Most clinicians know that patients achieve optimum physical health by eating healthy nutrient-based foods, staying active and consistently getting at least eight hours of quality sleep every night. But for patients with a traumatic brain injury (TBI), these tasks may be challenging.

“Regardless of the mechanism of injury, TBI can result in significant neurological impairment, acute clinical symptoms and functional disturbances,” said Gary McKinney, chief, office of clinical practice and clinical recommendations at Defense and Veterans Brain Injury Center (DVBIC).

McKinney and other experts from Walter Reed National Military Medical Center in Bethesda, Maryland, spoke about how primary care providers can apply the key focus areas of the Army Performance Triad (sleep, activity and nutrition) to boost patient recovery from TBI during a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) webinar July 14.

Army Medicine launched the Performance Triad plan in 2013 to help soldiers use educated lifestyle choices to maintain, restore and increase health. Patients with TBIs can follow the plan, which includes well-vetted clinical advice, to improve their levels of activity, nutrition and sleep, and to take an active role in their recovery.

Activity

“In the Performance Triad, physical activity is more than exercise: it is an active lifestyle. The Performance Triad breaks activity down by the level of active and sedentary exercise,” McKinney said.

Physical activity does not solely mean going to the gym; it can be taking long walks, doing yard work or playing with children. The plan supports using a variety of activities, including anaerobic, aerobic and relaxation activities to motivate patients to rebuild their physical health.

However, clinicians should alert TBI patients with certain limitations that they may need to modify some recommendations in the plan, McKinney said.

“If patients have recurring TBI symptoms, they should return to the previous stage of activity instead of continuing or moving to the next, as measured by physical exams, the NSI [Neurobehavioral Symptom Inventory], resting heart rate and blood pressure,” McKinney said.

To help providers as they modify the level of activity, DVBIC offers a clinical suite of tools to guide patients in their return to activity following concussions: Progressive Return to Activity (PRA) Following Acute Concussion/Mild TBI: Guidance for the Primary Care Manager in Deployed and Non-Deployed Settings. The guidance outlines six stages of progression for a patient returning to activity.

Nutrition

Patients with a TBI may initially have different nutritional needs from those highlighted in the Performance Triad, including the need for more calories and protein, said Army 1st Lt. Paul Rosbrook, assistant research director of the nutrition service department at Walter Reed National Military Medical Center.

“In the acute phase, calorie needs are increased by roughly 50 percent depending on the physiology of the wound, whether it was blunt trauma or penetrating,” Rosbrook said. The precise number of calories and protein recommended varies with each case.

Once TBI patients are in recovery, Rosbrook said that nutrition needs usually go back to their baseline requirement. At any stage, however, patients in recovery can follow the nutrition pillars of the Performance Triad. These pillars include:

• Remember proper fueling for performance and recovery
• Consume eight daily servings of fruit and vegetables
• Limit caffeine within six hours of sleep
• Maintain proper body weight to reduce risk of injury
• Be smart with supplementation

Rosbrook recommended two to three servings of fruit, four to five servings of vegetables per day, and three servings of dairy or dairy alternates. Dairy contains calcium and vitamin D, which will help reduce the incidence of fractures and other stress-related bone injuries, he said.

Rosbrook also detailed how poor sleep can affect nutritional outcomes.

“Acute and chronic sleep deprivation, less than four to five hours, correlates with an increased hunger hormone called ghrelin, a reduced satiety hormone called Leptin, impaired glucose utilization, and reduced fruit and vegetable consumption,” he said.

Sleep

Four sleep disorders are common following concussion, according to Dr. David Panakkal, a TBI subject matter expert with DVBIC: short-term insomnia, chronic insomnia, circadian rhythm sleep-wake disorder and obstructive sleep apnea syndrome. All four disorders can improve when patients follow the sleep recommendations of the Performance Triad:

• Keep a regular schedule
• When possible, schedule seven to eight hours for sleep
• Avoid LED screens two hours before bedtime
• Stop caffeine at least six hours before bedtime
• Do not drink alcohol before bed
• Get your exercise in by early evening
• Do not use over-the-counter medications without consulting a provider
• Go to bed only when you are sleepy. Get out of bed if you can’t sleep within 30 minutes
• Nap wisely (preferably in the late morning or early afternoon for 30 - 60 minutes)
• Move the bedroom clock somewhere you cannot see it

Visit the DCoE webinar archive to hear a podcast of the webinar, get a webinar PDF transcript and download a copy of the PDF presentation and PDF resources.