What kind of treatment is it rational to try out when you have a concussion?
I am currently suffering from the effects of a football hitting my head very hard from the side. I think it clearly produced a concussion since I’m still fatigued and off work. Below are some thoughts I wrote down when I previously had concussion after a bike accident. They were in response to a well-meaning attempt to give me advice, but which I didn’t find helpful. After this accident, I was off work for nine months and it took more than three years to fully recover. Clearly I’m hoping this won’t be the case this time.
Anyway, since I’m in this predicament – here are my conclusions on treatment from four years ago. The “you” is the acquaintance who gave me advice.
The whole area of medical treatment is obviously very complex. How do weassess which approach is more valid and productive than another? Youseem to agree that solid, supporting scientific evidence is crucial inhelping us determine that. While access to data has obviously beenenormously facilitated by the web, there’s an enormous amount ofinformation on the internet that isn’t reliable.How do we decidebetween the various sources? No simple answer, but informing ourselvesthrough reading clearly helps – a willingness to look at multiplesources. We also have to use judgement. Is the particular therapy beingpromoted by someone with sufficient scientific experience and knowledge?And if they have valid medical qualifications, are they being overlyinfluenced by commercial incentives – whether it be a largepharmaceutical company, or an alternative medicine store looking forcustomers? There aren’t always absolute distinctions – but I think ithas to be a balance of knowledge and judgement, with the principle thatreliable scientific evidence is the key.The gold standard is thesystematic review, carried out by disinterested, knowledgeable medicalexperts – who can sift those studies that are properly controlled,replicated and sufficiently large and robust to be taken into account –which can then make an assessment of the preponderance of evidence –since single, small studies – even if well conducted – are not alwayssufficient to base strong conclusions on.Fortunately there has been some good work in this area – notably thecreation of the Cochrane Collaboration – an international network ofpublicly funded health experts committed to evidence-based systematicreviews of current health treatments. It’s hard for them to covereverything of course – but it’s a very good initiative. https://www.cochrane.org/There are somearguments about its approach – from some who argue that it’s maybe eventoo narrowly evidence based. There are schools of thought that say thatit’s rational to also include scientific plausibility in an assessment –ie for a treatment to be considered thoroughly it should first have someplausibility and not contradict all previous scientific knowledge (thereare exceptions to this of course – but the old adage applies –extraordinary claims require extraordinary evidence.) One group arguingthis is the Science Based Medicine blog – from which I quote one extractfrom below.At this point, I do want to give more information though, about my ownhistory with concussion treatment. Over the past ten months or so I’vebeen seeing two specialists from the NYU medical center’s concussionunit. This at the recommendation of our PT, Maria Gerlich (excellent)who has considerable experience of working with Iraq vets with TBI. Shespecifically recommended that I get in with Dr Steven Flanagan, who shebasically regards at the top expert in the field in this locality – heis the head of the centre, a teaching professor and an internationallyrecognized expert in concussion management. I also saw Dr DonnaLangenbahn, a neuro-psychologist with 30 years of experience workingwith people recovering from brain injury. She also lectures round theworld on this subject.Two points. This doesn’t make these specialists infallible – of coursenot. But as a rule of thumb I feel it does make sense – ie it’s arational choice – for me to give more weight to their opinions andadvice, than to other people who are not medically trained specialistsin concussion, and who don’t have decades of experience in thatspeciality.The second point, from what I’ve seen and experienced with these highlyskilled professionals, is that I have no reason to conclude that theyare not open to considering “alternative” therapies. In fact I did dosome cranio-sacral therapy with Maria, who mixes conventional andalternative stuff. (I saw no harm in it – it was pleasant, butanecdotally I didn’t notice any difference after it – and my understanding is that it doesn’t have a credible scientific basis.)I then discussedthis and other alternative therapies with Donna, who was generallyrelaxed about it, and was always pointing me to all sorts of studies –so it’s certainly not the case that I have had treatment with people whodo not consider alternative treatments. These are people who’ve done agreat deal of research – and I have no evidence to suppose that theyhave ignored non-mainstream approaches.One of the issues is how you define “alternative” of course, since it’sa slippery, relative concept. If it means “approaches for which there isno scientific evidence” – yes, I’m firmly opposed, I’m biased against.If it means, on the other hand, scientifically plausible hypotheses orapproaches for which there might be some experimental evidence, but thatneed to be explored further – I’m open to that. As we agree, thescientific process amasses evidence and assesses probabilities – itdoesn’t decide anything absolutely, but it is cautious when claims aremade without evidence, and, crucially, it responds and adapts whenevidence shows that previously used approaches are ineffective.Anyhow, on those lines, during the treatment I read up about somecurrent research. One example was Buffalo University – where, theorisingthat blood flow, carrying in glucose, is restricted in the brainfollowing TBI, they felt that carefully graded running exercise may helpboost blood flow and accelerate recovery (by of course increasing bloodflow in the brain). Since I’m a runner anyway, and since I felt thatmoderate running could do no harm, I decided to up the amount of times Iran during the middle months of my treatment. The experimenters were atpains to say that their preliminary results needed to be backed up withmore data – it’s an essentially unproven hypothesis at this moment. Soin those terms, I think you could plausibly call this an “alternative”approach – which I tried with the approval of the specialists.Back to some of the larger issues I’ve reflected on since ourdiscussion. Do I pay more attention to modern medical approaches ratherthan alternative approaches overall? Yes, I do – for the followingreasons. For all its faults, our modern medical system obligatesextensive trials and an evidence-based approach before new treatmentsand approaches are approved (yes, the system isn’t perfect and there areabuses – and the regulatory system could and should be stronger). But Iwould surmise that, in the case of the majority of the alternativetherapies presented online, there isn’t an equivalent, extensive demandor indeed official requirement for the kind of rigorous testing andtrials that conventional modern medicine is submitted to. (I believethat unproven therapies usually have only to indicate that they are notFDA approved – but I’m not sure about all the regulations here.) I thinkyou would agree that a great many of these alternative therapies are notsupported by well-controlled scientific studies. So from that startingpoint, I think it’s absolutely reasonable to look first at therapieswhere there is a considerably greater likelihood that the claims arebacked with scientific studies.Does it mean that one should therefore ignore alternative therapies? Ofcourse not, but given that we have limited time on this earth, I use arule of thumb which prioritises scientific evidence – yes, I pleadguilty to that bias. Of course, not everything has – or can be tested –and some of those alternative therapies will no doubt be proveneffective at some point – but does that warrant that I should try anuntested and unproven hypothesis as opposed to an approach that has beentested – I think not – outside of extreme situations maybe, where forexample someone is at risk of dying and there are no proven therapies atall.Why does all this matter? Many unsound and unproven therapies are fairlyharmless – and rely on the placebo effect. I don’t think there’s a hugeproblem with someone taking treatment for a minor ailment and, throughthe placebo effect, feeling better. I do however think there’s a seriousproblem when someone has a dangerous, severe or life-threateningcondition and is encouraged to take a totally-non proven approach – whenthere are relatively effective treatments available in modern medicine –thus putting themselves at much greater risk. This definitely happens,alas fairly frequently.But there’s also a larger point. The scientific process is arguably (inmy view) the human race’s greatest achievement – it’s transformed ourlives, especially in the area of healthcare over the last few centuries.If people are encouraged to ignore scientific evidence in theirdecision-making (and especially in public policy) that’s a deficit forthe whole of society. Think of climate change for example – where thereare very large numbers of people who refuse to accept overwhelmingevidence – and this resistance and lack of command of the basic facts isexploited cynically by commercial interests. In this case, resistance toscience could literally have disastrous consequences for the wholeworld.There’s also a lesser but significant evil – for example, a substantialproportion of the $50 billion food supplement industry unscrupulouslyexploits gullibility to screw large amounts of money out of people –often desperate people with serious health problems. That’s a disgrace –if anything should be regulated more thoroughly, it’s that industry.What about some of the specifics of our discussion? Well, your firstsuggestion was that I take vitamins. In the context explained above, Ididn’t take very kindly to that – though I know you had kindlyintentions. I’ve done more looking through the data on this – yes, thereis research going on – some of it into vitamin treatment for concussion,and some of it might eventually lead to new insights – for example Ifound one study that showed possibly promising results with mice andVitamin E – but it’s mice, not humans of course and only a single study.However, the majority of the scientific surveys I’ve looked at concludethat no dietary supplements have so far been proven efficacious forconcussion treatment. In fact, it’s got to the stage where the FDArecently issued a warning against outlets who have been proposingvitamin supplement treatments for concussion – saying it’s unfounded anddangerous. I include several references and extracts just below to this.(As an aside, I’ve often heard criticisms from alternative sources thatmodern medicine ignores dietary and lifestyle issues – that’s a majorstraw man in my opinion – conventional medicine has, for centuries now,focused on sanitation, good housing, safe water and diet – we areinundated with conventional research and information on those issues.(Michael Bloomberg, for example, launched major lifestyle healthcampaigns in New York City against smoking and large soda drinks.) Andyes, my treatment with the specialists involved extensive discussion oflife-style management, diet, as well as the psychological aspects ofrecovery)References to vitamins and concussion: – extracts followed by urls:1) Since the 1980s, numerous studies have attempted to identifyneuroprotective agents. Because of the complexity of the biochemical andcellular cascades that follow TBI, there are many potential therapeutictargets that may help support individuals who have suffered TBI. Theseefforts have included magnesium administration, hormone supplementation,calcium channel blockade, bradykinin inhibition, use ofanti-inflammatory drugs, blockade of immune receptors, as well as use ofnumerous other vitamins, minerals, and antioxidant agents. These agentsoften work by multiple mechanisms that may include limiting glutamateexcitotoxicity, limiting of free radical and lipid peroxidation damage,or minimizing BBB disruption. Unfortunately, none of these completedtrials have demonstrated significant clinical benefit in humans.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307233/ (quote from above)2)http://newyork.cbslocal.com/2014/01/14/experts-no-evidence-that-dietary-supplements-can-treat-concussions/But the FDA on Tuesday issued a warning to consumers, saying thesupplements are untested, unproven, and possibly dangerous. “We don’thave any evidence that there is any medication, vitamin, or herb thathelps people to recover after head trauma,” said Dr. Andrew Russman ofthe Cleveland Clinic. (quote from above)3)as the marketing claims here are, the science doesn’t support the use ofany dietary supplements for the prevention of concussions or thereduction of post-concussion symptoms that would enable one to return toplaying a sport faster,” says Daniel Fabricant, Ph.D., director of FDA’sDivision of Dietary Supplement Programs. (quote from above)4)http://www.businessweek.com/articles/2014-01-03/fda-warns-against-concussion-curing-claims-on-supplementsContinued discussion: On vitamins generally – it’s interesting – as youprobably know, there have been several very large and robust studies ontaking multi-vitamin supplements which have concluded there is nooverall health benefit (and in the special case of taking anti-oxidants(beta-carotene, vitamin E See also:Goldacre, Ben (2010-10-12). Bad Science: Quacks, Hacks, and Big PharmaFlacks (Kindle Location 1486). Faber & Faber. Kindle Edition.) assupplements for preventing cancer, large studies have concluded thatthese supplements actually increase the risk of death and morbidity) – –I’ll include a link below.Just reflecting further on the meaning of the world “alternative” Ithink I could reasonably argue that in this case it’s an “alternative”position to argue against multivitamin supplements – since theconventional wisdom – especially in the US – is that they are good foryou, despite the now robust evidence against them.I’ll restrict myself (since this is getting very long here) to onearticle that summarises and refers to the above studies:Finally out of interest I did some reading on the megavitamins forschizophrenia thing. This was far from an exhaustive search and this isnot an area I claim to have any prior knowledge on, but I’ve come acrossa number of articles and studies which say that earlier studies claimingefficacity were flawed and not-properly controlled (ie notdouble-blinded) and that subsequent, more rigorous trails have shown nobenefit. There may well be other robust trials saying the opposite ofthis – I’d be interested in reading them if you can send them my way –but in the meantime, here are the sceptical analyses – and nullhypothesis trials – that I’ve found: