This week, our lead article, Novel virtual reality balance training program improves persisting symptoms after concussion in multiple domains is in the Therapies and Diagnostic Tools Under Research category.

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In this newsletter: Opportunities, Internship alum's first research publication, Novel virtual reality balance training program, Early treatment for pediatric headaches, and Concussion risk in Cirque du Soleil artists

Writers: Zoe Marquis, Sravya Valiveti, and Maya Chawla

Editors: Conor Gormally, Malayka Gormally, & Zoe Marquis

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Opportunities

Friday, November 21, 8 am PT: A free webinar, Enhancing School Psychologists’ Capacity to Identify and Support Students with Traumatic Brain Injury (TBI) from Early Childhood to School Age, presented by Cadice Campo, EdS and Cuong Hoang, EdS, hosted by The Center for Brain Injury Research and Training. Register in advance.

Tuesday, November 25, 6 pm ET: A free webinar, Post-Concussion Optometry, presented by Dr. Kristine Dalton, hosted by the Canadian Concussion Centre. Register in advance.

Tuesday, November 25, 7 pm ET: A free online session, Principles of Getting Back to School and Work, the second of three in an evening series for medical providers working with pediatric patients, hosted by University Health Network ECHO Medical Education. Register in advance.

Tuesday, December 9, 7 pm ET: A free online session, Management of Pediatric Concussion Symptoms, the last of three in an evening series for medical providers working with pediatric patients, hosted by University Health Network ECHO Medical Education. Register in advance.

Wednesday, December 10, 6 pm ET: A free webinar, Sleep Problems after Concussion, presented by Dr. Neal Parekh, hosted by the Canadian Concussion Centre. Register in advance.

Friday, December 12, 8 am PT: A free webinar, Youth Traumatic Brain Injury and the Law: Barriers to Participation and Justice, presented by Catherine Wiseman-Hakes, PhD and Joseph Wszalek, JD, PhD, hosted by The Center for Brain Injury Research and Training. Register in advance.

New With Us: Concussion Alliance Internship Alum Zach Napora publishes first research paper

We’re thrilled to write our first synopsis of a study authored by one of our internship alumni!

Concussion Alliance internship alum Zach Napora is the lead author of the synopsis Novel virtual reality balance training program improves persisting symptoms after concussion in multiple domains. Zach is a Kinesiology Master’s candidate at Penn State and is working in Penn State’s TBI lab under Dr. Semyon Slobounov. After completing his Master’s, Zach will pursue his PhD at Penn State. Zach has gone from using our resources to support his concussion recovery, to creating new resources for Concussion Alliance as an intern, to now pioneering rehabilitation programs that may benefit patients. We’re so proud of the incredible growth we’ve been lucky enough to see and be part of over the last 2+ years, and we know he will only continue to grow his impact and contributions to this field.

While completing a bachelor’s in neuroscience at the College of Wooster in Ohio, Zach spent two summers as an intern for Concussion Alliance. Zach was a Science Writer intern for our Summer 2023 Concussion Education & Advocacy Internship and returned as a Science & Technical Writing Mentor intern for the Summer 2024 program. Zach “stumbled across” Concussion Alliance while looking for help with his own recovery from concussions sustained as a soccer player. While he was already a neuroscience major and interested in concussion research, Zach found the internship program deeply inspiring and credits it with helping him along his career path. We’re honored to say that, in this, he joins a growing community of intern alumni making a difference for concussion patients in their careers.

“I also wanted to thank you for your help getting me started in this field. Without stumbling across your website, I would not be in this [graduate] program.” ~Zach Napora

Therapies and Diagnostic Tools Under Research

Novel virtual reality balance training program improves persisting symptoms after concussion in multiple domains

A recent case report published in Journal of Clinical Medicine suggests that virtual-reality-based balance training may be effective for resolving persisting symptoms after concussion. Lead researcher (and Concussion Alliance Internship Alum!) Zach Napora and his colleagues developed a virtual reality (VR) balance training program in which patients move a virtual “hockey puck” through a series of VR courses that increase in difficulty. This balance training program was designed to address persisting vestibular dysfunction after concussion, including “dizziness and balance-related deficits.” During the VR tasks, patients stand on a multi-axis force plate platform (a platform that measures the amount of force being exerted at a given time), which allows them to control the puck’s movement by shifting their weight. The tasks require patients to maintain their balance while moving their body and shifting their weight, which helps engage and rehabilitate the vestibular and ocular processing systems.

This case study followed a 20-year-old National Collegiate Athletic Association (NCAA) Division I football player who had sustained multiple concussions in a three-month period. The training program led to a reduction in the player’s self-reported balance-related symptoms and an objective increase in accuracy in his performance on the VR balance tasks. To the researchers’ surprise, the player’s self-reported cognitive- and mood-related symptoms also improved. The authors say that “[the program’s] objective measurement, engaging format, and ease of use suggest potential for broader application in concussion rehabilitation.”

The program consisted of 10 sessions over the course of 10 weeks. During each session, the player completed the VR balance training battery and a clinical interview about his symptoms. By the end of the program, the player’s accuracy in each of the VR courses had increased. Averaged across all courses, the player’s accuracy increased from 75.87% in the first session to 91.67% in the final session. In addition to self-reported and objective balance improvements, the authors were also interested in the player’s self-reported symptom improvement in non-balance-related domains (cognitive and mood). The researchers suggest that this improvement might occur through modulation of cerebello-prefrontal pathways or through stimulation of the hippocampus and parietal cortex via pathways connecting these areas to the vestibular system. Essentially, balance training might help “rewire” regions of the brain that support aspects of cognition and mood in addition to balance and proprioception. Limitations of this study include the possibility of a practice effect (the patient improving on the VR tasks due to practice rather than rehabilitation) and the limited information available on the player’s baseline symptom levels. The researchers say that a practice effect is unlikely, given the lack of a plateau in improvement.

Youth

Early treatment for new daily persistent headache associated with improved outcomes in children and adolescents

A scientific abstract presented at the American Headache Society 67th Annual Scientific Meeting highlights that a combination of early interventions and therapies is crucial for alleviating symptoms in pediatric patients (ages 5-17) with new daily persistent headaches (NDPH). The retrospective study, authored by Christina L. Szperka, MD, and Amy A. Gelfand, MD., was discussed in a Helio article by Robert Herpen. Although NDPH is distinct from both concussion and persisting symptoms after concussion, these findings may be relevant to treating concussion-related post-traumatic headache.

The researchers assessed four treatment categories: preventive* medication, preventive supplements, preventive non-medication therapies, and bridge therapies (treatments used for severe and unusually prolonged headache). Results showed that each additional month after onset that patients failed to receive initial treatment was associated with a reduction in symptom improvement of more than 15%. Additionally, early treatment was associated with improved outcomes at 1 year, whereas prolonged delays in treatment reduced the odds of achieving this symptom improvement by the 1-year mark.

*Terminology Note: ‘preventive,’ or ‘prophylactic’ treatments are used to reduce the frequency, duration, and severity of headaches. ‘Preventive’ treatments are distinct from ‘rescue,’ ‘acute,’ or ‘abortive’ treatments, which are used at the onset of a headache (commonly for migraines) to relieve symptoms.

The researchers reviewed the charts of 172 patients aged 5 to 17 years who were treated at CHOP. Those with a clinical history of abrupt-onset, new, daily-persistent headaches with symptoms lasting at least one month were included. The mean baseline severity was reported as a 6 out of 10 on the pain scale, and half the cohort reported severe disability. Patients who presented to the ED with headaches received bridge therapy while transitioning to a formal treatment regimen, and patients who presented to the neurology department were started on bridge therapy at presentation.

For bridge therapies, the median time to treatment was 49 days, and the first bridge therapy used was beneficial for 57% of patients. Bridge therapies (such as IV medications), with a median time to treatment of 40 days, were beneficial for 83% of patients. For preventive supplements, the median time to treatment was 93 days. Riboflavin was found to be the most beneficial preventive supplement, with 36% of patients who used it experiencing documented improvement. For prescribed preventive medications, the median time to treatment was 69 days. The first type of medication used was beneficial for 35% of patients, but 24% were worse off after initiation; all other therapies had no adverse effects. For non-medication therapies, habit modification benefitted 47% of patients, neuromodulation device use benefitted 46% of patients, acupuncture benefitted 42% of patients, and cognitive behavioral therapy with biofeedback benefitted 36% of patients. Compared to preventive medications, non-medication treatments had significantly fewer outcomes in which patients worsened after initiation.

Dr. Szperka adds that patients are typically prescribed a preventive medication or a supplement as the main treatment during their visit to the neurology department, followed by non-medication therapies later as needed. She emphasizes that it’s important for patients not to ignore any headache symptoms and urges providers to use a combination of therapies early, i.e., start patients on bridge therapies, followed by preventive and/or non-medication therapies.

Dr. Szperka notes that reports of new daily persistent headaches in pediatric patients are a serious concern that cannot be overlooked, especially pertaining to delayed treatment initiation. She highlights that understanding other barriers to treatment and the impact of early, aggressive treatment strategies for NDPH should be thoroughly examined in future pediatric and adolescent headache studies to improve outcomes and inform future clinical trials to advance treatments.

Statistics

Spotlighting a decade of concussion risk in Cirque du Soleil artists

Overwhelmingly, the conversation around concussion focuses on sports, while performing arts, even at a globally-recognized level, are given little attention. The scarce few existing studies on circus arts only consider musculoskeletal injury or student performers, but in September 2025, a group of performing arts scientists led by Dr. Jeff Russell pulled back the curtain on concussion risk in high-level circus artists for the first time. Russell & colleagues’ 10-year epidemiological investigation into the medical records of Cirque du Soleil performers, published in Sports Health: A Multidisciplinary Approach, identified a concussion incidence rate among Cirque artists numerically comparable to varsity and professional non-contact athletics, unique mechanisms of injury in circus that remain overlooked, and significant time loss before safe return to performance.

Examining the Cirque’s medical records from 2010-2019, the researchers quantified concussion incidence rates by calculating “artist exposures” (AEs); one AE is defined as one artist participating in one rehearsal, training session, or performance. Throughout the records, the researchers identified that for every 10,000 AEs, 1.3 concussions occur on average. The year with the lowest rate was 2010, with 0.86 concussions per 10,000 AEs, while 2019 had the highest rate at 1.93 per 10,000 AEs; the authors believe this increase is more likely due to increased awareness and reporting. According to Van Pelt et al.’s (2019) exposure scale, 1.3 falls within typical ranges for non-contact projectile sports such as women’s softball, baseball, and tennis.

Of the four types of Cirque performers, acrobats sustained 90% of all documented concussions. This is unsurprising for a group that performs physically treacherous stunts with apparatus like trapeze, suspension, or trampoline. However, the study also addresses the rarely considered (but non-zero) risk for non-acrobatic performers. In fact, the mechanisms of injury (MOI) accounting for 90% of Cirque concussions are collision impact from apparatus, other performers, or landing surfaces, which are in no way restricted to acrobats. This type of collision is still possible among dancers, musicians, or character performers, especially when their act accompanies acrobatics. The predominance of impact-based MOI in Cirque is a striking revelation, given that performing arts are often considered much less dangerous due to a lack of expected contact. However, this study also shows that concussions can occur without impact, with whiplash forces accounting for 7% of the concussions in the data.

Time lost due to concussion recovery averaged 35.5 days, with a minimum of 1 day and a maximum of 1,338. Additionally, 70.3% of concussions occurred during performances rather than rehearsals. Just as the social pressure of coaches and spectators can deter sporting athletes from reporting concussions, reporting a concussion in the performing arts is difficult when “the show must go on.” Furthermore, unlike non-artistic athletes, circus artists must execute feats of high athleticism in a way that appears effortless and easy, with the cognitive load of performing a storyline or emotion during their act. The practice of concealing effort may obscure the observers’ perception of the risks these performers take. While injuries from sporting impacts, such as hits and tackles, are approached with concern for athlete safety in non-artistic sports, collisions with apparatus or other artists are more likely viewed as a shortcoming of the artist in skillfully navigating their environment and as a disruption to the performance.

Over the course of the decade, concussion diagnosis and education protocols were still evolving within Cirque du Soleil, as the increase in concussion incidence between 2010 and 2019 appears to reflect not a greater count of concussions, but an increase in concussion reporting and identification. Although improvement in reporting and identification is encouraging, it is important to remember that the broader phenomenon of underrecognition, underreporting, and misdiagnosis can lead to incidence estimates that are substantially lower than the true number of people affected. Cirque du Soleil may be comparable to relatively lower-risk sports, but the fact that this risk has long been unacknowledged is dangerous. Fortunately, the inaugural efforts of Dr. Russell’s group to statistically quantify the risk of concussion in circus arts are a monumental step towards ensuring that the safety of these artists takes center stage.

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