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Brain injury

Pavard head injury ‘sickening to watch’

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The injury sustained last night by France defender Benjamin Pavard and the way it was dealt with was “sickening to watch”, with calls for urgent action to be taken to protect players from such a situation repeating.

Pavard was injured in the Euro 2021 match with Germany, when he collided with Germany’s Robin Gosens. Pavard hit the ground without his arms protecting him from the fall and later admitted he was ‘a little knocked out for ten, 15 seconds’.

Despite this, the player was allowed to continue after receiving on-pitch medical attention for less than three minutes – a decision labelled by brain injury charity Headway as “disturbing”.

While the Premiership last season became the first football competition in the world to trial the use of concussion substitutes – although its premise of permanent rather than temporary replacements has prompted widespread calls for it to go further – no such measures are in place during the Euros.

In the wake of Pavard’s injury last night, with football fans around the world fearing for the player’s welfare during the incident, Headway has called for urgent action to be taken to ensure such a situation does not occur again.

“This is another example of football authorities failing to protect the short and long term health of a player,” says Peter McCabe, chief executive of Headway.

“It was plain for all to see that Pavard was unable to protect himself from the fall. Pavard’s later statement that he lost consciousness confirms the seriousness of the incident.

“We have continuously been told that football’s concussion protocols are fit for purpose and that temporary concussion substitutes are not necessary. But here we have yet another example where it is simply not credible to suggest that a concussion could not be ‘suspected’ or a possible consequence of the impact. However, after a brief on-pitch assessment the player was allowed to continue.

“Furthermore, it appeared that the referee was attempting to speed up the medical team and usher them and the player off the pitch, rather than allowing them the time they needed to assess the seriousness of the injury.

“Why is it so hard for football to accept it has got this wrong and follow the example set by other sports by introducing temporary concussion substitutes?

“The way this incident was handled was sickening to watch. UEFA has to come out and immediately explain how it was allowed to happen and what action it will now take to ensure something similar does not occur in the future.”

Brain injury

 New Veteran Study Marks New Era of Concussion Treatment

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The shoulder of a US veteran taking part in a study on traumatic brain injury

A study has identified the first effective and highly scalable intervention to address cognitive deficits that can persist for years after a mild traumatic brain injury especially after a concussion or blast exposure.

The traumatic brain injury study utilised the computerised brain training app BrainHQ made by Posit science via Telehealth. The peer-reviewed study results were published in Brain: A Journal of Neurology.

The Department of Defense (DoD) funded the BRAVE study. It aims to determine if a computerised, brain training intervention based on the science of brain plasticity could be broadly or remotely applied. It tested to see if it could produce significant improvements in persistent cognitive defects across those with broad mild TBIs.

The study included 83 participants with a history of mild BTIs who had been diagnosed with cognitive impairment for more than seven years. These participants had typically been deployed to combat areas. Before training, they tested, on average, about two standard deviations below normal on the ANAM. The ANAM is a test used by the military to screen for cognitive impairment.

The participants were randomly placed into treatment groups (BrainHQ) and an active control group (computer games). Both activities were expected to have a positive impact due to their demands on cognitive realms such as attention, memory and reasoning. Each group self-administered the training online while at home with weekly telephone supervision from trained coaches. They were asked to train for one hour per day, five days a week over twelve weeks. This was followed by a twelve-week, no training follow-up period.

Read more: Head injuries in rugby players linked to brain structure changes

It was conducted through a network of five military and veterans’ medical centres in Bethesda, Honolulu, Houston, West Haven, Boston and with Posit Science in San Francisco.

The results showed that the BrainHQ group reported clinically significant improvement in overall cognitive function in comparison to the computer games group. The benefits lasted for at least twelve weeks after training was completed. Cognitive function was 3.9 times larger in the BrainHQ group than the control group. It was 4.9 times larger when measured again twelve weeks after training ended.

The US military have recorded more than 413,000 members who have been diagnosed with a traumatic brain injury (TBI). Of these, more than 82 per cent are classified as mild TBI referred to as a ‘signature injury’ of recent conflicts. In many cases, service members can experience a full recovery from this but for those who do not, cognitive consequences can persist for years. This can have life altering results.

Physician, Colonel (Ret.) Dallas Hack, said “When this study was selected for funding, we were hoping it would help troops impacted by mTBI. These results exceed my fondest expectations. The broad applicability, modest cost, and self-directed nature of the intervention mean it could be scaled very quickly.”

Currently, the best practice for the treatment of persistent cognitive deficits following a mild TBI focuses on in-person, customised cognitive rehabilitation. This can be helpful but is also costly and time-consuming as it requires travel for treatment and relies on healthcare expertise. No computerised cognitive training has previously been shown effective in a gold-standard trial.

Read more: Mental health NHS Trust extends roll-out of Perfect Ward

BrainHQ has been used in many military and Veterans’ facilities for cognitive rehabilitation, under the supervision of healthcare professionals. With the release of these results, Posit Science (maker of BrainHQ) has indicated it intends to work with clinicians, payors, patient advocacy groups, legislators, and administrators to make this intervention widely available, as quickly as possible.

Dr Henry Mahncke, CEO of Posit Science, said: “These are long-awaited and important results. This study provides strong evidence that this intervention could be deployed on a massive scale through military and veterans’ health facilities to meet our nation’s obligation to address persistent real (but often invisible) life-altering challenges for wounded servicemembers and veterans – even those in remote locations.”

Read more: Alzheimer’s Research UK receives diagnostics funding boost

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Brain injury

High-res computer modelling to shed new light on TBI impact

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Researchers have created a traumatic brain injury (TBI) computer model that maps blood vessels in a rat brain in the highest resolution yet.

The team at Imperial College London say the models could help improve understanding of how blood vessels are affected by TBI, as well as its effects on the protective layer encasing them known as the blood-brain barrier (BBB), which protects the brain from harmful circulating molecules and pathogens.

If the methods translate well onto human brains, Imperial say they could also help improve understanding of how TBIs develop and how best to treat and protect against them.

The simulations could even help to replace animal models of TBI, potentially reducing the use of animals in brain research.

TBIs are the most common cause of chronic disability in under 40-year-olds and result from severe blows or jolts to the head. 

Beginning at the site of impact, mechanical forces travel in waves through the brain, twisting, stretching, and shearing brain structures as the injury cascades. These forces are known to affect blood vessels, but the finer details of the relationship between mechanical forces and vascular injury are yet to be established.

Now, researchers at Imperial have created a computer model of TBI which maps the network of vessels in the brain – called the vasculature – in the highest resolution yet, incorporating rat brain vessels just 10 microns in diameter.

Using the models, they found that adjacent blood vessels sustain profoundly different levels of stress depending on their alignment with neighbouring ones.

Blood vessels at 90 degree angles to others were less likely to be damaged, and vessels could be stretched to up to 14 per cent of their original length without injury, while stretching by more than this amount would result in injury.

Lead author Dr Siamak Khosroshahi, who conducted the work while at Imperial’s Dyson School of Design Engineering, says: “Our unique approach explains the unrecognised role of the vascular anatomy and shear stresses in how large forces cascade through the brain. This new understanding could contribute to improving TBI diagnosis and prevention.”

The degree to which the BBB lets molecules into the brain is known as permeability. The barrier can become more permeable after injury, making it more likely to let pro-inflammatory molecules reach the brain and usher in further injury.

By using rat models of TBI, the authors demonstrated that greater BBB permeability occurs in TBI as a result of disruption of the vasculature, and that this is most evident soon after injury.

From this information they created brain models digitally in high enough resolution to highlight the vasculature. They found that the computer models allowed them to accurately predict the distribution of stress in the small blood vessels of the rat brains. The models also allowed them to slow down time to look at the details of TBI more closely.

Senior author Dr Mazdak Ghajari, also of Imperial’s Dyson School of Design Engineering, says: “Injury happens in a fraction of a second, making it hard to observe exactly what goes on. By slowing down the process, we can pinpoint exactly which brain areas sustain the most damage and go some way to understanding why.”

The new, high resolution computer simulations could provide a blueprint for studying TBIs using more computers and fewer animal models, in line with the principles of Replacement, Reduction and Refinement (the 3Rs) in animal research.

The researchers say their models could also provide a more objective way to assess protection systems like helmets. Future studies on humans that include detailed reconstructions of the biomechanics of TBI are also needed to confirm the findings before using them to predict injury risk in humans.

The improved understanding of the BBB could also help further research into drug delivery of brain-specific medicines.

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Brain injury

Head injuries in rugby players linked to brain structure changes

A study of 44 rugby players, almost half of which had sustained a mild head injury while playing has revealed a significant proportion had signs of abnormalities to the white matter.

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A study of 44 rugby players, almost half of which had sustained a mild head injury while playing, has revealed a significant proportion had signs of white matter abnormalities.

It is the first study to assess long term changes in MRI images of professional rugby players. It also revealed abnormal changes in white matter volume over time.

The researchers say that more work is needed to determine the long term effects of rugby on player’s brain health.

The research is part of the Drake Rugby Biomarker Study. It was led by Imperial College London and published in the journal Brain Communications.

The research

The study took 44 players of which 21 were assessed after sustaining a mild head injury called a mild traumatic brain injury.

These are one of the most commonly reported match injuries accounting for one in five injuries. The rugby players were compared to other athletes in non-collusion sports and people who do not play sport.

Participants in the study underwent two MRI brain scans a year apart during 2017 and 2019.

The study used two advanced types of MRI called susceptibility weighted imaging and diffusion tensor imaging.

This reveals the structure of blood vessels and white matter. The white matter helps the brain cells to communicate with each other.

The players were also asked to complete memory tests to assess brain function.

Scientists analysed the brain scans for changes.

The scans revealed that 23 per cent of all the players showed abnormalities to their cell axons or small blood vessel tears. These tears cause small leaks in the brain called microbleeds.

The changes were seen in the players with and without a head injury.

Read more: Same You, a catalyst for change

rugby players in a scrum with their heads and shoulders down

Further research needed

Senior author from Imperial’s Department of Brain Science, Professor David Sharp said: “Despite relatively high rates of head injury and an increasing focus on prevention, there has been relatively little research investigating the long-term effects of rugby participation. More objective measures of the effects of sporting head injuries on the brain are needed to assist with the assessment and management of individual players.

“Our research using advanced magnetic resonance imaging suggests that professional rugby participation can be associated with structural changes in the brain that may be missed using conventional brain scans.  What is not clear at this stage is the long-term clinical impact of these changes.

“Further research is needed to understand the long-term implications of repeated head injuries experienced during a rugby career and to provide more accurate ways to assess risk for an individual.”

Clinical services

The research was funded by the Drake Foundation. A not-for-profit organisation focused on understanding and improving the health and welfare of people impacted by head injuries.

It was supported by National Institute for Health Imperial Biomedical Research Centre, the UK Dementia Research Institute and the Rugby Football Union (RFU).

Dr Simon Kemp, medical services director at the RFU, added that a specialist clinical service for the assessment and management of retired elite players will be provided. It aims to assess the brain health of players.

“We welcome any research that helps to advance our knowledge which is why we actively collaborated with the academic institutions on the Drake Foundation Rugby Biomarker Study from its inception, particularly to promote the recruitment of players.

“While it is unclear from that research what the individual long-term implications are regarding the brain changes seen in these advanced imaging techniques, it is clearly a priority to investigate this further.”

Read more: Seven devices that are revolutionising dementia care

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