Concussion – what are the alternatives?

concussion 2What 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 we

assess which approach is more valid and productive than another? You
seem to agree that solid, supporting scientific evidence is crucial in
helping us determine that. While access to data has obviously been
enormously facilitated by the web, there’s an enormous amount of
information on the internet that isn’t reliable.
How do we decide
between the various sources? No simple answer, but informing ourselves
through reading clearly helps – a willingness to look at multiple
sources. We also have to use judgement. Is the particular therapy being
promoted by someone with sufficient scientific experience and knowledge?
And if they have valid medical qualifications, are they being overly
influenced by commercial incentives – whether it be a large
pharmaceutical company, or an alternative medicine store looking for
customers? There aren’t always absolute distinctions – but I think it
has to be a balance of knowledge and judgement, with the principle that
reliable scientific evidence is the key.
The gold standard is the
systematic review, carried out by disinterested, knowledgeable medical
experts – 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 always
sufficient to base strong conclusions on.
Fortunately there has been some good work in this area – notably the
creation of the Cochrane Collaboration – an international network of
publicly funded health experts committed to evidence-based systematic
reviews of current health treatments. It’s hard for them to cover
everything of course – but it’s a very good initiative. https://www.cochrane.org/
There are some
arguments about its approach – from some who argue that it’s maybe even
too narrowly evidence based. There are schools of thought that say that
it’s rational to also include scientific plausibility in an assessment –
ie for a treatment to be considered thoroughly it should first have some
plausibility and not contradict all previous scientific knowledge (there
are exceptions to this of course – but the old adage applies –
extraordinary claims require extraordinary evidence.) One group arguing
this is the Science Based Medicine blog – from which I quote one extract
from below.
At this point, I do want to give more information though, about my own
history with concussion treatment.  Over the past ten months or so I’ve
been seeing two specialists from the NYU medical center’s concussion
unit. This at the recommendation of our PT, Maria Gerlich (excellent)
who has considerable experience of working with Iraq vets with TBI. She
specifically recommended that I get in with Dr Steven Flanagan, who she
basically regards at the top expert in the field in this locality – he
is the head of the centre, a teaching professor and an internationally
recognized expert in concussion management. I also saw Dr Donna
Langenbahn, a neuro-psychologist with 30 years of experience working
with people recovering from brain injury. She also lectures round the
world on this subject.
Two points. This doesn’t make these specialists infallible – of course
not. But as a rule of thumb I feel it does make sense – ie it’s a
rational choice – for me to give more weight to their opinions and
advice, than to other people who are not medically trained specialists
in concussion, and who don’t have decades of experience in that
speciality.
The second point, from what I’ve seen and experienced with these highly
skilled professionals, is that I have no reason to conclude that they
are not open to considering “alternative” therapies. In fact I did do
some cranio-sacral therapy with Maria, who mixes conventional and
alternative stuff. (I saw no harm in it – it was pleasant, but
anecdotally I didn’t notice any difference after it – and my understanding is that it doesn’t have a credible scientific basis.)
I then discussed
this and other alternative therapies with Donna, who was generally
relaxed 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 who
do not consider alternative treatments. These are people who’ve done a
great deal of research – and I have no evidence to suppose that they
have ignored non-mainstream approaches.
One of the issues is how you define “alternative” of course, since it’s
a slippery, relative concept. If it means “approaches for which there is
no scientific evidence” – yes, I’m firmly opposed, I’m biased against.
If it means, on the other hand, scientifically plausible hypotheses or
approaches for which there might be some experimental evidence, but that
need to be explored further – I’m open to that. As we agree, the
scientific process amasses evidence and assesses probabilities – it
doesn’t decide anything absolutely, but it is cautious when claims are
made without evidence, and, crucially, it responds and adapts when
evidence shows that previously used approaches are ineffective.
Anyhow, on those lines, during the treatment I read up about some
current research. One example was Buffalo University – where, theorising
that blood flow, carrying in glucose, is restricted in the brain
following TBI, they felt that carefully graded running exercise may help
boost blood flow and accelerate recovery (by of course increasing blood
flow in the brain). Since I’m a runner anyway, and since I felt that
moderate running could do no harm, I decided to up the amount of times I
ran during the middle months of my treatment. The experimenters were at
pains to say that their preliminary results needed to be backed up with
more data – it’s an essentially unproven hypothesis at this moment. So
in 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 our
discussion. Do I pay more attention to modern medical approaches rather
than alternative approaches overall? Yes, I do – for the following
reasons. For all its faults, our modern medical system obligates
extensive trials and an evidence-based approach before new treatments
and approaches are approved (yes, the system isn’t perfect and there are
abuses – and the regulatory system could and should be stronger). But I
would surmise that, in the case of the majority of the alternative
therapies presented online, there isn’t an equivalent, extensive demand
or indeed official requirement for the kind of rigorous testing and
trials that conventional modern medicine is submitted to. (I believe
that unproven therapies usually have only to indicate that they are not
FDA approved – but I’m not sure about all the regulations here.) I think
you would agree that a great many of these alternative therapies are not
supported by well-controlled scientific studies. So from that starting
point, I think it’s absolutely reasonable to look first at therapies
where there is a considerably greater likelihood that the claims are
backed with scientific studies.
Does it mean that one should therefore ignore alternative therapies? Of
course not, but given that we have limited time on this earth, I use a
rule of thumb which prioritises scientific evidence – yes, I plead
guilty to that bias. Of course, not everything has – or can be tested –
and some of those alternative therapies will no doubt be proven
effective at some point – but does that warrant that I should try an
untested and unproven hypothesis as opposed to an approach that has been
tested – I think not – outside of extreme situations maybe, where for
example someone is at risk of dying and there are no proven therapies at
all.
Why does all this matter? Many unsound and unproven therapies are fairly
harmless – and rely on the placebo effect. I don’t think there’s a huge
problem with someone taking treatment for a minor ailment and, through
the placebo effect, feeling better. I do however think there’s a serious
problem when someone has a dangerous, severe or life-threatening
condition and is encouraged to take a totally-non proven approach – when
there 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 (in
my view) the human race’s greatest achievement – it’s transformed our
lives, especially in the area of healthcare over the last few centuries.
If people are encouraged to ignore scientific evidence in their
decision-making (and especially in public policy) that’s a deficit for
the whole of society. Think of climate change for example – where there
are very large numbers of people who refuse to accept overwhelming
evidence – and this resistance and lack of command of the basic facts is
exploited cynically by commercial interests. In this case, resistance to
science could literally have disastrous consequences for the whole
world.
There’s also a lesser but significant evil – for example, a substantial
proportion of the $50 billion food supplement industry unscrupulously
exploits 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 first
suggestion was that I take vitamins. In the context explained above, I
didn’t take very kindly to that – though I know you had kindly
intentions. I’ve done more looking through the data on this – yes, there
is research going on – some of it into vitamin treatment for concussion,
and some of it might eventually lead to new insights – for example I
found one study that showed possibly promising results with mice and
Vitamin 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 conclude
that no dietary supplements have so far been proven efficacious for
concussion treatment. In fact, it’s got to the stage where the FDA
recently issued a warning against outlets who have been proposing
vitamin supplement treatments for concussion – saying it’s unfounded and
dangerous. I include several references and extracts just below to this.
(As an aside, I’ve often heard criticisms from alternative sources that
modern medicine ignores dietary and lifestyle issues – that’s a major
straw man in my opinion – conventional medicine has, for centuries now,
focused on sanitation, good housing, safe water and diet – we are
inundated with conventional research and information on those issues.
(Michael Bloomberg, for example, launched major lifestyle health
campaigns in New York City against smoking and large soda drinks.) And
yes, my treatment with the specialists involved extensive discussion of
life-style management, diet, as well as the psychological aspects of
recovery)
References to vitamins and concussion: – extracts followed by urls:
1)      Since the 1980s, numerous studies have attempted to identify
neuroprotective agents. Because of the complexity of the biochemical and
cellular cascades that follow TBI, there are many potential therapeutic
targets that may help support individuals who have suffered TBI. These
efforts have included magnesium administration, hormone supplementation,
calcium channel blockade, bradykinin inhibition, use of
anti-inflammatory drugs, blockade of immune receptors, as well as use of
numerous other vitamins, minerals, and antioxidant agents. These agents
often work by multiple mechanisms that may include limiting glutamate
excitotoxicity, limiting of free radical and lipid peroxidation damage,
or minimizing BBB disruption. Unfortunately, none of these completed
trials have demonstrated significant clinical benefit in humans.
2)
  But the FDA on Tuesday issued a warning to consumers, saying the
 supplements are untested, unproven, and possibly dangerous. “We don’t
 have any evidence that there is any medication, vitamin, or herb that
 helps people to recover after head trauma,” said Dr. Andrew Russman of
 the Cleveland Clinic.  (quote from above)
3)
as the marketing claims here are, the science doesn’t support the use of
any dietary supplements for the prevention of concussions or the
reduction of post-concussion symptoms that would enable one to return to
playing a sport faster,” says Daniel Fabricant, Ph.D., director of FDA’s
Division of Dietary Supplement Programs.  (quote from above)
4)
Continued discussion:  On vitamins generally – it’s interesting – as you
probably know, there have been several very large and robust studies on
taking multi-vitamin supplements which have concluded there is no
overall 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 Pharma
Flacks (Kindle Location 1486). Faber & Faber. Kindle Edition.) as
supplements for preventing cancer, large studies have concluded that
these 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” I
think I could reasonably argue that in this case it’s an “alternative”
position to argue against multivitamin supplements – since the
conventional wisdom – especially in the US – is that they are good for
you, despite the now robust evidence against them.
I’ll restrict myself (since this is getting very long here) to one
article that summarises and refers to the above studies:
Finally out of interest I did some reading on the megavitamins for
schizophrenia thing. This was far from an exhaustive search and this is
not an area I claim to have any prior knowledge on, but I’ve come across
a number of articles and studies which say that earlier studies claiming
efficacity were flawed and not-properly controlled (ie not
double-blinded) and that subsequent, more rigorous trails have shown no
benefit. There may well be other robust trials saying the opposite of
this – I’d be interested in reading them if you can send them my way –
but in the meantime, here are the sceptical analyses  – and null
hypothesis trials – that I’ve found:
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