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Cognition in the Concussed

Concussions are considered mild forms of a traumatic brain injury (TBI) that occur after some sort of trauma to the brain. The concept of the concussion alludes many clinicians, largely due to the highly variable nature of concussion symptoms, some of which are quite mild and lack clear objective biomarkers. The importance of timely and holistic treatment is imperative to reducing risk for future sequelae such as Alzheimer’s disease, frontotemporal dementia, and chronic traumatic encephalopathies.1 Further, it is reported that approximately 15% of people who experience a concussion, go on to experience symptoms months or even years after their injury, and some never fully recover.2 Thankfully, the tide is turning, with significant attention and research being directed to how we can better understand and treat concussions its clear we are on our way to greater understanding.

The symptoms of concussion fall into four distinct clusters: somatic, sleep, cognitive, and emotional.3 We will specifically focus on the cognitive impairments that arise from these mild to severe traumatic brain injuries, though it is important to note symptoms often overlap and exacerbate symptoms from other clusters. For example, difficulty sleeping has been shown to reduce our ability to concentrate and impairs memory recall.

That being said, the cognitive difficulties experienced post-concussion can have a profound impact on an individual’s quality of life. From deficits in verbal and visual memory, processing speed, impulse control, orientation, attention, and executive function. The degree and type of impairment are dependent on a number of factors including type and intensity of trauma or impact, time left untreated, and comorbidities such as history of anxiety and depression, and baseline education status. Further, a significant factor in severe cognitive symptoms for a concussion is the history of concussions. Repetitive trauma from sports or motor vehicle accidents (particularly before full recover of a previous injury) compounds the adverse effects.4

The mechanisms of damage proposed relate to the dynamic changes in the thalamus and white matter (WM), increasing inflammatory by-products and protein accumulation in the brain.1 After suffering any traumatic brain injury, an individual is particularly vulnerable and should take every precaution to not expose themselves to the same trauma. A concept that professional athletic organisations such as the NFL and CFL have had to confront over the last decade. Specifically, is putting individual players at risk, with the pressures of continuous performance and expediting the recovery process without complete healing, really worth it? Particularly with young athletes whose developing brains may be more adversely impacted by the accumulated traumas. Interestingly, researchers published an article earlier this year that described the complex cyclical nature of “impulsivity” and brain changes following sports related concussions.5 Not only did they observe a strong correlation between individuals who compete in high-risk high contact sports and impulsive dispositions, but the impulsivity was which contributes to specific neural and functional brain changes following such concussions.

Diagnosing cognitive changes from concussion

As mentioned earlier common concussion symptoms are quite variable and easily “missed on initial assessment. Some symptoms manifest much later after an individual has seemingly moved on with their lives, therefore never reporting symptoms to their doctors.  Further complicated by the fact that imaging technologies such as CT and MRI scans don’t really show much by way of concussion diagnosis. In 2006 an inventory of psychometric and clinical properties of concussion symptoms known as the “Post-concussion scale” was developed which has become a key diagnostic tool used in clinical settings.6 This scale is most often used alongside cognitive impairment questionnaires such as the mini mental state exam (MMSE) and the Glasgow outcome scale (GOS). Proper assessment should be triaged through evaluations with speech-language pathologist, neuropsychologist, GP, and neurologists.  

Cognitive Symptoms – Management Options

Upon appropriate and timely diagnosis, patients with chronic symptoms after concussion often face somewhat fragmented and inconsistent access to holistic care. The heterogeneous nature of the symptoms often necessitates multiple disparate treatments (e.g., medications for headache, physiotherapy for balance issues, psychotherapy for depression and cognitive rehabilitation for memory problems, etc.) A review of common therapeutic approaches for concussion depending on symptoms clusters was conducted as shown below.3

A growing number of private concussion clinics have arisen over the last decade to facilitate this multi-tiered approach to recovery. Evidence based interventions include meditation, psychological counselling, graded exercise, and pharmacotherapy. Specific cognitive rehabilitation therapies include a combination of pharmacotherapies such as amantadine for cognitive fatigue and memory function, and/or methylphenidate for processing speed and central fatigue. Pharmacotherapies are most effective when prescribed alongside occupational, speech, and behavioural therapies. While cognitive exercises, which compensate for impairments by using preserved cognitive abilities, are scheduled to be slowly introduced, its equally as important to reduce cognitive stress as much as possible. A “cocoon therapy” approach was presented by researchers which removes all unnecessary stimuli from a student to potentially hasten recovery when returning to school following a TBI.7

As we expand our scope of knowledge it appears that nutrition and lifestyle optimization are not to be overlooked. Yoga, modified for concussion, combines many of the currently accepted therapeutics (meditation, gradual return to exercise, balance retraining, and sleep regulation) into a single effective, engaging, and accessible option. While high fat diets such as the ketogenic diet offer promise as they are being tested in post concussive syndrome management trials.8

A consensus among researchers is that individuals with a higher “cognitive reserve” are less impacted and recover faster from mild TBI’s.  The “cognitive reserve” relates to the ability of an individual’s brain to recover or withstand neuropathological changes or insults. Researchers have identified a number of ways to increase this cognitive reserve through the primary source is early education which improved verbal and spatial development.

As we always say an ounce of prevention is worth a pound of cure- therefore an important management strategy for recovery from TBI’s is improving our cognitive reserves.  Here are 5 easy tips to implement right away:

  1. Learn a new language or skill
  2. Regular exercise
  3. Clean eating
  4. Wear protective gear especially if you are engaging in high contact sports
  5. Read regularly

References:

  1. Giza C, Greco T, Prins ML. Concussion: pathophysiology and clinical translation. Handb Clin Neurol. 2018;158:51-61. doi: 10.1016/B978-0-444-63954-7.00006-9. PMID: 30482375.
  2. Porter S, Torres IJ, Panenka W, Rajwani Z, Fawcett D, Hyder A, Virji-Babul N. Changes in brain-behavior relationships following a 3-month pilot cognitive intervention program for adults with traumatic brain injury. Heliyon. 2017 Aug 4;3(8):e00373. doi: 10.1016/j.heliyon.2017.e00373. PMID: 28795168; PMCID: PMC5545767.
  3. Bramley H, Hong J, Zacko C, Royer C, Silvis M. Mild Traumatic Brain Injury and Post-concussion Syndrome: Treatment and Related Sequela for Persistent Symptomatic Disease. Sports Med Arthrosc Rev. 2016 Sep;24(3):123-9. doi: 10.1097/JSA.0000000000000111. PMID: 27482778.
  4. McAllister T, McCrea M. Long-Term Cognitive and Neuropsychiatric Consequences of Repetitive Concussion and Head-Impact Exposure. J Athl Train. 2017 Mar;52(3):309-317. doi: 10.4085/1062-6050-52.1.14. PMID: 28387556; PMCID: PMC5384827.
  5. Sharbafshaaer M. Impacts of cognitive impairment for different levels and causes of traumatic brain injury, and education status in TBI patients. Dement Neuropsychol. 2018 Oct-Dec;12(4):415-420. doi: 10.1590/1980-57642018dn12-040012. PMID: 30546853; PMCID: PMC6289484.
  6. Lovell MR, Iverson GL, Collins MW, Podell K, Johnston KM, Pardini D, Pardini J, Norwig J, Maroon JC. Measurement of symptoms following sports-related concussion: reliability and normative data for the post-concussion scale. Appl Neuropsychol. 2006;13(3):166-74. doi: 10.1207/s15324826an1303_4. PMID: 17361669.
  7. Halstead, M. E. (2018). Chapter 20 – Return to learn. In B. Hainline & R. A. B. T.-H. of C. N. Stern (Eds.), Sports Neurology (Vol. 158, pp. 199–204). Elsevier. https://doi.org/https://doi.org/10.1016/B978-0-444-63954-7.00020-3
  8. Taylor MK, Sullivan DK, Mahnken JD, Burns JM, Swerdlow RH. Feasibility and efficacy data from a ketogenic diet intervention in Alzheimer’s disease. Alzheimers Dement (N Y). 2017 Dec 6;4:28-36. doi: 10.1016/j.trci.2017.11.002. PMID: 29955649; PMCID: PMC6021549.

 

Dr. Navnirat Nibber

About The Author

Dr. NavNirat Nibber, ND is a graduate of the Canadian College of Naturopathic Medicine and a registered Naturopathic Doctor. She is a Co-Owner at Crescent Health Clinic, as well as a Senior Medical Advisor at Advanced Orthomolecular Research.

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