Nutraceuticals for Concussion – Part 3: Creatine Monohydrate

Concussions are highly challenging to treat and there are very few evidence-based interventions that have been shown to consistently accelerate recovery. Therefore it is important for the sports medicine practitioner to have as many tools in their toolbox as possible and to have a solid understanding when these tools can be effective. I have seen many nutritional supplements proposed for treating concussions, and I believe that they have a potential role in concussion management. I decided to conduct a review of the current literature exploring the evidence and logic behind some of these nutritional supplements. This article will be the third in this series, “Nutraceuticals for Concussion.”

This was written in 2016. I will try to update this post if new information comes out since this was written, but please be aware that this a information may become outdated before I am able to do so.

Again…the purposes of my blog posts are to facilitate thought and discussion or perhaps even motivate research to answer the remaining questions on this topic. That is all. If you think that you have a concussion, please go see a concussion specialist.

Let’s get to know Creatine Monohydrate…

Creatine monohydrate is a poplar supplement used to enhance strength and power in sports that involve a lot of explosive short burst efforts. In other words, Creatine supplementation has been found to enhance activities that rely heavily on the body’s ATP (adenosine tri phosphate) and anaerobic energy systems. Creatine is critically important in maintaining cellular energy reserves in tissues that have a wide range of energy demands. These include skeletal muscle cells and brain cells (neurons and glia) [1]. Creatine within the brain comes from both local synthesis via combining amino acids, and is directly absorbed through the diet. This is due to the fact that dietary creatine will readily cross the blood brain barrier when needed [2, 3]. Creatine’s mechanism is through the ability to shuttle a phosphate group to an ADP (adenosine di phosphate) molecule to create ATP, the body’s primary fuel source [2]. In other words, by increasing the overall pool of cellular phosphocreatine, creatine supplementation can accelerate the recycling of ADP into ATP. This can readily occur in skeletal muscle and in brain tissue (when Creatine is deficient).

creatine-pathway

(Image Credit: http://www.rice.edu/~jenky/sports/creatine.html)

With this mechanism in mind, we can understand how increasing Creatine intake (via creatine rich foods or via supplementation) can enhance this pathway increasing the availability of ATP and therefore energy available to our cells.

Dysfunctional ATP production and altered glucose metabolism are central to concussion pathophysiology. This is why concussion patients get symptoms (headaches, fatigue, dizziness etc.) when they are using their brain’s limited energy stores following a concussion.  There is certainly some logic for a potential benefit here in the setting of an energy/ATP deficit.

I was unable to identify a single study directly examining Creatine supplementation and concussion recovery in humans. There have been animal studies with some positive results looking at Creatine for other neurological diseases including Alzheimer’s and Parkinson’s disease [2, 4]. There has been a couple of promising studies in animal models for traumatic brain injury showing neuroprotective effects of creatine supplementation, which the researchers attributed to an improvement in mitochondrial bioenergetics (i.e. increased energy availability to brain cells) [5, 6].

In humans, there was an imaging study using proton magnetic resonance spectroscopy which was able to demonstrate that creatine levels in the brain decrease after a concussion [7]. There have also been two prospective pilot studies looking at creatine supplementation in pediatric patients with moderate-severe traumatic brain injuries [8, 9]. The results were promising, as Creatine supplementation was associated with improved cognition, improved level of functioning, as well as decreased symptoms including headaches, dizziness and fatigue (all symptoms commonly associated with concussions). Concussion and more severe TBI are not exactly the same thing, but there is a lot of overlap in the pathophysiology and symptoms of these two types of injuries.

The dosing recommendations that I found were primarily in the context of skeletal muscle enhancement. In adults the typical recommendation is a loading period involving 0.3 gram per Kg body weight per day for 5-7 days. This is followed by a maintenance period of at least 0.03 g/kg/day. For a 180lb person, this equals 25g/day for loading and 2-5g / day for maintenance. The absorption through the blood brain barrier is pretty regulated and will eventually plateau once the brain’s Creatine levels are optimal, so it is much less likely that the high of a volume of an oral creatine loading period will actually get into the brain (like it would for muscle cells). I therefore recommend just starting at and staying at the maintenance dose of 2-5g a day if one were to use it for a concussion.

The side effect profile includes muscle cramps, nausea, diarrhea, and stomach pain. There have been claims that Creatine can cause damage to kidney, liver, and heart, but this is not supported by the evidence, and there have been some high quality long terms studies at the 2-5g / day range [10-17] .

fish-creatine

With that being said, it is important to remember that the safest way to increase your body’s Creatine level is through the diet. The bioavailability is the same as with supplementing [18]. Foods high in Creatine include primarily muscle tissue. Especially red meat and fish. The highest performers include salmon, trout and sardines.  Salmon, trout and sardines?!?!? These are also high in omega-3 fatty acids, riboflavin, and magnesium. These fish just keep coming up in the discussion of diet and concussion. Multiple birds with a single stone…

How Food Can Influence Concussion Recovery: Part II

Nutraceuticals for Concussion – Part I: Magnesium

Nutraceuticals for Concussion – Part 2: Riboflavin

Whether it is through supplementation or, through the diet, Creatine has a lot of potential to be of benefit for those suffering from a concussion.

A great site to go further down the rabbit hole…  http://examine.com/supplements/Creatine/

Thanks for reading!

  1. Petraglia, A.L., E.A. Winkler, and J.E. Bailes, Stuck at the bench: Potential natural neuroprotective compounds for concussion. Surgical neurology international, 2011. 2.
  2. Béard, E. and O. Braissant, Synthesis and transport of creatine in the CNS: importance for cerebral functions. Journal of neurochemistry, 2010. 115(2): p. 297-313.
  3. Ohtsuki, S., et al., The Blood—Brain Barrier Creatine Transporter Is a Major Pathway for Supplying Creatine to the Brain. Journal of Cerebral Blood Flow & Metabolism, 2002. 22(11): p. 1327-1335.
  4. Gualano, B., et al., Exploring the therapeutic role of creatine supplementation. Amino acids, 2010. 38(1): p. 31-44.
  5. Scheff, S.W. and H.S. Dhillon, Creatine-enhanced diet alters levels of lactate and free fatty acids after experimental brain injury. Neurochemical research, 2004. 29(2): p. 469-479.
  6. Sullivan, P.G., et al., Dietary supplement creatine protects against traumatic brain injury. Annals of neurology, 2000. 48(5): p. 723-729.
  7. Vagnozzi, R., et al., Decrease in N-acetylaspartate following concussion may be coupled to decrease in creatine. The Journal of head trauma rehabilitation, 2013. 28(4): p. 284-292.
  8. Sakellaris, G., et al., Prevention of complications related to traumatic brain injury in children and adolescents with creatine administration: an open label randomized pilot study. Journal of Trauma and Acute Care Surgery, 2006. 61(2): p. 322-329.
  9. Sakellaris, G., et al., Prevention of traumatic headache, dizziness and fatigue with creatine administration. A pilot study. Acta paediatrica, 2008. 97(1): p. 31-34.
  10. Bender, A., et al., Long-term creatine supplementation is safe in aged patients with Parkinson disease. Nutrition research, 2008. 28(3): p. 172-178.
  11. Shao, A. and J.N. Hathcock, Risk assessment for creatine monohydrate. Regulatory Toxicology and Pharmacology, 2006. 45(3): p. 242-251.
  12. Lopez, R.M., et al., Does creatine supplementation hinder exercise heat tolerance or hydration status? A systematic review with meta-analyses. Journal of athletic training, 2009. 44(2): p. 215-223.
  13. Groeneveld, G., et al., Few adverse effects of long-term creatine supplementation in a placebo-controlled trial. International journal of sports medicine, 2005. 26(04): p. 307-313.
  14. Terjung, R.L., et al., American College of Sports Medicine roundtable. The physiological and health effects of oral creatine supplementation. Medicine and Science in Sports and Exercise, 2000. 32(3): p. 706-717.
  15. Brosnan, J.T. and M.E. Brosnan, Creatine: endogenous metabolite, dietary, and therapeutic supplement. Annu. Rev. Nutr., 2007. 27: p. 241-261.
  16. Gualano, B., et al., Effect of short-term high-dose creatine supplementation on measured GFR in a young man with a single kidney. American journal of kidney diseases, 2010. 55(3): p. e7-e9.
  17. Greenwood, M., et al., Creatine supplementation during college football training does not increase the incidence of cramping or injury. Molecular and cellular biochemistry, 2003. 244(1-2): p. 83-88.
  18. Deldicque, L., et al., Kinetics of creatine ingested as a food ingredient. European journal of applied physiology, 2008. 102(2): p. 133-143.

 

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