Vital Views

Joe Gaccione 0:01
Greetings, you're listening to Vital Views, UNLV Nursing podcast. I'm Joe Gaccione, communications director for the School of Nursing. What goes into a concussion? How does it truly impact someone suffering from one? Any average sports fan out there can probably tell you what it looks like, but we can only imagine what that does to someone's brain, having a traumatic injury, whether it looks mild or not. One of the unique aspects of nursing is through the research of nurse scientists who are exploring new ways to identify and treat conditions like this. We are joined by two very special guests today on the topic of traumatic brain injuries. First up is Dr. Henna Lee, associate professor with tenure at UNLV School of Nursing. Her focus is on cognitive health, including sleep disruption and brain injuries. Specifically, she studies bio-behavioral mechanisms for recovering from chronic mild traumatic brain injury or concussion. We also have Cynthia Lee, doctoral research graduate assistant who helps Dr. Lee in the research. Thank you both for coming in.

Henna Lee 0:54
Thank you.

Cynthia Lee 0:55
Thank you.

Joe Gaccione 0:56
Well, Dr. Lee, we'll start with you. How do we define traumatic brain injury?

Henna Lee 1:01
So I'd like to say towards NINDS, National Institute of Neurological Disorders and Stroke, one of NIH institutes, they define traumatic brain injury as a form of acquired brain injury occurring when a sudden trauma, usually outside of the body system, causing damage to the brain. So, in my study, I think this involves temporary or sometimes permanent neurobiological impairments, which lead to functional outcomes, following the injury because of the neuronal damage and loss in the brain. In my study, I'm looking at some different biomarkers in body fluid, in blood and saliva as well. You know, the brain is such a complicated system, so it's hard to understand fully how, if especially this mild type of brain injury, it's a closed health system, so it's hard to look into from outside, so we wanted to use some biomarker from saliva and blood. You know, a lot of other researchers are looking at that biomarker as well, some genetic expression, messenger RNA or DNA, some epigenetic markers as well. So currently, I'm looking at microRNA as one of potential biomarker for neurocognitive function, change after injury, this type of concussion or mild traumatic brain injury because microRNA is, it's not really directly involving making protein in the body system, but it does regulate from the top biological kind of pathway by actually gene silencing. So, it's blocking to make specific protein from specific gene, but it's a stable because it travels, actually when it travels to extracellular space from, even from the brain, it's protected in exosome or other microvesicles, so it can be detected from blood and saliva too, which can tell us about what's going on in the brain after injury, especially like cognitive or some psychological function-related symptoms.

Joe Gaccione 3:12
All that being said, and you mentioned that concussion studies are incredibly complicated, and we still don't know the full breadth of what goes into one, can concussions be considered mild?

Henna Lee 3:22
So, concussion is in fact generally referred to as a mild type of head injury. So, that's why we still kind of use “mild traumatic brain injury” as another term, so it's kind of interchangeably used mainly because there is no visible sign from outside in most cases, and also those individuals with a concussion not necessarily pass out after a concussion or the injury. I wanted to mention how America and Congress of Rehabilitation Medicine introduced the criteria for diagnosing mild TBI. So, there is mild type, moderate type, and severe type, but for mild TBI, like usually those individual has loss of consciousness less than 30 minutes or no loss of consciousness, or some post traumatic amnesia, meaning, you know, loss of a memory for less than 24 hours after injury. And there is also a clinical scale called the Glasgow Coma Scale, which tells the level of consciousness but that's usually only available in a clinical setting, so unless this individual, you know, sees medical health care providers after their injury, it's not really available for this, you know, the Glasgow Coma Scale is not, may not be available for concussion or mild TBI people. But from the diagnostic criteria, it's 13 to 15 out of 15, you know, best score. So, it's a really mild, so meaning, you know, they have close to a normal level of consciousness. So it's hard to tell in most cases, hard to tell whether these people have any specific symptoms from the injury.

Joe Gaccione 5:08
Cynthia, how did you get involved in this research?

Cynthia Lee 5:10
So, separate from what I'm doing with Dr. Lee, I'm actually an occupational therapy student at UNLV. So, they have a new program there that we're currently in the progress of getting accredited. And so, I was just honestly looking for any positions that would kind of help me with like my tuition, just realistically. So, I was looking at, I think it was Handshake, and I was just connected with Dr. Lee there. And then we were talking and she had a graduate research position open for doctoral students, so I thought that would be a good opportunity and that's what brought me to her.

Joe Gaccione 5:57
Stepping away from the research for a second, just in practical terms, when faculty have graduate assistants, what is that process like? What is the workload like for a graduate assistant? What are the benefits?

Cynthia Lee 6:11
For one, aside from like, financial reasons, which is definitely a plus, you get really involved in like, research and understand the research process. So, for us, for occupational therapy, one of the things that students can get into is research, especially for capstone projects. Working with Dr. Lee with like, various researches allowed me to kind of understand what the research process is like and connecting that with what I'm learning through like, quantitative studies, qualitative studies, courses and all that.

Joe Gaccione 6:42
Dr. Lee, your team looks at various ways to study traumatic brain injuries, from smartphone apps to eye-tracking devices, can you explain how these experiments work and how they relate?

Cynthia Lee 6:51
I can definitely speak to that. So, while working in different studies, we've had like, apps and eye-tracking devices that you've mentioned. And so, one of the apps that we were looking at is the Mhealth app. And so the Mhealth app is like an app that measures your gait and your dynamic balance. And so, what we have participants do is we have a kind of phone strap, and we put the phone in the strap and have them walk around, I think 400 feet, in a straight line, and so we can see what their dynamic balance is like there. And we have another app called Upload that we are collaborating with and that app is focused on dual task training. So, we have participants do a walking task and that could be either like a tandem type of walk, which is like a heel to toe, an eight-figure pattern type of walk and while they're doing that, simultaneously, they're required to do some type of cognitive task and that could be either counting backwards from a specific number or identifying household objects. And then lastly, we have like, the eyelink tracking, eye-tracking device. And what that is, is that we have participants sit in front of a computer, and they follow a red red dot that's moving. And so, what that program is doing is that it's tracking vertical eye movement, horizontal eye movement, and how fast the eye is moving from point A to point B, and that's particularly significant in our research, because eye movement impairment can be like, an indicator of a concussion, so that could potentially be something to look at when testing for a concussion.

Joe Gaccione 8:37
And that leads right into my next question. We talked about concussion symptoms, traumatic brain injury symptoms, they're not always obvious. What are some of the clear ones and what are some subtle symptoms? And this can be for either one of you.

Henna Lee 8:51
So, in our study, we wanted to take, you know, quite caution to interpret the data because it's all you know, one specific, you know, setting and a small sample size, but we found that before and after that specific, you know, it's called the dual task training, you know, while the person doing some one specific walking, but they're also asked to do, you know, some different types of cognitive, so that way those, your tasks kind of push the specific person's brain to complete two different tasks at the same time, which hypothetically helped the cognitive improvement in the end. So we, we checked, you know, pre and post and kind of functional changes. We found that cognitive improvement in specific, in mild TBI group compared to control or the control group still showed some improvement in executive functioning, but in mild TBI, we saw the psychomotor and processing speed improved, which is actually known to be a sensitive biomarker for neurodegenerative disorder development. So, we are excited about that, and the other thing is, you know, psychosocial symptoms like depression, most actual anxiety, and also sleep disturbance, that were all improved in MTBI group only, not control group. So, those are the cognitive part and psychosocial part and we are actually analyzing currently still eyelink, you know, eye-tracking the rapid eye movement to data, but so far what we know is in our sample, we know that multiple injury like repetitive injury had lower accuracy when they move their eye fast following the dots compared to a single injury group. So, which is actually same finding from others, you know, previous data as well. For walking balance, we are still analyzing those data, but we are more interested in finding objective, but non-invasive way to measure post-injury symptoms. So, we still use some surveys and questionnaires, you know, mostly self reported kind of manner, but we also use vital signs which is like, very comprehensive, but objective and cognitive test or assessment and also like, you know, eye-tracking and also the, you know, some balance measures, so we use as objective, functional measurement. So, those are what we found from even mild type of traumatic brain injury showed such, you know, cognitive and psychological and some balance issues, even after five years from their last injury. The thing that I wanted to mention here is, so I'm interested in chronic or long-term effect of, you know, one even single concussion or a single mild TBI. Not everyone, you know, going to have problem, you know, I wanted to emphasize that, that's, that's clear, but small subset of those with a concussion or mild TBI may suffer from either cognitive, psychosocial, or physical impairment, maybe, you know, those symptoms may develop a few days after but, you know, could be a month, some month after, or some years after. And so, there are quite a big epidemiology study, looking at more than, I believe, 160,000 veterans with lifetime mild TBI history, they found that even mild type, in addition to moderate or severe TBI, can increase almost more than 50% risk for Parkinson's Disease. And also another study with a football player, NFL players, 300 football players were followed over 19 years, and they also found post-injury after that specific, you know, sports game related to depressive symptom long after in their life. So, that's what I'm interested in, you know, chronic, you know, side of the effect from the concussion and mild TBI. Especially there is not enough health care system or support available for college students, like sports athletes, or you know, any individual with a concussion from car accident or, you know, falling, simply falling. And again, it’s not visible symptoms at the injury, so not many people seek for medical help right away, and they may not recognize either too. But then, you know, some symptoms may happen after you know, sometime after that specific injury, or though I'm not saying that concussion or mild TBI cause every, you know, problem, there will be a lot of other, you know, risk factors and, you know, some other factors in their life, like stressors or you know, pre-injury health condition, also playing together with this concussion for developing symptoms.

Joe Gaccione 14:04
You mentioned athletes, you mentioned veterans, are these populations more likely to suffer from TBI? Are there other groups that are just as vulnerable that you've noticed?

Henna Lee 14:15
I guess the researchers looking, looking into athletes and veterans more because they're the context where they're at, like, you know, they are exposed to more risk to not only head trauma, but some, you know, physical trauma and also for veterans or the active military service members too, you know, because of they're in such a, you know, traumatic kind of environment with a lot of unexpected, dangerous stimuli in that environment that can lead to their brain injury and also other parts of, physical injury too. Some people also think that we need to look at the more homogeneous or the same type of injury at a time so that we can have better understanding what’s really going on in the brain. So, that's another reason why people kind of chose those groups. But like I said, you know, car accident could be, you know, obvious, you know, common cause for brain injury and other trauma as well. And also elderly people, you know, those who like, more susceptible to like, because all different types of healthcare, health problems, they may be, you know, more prone to falling, and, you know, even in their, you know, the regular house environment. So, those are all, you know, we cannot say, one specific population are more prone to brain injury. I wanted to also mention teenagers and kids, you know, those also another groups that we need to consider for this type of injury.

Joe Gaccione 15:48
You touched on this a moment ago, but it has to be hard to study because there doesn't sound like one template for traumatic brain injury, you could react one way, another person could react another way, the time that it takes for symptoms to develop could be, that's why you're studying the chronic side of things. It's hard to classify because everyone's different.

Henna Lee 16:09
Yeah, that's true, but from a research perspective, we wanted to have at least, you know, some standardized way to understand, you know, what's going on after a specific injury. But another thing I wanted to mention is, you know, concussion or mild TBI, again, not every single injury will increase the risk, but some people may suffer from long-term neurodegenerative disorders, like more prone to developing Alzheimer’s or Parkinson’s disease. So, which means those post-injury symptoms and neurodegenerative disorders, they may have some commonality in symptoms, so we need to really look from all different angles, you know, not just from one single injury, but you know, maybe cognitive declines, executive function, or processing speed, how that are related to from one specific injury versus long-term consequences, which maybe it could be the whole process of developing neurodegenerative disorder too. So yeah, it's hard, everyone is different, you know, we cannot really, you know, put every, you know, human subject in one lab and then expose the same environment. So, so that's why we need to know, understand, and consider for even healthcare providers, about any, you know, specific risk factors. Again, my background, I'm coming from psychiatric mental health nursing, so I'm more interested in pre-injury psychological trauma, and because that affects how brain functions and even how well the brain recovers, like resilience from specific trauma. So, that all affects brain in addition to, you know, external force initiated brain injury too, so it's not easy or it's not simple area, for sure.

Joe Gaccione 18:06
Dr. Lee, you've worked with UNLV sports research and innovation initiatives, specifically with UNLV athletes. Can you talk about the partnership and what you're looking for?

Henna Lee 18:15
Yes. So, this is really exciting. I believe about five years ago, this, a group of faculty across disciplines on the campus started to gather together for, with, you know, specifically interested in sports research. Now, it's really growing a lot and it has 11 I believe, 11 different pillars, like covering sports management, marketing, also brain health is one of the groups where actually I belong to. And under brain health, military and first responder pillar is another, you know, subgroup that I also belong to, too. Dr. Jeff Kinney leading the brain health, and I'm working with Dr. Kara Radzak, John Mercer, Brian Schilling, Szu-Ping Lee, you know, different athletic training and also physical therapy too, working together for not only for research, but also again, we collaborate a lot with our industry executive in our sales organization. So, it's a fun time in Las Vegas, where there are different types of sports like professional NFL hockey, so Raiders and Golden Knights and so forth. So, we wanted to expand more collaboration with the different groups for the sports area. So, but not only professional, but also, collegiate college athletes and also young kids who's playing sports as well.

Joe Gaccione 19:42
On that subject, we think about athletes, we think about student athletes that might be concerned about concussions or brain injuries, especially the ones that play football, you know, not saying that it's inevitable, but some sports might be more likely to have this happen to them. What would be your advice what would be your, your messaging to these athletes that might be worried about concussion symptoms or concussion possibilities?

Cynthia Lee 20:07
I can actually speak to that. So one of the things that we've uncovered while we've interviewed different sports athletes is that the reason why a lot of people don't report that they have concussion symptoms, or they feel that something is wrong, is because they're worried about the repercussions of either being held back in their sport, or like losing their scholarships. So, understanding all that, it's definitely frustrating, and it could be a reason why people aren't reporting these symptoms to their coaches or their physicians. But given all that, and what we've talked about today, concussion symptoms can be very persistent, and they can impact one's not only sports performance, but also their work and their school. So, we really want to emphasize the importance of having a support system where you can report and talk about these symptoms and then from there, your physician or coach can kind of talk through about what you should do.

Joe Gaccione 21:13
Does it feel like with some of these athletes that there's a social stigma in sharing their story?

Cynthia Lee 21:18
Definitely, definitely. Yeah, especially because there's a lot of things that are on the line with them, especially for college athletes that have work in school and their scholarships on the line. So they probably feel a lot of pressure and that's maybe why they don't report these symptoms.

Henna Lee 21:36
Along the same line here, what Cynthia said, so we've, so it's kind of surprising, the literature show that like maybe some subset of you know, athletes may not hesitant, actually hesitant to report, you know, whether if they got concussion or not, but we kind of found that from the actual interviewees, they mentioned, you know, more than majority actually, more than half of the group not reporting because it's like, not a like, professional team, where, you know, medical team is available and all sports, you know, sports team, or medical teams are available for supporting these, those professional athletes. These college students, you know, they do not have such a system, support system, especially in medical help. Again, the concussion may not lead to specific symptom right away. It may take time to develop specific symptoms, so, it needs more like long-term or organized, standardized kind of monitoring system, which is not always available in school or university. If college students, even if they have, they suspect any concussion from, you know, specific sports activities, it's very important to communicate closely with their coach, and, you know, even their parents, and health care provider too, you know, because, like you mentioned, Joe, it's a subtle, mostly from subtle symptoms from concussion even could be physical or cognitive and emotional and sleep problems. But whenever they feel, “Oh, this is different,” you know, “This is different feeling, I have headache, which I never had before that specific concussion,” or, you know, sleep, hard to sleep or, you know, sleep more than usual or the less than usual, and in those kind of any change they can recognize, they need to be more sensitive about it, and then talk to a specific, like, if, you know, health care provider’s available, that'd be great, but talk to coaching and team other, you know, staff if possible, so that way they can, those symptoms can be monitored throughout the time. It may just go away naturally, but it's better to, you know, communicate closely with, you know, specific professionals, if possible.

Joe Gaccione 24:09
And also you have to have that support system too that exists not just with the students or athletes, but with their, their coaches, with their trainers to be comfortable to say, “I'm not feeling well, I think there might be something, you know, a little worse than what we we think,” you know, building that trust, to not be afraid to, to admit that you might have some type of brain injury.

Henna Lee 24:32
Right. Along with that, like, I think, you know, because of this whole brain injury research, it's growing, you know, in not only, you know, here, but like nationally and internationally too. So, a lot of policy kind of changes and, you know, in a way improved for us, especially in school system and university system. So, I believe it's not like you know, if, you know, one have a concussion, you know, “You just take care of it” kind of thing. There should be the system, university or again, school does have better safe guidelines to follow even after one concussion or you know, preventing guidelines too, which includes, you know, wearing helmet and so forth. So, building trust, yes, that's really important, but athletes, you know, I want them to think that, you know, you are in a better system with a better policy, compared to, you know, in the past, so, I'm sure there should be, you know, some help available, although maybe not right there, but just be always cautious and then, you know, try to recognize what's going on in their body, that's another important, so that way they can communicate with whatever, you know, healthcare provider’s available or coach or athletic trainer are available in their team.

Joe Gaccione 25:53
That's all the time we have today. Dr. Lee. Cynthia, thank you both for coming in.

Henna Lee 25:57
Thank you. Thank you for having us.

Cynthia Lee 25:58
Thank you.

Joe Gaccione 25:59
Thanks for listening out there. Hope you have a great day.