Did the Concussion CPG for PTs Go Far Enough?

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By Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CSCS, NSCA-CPT, CNPT, Cert-DN

Last month the Journal of Orthopedic and Sport Physical Therapy (JOSPT) published a lengthy Clinical Practice Guidelines (CPG) specific to physical therapy and concussion management. Here's a link to the authors' summary. The authors of the CPG offered a long list of references, well-thought out discussions, and clear evidenced-based recommendations. However, our team at Nutritional Physical Therapy feel the CPG did not go far enough for physical therapists (PTs). 

Managing patients with concussions, or mild traumatic brain injuries (TBIs), involves a multidisciplinary and multi-faceted approach. Concussions involve disruptions in cognition, planning, executive function, balance, physical performance, speech, vision, and even sleep. As such, the authors do a fabulous job outlining the need for PTs to screen for cognitive, vision, speech, and sleep issues. When identified, PTs ought to refer out for speciality care, such as that of a neurologist. Examination for balance and physical performance is an obvious skill set for PTs, and one that many PTs offer a slew of evidenced-based interventions for. 

The authors rank the evidence for PT concussion management according to the valid and standardized Agree II instrument. Such an instrument affords the PT the opportunity to see that a recommendation for a test, screening, or interventions is either highly recommended (Grade A) or merely expert opinion (Grade F), with varying levels in between depending on the volume and quality of the research. 

So what’s our issue with the JOSPT Concussion CPGs? They fail to mention the implications of nutrition within concussion management. Copious studies have shown the connection between the brain and gut, formally known as the gut-brain-axis. The gut-brain-axis is a two-way street where each structure can influence each other through various ascending and descending pathways. Current evidence suggests that the brain-gut axis is responsible for cellular communication linking the intestinal system with the central nervous system. Evidence has shown that neurotrauma, such as a TBI, can induce structural gut changes.1 You read that right: TBIs can actually inflict structure changes in the gut. Moreover, it has been well-demonstrated that poor dietary habits induce greater gut permeability, which promotes systemic and neural inflammation, which is particularly troublesome for damaged microglia.1 Diets high in fats, processed foods, and animal products shift the innate gut bacterial flora, which can induce changes in pathways that help to produce beneficial hormones (e.g. melatonin and serotonin) that mediate sleep, mood, and recovery. One such pathway is the shikimate pathway. Poor diets have been correlated with why some athletes develop marked post-concussion syndrome (PCS) after brain trauma.2 Post-concussion syndrome symptoms may be related with systemic inflammatory responses, and even neuroinflammation, related to gut-mediated pathways.2 The brain is not an isolated structure.

Emerging animal studies are showing that a high dose of omega 3 (DHA) increases serum levels and, if given prior to traumatic brain injury, reduces the injury response, as measured by axonal injury counts, markers for cellular injury and apoptosis, and memory assessment by water maze testing.3 This is great news but what about human trials? Although both animal models and human studies of brain injuries suggest they may provide benefits, there has been no clinical trial evaluating the effects of n-3 fatty acids on resilience to, or treatment, of TBI.4 Small case and cohort studies are showing some benefit with Omega 3 supplementation; however, could simply reducing excess Omega 6 fatty acid consumption (e.g. eating less fries and steak) confer the same benefit? Most likely, we see that systemic inflammation tends to be reduced as the ratio of Omega 3 fatty acids increases relative to Omega 6 -- that is, when Omega 6 fatty acids are reduced, Omega 3 really gets to exert its benefits. 

Could PTs intervene by promoting healthy diets before brain trauma to prevent or reduce the risk of PCS -- of course! Obviously there is little downside for PTs to be promoting a healthy diet in the first place. Explaining to athletes to reduce the consumption of foods high in Omega 6 and increase the consumption of healthier fats, like walnuts and flax, could give their brains an edge as it relates to TBIs. Eating more fruits and vegetables will boost serum levels of beneficial antioxidants, which may combat free radicals in the microglial. PTs recommending more fruits and vegetables does not take a dietician degree or certification. Are there robust randomized controlled trials on Omega 3:6 ratios and fruit and veg in athletes’ diets? Unfortunately not yet. However, the least the JOSPT authors could have done was to mention that Omega 3 supplementation was being trialed in animal studies and could have implications with neurological recovery. Would PTs offering athletes supplementation with probiotics boost the beneficial gut bacteria, which may help lessen neural inflammation? Perhaps. Again, the least the JOSPT authors of the CPG could have done is explored the notion of the gut-brain axis as level E or F data as it relates to concussion.

In the end, the JOSPT concussion CPGs is a good medically written piece of literature that falls short of addressing the whole patient. Nutrition is in the wheelhouse of most sports physios, PTs, and athletic trainers alike. To ignore the recent swelling evidence of Omega 3 fatty acids, the gut-brain axis connection, and basic sports nutrition in general is an act of omission and a hole in their research findings. Afterall, often when we talk about athletes we spend so much time talking about dietary recovery, nutrition to optimize performance, and supplementation --  let’s do better next time on these concussion CPGs and focus on the whole patient!

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References:

1. Rathbone, Alasdair Timothy Llewelyn, et al. "A review of the neuro-and systemic inflammatory responses in post concussion symptoms: introduction of the “post-inflammatory brain syndrome” PIBS." Brain, behavior, and immunity 46 (2015): 1-16.
2. Sundman, Mark H., et al. "The bidirectional gut-brain-microbiota axis as a potential nexus between traumatic brain injury, inflammation, and disease." Brain, behavior, and immunity 66 (2017): 31-44.
3. Mills, James D., Kevin Hadley, and Julian E. Bailes. "Dietary supplementation with the omega-3 fatty acid docosahexaenoic acid in traumatic brain injury." Neurosurgery 68.2 (2011): 474-481.
4. Barrett, Erin Cernkovich, Michael I. McBurney, and Eric D. Ciappio. "ω-3 fatty acid supplementation as a potential therapeutic aid for the recovery from mild traumatic brain injury/concussion." Advances in nutrition 5.3 (2014): 268-277.

Keywords: nutrition, continuing education, concussion, PT, physical therapy, TBI, Omega 3, sport, supplementation

Disclaimer: The above article is written as opinion piece and does not convey specific legal and/or practice act advice.