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From the Townsend Letter
May 2019

Concussion and Mild Traumatic Brain Injury:
A Functional Medicine Approach to Healing the Brain
by David Musnick, MD
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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 patho-physiology, 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.

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An effective approach to healing the brain must be based on the patho-physiology 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 belowapply 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.
     
Frequency Specific MicrocurrentThere 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 auto-immunity 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 manythings 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
     
HistaQuelIf 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.

Assessment
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.

BDNF EssentialsFunctional Neurology
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
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.

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