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We will recommend a diet, and supplementation for patients if the diet is interfering with progress. NLF is tracking the latest brain-focused supplements with ingredients that have a high level of scientific efficacy. One recent study helped active and retired professional football players reverse their brain damage, following specific lifestyle changes including nutrition, exercise and supplementation.

As doctors, we keep a close eye on the latest science coming out regarding nutritional supplementation. As part of a healthy diet, supplementation can fill in nutritional gaps left from a depleted nutrient supply. Plus, we are finding exciting brain-focused nutrition, which has been successful in recent studies. For example, omega-3 fatty acids — particularly from krill oil — benefit the brain, heart and body.

Nutritional supplements, herbs, and nootropics have been utilized for many years and are increasingly popular among the patient populations. There remains little clinical research on many of these agents, perhaps reflecting a lack of funding more than a lack of efficacy.

Acetyl-L-Carnitine is an ester of L-carnitine and is thought to protect brain cells after injury when glucose metabolic pathways are compromised. During this period, acetyl-L-carnitine supports alternative ketogenic pathways for metabolism (Prins and Matsumoto 2014). It is also believed to enhance cholinergic function. While there are several clinical studies in patients with Alzheimer’s disease and preclinical data in animal models of TBI, the clinical literature on TBI remains sparse.

Ginkgo biloba is a natural product of the tree by the same name. It has been shown to improve membrane fluidity and increase resistance to free-radical damage. It provides some subtle benefit to cognitive function in clinical studies of stroke, dementia, aging and hypoxia damage (Diamond 2000).It has not been systematically studied in TBI, but is used extensively in clinic, often in combination with meclofenoxate which is an avid scavenger of free-radicals (al-Zuhair et al 1998).

S-adenosylmethionine (SAMe) is a nutritional supplement which improves cell membrane fluidity and promotes the production of glutathione, an antioxidant. The benefit of SAMe has been assessed in a single clinical study of TBI (bacci-Ballerini). Patients receiving SAMe had a 77% improvement in clinical scores of postconcussive symptoms. Citicholine provides a source of choline which can cross the blood-brain barrier. It has been used extensively in Europe and Japan as a treatment for TBI, stroke, and dementia. However, two large U.S. studies failed to demonstrate significant benefit (Baskaya et al 2000; Zafonte et al. 2012).

Piracetam and the related oxiracetam and phenylpiracetam have shown some promise as nootropic agents. In one double-blind, placebo-controlled study, piracetam improved several symptoms of post-concussive syndrome, including headache and vertigo (Hakkarainen et al 1978)  More recent clinical studies have shown marginal benefit (Malykh et al 2010).

Huperzine-A, an extract of Japanese club moss, is a natural acetylcholinesterase inhibitor. It may serve as a natural alternative to donepezil, rivastigmine or galantamine. Galantamine warrants special mention as it appears to also modulate nicotinic receptors and appears to have more persistent benefit in the treatment of Alzheimer’s disease. It appears to modulate neuroimmune responses, in addition to its effects on acetylcholinesterase (Furukawa et al 2014).

Cerebrolysin is a polypeptide that purportedly mimics the actions of neurotrophic factors (Masliah et al 2012: Zhang et al 2013). Studies have shown it can reduce beta amyloid and phosphorylated tau protein accumulation. It may promote neurogenesis, synapse formation, and functional recovery (Masliah et al 2012). In animals models of acute TBI, cerebrolysin-treated rats had more surviving neurons in the area of impact and showed greater functional recovery (Zhang et al 2013). In a clinical trial of acute TBI, patients were recruited within 24 hours of injury and treated for three months with daily intravenous infusion of cerebrolysin. At three months, those receiving cerebrolysin performed significantly better on the Cognitive Abilities Screening Instrument (Chen et al 2013). It remains unclear if cerebrolysin provides long-term nootropic benefit.

Anti-oxidants — The elevation of free radicals in TBI suggests that anti-oxidants should be beneficial. Clinical trials of pharmacological anti-oxidants over the past 30 years have not yielded a useful agent in acute TBI (Marshall). Agents, such as tirilazad and polyethylene glycol-conjugated superoxide dismutase (Hall), have failed to show benefit in acute TBI.

Omega-3 fatty acids & Vit. D may enhance brain repair and recovery, based on animal and clinical studies (Hasadri 2013). Similarly, vitamin D may offer neuroprotective and restorative benefits (Aminansour 2012) in the acute TBI setting. I chronic TBI, vitamin D and omega-3 fatty acids may work synergistically, as they both may reduce neuroinflammation, apoptosis, and oxidative stress.  (Scrimgeour)  

Combination — A six month trial of ginkgo, vinpocetine, acetyl-L-carnitine, huperzine, alpha-lipoic acid, n-acetyl-cysteine, mutli-vitamins, and over 5 gms of omega-3 fatty acids daily yielded improved performance on cognitive testing and increased perfusion (function) on Single-Photon Emission Computed Tomography (SPECT) scan. (Amen) Long term use of Dietary Flavanols may improve cognition in mild TBI.  Other free radical-scavengers to consider include (Turmeric, Curcumin), Phosphatidyserine, Coenzyme Q-10B-complex, Choline and Inositiol, B-complex, L-Theanine, and Dietary Flavanols.

Exercise — High energy activities, and exercise programs completed through a health club facility or comprehensive rehabilitation program should focus on the same parameters of an age-adjusted and diagnosis-specific program for aerobic conditioning – flexibility, stabilization and strength. It appears safe and accepted intervention for TBI, there is a need for further well-designed studies. Exercise was a part of a six-month study of lifestyle changes described above which yielded improved function based on cognitive testing and perfusion SPECT scans. A program needs to include the following aspects: Proprioception-the body’s ability to react to changes in external forces, and stability; Coordination training to restore kinesthetic awareness, and forms the basis for agility and strength. It is a well known fact that high energy exercises increase blood flood to the organs of the body and most importantly to the brain.

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