changes in non-collar-wearers but not in those wearing the collar. However, the FDA has since warned that imaging studies have not been validated as a “future indicator of brain injury.” Multiple studies published in the Journal of Neuroscience have shown questionable results, with many unaddressed discrepancies. Although the Journal of Neuroscience contacted one lead author, the effort to review the data has been left to the study authors themselves. The Journal of Neuroscience has declined to independently investigate the Q-collar studies and the multiple instances of problems with the study data.

Yang and Smoligia argue that the investigations so far have been insufficient. Despite athletes continuing to rely on the Q-collar for protection, more comprehensive studies are needed to verify its effectiveness. As of now, the confirmation of the Q-collar’s actual ability to prevent brain injuries remains a topic of debate among researchers.

Co-founder and CEO Conor Gormally and Expert Advisory Board Member Dr. Julie Stamm on InDepth, Oklahoma News Report, PBS OETA

Student-athlete safety: Concussion Alliance on PBS Oklahoma affiliate OETA

Concussion Alliance CEO and Co-Founder Conor Gormally spoke on a panel about concussions in student-athletes for InDepth on the Oklahoma News Report, which was broadcast on September 20, 21, and 22 across Oklahoma on the state-wide PBS affiliate OETA. You can view the 17-minute discussion on YouTube here.

Dr. Julie Stamm, Concussion Alliance Expert Advisory Board Member, also joined the panel. Dr. Stamm is Clinical Assistant Professor in the Department of Kinesiology at the University of Wisconsin-Madison, and author of The Brain on Youth Sports. We are pleased to share Concussion Alliance expertise on concussion risk reduction in youth sports, as well as education for concussion recovery based on current best practices, treatment for persisting symptoms, and long-term impacts with the great state of Oklahoma.

Also on the panel: Leander Walker, Yukon Schools Head Athletic Trainer and past president of the Oklahoma Association of Athletic Trainers. The panel was hosted by InDepth host and producer Cassidy Mudd.

Therapies Currently Available

Acupuncture: a potential treatment for long-term relief of chronic neck pain

Chronic neck pain affects millions of people and is a common post-concussion symptom. A study published in the Annals of Internal Medicine aimed to assess the long-term effects of individualized acupuncture in patients with chronic neck pain. In this randomized controlled trial of 659 patients, Zhao et al. showed that, while no significant difference was seen immediately after the 4-week treatment period (involving ten 30-minute treatments), acupuncture improved chronic neck pain compared to sham and waitlist controls after a 20-week follow-up period. Acupuncture was individualized by treating patients at common neck pain acupuncture points to which they were most or least sensitive. The researchers suggest that “acupuncture could reduce the intensity of pain through modulation of the [nervous] system by acupuncture points.”

Initially, 716 participants were randomized into four groups: high sensitivity acupoints (HSA), lower sensitivity acupoints (LSA), sham acupoints (SA), and waitlist (WL), who did not receive acupuncture. The research team identified the 15 most commonly used acupoints for the treatment of chronic neck pain across five regions of the body and tested these points on each patient to measure individualized pressure pain thresholds (PPT). These points were reassessed every two weeks during the treatment phase of the study. Participants in the HSA group received treatment at the five acupoints that they were most sensitive to (greatest PPT values). Participants in the LSA group received treatment at the five acupoints they were least sensitive to (lowest PPT values). The SA group received treatment at five fixed points other than the 15 most commonly used acupoints for chronic neck pain.

Each group (aside from the waitlist group) received ten 30-minute acupuncture sessions over four weeks and were followed for the subsequent 20 weeks. Of the initial 716 participants, 659 participants completed the full 24-week protocol. Pain was measured using the visual analog pain scale (VAS) every four weeks. The VAS ranges from 0-100, with 0 equaling no pain and 100 equaling the worst pain possible. The researchers deemed a change of 10 to be the threshold for a “minimal clinically important difference” (MCID). When comparing the HSA group from baseline to week 4, there was a clinically significant reduction in pain of 12.16. However, when comparing the HSA and LSA groups to each other in week 4, the differences between the HSA and LSA groups did not reach the MCID threshold. After the 20-week follow-up period, the HSA and LSA groups showed clinically important decreases in pain compared to the sham and waitlist groups.

The researchers suggested that acupuncture’s modulation of the nervous system is the primary mechanism for its effectiveness. They reference previous research describing various mechanisms by which acupuncture modulates the nervous system, including releasing analgesic (pain relieving) substances such as endogenous opioids within the central nervous system. The researchers state, “Although the acupoint prescription was different in the HSA and LSA groups, analogous analgesic substances were both produced under acupuncture stimulation and exerted an analgesic effect.”

The findings of this study support that acupuncture was more effective in reducing chronic neck pain in 24 weeks compared to sham or no acupuncture. While the researchers state the clinical importance of these findings is “unclear,” they say “the selection of pressure pain, sensory-based objective acupoints could be considered as a treatment of chronic neck pain.”

Therapies & Diagnostic Tools Under Research

Promising immunotherapy shows potential as a late-start treatment for cognitive and headache symptoms of mTBI

A recent study published in the Annals of Neurology reveals the potential of a novel immunotherapy that may one day be a treatment for chronic symptoms following a mild traumatic brain injury (mTBI). In the study, the scientists found that administering low-dose interleukin-2 (LD-IL-2) to mice 4-6 weeks after sustaining an mTBI led to a remarkable reversal of both chronic pain and cognitive impairment. The study authors determined that LD-IL-2 treatment works by increasing the number of regulatory T cells in the membrane surrounding the brain and spinal cord. These immune attack cells play a key role in regulating immune responses and blocking excessive inflammation. Authors Katherine Czerpaniak et al. believe this therapy may restore a robust immune response and alleviate symptoms of mTBI. This theory is particularly significant as it suggests that LD-IL-2 could be a therapeutic option for those who initiate treatment weeks after the initial injury.

It is important to note that research on this therapy is ongoing, and a final treatment is likely still some time away. Nevertheless, the findings offer hope for a more flexible approach to managing the debilitating effects of mTBI, potentially reducing reliance on multiple medications and offering a broader therapeutic window.

Mental Health

October 10 is World Mental Health Day

On World Mental Health Day, it’s important to remember that a concussion can affect mental health by worsening pre-existing mental health issues, or increasing the risk of a new mental health issue. Concussion Alliance has several resources to help patients and their advocates address mental health after a concussion.

Mental Health
This resource starts with questions to help the reader identify if this mental health resource applies to them, then follows with resources on how concussions affect mental health and factors that influence mental health symptoms such as stress, loss of identity, school or work stressors, lack of empathy from others, sleep problems, and a history of mental health problems. Populations that are at higher risk for mental health problems after a concussion are identified. Resources for how to help yourself are provided for both youth and adults, and guidance on how to find an appropriate healthcare provider.

Mental Health Among High Schoolers
Concussions are alarmingly prevalent among adolescents and young adults, particularly in high school settings. The prevalence of at least one self-reported lifetime concussion among US adolescents was 24.6% in 2020; that’s almost 1 in 4 high school students. Symptoms like anxiety, depression, mood swings, difficulty concentrating, executive dysfunction, and memory problems can develop following a concussion.

This resource covers recognizing and understanding mental health symptoms, timelines for recovery, identity change, therapy, academic support and accommodations, available resources and where to seek help, support from friends and peers, support from parents or guardians, and personal stories from high school students.

Yoga and Meditation
We have a new resource on yoga and meditation, which includes a section on the science related to yoga, meditation, and concussion; a comparison of yoga and meditation; yoga and meditation for migraines, PTSD, and Major Depressive Disorder (MDD); types of meditation and yoga; how caregivers, those with limited access to healthcare, veterans, and others can benefit; and where to find yoga for concussion patients.

Youth

Return to sport is double the time of return to school; initial symptom burden is the primary factor in slower return to sport

In a meta-analysis and systematic review published in The British Journal of Sports Medicine, Margot Putukian et al. found that following a sport-related concussion (SRC), over 90% of athletes have a complete return to learning (RTL) by ten days post-concussion (mean RTL was eight days) while the return to sport (RTS) takes two times as long. The mean number of days until athletes were symptom-free was 14 days. The review included studies of children, adolescents, and adults over 18 with RTL considerations (college students).

The review found that an individualized approach for each athlete that considers key factors of clinical presentation, psychological readiness, and recovery trajectory is critical to proper RTS. Through a systematic review and meta-analysis of 278 studies, the authors identified several factors they considered to “define and track recovery.” Results of the meta-analysis suggested that RTS was most affected by the initial symptom presentation; the more severe the initial symptom constellation, the more days it took to RTS. Continuing to play sports after sustaining a concussion and delayed access to healthcare were linked with prolonged recovery times, as were migraine history and pre- or post-morbid depression and anxiety. Comparisons of gender and age differences suggest minimal differences in RTL and RTS, with a slightly longer recovery time for females and younger children.

The methodology included a review of eight databases; eligible studies were published from 2001 through March 2022 using a search of standard concepts pertinent to sports and concussions. All studies were included regardless of gender, race/ethnicity, socioeconomic level, or representation from marginalized groups. Researchers used the Scottish Intercollegiate Guidelines tool to reduce the risk of bias during analysis. Putukian et al. utilized numerous assessment measures across studies to determine clinical recovery. They included the following symptom domains: cognition, balance/motor, oculomotor/vestibular-ocular, physical examination, presenting symptoms, and biobehavioral.

In discussing clinical recovery from an SRC, the authors report that the time until symptoms return to a pre-injury baseline has increased over the last 20 years. Possible contributing factors include a higher number of initial symptoms coupled with greater severity of clinical presentation. Other contributing factors include increased awareness regarding SRCs, legislation regarding injuries, increased medical supervision of sports activities, and a more conservative approach to treatment. Of importance is that neither sex nor age factors manifested significant differences in recovery.

Limitations of this systematic review include the wide range of definitions across studies to operationalize the term “clinical recovery.” Therefore, the authors recommend creating a standardized definition of “clinical recovery” following SRC. Further, all reviewed studies were quantitative, suggesting the possibility that psychosocial or experiential factors might have been missed from other qualitative studies. Authors also argue that there are few comprehensive investigations addressing RTL strategies and encourage more studies that take into account the newest emerging evidence suggesting that encouraging prolonged rest and restricted activities delays RTL, while gradual cognitive and physical activity actually improves RTL.

Culture

Brett Favre’s Parkinson’s diagnosis

Even amateur high school and college football players may be at increased risk

Two weeks ago, Brett Favre disclosed that he had been diagnosed with Parkinson’s Disease while he was speaking to the House Ways and Means Committee about his alleged role in the misuse of federal welfare money. Ironically, some of that money was allegedly used to fund a failed pharmaceutical startup, Prevacus, that was developing a concussion treatment medication. Speaking at the committee meeting, Favre implied that his Parkinson’s Diagnosis was related to his many concussions, according to a New York Times article.

Favre’s announcement is notable against a backdrop of regular announcements that former NFL players have been diagnosed with CTE, which can only be definitively diagnosed after death. Favre’s case is different; a living Super Bowl victor was recently diagnosed with a neurodegenerative disease, which the public will watch him live with. Notably, Favre has stated that “five Parkinson’s specialists told him they believed head trauma played a role in his developing the disease,” according to an AP News article. “Head trauma” is a broad term, and recent research points to either concussions or repetitive non-concussive head impacts as potentially increasing the odds of developing Parkinson’s Disease or Parkinsonism.

A thoughtful article from Purdue University explains that there isn’t yet a consensus about whether concussions increase the risk of Parkinson’s Disease. It mentions a 2020 study (explained in a Parkinson’s Foundation article) that found a significantly increased risk even from one concussion. In contrast, the 6th Consensus Statement on Concussion in Sport references some studies that show a link to increased risk and others that do not.

Whether it was the vast number of concussions that may have caused Favre’s Parkinson’s or a career’s worth of repetitive non-concussive head impacts is also a question. The New York Times cites a 2023 study that found that individuals who had played an average of four years of football––over 80% of whom were not professionals but rather amateur high school and college players––had higher odds of Parkinson’s Disease or Parkinsonism diagnosis compared to those who played other organized sports. That risk increased with more years of play and higher levels of football play. Importantly, when selecting the 729 study participants, the researchers ruled out anyone who had experienced a TBI with a loss of consciousness. Some of the participants may have had a history of concussion, as many concussions do not involve a loss of consciousness. Yet, the researchers were attempting to rule out concussion to some degree to focus on the risks posed by repetitive non-concussive impacts.