Brain Injury - A Review of Concussions

Concussions are the most common form of traumatic brain injury. Thousands of young people under the age of 19 are treated every year in hospital emergency rooms for concussions related to sports or other leisure activities. Concussions are most commonly caused by blows to the head, including car and bike accidents, or falls. Effects of concussions are usually temporary, but can include bothersome symptoms like headaches, problems concentrating, forgetfulness, and can also impact functions of balance and coordination.^[1] A concussion can also cause issues with vision and may cause a loss of consciousness. In children, the symptoms may be slightly different, including irritability and crankiness, crying excessively, and changes in eating or sleeping patterns.

There are many possible complications of concussions that can negatively impact quality of life. For example, people who have had concussions have a higher risk of developing epilepsy within the first five years after the injury. There is a cumulative effect of having multiple brain injuries, which may impact people's ability to function. Something called 'postconcussion syndrome' can occur, and it describes symptoms such as headaches, light-headedness, and problems thinking. We've previously examined postconcussion syndrome in another feature article. It can last a few days after the concussion, but for some it can last weeks or months. If a second concussion is experienced before the symptoms of the first concussion have resolved, it could be extremely dangerous and lead to brain swelling.

In this article, we will review the diagnostic procedures for concussions, including a medical history, physical exam, and possible imaging. We will review the conventional recommendations in terms of management and discuss some of the natural treatments that could help ameliorate symptoms and reduce the time required until complete resolution. Natural treatments can also be used to help prevent further brain injuries. In particular, anti-inflammatory treatments and antioxidants seem to have the most evidence supporting their use. Employing a team of healthcare practitioners and following the recommendations provided can be especially helpful directly after the initial incident.

Diagnostics

There are different types of concussions. They are graded as mild to severe (grade 1 to 3) depending on a number of factors such as the symptoms present. For example, if there is a loss of memory and a loss of equilibrium, this may be more severe. The more mild concussions have symptoms that only last up to 15 minutes.^[1] While in severe concussions, the person loses consciousness. A doctor can evaluate signs and symptoms that a patient is experiencing. The doctor may ask several questions about the nature of the injury and may perform a neurological examination. Things like vision, hearing, and reflexes will likely be tested. To test memory and concentration, there are standardized tests that can test the ability to recall words or images. A health care practitioner may also suggest some imaging be performed, especially if there are more worrisome symptoms such as repeated vomiting. A CT scan is the standard test to assess the brain immediately after an injury and this can be performed at the hospital. X-rays or MRI are also potential tests that could be useful. The MRI in particular could identify bleeding in the brain, so could be used to help detect and prevent more serious complications.^[2] It may be recommended that the patient be observed overnight (either at the hospital or at home). This can be useful to ensure that symptoms aren't getting worse. If the patient is a child, parents will typically be advised to awaken them regularly to make sure they are able to wake up normally. After the initial injury, there will likely be some follow-up testing to ensure that full function has been recovered. The same exams and tests may be repeated to see if there are any differences over time.

Conventional Treatments

Rest is the best way to allow the brain to recover.^[1] This includes both physical and mental rest. Athletes in particular should not return to play or vigorous activity while symptoms of concussion are present. Instead, time off should be taken to help the brain recuperate. In terms of mental rest, it includes taking time off from activities that require thinking and concentration, such as video games, television, or using a computer. If headaches are present, pain relievers can be used (things like Tylenol for example). Advil and aspirin are usually not recommended as they could increase the risk of bleeding and thus could increase the consequent risks.

In addition to resting and taking breaks, it is recommended to guard against repeated concussions. Since repeat concussions can have cumulative effects (including brain damage, long-term disability), it is not recommended to return to normal activities until symptoms resolve. Protective measures can be taken, such as wearing protective gear during sports and leisure activities. Wearing a helmet or protective headgear during biking, or while skiing or snowboarding is recommended. While driving, a seatbelt may help prevent injuries. Finally, exercising regularly (especially if the patient is older) can be helpful to strengthen the leg muscles and improve balance, thus reducing the risks of falls and further concussions. One study that synthesized the evidence on prognosis after sport concussion found that delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of post concussion symptoms.^[3] Even though this is some of the most recent evidence on the topic, it still doesn't necessarily allow for the creation of perfect guidelines for exactly when to return to play for athletes. As a result, many doctors will suggest waiting until all of the symptoms are resolved, even if that takes a very long time.

Naturopathic Treatments

From a naturopathic perspective, there are a number of additional or conjunctive healing therapies that can be considered. The recommendations of resting and taking breaks are reinforced, but there are supplements that may be able to speed up the healing process or may help with pain.

To help reduce inflammation and help with optimal nutrition, EPA and DHA (omega-3 fatty acids) can be used.^[4] Although a regular daily dose of omega-3 fatty acids is often recommended for general health, a higher dose could be warranted in those with traumatic brain injuries to try to optimize the anti-inflammatory action. Other supplements like curcumin have been shown to help improve the energy levels of nerve cells.^[5] Curcumin also has very powerful anti-inflammatory actions and thus could help prevent brain swelling. Many antioxidants can be supplemented to help prevent damage caused by neurotransmitter imbalances, which can occur as a result of a concussion. These could include things like green tea, resveratrol, alpha-lipoic acid, and vitamin E as examples. Interestingly, many of these treatment options are also recommended to help in the prevention of dementia.^[6] The reasoning is that oxidative stress is directly involved in amyloid beta peptide cytotoxicity and the antioxidants can be protective. For instance, vitamin E has antioxidant and hydrophobic properties that allow it to be the main antioxidant present in biological membranes. It can prevent lipid peroxidation, carbonyl formation, and induce intracellular modulation of cell signaling pathways. In other words, the vascular damage that would be produced can be decreased or prevented by vitamin E.^[6]

Naturopathic Doctors have access to a range of other treatment modalities that could help reduce pain if it is present. For example, cranial adjustments and spinal manipulations can potentially be used in more mild concussions to help ensure the proper alignment of the bones and joints. Acupuncture can be used to help relax tight muscles that can occur as part of the body's compensatory mechanisms. Hydrotherapy is a treatment option that can help with improving circulation, which can help move some of the waste products of the injury out of the brain and help move fresh nutrients where they are most needed. Since naturopathic treatments are individualized, it means that if any other symptoms are present, they can also be addressed. For instance, if headaches are occurring, naturopathic treatments for headaches could also have some benefit.

Overall, concussions are extremely common and range from mild to severe. Many questions and tests can be performed to find out exactly what is happening. The best recommendations always include resting and taking breaks. Drugs to help with pain can be used as long as they don't increase the risk of bleeding. Patients should be closely monitored immediately after the injury to ensure there are no new symptoms and that the current symptoms improve. Naturopathic treatments can be added to the conventional approaches to help speed up recovery time and help prevent future damage.