Abstract
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. It is estimated that half of the people in the world will experience at least 1 episode of TBI during their lifetimes. While the primary injury to the brain parenchyma is usually irreversible, the secondary effects, which involve cellular dysfunction, derangement of blood flow, and blood–brain barrier changes in ionic flux and elevated levels of free radicals are potentially amenable to treatment. At present, there are no neuroprotective agents in mainstream medicine to interrupt these secondary processes and improve the patient's neurologic outcome. Acupuncture holds promise to fill this gap and scientific evidence to that effect is presented. Sports-related brain injury is discussed in detail.
Keywords: acupuncture, traumatic brain injury, concussion, head injury
INTRODUCTION
Atraumatic brain injury (TBI) is an injury to the brain that occurs as a result of a physical impact to the head or body. Mild TBI, also known as concussion, can be a result of the brain moving back and forth within the skull. For the majority of people, symptoms of concussion will spontaneously resolve. At the other end of the spectrum, is severe acquired brain injury (sABI) in which the symptoms can be debilitating and life-changing, potentially leaving a person in a vegetative state (VS).
The common features of concussion are:
Direct or indirect blow to the head or neck
Rapid or delayed presentation of symptoms and signs with spontaneous resolution
Negative findings on computed tomography (CT) or magnetic resonance imaging (MRI) indicating a functional rather than a structural injury
Absence of loss of consciousness or amnesia and stepwise resolution.
sABIs include a variety of acute brain lesions characterized by the presence of variably prolonged coma states (24 hours or more) and associated with motor, sensory, cognitive and/or behavioral impairments. Congenital, or degenerative brain injuries are excluded from this definition.1 The definition has not been consistent with variations in inclusion criteria.
TBI is one of the most common causes of neurologic morbidity and is more common in childhood and adolescence. Concussions in young people account for 90% of all TBIs.2 The diagnosis of concussion is clinical; there is no biomarker for making a diagnosis. It is based on the observed mechanism of injury, and signs and symptoms.
Loss of consciousness, ataxia, and seizures are uncommon. “Red flags” include double vision, neck pain, numbness/tingling in the extremities, persistent headache, loss of consciousness, vomiting, and increased restlessness. These signs should mandate hospital admission.
TBI IN SPORTS
Sports-related TBI represents about one third of all TBIs of all severities.3 Concussion is the most-common TBI.4 Sports-related concussion is defined as a complex pathophysiologic process affecting the brain that is induced by biomechanical forces.5 It is estimated that 1.6–3 million reported concussions occur in the United States per year in competitive sports; as many as 50% go unreported.6 Concussions do occur in most sports; the highest incidences are in American football, ice hockey, rugby, soccer, and basketball.6
Loss of consciousness is uncommon. Immediate symptoms following concussion are disorientation, poor balance, and varying levels of memory loss. Delayed symptoms include behavioral changes and sleep disorders, and these can last for weeks or months. Multiple minor concussions also can cause brain injury. The term second-impact syndrome is applied to a condition when there is a second brain injury before the brain has had adequate time to heal; this is associated with visual, motor, and/or sensory abnormalities and difficulties with cognitive processes.7 Repeated concussions have been associated with Alzheimer's disease, parkinsonism, chronic traumatic encephalopathy, and amyotrophic lateral sclerosis.7 Athletes who experience concussions are 2 times more likely to sustain subsequent musculoskeletal injuries.8
Sports-related concussion (SRC) is diagnosed on the basis of the observed mechanism of injury, signs and self-reported symptoms. The most common symptom is headache; other symptoms may include dizziness, brain fog, memory loss, fatigue, concentration difficulties, insomnia and visual disturbances.
A concussions in sports group has developed a sports-concussion assessment tool (Sport Concussion Assessment Tool 5th Edition) for adults and a separate tool for children ages 5–12 (Child Sport Concussion Assessment Tool 5th Edition) for initial assessment of a suspected SRC.9,10 These are to be used for initial screening to ensure absence of life-threatening traumata, such as cervical-spine fractures, intracranial injuries, and other aforementioned red flags, the presence of which mandate immediate admission to a hospital. Another protocol is a head-injury assessment protocol (HIA protocol)—a 3-stage process introduced by the a world rugby organization for elite rugby teams to identify, diagnose, and manage head injuries with potentials for concussions.11 The on-field assessment of a SRC is often challenging, given the elusiveness and variability of presentations, and the reliance on the athlete's subjective symptoms.
A standardized protocol is useful but should not take the place of a full neurologic and general clinical examination as well as the judgment of the clinician. If the athlete has returned to play after an HIA, further monitoring over 24–48 hours is advised. This usually involves reviewing video footage of the incident and performing a series of medical assessments in the next 24–48 hours to diagnose or exclude a suspected concussion. A history of SRC is a risk factor for future concussions.12 Multiple SRCs are often associated with increased physical, emotional, and cognitive symptoms.1 Neuroimaging studies, such as CT scans or MRIs, are not usually indicated for diagnosing SRC. If the diagnosis is concussion, 24–48 hours of cognitive and physical rest are recommended, during which the patient only engages in activities that do not increase existing symptoms or cause new symptoms. Advice should be given to refrain from using sedatives, alcohol, or recreational drugs, which can mask the appearance of symptoms. In patients presenting with persistent symptoms, a multifaceted approach involving neurologists, psychiatrists, physiotherapists, and occupational therapists is recommended.6
Use of pharmacologic agents is uncommon in SRC. In most cases, recovery can be expected in 7–10 days; children may take about a month. After recovery, the individuals are encouraged to return to sport in a gradual fashion, in a manner that would not exacerbate symptoms. A similar approach is recommended for returning to classrooms in the case of children and adolescents, although evidence suggests that student athletes who sustain SRCs have similar 12-month academic outcomes to students sustaining musculoskeletal injuries.13 However, in these patients, there are usually some difficulties with concentration, sensitivity to light and sound, symptom exacerbations in mental activities, and memory issues when retuning to classrooms.14
sABI is characterized by the presence of a prolonged coma, along with sensory, motor, cognitive, and/or behavioral impairments. There could be altered states of consciousness, varying from a coma to a VS. The minimally conscious state is a recently defined clinical condition that differs from the VS by the presence of inconsistent but clearly discernible behavioral evidence of consciousness of the self and environment.15
The underlying mechanisms of sABI are complex. The initial injury involves acute and mostly irreversible primary damage to the brain parenchyma. This is followed by the secondary stage, which often progresses slowly, involving Wallerian degeneration of axons, mitochondrial dysfunctions, oxidative stress, exitoxicity, and apoptotic cell deaths of neurons and glia.16 These secondary damages, which develop over a period of months or years, will need therapeutic strategies that target multiple mechanisms over an extended time. Feasibility of this strategy for managing severe TBI has yet to be established.16
TBI IN CHINESE MEDICINE
The essential pathology in Chinese Medicine (CM) for TBI is Blood Stasis. This can last for several years. Symptoms of headache can appear several years after the trauma, which, in many cases, the patient would have forgotten. The headache typically recurs in the same area as the injury, and is usually stabbing, or boring in nature. The pulse is often very weak in the front position in both wrists, and the tongue may have a purple spot at the tip, while the rest of the tongue appears normal. This is because, while the body of the tongue represents various internal organs, it also represents areas of the external body, and the tip of the tongue corresponds to the head. The recommended acupoints for addressing Blood Stasis are:
SP-4 + PC-6, in that order, to open the Penetrating Vessel (Chong Mai)
LI-11, LI-4, SP-6, LR-3, and all Ashi points in the head
TB-5 for pain in the sides of the head
BL-2 for the eye
Taiyang Extra point for the temples
TB-18 for the occiput
Sishencong for the vertex.
All points are stimulated using a reduction method with thick needles (0.3–0.5 mm) that are retained briefly (10–15 minutes). The acupuncturist uses a counterclockwise rotation, slow insertion, and quick withdrawal, going against the against channel flow, through intense manipulation.
EVIDENCE FOR ACUPUNCTURE
Acupuncture stimulation reduces oxidative damage in pathologic conditions.17 Oxidative damage is one of the features of TBI. Acupuncture applied to GV-26 and GB-34 significantly reduces apoptotic cell death of neurons and oligodendrocytes, leading to functional recovery after a spinal cord injury.18 Acupuncture at GV-20, Sishencong, GV-24, PC-6, CV-17, CV-12, CV-6, SP-10, and ST-36 reduces levels of 8-hydroxy-2-deoxyguanosine—a marker of oxidation damage—and improves cognitive function and quality of life (QoL) in patients with vascular dementia.19 Acupuncture stimulation of points in the Conception and Governing vessels continuously promote proliferation and differentiation of neural stem cells in the brain, upregulate expression of growth factors, accelerate angiogenesis, and inhibit apoptosis.20 Stimulation of GV-20, ST-36, LI-11, GV-26, GV-14, and LI-4 results in neurogenesis in the central nervous system and improvement of memory after stroke.21 Acupuncture stimulation of ST-36, LI-4, GV-26, and Ex-HN-3 reduces spastic muscular hypertonia in patients with TBI and disorders of conciousness.22
In a study, patients who received acupuncture for TBI had reduced use of emergency care and hospitalization in the first year of their injuries.23 Insomnia is a frequent symptom after TBI; this symptom can appear within 24 hours and can last for several years. Acupuncture was as effective as medications for treating insomnia in patients with TBI and also improved their cognitive functioning.24 Patients with TBI receiving acupuncture had a decreased risk of stroke, compared with patients who did not receive acupuncture.25 In TBI with limb paralysis, addition of acupuncture to the usual conventional treatment with mannitol and oxiracetam resulted in better improvement than with conventional treatment alone.26
Acupuncture has a positive effect for treating patients with TBI—regulating neurotransmitters, promoting nerve repair and regeneration, antioxidation, inhibiting intracellular calcium overload, regulating aquaporin content, regulating cellular energy metabolism, improving brain circulation, and inhibiting cell apoptosis.27 Acupuncture was associated with a significantly lower risk of dementia in patients with TBI.28 After combined stimulation of GV-20, GV-26, LI-4, and ST-36, brain-derived neurotropic factor (BDNF) and tropomyosin receptor kinase B (TrkB) were significantly elevated at 168 hours versus 48 hours after TBI, suggesting that acupuncture could elevate the BDNF/TrkB pathway, thus, promoting neurologic recovery after TBI. At the same time this explains the molecular mechanism of action involved.29
In an exploratory study, auricular acupuncture and Traditional Chinese Acupuncture improved headache-related QoL more than usual care in service members with TBI.30 Effectiveness of acupuncture at GV-23, GV-20, Yintang, PC-6, and SP-6 was demonstrated for protecting neurons and postponing Wallerian degeneration in cerebral infarction, thus facilitating recovery.31 Electroacupuncture therapy combined with Western medicine treatment was more effective than Western medicine treatment alone for addressing coma caused by TBI. The points used were KI-1, GV-20, and GV-26.32
ILLUSTRATIVE CASE
An 86-year-old man presented with recurrent dizziness and persistent headache in the right frontoparietal region, following a fall he had sustained 2½ months prior. His condition was investigated and treated in the emergency department of a major teaching hospital. He continued to have symptoms despite the treatment. He had no other symptoms or signs. Fundus examination was normal with no papilledema, and his eye movements were also normal with no nystagmus. His pain was strictly localized to the right frontoparietal region with no fluctuations. His pulse was generally weak in all positions and his tongue was generally reddish with the tip of the tongue being more red. A CM diagnosis of postconcussion Blood Stasis was made.
The points used to treat this patient were:
SP-4 left, PC-6 right to open the Chong Mai to remove Blood Stasis (note: in women, the sides would be reversed)
LI-4 and LR-3 bilaterally to move Qi and Blood
LI-11 both sides to reduce Heat
SP-10 both sides to remove Stasis
TB-5 both sides for its effect on the side of the head
Tai Yang Extra point and ST-8 both sides as local points.
All points were reduced. Six treatments at twice weekly intervals resulted in the patient becoming symptom-free.
In CM, dizziness is due to either not enough Qi reaching the head (Deficiency pattern) or a pathogenic factor in the head preventing Yang from reaching the head (Excess pattern). The Deficiency pattern includes Qi, Blood, or Kidney Deficiency; the Excess pattern includes conditions such as Liver Fire, Liver Wind, Liver Yang rising, or Excess Phlegm in the head. In elderly patients with possible atherosclerosis, there is existing Blood Stagnation, and the trauma acts as an insult to injury, aggravating the existing Blood Stasis and causing dizziness. In this situation, treatment directed toward the Blood Stagnation would address both headache and dizziness, which explains the symptom relief obtained in this case.
DISCUSSION
TBI is an alteration in brain function or other evidence of brain pathology caused by an external force. It is estimated that half of people in the world will suffer from at least 1 TBI during their lifetimes.33 The Lancet Neurology Commission estimated that 50–60 million people worldwide will suffer from TBIs in 2022 at a cost of $400 billion.33 The Commission also predicted that TBI would remain the largest contributor to neurologic debility globally until the end of the next decade, exceeding the burdens caused by cerebrovascular disease and dementia. TBI remains the leading cause of death in North America in people ages 1–45. Many people with TBI live with significant disabilities.34
Acupuncture has distinct advantages over conventional treatment for TBI. Acupuncture relieves all kinds of pain and does it very quickly without side-effects. Both Battlefield Acupuncture (BFA) and Traditional Chinese Medicine (TCM)–guided acupuncture are effective; the effects of BFA last a little longer than those induced by TCM.35 Inflammation, which follows tissue injury, plays a significant role in tissue regeneration and repair. Inflammatory signaling increases DNA accessibility so as to promote phenotypic fluidity in response to injury.36 While there is a well-researched and documented benefit for using anti-inflammatory medications for patients with coronary-artery disease, the rationale of suppressing inflammation by using anti-inflammatory medications in cases of physiologic responses for tissue repair and remodeling does not appear logical. Acupuncture has a clear advantage over anti-inflammatory drugs—and definitely over opioids with their inherent undesirable effects.
Acupuncture increases cerebral blood flow. Stimulation at GV-20 resulted in significant increase in the blood flow in the anterior and middle cerebral arteries and was associated with improvement in CO2 reactivity without alteration in blood pressure.37 Up to 12 days post injury, there is an overall reduction in oxygen and glucose metabolism across the brain.37 The primary target in treating TBI has been maintenance of cerebral blood flow, but it is just as important to ensure adequate glucose delivery.38 There is increasing evidence showing that TBI may increase the risks of neurodegenerative diseases, including Alzheimer's disease and mood disorders, by interfering with glucose metabolism.38 Acupuncture regulates glucose metabolism in human vascular dementia,39 and in patients with chronic-stage ischemic stroke.40 Evidence indicates that acupuncture treatment not only activates different brain regions in different kinds of diseases, but also modulates adaptive neurotransmitters in related brain regions to alleviate autonomic responses.41
Many patients, after TBI, show sympathetic dominance as evidenced by insomnia, irritability, chronic anxiety, and headaches. Acupuncture helps balance the autonomic nervous system, thus, relieving those symptoms.41 Combined stimulation of ST-36, GV-20, GV-26, and LI-4 increase the level of BDNF, which can promote repair of damaged neural tissue.29 Dizziness and vertigo are very common in patients with TBI. Stimulation of ST-36 and PC-6 often relieve these symptoms in a matter of minutes.42
Although acupuncture treatment for TBI has many positive aspects and advantages over usual conventional treatment, the lack of high-quality studies make this harder to validate. Tan et al. reviewed 49 studies involving 3511 patients with TBI and made the following observations.43:
Sample size in many studies were too small to draw firm conclusions.
All RCTs compared acupuncture versus basic treatment, no sham acupuncture or placebo was used, and patients were not blinded.
Some trials used acupuncture combined with other interventions in the control groups, which made proper evaluation difficult.
Duration and frequency of acupuncture and acupoints selection varied among RCTs.
The duration and grade of the TBIs were different in the included trials and not reported in many RCTs, which may have resulted in different outcomes in the clinical efficiency rate.
Adverse events and safety profiles were not reported.
There needs to be high-quality studies with sufficient sample sizes and truly randomized methods to minimize assessment bias. Generally recognized outcome measures such as the Glasgow Coma Scale (GCS), and the Glasgow Outcome Scale (GOS) should be adopted to ensure reliability, comparability, and validity. Researchers should report negative outcomes in relation to QoL, long-term efficacy, and objective outcomes shown by electroencephalography and functional MRI. Again, efficacy of acupuncture over sham acupuncture using the same acupoints should be studied.43
CONCLUSIONS
The various kinds of evidence presented support the view that the acupuncture therapy should be considered as a viable option for patients with TBI. While acupuncture may have distinct advantages over standard conventional pharmacologic, occupational, and physical therapies, at present acupuncture cannot be recommended as a stand-alone mode of treatment. This is due to lack of high-quality studies. However, acupuncture can be recommended as an add-on to existing conventional treatments to induce possible positive synergistic effects.23,26,32
ACKNOWLEGMENTS
The author thanks Alice Scott and Courtney Hayward for their secretarial assistance.
AUTHOR DISCLOSURE STATEMENT
No financial conflicts of interest exist.
FUNDING INFORMATION
No funding was received for work on this article.
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