The CAM options described here may help prevent trauma-related neurodegeneration over the long term.
JM is a 22-year-old student-athlete who reports increased anxiety, difficulty focusing on his studies, trouble falling asleep, and intermittent headache following his second concussion during a recent football game at his college. He saw the team physician immediately after the concussion and was treated appropriately in the acute setting.
For the past week, he has avoided playing football and has been jogging and trying to eat healthily. His primary concern is prevention of chronic traumatic encephalopathy. He has read some frightening reports in the news and is concerned that he may be developing early symptoms.
Long-term management of TBI
Recent data have shown that targeting secondary injury cascades may be an important component in preventing neurotrauma-related neurodegeneration.1 Unfortunately, limited emphasis has been placed on targeting these pathways to prevent disease progression. The primary guidelines deal with acute management of concussion and vastly neglect how to treat patients over the long term. This report focuses on complementary and alternative treatment options for the long-term management of traumatic brain injury (TBI).
TBI has been shown to activate endoplasmic reticulum stress, oxidative stress, and neuroinflammation within the brain.2 Endoplasmic and oxidative stress are primary contributors to long-term neuroinflammation, which is an initiator for the development of tauopathy.3
Oral supplements can help mitigate these secondary cascades. Endoplasmic reticulum stress is one of the early contributors immediately after injury. Docosahexaenoic acid (DHA), an omega-3 fatty acid, has been shown to significantly reduce endoplasmic reticulum stress.4 For patients with mild to moderate TBI, daily supplementation with DHA is recommended for 1 year after the initial injury and indefinitely for those with repetitive injury.
Oxidative stress occurs in the subacute period after injury. Lipoic acid has been shown to inhibit oxidative stress and prevent neuronal injury.5 Daily supplementation with lipoic acid is recommended from day 3 post-injury to 6 months after injury. For prevention of neuroinflammation, it is advisable to take vitamin D, vitamin E, and magnesium supplements daily from 2 weeks post-injury to 6 months after injury (Figure). Enzogenol is an emerging agent that may be added in the future to aid in cognitive recovery, but the data are still forthcoming.6
Depression and anxiety are common following TBI. Mind-body practices have been shown to be effective for patients with TBI and should be encouraged.7 It is important for patients to keep a daily log of their symptoms and physical functioning. Mind-body practices focus on controlling emotions and thoughts to enhance mental well-being. In addition, these practices can be combined with music therapy, massage, and exercise to improve outcomes.
Exercise should be in the form of sustained cerebrovascular-promoting activity such as running, biking, or swimming. These activities enhance cerebrovascular mechanics, improve clearance of toxic proteins throughout the brain’s glymphatic system, and decrease responsiveness to pain. Sustained cerebrovascular-promoting exercise is the single most important factor to aid in recovery and has been shown to greatly reduce the need for opiates in patients with TBI.8 A cerebrovascular-promoting exercise regimen should be started as soon as patients are clinically stable.
Eastern medicine can provide some beneficial options for the long-term management of TBI. Acupressure and acupuncture are helpful for stress management and pain reduction.9 Yoga has been shown to improve mental functioning.10 The data for tai chi and qi gong are less convincing but warrant further investigation. Mindfulness cognitive-based therapy is the best studied intervention and has a positive effect on self-esteem and mental clarity.11
These complementary approaches should be used as adjuncts to the supplements, not as stand-alone therapies. They should also not replace consistent and sustained cerebrovascular-promoting exercise.
More on TBI complications and the outcome of the case >>
Complications of TBI
Unfortunately, medical providers have provided no clear guidance for most patients with TBI. Thus, these individuals have been left to self-medicate. Patients with severe or repetitive injuries often resort to drugs of abuse to relieve suffering.12 This ineffective strategy disrupts relationships, prevents implementation of healthy lifestyle changes, and leaves the individuals alone with limited social support. Therefore, a huge need is apparent. For patients with TBI, the treatment approaches outlined here should be initiated as early as possible.
In addition, signs of neurodegeneration are often not caught early enough. Impulsivity and anxiety are hallmark features for further decline.13 The emotional disturbances precede the motor dysfunction and increased risk of suicide.14
While it is ideal to start preventive techniques early, implementation of the strategies described here may still benefit patients in the initial stages of chronic traumatic encephalopathy. Prospective studies are needed to determine how effective later-onset treatment strategies are for patients. Collaboration with public health experts will be critical in this initiative.
Outcome of the case
JM received DHA, lipoic acid, vitamin D, vitamin E, and magnesium supplementation. He also participated in a cerebrovascular-promoting exercise program, mind-body practices, and a yoga course. After careful consideration, he gave up football because he realized his brain health was more important. At 2-year follow-up he is feeling great, his anxiety has resolved, and he just got his acceptance letter for medical school.
Dr Lucke-Wold is a Resident in the Department of Neurosurgery, University of Florida, Gainesville.
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