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Light exercise might help teens recover faster from concussions

  • A carefully managed aerobic exercise program might help those suffering sports-related concussions recover faster.

A randomized clinical trial involving 103 teenage athletes who sustained concussions while playing sports found that those who underwent a supervised, aerobic exercise program took significantly less time to recover compared to those who instead engaged in mild stretching.

Those in the exercise program took on average 13 days to recover, while those in the control group, who performed placebo-like stretching exercises (that would not substantially elevate heart rate), took 17 days. In addition, only two patients in the exercise program took longer than four weeks to recover, compared to seven patients in the control group.

The treatment began within the first week of a concussion in adolescents, after a few days of rest. Each exercise program was individually tailored, on the basis of their performance on the Buffalo Concussion Treadmill Test, and each participant was given a heart rate monitor to ensure they didn’t exceed the given threshold. The assigned exercise took about 20 minutes each day.

The exercise “dose” was evaluated weekly, and increased as the patient’s condition improved.

Patients were also told to avoid contact sports, gym class, or team practice, and excessive use of electronic devices, since that can also aggravate symptoms.

Adolescents typically take the longest to recover from concussion.

The findings directly contradict the conventional approach to concussion, which often consists of nearly total rest, eliminating most physical and mental activities, including schoolwork.

https://www.futurity.org/concussions-exercise-teens-1973382/

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Effects of concussion more subtle and longer-lasting than conventional tests show

  • More evidence comes from several studies of more subtle brain damage that isn't captured in conventional tests of concussions.
  • A new brainwave monitor finds brain impairments in ice hockey players that had been cleared to return to play after concussions, as well as signs of impairment from players experiencing sub-concussive impacts
  • A new way of analyzing brain images has found clear brain changes six months after female rugby players suffered concussions
  • Young adults suffering multiple concussions showed brainwave changes accompanied by poorer cognitive control more than a month after the last concussion
  • Detailed scans found hockey players cleared to return to play showed loosened myelin (the insulating substance around brain wiring)
  • However one study of young football players showed no association between sub-concussive impacts and neurocognitive performance (but were their tests sensitive enough?)

New method finds undetected brain impairments in ice hockey players with and without diagnosed concussions

A hockey concussion study tracking the brain function of 47 Junior A male ice hockey players using a new brainwave monitoring method called "brain vital signs", has found that this more sensitive measure detected neurophysiological impairments, such as attention and cognitive processing deficits, in players who had been diagnosed with concussions and were cleared for return-to-play. Surprisingly, the team also found significant delays in cognitive processing for players who were not diagnosed with concussions at any time during the season (sub-concussive effects).

The new method is easy and quick to use, taking less than 10 minutes and being easily and fully deployable within a variety of sporting settings.

https://www.eurekalert.org/pub_releases/2019-01/cpr-bvs011519.php

New technique confirms persistent brain changes after concussion

A brain imaging study of 52 female athletes from a women's varsity rugby team, including 21 who suffered a concussion, has used a technique that combines multiple imaging measures to produce a much more sensitive and complete picture of concussion injury.

The study identified three unique signatures — one that shows acute brain changes after an athlete has suffered a concussion, another that can identify persistent brain changes six months after the concussion, and a third that shows evidence of concussion history.

Confirming growing evidence of persistent changes in the brain that last well beyond clinical recovery and clearance to return to play, the study showed clear brain changes in both structure and function that persisted six-months after injury.

https://www.eurekalert.org/pub_releases/2018-12/uowo-mts121918.php

Paper available at https://www.sciencedirect.com/science/article/pii/S2213158218303759?via%3Dihub

Lasting impact of concussions on young adults seen in brainwaves & cognitive control

A study involving 21 young adults (18-24) with a history of two or more concussions and 21 age- and gender-matched controls has revealed that those in the concussion group performed significantly worse on a task-switching activity. This was accompanied by greater desynchronization of brainwaves in relevant brain areas. It’s suggested that a change in neural communication occurs and persists after concussion.

All concussions were at least a month earlier.

https://www.eurekalert.org/pub_releases/2018-12/uonh-urf_1121918.php

Sub-concussive impacts in one football season not linked to cognitive harm

A prospective study following 112 youth football players age 9-18 found that sub-concussive impacts were not correlated with worsening performance in neurocognitive function.

The pre- and post-season assessments used to measure outcomes included:

  • Neuropsychological testing
  • Symptoms assessment
  • Vestibular and ocular-motor screening
  • Balance testing
  • Parent-reported ADHD symptoms
  • Self-reported behavioral adjustment

Sensors placed in the helmets recorded sub-concussive head impacts during practices and games.

https://www.eurekalert.org/pub_releases/2018-10/nch-csi101118.php

Concussions loosen insulation around brain cells

Detailed scans of concussed university hockey players found that myelin (the protective fatty tissue surrounding brain cell fibers) was loosened two weeks after the injury — even though the athletes felt fine and were deemed ready to return to the ice.

Myelin speeds the transmission of electrical signals between brain cells, and previous animal research has shown that this loosened myelin can completely deteriorate with subsequent blows. This is the first evidence in humans.

Conventional brain scans do not reveal myelin loosening.

Happily, the myelin had returned to normal after two months, but the findings provide more evidence that more time is needed before concussed athletes return to play.

https://www.eurekalert.org/pub_releases/2018-09/uobc-cli083118.php

Paper available at https://www.frontiersin.org/articles/10.3389/fneur.2018.00575/full

Reference: 

Manning, K.Y. et al. 2019. Linked MRI signatures of the brain's acute and persistent response to concussion in female varsity rugby players. NeuroImage: Clinical, 21, 101627.

[4371] Barlow, S. E., Medrano P., Seichepine D. R., & Ross R. S.
(2018).  Investigation of the changes in oscillatory power during task switching after mild traumatic brain injury.
European Journal of Neuroscience. 48(12), 3498 - 3513.

Rose SC, Yeates KO, Fuerst DR, Ercole PM, Nguyen JT, Pizzimenti NM. 2018. Head impact burden and change in neurocognitive function during a season of youth football. The Journal of Head Trauma Rehabilitation. [Epub ahead of print.]

Weber, A.M.et al. 2018. Pathological Insights From Quantitative Susceptibility Mapping and Diffusion Tensor Imaging in Ice Hockey Players Pre and Post-concussion. Frontiers in Neurology, 9, 575.

 

 

 

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New concussion recommendations for kids

  • The American Academy of Pediatrics (AAP) has updated its concussion recommendations.

The American Academy of Pediatric now supports children and teens engaging in light physical activity and returning to school as they recover. It also now advises against complete removal of electronic devices, such as television, computers and smartphones, following a concussion.

"We've learned that keeping kids in dark rooms and eliminating all cognitive and physical activity actually worsened a lot of kids' symptoms rather than improving them."

While young athletes should stop playing immediately after a concussion is suspected, light physical activity, such as brisk walking, can be incorporated as they are recovering. Similarly, academic workloads may need to be lessened after brain injury; however, such students shouldn't need to miss prolonged periods of school or disengage in learning.

However, the authors note that each concussion is unique, and specific recommendations should be tailored for the individual case.

https://www.eurekalert.org/pub_releases/2018-11/wuis-ncr111218.php

Reference: 

Halstead ME, Walter KD, Moffatt K, and the American Academy of Pediatric’s Council on Sports Medicine and Fitness. Sports-Related Concussion in Children and Adolescents. Pediatrics. Published online Nov. 12, 2018. https://www.childrensomaha.org/wp-content/uploads/2018/11/Sport-Related-Concussion.pdf

 

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Suggestions for protecting against sports concussions

  • Two studies suggest that those with stronger and thicker necks, and those with a specific gene variant linked to dyslexia, are less vulnerable to concussion.
  • One study points to the value of good nights' sleep when recovering from concussion.

Can stronger necks reduce concussion risk & severity?

A review of research on the role that the neck’s strength, size, and posture play in reducing concussion risk has concluded that neck strength, size, and posture may reduce risk by lessening the magnitude of force upon impact. It’s suggested that exercises that increase neck strength and possibly size could substantially reduce risk or severity of injury.

The researchers also note that women typically have less neck strength and experience a greater concussion risk as well as greater severity of symptoms and longer duration of recovery compared to men.

https://www.futurity.org/concussions-necks-athletes-1959052-2/

Good sleep quality encourages better recovery after sport-related concussion

Data from 356 athletes younger than 19 who were diagnosed with a sport-related concussion has found that those who have good sleep quality after sustaining a concussion are more likely to recover within two weeks. Those who don't have good sleep quality often take longer to recover, sometimes greater than 30 days.

Sleep quality was assessed using a standard sleep questionnaire. 27% of athletes had poor sleep quality (a score of six or more). Girls were more likely to have poor sleep quality post-concussion than boys. Athletes with poor sleep quality reported two (2) times greater symptom severity at their initial clinic visit and three (3) times greater symptom severity at their 3-month follow-up compared to those with good sleep quality, although both groups improved over time.

https://www.eurekalert.org/pub_releases/2018-11/aaop-gsq102318.php

Protection against concussions linked to dyslexia gene

A study of 87 varsity Penn State football players has found that the specific variant of a gene, KIAA0319, predicted the number of previously diagnosed concussions in the players. There was a direct increase in diagnosed concussions as one went from CC to CT to TT individuals.

Intriguingly, the CC genotype has previously been associated with dyslexia, suggesting that those with dyslexia may be less susceptible to TBI. It’s hypothesized that this protection may related to the more diffuse wiring often seen in those with dyslexia.

https://www.eurekalert.org/pub_releases/2018-10/nu-fpc102318.php

 

Reference: 

Streifer, M. et al. 2019. The Potential Role of the Cervical Spine in Sports-Related Concussion: Clinical Perspectives and Considerations for Risk Reduction. Journal of Orthopaedic & Sports Physical Therapy, 49 (3), 202-208.

The study "Association Between Sleep Quality and Recovery Following a Sport-Related Concussion in the Pediatric Population," was presented at the American Academy of Pediatrics 2018 National Conference & Exhibition, in Orlando, Fla.

Walter, A. et al. 2018. Past Concussions in a Division I Football Team: A Pilot Study. Journal of Neurotrauma. http://doi.org/10.1089/neu.2017.5622

 

 

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Population study confirms link between traumatic brain injury and dementia

  • A very large dataset shows that a history of TBI significantly increases the risk of later dementia, with risk increasing for more injuries and more severe injuries.

A review of nearly 2.8 million patient cases in Denmark found that the risk of dementia in individuals with a history of TBI was 24% higher than those without a history of TBI, after accounting for other risk factors.

Risk was greater when the TBI was characterized as "severe" — 35% compared to an increased risk of 17% for a single "mild" TBI or concussion.

Moreover, dementia risk increased 33% higher for two or three TBIs, 61% higher for four TBIs, and 183% higher for five or more TBIs.

Additionally, the study found that if you have a brain injury in your 20s, the risk of developing dementia in your 50s increased by 60%.

The findings suggest that those with a history of TBI (particularly multiple injuries) should make an effort to reduce other risk factors, such as limiting alcohol and tobacco use, engaging in regular exercise, preventing obesity, and treating hypertension, diabetes, and depression.

Among the nearly 2.8 million people observed, 4.7% had at least one TBI diagnosis. Among first TBI diagnoses, 85% were characterized as mild.

Among men and women with TBI histories, men had slightly higher rate of developing dementia (30% vs. 19%).

Note that an earlier study (much smaller) found no evidence of a link between TBI and Alzheimer's.

This study involved 706 older adults from the National Alzheimer's Coordinating Center database, of whom 274 had Alzheimer’s. It found that there was no significant difference in the rate of cognitive decline between demographically and clinically similar participants with and without a history of TBI. This held regardless of APOE4 status.

However, researchers added the caveat that the findings should be interpreted cautiously due to the crude and limited assessment of TBI history available through the database.

https://www.eurekalert.org/pub_releases/2018-04/uowh-scl041018.php

https://www.eurekalert.org/pub_releases/2017-07/bumc-snl070517.php

 

Reference: 

[4372] Fann, J. R., Ribe A. Riisgaard, Pedersen H. Schou, Fenger-Grøn M., Christensen J., Benros M. Eriksen, et al.
(2018).  Long-term risk of dementia among people with traumatic brain injury in Denmark: a population-based observational cohort study.
The Lancet Psychiatry. 5(5), 424 - 431.

Tripodis, Y. et al. 2017. The Effect of Traumatic Brain Injury History with Loss of Consciousness on Rate of Cognitive Decline Among Older Adults with Normal Cognition and Alzheimer’s Disease Dementia. Journal of Alzheimer's Disease, 59 (1), 251-263.

 

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Strategic brain training helps individuals with long-lasting TBI

  • A small study finds strategy-based reasoning training has greater benefit for those with persistent TBI difficulties than a knowledge-based training program.

A study showing that a certain type of instructor-led brain training protocol can stimulate structural changes in the brain and neural connections even years after a traumatic brain injury (TBI) challenges the widely held belief that recovery from a TBI is limited to two years after an injury.

The study included 60 adults with TBI symptoms lasting an average of eight years. Participants were randomly placed into one of two cognitive training groups:

  • strategy-based reasoning training called Strategic Memory Advanced Reasoning Training (SMART), focused on selective attention, abstract reasoning, and other thinking strategies
  • knowledge-based training called Brain Health Workshop (BHW), focused on education regarding brain structure and function and the effects of sleep and exercise on the brain performance

Both programs comprised 12 1.5-hour sessions over 8 weeks conducted in small group settings (4–5 participants), and instruction was given using a series of slides.

More specifically, the SMART group was trained to

  • block distractions and irrelevant information and avoid multitasking
  • understand main ideas and take‐home messages
  • examine information from different perspectives.

The BHW group learned about

  • brain anatomy
  • brain function
  • the effects of a TBI on cognitive function
  • the principles of neuroplasticity
  • the impact of diet, physical exercise, sleep, and social activities on brain health.

Those in the strategy-based reasoning training showed a greater change in cortical thickness and connectivity compared to individuals who received the knowledge-based training. Changes in cortical thickness and functional connectivity also correlated to an individual's ability to switch between tasks quickly and consistently to achieve a specific goal.

Moreover, those who showed the greatest change in cortical thickness and connectivity, showed the greatest improvements in cognitive performance.

https://www.eurekalert.org/pub_releases/2017-05/cfb-sbt052217.php

Paper available at https://onlinelibrary.wiley.com/doi/full/10.1002/brb3.687

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New consensus on preventing and treating sport-related concussions

Key points that are new in the 5th International Consensus statement on concussion in sport:

  • If a concussion is suspected, the athlete should be removed from the sporting environment and a comprehensive assessment should be conducted in a standardized way by a qualified health care provider.
  • A brief period of rest (24-48 hours) after injury is appropriate. After this time, patients should be encouraged to become gradually and progressively more active while staying below their physical and cognitive thresholds.
  • Most individuals recover in the initial 10-14 days. Treatments including psychological, cervical and vestibular rehabilitation are now recognized as important components of recovery in some people. Submaximal and sub-symptom threshold exercise may also be of benefit.
  • Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools but require further research before they can be used in clinical decision making.
  • The expected symptom duration in children is up to four weeks.
  • Children should not return to sport until they have successfully returned to school. However, early introduction of symptom-limited physical activity is appropriate.
  • The literature on long-term consequences of exposure to head trauma is inconsistent. Thus, further research in this area is needed to answer these important questions.
  • Helmets in skiing/snowboarding have been shown to reduce the risk of traumatic brain injury (including concussion). In addition, policy disallowing body checking in youth ice hockey reduces the risk of concussion in 11-12 year old ice hockey players.

Key points related to concussion for the general public:

  • A concussion should be suspected if any symptoms (such as headache, dizziness, blurred vision, etc) and/or visible signs of a concussion (lying motionless, slow to get up, disorientation, balance disturbances, etc) occur following a blow to the head.
  • Athletes should be removed from play and not allowed to return to play until medically assessed and cleared by a physician to return to sport.
  • Initially, a period of rest (24-48 hours) is recommended. After this time individuals are encouraged to become gradually more active and remain below their symptom threshold.
  • Most adults recover in 10-14 days and most children recover in the initial 30 days. Treatment should be directed based on individualized comprehensive assessments and could include treatments such as psychological, cervical and vestibular rehabilitation. Submaximal exercise may be of benefit.
  • Children should return to school prior to returning to sport.
  • A gradual return to sport protocol should be completed prior to medical clearance to return to sport.

https://www.eurekalert.org/pub_releases/2017-04/uoc-ncp042617.php

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Adding ADHD drug to therapy improves cognitive outcomes in TBI patients

  • A preliminary study suggests adults with persistent difficulties after TBI may benefit from a metacognitive training program in conjunction with use of Ritalin.

A small study involving 71 adults who struggled with persistent cognitive difficulties after suffering a traumatic brain injury at least four months before has compared two cognitive training programs with and without drug therapy.

The two six-week programs were

  • Memory and Attention Adaptation Training program, a brief cognitive-behavioral therapy aimed at enhancing skills for self-managing and coping with cognitive failures in daily life. It includes four components:
    • education regarding ‘normal’ cognitive failures, as well as potential effects of TBI on cognitive function
    • self-awareness training to identify ‘at-risk’ situations where cognitive failures are likely to occur
    • self-regulation training emphasizing applied relaxation techniques and stress management
    • cognitive compensatory strategy training
  • Attention Builders Training, involving
    • repetitive cognitive tasks to build skills through ‘mental exercise’
    • an educational component discussing common cognitive symptoms after TBI

Participants of both groups also received either the drug methylphenidate (Ritalin) or a placebo.

The best improvement (still modest) was noted in those who received methylphenidate along with the Memory and Attention Adaptation Training. They were better able to learn lists of words, while their working memory and their attention improved.

Do note, however, that these findings must be considered preliminary, due to the relatively small number of participants in the each group (17-19 people).

https://www.eurekalert.org/pub_releases/2016-11/s-hfp112216.php

https://www.eurekalert.org/pub_releases/2016-11/iu-aad112216.php

Paper available at https://www.nature.com/articles/npp2016261

Reference: 

McDonald, B.C. et al. 2016. Methylphenidate and Memory and Attention Adaptation Training for Persistent Cognitive Symptoms after Traumatic Brain Injury: A Randomized, Placebo-Controlled Trial, Neuropsychopharmacology. doi: 10.1038/npp.2016.261

 

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Can targeting inflammation ease chemo brain?

  • A small pilot study has confirmed that inflammation in the blood plays a role in chemobrain.

A pilot study involving 22 breast cancer patients currently receiving chemotherapy (mean age 54), has found that those with higher levels of inflammatory biomarkers did significantly worse on tests for short-term visual memory. One particular biomarker — tumor necrosis factor-alpha (as reflected through its two soluble receptors, TNFRI and TNFRII) — was the strongest indicator of cognitive problems.

The findings are consistent with an earlier study involving 174 breast cancer patients evaluated before chemotherapy, which found that higher levels of those biomarkers were associated with worse memory, and another study of 49 patients, which found that higher levels of sTNFRII were associated with more memory complaints after chemotherapy.

Cognition was assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB), looking at those domains previously reported to be affected in cancer survivors: visual memory, executive functioning, attention, verbal memory, and cognitive processing.

Almost all the patients were Caucasian and college-educated.

http://www.futurity.org/chemo-brain-cancer-1631232-2/

Reference: 

Williams, AnnaLynn M. et al. 2018. Associations between inflammatory markers and cognitive function in breast cancer patients receiving chemotherapy. Journal of Neuroimmunology, 314, 17-23. Full text available at https://www.jni-journal.com/article/S0165-5728(17)30198-4/fulltext

Patel, S.K., Wong, A.L., Wong, F.L., Breen, E.C., Hurria, A., Smith, M. et al. 2015. Inflammatory biomarkers, comorbidity, and neurocognition in women with newly diagnosed breast cancer. J. Natl. Cancer Inst., 107.

Ganz, P.A., Bower, J.E., Kwan, L., Castellon, S.A., Silverman, D.H., Geist, C. et al. 2013. Does tumor necrosis factor-alpha (TNF-alpha) play a role in post-chemotherapy cerebral dysfunction?. Brain Behav. Immun., 30, S99–108.

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The right diet may slow cognitive decline in stroke survivors

  • An observational study involving over 100 stroke survivors suggests the MIND diet may help substantially slow cognitive decline in those impaired by stroke.

A pilot study involving 106 participants of the Rush Memory and Aging Project who had experienced a stroke followed participants for an average of 5.9 years, testing their cognitive function and monitoring their eating habits using food journals. It was found that those whose diets scored highest on the MIND (Mediterranean-DASH Diet Intervention for Neurodegenerative Delay) diet score had substantially slower rates of cognitive decline than those who scored lowest. The estimated effect of the diet remained strong even after taking into account participants' level of education and participation in cognitive and physical activities. Those who instead scored high on the Mediterranean or DASH diets did not show the same slower decline.

Both the Mediterranean and DASH diets have been shown to be protective against coronary artery disease and stroke, but this finding suggests the MIND diet is better for overall brain health.

The MIND diet is a hybrid of the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets. It has 15 components: 10 “brain-healthy food groups” and five unhealthy groups (red meat, butter, cheese, pastries and sweets, and fried or fast food).

To adhere to the MIND diet, you need to

  • eat at least three daily servings of whole grains
  • eat a green leafy vegetable and one other vegetable every day
  • drink a regular glass of wine
  • snack most days on nuts
  • have beans every other day or so
  • eat poultry and berries at least twice a week
  • eat fish at least once a week
  • limit butter to less than 1 1/2 teaspoons a day
  • eat less than 5 servings a week of sweets and pastries
  • eat less than one serving per week of whole fat cheese, and fried or fast food.

The researchers stress that this is a preliminary study, observational only. They are currently seeking participants for a wider, intervention study.

https://www.eurekalert.org/pub_releases/2018-01/rumc-mdm012418.php

Reference: 

Laurel J. Cherian & Martha Clare Morris: Presentation at the American Stroke Association's International Stroke Conference 2018 in Los Angeles, January 25.

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