• How a concussion or more properly termed, traumatic brain injury (TBI), affects your brain
• Your body’s natural defense against TBI
• How CBD reinforces this defense and can help heal TBI

What is TBI?
We’re hearing a lot more about traumatic brain injury in recent years, with increasing diagnoses among many prominent figures from military combat veterans to figures in such high impact sports as football and boxing. There has also been attention focused on child and teen sports, where the injuries can be even more damaging to their more vulnerable bodies. Fortunately, TBI is being taken a lot more seriously now than ever before.

In TBI, the head is impacted by an external force that causes the brain to swell within the confines of the skull, thus decreasing blood flow, and causing other chemical changes that adversely affect brain function. In many instances, the brain fully recovers. Far too often, however, patients are left with lasting issues such as memory problems, depression, motor impairment, anxiety, migraines, vision problems, trouble processing, and much more.

Standard Medical Treatment of TBI
The biomedical standard of care for TBI consists of these doctor’s orders:

• Rest in a dark room
• Don’t spend time in front of screens
• Lay off the books, the job, the studying
• Don’t do excessive thinking

This, in addition to surgery and occupational therapy for more severe cases, is about all doctors have to offer those with a traumatic brain injury, commonly referred to as concussion. Then, it’s a game of watch and wait. The brain is left to heal largely without any specific therapies to support the body’s natural healing processes.

Functional Medical Treatment of TBI
In contrast, those of us who use an integrative or functional medicine approach which focuses on treating underlying issues, have found that there is a better way to treat TBI. There are a number of anti-inflammatory herbs, such as curcumin, that help heal the brain. There are modalities, like hyperbaric oxygen (HBOT), which rescue brain cells by enhancing the flow of blood and oxygen. Then there is neurofeedback to train the brain in forming new pathways. Add in acupuncture, an ancient but still powerful treatment for TBI. All these treatments already take us beyond the mainstream standard of care.

A treatment that is (too slowly) gaining more mainstream acceptance are orally administered omega-3 fatty acids that reduce the inflammation and thus, lessen the swelling in the brain. You can read more about this in When Brain Collide, written by my colleague, Dr. Michael Lewis. His omega protocol, in which patients take a mega-dose of fish oil over the course of a few weeks, has had remarkable results. It has restored brain function in many including bringing people out of coma. Some years ago, my friend JJ Virgin’s son, Grant, had a devastating head injury, and I saw personally how high doses of fish oil was instrumental in bringing him back. This was even covered by Dr. Sanjay Gupta on a special on the topic for CNN.

CBD for TBI
Now we have a new modality: the administration of CBD for brain repair. Like many of us, Dr. Lewis is not only enthusiastic about its use, but fortunately is using his platform as a recognized TBI expert to educate the public and doctors alike about the benefits of adding CBD to the protocol.

The proof? Animal studies have demonstrated that cannabinoids can not only reduce the acute effects of TBI, mitigating neurological damage, but can also help with the secondary effects, including those frustrating cognitive deficits that can linger after even after a “minor” TBI.

The Science
CBD takes us from “There’s nothing we can do,” to “We definitely can help you!” How does this happen? Here is some of the science behind the phenomenon.

First of all, as mentioned, TBI causes the brain to swell and induce a potentially toxic level of activity of the excitatory neurotransmitter, glutamate. This can lead to varying amounts of cell death in significant portions of the brain. Inflammatory compounds and free radicals are also released, creating oxidative stress. These acute effects of TBI can lead to a host of secondary effects, potentially killing off more brain cells, weakening the blood brain barrier, and contributing some of the hallmark symptoms of TBI like brain fog, mood disruption, and sleep problems.

In my blog on the endocannabinoid system, you know that the ECS, the bodily system controlled by cannabinoids, is responsible for relaxing your body and returning it to balance in times of stress. It is also your body’s natural defense against TBI.

The ECS has two main receptors: CB1 and CB2. When activated, CB1 decreases excitatory glutamate activity. Excessive glutamate is toxic to brain cells, and the ECS has evolved to fight against it.

CB2, on the other hand, when activated revs up the immune response. It helps repair cells and promotes the creation of new neurons. This directly combats brain damage caused by cell death. Notably, CBD also preserves memory by preventing neuronal loss in the hippocampus, the brain’s memory center.

Brain Damaged Mice and CBD
In one study, researchers inflicted a TBI on mice genetically engineered to lack either CB1 or CB2 receptors. Their injuries were more severe compared to those of mice that had both receptors. Moreover, studies have shown that after a TBI, ECS activity increases to enact healing.

Another study showed that after a head injury was inflicted on a group of mice; when half of them were untreated and the other half received a single dose of plant derived endocannabinoid called 2-AG, there was a definite difference in outcome. The mice who received treatment improved in cognitive function, motor function and every parameter examined, even months later—a remarkable success. Of course, in a lab setting the scientists had the advantage of being able to administer the dose of 2-AG shortly after brain injury, so while it proved the point, it may be harder to do this in everyday head injuries.

CBD works best if administered in the “window of opportunity,” the critical moments after a brain injury, in which intervention can actually prevent brain damage. Typically, this window is a matter of minutes, 10 minutes, maybe an hour. CBD widens this window of opportunity. It works best up to 12 hours after an injury.

However, even if you had a brain injury, months or even years ago, CBD can still help by reducing brain inflammation and treating the secondary effects mentioned above, just not as well as if treated at the time. As long as you have symptoms from a TBI, CBD can have a positive effect.

How does it work?
CBD is what’s called a “promiscuous compound,” i.e., a chemical that binds to a variety of different receptors. That means CBD not only binds to the receptors of the ECS, but other receptors such as the serotonin receptor 5-HT1A and the PPAR-gamma nuclear receptor. These two receptors, when activated, protect the essential blood brain barrier which can be damaged during TBI. The blood brain barrier is a network of blood vessels and cells meant to keep unwanted substances out of the brain. It’s exceedingly difficult to pass through, and any weakening of it can allow otherwise unwanted substances to enter the brain. This can lead to inflammation and other brain conditions.

Serotonin, as you may know, is a major regulator of mood, and is the purported target of popular antidepressant medications, the SSRIs. CBD is known to boost mood not only through its impact on serotonin, but also dopamine, the pleasure or “reward” neurotransmitter, and GABA, the calming neurotransmitter. Thus, CBD can ease the depression and anxiety that can be so troublesome for those recovering from TBI.

More Brain Benefits
And it doesn’t stop with mood. CBD can also improve memory and lift brain fog. As mentioned, CBD can promote neuron growth in the hippocampus. It also regulates acetylcholine, which boosts memory and mental acuity.

One more huge benefit is the effect of CBD on PTSD (Post Traumatic Stress Disorder). It acts in the area of the limbic system, the seat of emotions, to help “forget” the fearful emotions associated with the traumatic event. This is important since PTSD is difficult to treat successfully by conventional means. There are specific trauma treatments such as EMDR, somatic experience, tapping and more, and they all work well, but even better in conjunction with CBD.

With all of its healing ability, CBD has yet become a standard treatment for brain injury. We hope that with more studies on its use, and simply, more experience by the public and the medical profession, it will become better accepted.

Luckily, you don’t have to wait for researchers to construct the perfect clinical trial in order to start using CBD.

Choose a full spectrum hemp oil extract which delivers the remedy as nature intended, with other cannabinoids and terpenes, so you get the best effect possible, known as the “entourage effect.”

How to Take CBD
Start out with a small dose and increase gradually, using your own response as a guide. Typical doses are 25–100 mg daily in divided doses 1–3 times daily. Doses are quite individual, based on your unique ECS activity.

Interactions with medications:
Even though CBD has a good safety profile, if you are taking medication, you should check with your doctor before trying it. Both CBD and most pharmaceuticals are detoxified by the liver’s cytochrome P450 enzyme system. As a result, certain medications, including chemotherapy agents, anti-epilepsy drugs, and the blood thinner coumadin may be affected. In some cases, you just have to have the drug dose decreased. For a list of potential drugs that may interact with CBD, see this link: https://cbdorigin.com/cbd-drug-interactions/ The fact is, though, we have found that doses under 100 mg a day generally do not interfere with medications.

Adjunctive Care
In addition to taking CBD, take large doses of omega-3 oils. I also agree with the conventional wisdom to rest your brain until medically cleared to become more active. You can enhance this rest with meditation and breathing exercises as well as good nutrition. Steer clear of all processed foods and sugar, and eat a plant-based diet that is also high in healthy omega-3 fats in such foods as avocados and wild caught (or sustainably raised farmed) salmon.

Other integrative supportive measures include neurofeedback, low level laser, PEMF, hyperbaric oxygen, Transcranial Magnetic Stimulation (TMS), and acupuncture. The bottom line here is that while we still have a lot to learn, there are increasing resources for treating this serious condition. Most exciting right now is the promise of CBD or more properly, Full Spectrum Hemp Oil Extract for treating TBI.

Think about it this a moment. We are a big bag of water. Ever wonder why it doesn't just all flow down to our legs when we stand up?

The answer is, that it does. Because of this, our autonomic nervous system has to direct the blood vessels in our legs to contract and send the blood back up to our brain and muscles where it is needed. Otherwise, the effect can be similar to rapidly losing several units of blood.

When this system is not working properly, people's blood pressure can drop significantly when they are upright for an extended period. This can result in low blood pressure (Neurally Mediated Hypertension-NMH) or a compensatory rise in heart rate called Postural Orthostatic Tachycardia Syndrome (POTS). Whatever name you choose to call it, it falls under the umbrella of orthostatic intolerance. When people stay upright, they can get dizzy, exhausted, and brain fogged.

Orthostatic intolerance is a major and very treatable part of what causes disability in CFS and fibromyalgia. And research has shown that many people diagnosed with NMH and POTS actually have CFS or fibromyalgia.

Some Background
Just a quick refresher. Fibromyalgia essentially represents an energy crisis in the body. When this happens, the area that uses the most energy for its size, called the hypothalamus, malfunctions. Basically, it is like tripping a circuit breaker when one has an energy crisis. Just as there are hundreds of ways to blow a fuse; there are numerous triggers for the energy crisis that precipitates fibromyalgia.

So what does the circuit breaker that goes off-line control? The hypothalamus controls:

1. Sleep. Which is why insomnia despite exhaustion is a hallmark of this condition
2. Hormonal function
3. Temperature regulation
4. Autonomic function

We have addressed these other components in earlier articles. To summarize, our research showed that by treating with the SHINE Protocol, 91 percent of people with fibromyalgia improved with an average 90 percent increase in quality of life (p<.0001 vs. placebo). SHINE stands for:

• Sleep
• Hormonal support and Hypotension (Dysautonomia)
• Infections
• Nutritional support
• Exercise as able

To make this easier, there is a free Energy Analysis Program at www.EndFatigue.com that can analyze your symptoms and even lab tests. I had this illness in 1975 and it left me homeless. So my goal is simple. Helping to make effective treatment for people with this illness available—to everyone.

Orthostatic Intolerance
So basically, autonomic dysfunction is a routine part of fibromyalgia, and contributes markedly to its symptoms. People are upright for a few minutes, the blood rushes to their le.g.s, their tissues don't get adequate blood flow, and they feel wiped out and brain fogged.

Simple so far. It gets simpler

How to Diagnose It
The standard approach to diagnosis is to use a Tilt Table Test. It is unreliable, will make the person miserable, and the insurance tends to not cover it leaving them with a $2000 bill. An easier approach? A wonderful study in the Mayo Clinic Journal showed that this simple quiz could be quite reliable. It is free and takes about two minutes.

Self Report Orthostatlc Grading Scale Mayo Clin Proc. 2005;80(3):330-334 ("Orthostatic symptoms" include worsening dizziness, fatigue, Racing heart or brain fog when standing)

Circle 0 –4 below as best applies to you

A. Frequency of orthostatic symptoms
0. I never or rarely experience orthostatic symptoms when I stand up
1. I sometimes experience orthostatic symptoms when I stand up
2. I often experience orthostatic symptoms when I stand up
3. I usually experience orthostatic symptoms when I stand up
4. I always experience orthostatic symptoms when I stand up

B. Severity of orthostatic symptoms
0. I do not experience orthostatic symptoms when I stand up
1. I experience mild orthostatic symptoms when I stand up
2. I experience moderate orthostatic symptoms when I stand up and sometimes have to sit back down for relief
3. I experience severe orthostatic symptoms when I stand up and frequently have to sit back down for relief
4. I experience severe orthostatic symptoms when I stand up and regularly faint if I do not sit back down

C. Conditions under which orthostatic symptoms occur
0. I never or rarely experience orthostatic symptoms under any circumstances
1. I sometimes experience orthostatic symptoms under certain conditions, such as prolonged standing, a meal, exertion (e.g., walking), or when exposed to heat (e.g., hot day, hot bath, hot shower)
2. I often experience orthostatic symptoms under certain conditions, such as prolonged standing, a meal, exertion (e.g., walking), or when exposed to heat (e.g., hot day, hot bath, hot shower)
3. I usually experience orthostatic symptoms under certain conditions, such as prolonged standing, a meal, exertion (e.g., walking), or when exposed to heat (e.g., hot day, hot bath, hot shower)
4. I always experience orthostatic symptoms when I stand up; the specific conditions do not matter

D. Activities of daily living
0. My orthostatic symptoms do not interfere with activities of daily living (e.g., work, chores, dressing, bathing)
1. My orthostatic symptoms mildly interfere with activities of daily living (e.g., work, chores, dressing, bathing)
2. My orthostatic symptoms moderately interfere with activities of daily living (e.g., work, chores, dressing, bathing)
3. My orthostatic symptoms severely interfere with activities of daily living (e.g., work, chores, dressing, bathing)
4. My orthostatic symptoms severely interfere with activities of daily living (e.g., work, chores, dressing, bathing). I am bed or wheelchair bound because of my symptoms

E. Standing time
0. On most occasions, I can stand as long as necessary without experiencing orthostatic symptoms
1. On most occasions, I can stand more than 15 minutes before experiencing orthostatic symptoms
2. On most occasions, I can stand 5–14 minutes before experiencing orthostatic symptoms
3. On most occasions, I can stand 1–4 minutes before experiencing orthostatic symptoms
4. On most occasions, I can stand less than I minute before experiencing orthostatic symptoms

_____Total Score

Scores of 9 or higher suggest Orthostatic Intolerance In fibromyalgia, I consider a score of seven or higher to be suggestive.

In addition, the instructions for how to do NASA 10-minute lean test checking blood pressures can be found at https://batemanhornecenter.org/assess-orthostatic-intolerance/ So whether you simply want to diagnose it by history, checking blood pressures, or both, the diagnosis can be fairly simple.

Treatment

Basically, these simple treatments can markedly improve function:

1. Increase salt and water intake. I know. You are already "drinking like a fish." But you are also "peeing like a race horse!" This occurs because one of the hormone deficiencies is antidiuretic hormone (vasopressin—the anti-peeing hormone), which leaves you dehydrated. In addition, salt is the sponge that holds water in our body. You need to eat large amounts of salt, sometimes even licking sea salt. You can simply do this from the palms of your hands. If you notice, you will find that your body is craving salt. You will sometimes find that in an attempt to be healthy, many of you are salt restricting. That misguided advice is a good recipe to crash and burn.
2. It is remarkable how much improvement many people will see by simply using medium pressure (20–30 mm) compression stockings. They should use ones that go at least to mid thigh, but if they can't wear those, then kneehigh ones will still be fairly helpful. You should wear them during the day when you are active (not when you are lying down for extended periods). Although low cost, these first two treatments are very helpful. Wearing something that constricts the abdomen, such as a corset or a girdle, may also be helpful.
3. Improve adrenal function. This is a critical part of our holding onto salt and water. As discussed in earlier articles, some will benefit a prescription from low dose hydrocortisone (do not go over 20 mg daily). In addition, natural adrenal support with Adrenaplex or Adrenal Stress End is very helpful for optimizing adrenal function.
4. Salt and water retaining hormones (prescription). Florinef .1 mg each morning can be helpful, but is most helpful in those under 20 years of age or those with more severe orthostatic intolerance. DDAVP .1 mg 1–2 tablets once or twice daily (basically vasopressin or antidiuretic hormone) can also be quite helpful. These replace the hormones that are low because of the hypothalamic dysfunction. It takes six weeks to see their effect. Rapid shifts in fluid levels can trigger headaches and migraines in some people. In these, it is best to slowly raise the dose, increasing by a quarter tablet every one to two weeks.
   
   For those with problematic frequent urination during sleep, giving a dose of the DDAVP at bedtime can help with this as well. This is the same medication that is given to children who bed wet.
5. Increasing sympathetic/adrenaline tone. The medication midodrine (ProAmatine) 5–10 mg twice daily (morning and early afternoon) can be fairly helpful after six weeks of use. Do not use the medication after 5 PM, or when lying down, as it can drive blood pressure too high. Lower the dose or stop if it causes too high of a blood pressure or shakiness. I will occasionally increase the dose to a maximum of 10 mg three times daily, with the last dose at 4 PM.
6. Medications that increase serotonin and dopamine. Prozac, Zoloft, and Dexedrine have all been shown to help autonomic dysfunction.
7. Some people find that a gluten and milk free diet is also helpful.

Although all of these treatments can be combined, I would begin them in the order listed as needed.

Finding the Missing Link

Although we have given a simplified version, you will find that it serves very well clinically. But there is much more to the story. Those of you interested in a bit more of the science can read on.

Excellent research by Dr. Mark Sivieri in Maryland is showing that many people with fibromyalgia also are showing IgG1 and IgG 3 antibody deficiencies (deficiencies in our body's defense function) on blood testing. This expectedly contributes to the immune dysfunction, but research and clinical experience are additionally showing that these immune deficiencies are also associated with Small Fiber Neuropathy, which is common in fibromyalgia. This is one of many factors contributing to the pain, and also seems to cause a "shrinking" of the nerves involved in autonomic function.

Studies are showing that treating with IV gamma globulin actually can result in a growing back and recovery of these nerves, helping both the small fiber neuropathy pain and autonomic dysfunction.

So we are now finding a missing link between immune dysfunction, autonomic dysfunction, and small fiber neuropathic pain.

We have found IV gamma globulin to be very helpful in a small subset of the most critically ill people retreat that has fibromyalgia and orthostatic intolerance. Essentially, these are people who are often housebound and bedbound. Getting insurance coverage for this expensive treatment can be difficult, and I will have my patients consult with Denise Haire to help guide them through the process of getting insurance authorization. She does an excellent job and is highly recommended. It is important to start with a low dose of gamma globulin and work up to the half-gram per kilogram IV each three weeks. Otherwise significant Herxheimer (infection die off) reactions can be seen. Treatment benefits, often dramatic, usually begin at about four months on the optimal dose.

Addressing the autonomic dysfunction and orthostatic intolerance seen in fibromyalgia can be fairly simple using the above quiz for diagnosis, and the treatments listed above. In combination with the rest of the SHINE protocol, and even done on its own, the clinical benefits can be marked.

Fibromyalgia can be effectively treated. And you now have one more easy and powerful tool in your toolkit!

For a superb 27 page orthostatic intolerance information sheet written by my favorite orthostatic intolerance specialist, Dr. Peter Rowe at Johns Hopkins, see http://www.dysautonomiainternational.org/pdf/RoweOIsummary.pdf

It's time for you to get well NOW!