Fish Oils and Their Role In Concussion Recovery: Part 1

This is part 1 of a two part series on fish oils and their role in concussion recovery.

I'm joined by Dr. Michael Lewis who is an expert in the field of concussions and fish oils. 

In this episode we discuss what you should know about concussions and tackle many of the myths individuals fall for.

We briefly talk about fish oils in this episode as we lay the ground work for part 2 which will be released as episode 6. 

Transcript

Dr. Lewis is the author of When Brains Collide, what every athlete and parent should know about the prevention and treatment of concussions and head injuries. Dr. Lewis, welcome to the show. Hey, it's great to be with you today. Great to have you. We get to talk about one of my favorite topics, and I'm really excited to chat about this, and that is concussions, but also what can people do to prevent it? But then on the flip side, what can they do after they've sustained one? First, can you tell people a little bit about yourself and your background and how you kind of ended up where you're at as a medical provider? Yeah. I mean, I, you know, out of high school, um, I grew up in a medical family. My father was a small town surgeon. My mother was a nurse, but out of high school, I went to the U S military academy, West point and off to play army for a number of years and woke up one day and said, you know, what am I doing? I always wanted to be a doctor. So I ended up going to Tulane medical school down in new Orleans and back into, you know, the, through the Army program and back into the Army, surgical internship at Walter Reed in D.C., and every intention of being a surgeon, but they sent me out to do general practice for a couple years, and I just covered nights and weekends, and something that surgeons don't know much about, and ended up in preventive medicine and public health, and variety of different things, you know, training at Johns Hopkins University, Walter Reed Army Institute of Research, which really was a focus on international infectious diseases. And my first assignment out of there, I got sent to Bangkok, Thailand. And for a number of years, I was running around Asia as a disease hunter looking for new and Interesting things. And then the Army, he said, you've got all this great experience. Come back and teach medical students back in Bethesda at the Uniformed Services University, the military medical school. And while I was there, now Iraq and Afghanistan were going on. You got wounded warriors everywhere. And I kind of started to put different pieces of things together. I say I put two and two together, and I came up with an odd number. and i went to the head of research at the uh uh the uh veteran uh i'm sorry the uh the brain injury center uh defense veteran brain injury center i had to think of it there for us because it's changed names over the years um the head of research there and i asked is anybody looking at the use of omega-threes like you get from fish oil to help our soldiers recover from traumatic brain injury thought about it for a moment. And he said, no, why don't you? I made every excuse I could. I was like, I don't know anything about it. And he goes, but you're the only one asking the question. And so that was a massive career change. And that was eighteen years ago. I've been on that path ever since. Retired about thirteen years ago and continued that path even after I retired in private practice, running a small nonprofit, but always with the idea that there's more we can do to help people recover from traumatic brain injury, or even better yet, prevent them. Yeah, so you said about, you know, why were you the first person asking the question about these brain injuries i mean at that point in time the ward been going on for a few years lots of ied blast injuries and everything else like what was happening Well, you would think, and this was what shocked me. To me, it was almost common sense. I was an outsider. I'm not a neurologist, a neurosurgeon, a trauma guy. You know, I'm completely outsider. And I just... You know, it kind of, I said, I put two and two together, came up with an odd number. But one of the seminal moments was in January, two thousand six. There was a mining accident in West Virginia where twenty two miners were trapped in a coal mine. a mile underground after an explosion. And it took them forty one hours to get down to rescue them. And by the time they got down there, only one guy was still barely alive. And it was a young, previously healthy guy. But methane gas poisoning, carbon monoxide poisoning, you know, as you know, renal function had shut down at massive heart attack, all the things that would kill you. And somehow he was just barely alive. And so they did hyperbaric oxygen and dialysis and all these different things. But they were left with a guy that still had basically no brainwave function. And the neurosurgeon was prompted and called Barry Sears, the zone diet guy. And Barry Sears jumped on a plane, came down to Morgantown, West Virginia, and brought some fish oil with him. And they started pouring it down the guy's feeding tube. And short of the stories, a couple of months later, the guy walked out of the hospital and I kept hearing about this and hearing about this very different situation. But what struck me was, well, the brain is the brain. Wouldn't that work for traumatic brain injury as well? I call it my brick wall analogy. If you've got a brick wall, Wouldn't you want to use bricks to repair the wall? Well, omega-threes, DHA specifically, but omega-threes are essentially the bricks of the brain. So why not back up a truck and dump a bunch of these DHA bricks into the site and help the brain repair? And I had absolutely no other thing to go on other than it just made common sense to me. And yet, when I looked into it, I was the only one, essentially the only one in the world, besides the neurosurgeon in West Virginia, who was even talking about this. And so I just kind of ran with it. To me, it just made sense. Yeah, and there's a lot of things that we see in the concussion world that now is starting to make sense. But in the past, it was criticized. It was like, oh, you can't rehab a concussion. What are you doing? And now it's like, okay, everyone pretty much agrees you can do something. Now, not everyone's up to really where they should be. But as we're talking about concussions, before we truly go into the whole fish oil and what it can do, of the biggest things i've seen over my career you know we go back a little bit of my backstory my wife had concussions back from when she was a teenager in car accidents that were never diagnosed never evaluated and all of her symptoms were getting blamed on hormones changing you know oh you're going to a new grade it's puberty and different things like that so What are things that not only parents should be watching out for in their kids who are playing sports or, you know, have been in car accidents, but also anyone should be looking out for us. Concussions are so, unfortunately, still at this point in time, widely underdiagnosed. They are, and it's really scary in many ways, but it's also the nature of the injury, right? It's the invisible injury. You know, guys in the NFL will say, I'd rather have my ACL blown out because everybody understands that versus, you know, that terrible thing where you look at somebody, well, I don't see, you don't look like you have a head injury because you don't see it. It's that invisible injury. And, you know, even more scary is with kids. And so one of the things, and especially teenagers, you know, whether playing high school, you know, hockey, football, rugby, soccer, you know, basketball, you know, name your sport. I'm a huge believer in team sports. I mean, I grew up playing football. I switched to rugby in college and beyond. I am on the board of advisors, the medical advisory board for Pop Warner Youth Football. I am on the board of directors for National Collegiate Rugby because I believe in these sports and team sports are hugely important. And the lessons you learn in life were better to learn as you're growing up than through team sports. And unfortunately, collisions are part of these more aggressive sports. But can we make it safer is how I'm always looking at it. And we talk about different things like better helmets for football or lacrosse and things like that. But what we never have a discussion about and it's starting now. I'd like to think it's starting to change, but I'll say I'll back up for a half a second. If you look at the sports concussion conferences that have been held over the last number of years, the most recent one in twenty twenty two, it's the first time ever that they came out with a statement saying that exercise after a concussion is important. Before that, it was go sit in a dark room. And so finally, we're recognizing that exercise is an important part of recovery, but not a single word about nutrition. And to me, that's the biggest thing. You know, we're talking about better helmets and better protection. What about protecting it from the inside? And really, the only way you can do that is with nutrition. Correct. You know, and it's sad that exercise was neglected for so long. It was just, hey, go sit in a dark room, don't do anything. And then as you've talked about, you know, nutrition, it's still not even talked about in the consensus statements at all. There's no thought about like, hey, what you eat actually matters for your brain health. And yeah, it's it's pretty scary that we're still that far behind. It is, especially with like, the research is there. I mean, it's one of those things, right? If we were just like, hey, you know what? We just are coming up with this. But the research is clearly there to tell you, look, this can impact immune system function. This impacts how brains develop. If it impacts how brains develop, then it can ultimately impact how brains function and how they can even repair. So for those parents who are, you know, they've got their kids playing in sports, we've talked about, you know, teams and they're like, well, I don't want to pull my kid out of a sport, but I'm also worried that they may take a concussion. What, what like needs to happen for a concussion to occur, you know, because it's not losing consciousness, but what are some of those myths that people kind of hold onto that they really need to let go because by holding onto it, they're kind of doing more harm than good. Right. I mean, there's a responsibility of everybody and anybody in and around and on the playing field, whether it's the referee, whether it's the teammate, whether it's the kid himself, whether it's a parent on the sideline or the coaches. You know, the more that people are aware and can keep an eye out for things. I mean, I've been at rugby matches where I've gone down to the sideline and yelled at the referee, hey, number one, Eight, take, you know, he needs to come out of the game or she needs to come out of the game because, I mean, I saw it from the stands where, you know, there was a blow and they're kind of wandering around trying to figure out where they are and then kind of get back into the game. They needed to be evaluated. So I think it's a responsibility of everybody else. that can be and, and, and it's through education. Right. So, I mean, I know as a kid, I, you know, you weren't going to drag me out of a game. I mean, but yeah, we didn't know any better back then. And so I think that education is really important, not just for the coaches and the referees, but also the players, but also, you know, sometimes you, you, You may be in a high school or college game. Well, not maybe you should always have an athletic trainer at that level. But if you're talking about a ten, twelve year old on a weekend soccer game, you're not going to have athletic trainers on the sidelines. So parents need to also be educated as well to be, you know, and be empowered to pull a kid out. So the most important thing is get a kid out of harm's way. And so when there's an injury, you want to get them out of harm's way. You want to pull out of the game. You want to have them out of a game, not just for that game, but for probably one, at least one, if not two weeks or more. where they're symptom free and allow the brain to heal. So what kind of symptoms should we be watching for? Headaches is a really obvious one, but some of the subtle ones, you've got a good kid that all of a sudden is a little bit more flying off the handle. They're a little bit more anxious. They're more angry when they were never angry before. They're losing their temper and they never did before. So that volatility in their emotions which in a teenager, granted, it's sometimes difficult to tell. But I've also seen instances where you've got straight A students who now all of a sudden are failing classes. That's a major red flag. And when they looked into it, there was a couple of concussions that the kid, once it was confronted with it, admitted, yeah, I probably took a few blows to the head. So things like grades falling off and just not – nobody knows a kid better than their mother, really. And so those are the kind of things that just those intangibles sometimes – not just the headaches that won't go away, not, you know, and obviously you mentioned like, you don't have to be knocked unconscious to have some major deficits following a concussion. Yeah. And that's so important to know, you know, is I'll give expert reports from neuropsychs and they'll be like, they couldn't have had a concussion. They didn't lose consciousness. They weren't vomiting. They were, you know, I'm just like, this isn't even criteria. I know. I see that all the time. Yeah. From neurologists even. It's like, how can you call yourself a neurologist and actually put that in writing that this patient could not have had a concussion because they did not lose consciousness? I'm like, how can you say that in today's world? It's absurd to me. Absolutely. And the other thing is, you know, with those symptoms you were talking about, behavioral issues, grades, and it's really important because it's not necessarily that you have to have every single symptom pops up immediately when the injury happens. You know, we think about like you played football and rugby, I played soccer. How many times do we get banged up in a game? We finish it up and then afterwards we're limping the next few days. It's like, Look, you know, as the adrenaline comes down, you can get symptoms that start popping up. And we see this in the NFL all the time where you're like, whoa, someone's on concussion protocol. And but during the game, they finished it up and everyone thought they were OK. And I want to go into. you'd mentioned, you know, hey, if you've got these, you probably should stay out for one to two weeks. Now you were saying one to two weeks, that one to two week period was being symptom free for one to two weeks or typically from the injury? It's every single case is an individual and needs to be looked at that individually. And so ideally, you know, you would want to be out for roughly two weeks symptom free. But that's not always the case. And it also depends. I, you know, Little League soccer is not the end of the world if you miss a game or two. Right. And, you know, maybe not the emphasis in the big money game of, say, college football. But it's, and the science seems to be changing a little bit more as we learn more. And so that progressive return to play type of attitude, modality, if you will, is really important. And so it's sort of like, you know, crawl, walk, run, play type of thing. And, you know, so that's where that exercise starts to come back. It is as you're pushing an athlete A little bit more, a little bit more. Can they get up to game speed and still be symptom free? And that's a major, major criteria. I always think about I have to think of it as just blanked on the name. There's the best hockey player in the NHL, the best player in the world, probably about ten years ago. Yeah. What's that? Sidney Crosby. Sidney Crosby with the Pittsburgh Penguins, right? And he had a concussion one week. I think it was a Christmas day. And then one week later on New Year's Day. And he was so he was not kept out more than a week. And he really probably shouldn't have been playing that second match game a week later. And he had another concussion on top of the first one. And he was out of hockey for about eighteen months. And everything I read, all that cognitive testing all came back pretty quick. But what kept them out for about eighteen months was when he would get up to game speed of skating, he had a slight issue with balance that, you know, we're talking about ninety nine percent better. And it was just at that professional, at that high elite level, that one percent at the end was all, you know, all the difference. And so that kept them out of the out of the out of the game for, you know, like eighteen months. Because when he was skating at full speed, game speed, he wasn't quite a hundred percent. And so every individual is, should be treated individually. Correct, absolutely, you know, because symptoms are, they're really just misleading in concussion because we know with the research, if you have concussions, your risk of other injuries goes up. There's also research that I've read in the past week or two that even showed on like single task or dual tasking, you saw increased activation in the brain with single and then actually the dual tasking, the brain was basically fatiguing. But the kicker was, is the performance was considered adequate it was like the same as someone who didn't have a concussion and so it's kind of the same thing in the psych testing it's like well they did good on the cognitive test it's like well did they do good from what you could measure and i think that's one of the big things that's still lacking in the concussion world is we have symptoms we've got neurological based testing like eye movements and balance but I don't yet have a great way to evaluate the oxygenation issues and then the inflammatory immune system issues, which I know we'll talk about those a lot as we dive into fish oils. It's really those, it's that immune system with concussions is what really determines your ability to recover short-term, but then the long-term. Because what are some of those long-term issues? Because I know one of the things is, you were involved with the military in a longitudinal study of traumatic brain injury. You know, was there anything interesting that was found there or that you've just learned in your other research and observations on the long-term effects of traumatic brain injuries? And I think we should note that concussions are the most common form of traumatic brain injury. And we've got to let that old stigma of like, oh, well, you know, a concussion's not a TBI. you know, it is the most common form of TBI. Right. It just, you know, you don't want to worry a mother too much by saying your kid just had a traumatic brain injury. So we, you know, we soften the blow, call it a concussion. And it is a traumatic brain injury. So you're right. That's one myth that we've got to certainly try to dispel. And there's plenty of others, that's for sure. But interestingly enough, I'm just thinking about the recovery aspect of things. And it's funny how things come about. Out of University of Toronto a number of years ago, they were doing a study and what they found, it was just observations. And what they found was that the kids, the teenagers had ignored the advice and of go sit in a dark room and don't do anything until you get better, the kids that ignore the advice were getting better faster. And somebody realized this, and then that is how the whole exercise thing started out. Because, well, okay, if they're not, you know, if they're not just sitting around doing nothing, what if we exercise, you know, and so it carried on from there. It was probably... she's almost not fifteen, but probably about a good ten plus years ago, I was talking to the head of the program at Stanford, MD, PhD, neurosurgeon, inventor, entrepreneur, the guy that started the Brain Trauma Foundation sets all the standards for acute care and brain trauma. And I was asking him, I said, so what do you do with the athletes? And he goes, well, when I have an athlete, you know, he was the head of the Stanford university program. He goes, when I have an athlete that has a concussion, I put them on a treadmill the next day. I'm like, OK, well, what if they have a headache? And he goes kind of jokingly, but not so much. He said, I give him I give him a Motrin and I tell him to keep running. They're athletes. They just get better so much quicker. And that was like ten, twelve years ago, way ahead of his time. He goes, so he started, you know, exercising athletes within a day after a concussion, just not putting them back into the game, but getting their heart rate up. And so, you know, you need that blood flow. You need the adrenaline that that helps healing. But the other thing just in this last year that I thought was interesting was a similar study came out. like the University of Toronto study, and it showed that the kids that ignored the advice and went back to school sooner got better quicker. And so that has changed now the return to school aspect of things that were, you know, if you're following the most current research, kids should be getting back to school sooner with one minor, well, not so minor, but one exception is that they should be limiting their screen time, but they should be back into school with accommodations because the quicker they get back to school, the quicker they recover. And so this idea of go sitting in the dark room, no screens, no this, that, or the other, take away the phone, that's how kids communicate. And so, you know, you're taking away their communication. You're having them sitting at home, not doing anything, not on screen and not communicating with their friends. So no wonder they're not getting better because now you're throwing almost, you know, the prerequisite for depression on top of things because, you know, we're human. We need socialization. So all these things go together towards helping to recover. Yep, absolutely. You know, I mean, I always tell my patients screens, our brains were not meant for the screens. You know, I have them. I'm like, look, you've got to get printed material. Let's do as much of audio as we can. But screens really hurt quite a bit. And then the other part you mentioned, right? We do know based upon the research, if someone has depression heading into a concussion, it's going to take them longer to recover in general. or else if they develop depression because they're isolated, that also is going to prolong symptoms. And with what we've talked about with exercise, I'm gonna ask you to put out just a few little guidelines, because we know people who are listening to this or watching it are gonna say, all right, well, I can't have my kid do nothing. Let's get them active. Do you have just a few little tips of ways that parents can do it, or maybe a coach could do it for their kid, their athletes to be able to get some sort of physical activity without being like, oh, that was the worst advice I ever took. I was in a flare for a week. Right. Well, I mean, and, you know, I can't give specific advice. So nor should you, you know, in this format. But so it should work with your the treating physician. And but it's that crawl, walk, run type of thing. And so that's that return to play progression. Where at a minimum, it doesn't matter with a teenage athlete or a fifty six year old, you know, that slipped on the ice or was in a car accident. You need to exercise and you need to even if that means taking a walk around the block. And so, you know, maybe you can walk around the block once and then you feel wiped out. OK, that's fine. Good for today. You know, tomorrow, try it again. See if you can walk two blocks around, you know, two times around the block. So you want to I always tell my patients a mantra is push yourself, but don't hurt yourself. So you want to push the limits, whether it's screen time, reading time, exercise, whether that's measured in mileage or minutes. You want to push yourself, but not to the point where you feel worse. You want to push yourself up towards that. And there's more scientific ways to do that. A great way is by heart rate. And so if your heart rate, you know, your resting heart rate is sixty and you're young, so you could get your heart rate up to two hundred if you're running at a full on sprint. So, but now you get your heart rate up to, say, one hundred and twenty and you start to feel terrible headache and dizziness. And so now, you know, well, that's my threshold. Don't let your heart rate get that high. So, you know, maybe get up to one hundred, kind of keep it there for ten, fifteen minutes and then back off for the day. And that threshold is going to get better and better and better as you go on. But even that. It doesn't, even an elderly patient, I always tell them, you know, the most important thing you can do, and I prefer outside because I want fresh air and sunshine, hopefully, but Go outside for a walk, you know, and I said, whether it's one time around the block or, you know, three miles in the woods. Great. But push yourself a little bit. And, you know, we're talking about more of an athlete and a kid. OK, so now you can walk, you know, you can walk. at a slow pace for fifteen minutes good all right now you can walk at a fast pace for fifteen minutes great all right now what can you do you know a slow jog you know so you're picking up the pace to jog and then you're getting a little bit more running i i love sending kids back to practice as long as there's no contact Even if it's go to your soccer practice and you're not participating at all, anything, you're just running around the track on the outside. But now you're at least feeling like you're back part of the team. You're involved in the team meetings and things like that. But then kind of, all right, then you're doing some drills, no contact, no contact, no contact, right? And you work up to that. So you go from the walk to the jog to the run to the sprint to the game speed in practice before you get back to getting back into the game. yeah yeah that socialization component is so important and then like i said anything is better than nothing you don't want to flare up your symptoms but you know don't be so scared like i love stationary bikes i'll tell people look like look just do like three minutes three to five times throughout the day don't try to do thirty minutes all at once right just viewed as like you've got to sub yourself out of the game that's okay. And like you said, right, if you find at this threshold, you have issues, I typically tell people do eighty percent of what causes an increase of symptoms. Exactly. You said one twenty. Hey, do one hundred and tolerate it. Cool. Then you can go up. And, you know, this is where having a great health care provider that you're working with is really important because they can help coach you along the way, because there's a variety of factors that are going to impact how well you recover and how you progress.