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 >>
1. Badea A, Kamnaksh A, Anderson RJ, et al. Repeated mild blast exposure in young adult rats results in dynamic and persistent microstructural changes in the brain. Neuroimage Clin. 2018;18:60-73.
2. Logsdon AF, Lucke-Wold BP, Nguyen L, et al. Salubrinal reduces oxidative stress, neuroinflammation and impulsive-like behavior in a rodent model of traumatic brain injury. Brain Res. 2016;1643:140-151.
3. Yu J, Zhu H, Taheri S, et al. Impact of nutrition on inflammation, tauopathy, and behavioral outcomes from chronic traumatic encephalopathy. J Neuroinflammation. 2018;15:277.
4. Zhu W, Ding Y, Kong W, et al. Docosahexaenoic acid (DHA) provides neuroprotection in traumatic brain injury models via activating Nrf2-ARE signaling. Inflammation. 2018;41:1182-1193.
5. Lucke-Wold BP, Naser ZJ, Logsdon AF, et al. Amelioration of nicotinamide adenine dinucleotide phosphate-oxidase mediated stress reduces cell death after blast-induced traumatic brain injury. Transl Res. 2015;166:509-528, e501.
6. Theadom A, Mahon S, Barker-Collo S, et al. Enzogenol for cognitive functioning in traumatic brain injury: a pilot placebo-controlled RCT. Eur J Neurol. 2013;20:1135-1144.
7. Cikajlo I, Cizman Staba U, Vrhovac S, et al. A cloud-based virtual reality app for a novel telemindfulness service: rationale, design and feasibility evaluation. JMIR Res Protoc. 2017;6:e108.
8. Morris TP, Costa-Miserachs D, Rodriguez-Rajo P, et al. Feasibility of aerobic exercise in the subacute phase of recovery from traumatic brain injury: a case series. J Neurol Phys Ther. 2018;42:268-275.
9. Liu J, Xue X, Wu Y, et al. Efficacy and safety of electro-acupuncture treatment in improving the consciousness of patients with traumatic brain injury: study protocol for a randomized controlled trial. Trials. 2018;19:296.
10. Combs MA, Critchfield EA, Soble JR. Relax while you rehabilitate: a pilot study integrating a novel, yoga-based mindfulness group intervention into a residential military brain injury rehabilitation program. Rehabil Psychol. 2018;63:182-193.
11. Zibara K, Ballout N, Mondello S, et al. Combination of drug and stem cells neurotherapy: potential interventions in neurotrauma and traumatic brain injury. Neuropharmacology. 2019;145(pt B):177-198.
12. Devonish JA, Homish DL, Vest BM, et al. The impact of military service and traumatic brain injury on the substance use norms of Army Reserve and National Guard Soldiers and their spouses. Addict Behav. 2017;72:51-56.
13. Shaver TK, Ozga JE, Zhu B, et al. Long-term deficits in risky decision-making after traumatic brain injury on a rat analog of the Iowa Gambling Task. Brain Res. 2019;1704:103-113.
14. Thomas TC, Colburn TA, Korp K, et al. Translational considerations for behavioral impairment and rehabilitation strategies after diffuse traumatic brain injury. In: Kobeissy FH, ed. Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects. Boca Raton, FL: CRC Press/Taylor & Francis; 2015.