Nutrition's Role in Traumatic Brain Injury Recovery

Traumatic Brain Injury Recovery and Nutrition’s Role

Nutrition is understandably not priority one in the chaotic moments immediately following a traumatic brain injury (TBI), but as soon as the patient is stable, nutrition therapy shares center stage with other key tenets of TBI rehabilitation.

Soon after the initial injury, the brain gets to work repairing and rebuilding precious neural tissue, a process that requires a steady supply of high-quality fuel.

Thrown in the mix are a number of mechanisms too complex to be discussed at length outside of an academic paper, but suffice it to say, TBI rehabilitation brings highly specific nutritional demands.

In other words, even a very healthy diet by non-TBI-patient standards will leave major holes if specific nutrients aren’t addressed.

On top of all this, the TBI patient in acute phases can’t eat independently, voice their preferences and fullness level, or help clinicians with feeding in any way.

First, let’s take a look at these more complicated circumstances and how they can be accommodated—then, we’ll discuss the actual nutrients that can assist in the TBI recovery process.

TBI Rehabilitation Stages and Nutritional Complications

Nutrition Changes with Each Phase

Though every TBI patient is different, most go through a series of recovery stages characterized by certain behaviors and capabilities (or lack thereof). These stages can have a strong impact on what the patient should, can, or wants to eat.

We generally don’t stray into the clinical side of nutrition, but having at least a general understanding of the earlier stages of TBI recovery is critical to appreciating the nutritional needs and self-feeding capabilities of TBI patients.

When a person suffers a very severe blow to the head or a prolonged lack of oxygen that results in brain damage, they are said to have had a traumatic brain injury.

With the appropriate care, a TBI patient can recover some or even most of their vital cognitive abilities like memory, reading, speech, and so forth. 

One of the most widely used scales used by clinicians and friends/family of TBI victims to provide benchmarks for TBI (and coma) recovery is called the Rancho Los Amigos Scale (RLAS), which separates the recovery process into ten levels:

Level 1: No Response. Patient’s eyes remain closed. They will not respond to verbal commands, reflex tests, etc.

Level 2: Generalized Response. Patient may begin to respond inconsistently (eyelid flickering, moaning, etc.) to prompts from people and the environment.

Level 3: Localized Response. Patient’s responses become more specific, withdrawing from pain and engaging more with family members than healthcare providers. 

Level 4: Confused/Agitated. Patient displays erratic and agitated behavior; they are confused and easily frustrated. They may overreact to small complications, yell profanities, etc.

Level 5: Confused, Inappropriate Non-Agitated. Patient may still continue to use inappropriate language, but they’re less visibly angry, all the while becoming more independent in simple tasks, demonstrating improved memory, and other recovering faculties. 

We will leave off stages 6-10 because it becomes much easier to feed the patient beyond stage five; the point is that meeting nutritional needs of an early-stage TBI patient is a comprehensive effort, as the patient can’t assist in any way.

Determining the Nutritional Needs of Unresponsive TBI Patients

We recommend this highly informative book written by the Institute of Medicine (US) Committee on Nutrition, Trauma, and the Brain—Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel—for anyone who wants to learn about the best nutritional approach to early-stage TBI recovery.

The authors set forth several important guidelines for healthcare practitioners to use when determining an unresponsive patient’s optimal energy intake, pre-existing nutritional deficiencies, eligibility for certain feeding methods, and so on.

Here are a few key takeaways from the book, shortened and paraphrased for brevity:

Pre-feeding evaluations: Clinicians should evaluate how much weight loss has occurred between the injury and the initial feeding (highly common in TBI), as well as the severity of the injury, other pre-existing conditions the patient may have, and the patient’s gastrointestinal health to best establish a basis for caloric intake levels and nutrient targets. “Predictive equations” may also be used, according to the book, to establish calorie goals.

Determining optimal feeding route: Commonly, healthcare professionals will either use tube feeding (enteral) or intravenous/subcutaneous (parenteral) methods to feed early-stage TBI patients. According to the US Institute of Medicine book, the former method is associated with “less septic morbidity and fewer infections complications” than the latter, but not every patient is a candidate for tube feeding.

Goal setting: It’s important for clinicians to clearly define the goal of whichever feeding/nutritional program they choose, whatever that may involve (commonly, weight gain). 

Especially before having nutrition-related tests and assessments done, it’s important that factors like room temperature and patient positioning are consistently optimized, since they can affect the patient’s metabolic rate.

The fact that we haven’t mentioned a single nutrient yet should provide some insight into just how nuanced, unpredictable, and difficult TBI recovery is.

Without this upfront work, a cookie-cutter nutritional program would be much more likely to fall short of therapeutic targets.

Now that the basis has been established, we can take a look at evidence-based arguments for certain nutrients as TBI recovery enhancers.

Key Nutrients for TBI Recovery

This article authored by Instituto Estadual do Cerebro Paulo Niemeyer (Brazil) researchers provides a solid introduction to the most consistently recommended TBI recovery nutrients, which include:

  • Vitamin D
  • Vitamin E
  • Magnesium
  • Zinc

In some cases, these nutrients play off each other to support blood flow to the brain, cellular repair, and other vital functions, and in other cases, they work with other nutrients and structures in the body.

Going down the list, we’ll start with the authors’ comments on vitamin D.

Vitamin D

Per the article, a certain form of vitamin D (1,25[OH]2-D3) and a certain form of vitamin A (9-cis-retinoic acid) work together in the central nervous system to support “cell proliferation and neuronal differentiation and function,” which are vital to TBI recovery.

In plain English, vitamin D and vitamin A work together to prompt the brain cells to reorganize themselves and “work around” the injured tissue.

Speaking of, brain cells do not recover or regenerate once completely destroyed, unlike other tissues in the body.

However, the TBI patient can still recover much of their previous function as their brain adapts to the injury by rerouting neural connections, a process that vitamin D and vitamin A help with. 

Vitamin C and E

The Brazilian researchers reference a randomized trial from Shiraz University of Medical Sciences in Iran, in which the authors demonstrated that participants who received vitamins C and E outperformed control groups in achieving recovery benchmarks.

Specifically, the treatment group demonstrated “lower mortality rates and better Glasgow Outcome Scale (GOS) scores.” 

This finding leaves much to be explored in terms of the specific actions of these vitamins on the recovering brain, but it’s a strong starting point for other investigators to build on. 

Magnesium

Finally, one of the most undersold minerals in the modern diet, magnesium, appears to act as an accelerant in the middle and later stages of the TBI recovery process.

The Brazilian researchers noted that magnesium helps to counteract glutamate, an important chemical messenger that serves vital functions in the healthy brain, but can be problematic in the brain recovering from TBI.

As an “excitatory” chemical messenger, one of glutamate’s functions is to trigger the narrowing of blood vessels, which restricts blood flow to the brain.

In counteracting glutamate, magnesium cues the blood vessels to relax, i.e., expand, allowing more blood to reach the brain.

More blood means more high-quality fuel, which means a greater chance of recovery. 

Small Piece, Big Puzzle


The Wait-and-See Approach

TBI recovery is an extremely complicated process, and even with a consciously crafted nutritional program, patients have many other needs that must be met in order to maximize recovery.

Though many TBI patients progress through their recovery in a seemingly similar fashion, every case is still dominated by a host of unknown variables.

Even when all the appropriate steps are taken in the areas of nutrition and all other aspects of care, the vast majority of doctors follow a “wait and see” approach, meaning nobody can accurately predict the outcome of a TBI rehab program.

As such, there’s no guarantee that following all of these nutritional guidelines to the letter will save a patient’s life or maximize their recovery, but there is plenty of data supporting the notion.

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