Concussion – what are the alternatives?

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 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.

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 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)

http://www.rxlist.com/script/main/art.asp?articlekey=176000  “As amazing

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)

http://www.businessweek.com/articles/2014-01-03/fda-warns-against-concussion-curing-claims-on-supplements

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:

http://www.nytimes.com/2009/02/17/health/17well.html?emc=eta1&_r=0

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:

http://www.quackwatch.com/01QuackeryRelatedTopics/ortho.html

http://www.ncbi.nlm.nih.gov/m/pubmed/3896744/?i=3&from=/18587164/related

http://www.sciencebasedmedicine.org/pyroluria-and-orthomolecular-psychiatry/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518054/?page=1