Concussion and Mild Traumatic Brain Injury:
A Functional Medicine Approach to Healing the Brain
by David Musnick MD
The treatment of concussions and mild traumatic brain injury (mTBI) has been primarily based on the conventional medical model—the diagnosis and monitor symptoms method—and is basically a label. This conventional method of “treating” individuals with head injury does not treat most of the underlying pathophysiology, can lead to loss of brain reserve and can fail to treat troublesome and ongoing symptoms. An individual “treated” with this method likely would have suffered loss of neuronal tissue and synaptic networks and thus have lost brain reserve. They can have persistent brain, gastrointestinal, and mood dysfunctions. They would then be more susceptible to more significant effects from another head injury or other brain-damaging factors.
An effective approach to healing the brain must be based on the pathophysiology of the head injury. This article will focus on the functional medicine and pathophysiology approach to healing the brain. This article focuses on mild traumatic brain injury but can also be applied to moderate traumatic brain injury. It is not focused on severe traumatic brain injury as this type of injury will often require surgical intervention. Also, details on specific treatment protocols or supplement dosing may not be covered as this article is meant to be an introduction. The author is working on a Kindle eBook that will cover specifics in exhaustive detail.
Children, Adolescents, and Head Injury
Children and adolescents have very high levels of brain reserve. They can have one concussion or repeated concussions, as can athletes. Children and teenagers can have head injuries from having their head hit another child’s head, from falling, and from balls hitting their heads. They can manifest with headaches as well as poor attention, poor balance, and difficulty doing their school work. They can also have symptoms of exertional headaches. The treatments discussed below apply to children, adolescents, and adults although the author does not usually use HBOT for children. Also, children and adolescents usually respond remarkable well to frequency specific microcurrent. Children are more likely to take brain healing supplements if they are in liquid, are chewable, or emptied into applesauce.
Pathophysiology of Concussion and Traumatic Brain Injury
The mechanisms of injury and pathophysiology that have been determined to be important after head injury are listed below. Addressing the pathophysiology is extremely important to the functional medicine approach. The following is the known pathophysiological mechanisms and treatment targets after concussion.
There is mechanical shearing with hypoxia and a loss of neuronal structure and synaptic connections. The treatment approach to this is to limit neuronal damage, to improve oxygenation, and to stimulate trophic factors like BDNF to stimulate neurogenesis. There is membrane damage of mitochondrial and neuronal membranes. The treatment approach to this is to support neuronal and mitochondrial membranes.
There is a loss of synaptic connections and synaptic networks. The treatment target is to stimulate new synaptic connections and networks i.e. synaptogenesis. There are deficits in regional blood flow in injured areas. The treatment approach is to improve regional blood flow. There is excessive excitotoxicity leading to influxes of intracellular calcium in neurons and microglia. The treatment approach is to decrease excitotoxicity.
There is excessive free radical and oxidative stress. The treatment approach is to increase antioxidant support and to activate the NRF2 response. There is excessive neural inflammation of the neurons and the microglia cells. The treatment approach is to decrease neural inflammation. There may be damage and autoimmunity of the blood brain barrier (BBB) and brain tissues. The treatment approach is to heal the blood brain barrier and address the autoimmunity. There is mitochondrial dysfunction in the neurons in the brain. The treatment approach is to support mitochondrial membranes and energy production.
There may be injury to the pituitary gland and or dysfunction of hormone production especially of cortisol, thyroid, adrenaline and sex hormones. The treatment approach is to support hormone production. There may be intestinal permeability, small intestinal bacterial overgrowth, changes in the microbiome, vagus nerve dysfunction, and dysbiosis. The treatment approach is to heal intestinal permeability, heal small intestinal bacterial overgrowth, restore motility, and normalize the microbiome.
Stages of Head Injury
The treatment of head injury and traumatic brain injury can be related to the stage of the head injury and might be classified as acute, subacute, or chronic. This is based on the time from the head injury. In the acute stage the pathology is more axonal shearing, decreased oxygenation and inadequate blood flow, congestion and poor nutrient delivery. In the subacute stage there is a loss of neurons and synaptic connections and BBB autoimmunity may develop. In the chronic stage there may be more hormone dysfunction, BBB autoimmunity, GI dysfunction, and mood dysregulation. In the chronic stage one must focus on stimulating neurogenesis and synaptogenesis. In all stages, neuroprotection is very important.
The Blood Brain Barrier
The blood brain barrier is a network of blood vessels and capillaries that surrounds the brain. It usually has limited permeability and lets certain nutrients in and keeps many toxins and other substances out. It allows wastes to go back into the blood stream. There are many things that can damage the blood brain barrier, and one major one is a head injury. Antibodies can form to structural membranes in the BBB and if formed can lead to microglial activation and breakdown of the BBB.(1)
If the BBB becomes excessively permeable, antibodies can develop to brain tissue and neurotoxins can get into brain tissue leading to further brain tissue damage. The author advocates testing every patient with an antibody test for BBB antibodies. If the test returns with positive antibodies, the clinician should consider ordering further antibody testing for the intestinal lining and neural tissue; and a treatment plan should be instituted to treat the BBB.
Treating a permeable BBB is a complex task and will be outlined here briefly. The clinician should start neuroprotection strategies and treat the GI tract in the setting of BBB permeability. Ensuring eight-to-nine-plus hours of sleep is essential because insufficient quantity of sleep can damage the BBB.(2) In addition to the above the author uses melatonin,(3) r-alpha lipoic acid, and frequency specific microcurrent to heal the blood brain barrier. A clinician should retest the BBB test within about four months of the original test to document that the test becomes negative.
The Brain Injury-Gut Connection
It is very common for a patient with a concussion to develop gastrointestinal dysfunction in multiple parts of the GI tract. The GI tract may be adversely altered by a number of mechanisms.(4) The vagus nerve can be damaged and can adversely affect motility.(5) Common GI problems can be small intestinal bacterial overgrowth, intestinal permeability, large intestinal dysbiosis, and microbiome dysbiosis.(5) It can be helpful to check for antibodies to the small intestine (zonulin and occludin) and to treat intestinal permeability if it is present. The combination of leaky gut and increased blood brain barrier permeability can lead to more brain tissue damage and may lead to autoimmunity to brain tissue. If SIBO is present, it is important to treat it as it can lead to mood instability. Dysbiosis may increase endotoxins from gut bacteria. Endotoxins may get into the blood stream and may increase neural inflammation especially in the setting of a leaky blood brain barrier.
The author advocates a complete orthopedic and neurological exam as well as serum testing of hormone levels and BBB antibodies. It is important to assess cognitive function with questionnaires and other tools. One of the gold standards is an in-depth neuro-psych test done by a neuropsychologist. This type of test is expensive and likely would not be repeated. It is important in any medical legal case or any case in which there are cognitive deficits that need to be better defined.
There are functional tests that are less expensive and less time consuming. These tests include the Cambridge Brain Sciences test, the CNS Vital Signs test, and the ImPACT test. These tests can then be repeated after 8-12 weeks of treatment, and functional status can be reassessed. If the patient is seeing a functional or chiropractic neurologist, specialized functional neurology testing and treatment can be done.
A test that can assess brain region dysfunction is the QEEG. This test is moderately expensive and shows brain wave activity (under and over function) from different areas of the brain. It can then be reassessed after 12-16 weeks to determine if there is improvement.
SPECT scanning can dramatically show under and over functioning brain areas but is more costly than a QEEG and uses a dye that goes into the brain. In a center that does this test, it can show head injury areas quite dramatically along with patterns of brain activity that can lead to emotional lability. CT and MRI scans usually do not show areas of brain injury, especially in mild traumatic brain injury. A CT can be useful to rule out a brain bleed acutely but is not useful after the acute stage.
An assessment with a functional neurologist who is trained by either the Carrick Institute or with functional neurology seminars would be appropriate for any brain-injured individual, especially if they have dizziness, balance problems or visual problems. A functional neurologist with this training can determine functional deficits in the brain and design exercises to rehabilitate the patient.
Neuroprotection (NP) includes strategies that may protect the central and peripheral nervous system tissues. Neuroprotection strategies may slow or decrease damage to and loss of neurological tissue. These strategies should be introduced immediately upon diagnosis of concussion and maintained as long as possible to protect and preserve brain tissue. The following neuroprotection strategies are good to start after a concussion and are good to do in general to protect the nervous system.
Limit electromagnetic fields (EMF) exposure by limiting WIFI and turning WIFI routers off at night. It is desirable to limit radio frequency fields from cell phones by turning them to airplane mode and use blue tube ear sets or the speaker phone. It is good to opt out of smart meters from the power company or at least place a smart meter shield on the smart meter. It can be very helpful to turn off Alexa, Google, and Apple devices that work on WiFi. It is important to turn off the power to electric beds, smart beds, and electric blankets. Use organic foods whenever possible to limit neurotoxins and GMOs.
The Brain Injury Diet
The brain injury diet designed by this author is gluten and dairy free. It is rich in polyphenols, low in toxins, and low in GMOs. It is adequate in protein, high in choline, and moderate to high in vegetables that aid in detoxification. The diet should be primarily organic to be low in toxins. The diet should be low in foods that might contain heavy metals such as chocolate and seafood (shellfish and large fish). This diet should be low in browned proteins, coffee, crackers and chips to minimize acrylamide and AGEs (advanced glycosylated end products). Acrylamide is a neurotoxin. AGEs may break down the BBB.
It is important to activate the NRF2 factor by drinking green tea and using turmeric as a spice. Consuming broccoli and broccoli sprouts is also encouraged to activate NRF2. Blueberry, especially wild blueberries, are rich in polyphenols (anthocyanins and flavanols) and appear to have neuroprotective and antioxidant effects in the brain to combat oxidative stress.(6,7)
Other fruits that are high in anthocyanins are black and red raspberries, blackberries, black currents, and acai. Anthocyanins are also found in cloves, eggplant, purple corn, and black rice. All of these foods are good choices after a head injury. Blueberries have been studied the most in regard to their role in slowing neurodegeneration. It is reasonable after a head injury to have wild blueberries or other fruits high in anthocyanins almost daily. A practical way to do this is to make a brain-healthy smoothie.
A good starting recipe for a brain smoothie is one-fourth to one-third cup of wild frozen blueberries with 8 to 10 ounces of organic cranberry juice or pomegranate juice. One should add one to two scoops of an organic hemp protein or pea protein powder. One should also add leucine powder to equal 2.5 or more grams of leucine to help to prevent muscle loss. One can then add watercress or microgreens to aid in detoxification. For more smoothness and flavor, one can add half a banana.
After a brain injury an individual can mount immune responses to brain tissue related to molecular mimicry in regard to amino acids in gluten and dairy even if the patient did not have a prior problem with gluten or dairy. This may also be true with corn, soy, spinach, and tomato. Antibodies may be formed against certain dietary aquaporins and may potentially cross-react with brain aquaporin in astrocytes.(8)
Gliadin from gluten can cross react with Asialoganglioside, myelin basic protein, synapsin and cerebellar tissues. Milk butyrophilin can react with cerebellar tissue. Dairy casein can react with synuclein and oligodendrocytes.(8,9) Choline-rich foods can provide choline for acetyl choline for neurotransmitter support and phosphatidyl choline for membrane support. One should try and consume 2000-3000 mg a day of choline by consuming a few servings of choline-rich foods. Foods rich in choline are the following: chicken, turkey, collard greens, brussels sprouts, broccoli, swiss chard, cauliflower, and asparagus. A brain injury diet is also low in sugar, and patients should minimize sweets and processed foods.
Aerobic exercise can increase brain derived nerve growth factor (BDNF), which is a very important trophic factor for the brain.(10) The brain exercise prescription would be 40 minutes of aerobic activity in the patient’s training heart rate zone. This would be a zone of 70-80% of their maximum heart rate, which is calculated as 220 minus age. It is beneficial to start off with shorter time periods of exercise, like 15 minutes, and gradually to increase the duration by one to two minutes each exercise session until reaching the 40 minutes. Strength training two to three days per week can be introduced to maintain and build muscle mass. These activities should ideally be done without pain and should not precipitate headaches. If balance is a problem, the patient should start with stationary bike and balance exercises.
Supplements for Brain Healing
Certain supplements appear to have multiple pathophysiological benefits. These are taurine, curcumin, lithium, and DHA. This section will briefly address pathophysiology and some supplements. There are many more supplements that may be helpful but coverage of them is beyond the scope of this article.
It is quite challenging to choose a dose for a supplement for brain injury because most studies have been done on rats and mice and many times the supplement was not given orally. Some supplements have mechanisms that make physiological sense for brain injury but have not been studied specifically for brain injury. Doses have to be chosen based on extrapolation from the mice and rat studies or from a dose that can, at a minimum, achieve a serum level of the supplement. Because of the complex issues that must be taken into account to arrive at a dose, the author will not provide exact doses in this article but will be doing so in a future Kindle ebook and in future products.
Vinpocetine and ginkgo have been used to increase brain oxygenation and are reasonable to use especially for the first eight weeks after a head injury. DHA is an important fatty acid to supplement, starting about a few days from the head injury and during all stages of head injury. It may also have anti-inflammatory and anti-apoptotic effects.(11)
It is important to activate nuclear factor-erythroid 2-related factor (NRF2) to improve anti-inflammatory and antioxidant mechanisms. NRF2 is a transcription factor that can bind to DNA and lead to the production of the person’s own antioxidants. These are glutathione, SOD, and catalase; and they can bind free radicals and thus decrease free radical damage to neuronal and other tissue. NRF2 coordinates expression of genes required for free radical scavenging and helps to regulate inflammation. Tecfidera (dimethyl fumarate) is the only known drug that may upregulate NRF2. Tecfidera has only been FDA approved for relapsing MS and thus the author has used natural activators of NRF2. There are a number of natural products that can activate NRF2, including curcumin, DHA (omega 3s), and green tea. Curcumin is best given in the Longvida form as this form best passes the BBB into the brain. Melatonin is also used by the author to decrease neural inflammation.
Avoid all supplements with calcium and all foods with MSG and with hidden MSG during the first eight weeks after a head injury to decrease excitotoxicity. Taurine is a conditionally essential amino acid that may be able to provide some protection against excitotoxicity. Taurine appears to have a number of beneficial mechanisms in treatment of traumatic brain injury. These mechanisms include decreasing excitotoxicity, protection of cells from osmolar changes (important within the first few weeks), improvement of blood flow, enhancement of neurite growth, and triggering new brain cells to grow in the hippocampus. It is for this reason that the author advocates the use of taurine in all stages of head injury.
Neurogenesis is the process by which adult neural stem cells differentiate into nerve cells. This has been shown to happen in adults in the dentate gyrus of the hippocampus.(12) Neurogenesis may be mediated by trophic factors like BDNF. Aerobic exercise can stimulate the production of BDNF, and certain supplements may stimulate neurogenesis, like melatonin, taurine, and lithium.
Lithium is a mineral and appears to have multifocal neuroprotective benefits for the brain.13 Lithium has been shown to increase nerve growth factor in the frontal cortex and hippocampus and may increase brain derived nerve growth factor.(13) Lithium can be protective for the BBB. Lithium may induce nerve stem cells and neurogenesis of hippocampal neurons.(14) Lithium is used to treat bipolar depression in doses of 300-600 mg twice a day. If a patient has bipolar depression, then this dose will be continued or started. The author uses doses ranging from low dose lithium at 20 mg per day to bipolar dosing to treat head injury. Dosing levels for lithium have not been well established in humans for treatment of traumatic brain injury.
Mitochondria support of brain neurons is best accomplished with a mix of activated B vitamins, CoQ10, and with nicotinamide riboside (NAD).(15)
Brain Training and Synaptogenesis
Brain training is very important in healing the brain after head injury to create new synaptic connections i.e. synaptogenesis. This type of training should challenge the patient, and it should be slightly difficult in order to maximally stimulate new synaptic connections and to build synaptic density. I recommend multiple types of brain training that challenge thinking and the brain. Physical activities can be incorporated to do this, including dance lessons, Simon games, and ping pong. Mental activities of different types should be encouraged. Crossword puzzles and brain games are helpful but often are not enough. Patients are encouraged to join an online personalized brain training like BrainHQ and to do both the personalized program and specific courses to address their deficits. If an individual has had a QEEG, then they may be a candidate for neurofeedback training to train deficient brain areas.
There are a number of very helpful treatments that aid brain healing that the author has used, and these include frequency specific microcurrent, neurofeedback, audio visual entrainment, HBOT, counseling, and Brainspotting. Physical therapy, craniosacral therapy, and chiropractic care can be useful for balance, vestibular, and spinal problems. Working on sleep, vision, and hormone health are very important but beyond the scope of this article.
Frequency specific microcurrent (FSM) is a type of microcurrent that can be used to aid in healing different brain areas as well as headaches. In this author’s experience, FSM has been very valuable in helping patients heal their musculoskeletal and brain injuries. It may address the following pathophysiology: decreasing congestion, increasing ATP and mitochondrial function, decreasing neural inflammation, and in healing the blood brain barrier.
Neurofeedback is a treatment that can be helpful to restore brain function. It is best used after a QEEG to enable the practitioner to design specific treatment for areas that are under or over functioning.
Audio visual entrainment (AVE) is a type of treatment that can be especially helpful for patients having difficulty with concentration or depression after a head injury. The treatments are administered via a unit that generates visual and sound signals at certain frequencies. If it is helpful, home units are not very expensive and can be administered by a patient or family member.
Pulsed light emitting diodes in the red and near infrared spectrum applied to the head and neck may increase regional blood flow and may also stimulate ATP production.(16)
Certain forms of counseling may be helpful for patients. A cognitively trained speech therapist can be valuable for someone with moderate to more severe deficits who would have trouble doing the brain training on their own. Brainspotting is a technique that might help patients with anxiety, fear, PTSD, stress, and insomnia. EMDR counseling would be helpful for patients with PTSD. EFT tapping would be helpful to do for self-care for anxiety and stress related to the injury. Cognitive behavioral therapy can also be quite helpful.
Hyperbaric oxygen therapy (HBOT) has been used for years for wound care and diving injuries. Mechanisms of action of HBOT are primarily to improve oxygenation in congested or poorly oxygenated areas. There has been a number of studies evaluating the role of HBOT in treating patients with mild traumatic brain injury. Of interest is that these studies use variable pressures from 1.5 to 2 ATMs and there are no other interventions that are being used at the same time. The HBOT studies evaluate only an increase in oxygen delivery. In a Department of Defense study, only one of the groups showed improvement in symptoms when being treated with 2 ATM.(17) In a review of five studies only one study showed efficacy.(18) None of the studies showed any side effects.
In the author’s experience, about two-thirds of patients with head injuries referred for HBOT demonstrate a clinical benefit. It must be understood that this author has patients on a full program of supplements, brain injury diet, exercise, and brain training before referring for HBOT. HBOT can be used very soon after the head injury, as one of the main problems in early concussion is low oxygenation in certain injured areas of the brain. It can also be used after four weeks, but I would say that patients should only do this if they are doing a complete brain healing program to achieve maximum benefit. HBOT is usually prescribed as 1.5 – 2 ATM for 10 sessions. If there are no results after 10 sessions, no more sessions would be recommended. If there is benefit, another 10 sessions could be considered.
Concussion and traumatic brain injury are common and inadequately treated by the conventional medical system. Neuroprotection should be started and continued throughout the program. It is important to start with a brain injury diet and certain supplements like Longvida® curcumin, taurine, and lithium. Once the person is able to do some exercise, aerobic exercise should be started. Counseling and various types of brain healing modalities can be added to the program. The patient should have a team of clinicians to carry out the brain healing plan and should be periodically evaluated by a functional medicine clinician. The program as outlined above has the ability to significantly improve brain reserve and decrease symptoms after concussion and traumatic brain injury.
AVE equipment and information: https://mindalive.com
BBB antibody testing: ARUP Labs (New York), Mayo Clinic Labs, or Cyrex Labs (Arizona; Array 20)
EFT tapping: https://www.thetappingsolution.com
SPECT Scans: Amen Clinics
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David Musnick, MD, is board certified in sports medicine, internal medicine, and functional medicine.He developed the functional medicine approach to treating concussion and traumatic brain injury and presented it at the annual meeting of the Institute for Functional Medicine in Los Angeles in 2017. He was one of the featured speakers on the Broken Brain docuseries. He is specialized in functional medicine, frequency specific microcurrent, and prolotherapy. He practices at Peak Medicine in Bellevue, Washington.His web site is www.peakmedicine.com