Mild Traumatic Brain Injuries and Concussions

Mild traumatic brain injuries (mTBIs) and post-concussion syndrome are becoming more of a public health concern. Although termed “mild”, the effects can certainly be debilitating and severe in some cases. The symptoms of post-concussion syndrome range from headaches, memory and concentration difficulties, irritability, fatigue, nausea, visual disturbances, light & noise sensitivity, judgement problems, depression and anxiety^[1]. Most individuals symptoms resolve within 1 month, however poor management, misdiagnosis, female gender and pre-existing emotional struggles can cause symptoms to continue for months to years. It is unclear why females seem to experience post-concussion syndrome more frequently than males. Ongoing theories suggest that neck girth/strength, hormones and increased reporting may be reasons for this occurrence. Women experience constant hormonal fluctuations, and previous progesterone deficiencies (due to estrogen dominance) could possibly worsen symptoms. Its also thought that where a woman is on her menstrual cycle during the time of injury can also determine symptoms. 

Pathophysiology

Concussions were originally thought of as a grey matter injury, however current research suggests that the mechanism of the injury involves more of the white matter – causing shearing or tearing to the brain's white matter neurons. This initial phase, or the “energy-crisis” phase is more acute, in which the brain's ATP sources are limited and there is an influx of Ca2+ into the cells [1]. This can lead to suppression of certain neurological pathways (ex. Oculomotor, vestibular-ocular, cervical, other cranial nerves). In other words, a “functional”, as oppose to a “structural” change occurs. The second phase, and more long-term/chronic is the “spreading depression”, in which various neurological pathways are receiving inadequate neurological input or cerebrovascular blood supply. Research also shows that individuals with a pre-existing deficit in certain systems (ex. Oculomotor), may have a more difficult time recovering from such an injury. It is not uncommon for post-concussive individuals to experience dysautonomia, in which autonomic brain functions (heart rate, blood pressure, vision) are impaired. This state is often known as “sympathetic dominance”. Due to this, any therapies encouraging the parasympathetic response will be helpful in restoring vagal functions (ex. Resting heart rate, vision, digestion etc).

The treatment of post concussion syndrome is multifaceted. It involves an interdisciplinary approach with treatments not limited to the following: rest, active rehabilitation, exercise, vestibular, oculomotor (neuro-optometric), cervicospinal therapy, education,counselling, physical therapy, CBT, cognitive therapy, pharmaceuticals and acupuncture. Nutritional, supplement and herbal therapies have been less utilized, however can provide complementary support to mTBI management.

DIETARY INTERVENTIONS ^[2]

Ketogenic & Anti-inflammatory Diets

The ketogenic diet provides an alternate source of fuel other than glucose, since a brain injury impairs glucose utilization. Ketones in the blood have been shown to increase cerebral blood flow by 40%. The monocarboxylate transporters (MCTs) in MCT oil and Coconut oil also improve glucose utilization. Other notable benefits of Coconut oil are its benefit in reducing inflammation and increasing endogenous glutathione. Glutathione is a powerful endogenous antioxidant, scavenging free- radicals in the brain tissues.

Since inflammation is a hallmark feature in an mTBI, and may be a contributing factor to issues like post-concussion syndrome, an anti-inflammatory diet (which is commonly used in naturopathic medicine) may be helpful. Common anti-inflammatory foods are: fatty fish, walnuts, olive oil, berries and leafy greens. Avoiding foods that promote inflammation like sugar, processed carbohydrates, alcohol, red meats and caffeine should be suggested.

Overall, it is important to ensure that adequate nutrition and nutrients are being obtained. A study, surveying dietary and nutrient intake of TBI patients found that being deficient in 14 key nutrients led to worsened outcomes following a TBI. From this study, it showed that a diet deficient in Magnesium, Folate, Vitamin K and Vitamin C were correlated with an improvement in neurobehavioural symptoms.

Omega-3

Evidence shows anti-inflammatory and neuroprotective effects of omega-3 fatty acids towards brain injuries ^[3].Both eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are notable - EPA having a more anti-inflammatory effect, and DHA targeting neuronal membranes (DHA makes up to 97% of the fatty acids in the brain). Animal studies and clinical use suggest its benefit, however there have lacked human clinical trials of omega-3 fatty acids and brain injury. Preclinical animal studies have shown improvement in both cognitive and spatial memory using omega-3 fatty acids ^[4].

Melatonin

Melatonin is a strong antioxidant is found to have neuroprotective qualities. Its ability to bind to melatonin-specific brain regions and easily cross the blood brain barrier, make it an ideal supplement for post-concussion and brain injury symptoms _[5]. A rat study showed that in rats exposed to damage in the prefrontal cortex and hippocampus had improvement in baseline functioning after being treated with Melatonin ^[6].

Curcumin (Turmeric Longa) ^[7]

Curcumin is a yellow, orange Indian spice used for both culinary and medicinal purposes. Large amounts of research show anti-inflammatory effects on Curcumin in various neurodegenerative diseases. Curcumin contains a polyphenol compound called curcuminoids that have been shown to modulate mitochondrial dysfunction-related oxidative stress and inflammatory cytokines COX-2. Another mechanism is through increasing growth hormone in the brain (brain-derived neurotrophic growth factor). These biochemical mechanisms lead to improved cognition, learning/memory and body movements in research.

Vitamin D and Progesterone

Various studies show benefit from Vitamin D as an anti-inflammatory agent post TBI/concussion. Although named a vitamin, Vitamin D has broad effects hormonally in the body. In particular, it yields an increased benefit when combined with the hormone progesterone. Given that the pituitary gland can be impacted by TBIs and concussions, the production of progesterone can  also become impaired. Clinically, hormone replacement therapies of progesterone, testosterone and thyroid may also improve post-concussion symptoms. This is also due to the fact that TBIs and concussions may impact Pituitary gland function,  hence having a downstream effect on hormone function.

Mind Body Therapies

Acupuncture is a practice of naturopathic medicine that shows benefit in a wide variety of conditions. A Cochrane review of acupuncture use for TBIs found that overall function, motor and speech improved in a total of 294 participants ^[9]. Other research show improvements in sleep, cognition and depression. Acupressure has also shown to be useful, and less invasive.

Yoga, tai chi and mindfulness training are other mind body therapies researched to help in TBI recovery and management. Positive effects of these therapies in mental health care are their ability to enhance parasympathetic tone, heart rate variability, neuroplasticity, and more ^[10]. This is helpful in the mTBI population, along with its likely benefits on strengthening and balance which may be affected as a result of the injury.

Mental Health Support

Anxiety, depression and post-traumatic stress disorder are usually associated with mTBIs. This is likely from both an inflammatory response, and a neutrotransmitter imbalance post-injury.  On top of the physical symptoms that accompany post concussion syndrome, mental health concerns pose an additional struggle. In these cases, naturopathic mental health treatments would also be useful. These include, but are not limited to: 5-HTP, St. John's Wort, Magnesium, Curcumin, B Vitamins, Fish oil, Acupuncture and mind-body therapies. It has also been seen clinically that those suffering from mTBIs may have hormonal and thyroid insufficiency, so supporting these systems may also improve mental health. Overall, a sugar-reduced and anti-inflammatory diet, along with key neuroprotective supplements and hormone supports  may be helpful in aiding in mTBI and post concussion recovery. In addition to these, mind-body therapies such as acupuncture, mindfulness and yoga serve as other complementary and holistic management tools.