Full recovery after a sports-related concussion (i.e., mild traumatic brain injury) is critical in order to prevent cumulative damage from future concussion. Unfortunately, the pressure to return to play often outweighs the need to wait for full recovery, and athletes often return to play sooner than they should. There have been various tools proposed to measure recovery after a concussion, but these have shown inconsistent results. There is an urgent need for a more reliable measure of recovery after concussion.

Electroencephalography (EEG) measures brain activity and has been shown to be a sensitive tool for showing slight changes in brain functioning. In a recent study of high school football players, EEG was able to detect abnormalities of brain activity in those who had been concussed as compared to those who had not been injured. Using an emergency department-based algorithm, the researchers were able to show that abnormal brain activity occurred beyond the point in which traditional clinical tools had indicated full recovery.

The implication of this study is that traditional clinical tests of brain function after a concussion are not adequately measuring recovery, and players may be returning to the game too soon. EEG may be a more precise and reliable tool, and should be considered as a standard test in the future.

Barr WB, Prichep LS, Cahbot R, Powell MR, & McCrea M. Measuring brain electrical activity to track recovery from sport-related concussion. Brain Injury. (January 2012).

Mild traumatic brain injury (mTBI) makes up approximately 80% of all TBI cases. It is associated with a range of physical, mood, and cognitive symptoms such as headaches, depression, and memory problems. While these symptoms usually dissipate within three months after injury, some patients experience long-term symptoms. In clinical and research settings, the long-term symptoms of mTBI is called post-concussion syndrome (PCS).

However, the syndrome can be difficult to diagnose. The International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders use different diagnostic criteria. The symptoms of PCS often overlap each other (eg, depression, insomnia, and headaches may all lead to fatigue or memory impairment). And, under the current guidelines, patients without a history of brain injury may be as likely to fit the criteria as patients with mTBI.

These difficulties in diagnosis call for the development of less ambiguous criteria that take the most recent mTBI research under consideration. The current definitions of PCS may otherwise lead to misdiagnosis and missed treatment opportunities.

Dean PJA, O’Neill D, & Sterr A. Post-concussion syndrome: Prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Injury. (January 2012).

On September 30, 2011, BIAA, NASHIA, and NDRN met with both the offices of Congressman Bill Pascrell, Jr., Co-chair of the Congressional Brain Injury Task Force, and Senator Tom Harkin, Chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee to discuss TBI Act reauthorization in 2012. Both offices were receptive to entertaining changes in the legislation next year.

TBI Act stakeholders will continue to lay the legislative groundwork for reauthorization of the TBI Act in 2012. Check back in future editions of Policy Corner for updates on our progress.

As many of you know, BIAA was out front on the Concussion Treatment and Care Tools (ConTACT) Act, introduced in 2009 by Rep. Bill Pascrell, Jr., co-chair of the Congressional Brain Injury Task Force. Although the legislation wasn’t enacted, it was the only federal concussion bill to get any traction, despite the public relations muscle behind other proposals.

BIAA’s early support positioned us to help broker a deal between the House, Senate and CDC to carry forward provisions of the bill through CDC’s annual TBI Act budget. BIAA also ensured that the bill language included recommended collaboration between state brain injury associations and the state government agencies responsible for implementing many of the deliverables.

On September 27, 2011, Rep. Pascrell and Sen. Menendez (Senate champion for the measure) announced that CDC will begin to implement a major component of the ConTACT Act by forming an expert panel to define the need, scope, and expectations of federal concussion guidelines for student athletes. The guidelines that CDC develops will take into consideration advice from experts across the country and support the efforts of the current nationwide state brain injury concussion law initiative.

The CDC has notified the lawmakers that it will convene the expert panel during the next year. The resulting pediatric MTBI (mild traumatic brain injury) guidelines and recommendations are expected to be finalized by the fall of 2013. BIAA is currently working with legislative staff and CDC to address other key components of the ConTACT Act including grants to states for implementation of these federal guidelines and return to play regulations as specified in each state’s sports and concussion law, if applicable.

Traumatic brain injury, head injury, and concussion are all terms that can be used interchangeably when describing the now accepted clinical diagnosis “mild traumatic brain injury.” The clinical definition of mild traumatic brain injury has only recently been accepted, and clinicians and researchers still seem to struggle with the term. Understandably, the public is now very confused.

Researchers who polled random people from the community found that the public incorrectly evaluated 20% of basic statements made about traumatic brain injury. In addition, when different terminology was used, the public attributed more a negative association to “brain injury” than to “head injury.” Half of the participants who had experienced a concussion did not acknowledge to having had a brain or head injury.

One reason for this confusion is inconsistent information from the Internet. When a person experiences a concussion (mild traumatic brain injury), a decision has to be made whether or not to pursue medical attention. Confusion, inaccurate knowledge, and inconsistent information can mean that many people who require medical attention could be slipping through the cracks.

McKinlay A, Bishop A, & McLellan T. Public knowledge of “concussion” and the different terminology used to communicate about mild traumatic brain injury (MTBI). Brain Injury. (July 2011).

Studies have found that high levels of S100B, a protein that can be detected by a blood test, can help predict greater severity and worsened outcomes in brain injury patients. However, brain injury is often related to alcohol intoxication, which can make an accurate diagnosis of injury severity very difficult.  Researchers have begun to investigate if blood alcohol might interfere with the accuracy of S100B testing, or if it would be a useful test in absence of a clear neurological report.

A recent study found that alcohol consumption did not generally affect S100B levels, except in cases of mild traumatic brain injury. In these cases, S100B levels were higher than expected in intoxicated patients than in sober patients. Therefore, there was a slight decrease in the accurate diagnosis of injury severity when patients had consumed alcohol. In addition, S100B was less accurate for brain injury of any severity that was complicated by loss of consciousness, post-traumatic amnesia, or an abnormal CT scan.

Lange RT, Iverson GL, & Brubacher JR. Clinical utility of the protein S100B to evaluate traumatic brain injury in the presence of acute alcohol intoxication. Journal of Head Trauma Rehabilitation. (April 2011).

Mild traumatic brain injury (mTBI) can cause cognitive and psychological symptoms without any evidence of injury on a CT or MRI scan. Many scientists and clinicians now accept that this limitation is due more probably from the relatively low resolution of these scans, and not the absence of real damage.

A recent animal study has shown that, although an mTBI led to only small numbers of actual neuron deaths, this mild damage led to a more extensive degeneration of dendrites and synapses. Dendrites are the branches of a neuron, and are critical for the communication of one neuron to another. The reduction of dendrites led to a reduction in synapses, which are the spaces in between neurons that allow for electrical and chemical exchanges.

Dendritic and synaptic degeneration is too small to be detected by CT or MRI scans, and yet is considered to be physical proof of the damage caused by mTBI.

Gao X, & Chen J. Mild traumatic brain injury results in extensive neuronal degeneration in the cerebral cortex. Journal of Neuropathology and Experimental Neurology. (March 2011).

A tremendous number of soldiers are thought to have sustained a mild traumatic brain injury (mTBI). This number is thought to be even higher, but is difficult to verify because there is not yet an accurate, efficient diagnostic tool for mTBI. The military has therefore made diagnosis of mTBI a research priority—with speed, mobility, and accuracy being of the most concern.

A team of brain injury experts recently gathered to help focus this future of research. The results of their meeting will not only impact the military, but also civilian cases of mTBI.  Both military and civilian clinicians could benefit from more accurate and reliable diagnostic tools, and proper treatment and support could be offered to mTBI patients who might have otherwise been misdiagnosed.

Some of the results of the meeting were that:

1. Given the complex nature of mTBI, one test alone will probably not be sufficient.
2. For the highest potential accuracy without losing efficiency, a combination of three tests is recommended. Studies should use a structured interview, a detailed neurological assessment, and a biomarker as the gold standard of diagnosis.
3. The most promising tools for future research include: pupil reaction; postural stability and visual tracking; biomarkers in blood, saliva, or urine, NIRS (near infrared spectroscopy), and EEG or ERP (electroencephalogram and event related potentials).

Marion DW, Curley KC, Schwab K, et al. Proceedings of the Military mTBI Diagnostics Workshop held in St. Pete Beach, August 2010. Journal of Neurotrauma. (March 2011).

RNA is similar to DNA, but its job is to synthesize proteins. The last decade or so has led to the discovery of the microRNA, which is small and does not synthesize protein. Researchers have since clamored to discover what exactly microRNA does do, and it has been recently found that microRNA play a critical role in the brain.

In a recent research review, it was shown that microRNA respond to brain injury so that certain types of microRNA were increased, and others were decreased. The implication of this discovery is that a blood test to determine the levels of different microRNA may be an effective biomarker for diagnosing brain injury. This could be important, especially in instances where there is no external injury to the head and the traditional CT scan shows no damage—as is often the case in mild traumatic brain injury or diffuse axonal injury.

Saugstad JA. MicroRNAs as effectors of brain function with roles in ischemia and injury, neuroprotection and neurodegeneration. Journal of Cerebral Blood Flow & Metabolism. (September 2010).

Traditional assessment of mild traumatic brain injury (CT scan and neuropsychological assessment) can often fail to accurately assess the injury. Past research has shown that deficits can be more accurately detected by using functional imaging, as well as electrical, magnetic, and metabolic tests. Unfortunately, these assessments do not currently have general guidelines or parameters for brain injury assessment. As a result, these functional tests are often not used in clinical practice, and are refuted as accurate evidence in the courtroom.

To address this problem, the International Brain Research Foundation (IBRF) has developed a non-invasive, multimodal brain-mapping matrix in hopes of guiding not only accurate assessment, but also treatment. The matrix includes the following technologies: electroencephalography (EEG), quantitative EEG (qEEG), magnetoencephalography (MEG) with standardized, low-resolution brain electromagnetic tomography (sLORETA), evoked potentials (EP) and event-related potentials (ERP), magnetic resonance imaging (MRI) and MRI spectroscopy, near-infrared spectroscopy (NIRS), and positron emission tomography (PET).

The goal of the IBRF is to assess and develop general guidelines for the tools in their matrix. The outcome could be that more reliable tools will soon be put into practice in the assessment and treatment of mild traumatic brain injury.

Polito MZ, Thompson JWG, & DeFina PA. A review of the International Brain Research Foundation novel approach to mild traumatic brain injury presented at the International Conference on Behavioral Health and Traumatic Brain Injury. American Academy of Nurse Practitioners. (September 2010).