Dysautonomia with Dr. Vincent Schaller
Show Notes:
Are you experiencing unexplainable GI symptoms like IBS? Or do you have unexplained episodes of high heart rates? Then join us on this week’s episode of the Post-Concussion podcast, with our guest Dr. Vincent Schaller. Dr. Schaller is a board-certified physician with over 25 years of experience, he has been a certified impact consultant for over 10 years and is the medical director for the Mid-Atlantic Concussion Alliance. Dr. Schaller’s careful, complete examinations, combined with his friendly bedside manner have earned him the respect of doctors and the trust of many patients.
Join us for another insightful conversation about the invisible injury behind the invisible injury. Dr. Schaller shares important insights about concussion injuries and more about the MAC Alliance and what they’re doing with their programs. He unpacks the autonomic nervous system and how autonomic dysfunction manifests after brain injuries. Don’t miss out, so tune in now!
Key Points From This Episode:
We hear from Dr. Schaller about what created his interest in concussions.
He shares with listeners more about the MAC Alliance.
Dr. Schaller explains what autonomic dysfunction is.
A 101 on the autonomic nervous system.
How brain injuries affect this system.
He defines what a corner hit is.
How autonomic dysfunction is diagnosed.
Dr. Schaller explains what POT Syndrome is.
Why GI symptoms for autonomic dysfunction are so hard to diagnose.
How autonomic dysfunction affects temperature control.
The importance of grieving the old you and accepting the new you.
Dr. Schaller leaves listeners with one last tad bit of information and encouragement.
Learn more about Dr. Schaller and Mid-Atlantic Concussion Alliance: https://macconcussion.com/
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[INTRO]
[00:00:05] 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. So, 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]
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 80 of the Post-Concussion Podcast with myself,
Bella Paige and today's guest, Dr. Vincent Schaller. Dr. Schaller is a board-certified physician
with over 25 years of experience, including inpatient and outpatient medicine, ER, ICU, CCU
paediatrics, primary care, and concussion management. He has been a certified impact
consultant for over 10 years and as the medical director for the Mid-Atlantic Concussion
Alliance, he and his staff have successfully applied the latest University of Pittsburgh Medical
Centre concussion protocols 2000s in the tri-state area. Dr. Schaller is actively involved in
concussion research with BrainScope of Bethesda, University of Pennsylvania Medical School,
West Chester University, and Penn State University with EyeGuide infrared technology. Dr.
Schaller’s careful, complete examinations, combined with his friendly bedside manner have
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earned him the respect of doctors and the trust of many patients. Welcome to the show, Dr.
Schaller.
[00:02:17] VS: Thank you for having me.
[00:02:17] BP: So to start, do you want to tell everyone a little bit of what created your interest
in concussions?
[00:02:23] VS: Absolutely. My background is in a lot of hospital work, a lot of ER work, urgent
care work. It turned out where my interest in concussions kind of started building, especially
when I was doing ER and urgent care. In ER and urgent care, the one thing is, is that – I
actually ran my own urgent care centre from 2003 to 2013. In those 10 years, we start seeing a
significant influx of head injuries from athletes, work injuries, car accidents, and we really didn't
have a lot of tools back in the early 2000s to evaluate or even to treat head injuries be it
concussions in athletes, TBIs and work injury. It ended up, somewhere around 2005, we were
kind of in the middle of when the ImPACT Program started hitting all the schools, colleges. and
high schools. The ImPACT Program is a 30-minute test taken on a computer to be able to see
how your memory is working or how your processing speeds are working. It’s kind of was
started off at University of Pittsburgh, with Dr. Micky Collins and Dr. Mark Lovell.
The reason I became exposed to it was because, somewhere around 2005, athletes that would
normally come in with twisted ankles, and injuries from sports, and shoulder injuries, knee
injuries. Those same athletes are coming in saying, “Hey, Dr. Schaller. I think I hit my head.
Could you please do my post-injury ImPACT test?” I was like, “Oh, what's ImPACT?” So from
the fall of 2005 into the winter of 2006, we must have gotten over 100 requests for post-injury
ImPACT. It looks like a lot of schools are really taken on to this new technology. Through that
experience, I said, “Huh! Maybe there is some new tools, maybe there is some better way to
diagnose or treat a concussion or TBI.” So I decided to do some research, and checked with
ImPACT’s network around the US. Came across a really nice doctor, Dr. Berkner at Colby
College in Maine. They had liked the program so much with ImPACT in the Pittsburgh protocols
that they set the entire state up on it and shared all the information. So if you got injured at one
high school, you can go back to your middle school, the results would still be there accessible.
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We reached out then, and I went to visit the folks at Pittsburgh, and realized it wasn't just testing
they had, the ImPACT testing, but they actually had put together vestibular therapy protocols,
and ocular therapy, eye therapy protocols. They put together prescription protocols. Different
things that they could do to assist and facilitate the recovery from a concussion TBI. When I saw
that, I was like, “Wow! I’m definitely going start doing these post-injury ImPACT tests for the
students coming in, in the urgent care world.” I said, “But this looks like a lot of extra new tools,
as far as I never even heard of doing vestibular therapy after a head injury or I’d never realized
that eye movements are significantly affected by concussions and TBIs.” I learned all that at Pitt,
and I said to those guys, “How can I start applying this to my patients?” At that time, there was
no training online. You had to physically drive out to Pittsburgh. For me, it's about a four-and-a-
half-hour ride, and go to the conferences around with Dr. Collins, Dr. Lovell in their clinic.
The deal then was, take all our conferences and courses, go back to your office, see about 50
concussion patients, start to finish. Then take two oral exams, and if you passed those, and we'll
let you train other doctors, and other nurses, and other providers. It took about a year and a half
to do 50 patients and get certified. Once that happened then, we started setting up a network
just kind of like the one in Maine, we call the Mid-Atlantic Concussion Alliance. We started
adding schools, and doctors’ offices, and physical therapy centres, primary care doctors. We
start putting a whole network together we could share this information. So somebody had an
injury in one school, they could go to any of the facilities in the MAC Alliance, and get the post-
injury compared to the baseline and figure that out.
Over the years, though, we've really started with the PMC protocols, and their therapies and
their ImPACT Program. We expanded out to a lot of other tools for our tool chest, Cambridge
Brain Science was an addition. That's another test like ImPACT, but it actually can identify what
happens with an ADD student and some other interesting things. Then we added infrared eye
technology called RightEye, it tracks the movement of the eyeballs. Another infrared called
EyeGuide, it allows us to do a quick baseline, 10 second test at the schools. Then we ended up
picking up an EEG, a quantitative EEG right from the military called BrainScope EEG, that
allowed us to actually look for structural injuries. Meaning that the patient not only bruise their
brain, but they actually broke some nerve fibers.
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We put together kind of a whole program, and we've grown over to about 65 centres now, and
we take care of patients in six states. But it became kind of just doing urgent care, minding my
own business, and then tripping upon the success of the ImPACT Program, and then kind of the
fuse that lit the idea. But boy, we've added a lot more tools to our tool chest than just the
ImPACT Program since then.
[00:06:58] BP: It's great. I always love hearing about how people get interested in it, because
it's not always a typical route to get interested in. I also like that you mentioned it was a year-
and-a-half to get certified, because there is a lot of programs out there that are about two
weeks. It always makes me really nervous when I have people reach out saying they're going to
someone and I was like, “Oh, what is their background?” They mentioned it and I'm like, “Well, I
can do that course too” and I wouldn't treat someone for concussion. Personally, I was like – it's
good to see.
[00:07:32] VS: I can say from experience that even with a year-and-a half, 50 patients, it
probably took a good, probably good 500 patients when I started saying, “Well, I'm getting pretty
good at this.” You have to really immerse yourself. Now, we're over 17,000 patients we've cared
for in a little over a decade, and very complicated cases. We usually get the cases after three
months, if they’re not better. That tends to be a typical patient for MAC Alliance. Yeah, it takes a
long time to get really good at it. then you have to keep growing, the technology. I mean, you
have to keep checking the technologies out. Here at MAC, we read about 20 to 30 journal
articles a week internationally, to see if there's anything else out there that's good or can further
benefit our patients. That's the process we continue to do, but that's how we picked up so many
really excellent technologies that we are probably having good success with.
[00:08:15] BP: It's great to keep up with it, because it is something that was so behind 20 years
ago, medically. It is constantly changing, and it's great to see that you are continuing to grow
with that as well. So, our big topic for today is actually autonomic dysfunction. Do you want to
explain a little bit about what that is?
[00:08:37] VS: Absolutely. Autonomic dysfunction, I'm going to start by saying, concussions and
traumatic brain injuries, they're invisible, period. They're invisible to the real world, and that's the
biggest problem with diagnosing them. Just all the big excitement over this unfortunate week of
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the NFL and quarterback from Miami Dolphins, Tua. Unfortunately, in that situation, it wasn't
invisible. He obviously stumbled all over the field on Sunday. Then by Thursday, he literally went
into a complete posturing, very gruesome looking image for people to see. In case of Tua, it was
very visible. It's got everyone's shooken up and upset. But majority, I'd say, probably over 90%
of concussions, they're not visible. They happen, the person's brain’s impaired. They talk to you,
they're walking, they look good, but they could have a very severe concussion you're not even
aware of it.
Not only is it invisible diagnosis, but autonomic dysfunction from the concussion is even further
invisible. It's like behind the invisible, it's doubly invisible. That's the reason why I'm glad that I'm
discussing that with you today, because some of the symptoms people have with autonomic,
they kind of either not diagnosed or just kind of like blamed on another organ system, and not
on the injury to the brain.
The autonomic nervous system – kind of do a little 101 on the autonomic nervous system. The
autonomic nervous system is, I like to call it when I tell my patients and explain it to them. I say,
autonomic nervous system is really like the automatic nervous system. It's kind of on auto pilot,
okay. What it does is that it has two different components to it, and it runs nerves completely
parallel to the regular nerves you think about. The regular nerves are the nerves where sensory
is coming in, we call that afferent. Then, nerves go out to the organs and the muscles called
efferent. You can see those nerves when you hear about someone severs the nerve in their
arm. That's a nerve going out, and back and forth to the extremity.
There's a whole hidden nervous system called the autonomic nervous system, and it's based on
cranial nerves which come out of the skull, not out of the spine. It's also based on a separate
group of nerves running parallel to the spine called the sympathetic nervous system. To really
make it simple, this autonomic or automatic nervous system has two phases to it. It's got fibers
going down from the brain, that's called the sympathetic trunk. That is for fight or flight. That's
the one you classically hear about. You get scared by a tiger in the old days, you want to run
from the tiger, your signal goes from sympathetic to your adrenal gland that sits on top of your
kidneys. You have to adrenal glands, two kidneys. Fires up all this adrenaline in your system,
and next, you’re running, your eyes, pupils are dilated, and you're running away from a tiger
back in the old days. Okay, the fight or flight.
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[00:11:06]
The parasympathetic nervous system is more known for rest and digest. The parasympathetic
nervous system is actually controlling the GI tract and how it's moving, and the body in a resting
phase. If you over stimulate the parasympathetic, the pupils get pinpoint. If you over emphasize
or over stimulate the sympathetic, pupils get large. That's kind of the first thing you can notice if
someone's going through an autonomic dysfunction. Some of the things you might see after a
head injury, which will affect this, and you have to remember, the centre of control in the brain
for the autonomic or automatic nervous system is the brainstem. Okay? Think of the brainstem
as the primitive brain. When you build a brain – I'm not sure if showing pictures and all is of any
help on a podcast. But the brainstem literally sits on top of the spinal cord, and it's the primitive
brain because all that has makes us as humans, and allows us to have all kinds of higher
functions of thinking, is the cerebellum, is the gray matter that grew and evolved off of the
brainstem.
The brainstem is actually the primitive organ, it controls – I like to tell my patients, it's like the
thermostat of the body. The brainstem controls heart rate, and it controls temperature of the
body. It controls how fast the food is digesting, or how slow the food is digesting from that rest
and digest. It also controls, again, pumping adrenaline out. It will send a signal to the adrenal
glands and say, “Hey, listen. Pump the adrenaline out, we got to run. We're being chased by a
tiger.” The brainstem itself can actually be injured during a head injury. The way to think about it
is, you think of the gray matter smacks back and forth inside the hard skull. That's an easy
picture to envision. But what happens to it is that, you have to understand, the brain is floating
fluid inside the skull, and it's literally tethered by the spinal cord and the brainstem.
When the brain bangs around, if it's linear, acceleration, deceleration, front to back, usually the
brainstem is not injured too much. The biggest problem with the brainstem is what if the
person's head gets hit on the corner, or they're in a – their helmet gets hit on the corner. When it
comes to sports injuries, I always tell my patients, “I'm a little nervous about your brainstem
being injured when there's been a corner hit.” I say this to my patients all the time, “I think you're
a corner hit.” What a corner hit means is that, not only does the brain go through acceleration,
deceleration, but it actually goes through torsion or twisting.
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The classics and sports are a goalie who gets the puck, hit at high speed to the corner front of
his helmet. The corner front of his helmet is going to be, in medical terms, it’s going to be his
frontal and temporal lobe. But when he hits, the head turns, not only it recoils, but it turns. Then
turning, if you think of – I always explain to my patients. My fist is like the brain. As I clench my
fists, my wrist is like the brainstem, my forearm is like the spinal cord. When you twist the brain
on the spinal cord, unfortunately, you damage the fibers inside the brainstem. Injure the
brainstem, and now you have havoc with the parasympathetic sympathetic system. What could
you see? This invisible injury behind an invisible injury. What you would see is somebody – I've
had patients who literally, they're not exercising, they're just minding their own business, and
next thing, their heart rate is 140. That is when the sympathetic system has overdrive. That
injury to the sympathetic systems, falsely sending a signal to the heart, “Hey, man. We're being
chased by a tiger,” but you're not being chased by a tiger, the heart rate is up to 140. We have it
where their pulse goes way down, they pass out. Pulse goes way down, the blood pressure
drops, they pass out.
That cases where they have really bad GI problems after a head injury. They're having all kinds
of problems. It's diagnosed as IBS, or having colitis. In reality, their parasympathetic drive in
their brain is saying, “Move the colon, move the GI system or slow it down, slow it down,” it gets
constipated. You see all these different things that spin off of the abnormalities with fight or
flight, sympathetic nervous system, heart problems, and breathing problems, things that spin off
of the parasympathetic nervous system as well. They usually get misdiagnosed as like for
parasympathetic, IBS. For sympathetic to get diagnosed as, “Oh, you must have a cardiac
arrhythmia, the wiring in your heart must be abnormal.” Because you can see a young athlete
with 150 pulse, which is an abnormal heart problem called SVT. But if it's from a previous head
injury, the signals coming from the brainstem, it's not a problem with the heart.
[00:15:14]
A lot of times, for the heart situation, the fast heart rate, slow heart, they go through a huge
heart workup than they have to. They go through an echocardiogram, all sorts of ultrasound of
their heart. They go through an EKG, they go through a stress test, they might even do a tilt
table test looking for POTS, Postural Orthostatic Tachycardia. What ends up happening is that,
© 2022 Post Concussion Inc. 7
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when the whole workup is negative, then everyone says kind of like, “Well, we don't know what
it is, and they keep having 140 heart beat out of the blue over and over again.” Those patients
usually, when they're coming across into our environment, we're like, “Oh, you’ve got
unexpected tachycardia, and negative cardiac workup? Did you ever have a head injury?”
That's kind of where we lock in on at that point.
They're really hard to treat, because you slow heart rate down with a beta blocker, but I've had
patients with the problem with their speedy heart rate from a brain injury, you put them on a beta
blocker or calcium channel blocker, slows a heart rate down. But what ends up happening is
then, they end up having too low of a heart rate. Too low of a heart rate makes you dizzy.
I have actually had one patient with an autonomic dysfunction that couldn't find even balance of
a calcium channel blocker, beta blocker pushing the heart rate way down. She would get too
slow, so they actually put in a pacer. This is a lady who's only in her 30s. He's a school teacher,
injured in a car accident. They did put a pacer in to raise her pulse to 60, so they could put her
on high doses of beta blockers to bring down the tachycardia from autonomic dysfunction.
Believe it or not, she's actually doing fairly well now, where she's on these higher doses of beta
blockers, bringing the heart rate down. She's got the pacemaker protecting it from dropping too
low. Now, she can function much better than she did before the diagnosis, before that treatment
plan was figured out. That was done by very smart cardiologists that figured out that that this is
how we're going to try to make this lady have a quality of life.
[00:16:55] BP: Wow, that's quite the – it's a balancing act. I know for myself, I went in – this is
three years ago, maybe four years ago now. I had such a higher heart rate. When I went into the
ED, they were shocked because they thought I was really young, you're having a heart attack,
like what is happening. I was in the ICU, they did all these tests, bend over, stand up every
single test that you mentioned, as well. I'd wear a halter for like two weeks, and then take a
break and then do it again. A lot of time, everything would come up normal, like you said. It can
take a while to do a lot of these tests, but it's very important to realize that a lot of this is
invisible. On top of the invisible factor of your head injury, I really like it that way. Because all the
time, I know I wasn't alright, but the tests would say I was, because we weren't doing the right
tests.
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Finding out what tests can we do to actually show what's wrong was sometimes a lot of
guessing, and a lot of work from multiple teams of doctors who were like, “Okay. Well, this didn't
show it, so let's try this.” Or sometimes, some of the tests, even like I'd be, “Why are we doing
this?” But if you're okay with being a guinea pig, then a lot of the time you can get the help that
you need. But we are going to take a quick break, but you can learn more about Dr. Schaller
from the Mid-Atlantic Concussion Alliance at macconcussion.com, which of course you can find
in our show notes as well. With that, we'll be back soon.
[BREAK
[00:18:33] BP: Have you joined our support network, Concussion Connect? Did you know we
do monthly giveaways? Next month is a custom Post Concussion Podcast Yeti water bottle. Just
for being a member, you get entered to win, become a member, and get the support you need
by going to concussionconnect.com.
[INTERVIEW CONTINUES]
[00:18:56] BP: Welcome back to the Post Concussion Podcast with myself, Bella Paige and
today's guest, Dr. Schaller. We've been talking about autonomic dysfunction, which is quite the
topic. But I want to kind of get into a little bit about how we diagnose it when we can or how do
we start once we realized that it might be the problem?
[00:19:16] VS: Excellent question. We already talked about when it comes to the fast heart rate,
that patients are going to get a full cardiac workup. Okay? When it comes down to people being
lightheaded, passing out, one of the autonomic dysfunction syndromes is called POTS, Postural
Orthostatic Tachycardia Syndrome. What POTS is, is that, when we naturally stand up, and
when you naturally stand up to maintain the pressure to your brain, to your head, and your
upper extremities. Your arteries have to tighten up in your legs to make sure that the blood flows
properly to the brain. POT Syndrome, which is a bit of an autonomic and this is another function
of the autonomic nervous system. The autonomic nervous system actually is responsible for the
size of the arteries and arterioles in the entire body. it. When you stand up, naturally, the
autonomic nervous system brainstem should say, “Hey, everybody tighten up down there below
the waist, because we need that pressure to go up to the head.”
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The situation of POTS, the brainstem is not telling the lower extremities, arteries to tighten up.
Person stands up, all the blood rushes to their waist and below, brain goes, “I don't like this.”
The brain passes out, and the hearts going, “Wait a minute, I'm going to try to get the pressure
up by increasing the heart rate.” What ends up happening in POTS as they stand up, blood
flows down below the waist, and below, heart tries a beat away to try to get the brain more
blood, person falls down, hits their head. Now, that's a problem when the POTS is coming from
a head injury, because you're trying to recover from the head injury. And when you pass out and
hit your head again, it's like monopoly, going back to the start again. It's really frustrating,
because the patient may have spent two, three, four months making great recovery from their
concussion. But because unfortunately, there's an autonomic dysfunction associated with POTs,
now they just passed out when they got up to go to the bathroom middle of the night, smack
their head. Now, we have to go backwards, the headaches are worse, and we're starting all over
again with the concussion recovery.
It can really be very frustrating as a concussion specialist to have autonomic dysfunction that
has POTS, because truly, these people are really vulnerable. Be very careful. Explain to them,
when you sit up at getting out of bed in the morning, please sit there for a while and wait until
you feel good before you even try to get out and do everything slowly. In that scenario, to
diagnose POTS, you do something called a tilt table test. A tilt table test is where you literally lay
on a table that's flat, horizontal, and then they change the picture of the bed, so it could be
perfectly vertical, the bed spins up. They actually check the effect of your body's location
horizontal, working through vertical on how it affects the blood pressure, how it affects the heart
rate.
[00:21:41]
On a classic of POTS caused by the dysfunction of the autonomic nervous system, when all of a
sudden, they put that tilt table up really fast, they'll see the blood pressure in the arms drop
quickly, they'll see the pulse and rapidly paced away, and the patient may actually get dizzy and
almost pass out on the table. So you're kind of strapped to the table, kind of like in a little bit of a
Frankenstein mode, where you're strapped to the table in case you pass out, so you don't fall off
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the table when it's vertical. That would be the kind of the whole scenario, which you would deal
with POTS. Now, you would diagnose that and pinpoint that.
The GI symptoms are so much harder to diagnose. Now, we're three layers of invisible, because
now, the GI system has so many – as you understand, when you're making a diagnosis, if
someone has reflux, that's pretty straightforward. You scope them, you might see a bit of
esophagitis, you put them on an acid blocker, either proton pump inhibitor, or H2 blocker. They
get better, you maybe go back and scope them later, make sure that ulcers healed. But the
problem, you're not going to see ulcers with parasympathetic dysfunction, you're going to be
seeing faster moving bowels, which looks like IBS. I don't know if anyone in the audience has
had IBS. That's a hard diagnosis to make, and a hard diagnosis to treat. Because IBS is literally
somebody in the brainstem is taking the accelerator for the GI tract, and they push the pedal to
the metal, and they hit the brakes, and they push the pedal to the metal. IBS patients
unfortunately have the rhythms going both directions, it's very chaotic.
There are some medicines that try to help that, but it's really hard to diagnose IBS. Almost like
you do everything. You scope from the top, you scope from below, you do swallowing studies,
even [inaudible 00:23:06].
[00:23:08] BP: Diet changes.
[00:23:10] VS: Dietary changes, absolutely. Increase fiber and all the things. So really, the GI
diagnosis for our autonomic nervous dysfunction is very difficult. It really is hard to separate it
from like an IBS patient, because an IBS patient is born with wiring in their brainstem that’s just
doesn't have really good control. Or probably, you can say they're almost like the bad driver on
the street that goes too fast, and goes too slow, hits the brakes. It's unpredictable driving, that's
kind of what the brainstem is doing in a poor IBS patient, and we're just trying all kinds of
modalities to try to control it.
There are some new advances coming in IBS, obviously, but there's also new advances. Same
medicines will be good for an injured brainstem from a trauma. In those cases, some of the
benefits of the IBS studies and treatment plans might actually benefit people who are having
problems with the parasympathetic nervous system.
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As far as like extremity issues, not controlling the blood vessels in the extremities, that kind of
can be looked at, and people can say with autonomic dysfunction where you're not having good
circulation to your extremities. Your skin all of a sudden gets bright red, and then it gets pale
because you're having a hard time controlling the artery size. Those are scenarios that sound
like and look like Reynaud syndrome, so you have to be careful. Is it Raynaud's or is it an injury
to the brain? The good news is that we know how to treat Raynaud's, we usually use a medicine
called calcium channel blockers. Usually with Raynaud's, if you're not familiar with it, it's when
all of a sudden, the control of the blood vessels in your skin and in this case, your hands
because your hands have a lot of blood vessels. All of a sudden, your hands go white, then they
go purple, then they go red, and they hurt, hurt in the cold. That's an autonomic dysfunction
called Raynaud's phenomenon, and that is actually treatable by a medicine that relaxes the
arteries so they don't tighten up, and you don't get pale, you don't feel pain in your hands. There
are some overlaps of treatments for Raynaud's type phenomenon along with a treatment for
autonomic dysfunction if that's the presentation.
It really is, it's not like, “Okay, you have autonomic dysfunction, take medicine A.” It's not like
that, because autonomic dysfunction means that the parasympathetic system is not working
well, the sympathetic system is not working well, and you can go into GI problems, and pulse
problems, and passing out, POTS problems, and Raynaud's-type problems. There's really a lot
of different dysfunctions of it. The other thing I've actually had, I've had patients with autonomic
dysfunction. The only autonomic dysfunction they have, and again, you can imagine the
brainstem has different compartments, and different functions in different areas. They're like,
they can't control their temperature. Literally, you’ll have somebody who – if they're a female
patient pass 50 years old, could be having menopause, you'll have a teenager that acts like
they're having menopause, because their autonomic dysfunction is their temperature thermostat
is going all over the place.
We have had definitely patients with head injuries or like. I had one guy, he’s in his 40s. He’s
otherwise healthy, active, very good athlete. He actually said, every night, he breaks into a cold
sweat, and he had the whole workup for a cold sweat. He had the cancer workup, he had the
infection workup, and all these was negative. He just has these sweats that occur in the middle
of the night, wakes up soaking sweats. His thermostats broken from his head injury. It tends to
© 2022 Post Concussion Inc. 12
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come and go, and go through patterns of it where it’s very disruptive, and interrupts your sleep.
So even have that scenario where the thermostat can be broken from a head injury as well.
[00:26:20] BP: Yeah, mine is broken. It's actually something I've dealt with for a long time. For
example, I ride dirt bikes and things like that now. And in the summer, I don't know what,
probably be like 90 degrees out, 35 here. I was in motocross gear, and then I get off my bike,
and put a sweater on. My friends were like, “What? How are you – we are drenched, and you're
cold.” I'm like, “Yeah, I'm cold.” Or I was at a brain injury conference just two weeks ago, and I
went to a Yankees game. I had to buy a hoodie, and extra hat while I was there, because I was
so cold. It was like still not cold enough to be cold. But it goes through waves of wake up and
feel like a million degrees, even though like the temperature in the house didn't change, those
types of things, but you can manage it.
One of the things about the autonomic dysfunction, at least in my opinion is some of the things
are things you have to learn how to live with it, depending on what your symptoms are. Because
not everything has a pill to take to make it that easy to deal with.
[00:27:27] VS: That is so true with TBI concussion symptoms, is that my patients seem to make
a breakthrough when they say, “I think I figured out how to live with this.” And they make a
comment, “I've learned how to live with the new me” or “I figured out what triggers my
symptoms, what activities to be careful of or to avoid.” It's kind of like getting accustomed to the
new you. There are so many facets of the new you and a head injury, it could be a personality
thing, it could be like you said, a temperature thing. Be careful, because people around you will
be like, “What's wrong with you?” Even interacting with people is going to be affected. Some
people do it better than others. Some are just, get really frustrated, and anxious, and upset
about it. But when we try to – sometimes where I think for my patients, when they have all these
different kinds of symptoms, we try to get them into counselling if they’re acceptable to that and
open minded to that. Because a big part of it is like, there's a small percentage they have
different personalities after a head injury, and they're not the same person their friends knew, or
their siblings, and parents knew.
We do definitely keep an open door and open mind for counselling so people can kind of
understand, “This is my new life and I'm going to learn how to adjust to it. I'm not going to –”
© 2022 Post Concussion Inc. 13
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Because there's a mourning factor, a mourn for someone to feel bad because they’re mourning
the old you, the old person that was the stellar athlete, and they ran 10 miles or they were an
accountant that juggled tons of Excel spreadsheets. Now, they can't even do one. It's kind of the
new you they have to get used to. It's a mourning for, if you can't do the superpowers you had
before, multitasker extraordinaire, incredibly great at your profession, that's a lost, it's a lost art.
You have to grieve it, and grieve it then, as we know, we grieve something you can work through
it and then again, get accept the new you.
[00:29:05] BP: Yeah, for sure. It takes time to do that. It's not overnight, it took me a few – it
took me years. For example, my memory through my entire childhood, and after that was
photographic, essentially. So I could go write a test and get 100% every single time, because I
could just picture everything that I had learned. Then I went to the point where I couldn't
remember what I did yesterday, so that got difficult. Or I was a high-level athlete, so that was
hard as well. Something we do focus a lot here is the learning to live with it, and it's not being
negative. It's that science is getting there, and there's tons of treatments, and it's important to do
all those, but also learning to adjust your life so that you can still live your life while you're being
treated, because these aren't overnight treatments. But I just want to ask, is there anything else
you'd like to add before we end today's episode?
[00:29:59] VS: Autonomic dysfunction is something which is kind of, it's probably the last thing
diagnosed with a head injury. Just like you mentioned, some of the other things that you're
challenged by a memory issues, headaches, things like that. A lot of times, the autonomic
dysfunction is treated at the very end, because once you get the headaches under control,
hopefully they're back to the profession. Hopefully the memories improving with cognitive
therapy.
The autonomic dysfunction kind of like sticks around to the end, if it's really dramatic, like 140
pulse, or 160 pulse, it’s going to be addressed the same day in the ER, but eventually, it'll take a
while to figure out that none of the other causes. But the reality is, is that, autonomic
dysfunction, it's almost like a stepchild. It's so far, it's like three or four layers behind the problem
list. But people should be aware of the symptoms. Maybe it's not in a number 10 on the problem
list, maybe it can become number two, or three.
© 2022 Post Concussion Inc. 14
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So at least, they're asking their doctors, their providers, “I had this temperature imbalance, and I
read about this thing called autonomic dysfunction” or “Hey, I've never had this problem with my
heart running fast. But now all of a sudden, it's running faster.” I never had problems standing
up middle the night and passing out, but that's new.” So people know what the signs and
symptoms are, maybe they're not down at the bottom of the list that takes months or years to
get to. But if they're familiar with it, it's something that you can be doing more than one workup
on a head injury, more than one treatment plan that run parallels. What we usually say at MAC,
your treatment of each of the problems is running in parallel, you don't have to wait until the end
to get to autonomic dysfunction.
But if the autonomic dysfunction is suspected, it should be mentioned and discussed and
worked up earlier, because there's no reason to have to wait until the headaches are controlled,
and the memory is fixed, and the person makes a dramatic recovery. And like you said, it could
be years. Some of our patients present a year later, and it might take two or three more years to
really get things under control. You should be aware of autonomic dysfunction. I'm glad we're
having this discussion today. It's a great education. Get the signs, and symptoms, and things out
there. In that way, the little light bulbs are going off in someone's brain out in our listening
population. I might have that, then they bring that up with their primary care doctor, and make
sure that they address it. Because there are treatments there. They're not as easy treatments as
some of the other things we do, but there are medicines and treatment strategies. I’m not saying
everyone’s going to have a pacemaker and high dose beta blocker. But if that poor patient was
in the ER like six times with a rapid heart rate, nice to stop going to the ER once the they figure
that out, and to come up with a strategy to help them.
[00:32:15] BP: It's great, great advice to push your providers a little bit, ask them the questions.
It's okay to ask, because if they don't have the answer, hopefully they'll send you to someone
who can help you with that.
[00:32:25] VS: Absolutely. That's when the system works. When the system works, that's how
we hope that the challenging cases go to the places where they only see challenging cases and
the referral that's made on until the diagnosis is made, and the treatment plan works. We hope
our whole system works that way, but patient sometimes really has to be the instigator or the
questioner. A good doctor will be like, “Okay. Let's find a specialist that will figure this out.” Some
© 2022 Post Concussion Inc. 15
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doctors might be offended. “Don't tell me how to do my job.” But you want to find a doctor that's
kind of open minded, because you're on a journey together. You want doctors like the friendly
person sitting next to you in the airplane you can talk to, because you're going to be in a journey
together for a while, so you might still get along. But that's kind of – sometimes you want to –
might take a few tries to find that doctor that matches your personality, that's on board with the
team, and is going to take that journey with you.
[00:33:11] BP: For sure. Well, I want to thank you so much for joining us today, and sharing all
of your insights related to concussions.
[00:33:17] VS: My pleasure. Thank you for the opportunity to educate more folks out there.
That's the most important part.
[END OF EPISODE]
[00:33:25] 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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