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Why birth control pills help a concussion + Why you should care
The recently published study, "Menstrual Phase as Predictor of Outcome After mTBI in Women" is so exciting because this study goes a step beyond confirming that women's concussions are different than men's. This research explored why in detail the differences occur within the subset of women themselves compared to men's experience of concussion. The authors of the study are Kathryn Wunderle, BA; Kathleen M. Hoeger, MD, MPH; Erin Wasserman, BA; Jeffrey J. Bazarian, MD, MPH, of The University of Rochester.
I will now offer my layman's view of this study; and as always, I encourage you to read the original study posted below. Please feel free to correct/comment on my thoughts and send me any questions you would like me to pass on to the research team who conducted the study. I will post questions and responses in my next blog.
The Questions
Many of us who have experienced concussions or worked with women with mTBI have long felt there was a connection between concussion and a woman's cycle. In this study, researchers sought to prove the “Withdrawal Hypothesis,” which states that if a woman has a high level progesterone in her body at the time of an injury, she will experience sudden drop in progesterone. And that it is this decrease or "drop" that will cause worse concussion outcomes than a woman who had low level of progesterone at the time of injury and did not experience this "drop."
So who has a low level of progesterone (thought to be beneficial at the time of a concussion)?
- Men always naturally have low progesterone.
- Girls do before they get their first period.
- Women do, in later life, after their periods have ended.
Who has a high level of progesterone?
- Women of child-bearing years who progesterone levels rise and fall depending on the week of their cycle.
Researchers in this study hypothesized that women who experience mTBI during part of their cycles when progesterone is high, would have worse outcomes than women injured during time in their cycles when their progesterone is low.
Does anyone has level of progesterone which is resistant to this "drop?"
- Women taking birth control do not experience a drop as the pill provides constant high levels of synthetic progestins.
Remember in the case of this study, low progesterone levels at the time of concussion were predicted to be beneficial as they did not "drop" because they were low at the start. High levels which were subject to the "drop" were thought to predict poor outcomes.
The Answers
The final results of this study support the researchers' prediction that women in their cycle where "progesterone is highest, had worse post-concussion symptoms" than women whose progesterone is initially low. Similarly, women who were taking synthetic progestin as birth control seemed to mirror the women who were in the low progesterone phases.
The authors of the study warn that their findings must be "considered preliminary." Yet, they believe if their conclusions are "confirmed by others, it has important implications for both treatment and prognosis."
My mind races with the possibilities...
- Could this study be the starting point for a future hormone screening test - or even for a doctor to ask a simple question about when was an injured woman's last period?
- Could this simple screen alert doctors which women are more at risk and need more aggressive interventions?
- Could women in these risk groups based on their cycles be treated with progesterone after TBI?
As with every finding in the concussion field, more research needs to be done. But this study supports the hypothesis that the acute withdrawal of progesterone after mTBI may be the missing link (or one of the missing links) to why differences are seen in men and women's concussions. And in my opinion, this is a huge news for the concussion world - for men and women alike.
PDF of The Menstrual Phase as Predictor of Outcome After mTBI in Women Study
Objective: To determine whether menstrual cycle phase in women at the time of mild traumatic brain injury (mTBI) predicts 1-month outcomes.
Setting: Six emergency departments; 5 in Upstate New York, and 1 in Pennsylvania.
Participants: One hundred forty-four female participants (age, 16-60) who presented to participating emergency departments within 4 hours of mTBI.
Design: Nested cohort study with neurologic and quality-of-life outcome assessment, 1 month after enrollment. Female subjects aged 16 to 60 enrolled in the parent cohort study, with 1- month neurological determination data available, were classified into menstrual cycle groups by serum progesterone concentration and self-reported contraceptive use. Main Measures: Rivermead Post Concussion Questionnaire and EuroQoL/EQ5D.
Results: Women injured during the luteal phase of their menstrual cycle, when progesterone concentration is high, had significantly lower EuroQoL General Health Ratings and Index Scores than women injured during the follicular phase of their cycle or women taking oral contraceptives. Multivariate analysis confirmed a significant independent effect of menstrual cycle phase on EuroQoL Index Score and the Rivermead Post Concussion Questionnaire Somatic Subscore.
Conclusion: Menstrual cycle phase and progesterone concentration at the time of mTBI affect 1-month quality-of-life and neurologic outcomes. This association has important implications for treatment and prognosis after mTBI. Key words: brain concussion, brain injuries, follicular phase, luteal phase, menstrual cycle, postconcussion syndrome, progesterone, quality of life
PDF of The Menstrual Phase as Predictor of Outcome After mTBI in Women Study
Thank you to the authors - Kathryn Wunderle, BA; Kathleen M. Hoeger, MD, MPH; Erin Wasserman, BA; Jeffrey J. Bazarian, MD, MPH - and Leslie Orr of University of Rochester Medical Center - for allowing us to post this study.
Please direct questions to pricesned@gmail.com if you would like to take part in our exchange with the authors of the study.
NFHS responds to the IOM/NRC Concussion Report
After reading the IOM Concussion Report yesterday which put the NCAA and the NFHS in a leadership role, I called the NFHS to see what they thought about the report and how they viewed their role in the future.
I left a message for Bob Colgate, Director of Sports and Sports Medicine, National Federation of State High School Associations (NFHS) and Bob called me back today. I appreciate Bob taking the time to speak to me on a number of aspects about concussion including the online NFHS Concussion Training Course and NATIONAL HIGH SCHOOL SPORTS-RELATED INJURY SURVEILLANCE STUDY. We both agreed on the importance of concussion education for coaches, parents, school staff, and students - all students - not just student-athletes.
Bob then emailed me with the following press release: NFHS Responds to Concussion Report. Please see my follow-up questions/comments following the press release.
INDIANAPOLIS, IN (November 1, 2013) — On October 29, the Institute of Medicine (IOM) and the National Research Council (NRC) released a detailed report on “Sports-Related Concussions in Youth – Improving the Science, Changing the Culture.”
The National Federation of State High School Associations (NFHS), which has been a leader among national sports organizations in the area of concussion awareness and management the past five years, fully cooperated with the preparation of the report and is in support of many of the report’s recommendations.
“We support the report’s conclusion that a culture change is a national priority,” said Bob Gardner, NFHS executive director. “Concussions are not ‘dings’ – they are serious medical conditions that need to be addressed. I am pleased to report that the NFHS places its highest priority on risk minimization for the 7.7 million participants in high school sports.”
In 2008, the NFHS Sports Medicine Advisory Committee advocated that a concussed athlete shall be immediately removed from play and not return until cleared by an appropriate health-care professional. For the past four years, all NFHS rules publications have contained guidelines for the management of an athlete exhibiting signs, symptoms or behaviors consistent with a concussion.
In addition, with help from the Centers for Disease Control (CDC), the NFHS developed a free, 20-minute online course “Concussion in Sports – What You Need to Know.” More than 1.2
million administrators, coaches, officials, athletes, parents and health-care professionals have taken the course since 2010. (See www.nfhslearn.com)
The NFHS also agrees that injury surveillance is important to help prevent future injuries. Since 2005, the National High School Sports-Related Injury Surveillance Study (High School RIO), commissioned by the NFHS and compiled by Dr. Dawn Comstock, principal investigator from the Pediatric Injury Prevention, Education and Research (PIPER) program at the Colorado School of Public Health and Colorado Children’s Hospital in Aurora, Colorado, has been collecting injury surveillance data for the NFHS. (visit http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/projects/ RIO/Pages/Study-Reports.aspx for the full reports.)
The NFHS also works with the National Center for Catastrophic Sports Injury Research (NCCSIR) at the University of North Carolina-Chapel Hill, which has been collecting catastrophic injury data on all sports for more than 35 years.
“The NFHS strives to minimize risk for all high school athletes in all sports,” Gardner said. “The athletic community – administrators, coaches, officials, athletes, parents and health- care professionals – should know that this support system of rules, education and research exists to provide a safer environment for all athletes in all sports. We hope the report will encourage all these leaders in the high school athletic community to recognize and respond more effectively to concussions.”
### About the National Federation of State High School Associations (NFHS)
The NFHS, based in Indianapolis, Indiana, is the national leadership organization for high school sports and performing arts activities. Since 1920, the NFHS has led the development of education-based interscholastic sports and performing arts activities that help students succeed in their lives. The NFHS sets direction for the future by building awareness and support, improving the participation experience, establishing consistent standards and rules for competition, and helping those who oversee high school sports and activities. The NFHS writes playing rules for 17 sports for boys and girls at the high school level. Through its 50 member state associations and the District of Columbia, the NFHS reaches more than 19,000 high schools and 11 million participants in high school activity programs, including more than 7.7 million in high school sports. As the recognized national authority on interscholastic activity programs, the NFHS conducts national meetings; sanctions interstate events; offers online publications and services for high school coaches and officials; sponsors professional organizations for high school coaches, officials, speech and debate coaches, and music adjudicators; serves as the national source for interscholastic coach training; and serves as a national information resource of interscholastic athletics and activities. For more information, visit the NFHS Web site at www.nfhs.org.
MEDIA CONTACTS:
Bruce Howard, 317-972-6900 Director of Publications and Communications National Federation of State High School Associations bhoward@nfhs.org
Chris Boone, 317-972-6900 Assistant Director of Publications and Communications National Federation of State High School Associations cboone@nfhs.org
Questions I have after reading the release and have emailed Bob Colgate for clarification:
1. From this statement, "The National Federation of State High School Associations (NFHS)... fully cooperated with the preparation of the report and is in support of many of the report’s recommendations," can I take that the NFHS doesn't completely agree with "all" the recommendations?
What parts of the IOM report are not supported by the NFHS and which are supported by the NFHS?
2. I read the IOM committee's recommendation that the "NCAA and NFHS (in conjunction with others..) develop, implement, and evaluate" as if the current efforts of concussions education/training/research efforts are not enough, and in the future, the NCAA and NFHS would lead the way with new "large-scale efforts."
The statement from NFHS press release states all that the NFHS has done (which is very commendable) but it "appears" by saying "We hope the report will encourage all these leaders in the high school athletic community to recognize and respond more effectively to concussions,” seems that the buck is passed to the high schools themselves.
Is the NFHS going to initiate any new programs or initiatives based on what was learned in the IOM report?
Is there anyway for the NFHS to hold high schools accountable or reward the schools to make the changes needed?
...
We have been waiting for a year the IOM report and the APP report which is a clear blueprint for schools to follow. So now with these reports in hand along with the various concussion online trainings, and variety of education flyers, who is going to lead the way and how?
The IOM recommends the NCAA and NFHS as for the job of leading schools and sports organizations. The NFHS press release states what they have already been doing.
What can the NFHS really do beyond supplying its members with info (which they have already done) and funding the data collection of injury rates (which they are doing)?
I realized it is a balancing act for organizations which rely on voluntary members to require/demand their membership meet certain standards. I have talked with Steve Stenersen, President of US Lacrosse, over the years on the issues of carrot or stick with concussion education/training and youth lacrosse organizations. There are really no sticks to use with members who can leave your organization, and carrots cost money.
Note: From my read, the IOM Report does not suggest any source of funding for any organization to use to pay for any of the recommendations the report suggests. It is hard to be passed the command without the funds to pay the troops.
- Could there be an answer in the NFHS accrediting a high school with a NFHS "concussion-prepared," or "concussion-savy" stamp of approval when a school hires full time ATs and trains coaches, staff, parents and students?
- Could a seal of approval from the NFHS be something for the schools to strive for to be the "highest level" of prepared a school can be (in the concussion field which is still developing)?
- Would parents value this standard and pressure schools who did not meet the standard?
Concussion education isn't hard to understand, and the resources exist to teach coaches, parents and students. What is missing is the commitment of overburdened schools, sports organization and parents to make the time to attend the classes or complete the online trainings or read the flyers. We need leaders now find ways to ensure education takes place, to encourage individual states to update their concussion laws with mandatory requirements, and find sources of funding so the needed research is done.
Good News, Bad News in long awaited Nat'l Concussion Reports
Reblogged from www.SportsCAPP.com Good News...
The IOM and the National Research Council formed an expert committee to review the science of sports-related concussions in youth from elementary school through young adulthood, as well as in military personnel and their dependents. The committee’s report recommends actions that can be taken by a range of audiences – including research funding agencies, legislatures, state and school superintendents and athletic directors, military organizations, and equipment manufacturers, as well as youth who participate in sports and their parents – to improve what is knows about concussions and to reduce their occurrence.
The report finds that while some existing studies provide useful information, much remains unknown about the extent of concussions in youth; how to diagnose, manage, and prevent concussions; and the short- and long-term consequences of concussions as well as repetitive head impacts that do not result in concussion symptoms.
Bad News... There is no mention of any funding.
Good News... Here is who sponsored the IOM Report:
Bad News? Here is who the IOM Committee recommends to lead the effort...
Interesting neither group helped sponsor the study?
NCAA is not well thought of by many concussion field. In March, I had a face to face conversation with Mark Emmert NCAA President where I asked about limiting full contact practice in the NCAA schools to match the NFL and Ivy Schools reduced schedule, and he told me there wasn't enough evidence and there needed to be more studies before he felt he could act. I am wondering if the many lawsuits are helping to motivate him to move on something here?
I am going to contact the NFHS and ask how they see their role in the future. Here is what the NFHS said.
Good News... We now have a National Sports Concussion Coalition.
Bad News... This coalition was not mentioned in the IOM Report.
So in summary...
Good News... This week we do have two new reports - a very informative the IOM Concussion and Youth Sports Report with ideas and recommendations along with the new road map for schools in APP report on Concussions and Schools.
Bad News... There doesn't seem to be any funding mentioned in either report to fund any of these recommendations.