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Ayla Wolf  00:00

Honestly. I mean, this is where I think Functional Neurology excels, because the functional neurology perspective and training is that we can't have a situation where you've got 10 blind people feeling an elephant and all experiencing just one part of the elephant. You have to actually, you know, have the whole picture right of sensory integration, and be able to understand the connection between the vestibular system and the ocular motor system and eye misalignments and ocular motor eye movement disorders, and then pairing that with the neck trauma, and then pairing all of that with the potential dysautonomia.

 

Sophia Bouwens  00:43

Welcome to the life after impact podcast where we do a deep dive into all things concussion and brain injury related. We talk about all the different symptoms that can follow brain injury, different testing methods, different types of specialists out there, and different therapies available. I'm Sophia Bowens. I'm here with Dr Ayla Wolf, and we will be your guide to living your best life after impact.

 

Ayla Wolf  01:14

This episode is a continuation of Episode Six, where we continue our conversation about traumatic neck injuries and the importance of approaching them from a sensory integration perspective. If you haven't yet listened to Episode Six, we recommend you go back and do that first before continuing to episode seven. Thanks again for listening to life after impact, the concussion recovery podcast. We talked about a couple of these functional tests where we're looking at, say, a pinwheel testing on the face, and how that can change, whether the jaw is open or closed, or the head is turned left or right. There's also, you know, when you're looking at somebody's balance, if you have somebody standing on a foam pad, for example, so you're taking away their ankle proprioception, and you're asking them to rely more heavily on their vestibular system. What we can find too is that as soon as you change somebody's head position, their balance can break down. And so most people, if their head is neutral, or if their head is looking down, they're going to be more stable. But then a lot of times, what you find is that when someone tilts, someone tilts their head backwards, then they're not as stable. And so you have to also tease out the difference between, is this a vestibular issue, or is this a cervical issue? Or, you know, again, often it's often a sensory integration between those two, which is why the solution is a combination of head movements and neck movements and eye movements, and trying to kind of activate the vestibular system with the head in different positions and doing different eye exercises, you've got to, you know, craft a therapy for each individual person that helps them to feel more stable in the head positions where they're unstable. And I think that sometimes that also gets missed, where, if somebody can pass a basic balance test, they might think, Oh, well, I was my balance was tested, and they said it was fine. But then what you realize is, well, as soon as your head is tilted back into the right, you're falling over. And so that's, you know, that's where we need to start with. Our therapy too, is actually correcting this imbalance between when you are activating your right posterior semicircular canal of your vestibular system and your head is back into the right, you're falling over. So what do we need to do to kind of get this back into balance too, so that you feel stable in any head position, right? And that can be, you know, again, a combination of what's going on with the neck as well as what's going on with the vestibular system.

 

Sophia Bouwens  03:53

It's interesting, I think about neck strengthening, how that can be so helpful. We talked in the beginning, just how that is even a preventative measure for concussion itself in recovery. Do you find that strengthening the neck is helpful?

 

Ayla Wolf  04:08

I do. And there's a, there's some kind of, like, specific neck strengthening clinic, like they have this, all these different machines and this whole program, yeah. So I have actually had patients that have been referred to to go do that. And sure enough, a lot of their symptoms improve when they actually strengthen their neck. The

 

Sophia Bouwens  04:24

Tria neck and back program, I think, is one of them. It used to be called physicians neck and back. Okay, no, it's a Tria program where they just do neck stuff. And that's they have really great machines that stabilize your neck and prevent you from using your larger muscle groups so that you're actually strengthening the spinal muscles. Because oftentimes when those are weak or there's imbalances, we'll use larger muscle groups to take over these actions that really these smaller muscles, which are more intricately tied into the vestibular system or the autonomic system the visual system, to get those to strengthen. So. Are not being overridden by those larger muscle groups that don't have the same integration, and without that key integration, as you mentioned before, we can have a lot of the symptoms coming up for people. Yeah,

 

Ayla Wolf  05:11

and I think that's where either clinics like that, or physical therapists that have a whole arsenal of excellent neck strengthening exercises that they can guide people through. I think all of that is so important. And you know, even I think what happens a lot is in today's society, people are often on their phones or their computers, and so they have this forward head posture where they're kind of jutting their whole head forwards. I catch myself doing that all the time. Me

 

Sophia Bouwens  05:39

too. And my kids might get up, stop doing that. They're like, Mom, stop it. Yeah.

 

Ayla Wolf  05:44

And I think that sets a lot of people up too, for a lot of neck issues. And so that posture piece of it is also very important. And then we have, also in our clinic, these glasses that we have people wear that have a laser in the front. Oh, yeah. And so this little setup allows us to assess for what's called a joint position sense error, where we can have someone close their eyes and we turn their head so the laser is no longer pointing at the center target. It's lasers off to the side, and they have to try to line that laser back up on the center target with their eyes closed, just using their neck receptors Exactly. And so by assessing the level of joint position error in all the different planes of movement, you know, up, down, side to side and diagonals, we can start to pinpoint, you know, which movements, which positions seem to be the most difficult, and then also use that as a therapeutic kind of biofeedback tool. And then what I've also found is that if somebody's joint position sense has a lot of errors in it, by doing acupuncture points on the neck, I often find that after a treatment, there's an immediate improvement in their joint position since testing just based on like even one acupuncture treatment of needles along the spine, because

 

Sophia Bouwens  07:06

it is a sensory stimulus exactly can up regulate that. So for patients struggling with some post traumatic neck injury or concussion like symptoms after head injury, teasing out the different components that can be driving that as far as visual or neck position, head position, vestibular can also help you really understand where to start with therapies and how to progress them. Yeah,

 

Ayla Wolf  07:31

and I think that that's where working with somebody who has a really deep understanding of the sensory integration between all these systems and can start to do a lot of these tests to say, Where's the breakdown happening, and then what kinds of therapies do we need to do so that we can clean up the sensory integration that's so important. Somebody I was talking to who is a personal or, sorry, a physical therapist at a in a larger hospital setting, and she told me that there's a division between occupational therapy and physical therapy, where they were saying, Oh no, occupational therapy is allowed to work with these types of eye movements with their brain injury patients, and then the physical therapists are only supposed to work with these types of eye movements with their patients. And there was kind of this, like turf war happening between the different departments about who got to do certain eye movement rehab, and it's like, that's not helpful for the patient, when you're trying to tease out like, like, this is all about integration, right, not separation, right? And so when you've got, you know, one silo over here saying we're responsible for saccad eye movements and gaze stability, and those people over there are only supposed to do vestibular, ocular reflex exercises. It's like this is where the system kind of falls apart. And I also think that sometimes there's a hierarchy to what needs to be done in the first place. And if you've got somebody that has a lot of issues with gaze stability. If you try to immediately throw them into some really high level balance exercises or vestibular ocular reflex exercises where they're turning their head really fast, but they don't even have gaze stability working for them, I think that that's where people get really symptomatic. They don't that, you know, they get dizzy, they get nauseous, they get headaches, they don't feel good, they don't feel like they're getting better. And so a lot of people just end up quitting. They just end up dropping out of a therapy because it makes them symptomatic. And that's also where, when you've got too many siloed people who aren't communicating with each other, trying to do different parts of the rehab and not maybe in the right order, that can be a problem for the patient.

 

Sophia Bouwens  09:43

Kind of a mess, right? Can be a mess. So for therapists, too, who are out there trying to help their patients, and they see only one level of things, or testing in one area or one plane is fine, but their symptoms aren't getting better, even though their tests seem to be fine, maybe they could think about head position or. Opposition is something that might feed into that, or eye movement components too. I think that's an important piece. There's so much as therapists we're trying to manage or trying to figure out or decipher, and each patient we see is a different book, right? So we have to read that novel and understand it and then come up with some way of intervening for that person that's tailored to what they need, and also taking into consideration what other therapists might be doing. So it can be a lot. It can

 

Ayla Wolf  10:30

be a lot, and I think that I run into those kinds of situations most often when it is some kind of workers compensation case or motor vehicle case where they've got one kind of TBI Doctor overseeing them, but then that doctor is referring them out to occupational therapy, speech therapy, physical therapy, and then all of a sudden, those three aren't necessarily talking to each other, or they're all trying to kind of tackle their piece of it without recognizing maybe that one thing needs to be stable first before the other thing happens. And so, and then the patients, you know, they especially in a workers compensation situation, if they don't follow the doctor's orders, then they're seen as non compliant, and then their entire case can get thrown out. And so it's just when you start to bring kind of, like, I don't know if you want to call it politics or just insurance, you know, when you bring insurance into the conversation, things can go sideways real quickly in terms of, you know, people may be doing therapies they're not ready for, or working with too many different doctors that aren't communicating with each other about what needs to happen, and it can get very messy.

 

Sophia Bouwens  11:37

So as providers working to communicate with the partners that are also working with the patient is really helpful, really important for that patient, longevity and for patients, understanding what is going on for them and maybe what they are ready for or not ready for, or what might be driving symptoms can also be helpful to trust that your team can know that too, because it's hard as a patient waking up in the middle of this experience, having to figure out and navigate all this, right?

 

Ayla Wolf  12:02

And honestly, I mean, this is where I think Functional Neurology excels, because the the functional neurology perspective and training is that we can't have a situation where you've got 10 blind people feeling an elephant and all experiencing just one part of the elephant. You have to actually, you know, have the whole picture right of sensory integration and be able to understand the connection between the vestibular system and the ocular motor system and eye misalignments and ocular motor eye movement disorders, and then pairing that with the neck trauma, and then pairing all of that with the potential dysautonomia and being able to create and craft a very comprehensive rehab program that has, again, very much an individualized, tailored approach for that particular individual. And so that's where I'm a little biased in saying that the training that I've had through the Carrick Institute and with all of the most amazing, brilliant professors and chiropractic neurologists that have done all of this research on sensory integration and spent years and years and years trying to understand how to see that big Picture and have this very integrated approach. I think that's where people you know can get a huge amount of improvement, is when you've got people that have that deep understanding of how it's all connected and what needs to happen first in this hierarchy of of recovery from a brain injury. Yes,

 

Sophia Bouwens  13:39

that's so key and important and helpful for patients, and it's a lot to learn as providers, especially when there's a lot just to know for each patient, but it can be super impactful for our patients recoveries, if we can pull it all together and for patients to understand that it's not just a do this one thing and It's going to get better. Oftentimes, there's multiple steps needed, and partnering across your team to make sure that the steps are all in place is important.

 

Ayla Wolf  14:09

Absolutely. It's definitely an ongoing dance in in terms of, okay, let me do these different exercises until this certain aspect is stable, and then we can move to kind of the next complicated thing and try to get that cleaned up and and so it is this, you know, very fascinating dance that happens between, you know, trying to figure out what parts of the system need to be brought back into balance, and kind of, in what order, or how do we create enough of a therapeutic change that creates the neuroplasticity to this kind this understanding that a lot of this comes down to neuroplasticity. And I often tell people that if they're doing, for example, a gaze stability exercise in terms of neuroplasticity, I always say it makes more sense for you to do this for 15 seconds, five or six. Times a day than it is to sit down and do it for one or two minutes once a day, you know, being able to just touch into these systems. And if that, you know, especially people can only handle doing it for a short period of time, it makes more sense to actually do something multiple times throughout the day. And you know, when I'm driving, if I'm at a stoplight, you know, I'll just look at the red light and I'll do some, you know, gay stabilization exercises on the red light, get some of my neck strengthening in, you know, I'm, like, pushing up against the back of the seat, and especially when driving, I can, like, fit some of these therapies in, you know, while I'm at a stoplight, you know. So there's ways of, kind of incorporating some things into your daily lifestyle where it doesn't feel super intrusive, or time

 

Sophia Bouwens  15:44

which it can be a full time job recovering from these injuries absolutely Well, I think that's amazing how complex and that can be, how complex our nervous system is, and this integration between the neck, how important it is to decide or decipher what might be driving what maybe the diagnosis is right, but we need to figure out what's driving that diagnosis and how to intervene to help it.

 

Ayla Wolf  16:07

I just had a patient come in the other day who was kind of an interesting case where she came in because of a dysautonomia diagnosis, and she had been to the Mayo Clinic. They ran her through all of their autonomic reflex tests, and she passed all of them just fine, except for the Valsalva Maneuver showed that there was some cardiovagal insufficiencies happening. And so she basically was like, Well, I don't know what to do next. And so she found me, and as I was taking her through all my tests, what I noticed was that her neck was very, very stiff, and she wasn't moving her head at all. So when she walked, she walked like a robot, you know, stabilizing that neck system. And so then she's like, Oh, well, I forgot to tell you that I had a surgery, and I had two of my vertebrae fused in my neck. And her main complaint was dizziness, and so even though she had this dysautonomia diagnosis, which could certainly be playing into this, I actually think that the dysautonomia diagnosis might actually be related to the neck surgery which caused her for a long time to walk around without ever moving her head, and that she was probably experiencing a certain amount of cervicogenic dizziness, along with a down regulation of her vestibular system, because she's never moving her head. And so that vestibular system is not really being activated in a normal way as we kind of go through the world and are looking around and moving our head and and so I started to see this quote, dysautonomia problem as a sensory integration problem that had very much a lot to do with her neck and her in, you know, her, her fear around moving her head, and this inability to just naturally go through life, and as you're walking down the hall to kind of look up or down, or, you know, It's like there was none of that happening. And so, you know when, when I started to kind of put all this together with her history, it started to make more sense that this was not just a an autonomic dysfunction that's on its own, that there's very much a cervical component to this, right?

 

Sophia Bouwens  18:16

So almost like there's a symptom of the dysautonomia, but the driving factor is coming from the neck or other components. Yeah. I

 

Ayla Wolf  18:25

mean, I can't say 400% certainty, but that was my suspicion. And so once I have this suspicion, then the quest becomes okay, like, let's do all these functional exams. Let's collect information. Then let's start doing some treatments on the neck and getting her more comfortable with, you know, performing some gaze stability exercises as she turns her head and graduating from, say, doing that, laying down to seated to standing to walking. And, you know, taking her through these steps to the point where she can be comfortable moving her head while she's moving through life. And if we can get her doing that, you know, and then reducing the dizziness, then ideally, we would probably expect to see that these autonomic dysfunctions also start to correct themselves, too. If this is really as closely linked as I think it is,

 

Sophia Bouwens  19:16

do you expect that she'll find discomfort during that process of rehabilitation or therapy for that Well,

 

Ayla Wolf  19:23

surprisingly, as I was kind of giving her different therapies and different exercises in the office, she was struggling with the difficulty of them, but had an excellent attitude. And when I kept checking with her to saying, you know, Are you dizzy? Are you okay? Is this, you know, can you handle this, you know, she was very much like, you know, yes, like, I can handle this. I'm doing fine. And she came in feeling lightheaded and dizzy, and so I was very conscious of, like, continuing to check in with her, and she kept saying, Yep, I'm great. I can do this. Like, we're good to go. I

 

Sophia Bouwens  19:55

think that makes such a big difference working with patients who are okay with some of the. Comfort and giving through things, knowing that it takes time and a little bit of recalibration of these systems, which will throw you off patients that are hard working and not afraid of that is really important. I find that they have much better outcomes. Yeah,

 

Ayla Wolf  20:16

I think it is really important to be aware of people's fears and their anxiety, I find that sometimes I'll have somebody do just like, one basic thing, like, let's just turn you in a chair 90 degrees, and all of a sudden they're like, oh my gosh, I feel light headed, dizzy, nauseous, and it's like their symptoms rev up so quickly, right? And so it can get really tricky, because some people are highly symptomatic, like that, you do one tiny little thing and it's just like a domino effect on their system. And so it can get tricky, but I do find that, you know, people's willingness to deal with a little bit of discomfort is often necessary. And the way that I often phrase it to people is, I pay attention to how long does it take them to get back to the baseline that they were at before that therapy? So if somebody is practicing, you know, a gay stability exercise, my cue to people is to say, you know, tune into your body, and as soon as you start to feel light headed or dizzy, or your headache, you know, goes from a three out of 10 to a five out of 10, or you become super nauseous, like take a break. You know, let's get these things to calm down again, and then maybe they need to do the exercise slower. Maybe they forgot to breathe. Right? That happens all the time. People are thinking too hard about the exercise, and then they forget to breathe important. Then they get dizzy and lightheaded and nauseous. And so a lot of it is, I think, meeting people with where they're at, cueing them appropriately, getting people to, you know, be okay with a little bit of, perhaps dizziness, as long as they feel safe, right? And understand that. The idea is that with time, they're gonna be able to do this exercise longer or faster without getting dizzy. And you see that happen all the time. You know, people say, Okay, I used to only be able to do three repetitions of this before I would get symptomatic. Now I can do 15,

 

Sophia Bouwens  22:17

like I only lift 10 pounds, but now I can lift 15 pounds. It's like a weight gaining or a strengthening exercise, but it's a different component, and that muscular component is easy for people to relate to. Where, like, if you do a workout, you get sore, that's a good thing, but if you if you're too sore, you can set yourself back. So it's a listening between your symptoms, right? You don't want to do it so much that you're driving yourself up the wall or really setting yourself back, right? So listening to the body and having them stop or taper, take a break when they feel really symptomatic, not pushing through is that what I'm hearing you say

 

Ayla Wolf  22:53

absolutely, we have to meet each individual where they're at in terms of their metabolic capacity to do the work. And I think when it comes to even small, little, tiny eye exercises, those can be incredibly fatiguing very quickly. And so we have to educate people too, to like, help them realize that these these movements might look super simple, but they're really important, and they can actually cause a lot of fatigue within a system that's injured. And so people do need to keep checking in with themselves to say, you know, how much can I tolerate if I do push myself over the edge, how quickly can I recover in order to be able to then go again and do more? And that that should grow over time, and that should grow over time, yeah, like you said, just with an exercise program, yep. I mean, I remember when I was training for a trail marathon. I could barely run one mile when I first started training for that trail marathon, wow. I mean, I

 

Sophia Bouwens  23:52

can't imagine. Are you gonna do a marathon? You can barely run a mile. You have to work your way up. Yeah,

 

Ayla Wolf  23:57

I'm the world's slowest runner when I was training for this trail marathon, someone convinced me to do at least just a 5k race, just a fun run, right? I got beat by a speed Walker in a

 

Sophia Bouwens  24:10

5k run. Yes, but you still did it. You got yourself out there, and then did you do the marathon? I did the

 

Ayla Wolf  24:16

marathon. It was brutal, but after I did it, I ended up then moving to Central Oregon, where they have great running trails like through the forest. And I did find a lot of enjoyment going for trail runs, and I did get a lot better at it, to the point where there was a six mile loop through this one park that I loved, and it just gave me joy to run through the woods for six miles. So there was a point in my life where I did get faster and stronger and better at running, but I would say at this point in my life, I don't love it

 

Sophia Bouwens  24:52

at the time, you kept at it. You started where you were, and you were small in the beginning, and you worked your way up to the point. Or you were feeling good running six miles where one mile was brutal. Yeah,

 

Ayla Wolf  25:04

that's the stubborn gene in me.

 

Sophia Bouwens  25:08

That's success, right? So many of our patients with that stubborn gene, I find do better because they just stick with it, keep at it,

 

Ayla Wolf  25:16

yeah, that stubbornness you can use to your advantage for sure.

 

Sophia Bouwens  25:21

I'm excited for talking about this. We'll do another episode on cervical instability paper, because there's a lot of like international discussion around how to approach some of these things, not just neck injuries. What about when the neck isn't stable enough or strong enough? How do we help those patients who might be having neck pain or headaches, and what can be done for them?

 

Ayla Wolf  25:43

I think that's a really important topic, because the people that have cervical instability of varying degrees, they often have a lot of symptoms and a lot of therapies they're doing may not, might not be the most appropriate therapies, but until they actually have that correct diagnosis, they don't know that. And so you do have this category of people who have a lot of symptoms, a lot of neck pain, and they oftentimes are trying to do things. They think they are doing the right thing, and until they get that diagnosis, they're very confused about why they're not getting better. And you know, my heart goes out to people who are trying so hard to get better, but they don't have the right diagnosis, they haven't had the right tests, and they're just struggling. I mean, that's really the whole point of this podcast and the book that I wrote is like, this is all troubleshooting for people. You know, we're trying to do the troubleshooting for them so that hopefully we can catch people early, and they can get the information they need to go get the right testing, so that they don't spend three years struggling, say, with a case of cervical instability that they didn't know was there. I think

 

Sophia Bouwens  26:52

your book chapter on traumatic neck injuries and the concussion breakthrough book that you wrote, is a great way for people to kind of dive into and understanding some of the ways these symptoms might present and what might be driving them to be able to navigate that. The tool we have for headache to understand those better might be helpful to understand if it's neck components or what other things might be driving that what type of headache they might even be having, and how these all play together. And

 

Ayla Wolf  27:21

so in our next episode, we'll do a deep dive into cervical instability. And then from there, I think we'll also kind of start talking about dysautonomia, which is the next chapter in my book, which is a huge topic, huge topic. Excellent. Well, hopefully we got gave people some things to think about. And if people are finding this information useful, they can subscribe to our podcast. And there's a link in the show notes that says, Click to support the show. So you can subscribe, kind of at any level of membership that feels comfortable for you. We also have a lot of information on our website. Life after impact.com We've got a blog post. We have you can subscribe to be the first to hear about when my book comes out. We also have that free concussion headache tool, so it's a kind of a headache communication tool and journal that people can use to better explain to their physicians and providers what types of headaches they're having, what seems to be working, what's not working, so that hopefully they can get better diagnosis, better care. And then if you have certain questions or topics you want us to cover, feel free to shoot us an email at life after impact@gmail.com and we'd love to hear your thoughts on what you'd like us to talk about and cover in future episodes. So I think that's it, right? Yeah,

 

Sophia Bouwens  28:49

thanks for tuning in, for listening. Stay tuned for our next episode on cervical instability,

 

Ayla Wolf  29:01

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