Post Concussion Recovery at CognitiveFX with Dr. Loewen & Dr. Hanak
Show Notes:
After decades of research, Cognitive FX has discovered the secret to understanding and recovering from a concussion or traumatic brain injury: neurovascular coupling (NVC). Essentially, NVC is the connection between brain cells and blood vessels. When the brain is injured and unable to regulate blood flow, it can cause fatigue, exhaustion, headaches, and other common symptoms of traumatic brain injuries (TBI). Today, we are joined by two NVC experts, Dr. Jaycie Loewen and Dr. Tyler Hanak from Cognitive FX, the world's most advanced clinic for post-concussion syndrome treatment, and the generous sponsor of this podcast.
Dr. Loewen is the Director of Clinical and Research Operations and a clinical neuroscientist whose background includes the study of basic and clinical brain injury. Dr. Hanak is the Clinical Treatment Supervisor at Cognitive FX, where he participates in research initiatives that include facilitating the clinical use of functional near-infrared spectroscopy. In this episode, you’ll find out how Cognitive FX uses functional MRI scans to design and customize treatments for their patients, why their intensive treatment program is conducted across a variety of different specialists under one roof, and some of the parallel research studies that Dr. Loewen and Dr. Hanak are conducting about NVC, plus so much more. Make sure to tune in today for a better understanding of NVC and post-concussion recovery!
Key Points From This Episode:
A look at our guests’ backgrounds and what sparked their mutual interest in concussions.
Defining NVC and its role in healthy brain function.
How NVC dysfunction or uncoupling can cause many of the common symptoms of TBI.
Why Cognitive FX uses a type of neural imaging known as functional MRI.
Some pros and cons of functional MRI.
The multimodal interdisciplinary approach that Cognitive FX takes to treatment.
How Cognitive FX treats patients effectively across multiple different departments.
Further insight into the intensive treatment program at Cognitive FX.
Why the Prepare-Activate-Rest Cycle is a crucial aspect of treatment.
Dr. Hanak offers some clarity on functional near-infrared spectroscopy.
The multiple parallel research studies that Cognitive FX is conducting into NVC.
Check out CognitiveFX
https://www.cognitivefxusa.com/ AND remember to thank them for supporting the show!
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[INTRO]
[00:00:00] BP: Hi, everyone. I’m your host, Bella Paige. After suffering from Post-Concussion syndrome for years, it was time to do something about it. Welcome to the Post-Concussion Podcast, where we dig deep into life when it doesn’t go back to normal. Be sure to share the podcast and join our support network, Concussion Connect. Let’s make this invisible injury become visible.
[DISCLAIMER]
[00:00:17] BP: The Post-Concussion Podcast is strictly an information podcast about concussions and post-concussion syndrome. It does not provide, nor substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician, or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice, or delay in seeking it because of something you have heard on this podcast. The opinions expressed in this podcast are simply intended to spark discussion about concussions and post-concussion syndrome.
[EPISODE]
[00:01:14] BP: Welcome to episode number 88 of the Post-Concussion Podcast with myself, Bella Paige, and today's guest, Dr. Jaycie Loewen and Dr. Tyler Hanak.
Dr. Loewen is the Director of Clinical and Research Operations at Cognitive FX. She is a clinical neuroscientist who received her Doctorate of Neuroscience at the University of Utah. Her background includes the study of basic and clinical brain injury. Dr. Loewen is a Howard Hughes Medical Institute scholar with a Master's in Clinical Investigation, awarded in 2018, as well as a recipient of the Higher Education Teaching Specialist certificate. Dr. Loewen currently aids in literature analysis and publication of scientific articles for the clinic, alongside also providing patient care. Dr. Loewen has taught graduate neurobiology classes at Brigham Young University, facilitates blog and video content for Cognitive FX, and mentors research interns.
Now, Dr. Tyler Hanak is a Clinical Treatment Supervisor at Cognitive FX. He received his Doctorate of Neuroscience and Masters of Clinical Investigation at the University of Utah in 2018. Dr. Hanak is further a Howard Hughes Medical Institute scholar with a certificate in higher education teaching. Dr. Hanak currently participates in Cognitive FX research initiatives, including facilitating the clinical use of functional near infrared spectroscopy and brain injury. He works alongside Clinical Directors and manages to maintain exceptional standards of care for Cognitive FX patients. Here's a small reminder that Cognitive FX is our wonderful supporter of the podcast. Welcome to the show, Dr. Loewen. Dr. Hanak.
[00:02:55] JL: Happy to be here.
[00:02:56] TH: Sam.
[00:02:57] BP: To start, do you both want to tell us a little bit of what created your interest in concussions?
[00:03:03] JL: My background in my graduate work was actually seizures, viral induced models of epilepsy, so touching a little bit on the TBI brain injury realm, but a lot of my work was in actually a cell type that we're going to be talking about today, but they're called glial cell the support cells of the nervous system. Then, I'd actually read some research published by Cognitive FX and ended up seeing a job application pop-up and applied here, and loved it ever since. It's nice, because I've gotten to move more towards that clinical human side of TBI, which was my goal at the beginning. It's nice, because obviously, we're in neuroscience so the research will never stop.
[00:03:48] TH: Similar background, even after undergrad. I always wanted to straddle the line of research, but still working in clinics and helping people. My background involves being in the operating rooms during brain and back surgeries doing neurodiagnostics in real time. Essentially, remember the game operation, I was the red light that went “eh.” Essentially, whenever there were changes or anything, we would report that information to the doctor to decide if we needed to make any adaptations in the surgery. Then I research background I went back to grad school and did work in also epilepsy and the role of inflammation that can lead to seizures and eventually epilepsy. Again, always wanting to be in a clinical neuroscientist’s role and realize those jobs are few and far between, and through Dr. Loewen, I realized there’s an opportunity here. Now I'm here working in Cognitive FX.
[00:04:42] BP: Nice. That is great. I always love to hear everyone's stories, because I find they're all a little different on what gets people started, because concussions are definitely something that is growing in interest by a lot of people, but it was definitely a lot smaller for fields a little while ago. To start little bit more into the health fact of all this, do you want to talk about neurovascular coupling, and we're going to get into how that is related to concussions and all that.
[00:05:13] BP: Yeah. So it's a word thrown around a lot in this clinic. It'll be a main theme as we discuss how it's implicated in brain injury, but the simple way to think about is, let's just start with the brain inside of the skull. It's very heavily vascularized, so lots of blood vessels, the brain is really unique in that, in comparison to other organs in the body, let's say I'm looking at a muscle, it doesn't have localized energy resources. My muscle, I'm working out those cells can go, “Oh, I've got food right next door that I can use to build that muscle break it down and make it better.” The brain doesn't have that. It can't eat itself. Even though it's mostly fat and water, it actually needs to rely on the vasculature to bring oxygen, glucose, ketone bodies, and other energy molecules to allow those cells to do their jobs.
The process of neurovascular coupling is the link between that activity and the resources being supplied. The brain always has a buffer of about a second of blood flow available. So what needs to happen is that as those brain areas are activating, as those cells are activating, there needs to be a very quick response from the vasculature going, “Okay, let's get a lot of blood flow here.” It needs to be plentiful, and it needs to continue. In order for me, I like to use my hands, in order for me to do all these hand movements I need constant blood flow going to areas of the motor cortex, for example.
Now, the name neurovascular coupling seems to only indicate that there's two parts, that there's vasculature and there's neurons, but the third big piece to that is, in fact those glial. The name glial comes from glue, originally. They were just thought to be things that help the brain together. We're learning now that they are cells that can send messages, that are involved in the immune response, that are also some theories actually say that they're involved in neurotransmission or glial transmission, as it's called. Neurovascular coupling at its core, is how the nervous system gets energy. How that brain can function.
[00:07:20] TH: As a fun fact too, even though it started with the name glue, we know they do so much more now. If you ever want to start a fight at a conference, all you have to do is say glial or glue and see fists fly.
[00:07:35] BP: That’s like GIF or GIF, you hear that?
[00:07:37] TH: Oh, yeah.
[00:07:39] JL: Yeah.
[00:07:40] BP: All the arguments. How is that related to, like why should people, survivors be concerned about their neurovascular coupling after a concussion?
[00:07:51] TH: There's a lot of things that we believe can change that neurovascular coupling. A paper that came out by Dr. Allen in this clinic a few years ago, talked to the big overarching theory of what's happening. One of the things we believe is happening with patients is a neurovascular uncoupling. Whether that's the concussion, inflammation, that essentially there could be changes in some of those glial cells, or how the communication of the neurons, the vasculature is happening, that you can have an area that's active, but it is really bad at calling in for that supply that it needs. If you have an area that's active and not getting oxygen, glucose, etc. then what you think's going to happen. There is going to be fatigue, could maybe drive symptoms in our patients.
[00:08:40] JL: Yeah. We should clarify that it's difficult to know, which part is actually causing the decoupling, is it the neurons aren't really activating as well as they should? Is it the vasculature not responding? So that's actually something that we're currently researching with some imaging modalities to see what's the core of it, because that could be really essential for developing new treatment strategies for concussion.
[00:09:03] BP: When you brought up imaging and imaging is a huge part of Cognitive FX when you look it up. It's the first thing you come across. Do you want to get into why you use neural imaging?
[00:09:15] TH: It is a huge part of what we do here. It is the thing that gets a lot of love on the website, because it's really cool. What we use it for is essentially, to look to see what's going on and to help target treatment, because at the end of the day, what we are doing here and probably the one of the most important things is the treatment, right, because the imaging doesn't alone doesn't get the patient's better, but using what all the evidence that we can gather on that patient does.
[00:09:41] JL: The imaging that we use is called functional MRI. There's multiple forms of imaging that you can use. Many people might be familiar with, for example, structural MRI, so grey matter, white matter, great for looking at tumours and brain bleeds and things like that. When you're thinking of functional MRI, imagine an MRI machine, but rather than just laying there, and letting the machine do its thing, taking pictures of your brain. It's looking at that neurovascular coupling. When you're in that scanner, then we can go a little bit into the technicalities, but think that we can map out different areas of the brain structurally. Then, look at how oxygenated blood flow is going to that those areas and how it's being used.
The functional MRI can indirectly look at brain activity, but it's really good at looking at that neurovascular coupling and seeing when it's uncoupled. What we specifically do is that there's two forms of functional MRI; one is resting state where you're in that scanner, you're zoning out a little bit, you don't really have to be doing anything. It's actually the modality that allowed us to look at things like the default mode network, that seminal paper that came out, but you can also do the second type, which is task based. You're in that scanner and you're actually doing tasks. That could be cognitive tasks, visual tasks. It really drives where we can look at common symptoms, the underlying cause of symptoms, like where exactly in the brain there's that decoupling.
It's really nice, because we can design those tasks in house to be specific for the condition that we're looking at the patient population. Yeah, it gives us a really cool data, not just on the brain areas, but we are now able to look at connectivity. We're actually able to see how different brain areas are communicating with each other, if they're not communicating enough, if they're over communicating, and that's added a new piece of information for, again, designing a treatment and customizing it for our patients.
[00:11:39] BP: Yeah. I love that you can see it. I think that was a big problem for myself starting this about 10 years ago is I used to argue with my parents, because all my scans except for one, because I did have a brain injury after one of them with a brain bleed. I used to always get mad that you couldn't see it. I was like, “No, there has to be something on the scans.” I'd get regular MRIs and CT scans, when I'd go into the ER with headaches and constantly, “Oh, it's clean. It's clean. It's clean. We can't see anything.” So what I love is that you can see it, you can actually get some information. I think it really helps patients being able to see it, because you can prove that you're not okay.
I think that's a really hard thing for a lot of our guests and people that listen to the show is that they know they're not okay, but when they try to tell others or convince themselves that it's not just them making it up. It's really tough emotionally to be like, “I am not okay.” But nothing is proving that I'm not okay. Other than the fact that I can't get out of bed or symptoms like that, so I love that factor. Is there any like, really big pros or cons to using MRI other than just the treatment? I think it's a great factor, but do you get any other benefits of getting the scans done?
[00:13:03] TH: To answer your question, but also to touch on what you were just mentioning, when I first started sitting down with patients and going over the data. I remember having a situation where a patient looked at their scan and saw that there was a whole lot of things out of the norm. Of course, there was a totally understandable emotional response. They were getting teary eyed. I immediately went into, “It's okay. We're here to help. You're going to go into treatment.” They looked up at me went, “No, I'm happy. There's finally something." Then I've also had the other side where someone says, “Can I get copies? Because I want to show everyone else that told me nothing was wrong.”
[00:13:37] BP: Yeah, exactly.
[00:13:39] TH: Yes, a big pro is to show us like, hey, when you're in that scanner – are there things that are outside the norms compared to our control population? Are there things that we're going to look and say, “Hey, yeah. We can maybe focus on this and treatment.” But also tells us potentially underlying issues. One of my favourite analogies or both of our favourite analogies is that, when we have patients that say, “My memory is terrible. I can't remember anything. I have a memory issue.” Then we look at the scan and go, “Possibly attention, actually.” We looked at a lot of attention areas, that's going to affect memory. So it gives us a different perspective. Cons of course we do have patients that believe it or not, loud scanner fall asleep. It's sometimes hard to explain like, yeah, it's not perfect, we're not going to be able to see your brain if your asleep or heavily distracted. A lot of times are our scanner is loud and we have patients that have sound sensitivity. There's definitely some challenges. What would you like to add to that?
[00:14:39] JL: We're scientists, we're going to beat up the scanner, just because we can find all the things wrong with it. But I will say that what we really need to do, in order for any facility using a functional MRI, it takes a massive amount of resources. We're incredibly lucky as a clinic to be able to use it, but what needs to go into making that functional MRI is scanning many, many people. Keeping that scanner on, getting people in it, having technicians running people through, you need to have the scientists behind the scenes that are designing those tasks, that are setting it up, hypothesis driven science, evidence driven.
Then you have the statistics that come after. There was a great study that most people call it the Duke study that summarized a lot of the issues around functional MRI. There's some – I hate to say it, there's some bad science out there, where people are just chucking some people in a functional MRI using tests they downloaded from the Internet, and going, “We found this thing.” It takes a whole community to make sure that that functional MRI can be run correctly. We're lucky enough that we also have, for example, people that are involved in AI interfacing, artificial intelligence to be able to run that scan, improve it. Obviously, it takes neuroscientists to be able to tell the robot what to do.
[00:16:01] TH: Tell the patients what the results mean.
[00:16:02] JL: Yeah, exactly. We try to be extremely aware of all of the caveats that come with it, but it is really nice, because we've reached a phase with our functional MRI, where there's actually data that it spits out. To give you an example of what we're looking at, it's almost a statistical report, basically, the patients are handed this piece of paper, and they're looking down at it. There are lines to mark standard deviations. There are neurocircuitry that's being shown and the score is provided. It doesn't exactly tell us, for example, what was happening when that patient was in the scanner.
We actually get multiple outputs where we've been able to look at a patient's time lapse of what was going on in their brain as they were doing the scan. We might see that, oh, they were doing one of those tasks and were really struggling with that specific task, or we've caught people daydreaming in the scanner, we've caught people sleeping. We want to make sure that when we're sitting down with that patient, we have information that allows us to determine the accuracy of those results. In some cases, we have to rescan, but we know we have to do that to get the best data.
[00:17:12] TH: We constantly try to reef feed that information back into the machine, too. The scan that we use now was developed by Dr. Allen and Dr. Heath Lorzel. He too was an aerospace engineer. He's on a call with us every week where he's watching the scans come in, and he'll say, “Could you tell me more about this one.” We'll sit down, say the patient experience – this is their history, this is what they reported in the scanner. This is what they told us about their experience and we're always looking at ways to maybe update the software we use to analyze that scale to give us the most accurate or relatable responses that we can get.
[00:17:49] BP: I really liked that. I liked the ongoing part of it, which I think is the biggest thing about science is that we have an answer, but let's see if we can find a better answer and keep going and keep coming up with different things. I know you mentioned it's loud. I think that's just part of a lot of those types of scans. I used to close my eyes and pretend I was in a video game and make things up with the sounds, otherwise I get really dizzy laying there. So it's tough, but it's worth it in my mind. Like it is really worth to try it out.
I always try to encourage everyone to test it out, get the answers. Of course you might struggle and maybe you have to go lay down after, but that's okay. I've done balance exercises in therapy and had to lay down on the floor of a therapists office, because I got so dizzy. That's okay, too. Everyone’s really understanding. That's how that works, but I really do want to get onto all the treatments that can get performed after that scan. Before that, we're going to take a quick break.
[MESSAGE]
[00:18:55] Cognitive FX is a research-driven clinic that has successfully treated thousands of patients who have long lasting symptoms from concussions or other brain related injuries. Cognitive FX has an innovative approach to recovery that uses an advanced fMRI scan to map the function in your brain, so you can see which areas are not functioning the way they need to in order to support your daily life. Treatment at Cognitive FX takes five days to complete and uses your fMRI scan as a guide and baseline to ensure that your treatment is personalized and effective. They have more than 15 different therapies at our clinic that are uniquely selected to treat the troubled areas in your brain. This means that you won't need to schedule and keep track of multiple specialists’, locations, dates, times or therapies, because they will all be prepared for you when you arrive.
Once you've completed their treatment you receive a personalized at home plan to continue your recovery and gain access to their online patient portal that has instructional videos and resources for your continued recovery. Conveniently, Cognitive FX also offers free consultation, so both you and the doctors can ensure that treatment is a good choice for you and your injury. Visit their website at cognitivefxusa.com to learn more about the treatment. Take a two-minute symptoms quiz to get a quick idea if treatment is right for you. Don't delay your recovery any longer. Find solutions at Cognitive FX today.
[INTERVIEW CONTINUED]
[00:20:26] BP: Welcome back to the Post-Concussion Podcast with myself, Bella Paige, and today’s guest, Dr. Jaycie Loewen. Dr. Tyler Hanak. I really want to get into all the treatments actually, because I know there's a lot and you don't need to list them all, but do you want to walk us through some of the treatments that Cognitive FX has to offer after you get your scan?
[00:20:50] TH: Yeah. One thing before we go into treatments, I just wanted to mention it's a nice end to our scan conversation is that one of the biggest pros about that functional MRI is that it has shaped how we approach things here in the clinic. I think it's really helped lead us to a multimodal interdisciplinary approach.
[00:21:10] JL: Yup. Patients are always surprised. Our model is – it doesn't look like anyone else's model. To describe what a patient might, a bird's eye view of what a patient might see is there are multiple different departments, ranging from cognitive speech language pathology, vision, vestibular physical therapy. We describe it as like, under one roof, we have a concussion community. Now, many patients have seen a number of specialists before coming to us. I should probably describe who we're seeing, because that's really relevant to, again, how we design treatment, our initial research.
We typically see patients that have gone to neurologists, nutritionists, cardiologists, gastroenterologists, physical therapists, speech language pathologists, have been on numerous medications. We're the end of the line, sometimes. Many patients are very skeptical and a little bit of like, “Okay, who are you? What do you really do?” A lot of what we do is pretty standardized. We have CPT codes for our therapies. The difference is how we approach it, considering the patient as a whole. Tyler brought up, for example, the attentional issue. We have that scan, where we can recognize the functional units that will eventually contribute to symptoms, but that's not it. So for example, in that functional MRI, we're not able to look at some vestibular dynamics, because you have to remain still. You can't move in that MRI machine.
We may have, let's say, some of our vestibular specialists, or we call them the neurointegration team, they're going to be the one we talk about a lot, because they're super cool, but they may take a patient and they may be looking at those brain areas, and maybe looking at parietal areas of the brain, for example, involved in spatial processing. Then they're having them do different balance and vestibular exercises, and figuring out how all of these pieces work together.
Another component is we'll go into a little bit more, but having all of these therapists under one roof allows them to communicate. You have a physical therapist that's taking their patient to the speech language pathologist and they're going, “Hey, the patient is having a really difficult time activating their diaphragm. A lot of their headaches, symptoms are coming from not appropriately breathing. When you're working with that patient, keep an eye on them.” So the cognitive therapist will do that and be able to see, “Hey, John Smith you're not activating your diaphragm. That's the reason that when you're doing these different cognitive therapies, your headache is starting to climb. Let's work on that before we continue.”
It makes the therapies more engaging. It makes them more customized. It makes it more effective, because what's terrifying to our patients is that it's all crammed into a short period of time. Many people call it brain bootcamp, because it could be 35 to 40 hours of therapy in the course of about five days. Now, that's what's makes it effective, is actually that intensity, but it allows us to be able to treat and to work on symptoms of the same.
[00:24:08] TH: We think that layering all this stuff at once is important too, because concussion symptoms don't happen in a vacuum. You don't just have one. Your daily life is not just one thing. You're going to be doing multiple things. We have to make sure that we're sending you from someone working on vision to then vestibular, making sure those two systems are talking to each other. We even had a patient that had breathing difficulties. It was a long COVID patient. They had oxygen tank. They were walking with a cane, too.
One of our Neurointegration Therapists, who's amazing here in the clinic, called me over and said, “Watch this person walk.” He said, “Hold your breath and walk down the hall.” He didn't even need his cane. I've told him that right before he turns around, he needs to take a breath. So, he's walking straight, he takes a breath, and then suddenly he needs the cane again. We noticed that this patient can't multitask even with breathing or walking. That was an identification stage that we wouldn't have found unless we were checking everything we could with that patient.
[00:25:12] JL: Yeah. That actually brings up a point, which is our patients are typically educated. They're great compensators. They have learned methods to be able to survive, to interact with their families, to sometimes even continue stressful work positions, because they figure out well, if I turn down the lights, if I wear sunglasses, if I do this, if I do that. So sometimes, we're healing apart compensatory processes that these patients have developed. So for example, we treat a lot of athletes, sometimes professional athletes, where we might have them do a balance test, and they do great, but we asked them to do a simple cognitive game and they start to tilt.
We have a patient where we're looking at different eye movement dynamics, so convergence, when you're bringing something in and your eyes cross a little bit, or divergence where you're bringing something out. They may do fine when they're doing that one task, but if we have background music, suddenly their eyes stop working together. You'll actually have one eye that may over converge. That's why the therapists are right there one-on-one with the patient, so they can immediately see this happening and adjust.
[00:26:19] TH: I think another important thing is what do all these look like together? What does a whole week look like for a patient coming through? It all starts with – we do consultations. We look to see, hey, does this patient understand what they're going to be doing when they come to see us? Do they fit into that profile of a concussion patient that's going to respond well to treatment? At that time, we're already taking notes and we're writing down everything we can. In fact, I'll have patients that will say, “Okay, this symptom is really weird.” Usually we check on site trials. We've heard quite a bit, right? A lot of times patients are afraid to talk about symptoms. They don't realize that actually, this happens to quite a few concussion patients and everyone has a different way to describe it.
We do that consult, and then they might get some material before treatment, but they come in for treatment, usually the first day. We're doing evaluations. We do that functional MRI, neurostructurals that day. One of them will sit down with one of us or a nurse and go over the data of what we saw in that fMRI. Talked about what potential interpretations could be and also what we're going to do with that scan, but that's just one piece of information. Every patient is going to be like an Agatha Christie novel. You need as much evidence as possible to come to the conclusion. We send them to our neuromuscular therapists.
Those neuromuscular therapists, neurointegration therapists, they're going to be looking at things that we can't see in the scanner. Dr. Loewen mentioned the vestibular system, the autonomic nervous system. They're going to be looking and evaluating that patient. They'll go and see all of our therapists will see our psychotherapist, cognitive therapists, occupational therapists, and we get this profile. We are constantly communicating. In fact, we have a Teams channel for every single communication line with the patients. I will know when someone's headache goes from a four to a six on that day, which sometimes creeps them out. All the therapists are seeing it and going, “Ah, this is how they're reacting to therapy.”
Tuesday, Wednesday, Thursday, then we're doing all our treatments structured on that Prepare-Activate-Rest Cycle. We do interval cardio to give a cognitive boost and also start getting in at that automatic nervous system. Then we send them to all the therapists. Then we have a recovery period. We rinse and repeat and do that for Tuesday, Wednesday, Thursday. We're having meetings to see if what we're seeing with these patients, what else they need. Then Friday is a short day, because there's diminishing returns by that point. We go over the data from the week with them and help them come up with a way to construct a take home plan for when they go home and continue to do exercises and figure out how to recover and meet their life.
[00:29:02] JL: Actually, to tie things back in. The Prepare-Activate-Rest Cycle is one of the core pieces of treatment. Think of it as our framework that then the therapists insert the customized pieces. The reason that we started with Prepare-Activate-Rest is actually the neurovascular coupling piece. When the reason that we start off with that physical activity, we like to use very simple analogies of like, you're increasing your heart rate, you're increasing the availability of oxygen to the brain, but it's more than that. We're actually looking to specifically engage a lot of larger muscles in the body, because it's begins to initiate to this basically a BDNF cycle. It's called Brain Derived Neurotrophic Factor. I’m double checking on that –
[00:29:45] TH: Yes.
[00:29:47] JL: BDNF. It is involved in a lot of plasticity mechanisms. That's another thing that complements neurovascular coupling is this plasticity is that we're seeing in our patients that their brain is essentially rewired in a different way. Somewhere in that injury healing process, a pathway got rerouted, for example, resources were going to the wrong areas. By first doing that physical activity, we’re waking up chemical pathways, where the brain is going, “Okay, we're going to learn something new and we have the resources in order to do that.”
Then, the application of the specific therapies allows the brain to recognize, “Oh, that pathway isn't open. Why isn't that pathway open? That's like the main freeway from brain area to A to B. We need that.”
Then, the rest component or the recover component, after you've done those intensive therapies is a more of an active arrest. Some patients do fall asleep. We actually put them in quiet darkened rooms. They're using different techniques to activate the parasympathetic or that rest and digest system. We're also trying to get that brain to, it's almost like sleep. We have consolidation, where throughout the night, your brains recognizing, oh, let's get rid of this. Let's make this stronger. We're trying to stimulate that process. So, by the time we restart the Prepare-Activate-Rest, they're re-energized, their brain is getting used to these new slash old patterns.
Honestly, most of our job is done for us, because these structures are already there. The brain is used to many of these patterns. We're just trying to get back to those old healthy patterns. Then, it's like learning the piano. I mean, it's if you keep doing, or riding a bike. I haven't ridden a bike in over a decade. It wouldn't be as long to learn it, because I've learned it before. I can hop back on that bike, have some issues balancing at first, and then get back into that groove. That really comes back to our initial findings on functional MRI. It comes back to why we have the multidisciplinary and why we use that cycle to work with our patients.
[00:32:01] BP: Well, we did, actually, I think we've had a few guests that have been to Cognitive FX. One of them was like, I don't know how many times he said, “Thank you Cognitive FX” on the episode, but you get desperate. I got desperate, I remember feeling like anything, like you just are willing to try anything, because you just want to get better. I love the communication piece, because I think that's huge. It's really hard to update all of your doctors and all of your therapists on what you're doing at each one, so that they can all be cohesive, and they can all understand each other, or why you are really tired that week, because one therapist stepped it up. The other one hasn't yet. They're like, “Oh, why are you off this week.” So that communication is huge.
The coping mechanisms, I really understand for myself. Chronic headaches for about seven years, and I got so good at dealing with them, that I could do everything with a headache, from participate in sports, write an exam, go to school, hang out with friends, everything was severe pain. I know that I got good at coping with them, because if I get those headaches now, which is very rare. I'm out. I cannot function. I am stuck in bed, sleeping, maybe eat something that day and it's just crazy, because I was like, I used to be able to do everything being in this much pain. So it is scary how good your body can get at it, but you can really just come up with ways to get through it like wearing hats and sunglasses or taking lots of naps in the day, how you eat. There's so many things to cope.
I think it's so important to also treat a lot of your symptoms so that they can get better, because coping with them helps you live your life, but it's also nice if those symptoms can go away. I like that, you guys also mentioned the aspect of thinking that symptoms are weird and that comes up a lot. We have a support group called Concussion Connect. Someone writes about a symptom they're experiencing. Then tons of other people responding, “Oh, I've dealt with that, too. I explain it like this.” It is that piece of like you're not the only one.
It is really important to come see specialists that understand that you're not crazy, because I can't count how many doctor’s offices I walked into. They like, “You're the only one I've seen like this.” I'm like, “Oh, I don't know if this is a good thing, but thank you for telling me that, that I'm the only one you've dealt with like this.” Especially when I was really young, because I know 10 years ago, it was a lot different and at the beginning of my journey, some of the looks I would get when I was like, “Oh, no I am in pain every day, all day.”
I can't remember who like, people are some days and all those types of things and they just, the looks. I used to just like look away. I was like, “Don't look at me like that.” It is really important to go to a place that you get it. There is no, “Oh, you're crazy.” No, you're not crazy. We've seen people like you. We know how to handle this. We can hopefully help you get to the best that you can be. So you have talked about so much so far today. I don't want to overwhelm people. Is there anything else you would like to add before ending today's episode?
[00:35:28] TH: Not to add too much, but the fact that we're always – treatment is number one. That's our main focus. We're always looking to try to elucidate more of what's going on. We talked about neurovascular uncoupling. One of the future directions is we're looking at more ways to see if that's what's going on, because sometimes when we see in that scanner that an area didn't have an increase in response that we'd expect, is it because that brain areas not turning on or because of the uncoupling?
We're looking at something called functional near-infrared spectroscopy, which doesn't – fancy word of saying it's like having a bunch of pulse oximeters on your head. It looks at oxygenated and levels of deoxygenated blood in the brain. We're hoping to do some similar tasks and see, is this because there's neurovascular uncoupling in these populations or is there something else going on, or both? When is that the case? Still looking to try to find new toys to play with to learn about what's going on, because there's still a lot of unknowns.
[00:36:26] JL: Well, then we've had the privilege to be able to open our doors to more than just concussion patients through research. Originally, we were, this is the only data we have if you're coming to us for something other than concussion, we have to be really careful to go, “We don't know how you're going to respond,” but we found that neurovascular decoupling happens in stroke, hypoxia, or anoxia, severe TBI, and also long COVID. We're running multiple parallel research studies to figure out what's the best treatment for these? Do we need edits to our treatment approach for specific brain injuries? What did they look like in that functional MRI?
That's been a wonderful thing about working here is that we can always respond pretty immediately to the people that are in need, because we have that powerhouse. We have that functional MRI in our clinic that we can immediately just go. I want to answer this hypothesis. I want to see what comes out.
[00:37:23] BP: I love the ongoing research and ideas. Let's see if we can get this better and better. I can say that, because I've gone to specialists where they have the answer and there's no, no leeway, no change, and that doesn't work for concussion survivors, because everyone's situation is so different. I just want to thank you both so much for joining us today and sharing your work with post-concussion survivors.
[00:37:50] TH: Thank you.
[00:37:50] JL: Of course, thank you.
[END OF INTERVIEW]
[00:37:55] BP: Need more than just this podcast? Be sure to check out our website, postconcussioninc.com to see how we can help you in your post-concussion life, from a support network to one-on-one coaching. I believe life can get better, because I've lived through it. Make sure you take it one day at a time.
[END]
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