DTI: A New Era in Concussion Diagnostics with Dr. Rebecca Romero | E73

Dr. Rebecca Romero: 00:00 What that translates to is of these 48 bundles or 33 bundles, how many are reading as normal or how many are disrupted? And so it gives me a number, a flat out number, one of 33 bundles, two of 33. For me to kind of go, okay, that's part one of three. Let me see if the rest of the MRI report fits that, that I could build into the story of, yeah, this is a concussion or a mild TBI. Dr. Ayla Wolf DAOM: 00:30 Welcome to Life After Impact, the Concussion Recovery Podcast. I'm Dr. Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating, and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information. Whether you're dealing with a recent concussion, struggling with post-concussion syndrome, or just feeling stuck in your healing process, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. Dr. Rebecca Romero, welcome to Life After Impact. Thank you for having me. You are welcome. You are a board-certified neurologist with fellowship training in multiple sclerosis and clinical neuroimmunology, which means at some point I want to pick your brain about brain inflammation. But I know that in your clinical practice, you see a lot of people that have been in motor vehicle accidents. Absolutely. Dr. Rebecca Romero: 01:32 So the majority of the patients that I see have been involved in some sort of motor vehicle accidents. I would say about 90%. And then the others are going to be patients that have had a slip and a fall, some patients that have been in workplace explosions. But the majority of my motor vehicle collision patients that I see, and I see them throughout Texas, they're new patients who have been in a motor vehicle accident, with the vast majority being rear-ended. That seems to be the most common collision that I see. I also see patients that have been T-boned, but any variety of vehicle accident, including those with 18-wheelers, which always kind of takes my breath away when I speak to these patients that have been in these accidents. And you're absolutely right. The vast majority of them, when I asked them, okay, after the accident, what happened next? Did you go to the hospital? And 99% of them say, I felt fine. I had the adrenaline rushing through me. So I I just went home. And oftentimes there's a bit of reluctance because they feel guilty they didn't go and seek help. But you can't blame anybody that's just been in something that was very uh almost life-altering potentially. And and they feel they feel fine at the time. Oftentimes it's not until later that day, like hours later, or the following day when that initial adrenaline has worn off that neurologic symptoms begin. Yeah. So there are there are a variety of reasons uh why that can happen. Uh just with the, for example, the rear being rear-ended, there's that initial, especially if you didn't see the vehicle other vehicle coming, this initial shock of what just happened. I didn't see the car approaching. I'm just completely disoriented. This is not what was on my my plans for the day, is to be in this car accident. And and so there's that shock. And trying to do kind of a body screen at the time when people are asking you, Are you okay? Okay, it can be overwhelming. And so patients may not be able to directly answer and assess how their body is feeling, especially if they've never had anything like a concussion before. There's also this evolution of symptoms that may occur over time. Um, there's something called a metabolic cascade progression, which uh patients will experience some dizziness, nausea, fatigue. And so one of the screening questions I'll have is after the accident, did you have any nausea or vomiting? Twofold reasons. Uh one, it helps me address how to treat them, but also if they start vomiting and then they have kind of continued vomiting, that's a red flag for me if they haven't had, for example, a CT head. Um while not all imaging is required within an ER, it certainly all patients, a lot of patients don't get CTs of their head, which is fine. But if the red flags haven't been raised, then I try to get them to the appropriate imaging at that point. Um one to three days approximately afterwards, the patients will um have problems with, if not in originally, memory problems, sleep, uh, mood disorders. And so you kind of want to have a, I think a sh a very short uh threshold, low threshold for seeking help right after a car accident. Dr. Ayla Wolf DAOM: 05:11 Right. Because I work with people who have been in car accidents. They kind of had a mindset of, well, let me just wait and see if all these symptoms get better. And then a week goes by, two weeks go by, and they go, wow, I'm I'm still dealing with dizziness, nausea, headaches, blurry vision. So then they go and they seek care. And then again, they don't really have record of what their status was during the first week. And so do you find yourself often kind of functioning as a quarterback in a sense where you're having to say, okay, have you done this therapy? Have you seen that specialist? Have you kind of crossed all these things off of your boxes so that people are getting the right care? Dr. Rebecca Romero: 05:56 I do. I think that's a perfect example of being a quarterback and trying to facilitate all the patient's care. I will tell you, um, stepping back for a second, when we talk about, well, Doctor, I went to the ER and they didn't do anything for me. I'm starting to really understand that there is uh some additional training that that could be done within ERs in terms of concussion evaluation, um, even documentation. Uh, I think some providers are just in my experience are reluctant, unless it's a slam dunk for concussion, to to diagnose a concussion. And if you don't diagnose the concussion, then you are less likely to be referred for assistance. And or we we don't have, in my opinion, adequate um mechanisms by which to send our patients for concussion evaluation. Um many of the patients that I treat are involved with um attorneys. They seek an attorney and then get referred to us. But it would be nice to have them, you know, if they get diagnosed with a concussion, then be referred directly to somebody for concussion treatment. It's just an it's an underserved area of medicine that um certainly hoping to change. Dr. Ayla Wolf DAOM: 07:15 Well, and it seems like we don't have enough neurologists because the people that I talk to are all immediately put on a six-month waiting list to get in to see somebody. And when you've had a brain injury, that's not okay. That is very, very true. Dr. Rebecca Romero: 07:28 There's a lack, there's there's a lot of reasons behind that. It's it's been um for various reasons. Um obviously I think neurology is incredibly important, and I love the field, I love everything about it, but um retaining and recruiting neurologists is a challenge, and you're absolutely right. Um, you've got something neurologic, you don't want to wait six months. So access is also an issue. Um, so multi-layers uh where where there are problems and that could be addressed. Dr. Ayla Wolf DAOM: 08:01 Mm-hmm. And then so many times when people do have a concussion, their MRIs are normal, their CT scans were normal in the ER. And so then as a neurologist, you have to base it on a combination of both their symptoms and a neurological exam. How much time are you spending doing neurological exams at this initial visit and seeing things that, you know, are certainly indicators of a concussion even when their scans are normal? Sure. Dr. Rebecca Romero: 08:28 So you're absolutely correct. Standard CT scans and MRI of the brain are going to be normal in the vast majority of patients. 1% of my patients have had a subdural or a subarachnoid hemorrhage. But when we, as of now, and as as concussions are diagnosed, it still remains a very much a clinical diagnosis and exam diagnosis. Dr. Rebecca Romero: 08:52 Uh so when I first uh when these first patients first come to our our system, our clinics, they're actually scanned through this, it's called an MD intake team, who initiate uh things like the River Mead concussion questionnaire. Um then we send them for dirt neurodiagnostics. So one of them is called a WABI, which is like an EEG event-related potential. I'll also send them for right eye, which is to look for oculomotor dysfunction. And finally, we'll send them for balance tracking to look for postural instability. That work will all get done before I see the patient because we want to capture as closely as we can to the accident the deficits the patients are having. And because I work and seek patients throughout Texas, um, we need to be able to get some objective evidence. And that objective evidence comes through the right eye, the balance track where there's there's neurologic deficits that we see. Um, and some of the patients, after I evaluate them, which could be a month later, you know, there there's a delay for sure. Um, I'll actually spend an hour with the patient going through a very detailed history when I see them initially, going through all the test results. We'll sit down and actually go through the BIST2, the brain injury screening test, so that it facilitates the conversation of their symptoms. So we'll talk about if you have a headache as it is right now, how bad is it from zero to 10? Tell me about the headaches, where they're located, how often. And so, you know, the beauty of neurology is that everything really kind of fits together, but it takes time. It takes time to see the patients. Dr. Ayla Wolf DAOM: 10:34 Yeah. Well, and I love hearing that your clinic and your uh kind of clinical network has this system of actually collecting all that data for eye movement, pathology, balance issues. Um, because so many neurologists, not to throw anybody under the bus, but oftentimes the patients I work with, when they see the neurologist, it is a short, maybe 15-minute appointment. They had to wait three to six months to get in, and the neurologist maybe refers them out for PT or OT, but doesn't actually have any of that testing data on their desk when they first see the patient. And so I love that you're actually collecting all that on the front end to be able to get a better picture of what is this person dealing with and what are these biomarkers of concussion before you even see them. Dr. Rebecca Romero: 11:19 Right, right. And and we have um we're working right now through getting um the MOCA or the Montreal cognitive assessment as included in those initial diagnostics, just because it's, you know, most of us will understand that uh that cognitive deficits are the a lot of the times the most impactful um or can be the most devastating when you're trying to retain a job or function. And so really addressing those cognitive symptoms is is so important. And we want to include that in our neurodiagnostics up front. Um for some of our patients, when we talk about neuroimaging, when after I see them, I will sometimes order an MRI of the brain with diffusion tensor imaging, which is kind of the fanciest, latest, but also the most sensitive in terms of um trauma that we can see. It kind of takes a microscope up to the brain. Um it's not for every patient, though. It has to be hand selected. Um, and the reason for that is you can get a lot of false positives. Um if I have a patient that's 80 years old, has had multiple concussions, the MRI really won't help me that much. Or they have a lot of comorbidities like hypertension that's not well controlled, diabetes. So it has to be in the right patient. Um, and and we do utilize that as well, which has been very, uh, very, very interesting to see, but also helpful. Dr. Ayla Wolf DAOM: 12:48 Yeah. And I know that those diffusion tensor imaging, that technology was really only in the realm of research for a very long time. And it's only been the last few years that we now have access to that clinically. And so my understanding was that at one point in time, it would take like an a month for someone to actually like go through the data of that and create a report. Um, what is the the lag time on when someone goes to have that and when you have a report on your desk? And then what are the details in those reports? Sure. Dr. Rebecca Romero: 13:18 So uh it it it absolutely used to be done. I in my fellowship, I worked a lot with MRI and post-processing of these images. And so it would have to be by hand, which was really painful. But as a fellow, that was my my job was to do the things that other people did not want to do. But it really gave me an appreciation for how much um computer power and time it takes. So on average, when the patient gets their MRI brain with a DTI, the scan itself will be 30 to 45 minutes long. And then the post-processing time with the report is about two weeks. Okay. So it's much shorter. And there are three things that I'm really looking for when we're looking, when we're talking about an MRI brain with DTI. The first is gonna be if there are abnormalities in the the uh diffusion, or rather, the white matter tracks. So as I try to explain to my patients, these white matter tracts are kind of these connections, like these information highways that go between the frontal lobe, occipital lobe. They just it's it's the information uh channels. And the computer program, depending on the strength of the magnet, will look at 33 bundles, 48 bundles. And of those, we're trying to see how well basically the information travels. On a scientific level, we're looking at something called FA or fractional anisotropy, which is looking at how well or how straight the white matter tracks are based on this model of diffusion of water. What that translates to is of these 48 bundles or 33 bundles, how many are reading as normal or how many are disrupted? And so it gives me a number, a flat out number, one of 33 bundles, two of 33, for me to kind of go, okay, that's part one of three. Let me see if the rest of the MRI report fits that, that I could build into the story of, yeah, this is a concussion or a mild TBI. The second part is going to be I'm looking for something called hemosiderin deposition, which is found on uh a special sequence called a susceptibility-weighted imaging. Um previously we had something called gradient um imaging GRE, but this is much more sensitive. And it's looking at um, as I mentioned, hemociterin deposition, which are these tiny, tiny, tiny like size the the head of the pin of blood vessels that have been ruptured. And so when I tell this to patients, I've seen a lot of, oh my gosh, like wide, you know, very wide eyes, which are completely understandable. But I basically tell them when you're in a car accident and there's this acceleration, deceleration forces, there is this mechanism of a shear injury. Um, and we're looking for those areas with hemocitorin deposition, meaning that that shear injury was strong enough to cause small blood vessels to rupture. So SWI or hemocitorin deposition, if they have it, also builds it into the picture of a concussion. And finally, we're looking at volumes of the brain. So it's not just the white matter and the gray matter, it's the corpus callosum, the basal ganglia. And oftentimes in our patients who have had concussions, there's going to be an asymmetry. The left side may have a few structures that are smaller than the right side, and it's out of the normal range. And so if I get those three components with the uh abnormal white matter tracks, hemociderin deposition, and volume changes, for me, it's a slam dunk pretty much that the patient has sustained a mild traumatic brain injury or concussion. If all three aren't there, but still some of it fit, it helps me again build that picture that I could really um tell the patient and and their loved ones, no, this is this is real. Um, this is this is something that the patient is experiencing and we can document it objectively. Dr. Ayla Wolf DAOM: 17:20 Yeah. And so uh correct me if I'm wrong. On kind of a typical MRI, if somebody has a severe TBI, you might actually see axons that have been fully damaged. Whereas with a concussion, there's more of, like you mentioned, the shearing force, which I kind of think of it as like you have a thread and the thread gets twisted. And so the damage is really happening on the inside of the axon with the microtubule, the integrity of those have been affected. And so you don't actually see an axon breaking apart on an image, but with a DTI, you can actually still show that there's been damage to the axons with that twisting, shearing force. And that's part of what the DTI adds to the clinical picture is being able to pick up on that type of damage. Dr. Rebecca Romero: 18:07 Yeah, you're absolutely right. It is severe TBI, um, very devastating clinically, but easier to pick up on imaging. You can see whether it's on the with the hemociderin deposition, you could see it in certain parts of the brain that are more obvious than with a concussion. And also on flare imaging, which is looking at um basically making the white matter dark, you can see on severe TBIs the damage a lot easier than you can with a concussion. Um, you're absolutely right. We're looking for those minuscule microstructure abnormalities with a concussion. Dr. Ayla Wolf DAOM: 18:46 And then I know a lot of the research points to the fact that very often with a concussion, the frontal lobe is affected and specifically the dorsolateral prefrontal cortex, which is involved in our executive functioning, the things that kind of keep us organized and moving forward in life. And so because you do the wavi, are you finding a lot of EEG evidence of problems happening within the functionality of that prefrontal cortex and this executive functioning center? Dr. Rebecca Romero: 19:16 Well, we are actually. So it's we see it the most with the event uh related potentials. So we're looking for something called the P300 wave and the amplitude. And essentially, as I explained it to the patients, we're looking for, we give them a sound stimuli during a set amount of time and we're looking for how well the brain responds to it. And when the amplitude of the P300 wave is decreased, it points towards and leads towards, or rather, points towards cognitive impairment. And the sooner you get the Wavi, the closer or immediately after the accident, the more sensitive the test is. Another reason for getting the test done, ASAP after the accident. So I have had some patients where uh I would say it's 50-50, their uh Wavi is abnormal and they're still struggling with neurocognitive symptoms. And then the other where the WAVI is abnormal and then they feel they feel pretty well. I think that has to do with um age, medical comorbidities. I mean, my 20-year-olds, in my experience, bounce back so much faster than someone, you know, 40 plus or 30 plus. There's there really is a beauty about being young, you know. It's uh it's uh uh pretty, pretty impressive. So uh certainly we use the wavi as as a tool for uh cognitive, and then we reinforce that with uh the mocha. Dr. Ayla Wolf DAOM: 20:43 Mm-hmm. Yeah. Oh my gosh. I just I love that you're collecting all this data as part of just routine care. Um when are you gonna open a branch in Minnesota? Dr. Rebecca Romero: 20:54 We wanna be top-notch, uh, evidence-based medicine, want to really bring a lot of credibility to our clinic and and the most up-to-date uh science. Now, I will say I haven't started using the biomarkers as of yet. Um, and I think part of that is with just the um the timing. A lot of times when I see these patients, it's past 12, 24 hours. We're talking about a month afterwards. And so I I do want to see with more research that's being done, kind of like how the DTI was rolled into our practice, how long, how long after an accident a patient I can send them for those lab tests, those biomarkers. But as of right now, that would be the one thing that um it could still consider, but we're not using as of yet. Dr. Ayla Wolf DAOM: 21:45 Mm-hmm. And then within ProCare, what types of rehabilitation uh services do you guys offer? Dr. Rebecca Romero: 21:52 Yeah, so we have uh neurologic rehab text at uh, I believe eight of our 13 clinics. And so There's a variety of ways that we can uh treat them. As I mentioned, oculomotor and postural or balance issues are the most common that we see. And so we can actually do real uh neurologic rehabilitation within those or on those machines. And so the plan for the patient is to do two sessions a week for a total of eight sessions and then re-evaluate. We do redo diagnostics and see if they improved or if they didn't really improve. And I'll take feedback from my texts. Hey, you know, you think they need some more sessions, they need more evaluation. Or sometimes we'll have patients in the rare cases that just are such an acute high fall risk or having such bad diplopia that I need to refer them outside. That's that's very rare, but that can happen. And then finally, we're starting to uh bring in some kind of cognitive motor rehab that we're going to be doing, captured initially by the MOCA and then directed towards what their deficits are in the MOCA. And as you mentioned, executive function is one of those very important um cognitive domains where patients need to be able to plan, to execute, and some of them really do struggle with it. Or if they're having problems with word fluency, we'll work on that. So we're trying to really um provide a one-stop shop as as much as we can for our patients. Dr. Ayla Wolf DAOM: 23:30 Yeah, fabulous. And I know that there's so much talk these days around the connection between chronic neuroinflammation and the onset of different neurodegenerative disorders. And I think many of my patients, when they've had concussions, one or more, um, and many have had more than one, people are concerned about how that will impact their long-term brain health. And they want to understand, you know, what can I do to keep my brain healthy? And yes, we have all these wonderful lifestyle factors and things that we can do, like exercise and diet, um, but we don't really have readily available, easily testable biomarkers to say what is your level of neuroinflammation. So I would love to hear more about your background with neuroimmunology and what is happening in that space, and how can we ever develop some kind of assessment for that? Dr. Rebecca Romero: 24:26 I think, I think that's a uh that's a million-dollar question because um, and a fabulous question, because you're talking about the the central nervous system oftentimes or the neurologic system, which is often walled off with the um blood-brain barrier. And so getting access to what exactly is going and involving within the that environment is hard to do without getting, you know, a spinal tap, which I mean, that's just not, you know, reasonable to want to do that on a patient with a concussion. Um, and I think it's it's it's fascinating to look at neuroinflammation in patients. Um it's gonna be just like with many things, there's gonna be a spectrum of it. Um, there's gonna be some patients where they neuroinflammation resolves within uh days, uh weeks, and then others where it goes on for months or years. And that's really scary because I mean, you're absolutely right. We have these lifestyle measurements, but how do we look at those patients, for example, that have other autoimmune diseases and try to control that inflammation? Um, as of now, we have to default on lifestyle interventions, but I actually was just reading this one um uh article. They're they're starting to look at um, you know, different commonly used medications. This one wasn't for neuroinflammation, this was more on um kind of uh this is with gabapentin, uh using it in patients who uh were in the hospital, though, and using small doses during their recovery. Not sure what the doses were, and as we know, gabapentin itself has its own risk factors with it, causing sedation and balance issues. But I think that people really understand now that it's not just, you know, it's not just a uh mechanical impact that the brain is is having or the spinal cord is having. It's it's the whole body, it's the whole system, it's metabolic uh damage, it's neuroinflammation. Um, for my patients, um, I really do if we're getting to that point where they're really feeling, uh, for example, I've had a couple of lupus patients, and I'll work with a rheumatologist on maybe they need some steroids because it's a whole body that's inflamed. Um, and and we're talking about a short course of steroids, like a very like a one-time dose. But it's kind of like you have to bring the entire system down. You have to make the inflammation calm down. And as of right now, other than directly targeting, for example, their lupus or their multiple sclerosis, we don't have great therapies. So I think it's an unmet need at this point. Dr. Ayla Wolf DAOM: 27:04 Right. And I know too, there's research to say, for example, if somebody has a stroke, that their blood brain barrier can become more permeable actually for a longer period of time than we originally thought. And I would say too, I imagine with people with concussion and brain injuries, that blood brain barrier becomes permeable as an immediate response, but in some cases might also not resolve in an appropriate amount of time. And then if you, I don't know, I feel like ever since the pandemic, more and more people are just inflamed in general. And so you've got more people that already have kind of systemic inflammation, or as you mentioned, other comorbidities. You throw a concussion on top of that, you have a permeable blood-brain barrier, and now you kind of have this perfect storm of potentially exacerbating a neuroinflammatory cascade. Absolutely. Dr. Rebecca Romero: 27:53 Yeah, uh, we see that, and it's it's kind of like with this kind of a leaky blood-brain barrier. How do we how do we attack that? And to your point, we don't have great therapeutics. Um, I, you know, it's it's hard with some of these patients too, when the the fatigue is how I see it most commonly, fatigue and brain fog. And so I try as best as I can, like, okay, we don't have great therapies, and I'm not into just prescribing medications just because, because of interactions. And I my my goal is to just prescribe them what they need at that time, not to involve a lot of medications because of drug-drug interactions. Um, but you know, we have to come, we have to figure out how to get that patient's inflammation in a lower state. And I do talk to them about diet, you know, especially with my diabetics, you know, it has to be really tight control of your glucose. Um, we have to have your blood pressure in check. Um, I like the the mind-dash diet for uh treatment of um or for kind of this low inflammatory state, um, avoid processed food, sugars, all that bit. Um, we do try to go there as well. And then exercise, as you mentioned, I think is so critical for their recovery and kind of the sooner the better. Dr. Ayla Wolf DAOM: 29:11 Yeah. Sometimes I have patients who use the word inflammation uh in a way that's maybe like they kind of jump to the conclusion that that any symptom that they're having, whether it's a sharp stabbing headache or brain fog or um a sense of like their head being hot, um, sometimes people kind of jump to the conclusion that this symptom equals inflammation in my brain. And do you hear that often? And do you talk to people around, well, we don't know for sure if this is inflammation or like this could be coming from something else? Yeah. So it it's it is hard. Dr. Rebecca Romero: 29:49 It's hard to kind of like suss out like which is which. Um, I think I do have those conversations with patients. Um, more often I have the conversations of, I thought I was going crazy, like the symptoms I'm having, and you've just kind of validated that I'm I'm the symptoms I'm having from a concussion are real. I'll have patients that will have some symptoms that um they they worry, oh my gosh, is this the inflammation? Is that inflammation? And so I have to sit down and really kind of figure out, okay, when did it start? What were you doing? Um, how long has it been going on? I I think that's important in figuring out, you know, is this really a cause of inflammation or not? Um some patients have even asked, well, can't you just draw blood and figure out uh if it's inflammation? And I haven't tried doing that, but again, I go back to the fact that the the blood has a different appearance that's in our system than the the fluid within our brain. They're separate environments. And so it's it's a challenge um to actually assess what the inflammation is within the brain. I I also do try to stick with the the typical, okay, well, you know, the patient is having nuanced headaches three months after the accident. Okay, let's look for other causes. So the timing is is important as well. Dr. Ayla Wolf DAOM: 31:15 And then some people have just an intractable sense of head pressure. And sometimes that can be one of the trickiest symptoms to treat. Um, when people say that they just have this constant sense of head pressure, does that kind of set off certain alarm bells about which direction to go? Dr. Rebecca Romero: 31:33 It it does. I've heard that it's this low-level kind of insidious pressure. And so I'll I'll try to dissect it with with okay, anything make it worse. You know, the tempo, the typical questions. Um, their medical comorbidities, okay, are you are do you have sleep apnea? Is that what's going on? Um and and so, and then also, of course, reassess their exam. Anything focal on their neurologic exam is takes it to a different level that I need to send them for an MRI of the brain or CT of their head. Um, but oftentimes, depending on the location of this kind of pressure, um, I I don't immediately act. I kind of re-evaluate them at a later date, kind of provide some reassurance. Um, you know, I've had a lot of patients that while it's not headache, they they complain of the dizziness. And so, as my um prior residents know and my neurorehab text, I hate the word dizziness. Like the dizziness is so, it's so infuriating to me. Um because uh because it can mean so many different things. A lot of the times when you nail in on what they mean by dizziness, it's lightheadedness, and so they get a lot of orthostatic hypotension. And as you know, it's from the mechanism of injury, you get dysfunction of your autonomic system. And so I wonder if some of that maybe hypoperfusion they're getting to their brain is also can, you know, part of their their low-line or kind of low level of headaches they're getting. Dr. Ayla Wolf DAOM: 33:07 One of the papers that got published in 2024 was um by uh Peter Goadsby was one of the authors, and it was on medication overuse headaches. And I still have people coming in that uh I find out that they're just habitually taking ibuprofen every day. And so are you finding that as well that a lot of people don't recognize that it's dangerous to just take ibuprofen every single day or Tylenol or the combination of the two? And are you having to talk to people about the potential for medication overuse headaches if if that's what they're doing? Dr. Rebecca Romero: 33:41 I am. I am having to talk with them. And in fact, even if I if I think they're having migraines, one of the insurance questions is like, have you evaluated for medication overuse headache? Um, I do have some patients that are like, I just I'm taking Tylenol. I'm like, okay, well, what's the milligrams? 500 milligrams, okay. How much are you taking a day? Oh, I take three or four once, and maybe four hours later, I'm like, oh, no, no, no, no, no, no, no. Let's take a step back. Let's let's talk about this. The medication overuse headache presents its own issues. And um, even with headache treatment in general, it gets a little tricky because sometimes these patients are on opioids as well. And and if you're talking directly about a migraine, sometimes an opioid can make a migraine worse. And so but, you know, I I am lucky that that's not, I don't see very many um narcotics being prescribed nowadays unless the patient has like a broken bone, which I think is good. I think we've made progress by not over-prescribing narcotics within the medical field. And I will tell you, uh, the majority of my patients actually are just like, I'll maybe take an ibuprofen, but I don't want to be on medication. I don't want to put anything in my body. I mean, I have been very impressed. Um, and in fact, a lot of the times I'll have to tell them, okay, well, let's do maybe some magnesium or CoQ10 or riboflavin um as a way to treat your migraines. But certainly um we do have to talk about medication overuse and, you know, what exactly they're trying to treat and is there a better strategy to treat those headaches? Dr. Ayla Wolf DAOM: 35:19 Yeah, yeah, absolutely. And I think so many people just assume well, if I can buy it over-the-counter, then it must be safe and I can use it as much as I want to. No, I know. Dr. Rebecca Romero: 35:29 And we're seeing that with melatonin now, right? Melatonin um being with a potential uh, you know, risk of long-term use of it, potentially causing congestive heart failure. It was a retrospective analysis, but still it's it's alarming to see even the possibility. So I've really backed off of using melatonin as a sleep aid uh for my patients and saying, well, let's steer towards magnesium glycinate, for example. And a lot of them will um a lot of them will try it and and mixed responses, but but in general, very safe and they do well with it. Dr. Ayla Wolf DAOM: 36:06 Yeah. I mean, so many people sleep poorly these days, and especially when you have a concussion, that seems to really throw off those circadian rhythms, neurotransmitters, ability to fall asleep. So I do know a lot of people try melatonin, and frankly, you know, the research has also shown that based on from one brand to the next, your dosing might be all over the place and not actually matching up what's on the label. So um it is a hormone, and uh sadly the quality within the supplement industry is suspect. Dr. Rebecca Romero: 36:38 Yeah, no, that's very true. And and also one of the other things we'll sit down rather than just jumping to supplement like magnesium, and we'll go through the sleep hygiene. Um, because as you said, uh a lot of people have problems with insomnia, and then they get a concussion, and then it's just exacerbated. And it's very frustrating. If anybody has ever had just one night where they couldn't sleep, it just tears up your next day, uh, and and you can't think, which compounds on their cognitive problems, and then moodability, which if they've had frontal lobe dysfunction from their accident, it just it builds. So we try to go back to the basics of of good sleep, which is just so critical for normal functioning. Dr. Ayla Wolf DAOM: 37:22 Yeah. And then I'm gonna throw a curveball at you because we didn't talk about this ahead of time. But when you have women that are in their mid to late 40s and 50s, that sudden change in estrogen and progesterone can also cause a lot of brain fog, anxiety, poor sleep, headaches, all kinds of things that um are similar symptoms that people struggle with with a concussion. So when you've got women that have had a concussion, been in a car accident, they're in their 40s, 50s, um, are you also paying attention to their hormones and the possible role that abrupt hormone changes are making in terms of their brain function? Dr. Rebecca Romero: 38:02 Absolutely. I think that's one of the kind of infuriating uh but most understudied areas. I think it's gained a lot of traction now, finally. So I certainly asked the patients, I said, well, let's look at your age. Are you perimenopausal? Are you menopausal? Um, kind of screen for some like hot flashes that they have. Um I I know through, for example, in this is a study that was done with multiple sclerosis patients, but again, we're talking about a disease that vastly affects women. So, like 80% are women, and going through all stages of their life while they have this disease to include pregnancy as well as menopause. So, what they did in this one study is they gave them a traditional MS medication plus estradiol. Um, and the other group had just the um just the MS medication, and they had a lot of dropout because of breakthrough bleeding with the estradiol. Um, so that was a learning point. But the other thing is that it didn't change their MS, but what it did is their cognitive scores in that group with the MS medication and the estradiol were off the charts better. They did so much better. And so is it a direct hormonal influence? Is it uh, which could be, is it also that they slept better at night? Um, and so I think that's that's fascinating. And in fact, for my patients, I'll tell them, I said, you know, again, I think that this is a very important area of your life. Um, I think we need to, or I can talk to your OBGYN. I have no problem with hormone replacement therapy. Um, I think that's an area that we really need to focus on. I'm not directly checking their hormonal levels, but I I like them to talk to their OBGYN. And I think that's another area that we need to move through and and get probably between a neurologist and OBGYN to talk about hormone replacement therapy because it is so critical and to recovery. Um, as you know, uh women, they it it takes longer for them to recover from concussions. Uh, and I do think a lot of it is in large part due to hormonal fluctuations. Dr. Ayla Wolf DAOM: 40:04 Yeah. Well, I love that you're taking that into account and pointing that out to people as an important consideration as part of their program and team to consider that. Absolutely. Absolutely. Critical. Yeah. Dr. Ayla Wolf DAOM: 40:17 Uh is there anything else that you want to talk about that we haven't talked about? Dr. Rebecca Romero: 40:22 Um, I think you you raise a really good point with with the neuroinflammation and really how to get to that and novel treatments. Uh, as you know, we we don't have a therapy yet for concussions for that. And and how do we stabilize the brain during its recovery period? Um those are all fascinating areas. And one of the reasons why I love this this field is that there's it's there's like a black box, like there's so much yet to be discovered. And um I like to be on the forefront of that. And so I very much enjoy the field. Dr. Ayla Wolf DAOM: 40:57 Yeah, I mean, it definitely keeps you on your toes. What what a person learns in one year is already outdated a year later. So you kind of have to have a humble attitude of like, okay, what I learned last year might already be outdated. Dr. Rebecca Romero: 41:11 That's exactly right. And then I think that it's it's um learning from your colleagues, like what are they doing, how are they treating their patients is also um is also an important characteristic of this evolving field. Dr. Ayla Wolf DAOM: 41:25 Yeah. Dr. Ayla Wolf DAOM: 41:26 Yeah, absolutely. Well, why don't you let people know where they can find you? I know there's many clinics, but you're located in Austin, correct? Correct. Dr. Rebecca Romero: 41:33 So uh my office is uh in central Austin. Um I'm near the main medical center, um, but I also will see patients not only there, um, but um, I'm also gonna be moving to the South location, which is off of 35 and um like West William Canon within Austin at the end of this month. Um for patients that um want to come see me, I'll be there. Otherwise, telemedicine is um highly utilized, especially since I have patients from Corpus all the way up to Lubbock. Um, and then oftentimes we'll arrange for patients to come and bring them to town so I can do a hands-on physical evaluation if um feel that's necessary as well. Dr. Ayla Wolf DAOM: 42:16 Yeah, Texas is a big state, so telemedicine sounds like uh a good way to get around that. Dr. Rebecca Romero: 42:23 It's been it's been really, really a good tool to use. Dr. Ayla Wolf DAOM: 42:26 Yeah. Okay, well, one last question. I know you are a competitive power lifter and strong woman. So what is your favorite lift? Dr. Rebecca Romero: 42:34 Oh my goodness. Oh, I I um you did your research. That's fantastic. Uh so I love deadlift. I love deadlift for a variety of reasons. Um, I've always trained with the coach because I don't want to get injured. Uh, but I, you know, I got a day job, I gotta be upright for. Uh I love a deadlift. I've gotten in the 300s, but my goal is before I completely retire from powerlifting, is to get to a 400-pound deadlift. Amazing. Okay. Dr. Ayla Wolf DAOM: 43:04 I I've been stuck at 225 for a long time. Dr. Rebecca Romero: 43:07 Oh, I yeah, it's it's a technique and you can really get in your head and and it's just um, man, it's such a good release. And I just, I don't know, it's for me, it's like almost a meditation, you know, just kind of getting in there and and doing that exercise. Dr. Ayla Wolf DAOM: 43:22 So I love it. All the research on the beneficial effects of lifting weights for women is is huge too. So 100%. Dr. Rebecca Romero: 43:32 Absolutely. Dr. Ayla Wolf DAOM: 43:33 Yep. Awesome. Well, thank you so much for your time. I will share all your contact information in the show notes. And I'd just love to hear everything that you're doing from a very comprehensive standpoint in actually evaluating people's brain function in a number of different ways. That's really exciting to hear. But thank you. Thank you so much for having me. Dr. Ayla Wolf DAOM: 43:55 Medical disclaimer. This video or podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice, diagnosis, or treatment, and consumers of this information should seek the advice of a medical professional for any and all health related issues. A link to our full medical disclaimer is available in the notes.