The Clinical Coach: Nutritional Management for Persistent Post-Concussion Syndrome in Non-Athletes

Happy Friday !

Welcome to another Clinical issue of The Performance Doctor!

, in this issue we are talking nutrition based recommendation for persistent post concussion syndrome.

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Let’s get to it.

First of all…

This is not a ONE SIZE fits all solution.

The solutions and recommendations that I will be sharing in this nutrition guide are based on current evidence. However, I find it necessary to mention:

Recommended dosages and servings need to be adjusted per individual as they may respond to different dosages and servings.

I will share with you the dosage that I start patients with, but I will not share specific dosages as a FIX.

This approach is a very individual approach and if you do not feel confident/comfortable managing nutritional based approaches I am happy to help you co-manage your patients. Simply send me a message and we can chat.

If you missed Part 1, click here. 

Current evidence in neurobiological recovery post concussion?

Persistent post-concussion syndrome (Post Concussion Syndrome) presents with a variety of physical factors that may be directly linked or indirectly linked to physical or metabolic changes.

As of today, the underlying aspect of persistent post-concussion syndrome is based on metabolic injuries within the system. Most patients with P/PCS are currently managed through a combination of prescription medication to treat symptoms of PCS.

The reality is PCS is a combination of physical, psychiatric, and metabolic changes following brain trauma. While some patients may benefit only from physical treatments, others may require a much more in-depth approach.

To this day, there is no definitive blood test that provides us with accurate information on the recovery of concussions — however, this new research shows promise in tracking a few biomarkers to track neurobiological recovery.

In the same light nutrition protocols are not set in stone and while they show promise in the research, patients may respond differently to each intervention.

Regardless of what supplements your patient’s favor, there needs to be a foundation in order to provide the brain with the nutrients it needs.

The brain uses 20% of calories consumed, and requires over 40 nutrients for metabolic processes. When injured, just like any other tissue, it requires additional calories and nutrients to heal.

What do we aim for first?

The first thing we need to look into is the patients current diet.

• What are they eating?

• How often are they eating?

• How many calories are they consuming?

• How much protein are they consuming?

• How much processed sugar/sweetener are they consuming?

• How much coffee/alcohol are they consuming every day/weeek?

• What supplements/medication are they currently on and how often?

We want to understand what our patient’s lifestyle is. While some changes are easy to make, it may be financially difficult to opt out from consuming certain categories. This will not derail the progress, it will however slow it down to a degree.

These are expectations you need to share with your patients in order to increase your patients follow through.

Food Guidelines.

1. Calorie Intake. 80% of patients suffering from PCS are undereating. Not because they are on a diet. Mostly because the symptoms stop them from eating. The first thing you need to do is make sure they are eating enough calories to maintain healthy levels of cellular energy and repair.

2. Macronutrient management. There is strong evidence that following the Mediterranean diet, or a ketogenic diet improves recovery in patients with a TBI (traumatic brain injury). This means that your patient must consume adequate amounts of protein and fats in order to improve their recovery.

3. Protein. We aim to get our patients to at least .8g of protein per body weight. This is one area where majority of people are under consuming regularly. If they are already consuming .8g per body weight we increase it to 1g.

4. Fats. We aim to get about 40-45% of our calories from healthy fats. Avocados, fish, meat, etc. Here’s were it starts to get tricky, not every fat is a good fat.

5. Carbs. We highly recommend restricting over processed carbohydrates and we aim to push fruits and vegetables. However, we understand some people may not be good cooks, may not want to cook, or simply just don’t want to stop the over processed carbohydrate. Here’s where we keep track of how much sugar they are consuming. We’ve had some difficult conversations with our patients on which items not to buy at the store anymore. Most do what needs to be done so they get better, but every once in a while you’ll get a person who likes to DIY some of their recommendations.

Once calorie and macros are in check, it’s making sure they have a fair amount of micronutrients. Here’s where we recommend a general multi-vitamin. We use thorn for a large selection of our supplements and they have been great. Tho some of the shipping times are quite outrageous. You may use any supplier you like. If you have one you highly like, let me know.

Now it’s a good time to talk about coffee and alcohol.

Yes. You already know I am a coffee aficionado. Nothing beats a medium roast espresso shot before a hard training session. Not even preworkout.

While coffee is a great mental booster, it’s the caffeine that we are most concerned about. The patient is already in a fatigue and most likely depleted state. Boosting their energy with caffeine will only send them crashing later in the day. If your patient won’t give up coffee for a couple of weeks. Try switching them to a non-caffeinated coffee. Same taste, just less energy. It might be just the energy they need to not crash throughout the day. Keep the coffee to 1-2 cups per day and no coffee after 12pm.

We definitely say no to alcohol. Period, full stop. Alcohol is just not beneficial to the recovery of the system period. Not even in the social scene. I don’t think I need to tell you why…

This is an important conversation as many patients seek out alcohol to “make themselves fall asleep.” Not a healthy option.

Now that we have our foundation, let’s talk about supplements.

It does not matter if your patient takes all of their supplements if they are not eating enough calories because they are nauseous, over consuming alcohol to manage their migraines, or not sleeping well because they are consuming caffeine into the later hours of the evening.

What Supplements are a must?

There is currently strong evidence in support of DHA, Omega 3FA, Creatine, Melatonin, Sodium, and Magnesium.

Evidence suggests that creatine monohydrate and omega-3 fatty acids (DHA and EPA) help decrease inflammation, reduce neural damage and maintain adequate energy supply to the brain following injury. We highly recommend 10g of creatine per day with a the Advance DHA supplement from Thorne as recommended in the bottle.

Similarly, melatonin supplementation may improve some of the sleep disturbances. Keep in mind that in some patients melatonin may not be effective. We’ve seen patients who, even on the lowest dose of melatonin experience some negative side effects like nightmares and drowsiness post-wake.

Magnesium Citrate is the one we recommend our patients as it’s the most common available at stores. For better absorption we recommend Magnesium Glycinate, but there’s not a lot of subjective evidence that one is better than the other.

Sodium is one of the newest supplements that we have started promoting to our patients. Not because we like LMNT that much, but because we’ve come across enough research and subjective data that majority of our patients are under consuming salt, and are overhydrating. This can lead to intracellular deficiencies and therefore dysfunctional communication between cells. We don’t typically recommend a lot of sodium supplements, we simply ask our patients to salt their food more than they would normally do - if they are cooking. If they aren’t cooking, we recommend a hydration supplement that contains salt. This is where we recommend LMNT. No, we are not an affiliate for them, we simply like the formula and the effects it has provided to the rest of our patients.

Most patients already underconsume sodium. We typically recommend they ingest anywhere between 1 - 2 grams of sodium per day, while maintaining their level of hydration. This is were the LMNT’s come in. Considering they have 1g of sodium if they consume one pack, plus the salt that is available in their food, they’ll be at or slightly above the 2 grams a day mark.

What supplements show promise?

Probiotics have shown great promise in helping patients recover from TBI’s. My only concern when it comes to probiotics is whether or not the current bacteria in the patient’s gut will support the new probiotics or will reject them.

We don’t currently do any stool testing, which would be the best way to figure out whether or not your patient would benefit from probiotics. Personally, I think it’s something we’ll start doing in the future, but at the moment we simply don’t.

If you are thinking about diving into pre/pro-biotics, make sure you test for them.

One of my biggest pet peeves is when doctors recommend supplements or prescription treatments without baseline measurements.

How often should you update your patients nutrition?

Unlike physical treatments, nutrition takes more time to have an effect on the system, and from what we have seen it has taken anywhere from 21 to 45 days for patients to see any difference in how they feel.

Granted, we believe that majority of patients whose symptoms persist into day 45 is most likely because they are not eating or supplementing as recommended. We don’t have hard data on this, but majority of our patients not they follow our recommendations 80% of the time.

When to update calories?

We track morning weight three times a week. We simply ask our patients to weight themselves after going to pee and submit it via our app.

We do not aim to lose or gain weight. We simply want to maintain their body weight were they are at. If patients are gaining weight week after week, we may reduce the calories based on their symptoms. If they are losing weight, we may maintain or increase their calories based on their symptoms as well.

The goal is to maintain a sustainable calorie intake that continues to improve symptoms.

When to increase or decrease supplementation?

Currently we have a loading protocol for creatine. Since we recommend powdered creatine, some patients have some trouble with how gritty the powder can be. Once we reach our goal, 10-15g of creatine we will stay here for 3-6 weeks. New research suggest that 20g of creatine has shown to improve brain health. We have yet to try it.

For the rest of the supplements, we tend to follow the advice on the bottle for most of them, specially magnesium as it can cause patients to go to the bathroom too often.

The dosage is where every person will respond differently. Typically we start at the recommended doze on the label for 21 days and increase as needed up to 45 days.

As of today the highest Creatine monohydrate recommendation we’ve given has been 12g with successful improvement in symptoms, while everything else has been 1.5x of what is recommended in the bottle.

Keep in mind that none of our patients have had kidney or GI complaints to begin with. We definitley monitor any GI symptoms and adjust accordingly. If we increase consumption of creatine and our patients complain of GI issues, we’ll go back to the prior recommendation.

We never increase all of the supplements at the same time for this reason. If we change something, we want to make sure we know which one is most likely the cause. You can’t be certain that creatine caused the bloating when DHA, EPA, Magnesium, Sodium and Melatonin were all increased at the same time.

Every patient responds differently to care.

When we are developing a treatment plan we think about what is the minimum effective dose that will stimulate a positive adaptation to your patient. In the case of patients with PCS or a TBI, this number tends to be relatively higher than in normal “healthy” patients.

Keep good records and make sure to note regressions and fast progressions as you see them.

TL;DR: The management of persistent post-concussion syndrome is unique to every individual. There has been a link between nutrition and supplementation in the recovery from TBI’s and PCS. While the link continues to be studies, several connections including proper nutrition focusing on protein and fats, as well as supplementing with Omega 3FA, Creatine, and Magnesium have shown improved recovery.

If you have further questions on post-concussion care, send me an e-mail.

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Until our next issue!

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