TBI and PCS Treatment:

Transcription

1 TBI and PCS Treatment: Nutrition, Biomechanics & Pathophysiology Tara Lillemon, DPT, MTC, CMPT Contract Physical Therapist, 3 rd Special Forces Group THOR3 Laurel M. Wentz, PhD, RD Assistant Professor Nutrition, Appalachian State University Disclosure The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. 1

2 Learning Objectives 1. Explore mechanisms by which physical therapy and dietary interventions may improve recovery from traumatic brain injury. 2. Identify the link between upper cervical dysfunction and its influences on mtbi and PCS recovery. 3. Identify specific nutrients that play a role in neurological health and present appropriate targets for nutrition intervention to reduce risk of post-concussive syndrome following TBI. Military s TBI Exposure Since 2001, >1.5 million US military personnel have deployed to Iraq or Afghanistan (Hoge, 2008). Reported TBI rates in a military combat setting, range from 15-22% of the deployed population. (Hoge, 2008; Terrio et al, 2009; Schell et al, 2009) >85% of reported TBI diagnoses, within the DoD, are classified as mild TBI (mtbi) and are treated with outpatient services (DVBIC, 2017) 2

3 DoD TBI Statistics 250, , , ,000 50,000 0 ARMY NAVY MARINES AIR FORCE Accessed at Multidisciplinary Approach While most overt concussive symptoms resolve within 7-10 days, covert symptoms may persist for years. In many instances, an multidisciplinary approach is necessary for the management of mtbi and PCS. Physicians Physical / Occupational Therapy Speech Language Pathologist Dietitian Audiology / Vestibular Optometry Cognitive Rehabilitation 3

4 Cervical Pain Prevalence There is a strong indication that injury to the cervical spine plays an impact on mtbi biomechanical and pathophysiological pathways, and likely plays a role in both acute mtbi and long-term recovery with PCS (Morin, et al, 2016; McCrory,et al, 2012) Although there is currently a lack of scientific evidence in the literature on the involvement of the cervical spine in mtbi and PCS; its involvement is clinically accepted, and more research is warranted to determine the prevalence. Whiplash Effects to Cervical Spine Many of the injury mechanisms that cause mtbi, also induce a form of whiplash, resulting in abnormal force transmission throughout the cervical spine, leading to long-term damage and painful symptoms in the head and neck. 1. Impact 2. Acceleration of the target vehicle 3. Seatback contact with the body 4. Simultaneous forward + upward movement of the Occiput 5. Extension + compression of the lower C-spine; Flexion + compression of the upper C-spine --- S-curve formation 6. Head contacts the headrest 7. Cervical spine extension and post ROT of the head 8. Forward acceleration of the head past the shoulders 9. Flexion of the entire cervical spine 4

5 Cervical Spine Influences TBI Recovery Cervicogenic headaches are most common after a whiplash injury (Hecht, JS, 2004; Becker WJ, 2010). Dysfunctions of the craniovertebral region are commonly found after mtbi whiplash; C2/3 has highest prevalence of injury (Hecht JS, 2004; Bogduk N, 2011; Becker WJ, 2010) Post-traumatic headaches are a serious contributor to patient s disability; therefore evaluation of the cervical region after head trauma is recommended (McCrory, et al. 2014). This will also contribute to minimizing the morbidity of mtbi and help clinicians identify the International Headache Society cervicogenic characteristics on mtbi patients (Morin, et al, 2016) Common Symptoms Associated with mtbi Fatigue Headaches Visual Disturbances Memory Loss Poor Attention/Concentration Sleep Disturbances Dizziness/Loss of Balance Feelings of Depression Seizures Nausea Difficulty with short-term memory Slowness in thinking Irritability-Emotional Disturbances 5

6 C2/3 Influence on mtbi + Neck Pain C2/3 is the first level with a disc Transitional zone: Superior Facets = horizontal axis Inferior Facets = 45 deg axis During whiplash: C2/3 is becomes fixated Shear + compressive forces through the lower cervical spine (C4-7) Cervical Trigeminal Connection The spinal nucleus, of the Trigeminal Nerve (TN), consists of: Pars Oralis Pars Interpolaris Pars Caudalis Afferent terminals of the TN, and C1- C3 converge in the Pars Caudalis The Pars Caudalis forms a functional nucleus--- Trigeminocervical Nucleus 6

7 Trigeminal Nerve -trifurcates into 3 divisions: ophthalmic, maxillary, and mandibular Visual Disturbances Related to mtbi VOR and COR are affected in whiplash injuries 7

8 Case Study 36 yo ADSM, 18Z, with 17 years of service, and 10 combat deployments. C/o chronic neck pain, and intermittent radiating pain to the R arm. He reports frequent unilateral H/A, which begin at the base of the skull and radiate around to the front of the forehead, and behing R eye. When H/A are intense, he also notes visual changes. Upon further subjective questioning, the patient comments that he experiences difficulty with sleep (unable to sleep continuously >3-4 hrs/night), frequent waking, generalized malaise, GI distress, balance difficulties, poor concentration, and difficulty with short term memory. Where do you begin???? Nutrition and TBI in Military Personnel In 2011, the Institute of Medicine published a report summarizing nutrients that may play a role in resilience and recovery from TBI The committee concluded: Nutritional interventions could be important to augment mechanisms that defend against the effects of TBI and to serve as an integral component of multidisciplinary postinjury treatment to lessen the primary and secondary effects of TBI Nutrition will not be the sole treatment for TBI, but it is a potentially powerful adjunct to promote metabolic support during wound healing and may even exert neuroprotection if provided prior to injury Little research was presented on nutrition for mild TBI 8

9 mtbi Causes a Metabolic Cascade Target for nutrition interventions Excitotoxicity/Ionic disruption Neuroinflammation Oxidative stress Cellular damage and death Axonal and neuronal damage Altered metabolism Barrett et al. 2014; Adv. Nutr. 5: Ling et al doi: /j.mcn

10 Targets for Nutrition Interventions in mtbi Moderate inflammation is protective and required for immune defense Excessive and chronic inflammation contributes to irreversible tissue damage Goal of nutrition is to reduce secondary sustained inflammatory response Modulate inflammatory response and oxidative stress Limit secondary cascade and cytotoxicity Improve prognosis and functional recovery No FDA approved pharmacological intervention to treat concussion Nutrition deficiencies at the time of injury may exacerbate post-concussive symptoms and long-term recovery Consuming certain nutrients following injury may reduce acute effects and promote functional recovery Nutrients Summarized in Nutrition and TBI Report Paucity of human clinical trials 10

11 Nutrients that Impact mtbi Recovery Supplemental DHA reduced TBI biomarker concentrations in collegiate football players Oliver et al. 2016; Med Sci Sports Exerc. 48(6): CPSDA Research at a Glance sportsrd.org Veterans with TBI Consume Inadequate Nutrients Veterans with the lowest overall nutrient intake had worst neurobehavioral scores Lowest nutrient intakes were for Vitamins A, E, and C; Folate, Zinc, Magnesium, and Potassium These results emphasize importance of baseline nutrition and consuming a nutrient-rich diet Wahls et al. 2014; Nutr Neurosci. 17(6):

12 Service Members have Dietary Deficiencies in Nutrients for mtbi Recovery Frequent deployments reduce dietary quality in SOF operators (Farina et al. 2017; Nutr J. 16:41) Omega-3 fatty acid concentrations, especially DHA, are clinically low in service members Low DHA concentrations were associated with significantly increased the risk of suicide (Lewis et al. 2011; J Clin Psychiatry. 72(12): ) 52-55% service members have deficient or insufficient vitamin D status (Wentz et al. 2015; FASEB J. 29: Suppl 733.5; Barringer et al. 2016; Mil Med. 181(9):1114) Vitamin D deficiency was associated with significantly increase risk of suicide (Umhau et al. 2013; PLoS ONE. 8(1): e51543) Nutrition Intervention Post-Injury Reduce oxidative stress and inflammation Omega-3 fatty acids (DHA, EPA), vitamin D, antioxidants (glutamine, vitamin E/C, flavonoids) Restore cellular energetics Zinc, creatine, BCAA, magnesium, ketogenic diet Repair and recovery Antioxidant, flavonoids One study has tested a combination nutrition supplement intervention in retired NFL players who demonstrated brain damage and cognitive impairment Supplement included 2880 mg omega-3 (EPA and DHA), multivitamin, and herbal brain enhancement supplement Treatment enhanced cerebral flood flow and improvements in general cognitive processing Amen et al. 2011; J Psychoactive Drugs. 43(1):

13 1). Reduce Oxidative Stress and Inflammation Omega-3 Fatty Acids DHA and EPA Vitamin D Treatment with progesterone Antioxidants Glutamine becomes conditionally essential in injury Vitamin E reduces protein oxidation and increases SOD Polyphenols Resveratrol inhibits inflammatory enzymes and transcription factors and increases expression of anti-inflammatory cytokines Curcumin inhibits pro-inflammatory cytokines in cellular response to stress 2). Restore Cellular Energetics Magnesium Magnesium in brain reduces influx of calcium and glutamate to postsynaptic neuron Branched-Chain Amino Acids Precursors to neurotransmitters Provide alternative energy source to glucose Ketogenic Diet Provide alternative fuel to brain when glucose utilization is impaired Zinc Reduce glutamate-induced excitotoxicity Creatine Restore energy in tissue with high energy requirements Increase cerebral blood flow IOM 2011Nutrition and TBI Report 13

14 3). Repair and Recovery Antioxidants Improve neuroplasticity Flavonoids Protect neurons against neurotoxin injury Suppress neuroinflammation Inhibit apoptosis Increase cerebral and peripheral blood flow May affect gene expression Choline Phosphatidylcholine in cell membranes Practical Recommendations for Nutrition in mtbi Current evidence suggests that service members have low status for many key nutrients that may exacerbate post-concussive symptoms and long-term recovery Optimizing omega-3 fatty acids, vitamin D, zinc, and creatine concentrations pre-injury may improve recovery Consuming certain nutrients following injury may reduce acute effects and promote recovery 2-4 g DHA, IU vitamin D, antioxidants, flavonoids Currently, there is no recommended protocol for assessing nutrition markers and supplementation at baseline or following injury 14

15 Conclusions mtbi is complex heterogeneous injury characterized by molecular, cellular, and physiological events Integrating physical therapy and dietary interventions into mtbi management may minimize post-concussive symptoms and maximize return to duty progression These strategies provide a non-invasive intervention to provide biomechanical and metabolic neuroprotection during healing Need for more human clinical trials on mtbi treatment Contact Information Tara Lillemon THOR3 3 rd SFG(A) Physical Therapy tara.l.lillemon@socom.mil Laurel M. Wentz Appalachian State University Boone, NC wentzlm@appstate.edu 15