Conflict of Interest Statement

• The speaker has no financial affiliation with

company or product mentioned in this

presentation.

Integrative Approaches

For Traumatic Brain

Injuries

Adam Breiner, ND

Overview

1. What is a TBI and What is a Concussion?

2. Signs and Symptoms

3. Diagnostics and Standard Medical Treatment

4. Cutting Edge Approaches • EEG and Neurofeedback

• Hyperbaric Oxygen

• Photobiomodulation

• Altitude Contrast

• PEMF, tDCS, tACS

• PRP

Severe Traumatic Brain

Injury• Diffuse Axonal Injury

• Subdural hematoma

• Epidural hematoma

• Intra cerebral hematoma

• Intracranial hemorrhage

• Cerebral contusion

Traumatic Brain Injury

Teasdale et al. Lancet 1974 ii: 81-4

What is a

Concussion?

• Referred to as a mTBI

(mild TBI)

• Impact to the head

• Rapid change in force or

direction of the head

(acceleration,

deceleration)

• Resulting in disruption of

normal brain function

Concussion Grading

Grade 1• Person is confused but remains conscious

• SIGNS: Temporarily confused, dazed, unable to think clearly, has trouble following

directions• TIME: Symptoms clear within 15 minutes

Grade 2• Person remains conscious, but develops amnesia

• SIGNS: Similar to Grade 1• TIME: Symptoms last more than 15 minutes

Grade 3• Person loses consciousness

• SIGNS: Noticeable disruption of brain function exhibited in physical, cognitive and

behavioral ways.

• TIME: Unconsciousness for seconds or minutesConcussion as detailed by guidelines developed by the American Academy of Neurology (AAN) and the Brain Injury

Association (BIA)

Common Perceptions

• Didn’t lose consciousness, so

it’s not that bad.

• Just a “Ding”

• “I didn’t even get hit in the

head, so it’s not a concussion”

• “I’ll just rest for a few minutes

and go back in the game”

• It only happens in Football

Concussions Are NOT To Be

Taken LightlySchool football player hanged himself

two days after suffering blow to head

during game By DAILY MAIL REPORTER

UPDATED: 09:44 EST, 31 August 2011

The parents of a Virginia high school football player

who got concussion while playing and committed

suicide two days later are calling for his death to be

investigated.

Austin Trenum, 17, was a college-bound senior who

was injured while tackling a quarterback in a school

game in Nokesville. Two days later he went up to his

room and hanged himself.

To the grieving parents, there is no doubt that one

caused the other.

They believe that concussions still aren't taken as

seriously as they should be, that athletes, parents,

coaches, trainers and even emergency room workers

are often ill-informed as to how to treat them and that

more of a culture change is needed in a sport in which

blows to the head are considered badges of honor.

Concussions Are NOT To Be

Taken Lightly

Suicide Reveals Signs of a Disease Seen in N.F.L.

ALLENTOWN, Pa. — A brain autopsy of a University of

Pennsylvania football player who killed himself in April

has revealed the same trauma-induced disease found in

more than 20 deceased National Football League

players, raising questions of how young football players

may be at risk for the disease.

Owen Thomas, a popular 6-foot-2, 240-pound junior

lineman for Penn with no previous history of depression,

hanged himself in his off-campus apartment after what

friends and family have described as a sudden and

uncharacteristic emotional collapse. Doctors at Boston

University subsequently received permission from the

family to examine Thomas’s brain tissue and discovered

early stages of chronic traumatic encephalopathy, a

disease linked to depression and impulse control

primarily among N.F.L. players, two of whom also

committed suicide in the last 10 years.

Statistics

• Estimated there is a concussive Injury once every 23 seconds

• 1.6-3.8 Million sports-related concussions per year in US

• 230,000-500,000 hospitalizations per year

• Economic toll of TBI exceeds $60 Billion per year

• Estimated by 2020 TBI will surpass many diseases as the

leading cause of morbidity and mortality in individuals in the

world.

- Brain Injury Association of America.

- Langlois, J. et al The Epidemiology and Impact of Traumatic Brain Injury: A Brief Overview; Journal of Head Trauma Rehabilitation, Vol. 21, No. 5, pp. 375378 2006

- The costs of traumatic brain injury: a literature review; Clinicoen Outcomes Res. 2013; 5: 281-287

Nonfatal TBI related to sports and recreation activities among persons aged <19 yeas in USA during 2001-2009 (CDC)

Signs & Symptoms

mTBI &

Post-Concussive Syndrome (PCS)

• Headache 71 %

• Feeling slowed down 58 %

• Difficulty concentrating 57 %

• Dizziness 55 %

• Fogginess 53 %

• Fatigue 50 %

• Visual Blurring/double vision 49 %

• Light sensitivity 47 %

• Memory dysfunction 43 %

• Balance problems 43 %

Lovell, Mark, et al. Return to play following sports-related concussion. Clin Sports Med 23 (2004) 421-441

Diagnostics

• MRI & CT - will not detect

• SPECT (Single Photon Positron

Emission Tomography)

• PET (Positron Emission

Tomography)

• fMRI (Functional MRI)

Neurocognitive Testing• Full Neurocognitive Testing Performed by Clinical Psychologists

• Computerized neurocognitive tests standardized to allow evaluation

of areas most impacted by a concussion

• Baseline assessments before season.

• Testing post-concussion/suspected concussion. Assessment tool,

and help with decisions on return to play.

• imPACT

• Popular among coaches and many physicians

• CNS Vital Signs

• Worldwide usage

• U.S. Military

• Better database and accuracy

• Less chance of patient induced errors

• Covers evaluation of many neuropsychiatric conditions

Gualtieri, T., Johnson, L. Reliability and validity of a computerized neurocognitive test battery, CNS Vital Signs. Arch. Clin Neuropsychology 21 (2006) 623-643

EEG Neuro Imaging

• EEG = ElectroEncephaloGram

• Listening to the electrical signals created by the

neurons = “Whispers of The Brain”

Basic Brain Wave Patterns

DELTA 1-4 Hz

THETA 4-7 Hz

ALPHA 8-12 HZ

BETA 15-25 HZ

GAMMA 30-42 HZ

Basic Brain Wave Patterns

All Parts in the Symphony of The Brain

These waves are mixed together in various states of

consciousness and areas of the brain.

Electrical Encephalogram (EEG)

• EEG can be considered a diagram of the communication

of system of the brain.

• When frequency and amplitude of the electrical activity

are optimal, communication is unimpaired

• However, If damage occurs to the brain, (stroke, TBI,

etc..), both the frequency and amplitude are altered.

EEG As a Diagnostic Tool

• Brain Wave Morphologies Patterns Can Be Seen

• Brain Mapping with qEEG to detect various areas of

dysfunction and miscommunication. Comparative to

normative database.

• sLORETA

Patterns of Brain Injury

Normal Brain Wave Pattern on Real-Time EEG

Head Injury Pattern (spikes seen)

Coma with anoxia

Ayers, Margaret. Whispers from The Brain. 2006

Correlates with Other Brain Imaging

• 16 y.o male, hit his left face and forehead when 9 yrs old

• CT revealed no brain injury. 2 months later started having seizures. 5

months later was up to every 1.5 hrs

• Medication (Depakote and Trileptol) eased seizures. Eventually weaned

off medications

• 2 yrs later headaches started.

• Severe headaches – lasting 1-2 weeks and will have this 2x/month!

Correlates with Other Brain Imaging

Brain Mapping

• qEEG data compared to normative database

• Clinical Correlations of areas of dysfunction

• Patient questionnaire comparison to qEEG finding

• Standardized Low Resolution Electromagnetic Tomography

• Localize current source densities of brain activity (even from deep

brain structures).

• Voxels (space volume of cortical matter)

• Can compare to normative database

• Research in comparison to fMRI BOLD for more thorough

understanding of brain function.R.D. Pascual-Marqui. Standardized low resolution brain electromagnetic tomography (sLORETA): technical

details. Methods & Findings in Experimental & Clinical Pharmacology 2002, 24D:5-12

sLORETAStandardized Low Resolution Electromagentic Tomography

Imaging The Whole Brain

• Patient wears a cap with

electro-conductive gel -

Painless!

• 19 Channels (10-20

system) captured all at

once

• No Radioisotopes!

• No Delay!

Importance of a Baseline

• Baseline EEG Imaging Before

Season - Can Compare Before and

After Suspected Concussion.

• True “Window” Into the possible

neuro-physiologic damage caused

by an injury.

• Best Indicator When Safe to

Return to Play (including PE signs,

and neurocognitive testing).

• Neurofeedback can help in

restoring normalized

functioning…. (more to come)

Balance Assessment

• Baseline assessment

• Post Injury Tracking

• Easy and Reliable

Treatment for Concussions

Standard Approach

• Evaluation: On-field, Clinic, or

Emergency Department

• Imaging if appropriate

• Monitoring for 24-48 hours for

signs of deterioration

• Rest (Cognitive and Physical)

• If Sx’s persist more than 10-14 days see specialist

• 5 Step Return to Play

Standard Approach

• Post-Concussive Syndrome:

‣ Symptoms can last for weeks, months, or longer

‣ 5-8% of patients with history of multiple concussions.

• What is the approach then?‣ More Rest‣ Keep monitoring‣ Go on a 504 plan

• Are There Other Options

To Help Heal the Brain?

Hyperbaric Oxygen Therapy

(HBOT)

What Is HBOT?

Hyper = Excess

Baric = Pressure

Therefore Oxygen Under Pressure!

Physiologic Definition of

HBOT

Hyperbaric Oxygen Therapy is the use of

increased…pressure and increased

oxygen… as drugs treat pathophysiologic

processes of diseases.1

HBO Therapy in Global Cerebral Ischemia/Anoxia and Coma. Chapter 20.

Textbook of Hyperbaric Med., 6thEdition, K.K. Jain (Ed.), 2017.

Conventional Uses of

HBOT

•Decompression sickness (Bends)

•Gas Embolism

•Carbon monoxide and cyanide poisoning

•Gas Gangrene (myositis and myonecrosis)

•Anemia assoc. with exceptional blood loss

•Necrotizing soft tissue infections

• Radiation necrosis injuries

• Intracranial abscess

•Crush injury

•Non-union fractures

• Problem wounds

• Skin grafts and flaps

Cutting-Edge Uses of

HBOT

• Cerebral Palsy

• Multiple Sclerosis (MS)

• Stroke

• Traumatic Brain Injury

• Coma

• Lyme Disease

• Autism

• Anoxic Ischemic Encephalopathy

(near drowning, near hanging, cardiac arrest ….)

• Macular Degeneration (age related)

• Chrohn’s Disease

• Chronic Fatigue

• Mitochondrial Disorders

• Reflex Sympathetic Dystrophy (RSD)

How Does HBOT Work?

• Our Blood Cells are fully saturated under normal

atmospheric conditions 1ATA.

• Plasma is 0.4 volume % O2.

• 2 ATA (33 FSW)100% Oxygen Plasma is 4.3 volume

% O2! (Getting More O2 in One session than you

would in an entire day)

• MORE CAN DISSOLVE AND DIFFUSE INTO ALL

TISSUES AND ORGANS - BRAIN NEEDS THE

MOST!

Hyperbaric Oxygen is a

Genetic Therapy

In a Single HBO Session:

• 8,101 genes turned on and off

• Up-regulated genes: growth and repair, anti-

inflammatory

• Down-regulated genes: Inflammatory and cell

death

Goodman CA. Cell Stress and Chaperones, DOI 10.1007/s12192-009-0159-0. & Paul Harch HBOT IHMS 2018 Symposium

Hyperbaric Oxygen Therapy

AWAKENING THE PNEUMBRA

Mikey

HBOT & mTBI

• Paul Harch, MD - Journal of Neurotrauma (2012)

• Combat veterans who suffered from traumatic brain

injures/post-concussive syndrome and PTSD.

• Treated with Hyperbaric Oxygen Therapy.

• Over 80% Improvement!

HBOT & mTBI

HBOT can Improve Post Concussion Syndrome Years after Injury

Hyperbaric Oxygen Therapy Can Induce Angiogenesis and Regeneration

of Nerve Fibers in Traumatic Brain Injury Patients

SigalTal,, Amir Hadanny,EfratSasson, Gill Suzin,andShai Efrati.

Front.Hum. Neurosci, oct 2017

• Conclusions: The Mechanisms by which HBOT

induces brain neuroplasticity can be

demonstrated by highly sensitive MRI techniques

of DSC and DTI. HBOT can induce cerebral

angiogenesis and improve both white and grey

microstructures indicating regeneration of nerve

fibers. The microstructure changes correlate with

neurocognitive changes.

Increased White Matter Tract

Case of mTBI

Pre-Post HBOT

• 22 y.o male hit repeatedly by his “friend” who was intoxicated

• Came to clinic 4 days after attack with concussive injury symptoms:

Confusion

Headache

Lethargy

Insomnia

Anxiety and Depression

Neurofeedback

Neurofeedback• A subconscious retraining of the brain’s neuropathways

• Giving the brain a “mirror” to see and then correct itself

• Uses positive reinforcements via reward sounds and/or visual

aids

• As the desired patterns continue to be reinforced,

they eventually form new and permanent neuropathways.

1. May, G. Et al. Neurofeedback and traumatic brain injury: a literature review. Ann Clin Psychiatry. 2013 Nov; 25(4)

289-96

Nelson, DV et al. Neurotherapy of traumatic brain injury/post-traumatic stress symptoms in Vietnam veterans. Mil Med.

2015 Oct; 180(10)e 1111-4

Nelson, DV, et al. Neurotherapy for chronic headache following traumatic brain injury. Mil. Med Res. 2015 Aug 31:2:22

Gray, Sarah. An Overview of the Use of Neurofeedback Biofeedback for the Treatment of Symptoms of TBI in Military

and Civilian Populations. Med. Acupuncture 2017, Aug 1; 29(4) 215-219

Simkin, DR, Thatcher RW, Lubar J. Quantitative EEG neurofeedback in children and adolescents: anxiety disorders,

depressive disorders, comorbid addiction and attention-deficit/hyperactivity disorders, and brain injuries. Child

Adolesc Psychiatry Clin N Am. 2014 July;23(3) 427-64

Some references

Neurofeedback

A Powerful Tool

Traumatic Brain Injury

HBOT & Neurofeedback

Tito

PRP• Platelet Rich Plasma

• Growth factor and cytokine rich, which can effect inflammation,

angiogenesis and stem cell migration and cell proliferation.

• Giving growth factors such as EGF, bFGF (found in PRP), can

enhance TBI-induced cell proliferation in injured adult animal (Dong Sun, Neural Regen Res. 2014 April1; 9(7) 688-682)

• PRP given intra-arterially helps attenuate brain injury after focal

ischemia (Zhang Y, et. al, Administration of human platelet-rich plasma reduces infarction volume and improves motor

function in adult rats with focal ischemic stoke. Brain Res. 2015 Jan 12;1594:267-73)

• Collagen VI helps protect against amyloidbeta proteins

associated with AD (Mucke et al. Collagen VI protects neurons against AB toxicity. Nat. Neurosci. 2009 Feb):

12(2) 119.)

Intranasal Insulin

• Intranasal Insulin shown to help with AD patients

• Post injury there is decrease in cerebral glucose intake,

creating a severe metabolic crisis. Length and severity

directly correlated to patient outcome.

• INI increases neuronal viability, M2 (anti-inflam) activation,

and functional recovery following TBI.

Frey et al. Intranasal insulin treatment of an experimental model of moderate traumatic brain injury. JCBFM. 2017 Vol 37(9) 3203-32)

Intranasal Insulin-PRP

• Patented Process

• Access CSF via cribriform plate or through paravascular

channels associated with the olfactory or trigeminal

systems.

Benefits:

✓ Regrowth of Brain Collagen

✓ Activation and Targeting of Stem Cells

✓ Increased Angiogenesis

✓ Decrease in Inflammation

✓ Reduction in Amyloid Proteins

Pub No. US 2016/0235786 A1, John C. Hughes

Stem Cells

Other Interventions• Homeopathic medicine

• Neutraceautical (including IV) and Botanical Medicine

• Detoxification - Diminished Brain Resilience Syndrome (Seneff, etc. al, J. Surgical Neurology 2014)

• Bio-identical hormones

• Osteopathic Cranial Sacral, Chiropractic

Other Interventions• Phototherapy

• Increase blood flow

• Improve mitochondrial function ATP

• Decrease inflammation

• New nerve growth• Rosso, et. Al. Photobiomodulation Therapy in Peripheral Nerve Regeneration. A Systematic Review. Bioengineering (Basel) 2018 Jun 9;5(2). Pil E44

• Hamblin, M. Shining light on the head: Photobiomodulation for brain disorders. BBA Clinical 6 (2016) 113-124

• Altitude Contrast Therapy

• Exercise with oxygen

• 100% O2 15% O2 (Aspen) 100% O2, etc.

• Vasodilation leading to opening of inflamed constricted blood vessels

• O2 floods in clearing of waste products and decrease inflammation,

healing.• Cipolla, Marilyn. Cerbral Circulation. Margan & Claypool Life Sciences 2009. Chap 5

• Stellingwerff, Trent. Altitude, hypoxic and hyperoxic Training: research evidence vs. practical applications. 53rd annual American College of

Sports Medicine Review. 2006.

• PEMF

• Pulsed magnetic therapies

• Reduction in inflammation and increase healing

• better blood flowSmith, Thomas L., et al. Microcirculatory effects of pulsed electromagnetic fields. J. Orthopedic Res. Jan 2005, 80-84

Gaynor J. Veterinary application of pulsed electromagenetic therapy. Res. In Vet. Science 119 (2018) 1-8.

Thank You!