DESCRIPTION:

BACKGROUND OF THE INVENTION:

Field of the Invention

Traumatic brain injury (TBI) occurs when an external force suddenly impacts on the body and particularly the head inflicting a traumatic injury on the brain. TBI can be classified based on severity from mild to moderate to severe, with mild TBI comprising a brain trauma without any opening of the skull, and severe TBI usually involving a penetrating head injury. For the purpose of this disclosure the term TBI is understood to include concussion. The damage to the brain can be local, being confined to a particular area, or diffuse, affecting many different parts of the brain. There can be physically visible damage to brain tissue, microscopic damage that is detectable by sophisticated methods like magnetic resonance imaging, or there can be damage to the brain that is not physically detectable but manifests itself in loss of brain functions. TBI symptoms including cognitive deficits can manifest within days, weeks, months or sometimes years after suffering a TBI, and can affect many brain functions including consciousness, sleep, memory, learning, attention, mood, emotional stability, behaviour, and other cognitive abilities. Cognitive deficits due to TBI have been reported to occur in 69% to 80% of individuals. In 36% of people with severe TBI, the cognitive impairments will be permanent, and even for those with mild TBI, poor cognitive functioning is reported as a significant concern for 25% of consultation seeking patients and an additional 15% of non-seeking patients one year after injury. Background Art

TBI is a leading cause of disability and death in youth and early middle aged people, having a significant impact on the individual, their immediate and extended family, friends, and society ^{1 ,2} . In the UK, Australia and North America 200-300 people per 100,000 are admitted to hospital with a TBI each year ³ . Incidence in NZ is higher, estimated at 660/100000 yearly ⁴ . Though higher than for overseas populations, these rates are still likely a significant

underestimate; excluding cases of mild TBI ¹ (approx. 70-90% of all TBIs), fatal TBIs, and TBIs undiagnosed due to being overshadowed by other conditions. Due to the high incidence of TBI at an early age and long-term impact on employment, TBI-related disability has enormous personal, economic and social consequences across the lifespan ^8,9 .

Disturbances in cognitive functioning are the most marked and persistent sequelae of TBI, often persisting beyond the period of immediate recovery. Cognitive deficits due to TBI have been reported to occur in 69% to 80% of individuals. The severity of TBI, which is typically determined at the time of injury using the Glasgow Coma Scale (which indicates level of consciousness) and length of post-traumatic amnesia, is related to the degree and persistence of the resulting cognitive deficit, with more severe injuries producing greater deficits. However, even for those with mild TBI, poor cognitive functioning is reported as a significant concern for 25% of consultation seeking patients and an additional 15% of non-seeking patients one year after injury. Longitudinal studies do not demonstrate significant decreases in complaints of memory and other cognitive deficits one, five, or even seven years post-injury.

Although the precise biological underpinnings of post-TBI cognitive impairment have not been conclusively determined, there are likely a number of mechanisms involved. TBI triggers a wide range of biochemical changes including the induction of oxidative stress and inflammation ^5,6 . The brain is particularly vulnerable to oxidative stress because i) its high rate of oxidative metabolic activity leads to an intense production of reactive oxygen metabolites, ii) the non-replicating nature of neurons, Hi) the high membrane-to-cytoplasm ratio with high levels of polyunsaturated fatty acids in the membrane lipids being a source for lipid peroxidation reactions, and iv) the high levels of transition metals, such as iron, that are capable of catalyzing the production of reactive radicals. Free radicals oxidative damage and inflammation may play a central role in mediating secondary damage after suffering a TBI. Secondary mechanisms of post-TBI cognitive impairment are potentially amenable to post-injury therapeutic intervention because of their sometimes delayed onset and their progression over hours to days and months after the TBI. Proanthocyanidins are well known for exhibiting anti-oxidant and anti-inflammatory activities in different biological systems ⁹ . These activities are thought to contribute to several types of beneficial effects these compounds are thought to have in the human body.

Proanthocyanidins are naturally occurring plant metabolites that can be found in many different plants, or can be artificially synthesised from chemical precursors. A common industrial source of proanthocyanidins is pine bark. Different plants contain different types of

proanthocyanidins, and it is not well understood amongst those skilled in the art whether proanthocyanidins from different plant sources have the same, similar or different biological activity spectrums when they are ingested. Food products, dietary supplements and therapeutic formulations containing proanthocyanidins from various plant sources are commonly available in many countries, and are often consumed with the intent to improve general health or to alleviate specific health problems. The efficacy of the different proanthocyanidin formulations from different plant sources may vary.

US5719178 by Tennenbaum describes a method for treating attention deficit hyperactivity disorder (ADHD) by taking by mouth proanthocyanidins extracted from a conifer bark in a quantity sufficient to relieve symptoms of ADHD but not to exceed approximately 0.625 mg per kg of body weight per dose, every approximately 3.5 to 4.0 hours. Symptoms of ADHD may include a lack of attention and concentration. The present invention does apply to therapeutic use of proanthocyanidin from pine bark for relieving symptoms including lack of attention and concentration. However, the symptoms referred to in the present invention are the result of a traumatic brain injury and are therefore different in their pathophysiological origin. The effectiveness of proanthocyanidins to alleviate symptoms of ADHD does not infer effectiveness to alleviate symptoms of TBI. This applies even if the symptoms are similar in nature since disease etiology of ADHD and TBI are different, and hence, symptoms are likely caused by different physiological impairments.

EP1631302 by Stenswick et al describes a method of treating migraine symptoms by orally administering a plant extract rich in proanthocyanidins. The effectiveness of

proanthocyanidins to alleviate symptoms of migraine does not infer effectiveness in treating symptoms of TBI. NZ539962 by Frevel et al describes a method of improving cognitive abilities in a healthy human that does not suffer from any neurological disorder or disease, wherein the human consumes a composition of pine bark extract. The described improvement in cognitive abilities are over and above the normal functioning of the human and do not involve any therapeutic efficacy against a pathological loss in brain function. Hence this method does not infer any effectiveness of proanthocyanidins or pine bark extract to improve loss of brain function after TBI.

Currently, very limited treatment options exist to improve cognitive deficits in post-TBI patients. Treatments focus on using techniques to help people to manage their cognitive impairments, rather than treating the possible biological cause of the problem. There are no specific pharmaceutical or nutritional compositions available that can reliably improve symptoms of reduced brain function in people, where these symptoms are due to sustaining a TBI.

Accordingly, it should be appreciated that it would be desirable to have a formulation for use in alleviating symptoms of TBI that does not include any unfavourable side-effects. It is an object of the present invention to address the foregoing problems or at least to provide the public with a useful choice.

All references, including any patents or patent applications cited in this specification are hereby incorporated by reference. No admission is made that any reference constitutes prior art. The discussion of the references states what their authors assert, and the applicants reserve the right to challenge the accuracy and pertinence of the cited documents. It will be clearly understood that, although a number of prior art publications are referred to herein, this reference does not constitute an admission that any of these documents form part of the common general knowledge in the art, in New Zealand or in any other country.

BRIEF SUMMARY OF THE INVENTION

The present disclosure provides a method of treating traumatic brain injury (TBI) by administering to a subject afflicted with TBI an effective amount of a composition comprising proanthocyanidins. It is shown herein that administration of a composition comprising

proanthocyanidins can reduce the severity of cognitive symptoms in people afflicted with TBI. The phrase "cognitive symptoms" of TBI include but are not limited to concentration, memory, attention, learning, recall, responsiveness, speech, behaviour and combinations thereof.

In a further aspect, the present disclosure provides a method of using an effective amount of proanthocyanidins in the manufacture of a composition to be administered to a subject afflicted with TBI for the purpose of improving, alleviating, or reducing symptoms of TBI.

The proanthocyanidins present in the composition can be derived synthetically or be derived from a plant source. In some embodiments the composition can comprise proanthocyanidins as the only active constituents. In some embodiments the composition can comprise proanthocyanidins as one of several active constituents.

In some embodiments, the composition comprises an extract derived from pine bark that contains proanthocyanidins as one constituent alongside several other constituents that are co- extracted from the pine bark. In some embodiments, such co-extractives from the pine bark include dihydroquercetin, catechin, epicatechin, quercetin, and stilbenes.

Various forms of TBI that can be treated with the proanthocyanidin-containing composition include, among others, closed-head injuries, concussions or contusions; or penetrating head injury, The type of TBI can be mild, moderate or severe, and involve diffuse axonal injury or hematoma.

The composition of proanthocyanidins can be can be administered parenterally or orally, or combinations thereof. In the embodiments herein the proanthocyanidin-containing composition can be administered in various regimens sufficient to provide a therapeutic benefit, including variations in time periods between the occurrence of the TBI and the start of the treatment, variations in duration of treatment, or amounts of the composition administered.

In some embodiments, the invention is directed to a method of protecting the brain of a human subject from cognitive symptoms of TBI, the method comprising administering to the subject, immediately before, during or after an activity associated with a potential traumatic brain injuring event, an oral dosage form comprising proanthocyanidins or pine bark extract. In some embodiments, the phrase "protecting the brain" refers to reducing or eliminating the loss of cognitive functions associated with TBI. In some embodiments, the phrase "protecting the brain" refers to an increase in brain resilience leading to a faster recovery from cognitive symptoms in the event of suffering a TBI. In some embodiments, the activity associated with a traumatic brain injuring event is selected from the group consisting of contact sport activities, that involve body to body contact, including boxing, rugby, or football, and other sporting activities where a TBI event or concussion can be reasonable expected to occur, in particular where these sporting activities are carried out competitively at the amateur or professional level. In some embodiments, the activity associated with the traumatic brain injuring event is selected from the group consisting of armed conflict or brain surgery.

In some embodiments, the invention is directed to a method of protecting the brain of a human subject from cognitive symptoms of TBI, the method comprising: (1 ) indentifying a subject who has experienced a traumatic brain injuring event, and (2) administering to the subject after experiencing the traumatic brain injuring event, an oral dosage form comprising proanthocyanidins or pine bark extract.

BRIEF DESCRIPTION OF THE DRAWINGS/FIGURES For a better understanding of the present invention reference is made to the following descriptions and accompanying drawings, while the scope of the invention is set forth in the appended claims.

Figure 1. Shows an illustration of the design of a clinical study to determine the extent of efficacy of the proanthocyanidin treatment in improving TBI cognitive symptoms. Figure 2. Shows the change in cognitive failure scores after a 6 week treatment of TBI sufferers with either a placebo or a proanthocyanidin-rich pine bark extract. DETAILED DESCRIPTION OF THE INVENTION

For the description herein and the appended claims, the singular forms "a", "an" and "the" include plural referents unless the context clearly indicates otherwise. Thus, for example, reference to "a composition" refers to more than one type of composition.

The use of the word "or" means "and/or" unless stated otherwise. Similarly, "comprise," "comprises," comprising," "include," includes," "including" are interchangeable and not intended to be limiting.

Further, where descriptions of various embodiments use the term "comprising," those skilled in the art would understand that in some specific instances an embodiment can be alternatively described using the terms "consisting of or "consisting essentially of."

Technical and scientific terms used in the present description will have the meanings commonly understood by a person with ordinary skills in the art, unless specifically defined otherwise.

In one aspect, the present disclosure provides a method of treating traumatic brain injury (TBI). In another aspect, the present invention provides a method of using an effective amount of proanthocyanidins in the manufacture of a composition to be used in the treatment of TBI.

TBI is a leading cause of disability and death in youth and early middle aged people in New Zealand (NZ) and internationally ^{1 ,2} . Most TBIs are caused by vehicle accidents, but many other events can result in suffering a TBI including falls, sporting activities, armed conflict, any type of violence, accidents at work or in the home, and brain surgery. TBI is generally the result of receiving a sudden impact force to the face, head or neck or elsewhere on the body with the force being transmitted to the head. This sudden impact then inflicts a traumatic injury on the brain. TBI can be classified based on severity from mild to moderate to severe, with mild TBI comprising a brain trauma without any opening of the skull, and severe TBI usually involving a penetrating head injury. It is sometimes unclear after a person has suffered a blow to the head or body resulting in a loss in brain function whether this event is better described as a mild TBI or as a concussion. Therefore, the present disclosure understands the term TBI to include concussion. TBI can result in a number of pathological effects or symptoms that include physical, cognitive, emotional, and behavioral effects. The outcome can range from death, substantial disability, or minor disability, to complete recovery. The onset of symptoms of TBI can range from within minutes or hours to within weeks months or even years after the brain injuring event occurred. Impairments of cognitive functions, including concentration, memory, attention, learning, recall, responsiveness, speech, behaviour, among other symptoms, often cause considerable disabilities for the affected individual. The severity of TBI, which is typically determined at the time of injury using the Glasgow Coma Scale (which indicates level of consciousness) and length of post-traumatic amnesia, is related to the degree and persistence of the resulting cognitive deficit, with more severe injuries producing greater deficits. However, even for those with mild TBI, poor cognitive functioning is reported as a significant concern for 25% of consultation seeking patients and an additional 15% of non-seeking patients one year after injury. Longitudinal studies do not demonstrate significant decreases in complaints of memory and other cognitive deficits one, five, or even seven years post-injury. As used herein TBI does not encompass brain injury resulting from ischemia / reperfusion. In some embodiments, when the brain has repeatedly suffered traumatic injuries, the

TBI can be chronic leading to an increased incidence, severity or duration of loss of cognitive functions, and resulting for the affected individual in an increased likelihood of suffering other neurological disorders in the future.

Whilst acute care recognizes the potential for neural reorganization and regeneration, rehabilitation is currently predominately focused on compensatory strategies - for all sorts of reasons, particularly given the state of knowledge in the field. Whilst that has lead to some improvement in outcome, patients find neurorehabilitation difficult and frustrating and it may not be appropriate for some individuals. For example, those who deny or lack awareness of their deficits (anosognosia) are unlikely to participate fully in rehabilitation. Similarly, those with very significant deficits may be cognitively unable to implement such compensatory strategies without outside assistance. Hence, if it is possible to address the consequences of impairment at the level of biology, even in part, this would be very advantageous.

Although the precise biological underpinnings of post-TBI cognitive impairment have not been conclusively determined, there are likely a number of mechanisms involved. TBI triggers a wide range of biochemical changes including the induction of oxidative stress and inflammation ^7,8 . The brain is particularly vulnerable to oxidative stress because i) its high rate of oxidative metabolic activity leads to an intense production of reactive oxygen metabolites, ii) the non-replicating nature of neurons, iii) the high membrane-to-cytoplasm ratio with high levels of polyunsaturated fatty acids in the membrane lipids being a source for lipid peroxidation reactions, and iv) the high levels of transition metals, such as iron, that are capable of catalyzing the production of reactive radicals. Oxidative damage and inflammation may play a central role in mediating secondary damage after suffering a TBI. These secondary mechanisms of post-TBI cognitive impairment are potentially amenable to post-injury therapeutic intervention because of their sometimes delayed onset and their progression over hours to days and months after the TBI.

The present disclosure shows that administration of a pine bark extract comprising at least 80% proanthocyanidins and comprising up to a maximum of 20% of other potentially active co-extractives to a human can reduce the severity of cognitive symptoms of TBI. Accordingly, in some embodiments the method of treating TBI comprises administering to a subject afflicted with TBI an effective amount of a composition comprising

proanthocyanidins.

Further, in some embodiments the method of treating TBI comprises administering to a subject afflicted with TBI an effective amount of a composition comprising a pine bark extract.

Proanthocyanidins are polymers most commonly comprised of the monomeric units catechin and epicatechin connected between carbon C-4 of the heterocycle and carbons C-6 or C-8 of the attached A and B rings. Proanthocyanidins are typically 2-12 units in length, but can be larger, so that a great number of isomer proanthocyanidins exist. Proanthocyanidins are well known for exhibiting anti-oxidant and anti-inflammatory activities in different biological systems ⁹ . These activities are thought to contribute to several types of beneficial effects these compounds are thought to have in the human body including reduction of oxidative and inflammatory processes. These activities and subsequent benefits for the human body may extend to the brain. Proanthocyanidins are naturally occurring plant metabolites that can be found in many different plants, or can be artificially synthesised from chemical precursors. A common industrial source of proanthocyanidins is pine bark. Food products, dietary supplements and therapeutic formulations containing proanthocyanidins are commonly available in many countries, and are often consumed with the intent to improve general health or to alleviate specific health problems. When proanthocyanidins are extracted from pine bark a number of other compounds including monomeric catechin, epicatechin, dihydroquercetin, also known as taxifolin, quercetin, stilbenes and several types of phenolic acids are co-extracted and present in the pine bark extract alongside the proanthocyanidins. The amount of these co-extractives can vary depending on the pine species used and the particular type of extraction used. The co- extractives are also known to have anti-oxidant and anti-inflammatory activities in different biological systems and may therefore contribute to the therapeutic effect of the

proanthocyanidin-containing composition. In some embodiments, the TBI treated with the proanthocyanidin-containing composition can be the result of a closed head injury.

In some embodiments the TBI treated with the proanthocyanidin-containing composition can be the result of an open head injury in which the skull has been penetrated by an object resulting in an open wound with or without the object having entered into the brain tissue. In this type of embodiments the penetrating injury may also be the result of brain surgery.

In some embodiments, the TBI treated with the proanthocyanidin-containing composition is a diffuse axonal injury that involves damage to nerve cells and the connections between nerve cells.

In some embodiments, the TBI treated with the proanthocyanidin-containing composition is a hematoma caused by an injury to blood vessels in the head resulting in bleeding into the brain or within the skull.

In some embodiments, the onset of TBI symptoms, that may result from partaking in a sporting activity known to increase the chance of suffering a TBI, can be prevented by administering a proanthocyanidin-containing composition of the present invention before taking part in the activity. In the embodiment herein, the invention is directed to a method of protecting the brain of a human subject from loss of cognitive functions that can result due to suffering a TBI. In some embodiments, the phrase "protecting the brain" refers to reducing or eliminating the loss of cognitive functions associated with TBI, or reducing or eliminating the likelihood of occurrence of such a loss in cognitive functions. In some embodiments, the phrase "protecting the brain" refers to an increase in brain resilience leading to a faster recovery from cognitive symptoms in the event of suffering a TBI.

In some embodiments, a regimen of administration of a composition comprising proanthocyanidins prior to suffering a TBI can reduce the risk of experiencing a loss in cognitive functions from a TBI event, because the extend of secondary damage from oxidation and inflammation in the brain after sustaining a TBI can partly be responsible for the loss in cognitive functions.

In some embodiments, the activity associated with a traumatic brain injuring event is selected from the group consisting of contact sport activities, that involve body to body contact, including boxing, rugby, or football, and other sporting activities where a TBI event or concussion can be reasonable expected to occur, in particular where these sporting activities are carried out competitively at the amateur or professional level.

The presence of a TBI can be determined by a number of techniques used by a physician of appropriate skill. The techniques to assess a person for TBI include, but are not limited to, Glasgow Coma Scale, brain imaging techniques such as computer assisted tomography, magnetic resonance imaging, diffusion tensor imaging, measuring intracranial pressure, neurobehavioral, neuropsychological and cognitive tests, that may include mini- mental state exam, cognitive failures questionnaire, post-concussive symptoms questionnaire, clinical dementia rating scale, information processing tests, working memory tests such as

Wechsler adult intelligence scale III, verbal memory tests such as California verbal learning test, other computerized cognitive tests, or general health questionnaires such as SF-36.

In some embodiments, the composition administered to the human comprises proanthocyanidins in a dosage range from 1 mg to 20mg per kilogram bodyweight per day. In some embodiments, the proanthocyanidin-containing composition is administered to the human in a single dose or in several dosages over the course of each day, and the administration can continue for a period of time from one week to several months or years.

In some embodiments, the administration of proanthocyanidin-containing compositions to humans after suffering traumatic brain injuring events reduces, mitigates, improves or supports recovery from pathological symptoms resulting from the TBI. In the embodiments herein, these TBI symptoms include neuro-inflammation, post-TBI oxidative damage to the brain, loss of neuronal functioning in the brain, neurotransmission, nerve cell damage, nerve cell death, and/or loss of cognitive functioning including concentration, memory, attention, recall, learning, responsiveness, speech, behaviour and combinations thereof.

In the methods described herein, the human suffering a TBI is administered a

composition comprising proanthocyanidins. In the embodiments herein, the term

proanthocyanidins refers to all the terms alternatively used in the literature to describe this group of plant compounds including "oligomeric proanthocyanidins," polymeric

proanthocyanidins," "condensed tannins," "flavan-3-ols," "procyanidins," "oligomeric

procyanidins," "polymeric procyanidins," "procyanidolic oligomers." The term proanthocyanidins comprises all un-conjugated and conjugates, i.e. glycosylated or otherwise conjugated, proanthocyanidins.

In some embodiments, the proanthocyanidin-containing composition of the present invention can be an extract from a plant or an extract from a part of a plant wherein the extract contains a therapeutically effective amount of proanthocyanidins. In the embodiments herein, the plant can be a tree and the plant part can be the bark of a tree. In the embodiments herein, the tree can be a pine tree, and in a further embodiment the species of pine tree can be Pinus Radiata. In some embodiments, the pine bark extract may be produced using a water-based process. One example process is that of NZ329658 / US5,968,517. The extract from bark is a complex mixture of mainly flavonoids with some non-flavonoid compounds. This extract is rich in a variety of proanthocyanidins. The extract also contains other flavonoids and plant-phenolic compounds that may be selected from: catechin, epichatechin, gallocatechin, epigallocatechin, quercetin, dihydroquercetin, myricetin, astringenin, pinosylvin, taxifolin, stilbenes,

hydroxylstilbenes, phenolic acids, and combinations thereof.

In some embodiments, the proanthocyanidin-containing composition may also include other active or non-active components including: flavonoids, vitamins, minerals, other known therapeutically active compounds, additives or excipients. However, it should be appreciated by those skilled in the art that the composition may be effective even if it only includes

proanthocyanidins or pine bark extract.

In some embodiments the composition may be formulated using components selected from: fillers, excipients, modifiers, humectants, stabilisers, emulsifiers, flavouring agents, preservatives and other known formulation components.

In some embodiments, the administration forms of the composition can include, but are not limited to, tablets, capsules, dragees, caplets, gelatine capsules, pills, suspensions, drinks, tonics, syrups, powders, solid or liquid foods which contain proanthocyanidins.

In some embodiments, the proanthocyanidin-containing composition is a neutraceutical or dietary supplement or pharmaceutical dosage form.

In some embodiments, the proanthocyanidin-containing composition is a medicinal food or functional food form. The present invention is also directed to kits or packages comprising one or more dosage forms of proanthocyanidin-containing compositions to be administered according to the methods described herein. These kits or packages may contain different combinations of compositions with at least one composition comprising proanthocyanidins and the kit or package being used for the purpose of treating TBI as described herein.

In some embodiments, the composition may be administered orally as a regular daily dose. In embodiments herein, the dose may be a total of 1 to 10 capsules or tablets taken orally each day containing approximately 200mg to 1000mg of proanthocyanidins or pine bark extract. It should be appreciated by those skilled in the art that dose rates may vary between these levels depending on the severity of the TBI, the size or weight of the subject, the metabolism level of the subject and other biochemical factors, and extract potency. It should also be appreciated by those skilled in the art that a dosage lesser or greater than that above may also be used without harm and may still be effective. Pine bark extract is non-toxic, has a naturally occurring source, and is a proa nthocyanid in-rich substance. Higher doses of this extract would not produce any toxic reactions to the subject and may in fact be advantageous for some subjects. Lower doses may also be advantageous and achieve the same efficacy in treatment.

In some embodiments, the administration may be continued as a regimen, i.e. for an effective amount of time, e.g. daily, weekly, monthly, bimonthly, biannually, annually or in some other regime as determined by a person skilled in the art for such time as necessary. The administration may be continued for at least a period of time sufficient to improve TBI symptoms.

In some embodiments, the proanthocyanidin-containing composition can be used in combination with other agents used for treating TBI including, but not limited to, diuretics; antiseizure drugs; cholinesterase or NMDA receptor inhibitors. The present invention is also directed to methods of educating consumers and health professionals about methods of treating or preventing symptoms of TBI, the method comprising distributing the proanthocyanidin-containing dosage forms together with appropriate information regarding the treatment or prevention of TBI symptoms at a point of sale. The "appropriate information" can include, but is not limited to, printed texts, images, charts, recordings, audio or visual media, websites, or access to live customer service representatives.

It has been found by the applicant that TBI patients with persistent losses in brain function recovered from these TBI symptoms and regained normal brain function after taking an oral dose of compositions containing proanthocyanidins for some time. The main advantages found are that the subject recovered from TBI symptoms that had persisted without change for several weeks or months, after a fairly short period of daily administration of the proanthocyanidin composition; the recovery being so substantial that the subject could return to work and perform all its usual activities as before the TBI.

A further advantage of the present invention is that it has no or little adverse side effects after treatment with the composition of the present invention. This is a major improvement on the prior art where adverse side effects are a common occurrence for pharmaceutical drugs that are used in patients with TBI.

It should be appreciated from the above description that there is provided uses and methods for treating a range of symptoms frequently encountered in subjects afflicted by TBI that are caused by physiological changes initiated by the injury. No adverse side effects are noted from the composition hence the methods may provide a useful alternative to any existing methods and treatments.

EXAMPLES Various features and embodiments of the present disclosure of invention are illustrated in the following representative examples which are intended to be illustrative, and not limiting.

Effects of administration of a proanthocvanidin-rich pine bark extract in patients with traumatic brain injury The invention methods and uses are now described with reference to a series of studies serving as examples to determine the effects on TBI patients from administration of a proanthocyanidin-containing pine bark extract.

Example 1

This example is predicated on an adult who suffered a mild TBI and, as a result of this injury, experienced symptoms that commonly occur immediately after or several days, weeks or months after the original injury including memory lapses, difficulties concentrating or thinking, speech difficulties, difficulties finding words or understanding the speech of others, other brain function impairments and other symptoms typical after TBI. The symptoms persisted for more than 6 months after the injury had first occurred, and caused the individual to have to stop working and mainly rest at home, also being unable to carry out most of the daily necessities in the household.

The individual swallowed a composition containing 240 mg of pine bark extract 2 to 4 times per day for 6 months. This treatment began approximately 6 months after the injury was sustained, during which time the individual had tried several other therapies including pharmaceutical drugs to overcome the persistent TBI symptoms without success.

The symptoms of the TBI started to reduce within approximately 4 weeks after beginning the treatment regimen with the pine bark extract. The improvements in brain function progressed continually over several weeks to such an extent that they did not adversely affect the individual anymore. After 2 months the individual was able to return to work and carry out most daily tasks. After approximately 6 months the TBI symptoms had almost completely disappeared.

Example 2 Methodology

Treatment composition

A proanthocyanidin-rich extract from the bark of Pinus Radiata (pine bark extract) was used in the study in the form of a capsule to be taken orally. In this particular case, the pine bark extract contained approximately 80% (w/w) proanthocyanidins, and at least 10% (w/w) other flavonoids, stilbenes, and phenolic acids. Each capsule contained a dose of approximately 500 mg pine bark extract. Alternatively, in particular phases of this study, subjects were taking a placebo capsule that was indistinguishable from the pine bark extract capsule, but contained an inert, inactive filler material.

Study - Short Description The pine bark extract used in this study is a product by the brand name of Enzogenol. It is a safe, well-tolerated extract from the bark of New Zealand grown Pinus Radiata trees.

The study examines effects of Enzogenol on cognitive impairments in 60 people who have experienced a traumatic brain injury in the last 3 to 12 months. Participants will be given either the Enzogenol composition or the placebo to take once daily for 6 weeks. All participants will then be given the Enzogenol composition for 6 weeks and then given a placebo for 4 weeks, as illustrated in Figure 1.

Participants will be asked to complete questionnaires about their symptoms, memory difficulties and quality of life and to complete a short task looking at how quickly people process information and working memory. These assessments will be carried out before, during and after participants have taken their treatment so that we can compare the results between the two groups. Subjects

Inclusion criteria: Adult patients who are 18-64 years old; classified as being 3 to 12 months post-mild TBI (as defined by a Glasgow Coma Score of 13-15 and post traumatic amnesia < 24 hours); experiencing persisting cognitive difficulties as indicated by a score of >38 on the Cognitive Failures Questionnaire; and are willing to avoid taking any other compositions (e.g., Gingko Biloba, Bacopa or vitamins) for the duration of the study.

Exclusion criteria: Individuals will be excluded if they are not fluent in English or have dysphasia, as this would impact on assessment; are unable to give informed consent; are known to have another condition that could impact on the results (e.g., significant substance abuse, diagnosed dementia or MMSE <23, significant mental illnesses, diabetes requiring insulin injections, severe agitation, advanced cancer or other severe conditions requiring nursing or hospitalisation); were already dependent on others for everyday activities before the onset of the TBI or are pregnant or breast feeding; are known to have an allergy to pine trees; or are currently taking anticoagulant medication.

Randomisation: After consenting to participate in the study and completing the initial screening assessments eligible participants will be randomised to receive either the Enzogenol composition or placebo using minimisation randomisation. This approach will help to balance for possible prognostic factors (i.e. age [16-45, 45-64], gender, ethnicity Maori and Non-Maori) across the two treatment groups. Intervention

The Enzogenol composition and identical placebo (comprising of cellulose - microcrystalline [MCC = microcrystalline cellulose] which is known to be a common additive in food, supplements and drugs and is used as a non-toxic, inactive filler material) capsules will be presented in blister packs. The packaging will be labelled as either 'A' or 'B' so that both researchers and patients will be blind to the nature of the treatment received. The labels 'A' and 'B' may refer to a different treatment during the three study time points to ensure that the researcher remains blinded to the treatment group that participants have been randomised into. The sponsor will hold the information about which treatment corresponds to 'A' and 'B' at each of the three treatment time points, until the end of the randomised component of the study and the group analyses are completed.

Participants will be randomised to receive either Enzogenol (1000mg 2 capsules of 500mg once daily, N=30) or placebo (2 identically looking capsules once daily, N=30) for the first 6 weeks. All participants will then be given the Enzogenol for 6 weeks followed by the placebo for 4 weeks (see figure 1.). This design will enable us to provide the treatment for all participants taking part in the study and to monitor the duration of any observed effects after the treatment is stopped.

Participants will take 2 capsules every morning with a large glass of water (200ml- 250ml) approximately 15 minutes before breakfast. Participants will be advised that they will be given the composition (the exact name of the supplement will not be disclosed during the study), a placebo or both during the course of the study. Participants will be given their blister pack of capsules at each assessment visit (at baseline, 6 and 12 weeks) by the assessor. Any leftover capsules (e.g. tablets that participants had forgotten to take) will be collected at the end of each time period (e.g. at 6, 12 and 16 weeks). If a participant does not take their capsules in the morning they will be advised to take them as soon as they remember if it is within 12 hours since they were supposed to take the treatment. If 12 hours or more have passed since they would usually have taken the treatment the participant will be advised to miss that dose and to continue the treatment as usual. They will also be asked to not discard any capsules that they have not taken to be able to assess compliance in taking the composition.

Testing

The outcomes will be information processing speed as assessed by the Computerised Test of Information Processing;- working memory and attention span (Wechsler Memory Scale- Ill Working memory index subtests); verbal memory measured by the California Verbal Learning Test; everyday memory difficulties (Cognitive Failures Questionnaire); post concussion symptoms (Rivermead Post Concussion Symptoms Questionnaire); health related quality of life (SF-36); health care use, employment status and possible side effects. All assessments will be completed in the participant's home. The assessments conducted by the assessor are expected to take approximately 1 hour. The self administered questionnaire battery takes approximately 20 minutes to complete and the weekly contact calls with an assessor are likely to take approximately 10 minutes.

Results

Randomisation: Analyses showed that the randomisation of participants worked well and has ensured that the two groups were equally matched for key demographic characteristics. Side Effects: The intervention did not cause any treatment related side effects. Seven side effects were reported in total (over 6 participants) all lasting less than 3 weeks (range 8 days to 20 days in duration). Five participants in Group A reported the following side effects: headache x 3 (1 x experienced when taking the placebo, 2 x experienced when taking the Enzogenoi); headache/nausea x 1 (experienced when taking the placebo); sleep disturbance x 1 (experienced when taking the placebo). One participant in Group B reported the following side effect: sleep disturbance x 1 (experienced when taking Enzogenoi).

Working Memory: The WAIS-III provides a measure of general intellectual function in people aged between 18-89 years and consists of 14 sub-tests delivered by a trained researcher. Only the sub-test exploring working memory (consisting of the digit span, letter- number sequencing and arithmetic tasks) were delivered by a researcher for this study. The participants' responses were recorded in an individual response booklet and scored according to the instructions in the WAIS-III Administration and Scoring Manual. The sub-tests have revealed good sensitivity and discriminability in people with TBI. High scores are indicative of better working memory with group mean scores shown in Table 1.

Statistical analyses showed a trend in improvement in digit span scores observed in the Group B when taking Enzogenoi between 6 and 12 weeks, and a trend in improvement in arithmetic scores between baseline and 6 weeks. There was also a trend toward improvement in arithmetic scores between 6 and 12 weeks in Group A when on the Enzogenoi. Hence, trends toward improved working memory performance were apparent in both groups but only in "active" phases of the study when the participants were taking the pine bark extract, but not during the placebo phases.

Table 1. WAIS Assessment Scores

Group A: Placebo/Enzogenol Group B: Enzogenol/Enzogenol

Baseline 6 Weeks 12 Weeks Baseline 6 Weeks 12 Weeks

WAIS Digit Span Forward 11.53 11.66 11.64 10.50 10.81 10.84

(Mean, SD) (1.98) (2.37) (1.85) (2.50) (2.06) (1.93) WAIS Digit Span 6.33 6.83 6.25 6.19

7.00 (2.84) 7.24 (2.40) Backwards (Mean, SD) (2.44) (2.54) (2.27) (2.59)

WAIS Digit Span Total 17.83 18.48 18.64 16.71 17.00 18.08 (Mean, SD) (3.62) (4.23) (4.05) (3.73) (3.88) (3.24)

WAIS Letter/Number Part 5.97 5.97 5.82 5.88

6.00 (0.00) 6.00 (0.00) A (Mean, SD) (0.18) (0.19) (0.77) (.059)

WAIS Letter/Number Part 12.17 12.83 12.64 11.46 11.92 12.08 B (Mean, SD) (2.34) (2.88) (2.98) (3.04) (3.44) (3.66)

WAIS Letter/Number

18.13 18.79 18.71 17.29 18.19 18.00 Total Combined Score

(2.33) (2.96) (3.02) (3.23) (2.67) (3.71 ) (Mean, SD)

WAIS Arithmetic (Mean, 12.93 12.76 13.64 11.79 12.69 12.44 SD) (3.72) (3.11 ) (3.74) (2.78) (3.22) (2.57)

Cognitive Failures Questionnaire (CFQ) Scores: To explore the amount of change in CFQ scores that occurred between baseline and 6 weeks and between 6 and 12 weeks the change scores were calculated as shown in Table 2.

Table 2. CFQ Scores

Group A: Placebo / Enzogenol Group B: Enzogenol / Enzogenol

Baseline (Mean, SD) 59.34 (16.03) 61.27 (17.2)

Week 6 (Mean, SD) 46.07 (12.43) 43.83 (20.42)

Week 12 (Mean, SD) 44.19 (13.71 ) 41.08 (19.19) Change: Baseline to 6 weeks -13.27 -17.44

Change: 6 weeks to 12 weeks -1.88 -2.75

Analyses of the CFQ showed that there were improvements in both groups of the study with the greater improvements evident in the first six weeks of treatment. The comparison of the first phase of the study when Group A was receiving placebo and Group B was receiving the pine bark extract (as shown in Figure 2.) showed that Group B had a greater improvement than Group A indicating that the pine bark extract treatment was more effective than the placebo in reducing symptoms of TBI.

Post Concussion Symptoms: The Rivermead Post Concussion Symptoms Questionnaire (RPQ) asks people about the occurrence of 16 post-concussive symptoms such as headaches, fatigue and restlessness. Participants are to state whether the extent to which they experience each symptom, in comparison to before their accident, on a 5 point scale ranging from 0 (not experienced) to 4 (severe problem). The first 3 items relate to early onset symptoms and individual item scores are summed to give a summary score between 0-12. Items 4-16 are indicative of more severe post concussive symptoms and are summed to reveal a score between 0-52. Total scores for all 16 items can be used to determine the presence or absence of post-concussive syndrome (PCS). Those with a score of <5 were defined as 'No PCS' and those with a score >5 as 'PCS'. This cut-off was based on 1 SD below the mean RPQ scores previously reported for mild TBI patients with Diagnostic and Statistical Manual IV-defined PCS.

According to the RPQ scores at 6 and 12 weeks of treatment two participants in Group B that had received the pine bark extract dropped below the cut-off score of 5 and were therefore no longer classified as suffering post concussive syndrome. This result indicated a trend towards reduction of PCS for the pine bark extract treatment. Studies Summary

Oral consumption of pine bark extract compositions improved cognitive impairments in post-TBI subjects.

It should be appreciated that the improvements noted above show that proanthocyanidin administration may be a useful treatment for TBI patients, in particular with respect to recovery from cognitive impairments and the ability to regain normal brain functioning, and with respect to carrying out any activities, such as professional work, that they were unable to carry out as a consequence of suffering a TBI.

As the treatment does not exhibit any adverse side effects and appears to be effective within a relatively short treatment period, it has a significant advantage over any existing treatments.

Aspects of the present invention have been described by way of example only and it should be appreciated that modifications and additions may be made thereto without departing from the scope thereof.

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