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Brain injury

Saliva test to diagnose concussion set to trial in football

Through a new joint action plan on brain health, education and research are identified as being at the heart of understanding concussion

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A breakthrough saliva test to diagnose concussion is set to be trialled in the Premier League, with a series of research projects also given backing, as efforts to protect players from the impact of head injury are stepped up within English football. 

In a new joint action plan on brain health, the need for research, education, awareness and support for players has been recognised, with a series of steps identified to better manage head injuries and to further understand the links between football and neurodegenerative disease.

The plan – from The FA, Premier League, EFL and PFA – includes a raft of measures, including the funding of an academic study to validate a diagnostic tool that uses salivary biomarkers, with reports that a trial could begin in the sport later this season.

It follows the publication of the SCRUM study findings in March, which showed a saliva biomarker tool was able to accurately detect concussion in elite male rugby players.

SCRUM, led by academics at the University of Birmingham, successfully predicted the outcome of head injury assessments in 94 per cent of cases during testing in the 2018-19 Premiership and Championship season. 

Furthermore, The FA is supporting the new BrainHOPE study, part of the wider Prevent Dementia study, which starts in 2022 at Glasgow University. 

The study will give an analysis of deterioration of cognitive function in the mid-life of ex-professional footballers to understand potential early interventions which could help reduce risk or speed of developing dementia. Its £1.2m investment will run until the 2024/25 season.

It is also partnering with the RFU and Premiership Rugby to expand the Advanced BRAIN Health Clinic, a new specialist clinical service and associated research programme for retired elite rugby players. The expansion to retired football players is due to start operating in 2022.

Trials of a new revolutionary mouthguard which includes a sensor that can relay real-time information to the sidelines – launched with players from Liverpool and Manchester City last season – is being expanded to include additional teams across the Premier League, EFL and The Barclays FA Women’s Super League (WSL).

Education is also highlighted as being of significant importance, and an expert working group formed by the Premier League is devising neck strengthening guidance. This will provide clubs with an introductory programme which is recommended to be implemented by strength and conditioning coaches.

In the grassroots game, authorities are working with brain injury charity Headway on a campaign – set to launch later this season – that will seek to improve awareness of concussion and ensure existing guidance is understood and accepted as standard practice. Referees will also be given greater support in dealing with concussion. 

“Understanding the risk factors of neurodegenerative disease in football is an incredibly complex area of medical science which requires exploration of many different lines of research,” said FA chief executive Mark Bullingham. 

“Football is working together to try to build a more complete picture by supporting a variety of projects.  Until we have a greater level of understanding, we are also reducing the potential risk factors. 

“This new joint action plan will further help to build our understanding across English football of this complex area.”

Richard Masters, Premier League chief executive, said: “It is important that football has come together to work collaboratively on this issue. With the help of experts, and alongside other sports with similar challenges, we want to ensure we have the right approach in place to protect the welfare of players.”

Trevor Birch, CEO of the EFL, said: “English football has a collective responsibility to understand and act upon the risk factors of neurodegenerative disease and therefore the EFL is pleased to support the game’s new joint action plan on brain health. 

“By working together in this collaborative approach, we will acquire the information to be better equipped to improve safeguarding measures for those who play football at all levels of competition.”

Maheta Molango, PFA Chief Executive – who has pledged to donate his brain to research to increase understanding of neurodegenerative illness – added: “A joined-up approach is essential to improve the health and safety of our current and future members. 

“A co-ordinated response is also required to provide comprehensive and dedicated support to our former players, and their families, currently living with dementia and other neurodegenerative diseases.

“This is a vital and complex area. It has to be the top priority for all involved in football.”

Brain injury

New light shed on Brazilian Jiu-Jitsu and brain injury

Athletes may be at less risk of causing long-lasting injury than has previously been feared, new research has revealed

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Brazilian Jiu-Jitsu (BJJ) athletes may be at less risk of causing long-lasting injury to the brain than has previously been feared, new research has revealed. 

BJJ is a popular martial art that exposes participants to recurrent intermittent asphyxiation due to controlled application of neck chokes. 

Unlike several combat sports, BJJ categorically prohibits strikes to the body, especially the head, favouring limb manipulation and neck chokes to coerce an opponent into submission.

However, concerns have been raised regarding the potential link between repetitive neck chokes, structural brain damage and implications for cognitive function.

But now, in the first study of its kind, researchers at the University of South Wales (USW) – who have previously led pioneering research to show the extent of rugby players’ cognitive decline in just one season – have shed new light on BJJ. 

The team from the Neurovascular Research Laboratory at USW examined blood flow to the brain using Duplex ultrasonography and cognitive function via neuropsychological tests in elite BJJ athletes. 

They found preliminary evidence that the BJJ athletes had a higher resting blood flow to the brain, alongside intact cognitive function, when compared to a control group of athletes matched by age, gender, and cardiorespiratory fitness.

Benjamin Stacey, lecturer in clinical science, said: “The popularity of BJJ is growing exponentially and is likely attributable to many people witnessing its effectiveness in Mixed Martial Arts (MMA) on promotions such as the Ultimate Fighting Championship (UFC) and Bellator. 

“The inclusivity of BJJ allows for all individuals to train together, regardless of age, sex or physical ability and when compared to other combat sports, BJJ carries a lesser risk to injury.

“Our unique findings argue against the notion that BJJ predisposes an individual to greater risk of long-lasting brain damage and conversely, provides evidence for enhanced protection for the brain. 

“These observations may be attributed to choke-induced pre-conditioning and/or exposure to BJJ-specific high-intensity interval training, which we know can confer protective benefits for the brain.

“These findings can help to inform much-needed follow-up research to extensively examine both the short and long-term implications of participation in the sport.”

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Brain injury

Can VR help with sight problems after brain injury?

The development of new immersive game-based technology could help with visual neglect, researchers believe

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Research is underway to discover the role virtual reality (VR) could play in the rehabilitation of sight after traumatic brain injury. 

TBI can have significant impact on vision, causing impaired visual attention – also known as visual neglect – even when there is no injury to the eye. 

Individuals with visual neglect lose the ability to explore the full extent of their surroundings and have difficulty reading, locating personal belongings, finding their way to destinations, and many other daily activities. 

Visual neglect is caused by disconnected neural networks and has been studied extensively in stroke but remains largely unexplored in other types of brain injury.

Now, Kessler Foundation is embarking on a two-year study, A Virtual Reality (VR) Exercise for Restoring Functional Vision after Head Trauma, to look into how technology can assist. 

The project uses immersive VR technology developed with the armed services and provided by Virtualware, an award-winning VR technology company based in Spain. 

The to-be-developed treatment is an intensive, game-like rehabilitation program leveraging a combination of VR and eye-tracking technologies to implement an oculomotor exercise protocol based on smooth eye pursuit.

Dr Peii Chen, senior research scientist in the Center for Stroke Rehabilitation Research at Kessler Foundation, said: “Our study will fill this knowledge gap by exploring visual neglect in TBI and developing a new treatment modality.”

Smooth eye pursuit exercise is an evidence-based treatment that improves patients’ ability to move their eyes toward the neglected side of space and voluntarily pay attention to the entire workspace relevant to a given task.

This ability is fundamental to spatial explorations that are required in learning, reading, and way finding. 

Dr Peii Chen

Conventionally, smooth eye pursuit exercise for treating visual neglect requires intensive and close supervision from therapists. VR technology combined with eye tracking can reduce therapist burden. 

Research participants will experience a VR session of smooth eye pursuit exercise and share their feedback. 

The study will reveal the feasibility and benefits of applying new technologies to rehabilitative treatment activities.

Research participants will also undergo functional and structural neuroimaging studies of the brain. 

The study outcomes will broaden the understanding of spatial processing and visual cognition as functions of brain connectivity and advance the development of treatments targeting head trauma-related visual dysfunction.

“Knowledge gained from this clinical study will advance patient care by identifying the neural basis of visual neglect due to TBI at rest and during smooth pursuit eye exercise,” said Dr Chen. 

“Reaching our goals will lead to improved visual health and quality of life for civilians, as well as active-duty military and veterans with trauma-related visual dysfunction.”

Dr Chen has been awarded a $376,109 grant from the US Department of Defense, US Army Medical Research & Development Command, Congressionally Directed Medical Research Programs (CDMRP), Vision Research Program.

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Brain injury

Consequences of repetitive head impacts in sport laid bare

Players experience an array of consequences through the cumulative effect of impacts over a decade, new study finds

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Sports players with at least ten years’ experience of contact sport are experiencing an array of health consequences as a result of repetitive head impacts, a new study has found. 

While they may appear healthy, research has established that athletes have problems with inflammation, energy production and coordination. 

These are as a direct result of the head impacts they experience, Northwestern Medicine and Pennsylvania State University report. 

The head impacts individually may not have been severe enough to cause a clinical concussion, but show the cumulative effect of repeated blows to the head over several seasons. 

The issues were found in measures that show abnormal regulation of inflammation, less coordinated movement and abnormalities in how cells produce energy, and add further to existing research showing the long-term impact of head injury in sport.

These three measures are significantly related to each other before the football season and to changes observed across the football season. They were also related to the number of head impacts a player received over the season.

“These findings support over a decade of reports about the negative effects of repetitive head impacts, along with studies of animal brain injury,” said co-senior author Dr Hans Breiter, professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine. 

“At this point, it appears the canary is dead in the coal mine.”

“This problem affects much of youth and professional impact sports in the US, along with training of US military personnel,” said co-senior author Dr Semyon Slobounov, professor of neurosurgery at Penn State College of Medicine.

This study – which assessed college American Football players – used measures previously found to be increased in football players before the season began and at a level similar to what is observed in individuals needing hospital treatment for a concussion. 

These measures have been associated with inflammation regulation and were increased over the course of the football season. In this study, these regulatory measures of inflammation were linked with measures of energy production and coordination.

The football players’ coordination – measured as accuracy maintaining balance, speed at correcting balance and ability to remember movements – related to measures indicative of energy production issues and inflammation regulation. 

Before and during the season, the higher the regulatory measures of inflammation were, the lower the coordination measures.

The study of repetitive head impacts in sport also showed abnormalities in energy production, resulting in decreased energy. These abnormalities linked abnormal inflammation regulation with reduced coordination. They also showed relationships with measured head impacts.

“A lack of energy can have significant consequences, especially in regard to brain function, raising questions of the long-term consequences,” said co-lead author Sumra Bari, a postdoctoral fellow at the department of psychiatry and behavioral sciences at Northwestern. 

To perform this study, 23 athletes from a collegiate football team were enrolled who had been playing football for an average of 11 years. The athletes participated in a full season of competitive collegiate play. 

Nine of them had experienced one to two concussions in prior seasons. Blood was collected and coordination was tested both before and after the football season. 

The coordination tests were designed to assess balance and to test their ability to remember a virtual pathway – collectively referred to as “coordination.” 

In addition, head impacts were recorded at all practices across the season using sensors which were attached to the players’ helmets.

Future research should expand to a larger cohort of athletes to confirm the findings, scientists said.

“Ultimately, the goal is to develop preventative interventions that minimise abnormal changes in the brain that have been observed in studies of contact sport athletes time and time again,” said lead author Nicole Vike, a postdoctoral fellow at the department of psychiatry and behavioral sciences at Northwestern. 

“Collectively, we need to use interdisciplinary approaches, like those used here, to better quantify the unseen damage of contact sports.”

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