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DHA For The Treatment of Pediatric Concussion Related to Sports Injury

Primary Purpose

Concussion, Mild Traumatic Brain Injury

Status
Completed
Phase
Phase 1
Locations
United States
Study Type
Interventional
Intervention
Docosahexaenoic acid (DHA)
Placebo
Sponsored by
University of Texas Southwestern Medical Center
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Concussion

Eligibility Criteria

14 Years - 18 Years (Child, Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. Male or females age 14-18 inclusive
  2. Diagnosed with concussion due to sports-related injury. Concussion is defined as:

    1. Direct blow to the head, face, neck or a blow elsewhere on the body with an "impulsive" force transmitted to the head.
    2. Rapid onset of short-lived impairment of neurologic function in one or more of the following clinical domains that resolves spontaneously:

    i. Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog and/or emotional symptoms (eg, lability).

    ii. Physical signs (eg, loss of consciousness, amnesia).

    iii. Behavioral changes (eg, irritability).

    iv. Cognitive impairment (eg, slowed reaction times).

    v. Sleep disturbance (eg, drowsiness). c) No abnormality on standard structural neuroimaging studies, if such neuroimaging studies are completed for a clinically-indicated reason. Note: neuroimaging is not a part of this study protocol. Study participants will not undergo neuroimaging as part of this study.

  3. Concussion within 4 days of enrollment
  4. Presenting for treatment to the Sports Medicine Center at Children's Medical Center

Exclusion Criteria:

  1. Subjects not actively participating in an organized sport at time of enrollment
  2. Subjects who received a concussion from an event other than playing a sport (motor vehicle accident, fall, etc.)
  3. Subjects who participate in or received a concussion during participation in motorized sports (i.e., motorcross, dirt biking, jet skiing, etc.)
  4. Subjects with radiographic evidence of traumatic brain injury (i.e., skull fracture, intracranial hemorrhage, cerebral contusion, etc).
  5. Subjects with a prior diagnosed concussion in the previous 6 months.
  6. Pregnant women.
  7. Subjects sensitive to aspirin
  8. Subjects diagnosed with high blood pressure and currently being treated with blood pressure medications
  9. Subjects allergic to soy bean oil or corn oil.
  10. Subjects currently taking fish oil or DHA supplements.

Sites / Locations

  • Sports Medicine at Texas Scottish Rite Hospital for Children

Arms of the Study

Arm 1

Arm 2

Arm Type

Placebo Comparator

Experimental

Arm Label

Placebo

Docosahexaenoic Acid (DHA)

Arm Description

The placebo capsules are supplied as 950 mg capsules consisting of 475 mg corn oil and 475 mg soy oil. Both DHA and placebo are flavored with sweet orange flavoring and masking agents. Subjects will be instructed to take 2 capsules at breakfast and 2 capsules at dinner (with food). Subjects will take their first dose in the office to assure their ability to swallow the pills. Subjects will be dosed with the placebo for 12 weeks.

The DHASCO capsules are supplied as 950 mg capsules with an effective dose of 500 mg DHA per capsule. Both DHA and placebo are flavored with sweet orange flavoring and masking agents. Subjects will be instructed to take 2 capsules at breakfast and 2 capsules at dinner (with food). Subjects will take their first dose in the office to assure their ability to swallow the pills. Subjects will be dosed with the DHA for 12 weeks.

Outcomes

Primary Outcome Measures

Safety of Higher Dosage of DHA
Determine the safety of a higher dosage of DHA through reported drug-related adverse events during the study period.

Secondary Outcome Measures

Drug Adherence During Study Period
Determine the protocol treatment adherence/compliance of enrolled study participants.
Time to Initiation of the Return to Sport (RTS) Progression
Time to initiation of the return to sport progression (in days) was determined by calculating days from injury to when the participant was cleared to begin the return to sport progression by the physician. Time to initiation to return to sport progression was chosen as a clinically significant measurement for medical professionals in the sports medicine field. The investigators will determine time to initiation to return to sport progression according to Consensus Statement guidelines and following the law in Texas, House Bill 2038. Criteria for return to play progression include returning to baseline symptoms, exam and neurocognitive function. We hypothesize that participants who take 2g of DHA daily will experience no significant differences in recovery time when compared to participants who take a placebo.
Resolution of Balance Impairment
Improvement in balance impairment associated with the injury, as assessed by the modified Balance Error Scoring System (mBESS) which is a component of the Sport Concussion Assessment Tool 3 (SCAT-3). We hypothesize a shorter time to resolve balance disturbance associated with the treatment of DHA. The mBESS is scored from 0-30 errors, with higher scores indicated a worse outcome (more errors).

Full Information

First Posted
July 9, 2013
Last Updated
December 16, 2020
Sponsor
University of Texas Southwestern Medical Center
Collaborators
Children's Medical Center Dallas, Texas Scottish Rite Hospital for Children
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1. Study Identification

Unique Protocol Identification Number
NCT01903525
Brief Title
DHA For The Treatment of Pediatric Concussion Related to Sports Injury
Official Title
Docosahexaenoic Acid (DHA) For The Treatment of Pediatric Concussion Related to Sports Injury
Study Type
Interventional

2. Study Status

Record Verification Date
December 2020
Overall Recruitment Status
Completed
Study Start Date
September 2013 (undefined)
Primary Completion Date
August 2017 (Actual)
Study Completion Date
August 2017 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
University of Texas Southwestern Medical Center
Collaborators
Children's Medical Center Dallas, Texas Scottish Rite Hospital for Children

4. Oversight

Data Monitoring Committee
No

5. Study Description

Brief Summary
In recent years, media attention has focused on the long-term sequelae of repeated concussive episodes in professional athletes. The growing understanding of the damage done by what was once considered a "ding" during a game or match, and the neurologic consequences of "playing through" or returning to play too soon has led to additional interest in and concern for pediatric athletes (18 or under) who experience sports-related concussions during game or practice play. Because it has only been in recent years that the full scope of damage done by repeated concussive episodes has come to light, very little research has been done on treatment of concussion in either adults or children. Brain injuries in children can be especially problematic, as the brain may continue to develop until the child reaches the age of 24 or older, so concussion during this time of development may be particularly damaging. Docosahexaenoic acid (DHA) is an omega-3 fatty acid commonly found in both fish oils and algae. DHA is known to improve development of the eyes and brain in young children. It is thought to be an effective anti-inflammatory and anti-oxidant, and since it occurs naturally and causes very few harmful side effects, it may be a useful compound in the treatment of pediatric concussion. This is a feasibility trial of DHA for the treatment of sports concussion in a pediatric population. The investigators' primary aim is to determine acceptability of randomization for this compound as well as rate of enrollment given our clinical population. The investigators' secondary aim is to examine preliminary outcomes. The investigators hypothesize that subjects who take 2 g of DHA daily for 3 months will see a shorter time to full recovery and return to play and a shorter time to resolve balance disturbance. These are good, albeit unvalidated, clinical indicators of concussive recovery.
Detailed Description
This is a double-blind, randomized, placebo-controlled feasibility trial of DHA for the treatment of pediatric concussion related to sports-injury. The definition used for concussion is from the Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport (Br J Sports Med 2009;43:Suppl 1 i76-i84 doi:10.1136/bjsm.2009.058248) and will meet the following criteria: Direct blow to the head, face, neck or a blow elsewhere on the body with an "impulsive" force transmitted to the head. Rapid onset of short-lived impairment of neurologic function in one or more of the following clinical domains that resolves spontaneously: symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability). physical signs (eg, loss of consciousness, amnesia). behavioural changes (eg, irritability). cognitive impairment (eg, slowed reaction times). sleep disturbance (eg, drowsiness). No abnormality on standard structural neuroimaging studies, if such neuroimaging studies are completed for a clinically-indicated reason. Note: neuroimaging is not a part of this study protocol. Study participants will not undergo neuroimaging as part of this study. Subjects will be randomized in a 1:1 fashion. DHA is an omega-3 fatty acid that occurs naturally in fish oil and algae. There are many dietary supplements containing DHA available in the marketplace. Martek Biosciences provides an algae-based DHA compound which minimizes the side effects of "fishiness" in both flavor and "fish burps." The DHA produced by Martek Biosciences is also used for many infant formula companies in the US. DHA and identical placebo will be provided by Martek Biosciences. The DHASCO capsules are supplied as 950 mg capsules with an effective dose of 500 mg DHA per capsule. The placebo capsules are supplied as 950 mg capsules consisting of 475 mg corn oil and 475 mg soy oil. Both DHA and placebo are flavored with sweet orange flavoring and masking agents. They are supplied in sealed white plastic bottles containing 100-200 capsules per bottle, depending on dose. Each bottle has the lot number stamped on it. The capsules will be stored in a dry, locked compartment at room temperature (60 to 75 F). Martek's Quality Assurance department completes regularly scheduled chemical and long-term stability analyses on each lot of capsules. If shipments will occur during warmer months, arrangements will be made for capsules to be shipped with ice packs or other temporary refrigeration. Capsules will be dispensed to subjects in separate bottles in quantities sufficient to last until their next appointment. Any unused capsules will be returned to the PI or research staff and sent to the pharmacy for destruction in compliance with Children's regulations. Subjects will be randomized to 2 g of DHA or matched placebo for 12 weeks. In order to achieve this dose of DHA, subjects will receive 2 950 mg capsules twice a day. Subjects who cannot tolerate the divided dose of 2000 mg per day will be discontinued from the study. Although much of our knowledge of the pathophysiology of concussion comes from animal models, it is believed that the mechanical trauma to the brain causes a sudden disruption in the ionic balances, leading to an increase in calcium and an increase in glucose metabolism as cells try to compensate for the potassium/calcium imbalance. This is followed by a period of decreased glucose metabolism which may last up to 4 weeks in humans, resulting in continued high levels of calcium which interfere with mitochondrial oxidative metabolism. This decrease in mitochondrial oxidative metabolism appears to be biphasic, with improvement seen at 2, followed by a decrease which bottoms out on day 5 and recovers around day 10. Other important aspects of the concussive trauma include free radical production, initiation of inflammatory responses, and altered neurotransmission. DHA has several important functions in the brain with relatively few side effects, making it a good option for concussion treatment. DHA is helpful in modulating ion channels; higher levels of DHA are associated with higher levels of sodium pump activity, so it is possible that providing DHA post-injury may help the cells reduce the calcium balance more quickly or efficiently. DHA also has an apparent anti-inflammatory action. DHA interferes with the inflammatory arachidonic acid cascade by reducing the affinity of platelet thromboxane A2/prostaglandin H2 (TxA2/PGH2) receptor for its ligand. Additionally, higher levels of DHA in the cerebral cortex cause significantly higher levels of the anti-oxidant enzymes catalase, glutathione and glutathione peroxidase -- resulting in decreased cerebral levels of lipid peroxides. DHA reduces formation of the peroxynitrite free radical and reduces formation of pro-inflammatory cytokines by inhibiting transcription factor NF-κB and inducible nitric oxide synthetase. Finally, DHA is highly concentrated in synapses, indicating a role in synaptic signal transduction. DHA appears to address many different aspects of how we believe concussive injury affects the brain. The primary outcomes of this feasibility trial are to determine the willingness of patients to be randomized, the expected rate of enrollment based on the clinic population, and protocol adherence of enrolled study participants. We anticipate the results from this study will provide data to inform a larger randomized trial of DHA for the treatment of pediatric sports concussion. Secondary outcomes are time to clearance to return to play (in days) and improvement in balance, as assessed by the Balance Error Scoring System (BESS) which is a component of the Sport Concussion Assessment Tool 3 (SCAT-3). Time to clearance to return to play was chosen as a clinically significant measurement for medical professionals in the sports medicine field. The investigators will determine clearance for return to full competitive game play (Stage 6 of graduated return to play protocol) according to Consensus Statement guidelines and following the law in Texas, House Bill 2038. Criteria for return to play include complete clinical recovery from the concussion including returning to baseline symptoms, exam and neurocognitive function and successful completion of a gradual return to play progression. The BESS was chosen because it is a relatively simple assessment that has been noted by the investigators to be a good predictor of neurological recovery. In addition to time to return to play and the BESS, the SCAT-3 and Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) computerized neurocognitive testing programs will be used to evaluate recovery. The SCAT-3 is a standardized method of evaluating injured athletes for concussion and can be used in athletes aged from 10 years and older. The ImPACT program is a computerized exam that helps to quantify the degree of symptom, injury, or dysfunction that occurs after a sports related concussion. Although this test is utilized by many professionals, college, and high school sports programs throughout the country, it is unclear if its use contributes to a safer or more expedited return to activity. Finally, information on side effects will be collected at every visit in order to track the rate and severity of side effects in this patient population. We plan to enroll 40 subjects for this study, which consists of 20 subjects to be treated with DHA and 20 subjects to be treated with placebo. In order to achieve enrollment of 40 total subjects, we anticipate screening 80 subjects in order to consent 40. Because this is a pilot study, information on early withdrawals is important to us and no extra subjects will be consented due to this. We anticipate that it will take approximately 12 months to complete enrollment, with an additional 3 months for patient follow-up once the last patient has been enrolled. We anticipate that it will take approximately 6-9 months to complete data clean-up, analysis, and manuscript submission for total study duration of 2 years. Subjects who are non-compliant with the protocol either by not keeping appointments or by not taking study pills as directed may be discontinued from the study. Subjects who do not tolerate the minimum dose of 2000 mg of DHA per day or who experience intolerable side effects will be discontinued. Subjects who choose to withdraw consent will be discontinued early.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Concussion, Mild Traumatic Brain Injury

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 1
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
40 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Placebo
Arm Type
Placebo Comparator
Arm Description
The placebo capsules are supplied as 950 mg capsules consisting of 475 mg corn oil and 475 mg soy oil. Both DHA and placebo are flavored with sweet orange flavoring and masking agents. Subjects will be instructed to take 2 capsules at breakfast and 2 capsules at dinner (with food). Subjects will take their first dose in the office to assure their ability to swallow the pills. Subjects will be dosed with the placebo for 12 weeks.
Arm Title
Docosahexaenoic Acid (DHA)
Arm Type
Experimental
Arm Description
The DHASCO capsules are supplied as 950 mg capsules with an effective dose of 500 mg DHA per capsule. Both DHA and placebo are flavored with sweet orange flavoring and masking agents. Subjects will be instructed to take 2 capsules at breakfast and 2 capsules at dinner (with food). Subjects will take their first dose in the office to assure their ability to swallow the pills. Subjects will be dosed with the DHA for 12 weeks.
Intervention Type
Drug
Intervention Name(s)
Docosahexaenoic acid (DHA)
Intervention Description
Subjects presenting with a new concussion within 4 days of their initial injury will be identified and screened for eligibility from the investigators' regularly scheduled clinic patients. Subjects who enroll will complete 5 scheduled visits, although additional visits may be clinically indicated for symptom evaluation and treatment. All assessments done for this study are routinely done as part of the standard clinic visits for concussion at the Sports Medicine Center. Subjects will be randomized to either DHA or placebo in a 1:1 ratio, and receive enough DHA or placebo capsules to reach the target dose of 2 g of DHA per day (or placebo) until the day of their next appointment. Subjects will be instructed to take 4 capsules (2 at breakfast and 2 at dinner) for 12 weeks.
Intervention Type
Drug
Intervention Name(s)
Placebo
Intervention Description
Subjects presenting with a new concussion within 4 days of their initial injury will be identified and screened for eligibility from the investigators' regularly scheduled clinic patients. Subjects who enroll will complete 5 scheduled visits, although additional visits may be clinically indicated for symptom evaluation and treatment. All assessments done for this study are routinely done as part of the standard clinic visits for concussion at the Sports Medicine Center. Subjects will be randomized to either DHA or placebo in a 1:1 ratio, and receive enough DHA or placebo capsules to reach the target dose of 2 g of DHA per day (or placebo) until the day of their next appointment. Subjects will be instructed to take 4 capsules (2 at breakfast and 2 at dinner) for 12 weeks.
Primary Outcome Measure Information:
Title
Safety of Higher Dosage of DHA
Description
Determine the safety of a higher dosage of DHA through reported drug-related adverse events during the study period.
Time Frame
12 weeks
Secondary Outcome Measure Information:
Title
Drug Adherence During Study Period
Description
Determine the protocol treatment adherence/compliance of enrolled study participants.
Time Frame
12 weeks
Title
Time to Initiation of the Return to Sport (RTS) Progression
Description
Time to initiation of the return to sport progression (in days) was determined by calculating days from injury to when the participant was cleared to begin the return to sport progression by the physician. Time to initiation to return to sport progression was chosen as a clinically significant measurement for medical professionals in the sports medicine field. The investigators will determine time to initiation to return to sport progression according to Consensus Statement guidelines and following the law in Texas, House Bill 2038. Criteria for return to play progression include returning to baseline symptoms, exam and neurocognitive function. We hypothesize that participants who take 2g of DHA daily will experience no significant differences in recovery time when compared to participants who take a placebo.
Time Frame
12 weeks
Title
Resolution of Balance Impairment
Description
Improvement in balance impairment associated with the injury, as assessed by the modified Balance Error Scoring System (mBESS) which is a component of the Sport Concussion Assessment Tool 3 (SCAT-3). We hypothesize a shorter time to resolve balance disturbance associated with the treatment of DHA. The mBESS is scored from 0-30 errors, with higher scores indicated a worse outcome (more errors).
Time Frame
12 weeks

10. Eligibility

Sex
All
Minimum Age & Unit of Time
14 Years
Maximum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Male or females age 14-18 inclusive Diagnosed with concussion due to sports-related injury. Concussion is defined as: Direct blow to the head, face, neck or a blow elsewhere on the body with an "impulsive" force transmitted to the head. Rapid onset of short-lived impairment of neurologic function in one or more of the following clinical domains that resolves spontaneously: i. Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog and/or emotional symptoms (eg, lability). ii. Physical signs (eg, loss of consciousness, amnesia). iii. Behavioral changes (eg, irritability). iv. Cognitive impairment (eg, slowed reaction times). v. Sleep disturbance (eg, drowsiness). c) No abnormality on standard structural neuroimaging studies, if such neuroimaging studies are completed for a clinically-indicated reason. Note: neuroimaging is not a part of this study protocol. Study participants will not undergo neuroimaging as part of this study. Concussion within 4 days of enrollment Presenting for treatment to the Sports Medicine Center at Children's Medical Center Exclusion Criteria: Subjects not actively participating in an organized sport at time of enrollment Subjects who received a concussion from an event other than playing a sport (motor vehicle accident, fall, etc.) Subjects who participate in or received a concussion during participation in motorized sports (i.e., motorcross, dirt biking, jet skiing, etc.) Subjects with radiographic evidence of traumatic brain injury (i.e., skull fracture, intracranial hemorrhage, cerebral contusion, etc). Subjects with a prior diagnosed concussion in the previous 6 months. Pregnant women. Subjects sensitive to aspirin Subjects diagnosed with high blood pressure and currently being treated with blood pressure medications Subjects allergic to soy bean oil or corn oil. Subjects currently taking fish oil or DHA supplements.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Shane Miller, MD
Organizational Affiliation
University of Texas Southwestern Medical Center
Official's Role
Principal Investigator
Facility Information:
Facility Name
Sports Medicine at Texas Scottish Rite Hospital for Children
City
Plano
State/Province
Texas
ZIP/Postal Code
75093
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
35722886
Citation
Miller SM, Zynda AJ, Sabatino MJ, Jo C, Ellis HB, Dimeff RJ. A Pilot Randomized Controlled Trial of Docosahexaenoic Acid for the Treatment of Sport-Related Concussion in Adolescents. Clin Pediatr (Phila). 2022 Nov;61(11):785-794. doi: 10.1177/00099228221101726. Epub 2022 Jun 19.
Results Reference
derived

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DHA For The Treatment of Pediatric Concussion Related to Sports Injury

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