Traumatic Brain Injury
Dr Hart was the first doctor in Australia to be trained and registered with Dr Mark Gordon's Millennium - Traumatic Brain Injury Network.
Dr Hart has advanced diagnostic and treatment skills in identifying the underlying damage and remediating the physiology of traumatic brain injury. Pharmaceutical drugs provide poor symptom control, and usually cause more symptoms (requiring more drugs) than they treat in traumatic brain injury.
Traumatic brain injuries cause neuro-inflammation, damaging our nerve cells and contributing to our brain fog and fatigue, and pushing us towards brain failure - dementia.
First, we need to understand inflammation, before understanding neuro-inflammation.
Inflammation is the process run by our immune system, that has developed over 2 million years, to deal with the commonest causes of disease and death - infection and trauma. Whenever we have localised infection or trauma, chemicals called chemokines and cytokines, are released that cause the blood vessels in the area to dilate so that more blood is brought to the area. This causes the redness and heat that one perceives. The blood vessels increase their permeability, allowing immune cells that are attracted to the area, to leave the blood and enter the infected or damaged tissue. At the same time, fluid leaks from the blood vessels, leading to local swelling or edema. Cells attracted to the area, such as macrophages, then phagocytose the invading organisms and the damaged tissue, and other cells attracted to the area, such as fibroblasts, repair the damage. Once the invading organism is destroyed and the damaged tissue is repaired, then the inflammatory process resolves, the redness, heat and swelling disappears, and tissue function is regained.
So an acute, localised inflammatory response is a great way to protect the body from the common causes of disability and death. It stops the infection from spreading and killing us, and repairs tissue so that we can use it again.
However if the underlying triggers can not be removed, then the inflammatory reaction persists, becomes chronic, and causes further local tissue dysfunction and damage.
The brain, is an organ of the body. It has numerous responsibilities, including mood control, memory and attention, cognition, sleep and libido control and body function management. Inflammation within the brain, known as neuro-inflammation, reduces brain cell function, leading to a decrease in the brain’s abilities ie poor mood control leading to anxiety, irritability, anger, depression, reduced focus and recall, poor decision-making, decreased sleep quantity and quality, low libido and reduced body control and health.
Next, I’ll discuss the mechanisms of traumatic brain injury, and how the functional medicine approach can identify the root causes of neuro-inflammation and remediate them, providing an environment for brain repair.
The prevention of physical trauma to your brain is much more effective than cure. However, once trauma has occurred, optimising the conditions for brain repair and reducing the neuro-inflammation, enables the optimum return and maintenance of brain function.
Brain trauma can occur without a penetrating injury. Blows to the body and head can transmit compressive, tractional and torsional forces into the brain and cause damage i.e. direct blows (soccer ball, boxing, MMA, assaults), falls (learning to walk, bikes, ice skating, snow skiing/boarding, wrestling, contact sports), collisions (contact sports, motor vehicle accidents), concussive forces from nearby explosions (ie gun, cannon, grenade, fireworks, IED, jet/helicopter engines), and theme park rides (roller-coasters, dodgem cars).
The primary physical injury occurs at the time of the event, causes cell death, and is regarded as permanent. However, secondary injury caused by persisting chemical neuro-inflammation, can lead to ongoing brain damage and decline that can lead to brain failure - where the brain can no longer interact adequately with the environment and manage the person’s life independently, a state called ‘dementia’.
When nerves are stretched 5%, the cell membrane is broken, and cell contents can leak out. This will usually repair. If nerves are stretched 10%, the cytoskeleton within the nerve is damaged, leading to permanent cell dysfunction. If the nerve is stretched 20%, the cell is torn and often dies, releasing more cell contents into the fluid between the brain cells.
Energy waves from explosions (which travel faster than sound) cause tiny bubbles, or ‘micro-cavitations' to form, pop, and disappear so quickly that they can’t be detected by brain-imaging conducted after the event — but they can cause tissue damage and trigger the inflammatory response in the brain.
The brain has the consistency of toothpaste, and is housed within a rigid bony skull. The lower surface of the skull cavity, upon which the brain sits, has many sharp ridges. The small pituitary gland sits in a bony cup underneath the brain, and is connected by a narrow stalk to the hypothalamus. The hypothalamus instructs the pituitary when and how much hormone to release. These messages are relayed by nerves and blood vessels that travel from the hypothalamus to the pituitary gland via the pituitary stalk. When the skull moves rapidly, the soft brain is stretched and compressed and dragged over these basal ridges, the pituitary stalk is stretched and nerves and blood vessels can be torn, and different regions within the brain are variously stretched and compressed.
Nerve cell contents, and blood from torn blood vessels are released into the brain, triggering reactive neuro-inflammation from the brain’s immune cells, the microglia and the supportive astrocytes. This inflammation damages the blood brain barrier allowing further pro-inflammatory cells and toxins into the brain, and potentiating ongoing inflammation and tissue damage.
Over time, continuing neuro-inflammation causes accumulating cell dysfunction and death, leading to the experience of many different symptoms of brain dysfunction :
Inability to concentrate and communicate
Loss of libido
The deep inner brain structures control consciousness. You can significantly damage the outer cortical processing region without affecting the deeper regions i.e. you can receive significant, permanent brain injury without a loss of consciousness. So traumatic brain injury may cause minor immediate symptoms, with medical imaging of the physical structures via a CT or MRI showing no abnormality, but over the following weeks and months the person will gradually start to show more signs of brain dysfunction as the neuro-inflammation accumulates. These signs include :
Hypertension, heart attack, stroke
Increased blood glucose
Loss of muscle and bone mass and strength
Poor skin quality
Increased body fat
This means that the brain cells are not working correctly and some may be dying. This may be detectable by advanced imaging modalities such as MRI scan, PET scan, SPECT scan or quantifiable EEG. The end result of multiple small injuries or one large insult is the ‘walkie-talkie’ – a brain-injured person who can walk and talk but whose brain function is permanently impaired and may be undergoing an accelerated decline and premature ageing.
Studies demonstrate that hypopituitarism - where the pituitary gland fails to produce normal hormone levels - is relatively common following traumatic brain injury. Deficiencies in Growth Hormone, Testosterone, Estradiol, Progesterone, DHEA, Pregnenolone, Thyroid hormones and Cortisol, singularly or in combination, are responsible for many of the psychological and physical symptoms of TBI.
These hormones are made in the brain for the brain (neuro-steroids) and in the body for the brain (neuro-active steroids).The primary injury, and the secondary neuro-inflammation interfere with hormone production, brain and body function, and inhibit tissue repair. This state is variously referred to as post-concussion syndrome, PTSD or post-traumatic brain injury. A meta-analysis found that 48-80% of post-TBI subjects had hormone deficiency.
We can’t measure neuro-steroid levels in the living brain, but we can measure the neuro-active steroid levels in the peripheral blood, and supplement them with bio-identical hormones.
While severe TBI, associated with loss of consciousness and coma, often causes impairment of cognition, mood, learning and physical functioning, even mild TBI can cause symptoms, especially if recurrent. US military neurologists estimate that up to 30% of troops on active duty more than four months are at risk of neurological damage.
One study showed 56% of TBI patients had anterior pituitary gland hormone deficiency at 3 months, and 36% at 12 months. The common declines were in Growth Hormone and Testosterone. Other declines were in the thyroid axis and ACTH-cortisol axis, and occasionally in ADH (vasopressin) leading to diabetes insipidus. Common associated psychiatric disorders are depression, alcohol abuse / dependence, panic disorder, specific phobias and psychotic disorder.
In addition, to locally generated neuro-inflammation causing reduced brain function, systemic inflammation can also cause increased blood brain barrier permeability, decreased nutrient and trophic hormone support to the brain, and increased toxin and allergen supply to the brain.
A healthy body needs a healthy brain, and a healthy brain requires a healthy body.
Systemic neurotropic factors include vitamins, minerals, phytonutrients, trophic hormones like pregnenolone, DHEAS, testosterone, estradiol, progesterone, growth hormone, IGF-1, insulin, vitamin D, BDNF, NGF. These are influenced by lifestyle factors such as a nutrient-dense diet, regular movement and exercise, sleep quality and quantity, physical and psychological stress, sun exposure, earthing and light management.
Systemic neurotoxic factors include excess cortisol and insulin, sympathetic dominance, heavy metals, myco-toxins, man-made electro-magnetic radiation, inflammatory cytokines and chronic infections (ie dental, sinus, gut, respiratory, urinary tract).
Think of your brain before doing activities that put it at risk. Children must wear protective headgear while playing sports that involve any element of physical contact including football and hockey. It is essential to minimise or disallow them to head soccer balls, with the encouragement geared towards non-contact sports. It is also imperative to ensure seat-belts are worn in cars, that age-appropriate restraints are used when transporting children in a vehicle and that helmets are always worn when riding a bike. Other key ways to minimise physical trauma to the brain and body include not riding motorcycles, obeying road rules including staying aware of traffic around you, and using a ladder to reach something high instead of hastily grabbing a chair or standing on a countertop. Just as important is ensuring infants are protected from physical trauma, so never shake a baby or toddler, always fasten the safety belt on a high chair and a changing table, and use a safety gate to protect toddlers from falling down stairs.
Clinical tips for TBI:
- the intensity of brain trauma does not predict the degree of neurological dysfunction. Subtle injuries, especially if recurrent, can cause TBI.
- perform baseline hormones immediately after the injury - IGF-1, FSH, LH, pregnenolone, DHEAS, testosterone, estradiol, TSH, FT3, FT4, ACTH, cortisol, prolactin
- trauma that occurred decades ago can be more significant than recent events
- early systemic inflammation control and hormone supplementation can minimise psychological and physical sequelae
- hormone assessments can be done three monthly
- past TBI can be identified structurally by deficits in MRI DTI and SWI, SPECT and FDG PET scanning, often in the frontal and temporal regions.
Effective prevention and treatment of traumatic neurodegenerative disease requires a personalised approach based on the principles of functional medicine.
By increasing neurotrophic factors that are absent, and reducing neurotoxic factors that are present, the traumatic brain injured person can be returned to optimal functioning.
Using the multi-factorial, system’s biology functional medicine approach, you can add years to your life, and life to your years.
THE HART CLINIC