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Traumatic Brain Injury

The Latest in Concussion Treatment and Recovery

There is "cool" new evidence.

Key points

  • New evidence suggests that there are effective treatments to help speed recovery from concussion.
  • These treatments include early initation of moderate excercise.
  • Head and neck cooling immediately post head injury also appears to be a promising treatment for concussion.

Irritability, headache, nausea, light sensitivity, forgetfulness, insomnia. Ask someone with a concussion about what it feels like, and you are likely to hear some of these descriptors. Vertigo, brain fog, blurry vision, difficulty word finding. There are many possible symptoms of concussion, and they can vary greatly in duration and severity.

Once brushed off as a temporary affliction with a veneer of masculinity and toughness (“Wow, he got his bell rung on that one!”), we now recognize concussion as a major public health challenge. Data from the Centers for Disease Control and Prevention (CDC) estimates that there are nearly three million significant head injuries in the U.S. each year. Nearly 300,000 of these affect children and adolescents who sustain concussions during sporting activities.1,2

In recent years, the pendulum has swung regarding awareness and diagnosis of concussion. For example, if you watch a quarter of an NFL game, you are likely to see at least one player escorted into the “Blue Tent” for a physician’s neurological assessment. We’ve also made progress with prevention, especially in children younger than 17 playing contact sports, resulting in 32 percent fewer emergency department visits for sports-related head injuries in the U.S. between 2012 and 2018.2

Nonetheless, concussion remains problematic in many ways. Tainted by profits, the politics surrounding concussions are complicated. Right now, against the backdrop of a FIFA World Cup and the height of the professional and collegiate football seasons, there was a scandal at the International Consensus Conference on Concussion in Sport, which–up until recently–was the most respected medical authority on sports concussions. In short, the former chair of the conference resigned due to plagiarism charges, putting the veracity of the conference’s prior and current work under scrutiny.

Unfortunately, preventing and caring for concussions is as problematic for individual patients and their healthcare providers as it is for society at large. While concussions usually aren’t hard to diagnose, they are hard to predict (in terms of their course and recovery) and nearly impossible to treat. There are near as many proposed treatments and studies on treatments as there are potential symptoms. Yet, until recently, the only firm recommendation was rest–physical and mental. Recent evidence has, however, even started calling this into question beyond the short term. Luckily, there are some promising, easily accessible alternatives.

Let’s review three of these; supplements, exercise, and cooling of the head and neck.

Supplements

It sure would be convenient if there was a cheap, readily available, and safe nutritional supplement for concussion treatment. But despite what many marketers would like you to believe, the evidence doesn’t support any such therapy. Certain supplements have been studied but have not yet shown any treatment benefit in humans with concussion, including omega 3 fatty acids (fish oil), vitamins C, D, and E, curcumin (found in turmeric), resveratrol, melatonin, and creatine. Of course, future investigations may change this narrative.

For example, there are two separate clinical trials starting up: a Canadian study of the effect of omega 3, vitamin D plus creatine on persistent post-concussion symptoms; and a U.S. study on melatonin in acute pediatric concussion. Given that sleep disturbances are common after concussion and that many concussion symptoms (like trouble concentrating and irritability) mirror those of sleep deprivation, one would hope that there is a sleep aid out there that can help treat concussion. Also, concussion notwithstanding, there can be perfectly good reasons to take nutritional supplements–omega 3 and melatonin are part of my own routine.

Exercise

Wouldn’t it be great if a simple intervention, like moderate exercise, could help speed concussion recovery? Well, good news: There is at least moderately convincing evidence that early initiation of targeted exercise after concussion can make a positive difference. The physiological concept here is that aerobic exercise increases blood flow to the brain, which, in turn, helps with oxygen delivery and the production of brain-derived neurotrophic factor (BDNF), which stimulates neuron growth and enhances neuroplasticity.

Working off of the hypothesis that such neuro-processes could help the brain recover after concussive injury, Leddy and colleagues have published several studies demonstrating the benefits of post-concussive exercise. One is entitled Exercise is Medicine For Concussion.3 So, while old post-concussion return to sport protocols recommend a week or more of strict physical rest, the new consensus is that exercise can be restarted almost immediately if done within constraints. The goal is “subthreshold” aerobic exercise–which essentially means that a concussed athlete tests their tolerance for exercise on a treadmill or stationary bike (or with similar safe activity) while tracking their heart rate. If (or when) they experience worsening of their concussion symptoms, then the trick is to dial back effort until their heart rate is roughly 10 percent slower and then continue exercise for a reasonable interval (30 minutes or so). Leddy’s work has demonstrated that in adolescents, at least, this type of regimen can help speed recovery by four days or more.4

Thermal Treatment

What about a treatment that could be started immediately after head trauma to prevent or mitigate concussion symptoms? Well, my response is not as frosty as you might expect! A study just published in the Journal of Neurotrauma looked at the impact of immediate head and neck cooling for concussed ice hockey players.5 We know that increasing temperature after an injury can be deleterious–causing more inflammation and cellular damage. This is why we toss ice packs onto sprained ankles and run cool water over burned skin.

In the Swedish hockey player study, the researchers tested whether the same principle might apply to the injured brain and implemented a protocol of 45 minutes of immediate post-head injury cooling using a head and neck cooling cap and measured its impact in time return to play. The investigators enrolled elite adult male hockey players (average age 26) over five years (2016-2021), capturing a total of 132 sport-related concussion events. Compared to players who received standard post-concussion care, those in the cooling intervention group returned to play in nine days versus 13 days with standard care–a four-day difference quite similar to what was seen in the subthreshold exercise study. This is promising but would be challenging to broadly replicate as the head, and neck cooling cap contraption is more technologically nuanced than an ice pack. The authors described it as such:

...the system consists of a high-powered portable cooling system, using a circulating coolant controlled and maintained at 0°C. The coolant flows through a silicone-based head cap that has an insulating neoprene cover.

It doesn’t seem far-fetched to have such systems in the NFL’s “Blue Tent,” but it’s a stretch to have them on the sidelines of tens of thousands of high school playing fields. Furthermore, in the Swedish study, this contraption was applied really quickly–about ten minutes after injury. So not only would teen sports need to have the device on the sidelines but coaches and parents would also need to make the decision to use it stat. Maybe more delayed cooling could be beneficial, too, but more likely not. You can’t unboil an egg.

Collision. Clock cleaning. Header. Knockout. The vernacular of head trauma is omnipresent in our sports, and so are concussions in our health system. There is still much to be done to wrap our heads around this public health challenge, but there have been advances, and I think we can look forward to more.

References

1. Taylor, Christopher A., et al. "Traumatic brain injury–related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013." MMWR Surveillance Summaries 66.9 (2017): 1.

2. Waltzman, Dana, et al. "Trends in emergency department visits for contact sports–related traumatic brain injuries among children—United States, 2001–2018." Morbidity and Mortality Weekly Report 69.27 (2020): 870.

3. Leddy, John J., et al. "Exercise is medicine for concussion." Current sports medicine reports 17.8 (2018): 262.

4. Leddy, John J., et al. "Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial." JAMA pediatrics 173.4 (2019): 319-325.

5. Al-Husseini, Ali, et al. "Shorter Recovery Time in Concussed Elite Ice Hockey Players by Early Head-and-Neck Cooling: A Clinical Trial." Journal of Neurotrauma (2022).

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