Course: 12th Annual NYU Langone Concussion Conference: Advancing Concussion Health Equity and Innovative Care: Exploring the Latest Developments and Best Practices
So obviously fueling recovery is very important because as you can see there's a multifaceted way to uh manage, diagnose and treat concussion patients and clinically this is extremely important to support them through their healing. All right, so I know Doctor Giza already sort of teed up the pathophysiology of concussion damage. We know the primary and secondary injury, uh, causes oxidative stress, uh, inflammation. Uh leaks out excitatory toxins and causes cell deaths, and we know that this is acute, but we also want to consider what he said that there are brain changes that occur chronically that we are seeing outpatient as clinicians. So I actually look at concussions and concussion patients or brain injury patients as an opportunity for nutritional repair. Why? Because there's an energy crisis. We know that in the brain. There's uh acute functional disturbances. There are imbalances between the cellular ions, right, sodium, potassium, AT paste, calcium, and a lot of overproduction of free radicals. So what happens, right? These free radicals are here. Um, and there is actually something we can do about it. Uh, this is why I'm, I'm actually going to highlight in this talk, and this energy supply and demand mismatch is what's making them so fatigued, tired, unable to sleep, unable to walk, and then. The secondary phase of injury causes this free radical production, oxidation, and inflammation, right? So we know brain disturbances as well as chronic issues in the brain like MS and stroke all cause inflammation. This is no different. As a result, these changes increase the brain's need for anti-inflammatory and antioxidant nutrients. So this is a lovely graphic of the mouthful that I always love to say is the microbiota gut brain access. We'll call it the MGA, uh, for the rest of the talk. So number one here, the immune cells, um, that secrete cytotoxins or cytokines and then neuroactive modules. Act upon the gut microbiota and the neuroendocrine cells, uh, and the vagus nerve is the one that actually is cross talking between the brain and the gut, right? So why is it called the axis is because of this there's a cross talk and then there's a lot of metabolites that are, uh, secreted as a result of any type of brain trauma, injury, or broad brain barrier dysfunction that then 4 acts upon the brain. All right, another schematic really hits home, you know, neurodegenerative diseases, neurodeformmental, as well as neuropsychiatric diseases as a way to illustrate altered neurotransmission and really a lot of these diseases have overlaps in the way that concussion or traumatic brain injury presents, and everyone is confused, but this should give us a little bit of insight that. Immune system, neuroendocrine system, the enteric nervous system, the vagus nerve, they all secrete peptide, gut hormones, uh, microbiota derived products that basically are giving us that are giving us, uh, cross talk and, um, are a way that we can, um, affect the gut microbiome. So how do we do this right at the center of this whole thing is food. Basically what we do is we have gut derived molecules like neuronal, immune, and neuroendocrine um that cross talk. Once we have food this uh affects the gut microbiota and then the neuroactive peptides are affected and so everything's sort of cross talking. So you know when we say you are what you eat, um, it really, uh really does uh kind of play out in in this schematic. So this, uh, basically, um, legend is showing us this, um, what I really like to call is a sexy name psychobiotics, right? So psychobbiotics are these, uh, things that we can ingest that are fermented like yogurt and, um, uh, kimchi, uh, things of that nature. Uh, the psychobbiotics basically work on the gut wall, um, and then vagal terminals, uh, to affect the gut-brain barrier and the immune system. Uh, then it affects the bloodstream as well as the inflammatory, uh, neuro interleukins as well as the neuroactive factors, and then basically the effect on the brain is that we have impact on behavior, mood, memory, cognition, work performance, sleep, waking, rhythm, etc. So this actually gives us a really good idea of the bacteria that make up brain chemicals, right? Um, so we have, I'm not going to, um, you know, go over all of them, but you can take a quick screenshot if you'd like. The one that we should be really interested is in GABA, right? The GABA calms everything down. It's sort of our benzo internal, and that is affected by bifidobacterium. These are all tongue twisters, um, so as you can see, a lot of the good bacteria in our gut are making. Brain chemicals. So if we have a central inflammation because of any cause, it's not going to help the brain chemicals release and work correctly. All right, so what is the nutritional support that we can um give an MTBI concussion, right? And what is the current data? And, um, right now I'm talking about supplements, but obviously I prefer to tell people to supplement more via diet. Um, uh, and, and lifestyle modifications than just taking supplements, but obviously this gives us a way to give concentrated nutrition. Omega 3 fatty acids, they have a role in acute recovery, uh, per 3 human RTCs, uh, doses are 2000 mg, so be careful of telling them to start at 2000 mg right, right away. Um, omega 3 is a potent. Uh, antiplatelet, anticoagulant, um, also they combined the DHA, um, and EPA with this as well. This showed, um, improved RTP and symptom resolution. Usually I start them on lower doses and work up so they can tolerate it. Um, it also can cause stomach upset. So one, fun hack that I have is I tell them to freeze the omega 3 capsules and take them so it could bypass the gut a little bit. So vitamin D, right, what is the target? Everybody is low in vitamin D. Anyone tests it, we know that are low, um, but you know, once it's repleted, it's 30 to 60 is, is normal. But you know, for neurologic purposes, my target is 90. That's the MS target, and I do believe concussion patients benefit from the target of 60. Um, and this has shown the greater overall rates of recovery improve, improve, uh, mental status, um, as well as the mini mental, um, status examination, and this mild to moderate TBI, this can improve long term and cognitive performance, um. We also have a role in decreasing vertigo with vitamin D supplementation and role in improved cognitive function, so we to continue the omega 3, obviously we know this is, um, uh, present in fatty fish. Uh, it's great for the, and I sell it to my teenage patients. Oh, it's gonna be great for your, your hair and it's reduced inflammation in your skin, so they're, you know, really perk up and. Uh, then like to take it, so obviously we, we discussed that there's post-injury improvement in neurologic and cognitive, uh, performance. It's a potent anti-inflammatory antioxidantant and neuroprotective and has a, a beneficial effect on depression. Anyone that, um, of my patients that are on antidepressants, they automatically do get recommendation for omega 3 and vitamin D. Continuing on, uh, with the nutritional support paginal. OK, this is not something that's routinely talked about. It's a French maritime pine pine bark. Um, it, uh, the study was done, uh, to report impossible vivo neuroprotective effects following cortical concussion injury. What this means is they gave poor rats some concussions, and, uh, they saw that if they were given some Pna within 15 minutes following this injury, reduced levels of oxidative stress, increased levels of key synaptic proteins, and reduced. Levels of neuroinflammation. Sure, we can say we don't have larger studies or data, but you know what, um, I've been using it in my patients. I take it myself and I think it really works. Uh, this is, uh, another study, uh, for branch, uh, chain amino acids out of CHOP. Um, it's found that it was done in teenage, uh, uh, patients and showed reduction resolution of total symptom score in a dose dependent fashion. Uh, what it means is that, you know, they saw improvements for faster return to physical activity, um, and then, uh, uh, the increase of physical activity was 0.5 on a 0 to 5 scale of physical activity for each 500 g of the defined BCAA supplement that was consumed. Vitamin C, there's no good human trials, but I'll just leave you with the fact that it is a co-factor, you know, in, uh, most of collagen, so neck, spinal tendinopathy, um, uh, things, it tends to improve, um, and the brain levels are 100 times higher, uh, than other tissues. Magnesium is uh one that's really good for anxiety, uh, sleep, uh, levels drop after NTBI. Zake, um, we can see the increased urinary excretion after TBI. So that is another one to look into supplementing and this is a great schematic of all the different magnesiums and what we would like to, um, use targeted, uh, for our patients, OK. This is the role of mitochondria and fatigue. Um, what I use for fatigue basically is CoQ10. Um, it works really well for patients who have post viral fatigue, um, post-concussion, long COVID, um, and 200 mg what I use, uh, in terms of the dose and can go up to 600 as long as they don't have clotting issues. The other thing we wanna consider is diet, obviously. Uh, this is the diet, uh, that we're, I was just talking about. We know that ketogenic diets has had anti-inflammation, anti-seizure effect, but the really high fiber diet, um, is what helps the gut bacteria make all of the anti-inflammatory and anti-anxiety components. So that's something that, you know, I usually tell patients and really the Mediterranean diet, um, is what I. Try to simplify and tell them to follow, um, obviously that includes a lot of anti-inflammatory components like olive oil, fruit, legumes, nut seeds, uh, vegetables, whole grains, and excludes red meat, refined and processed, uh, foods as well as sugar, and this is a great schematic of, uh, uh, you know, showing us what a patient on a Mediterranean diet versus a Western diet, uh, can show, um, on, uh. On the vascular effects of, of, uh, biomarkers, right, so the high brain activity is shown in red, uh, on the left, on the western diet, on the right, you don't see as much brain activity, so it definitely does affect the brain activity when you are. Um, looking at it objectively like this, so future directions, um, for concussion treatment, you know, we are now as clinicians ready to think outside the pill box, um, at the suggestion of Hippocrates, let food be thy medicine and medicine be thy food, um, and based on the findings that I just spoke about that we suggest that inflammation, uh, may be an underlying mechanism. Um, that we can target via probiotics, diet, food, um, and these novel strategies can treat MTBI and mood related symptoms, um, so the gut microbiota can be a potential diagnostic and therapeutic target for MTBI to improve gut brain protective function, and I just leave you with this photo. It's a jockey conference, uh, and you know, uh, I spoke at this conference this past year. And these are some of the championship horses after the race, but they have significant issues with maintaining weight and diet, and a lot of times they, uh, they, they do purge and binge, and it really was, uh, you know, uh, pivotal and sort of sad to see how much support that that these athletes need, uh, that they're getting ignored. Um, thank you very much. Uh, my email address is here if you have any further questions.
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