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From the Townsend Letter
May 2019

Concussion and Mild Traumatic Brain Injury:
A Functional Medicine Approach to Healing the Brain
by David Musnick, MD
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After a brain injury an individual can mount immune responses to brain tissue related to molecular mimicry in regard to amino acids in gluten and dairy even if the patient did not have a prior problem with gluten or dairy. This may also be true with corn, soy, spinach, and tomato. Antibodies may be formed against certain dietary aquaporins and may potentially cross-react with brain aquaporin in astrocytes.8
     
Gliadin from gluten can cross react with Asialoganglioside, myelin basic protein, synapsin and cerebellar tissues. Milk butyrophilin can react with cerebellar tissue. Dairy casein can react with synuclein and oligodendrocytes.8,9 Choline-rich foods can provide choline for acetyl choline for neurotransmitter support and phosphatidyl choline for membrane support. One should try and consume 2000-3000 mg a day of choline by consuming a few servings of choline-rich foods. Foods rich in choline are the following: chicken, turkey, collard greens, brussels sprouts, broccoli, swiss chard, cauliflower, and asparagus. A brain injury diet is also low in sugar, and patients should minimize sweets and processed foods.

Physical Exercise
Aerobic exercise can increase brain derived nerve growth factor (BDNF), which is a very important trophic factor for the brain.10 The brain exercise prescription would be 40 minutes of aerobic activity in the patient's training heart rate zone. This would be a zone of 70-80% of their maximum heart rate, which is calculated as 220 minus age. It is beneficial to start off with shorter time periods of exercise, like 15 minutes, and gradually to increase the duration by one to two minutes each exercise session until reaching the 40 minutes. Strength training two to three days per week can be introduced to maintain and build muscle mass. These activities should ideally be done without pain and should not precipitate headaches. If balance is a problem, the patient should start with stationary bike and balance exercises.

Researched NutritionalsSupplements for Brain Healing
Certain supplements appear to have multiple pathophysiological benefits. These are taurine, curcumin, lithium, and DHA. This section will briefly address pathophysiology and some supplements. There are many more supplements that may be helpful but coverage of them is beyond the scope of this article.
     
It is quite challenging to choose a dose for a supplement for brain injury because most studies have been done on rats and mice and many times the supplement was not given orally. Some supplements have mechanisms that make physiological sense for brain injury but have not been studied specifically for brain injury. Doses have to be chosen based on extrapolation from the mice and rat studies or from a dose that can, at a minimum, achieve a serum level of the supplement. Because of the complex issues that must be taken into account to arrive at a dose, the author will not provide exact doses in this article but will be doing so in a future Kindle ebook and in future products.
     
Vinpocetine and ginkgo have been used to increase brain oxygenation and are reasonable to use especially for the first eight weeks after a head injury. DHA is an important fatty acid to supplement, starting about a few days from the head injury and during all stages of head injury. It may also have anti-inflammatory and anti-apoptotic effects.11
     
It is important to activate nuclear factor-erythroid 2-related factor (NRF2) to improve anti-inflammatory and antioxidant mechanisms. NRF2 is a transcription factor that can bind to DNA and lead to the production of the person's own antioxidants. These are glutathione, SOD, and catalase; and they can bind free radicals and thus decrease free radical damage to neuronal and other tissue. NRF2 coordinates expression of genes required for free radical scavenging and helps to regulate inflammation. Tecfidera (dimethyl fumarate) is the only known drug that may upregulate NRF2. Tecfidera has only been FDA approved for relapsing MS and thus the author has used natural activators of NRF2. There are a number of natural products that can activate NRF2, including curcumin, DHA (omega 3s), and green tea. Curcumin is best given in the Longvida form as this form best passes the BBB into the brain. Melatonin is also used by the author to decrease neural inflammation.
     
Avoid all supplements with calcium and all foods with MSG and with hidden MSG during the first eight weeks after a head injury to decrease excitotoxicity. Taurine is a conditionally essential amino acid that may be able to provide some protection against excitotoxicity. Taurine appears to have a number of beneficial mechanisms in treatment of traumatic brain injury. These mechanisms include decreasing excitotoxicity, protection of cells from osmolar changes (important within the first few weeks), improvement of blood flow, enhancement of neurite growth, and triggering new brain cells to grow in the hippocampus. It is for this reason that the author advocates the use of taurine in all stages of head injury.
     
Neurogenesis is the process by which adult neural stem cells differentiate into nerve cells. This has been shown to happen in adults in the dentate gyrus of the hippocampus.12 Neurogenesis may be mediated by trophic factors like BDNF. Aerobic exercise can stimulate the production of BDNF, and certain supplements may stimulate neurogenesis, like melatonin, taurine, and lithium.
     
Lithium is a mineral and appears to have multifocal neuroprotective benefits for the brain.13 Lithium has been shown to increase nerve growth factor in the frontal cortex and hippocampus and may increase brain derived nerve growth factor.13 Lithium can be protective for the BBB. Lithium may induce nerve stem cells and neurogenesis of hippocampal neurons.14 Lithium is used to treat bipolar depression in doses of 300-600 mg twice a day. If a patient has bipolar depression, then this dose will be continued or started. The author uses doses ranging from low dose lithium at 20 mg per day to bipolar dosing to treat head injury. Dosing levels for lithium have not been well established in humans for treatment of traumatic brain injury.
     
Mitochondria support of brain neurons is best accomplished with a mix of activated B vitamins, CoQ10, and with nicotinamide riboside (NAD).15

Brain Training and Synaptogenesis
Brain training is very important in healing the brain after head injury to create new synaptic connections i.e. synaptogenesis. This type of training should challenge the patient, and it should be slightly difficult in order to maximally stimulate new synaptic connections and to build synaptic density. I recommend multiple types of brain training that challenge thinking and the brain. Physical activities can be incorporated to do this, including dance lessons, Simon games, and ping pong. Mental activities of different types should be encouraged. Crossword puzzles and brain games are helpful but often are not enough. Patients are encouraged to join an online personalized brain training like BrainHQ and to do both the personalized program and specific courses to address their deficits. If an individual has had a QEEG, then they may be a candidate for neurofeedback training to train deficient brain areas.
     
There are a number of very helpful treatments that aid brain healing that the author has used, and these include frequency specific microcurrent, neurofeedback, audio visual entrainment, HBOT, counseling, and Brainspotting. Physical therapy, craniosacral therapy, and chiropractic care can be useful for balance, vestibular, and spinal problems. Working on sleep, vision, and hormone health are very important but beyond the scope of this article.
     
Frequency specific microcurrent (FSM) is a type of microcurrent that can be used to aid in healing different brain areas as well as headaches. In this author's experience, FSM has been very valuable in helping patients heal their musculoskeletal and brain injuries. It may address the following pathophysiology: decreasing congestion, increasing ATP and mitochondrial function, decreasing neural inflammation, and in healing the blood brain barrier.
     
Neurofeedback is a treatment that can be helpful to restore brain function. It is best used after a QEEG to enable the practitioner to design specific treatment for areas that are under or over functioning.
     
Audio visual entrainment (AVE) is a type of treatment that can be especially helpful for patients having difficulty with concentration or depression after a head injury. The treatments are administered via a unit that generates visual and sound signals at certain frequencies. If it is helpful, home units are not very expensive and can be administered by a patient or family member.
     
Pulsed light emitting diodes in the red and near infrared spectrum applied to the head and neck may increase regional blood flow and may also stimulate ATP production.16
     
Certain forms of counseling may be helpful for patients. A cognitively trained speech therapist can be valuable for someone with moderate to more severe deficits who would have trouble doing the brain training on their own. Brainspotting is a technique that might help patients with anxiety, fear, PTSD, stress, and insomnia. EMDR counseling would be helpful for patients with PTSD. EFT tapping would be helpful to do for self-care for anxiety and stress related to the injury. Cognitive behavioral therapy can also be quite helpful.

Hyperbaric Oxygen
Hyperbaric oxygen therapy (HBOT) has been used for years for wound care and diving injuries. Mechanisms of action of HBOT are primarily to improve oxygenation in congested or poorly oxygenated areas. There has been a number of studies evaluating the role of HBOT in treating patients with mild traumatic brain injury. Of interest is that these studies use variable pressures from 1.5 to 2 ATMs and there are no other interventions that are being used at the same time. The HBOT studies evaluate only an increase in oxygen delivery. In a Department of Defense study, only one of the groups showed improvement in symptoms when being treated with 2 ATM.17 In a review of five studies only one study showed efficacy.18 None of the studies showed any side effects.
     
Biotics Fish OilIn the author's experience, about two-thirds of patients with head injuries referred for HBOT demonstrate a clinical benefit. It must be understood that this author has patients on a full program of supplements, brain injury diet, exercise, and brain training before referring for HBOT. HBOT can be used very soon after the head injury, as one of the main problems in early concussion is low oxygenation in certain injured areas of the brain. It can also be used after four weeks, but I would say that patients should only do this if they are doing a complete brain healing program to achieve maximum benefit. HBOT is usually prescribed as 1.5 – 2 ATM for 10 sessions. If there are no results after 10 sessions, no more sessions would be recommended. If there is benefit, another 10 sessions could be considered.

Conclusion
Concussion and traumatic brain injury are common and inadequately treated by the conventional medical system. Neuroprotection should be started and continued throughout the program. It is important to start with a brain injury diet and certain supplements like Longvida® curcumin, taurine, and lithium. Once the person is able to do some exercise, aerobic exercise should be started. Counseling and various types of brain healing modalities can be added to the program. The patient should have a team of clinicians to carry out the brain healing plan and should be periodically evaluated by a functional medicine clinician. The program as outlined above has the ability to significantly improve brain reserve and decrease symptoms after concussion and traumatic brain injury.

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Resources
AVE equipment and information:
       https://mindalive.com
BBB antibody testing: ARUP Labs (New York), Mayo Clinic Labs, or Cyrex Labs (Arizona; Array 20)
EFT tapping:
       https://www.thetappingsolution.com
Frequency specific microcurrent:
       https://frequencyspecific.com and https://mendtechnology.com/
Functional neurology:
       https://functionalneurologyseminars.com; https://carrickinstitute.com
Headsets: https://www.smart-safe.com/collections/radiation-free-headsets; https://products.mercola.com/blue-tube-headset
SPECT Scans: Amen Clinics

References .pdf

David Musnick, MD, is board certified in sports medicine, internal medicine, and functional medicine. He developed the functional medicine approach to treating concussion and traumatic brain injury and presented it at the annual meeting of the Institute for Functional Medicine in Los Angeles in 2017. He was one of the featured speakers on the Broken Brain docuseries. He is specialized in functional medicine, frequency specific microcurrent, and prolotherapy. He practices at Peak Medicine in Bellevue, Washington. His web site is www.peakmedicine.com.

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