A Review on The Concussion Repair Manual (A Practical Guide to Recovering from TBI)

I learned of this books existence from Kyle Kingsbury who is a former UFC fighter and now a proponent of human optimization. I have always been interested in learning about what can be done about concussions. A few cursory searches on google will show you that not a lot is known about treatment and prevention. I was very lucky to happen upon this book and its comprehensive list of treatment options. I hope that the knowledge I translate into this summary will be useful for you or your loved ones who have experienced TBI (traumatic brain injury) or will in the future. Concussions are an unfortunate consequence of my favorite activities (namely martial arts) and I hope that by sharing this information we can make our favorite contact sports less risk and more reward.

The author Dr. Engle opens up his manual with a brief backstory on his path to learning about healing the brain. He was a collegiate athlete and experienced multiple head traumas up to the point he refers to as a cracking of his “cosmic egg”. Just two weeks before entering medical school, Dr. Engle accidentally drove his car off of a 20 foot high pier into a sandbar and knee high water. He received a compression fracture of his C5 vertebrae and was put in a halo device (a device that resembles a halo but it is screwed into the patients head to immobilize their neck) for three months and one day. This event led to his all out attempt to understand TBI through any means possible. Due to his brain injuries Dr. Engle was diagnosed with narcolepsy and was put on a stimulant called Cylert (a relative of Ritalin) to keep him awake and safe during the day. After graduating medical school he has come to realize that he was hooked on this pill with “no end in site”, a fate he recognized was shared with many of his patients. Frustrated with this outcome, Dr. Engle dove deep into a large variety of alternative medicines to find a way to treat his and his patients symptoms at the root cause instead of just mitigating symptoms. Focusing on his diet and lifestyle, he adapted his sleep schedule and learned how to manage stress levels to alleviate the symptoms of his TBI. Today, he is still considered to be experiencing post-concussive syndrome (which we will talk about later) but his relationship with his symptoms has changed entirely according to him. He is also off the stimulant medication and no longer experiences any symptoms of narcolepsy. Using the modalities described in this book, Dr. Engle was able to change his life for the better in spite of the TBI’s he had built up in the past. He describes his mission as being here to “...help guide, support, teach and treat patients and families on the journey to concussion recovery.”.

Before getting into the contextual background of TBI and the history of its treatment, Dr. Engle provides a short section of the book that explains how you can use it as a manual for healing. I will use this section to briefly clarify that this summary will not include everything provided in the full text. If you are truly concerned with the knowledge in this book I recommend that you read it for yourself or find some of Dr. Engle’s content online to help you understand the nuances of treating an individual TBI issue. The book does an excellent job of reminding the reader that each case (just like each person) is unique and requires an individualized approach to make this information optimally useful. Please remember that my summaries are never going to be as exhaustive as the entire text that I am summarizing. I am just doing my best to bring out the main points of each section so that you can have a starting point on your journey for more knowledge.

This book was published in 2017, and according to Dr. Engle, 3.17 million Americans were “living with long-term disabilities related to TBI”, which the author considers a low estimate. In 2009, 3.5 millions people received medical attention for injuries related to concussion. Between 2001 and 2010, there has been a 60% increase in TBI-related deaths, hospitalizations and trips to the ER. The author goes on to represent the data on concussions through various graphs and charts (again, might be a good idea to get the book for yourself to see the full breadth of information). Dr. Engle also details which activities were likely to cause TBI in men and women. Among men, bicycling, football and basketball were the top three offenders. Among women, Bicycling, playground activities and horseback riding caused a majority of the damage (with women’s soccer coming in a close fourth, which makes sense if you watch college level women’s soccer). The author also makes sure to include the data surrounding TBI in active military members, which is currently on the rise. He claims that 4% of the total 5.6 millions service members have been diagnosed with a TBI. While 4% seems small, the number of service members with TBI is 224,000 people with a TBI that has been diagnosed. The author is also quick to remind readers that concussions can be tricky to detect, especially for long-term effects. This means that the numbers you just read are most certainly higher in reality.

Dr. Engle provides a brief section on the long-term effects of TBI often referred to as post-concussive syndrome. Some of the long-term effects include: problems with thinking and memory, trouble communicating, issues with sensation, mood swings and sleep problems. This, however, does not cover the entire spectrum of issues. TBI has also been linked to Parkinson’s, Alzheimer's, early on-set dementia and even premature death. For example, a moderate brain injury can double your chances of getting Alzheimer's and a severe brain injury can quadruple your chances. Dr. Engle also explains the cost of brain injury to the individual and the state. By the year 2000, researchers estimated an economic cost of more than $221 billion dollars (by 2009 currency standards) for TBI treatment. A shocking stat that he also shared in this section relates to sufferers of TBI and unemployment. He claims that the unemployment rate for TBI patients who had completed in patient care (were no longer treating their TBI at a hospital) was 60.4 percent between 2003 and 2012. The Average US unemployment rate in 2017 was 9 percent. This is a testament to the life changing effects of a traumatic brain injury.

Up until recently, the understanding of TBI and its subsequent treatment has been ineffective at best and life-threatening at its worst. Dr. Engle describes how a TBI can cause “virtually any type of psychiatric symptomatology” from depression and anxiety all the way to personality changes. Human’s first attempt to heal brain injuries was done through boring the skull. This type of treatment was done up until the civil war era with little benefit. Blood-letting was also a common treatment (but back then, they used blood-letting for everything). By the 1930’s, when patients displayed psychological symptomatology (from TBI or otherwise) frontal lobotomies were a common treatment. Between 1936 and 1956 an estimated 60,000 frontal lobotomies were performed. Luckily, all of these practices are no longer utilized in the treatment of TBI (or anything for that matter).

In the next section, Dr. Engle describes how a healthy brain should function so that it can be compared with a brain that has received a TBI. He describes a few of the various aspects of brain anatomy including neurons (the cells that transmit nerve impulses) and glial cells (namely astrocytes and microglia) which are critical for supporting the functions of neurons. It is important to note that these glial cells are involved in the brain’s immune system and they help to form the Blood Brain Barrier (BBB or B3 is how I will refer to it). The BBB is a critical wall of defense that allows only certain nutrients into the brain. When other substances enter the brain (say when the B3 is weakened from head trauma) a cascade of injured brain cells results. As these unwanted elements of the body enter the brain through the weakened BBB, the brain starts to swell, which can limit oxygen to the brain. With limited oxygen, the brain’s energy mechanism (called glycolysis) starts to produce a substance called lactate which is usually combined with oxygen to create energy. As there is less oxygen in a swollen brain, this lactate starts to build up and even more cell death will occur. Seeing the damage in the brain, the brain’s immune system responds which increases the amount of swelling in the brain. The immune system also leaves behind a residue called amyloid beta plaques. These plaques cause even more inflammation which leads to even more swelling. You can see where this feedback loop is heading and its not in a good direction.

The following section of the manual covers genetics and Apolipoprotein E (or ApoE pronounced AY-POE-EE) in particular. Apolipoproteins are a subtype of proteins that help shuttle cholesterol and fatty acids to neurons. The ApoE gene has 3 known variants named ApoE2, ApoE3 and ApoE4. You won’t need to remember anything about variant numbers 2 and 3 since they function normally in the brain and aren’t associated with any brain issues. ApoE4 on the other hand, is problematic, and having just one copy of ApoE4 is linked to a tenfold increase in Alzheimers risk. Let me repeat that, a TENFOLD INCREASE! An unlucky 2% of the US population has two copies of ApoE4 and their risk for Alzheimer's is even higher. This issue essentially breaks down to tau tangles (a brain structure linked to Alzheimer's) and amyloid beta plaques not being cleared from the brain at a sufficient rate. This results in an unhealthy build up of these substances. Under normal conditions, both tau proteins and amyloid beta plaques play important roles in healthy brain function but too many can cause essentially a traffic jam of nutrients and waste products. Dr. Engle recommends getting genetic testing so you can see how careful you will need to be about

receiving a brain injury.

Diagnosis of TBI can be difficult but having some basic knowledge on what to look for and how to grade the severity of the injury can be helpful. Most of the concussions from sports would be considered mild and about 90% of diagnosed concussions don’t include a loss of consciousness, but they should still be treated cautiously. Mild TBI symptoms include: headache, light sensitivity, nausea/vomiting, poor coordination, tingling/numbness, visual changes and problems with concentration or memory. Something that Dr. Engle notes as a possible symptom is abnormal behavior. So, I believe it is critical to have potentially concussed individuals speak with someone they know well so that they can identify any odd behaviors (some people are just weird or slow, it doesn’t mean they are concussed). Higher tech diagnostics come into play once the injury seems moderate or severe. Unconsciousness that lasts longer than 30 mins and amnesia that lasts longer than 24 hours indicate a moderate to severe TBI. In my opinion any period of unconsciousness and any lack of memory should be taken seriously but these are just useful tools to scale the possible severity of the injury. Dr. Engle also describes the use of the Glasgow Coma Scale to diagnose the severity, which can help quantify the individual’s symptoms.

Dr. Engle then provides his 5 keys to effective treatments which are listed as follows:

1.) Nerve growth and repair

2.) Decreasing inflammation and oxidation

3.) Increasing circulation and oxygenation

4.) Removing scarring, proteins and tangles (amyloid beta plaques and tau tangles)

5.) Improving cell signaling and function

The next section of the manual covers the various treatments he believes are useful. I will briefly list their pros and cons so you can get the basic idea about each treatment.

The first therapy in the manual is floatation therapy. This treatment includes placing oneself in a sensory deprivation tank and just floating there with limited stimulation (breath-work and meditation help but are not necessary). Dr. Engle finds this therapy to be extremely useful and suggests that it comes with very little risk and tons of reward. The rewards generally revolve around limiting stress. A meta analysis of 27 studies from 1983 to 2002 (including 449 people) suggested that floating was more useful for stress relief than biofeedback and other stress-reducing techniques. These studies indicate that floating reduces the amount of cortisol (a stress hormone) and other hormones like ACTH (a cortisol releasing hormone), norepinephrine and epinephrine. Lowering these hormones brings the body into a more parasympathetic (rest and digest) mode and lowers levels of inflammation. This therapy is widely available in larger cities and individual therapies are not very expensive. A single float can cost between $30-100 (although I have floated for cheaper) and you can even get a float tank in your own home if you ball like that. It should be noted that people who struggle with tight spaces may find this therapy to be panic inducing but hey, maybe you should work that out too. From personal experience I can say that you will never find anything in life that feels similar to being completely still in a tank and just experiencing your breathing. Originally, these tanks were developed for psychedelic adventuring so if your a freaky hippy like me you can see the benefits of doing a deep dive into the brain with no outside stimulus.

The next therapy discussed is called low level laser (light) therapy. This therapy acts on particular cells called chromophores which respond positively to certain frequencies of light by increasing cellular respiration and generating more ATP (energy at the cellular level). This treatment has been used successfully for healing musculoskeletal injuries more rapidly and has had great success in treating TBI in mice. This therapy is becoming more available and I expect within the next few years it may even become a common household tool in developed nations. Currently, and in-home unit can cost $500-5,000 dollars but you can also go and get individual treatments in a clinic to see if buying one would be a good idea. It’s important to note that this light should not shine on a thyroid or pregnant lady as we do not know the full spectrum of effects this can have on sensitive populations. Speaking of sensitive, I have heard of people using this therapy on their genitals to increase sexual performance with some positive effects. So if you can shine the LLLT lights on your little brain, I am sure it can work well on your big brain.

Hyperbaric Oxygen Therapy (HBOT) comes up as the next treatment. Like the last therapy, this treatment works using all five of Dr. Engle’s keys to an effective treatment. The treatment involves being placed in a closed chamber full of highly oxygenated air. This short increase in oxygen improves cellular signaling and blood flow to damaged areas. This therapy has limited research in regards to TBI but one study that included 16 US servicemen who had received a mild to moderate blast induced trauma, indicated that this therapy can relieve the symptoms of TBI. Although one person didn’t complete the study, (so N=15) the subjects increased their IQ by 14.8 points and noted “significant increases in their cognitive, physical, and emotional functions…”. It should be noted that HBOT has risks including mild pain in the ears, sinuses and/or joints. You can also become poisoned by too much oxygen exposure (called oxygen poisoning) which strongly backs the notion of “everything in moderation”. This treatment will generally only be available at larger hospitals and private clinics that specialize in this therapy.

The last three therapies in this section will all get bundled into this paragraph since they all utilize electromagnetic fields. Pulsed electromagnetic fields (PEMF) are the first to be covered and it differs from other EM (electro-magnetic) therapies in that it is using a weaker field of energy. PEMF units can be bought in various sizes and treatment in clinic is possible as well. Transcranial magnetic stimulation is a stronger EM treatment that is specifically for the brain and has been cleared by the FDA for treatment-resistant depression but has shown promising results for brain injury. If you feel that you are experiencing depression because of a brain injury this may be a good treatment option. TMS is only available in a clinic and it can cost $150 per treatment. Transcranial Direct Current Stimulation is the last EM therapy discussed and it uses a low current directed directly at the scalp. The effect of this treatment is not currently well understood but many studies have shown it to be beneficial for attention, learning and memory in healthy individuals. Very little research has been done on TBI patients but Dr. Engle doesn’t want you to count this treatment out, especially if you are suffering from more long term post concussive symptoms. This device supposedly increases neural plasticity which is essentially the brain’s ability to change. Seeing as how a concussed brain is in need of change you can understand how this treatment could be useful. So far, the literature on it is mixed but it may be a good idea to see what new research is out on TDCS. TDCS devices range in price from $150-$300 per unit.

Now that we have covered the technology in the field of brain recovery, Dr. Engle takes the reader through a series of interventional therapies starting with Hormone Replacement Therapy or HRT. Dr. Engle believes that the hormonal impact of TBI is greatly under-appreciated and highlights the effect that TBI can have. He discusses the three most prominent glands involved in hormone regulation: the hypothalamus, pituitary gland and pineal gland. These glands are in charge of many of the bodies functions including sleep, hunger/thirst, stress, growth and more. In summarizing the studies he sites in this section, Dr. Engle claims that “about half of all people with a major head injury will have some type of significant hormonal imbalance…”. The rest of this section covers the nuance of HRT and how it must be personalized to each individual case. Testing to see if HRT is right for a patient is extensive and thorough. Testing for thyroid hormones, stress hormones, sex hormones and hormones of the brain can cost between $200 and $500. Something I think should be noted for this section is HRT isn’t the only way to reset hormonal balance. Correcting errors in sleep, sun-exposure and eating times can have profound effects on hormone regulation as well.

The next interventional therapy in the manual revolves around learning devices (or cognitive rehabilitation devices) such as neurofeedback monitors, virtual reality and brain training mobile apps. Since these devices have not been on the market long there is little scientific literature that supports their efficacy in TBI recovery. However, Dr. Engle is convinced through anecdote and personal experience that these therapies will be found to be useful. I will add that there is very little downside to using these devices so it's more of an issue of time, interest and convenience as to whether or not you should use these modalities. The brain games are only a couple dollars a month and VR headsets are getting cheaper but the neurofeedback devices and other hand-eye coordination machines (like the Dynavision Board) are rather expensive.

There is also a device that is in close relation with the ones previously mentioned which can help you achieve an Alpha brainwave state. Dr. Engle claims that being in an alpha brainwave state is “conducive to healing” and helps keep neurons alive. These devices are used for neurofeedback therapy and utilize an EEG on the scalp to show an individual their brain waves in real time. Some weeklong courses are available for $5,000 to $20,000 and according to Dr. Engle’s personal experience these courses are like “rocket fuel for self awareness”. He mentions that people who undergo these courses can achieve brain states that are similar to zen meditation practitioners, even without previous yoga or meditation experience. So this type of therapy might be good for anyone looking to boost their cognition, regardless of a TBI.

Stem cell therapy is the next interventional therapy mentioned. For those of you who don’t really get what stem cells are I will give you the briefest explanation I can. Stem cells are essentially what every cell starts out as. It's a blank slate that can become any kind of cell the body needs. This characteristic of being able to become any type of cell is called pluripotency. Before, the only way to get stem cells was through embryos or bone marrow but now we have ways of taking specific cells (like muscle cell or neuron) and altering them to become pluripotent again. Once they become pluripotent, the therapy involves injecting the stem cells into an area that needs cell growth (like a brain post-TBI). There has been some solid success with this therapy that includes taking people who were in vegetative states towards showing signs of consciousness and reversing paralysis. Stem cells are a very promising therapy and their only drawback is that they may lead to cancer in some people (I know, big drawback). This is one of the reasons why stem cell therapy isn’t fully legal in the US. As we gain a better understanding of cancer and stem cells I am sure we will learn to mitigate this negative outcome. Keep your eyes open for new information on stem cell therapy if you are interested.

The author briefly mentions acupuncture as a viable therapy for TBI but I would caution you to consider the efficacy of such treatments in regards to healing the brain. While Acupuncture has been shown to alleviate some pains and potentially decrease inflammation, claims beyond that may be exaggerated. Consider using a therapy that has been more rigorously studied before using acupuncture, or consider using acupuncture as a complementary therapy to others like flotation and HRT.

Before Dr. Engle gets into a discussion of biological nootropics (Noo= mind, tropic= towards) which are non-synthesized chemicals that improve cognition, he discusses some pharmaceutical or synthesized nootropics. Namely, cerebrolysin, modafinil, Piracetam and Aniracetam. In short, these drugs are useful for creating new neurons, increasing memory and attention as well as other desirable benefits. Their long term side effects are not completely known but the safety of these drugs is dependent on the individuals chemical makeup. The side-effects of these drugs include nervousness, anxiety, increased heart rate and blood pressure and potentially headaches and diarrhea, but these side-effects are short lived and not seen in most of the tested population. I believe that these drugs can be useful for even healthy individuals looking to increase cognitive performance but be cautious in choosing and dosing these drugs as many are not prescription medications and your doctor may not know of them. Most of these drugs are available online, along with a whole host of other nootropic drugs. Do your own research into whatever drug you want to use and make sure to bring it up with your general practitioner before attempting to self-medicate.

After discussing pharmaceutical nootropics, Dr. Engle brings biological nootropics to the discussion. These nootropics include fish oil (DHA/EPA), phosphatidylserine and phosphatidylcholine, glutathione, vitamin C, lithium orotate, vitamin B12 (Methylcobalamin), Alpha Lipoic Acid and Acetyl-L carnitine. Dr. Engle also mentions that this is not a full list of nootropics and more will be introduced in later sections. For fish oil, a suggested dose for brain support and repair is 2,000+ mg per day. EPA and DHA are essential fatty acids that make up much of your brain tissue and roughly 60% of the brain is made of fat. Having higher amounts of DHA and EPA has also been shown to be anti-inflammatory on top of being a preferred brain nutrient. Dr. Engle recommends krill oil for your supplement source since krill are less toxic, contain more DHA than other sources, are more bioavailable than other sources (easier to absorb the nutrients) and more sustainable to source (has less dramatic environmental impact). I personally use krill oil supplements that supply 240 mg EPA and 110 mg of DHA per day. Phosphatidylserine (PS) and phosphatidylcholine (PC) are phospholipids that are critical in neuronal function (another set of supplements that I currently use). It has been shown that higher levels of PS are correlated with higher levels of neurotransmitters like acetylcholine, norepinephrine, serotonin and dopamine. PS can also reduce stress through limiting levels of cortisol and enhancing an individual's tolerance of stress. PC is used as a reserve to tap into once PS levels have dropped. Recommended doses for PS is between 500-1,000 mg taken at night before bed. Recommended dose for PC is 800-2,400 mg per day. Both are relatively inexpensive and can be aided by higher levels of DHA so it might be wise to consider supplementing fish oil concurrently. The substance glutathione is a nootropic that Dr. Engle believes to be essential in the process of healing from TBI. Glutathione interacts with the body to neutralize free-radicals (or reactive oxygen species) that cause a large portion of the damage in regards to TBI and other ailments like cancer. Supplementing Glutathione is difficult since it cannot be administered orally (IV, suppository and nasal spray are all options). Vitamin C is well known antioxidant and that antioxidant effect can be very useful in a brain that is becoming more and more oxidized during the swelling from TBI. Consider increasing your vitamin C intake by 1,000-3,000 mg a day during injury. Remember, since vitamin C is a water-soluble vitamin, you will urinate out whatever amount of vitamin C that’s excessive. There is some documentation regarding vitamin C toxicity so if you notice any symptoms (such as headaches, abdominal cramps, insomnia etc.) try a smaller dose or using a different antioxidant. Lithium orotate can be used at low doses to repair damaged neurons and improve neurotransmitter balance. A dose of lithium orotate can be anywhere from 5-10 mg per day. Don’t overdose on lithium orotate or your kidneys will pay the price of lithium orotate toxicity. Vitamin B12 or methylcobalamin can aid the wounded brain by reducing the amount of glutamate that is present between the neurons. Glutamate can also build up through consumption of MSG (monosodium glutamate) and, according to Dr. Engle, the artificial sweetener aspartame. B12 also helps the neurons myelinate (which refers to the building the myelin sheath that covers the outside of axon of a nerve cell). Doses start around 1-2 mg a day but as far as I know, know has ever become harmed by a B12 overdose, since it is also a water-soluble vitamin that will not be stored in excess. Alpha Lipoic Acid is our second to last substance. Dosed at around 600 mg per day this substance is referred to as the “universal antioxidant” and has shown to be apart of a pathway that can regenerate vitamin C and E and can prevent deficiencies in both vitamins. Our final biological nootropic in this section is Acetyl-L Carnitine. This substance can help network of dendrites (the receiver end of neurons) recover and expand. It is also an antioxidant that helps clean up damaged lipid (fat) molecules in and around the cell. Doses of Acetyl-L Carnitine range from 500 mg to 1,000 mg twice daily.

This next section is one of my favorite portions of this book. Dr. Engle describes the following methods as the 5 S’s: sleep, sun (heliotherapy), sex, sound (music therapy) and Skin (earthing technology). These 5 topics are not only good methods for recovering from TBI but also for optimal living for the general population. Sleep may be one of the most important tools for recovering from brain injury but paradoxically, TBI patients have a higher incidence of insomnia and poor sleep. According to the author, 40-65% of TBI patients with a mild TBI suffer from chronic insomnia. Dr. Engle recommends using sleep tools such as calming botanicals (valerian, kava kava, chamomile etc), melatonin supplements, magnesium, and inversion before bed. It is also wise to stop eating 2 or even 3 hours before laying down for sleepy time. All of these tools help to increase sleep quantity and quality. I would like to add that common “nightcaps” such as a glass or two of wine or a joint are actually detrimental to good sleep. So try and stay sober while recovering from TBI (especially before bed). All cycles of sleep have some sort of positive affect on the brain and using substances like alcohol and marijuana can dampen these affects by limiting your exposure to particular cycles. Also, speaking of exposure, make sure to limit the amount of blue light you are exposed to a few hours before bed. On the topic of light, vitamin D synthesis from light exposure is helpful for getting sleep and exposing your eyes to the suns full spectrum of light helps your body understands that its daytime. When paired up with limiting blue light at night, your body gets a better grasp of its circadian rhythm (body clock) and you will more likely be tired when its time to sleep and feel more awake when its time to be up. Another paradoxical aspect of treating TBI is that orgasms (especially in a partner setting) help you heal from TBI by balancing hormones, but many TBI patients report having a decreased libido. Dr. Engle recommends personally reflecting on how the TBI impacts your sex drive and discussing it with your partner or people who your are close with. You can also consider taking sexual performance enhancing medications or HRT but examine your options carefully and as always, discuss it with you doctor. The author also recommends maca powder (which I personally think tastes good in smoothies) and sex therapy as possible treatment options for low sex drive. Sound therapy is described next as a way of retraining the brain. Things like active listening have been shown to increase neural plasticity within minutes of trying. Passive listening can increase the production of neurotransmitters like dopamine but Dr. Engle recommends active listening over passive for neuronal development and brain healing overall. Dancing to music has also shown to be useful for the aging brain ( and possibly the injured brain), as elderly people who dance decrease their Alzheimer's risk by 76%. Dr. Engle also states that elderly people who play an instrument decrease their Alzheimer's risk by 69%. For a more rigorous approach to sound therapy Dr. Engle recommends the following programs: Integrated Listening Systems, Rhythmic Auditory Stimulation and Neurologic Music Therapy. He also adds that you should find people who are well experienced in their chosen sound therapy system. The last tool is skin and earthing that skin. Putting your bare skin on the earth has been shown to improve sleep, lower blood pressure, reduce pain and inflammation, decrease cortisol levels and thin the blood (which may help improve circulation in some people). Obviously, putting your bare skin on the earth is free but you can also purchase devices that can “ground” you while you are indoors. These come in various forms but you have access to mats, bands and even sheets for your bed that can get you in touch with the earth while you are inside. These can cost anywhere from thirty to a couple hundred dollars. The basic concept of earthing is that your body absorbs some of the earths free electrons that help you deal with the reactive oxygen species in your body that cause all sorts of trouble. There is limited research on this topic but it is a growing field and we are learning more and more each year about this process of earthing. So go get some sun, in your bare feet, listen to your favorite tunes and listen in on good conversation, go home, get laid and get some quality sleep, you deserve it!

The following sections focus on personal practices including balance and bodyweight training, Qi Gong, Tai Chi, Yoga Meditation, Inversion Therapy and lastly faith and perseverance. This section is built on a lot of anecdote and case studies so I will try to focus on the points backed by science. I think it’s important to note that the benefits of these personal practices may not be direct but the benefits are still there and should not be taken lightly. As far as general exercise (like bodyweight training, balance training and aerobic exercise), the neurologic benefits relate to the type of exercise performed. Many TBI patients experience poor motor control and proprioception (the bodies ability to sense where it is in space). So, by training balance and performing difficult tasks that require higher levels of coordination, the brain and body synchronize according to the intensity of the training. Dr. Engle claims that many people who undergo balance and bodyweight training also feel more confident in their physical capabilities which is important for TBI patients. Aerobic exercise has been shown to increase capillary density (more blood to the brain), as well as increase the length and number of dendritic connections in the brain and improve the function of the hippocampus which is important for memory formation and storage. It’s important to note that this information comes predominantly from animal studies but I think it’s safe to assume similar processes occur in humans. Dr. Engle’s section on Qi Gong, Tai Chi and Yoga relies heavily on anecdote and his personal and clinical experience with patients. However, these practices are very similar to meditation and have been shown to improve focus in practitioners of these disciplines. Meditation has undergone extensive research and one of the main findings on meditation revolves around taking the body from a sympathetic (fight or flight) mode to a parasympathetic mode with time and practice. This process is so powerful that it has even been shown to improve the immune response of practiced meditators. In one study cited in this book, a group of people went through an 8-week meditation program and showed an increased resistance to the influenza virus. Dr. Engle states that meditation decreases the body's cortisol levels which has a direct affect on the function of the immune system. An overactive immune system can lead to a slow healing brain, so staying relaxed is a critical part of the healing process. The author also briefly discusses inversion therapy (going upside down) as a way of calming the mind and bringing more blood flow to the brain. He cautions against diving headfirst (pun intended) into this therapy as it can cause headaches and dizziness. Eventually, he believes that people can get to a 20 minute inversion session daily and receive positive results from this daily practice. Inversion seems to be something that Dr. Engle does personally and his experience with it may cause him to be overly enthusiastic. He cites very little science and mainly just provides a current working model that involves the motion of CSF (cerebro-spinal fluid) into the brain which may provide the benefits he discusses. The last practice he talks about (which includes a promising meta-analysis) is faith and the mental side of healing. He cites a meta-analysis of 122 studies that claims people who have a close relationship with a cohesive family unit are 3 times more likely to follow the treatment plan. This is critical because adherence is the first and most important aspect of any treatment protocol. Subsequently, the people in the study with poor family ties were 2.35 times less likely to follow the treatment plan. He also points out that people with roommates had higher levels of adherence than people who lived alone. I think this is a great point to make in regards to general principles of health as well. Feeling connected and having something (or someone) to be healthy for, will greatly improve your likelihood of being healthy. Takeaway from this section, move, meditate, maybe invert and definitely give your loved ones a call.

Our next section of this book covers the topic of foods for TBI recovery. The foods covered in this section are great for brain health in general (just like almost everything in this book). So, even if you aren’t suffering from a TBI it’s a good idea to consider the concepts in this section. The various subjects of the food discussion are the ketogenic diet, oily fish, coconut oil, turmeric and egg yolks/lecithin. You’ll notice that almost every subject relates to fats and increasing fat consumption. If you have not caught wind of the ketogenic trend in the fitness industry than some of this may come as a shock to you but I think it is important to know of the importance of fats in your diet. Fat is not bad but not all fats are created equal. Your cells are literally composed of fats in a structure called a phospholipid bilayer (lipid meaning fat) and your brain is nearly 60% fat. So, it is a good idea to make sure you are consuming enough fats and also the right kind of fats. In this section, Dr. Engle warns against the dangers of trans fat. Trans fats are currently on their way out of the US food market as the research relating trans fats to negative health outcomes (namely cardiovascular disease) increases. They are finally being treated as a poisonous substance. Dr. Engle claims that trans fats are “sticky” and can harm the motion of nutrients into the brain and toxins out of the brain. That being said, saturated fats and omega-3 fatty acids should be considered safe fats as long as they fit into your dietary protocol. I am currently not on a ketogenic diet but I have slowly increased my fat intake so that I can balance out the macronutrients (fat, carbs and proteins) in my diet to better fit my lifestyle. This approach is what Dr. Engle recommends if a keto diet is something you are considering. He doesn’t want people to go from a high carb low fat diet to a strict ketogenic diet overnight. It is probably best to be gradual and mindful of a slow change over into incorporating more fat and limiting carbohydrate intake (preferably starting with limiting processed carbs/sugar). The author cites a study that followed 937 elderly people through the process of aging while keeping track of their macronutrient intake. They found that those who ate a high carbohydrate diet doubled their risk of dementia or mild cognitive impairments as compared to those with a moderate carb intake. He ends the keto segment by discussing what kind of oils to buy and how to source your diet for optimal recovery. Of those oils to buy, oily fish may be the most important. DHA, a particular fatty acid found in fish has been shown to improve cognitive function. The author cites a study in which people supplemented 900 mg of DHA and the participants improved their cognition in regards to memory, even though they were previously struggling with mild memory issues (like forgetting names and appointments). He also cites various animal studies that focused on the more rapid healing of rat brains who had been supplementing either before or after a TBI. He also mentions coconut oil as a good source of fats. Coconut oil contains a particular fatty acid that has a shorter chain length which is easier to absorb and utilize in the body. The next section discusses turmeric (finally something that isn’t about fat!) and its active compound curcumin. Curcumin has been shown to decrease inflammation which is critical in any form of healing. The only issue with turmeric is absorption, but as long as it is bound to a fat source it should be absorbed adequately (again with the fats). Lastly, he brings up the topic of egg yolks and particularly lecithin. You may have heard about the egg debate and whether or not it increases your cholesterol in a negative manner. Eggs are not a bad food, they may be one of the most powerful foods in regards to micronutrient density (amount of vitamins and minerals). They also help your body regulate between the levels of HDL (considered the “good” cholesterol) and LDL (the “bad” cholesterol known to be apart of atherosclerosis). In general, consuming cholesterol does not increase your chances of cardiovascular disease. Lifestyle choices like smoking and exercise habits are the real determinants of heart disease among a few other things (like genetics). Takeaway from this section, eat more high quality fats and include foods that will decrease inflammation like DHA or curcumin.

I will cover this next section quickly as it will be very obvious to most. Dr. Engle provides a list of things to avoid in order to recover from a TBI. They include avoiding, a repeat TBI, sugar, obesity and alcohol. Obviously, if you are trying to heal your brain you don’t want to add another injury on top of the previous one. Stacking brain injuries is one of the reasons the concussion discussion has become so big in the NFL. CTE (chronic encephalopathy) is a condition described by repeat minor brain impacts that stack up over time and cause poor brain health outcomes. When you add another injury on top of a previous one, the body doubles down on the inflammatory response that was already causing your brain trouble. Avoid a repeat brain trauma at all costs! Less obviously, you should probably avoid sugar and being overweight or obese. Excess sugar in the diet (and excess eating in general) is taxing on your body and increases levels of inflammation. Again, anything that causes inflammation is bad news! We want to avoid inflammation in order to heal well. Along those lines alcohol does us no favors in the inflammation department. Beyond that, alcohol also depresses the function of the central nervous system in general (not something you want if its already struggling). Dr. Engle takes this a step further by citing a study that showed people who had alcohol dependence issues were far more likely to experience poor moods and behaviors after getting a TBI than those who didn’t have those same issues. Takeaway: Limit sugar, limit alcohol, be slim and NO REPEAT INJURIES!

The second to last section of this book covers the various forms of TBI assessment tools that are currently in use. I will briefly mention what they are what they do. Single Photon Emission Computer Tomography (or SPECT) provides a 3D view of the blood flow in the brain via injecting a radioactive substance into the body and using the SPECT device to monitor the flow. An unhealthy brain will have noticeable spots with limited blood flow and/or pooling of blood. EEG supported testing displays the brain in regards to synaptic activity and is highly accurate in assessing TBI. This technology is becoming increasingly mobile and easier to use in the field. Dr. Engle also discusses the use of non-EEG based computerized assessments that include a software that runs the individual through a series of memory, symbol/color matching and word discrimination games to test their cognitive function. These tests are not as accurate as the first two mentioned but they are much more accessible. There are also various on-field and at-home paper form assessments that are essentially just questionnaires with info for parents and coaches. Some mobile apps are also available that function in a similar way. The current assessments that you can consider using are the SCAT3 (sports concussion assessment tool) assessment, SCRT (sports concussion recognition tool) and PCSS (post-concussive symptom scale). Lastly, there is also a device that's been developed to check for blood pooling in the field called an infrascanner. This device uses infrared light on a particular brain area for 10 seconds to differentiate between pooled blood and flowing blood. More mobile devices like this are coming in the future and detecting TBI’s will become easier with the development of new technology.

The last section details how the author intends for the reader to use the manual. I will briefly cover his top 5 therapies in the categories of to do, to take and to avoid. To do: get a thorough examination from a concussion care specialist, rest and optimize sleep patterns, float in a sensory deprivation tank, consider acupuncture/acupressure (or massage) and alter your diet towards a ketogenic diet. To take: glutathione, vitamin D, melatonin, CBD and curcumin. To avoid: Any kind of contact sport or activity that risks a repeat head injury, high sugar diet, stress, bright light/loud music/excessive EMF’s (from phones, computers, video games etc.) essentially excessive stimulation and excessive pain medication. These top fives are obviously Dr. Engle’s favorite therapies but he is not saying that they are the best ones for everyone, just the ones that he has had the most success with. He also lists his top ten rules of engagement in a treatment protocol in the following order:

1.) Be curious: New science is coming out all the time so stay curious about new and useful information.

2.) Stack Therapies: not all therapies work well with each other but stacking one’s together that do work well in unison is wise for a speedy recovery.

3.) The first 1 or 2 therapies in each chapter are likely the best places to start.

4.) Start with symptoms and severity: Before utilizing any therapy make sure to establish your baseline of symptoms so you can track progress and move forward intelligently.

5.) Give it 30 days: A new therapy may not show signs of working until 30 days in (especially the supplements or dietary changes) so give it time to see if its really working before you move on.

6.) Keep moving: If the therapy has failed to improve symptoms after 30 days move on to a new therapy with a different mechanism of action (or a more potent effect).

7.) Maximize methods that work: If you are currently seeing benefits from a therapy at a minimal level of intensity consider increasing the intensity (dosage, therapies per week, length of session etc.) as long as you are not already using it at the maximum dose.

8.) Find the right fit: If you doctor is conflicting with you frequently and adding stress to your recovery process consider getting a new doc. This does not mean that you should get a new doctor every time they disagree but understand that there are plenty of doctors and one may be better for you than the one you have.

9.) Everyone is unique: Avoid comparing yourself to others and instead focus on your own progress and celebrate small victories. Your path to healing will be your own.

10.) Keep the faith: maintaining faith in your capacity to heal will be critical on your journey, so do what you can to maintain a positive outlook. Remember, seeking support and encouragement will increase your likelihood of adhering to protocols and getting better.

The rest of this book is dedicated to worksheets that you can use to track your progress throughout your healing journey. Similar worksheets can be found online if you google concussion tracking, as well as apps and other online resources. In summary, don’t get a repeat TBI, avoid inflammation and reintegrate your mind and body slowly but consistently until your recovery is complete. Dr. Engle believes that people can not only heal from a TBI but that they can improve their mind and body past their pre-TBI function. Don’t give up

hope and the belief that things can get better, they always can.

Follow this link to Dr. Engle’s online concussion resources:

https://concussionrepairmanual.com/media/