Why Your Eyes Still Hurt After a Concussion with Dr. Melissa Biscardi | E77

Dr. Melissa Biscardi PhD: 00:00 The tolerance to the technology improved for both over time. But interestingly, females had more symptoms in the last half. So the trend was that they improved, but they got more symptoms with time. And how that can be used in clinical practice is okay, so maybe females need a longer like intervention period. So instead of squeezing it into six weeks, maybe it should be over eight weeks and just a little bit more of a gentle ramp-up. Dr. Ayla Wolf DAOM: 00:36 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. Melissa Biscardi, welcome back to the show. Thank you. I'm so excited to be back. Yeah. Congratulations on finishing your PhD. Thank you. That is a huge, a huge one. Did you go on vacation after? Did you give yourself some downtime? Dr. Melissa Biscardi PhD: 01:32 You know, I um so I defended in January and then I went to Hawaii, I think, for 10 days. But you have to um there's always, well not always, but there were revisions and those were due mid-February. So I was away, but I didn't get to be totally carefree. But um, but that was still nice. And then I'm actually I have not traveled enough, but I'm going to Portugal um next month. So that will be a true freedom celebration. Dr. Ayla Wolf DAOM: 02:07 Amazing. I would love to hear about that. I've always been interested in going to Portugal. Dr. Melissa Biscardi PhD: 02:11 I've never been before, so I'll let you know. Dr. Ayla Wolf DAOM: 02:15 Yeah, I've heard it's gorgeous. Well, talk to me a little bit about the the research that you did during your PhD and where you ended up with that. Because I know you were studying eye movements and concussion. Dr. Melissa Biscardi PhD: 02:29 Yes. So um I think I had a really interesting project, of course, and it involved three different studies. So the first one was a systematic review and meta-analysis. So essentially getting a lay of the land, what research was already out there on the topic of eye movement interventions after concussion. And the research was mixed. Even though it's used a lot in clinical practice, the research has hadn't caught up. So after that, we looked at the general population to see how common eye movement disruptions were. And you know, a lot of the research is on athletes. So this was general population, which is everybody who isn't an athlete, so that was great. Um, and then the big thing was a randomized control trial, where we looked at a six-week intervention in virtual reality with various eye movement trainings that became more and more difficult as the weeks went on, but also it was personalized. So not everyone got the same intervention over the six weeks. And and that was great. We had in the end 48 participants and more females than males, which was interesting. And yeah, that was it. Dr. Ayla Wolf DAOM: 03:54 That was five years. Yeah, and that was five years, and five years went by. Dr. Ayla Wolf DAOM: 04:00 Okay. And so since everybody has differences in what types of eye movements they may be struggling with, um, how did you do your initial assessment of eye movement disorders? And then how did you tweak the program for each individual person? Dr. Melissa Biscardi PhD: 04:19 On week one, everyone went through an assessment using the VR goggles. So we got the objective um measurements of various eye movements. So gaze stability, smooth pursuit, cicades. So those are smooth eye movements or jump eye movements. We did the vestibular ocular reflex, um head and eyes together, anti-saccades, OPK, so the whole battery, uh, really focusing on eye tracking, though, because it wasn't an optometry study, and I'm not an optometrist, so a little bit of a different lens, and um other assessments like near point of convergence, stereopsis, visual acuity, and symptoms, which is why people come in usually, and then went from there. The first week everyone got the same interventions, and then based on how they tolerated it and what we were picking up, for example, if someone really had trouble with convergence, then we would add more activities that focused on that. So, similar to what we would do in clinical practice, not so much protocol based, we also used what do we use? Uh rate of perceived exertion. So, like we would use an exercise, but applied to like how hard are you finding these eye trainings? Um, how are your symptoms? So we tracked that throughout, and no one had so many symptoms that they wanted to stop, but definitely people felt uh the intervention. Especially VR can be st over stimulating even without a concussion. So we have to be mindful of that. Dr. Ayla Wolf DAOM: 06:12 And then how were you tracking outcomes in this study at the end? Dr. Melissa Biscardi PhD: 06:18 So at the end, we did the entire the same assessment battery as we did at baseline. And our primary outcome will be near point of convergence. So how much better or not better were they able to focus their eyes at near, which is what we do all day, right? Looking at phones and computers. And then we collected so many eye movement metrics, though, even just thinking of the cicade or the jump eye movement, we would have collected the accuracy. So are they actually looking at the target? Um, the latency, how quickly do they move to the target, and also um mean virgen? So are their eyes pointing in the right direction, essentially, at the right angle? And so there's a lot of data. I think 51 different data points. And the thing is, with with so much data, if you fish, you'll always find something. So we have to sort of take it as a whole. Um, yeah. Did you find improvements in saccade latencies? That I haven't looked at yet. Or like I have not enough to say. Um still sifting through the data. Right. But data I was just looking at today. Um so anti-saccades, which there's the cognitive piece in that, but still it involves an eye movement. The the person I was just because I was looking at individual level, um directional accuracy improved by what was it, maybe 33%, which I feel like is that's pretty good. Something was happening faster and more accurately, right? So it'll be interesting to see how how all of it sort of fleshes out. Dr. Ayla Wolf DAOM: 08:13 Yeah. Okay, so you're still sifting through the data. Um, so you haven't published this one yet. Dr. Melissa Biscardi PhD: 08:19 There's one on the ver, like, so we're publishing the first 40 people, but that's looking more at tolerance to the technology, um, perceived benefit. Like, you know, do people actually think it helped them? Um, those sort of metrics, which they did. What was it? It's about to be published, so I can say this out loud. But I think it was, it was on a scale of uh zero to four. I want to say it was 3.5, something like that. And what we were doing with that study was seeing, okay, you know, is this intervention good enough to bring in a few more people? Like, do patients like it? Do they tolerate it? Because if it wasn't tolerated, then really in theory, we shouldn't be trying to um expand it to the to the world. It has to be modified. So that was good that it was tolerated. You know how I said not everyone got the same intervention over time. Um, but when we looked at males and females and biological sex, that's what we were looking at, uh, separately. The tolerance to the technology improved for both over time. But interestingly, uh, females had more symptoms in the last half. So the trend was that they improved, but they got more symptoms with time. And how that can be used in clinical practice is okay, so maybe females need a longer like intervention period. So instead of squeezing it into six weeks, maybe it should be over eight weeks and just a little bit uh more of a gentle ramp up. So I think that's actually clinically relevant, like how the how the intervention is being tolerated because we're putting something super stimulating on people. Dr. Ayla Wolf DAOM: 10:14 Right. And did you do a post-concussion symptom score of like general sleep and mood and energy and all of that to see if the improvements in eye movements correlated with a decrease in symptoms in other areas? Dr. Melissa Biscardi PhD: 10:28 Yeah, we collected a lot. We we used the rivermead, so we got some general information there. But then we did the insomnia severity index, um the Sheehan disability questionnaire, I want to say, f fatigue severity scale, a bunch of others. So we definitely wanted to get the full picture because even um just thinking back at the intervention, sleep was huge. Um, even just in influencing the tolerance to the intervention that day. But we do know that yeah, sleep is like the what do you call it, the kingpin, the queen pin of everything. Dr. Ayla Wolf DAOM: 11:09 Yeah, yeah. You improve that and quality is a big game changer. Dr. Melissa Biscardi PhD: 11:14 Yes, yes. Dr. Ayla Wolf DAOM: 11:15 Um there there was a lot of that data. One of one of the things that I have been personally working on is a big gap in the but not only the research, but also in clinical practice, where patients that have concussions, it's very commonly understood that eye movement dysfunction and eye movement disorders are common and they should be evaluated and then treated. However, the people that walk into my clinic often have already, they're already several years into their post-concussion syndrome. They've already seen multiple optometrists, they've already done vision therapy. And so I'm seeing a very specific cohort of people who actually have gaze-evoked orbital pain and a lot of what I would call physical eye pain that is not necessarily a direct one-to-one association with a convergence insufficiency or a problem with saccade accuracy or a difficulty in pursuits. Many times these people have actually done the vision therapy. They've kind of passed the test, so to speak, and yet they still suffer from chronic daily post-traumatic headache. And so what I've started to do is run people through almost just an a physical eye pain assessment with um the goggles on to look at, you know, when they're moving their eyes, do they have a good understanding of where their eyes are in these different orbital positions? And then also what does what do their eyes do when they're in the dark and they don't have anything to fixate on? Then I have them without the goggles with closed eyes look in the different directions and tell me which direction elicits the most pain. And then we do the same thing with their eyes open. And I'm starting to put together this entire assessment tool and treatment approach to dealing with actual eye pain, because what I'm seeing in my clinic is that their eye movements have already been corrected. They're still having daily pain. And the pain actually seems to be coming from their eyes and then driving a lot of their headaches. And as long as that eye strain is there, then that's going to continue to drive those headaches until it's resolved. And yet, very few people are looking at how do we reduce the actual physical eye pain. And so I would love to talk about that with you because I know that you are kind of an expert in both of these worlds from both a hands-on osteopathic world as well as an expert in eye movement disorders. So I would love to talk more about that with you because this is something that I'm seeing in a lot of my patients. And and again, it's not being looked at or addressed or spoken about in the general concussion rehab space. Dr. Melissa Biscardi PhD: 14:09 Yeah, it definitely shows up a lot for me as well. Um, and to what you said, sometimes they've already done, they've done all the stuff, um, vision therapy, scene, an optometrist, a vestibular, or physiotherapist. Um, when I think of eye pain, I do think a lot about the connection to the trigeminal nerve, whether it be locally or, you know, everything is so close together in the brainstem. Um, so from a neurological standpoint, that's often what I'm thinking about. I do a lot of manual therapy in the eyes, or like, you know, hands on the eyeball, trying to create ease in the eye muscles. So if we think of wherever the actually, you know what I use a lot is the greater wing of the sphenoid, just putting gentle compression to create ease on the annulus of zin attachment, which most of the eye muscles attach to. So trying to just create a little bit of ease and then have the patient move their eyes and see, okay, does it elicit pain once we create some ease in that tissue? So I definitely look sort of structurally what is influencing it. Um I do something similar. Eyes closed, eyes opened, um, also looking for any flutter or anything like that. Eyes closed, because you know, sometimes it's we pick something up somewhere, um, and it's not showing somewhere else, essentially. I like, I don't know if you use this also, the SeraMod Um stimulator. Dr. Ayla Wolf DAOM: 15:52 So I have a a different peripheral nerve stimulator that I use on the trigeminal nerve. Yeah. Dr. Melissa Biscardi PhD: 15:59 But then I don't know if you see this as well. It doesn't work for everyone. Like sometimes you get the opposite, the opposite effect. But I'm sure you use acupuncture quite effectively for that. Dr. Ayla Wolf DAOM: 16:12 I do, yeah. So again, tools in the tool bag, right? Just to kind of play around with what works. Is it acupuncture? Is it a different peripheral nerve stimulation device? Is it hands-on work? Is it um I've been giving people almost like eye muscle exercises too that are not trying to correct eye movement disorders, but more so trying to create more ease within that system, just like we would stretch our other muscles. Um, so I've been developing what I just call face yoga. Dr. Melissa Biscardi PhD: 16:41 Oh, yes, I love it. Dr. Ayla Wolf DAOM: 16:42 I mean, that's actually been working really well. Dr. Melissa Biscardi PhD: 16:45 Well, and whether whether you've had a concussion or not, we're spending so much time just focused on near that I think everyone can benefit from, you know. So some people say this is a pencil push-up, like just following your thumb in and out, right? Which I don't think most people need because we do that all day long. So the opposite is I will have people just focus on something relatively near and then very, very far, like really trying to get people to open up what their eyes are doing. Dr. Ayla Wolf DAOM: 17:18 Yeah, I had one patient who had been doing the kind of the Brock string with working on convergence, divergence, but within, I would say, five feet from her face. And she wasn't really making progress in the sense that every time she did it, she was still having autonomic reactions and headaches. So I said, I want you to double the length of your string, get that thing six feet away from you. And we've been literally inching it like one to two inches closer once a week. And she's now able to perform those exercises without having the autonomic responses and the headache. And so I had to just push those beads like double the distance, and then we're slowly inching them in. Um, I feel like we're trying to like trick the autonomic nervous system, like you didn't notice we moved these an inch, did you? Dr. Melissa Biscardi PhD: 18:08 That's what we have to do sometimes. Yeah. Um, but to your point, um, the you know, sometimes the body can't handle a certain level of stimulus or a certain distance. So how so the autonomic nervous system, like we can observe eye fatigue or you know, blinking, we sometimes sweating, um, changes in facial expression, and then which are we can observe, or do you put an O2 sat um on their finger? Sometimes I'll do that to see if what I'm doing is stressful, essentially. Dr. Ayla Wolf DAOM: 18:44 Um I I would say more so like in the very beginning. If I'm working with somebody, I might pay more attention to those metrics. Dr. Melissa Biscardi PhD: 18:49 On the other side, I feel like you probably see this in your practice as well, is when people don't notice that it's very stressful for their system. Like we can see it in what the eyes are doing. Um that one I find a little bit more challenging. It's like convincing that there's something we have to work on. Dr. Ayla Wolf DAOM: 19:14 Right. I I see that a lot where you know people are either highly attuned to what's happening in their body, or there can be people that are the opposite where their body's having all kinds of responses and they're not aware of those responses, whether it's their jaw moving, you know, in the same direction as their eyes, or whether there's all these kind of facial twitches happening that they don't notice, or you can like see all of these nervous system responses to assessing eye movements that they're completely unaware of in the moment. Yeah, absolutely. Yeah. And so it sounds like you are then paying attention very closely to both physical eye and orbital pain as well as the actual eye movements themselves. And so I imagine that by combining both of those, uh, you are able to get good outcomes when it comes to some of these intractable daily chronic post-traumatic headaches. Dr. Melissa Biscardi PhD: 20:12 Yeah, absolutely. And I think sometimes the neck has, you know, always um is going to be a factor there. But it's very true that sometimes the neck is feeling and looking pretty good, and it's not, it's not so much a variable um anymore, or it doesn't seem to be from my assessment standpoint. Um yeah, but I think not all practitioners really get their hands in and around the eye tissue. I mean, it's changing, but I I really think that's sort of uh up and coming for us manual therapists, right? Dr. Ayla Wolf DAOM: 20:49 Yeah, yeah, absolutely. And to your point, going back to the trigeminal nerve, I mean, you know, again, we look at eye movements themselves, cranial nerves three, four, six, but then all of the actual what we would call no susceptive input, the pain inputs, are all coming through that V1 branch of the trigeminal nerve. And so knowing this overlap between both headaches or like any kind of head pain involves a trigeminal nerve. And then any kind of eye pain also involves a trigeminal nerve, and then any kind of light sensitivity also kind of rides those same pain pathways, you're really getting this almost trifecta of eye pain, head pain, light pain. And it's like no wonder if we don't unravel that why people get stuck in chronic pain patterns. Yes, absolutely. Dr. Melissa Biscardi PhD: 21:43 And I think sometimes it can be um, I don't want to say hard to appreciate, but that the eye itself might not be causing the pain, even though it's experiencing the pain. Like that's a whole um, well, it's a whole conversation with the patient. Right. We c and it goes with the body too. Sometimes we have elbow pain, but it's the shoulder or whatnot. Um but I think when it comes to uh the eyes in particular, they're their own um they're their own monster in terms of how we feel them. I don't know. Do you think that? I think we perceive eye pain differently. Like it's more threatening when you have a pain in your eye than if you have a pain in your elbow. Dr. Ayla Wolf DAOM: 22:30 I see what you're getting at. Yeah. So I cannot watch movies where like people are being tortured and someone's coming at their eyeball, right? Like anytime you go for the eyes in a movie, I'm shutting my eyes. I am absolutely so I think what you're getting at is that we have this like extra visceral fear response to anything coming at our eyeballs. Dr. Melissa Biscardi PhD: 22:54 Yes. Dr. Ayla Wolf DAOM: 22:54 And so therefore, our our nervous system is almost wired to be hyper-responsive to pain coming from the eyes. Dr. Melissa Biscardi PhD: 23:03 Yeah, absolutely. That's juicy. Dr. Ayla Wolf DAOM: 23:04 I haven't really thought of it that way. I just thought of it now. I was like, okay, brilliant awful light bulb moment on the podcast. So let's do it. Dr. Melissa Biscardi PhD: 23:14 Let's do a lot of circulate on it. But yes, I don't want to say any grotesque things that will create a visceral visceral reaction, but I think eye injuries, they're their own. And maybe because the eyes are the brain at, you know, at the root of it. So we we perceive it a little bit differently. Dr. Ayla Wolf DAOM: 23:33 That makes more sense too. The eyes are literally, you know, cranial nerve one is a direct extension from our brain into our eyeballs. And so our eyes are like the m the outermost part of our brain. Dr. Melissa Biscardi PhD: 23:46 Which is so um interesting to think about. Dr. Ayla Wolf DAOM: 23:50 Yeah. So no wonder we're extra sensitive to any kind of pain involving the actual eyeballs. Yeah. Wow. Mm-hmm all kinds of aha moments. Yes. We need to talk more. Yes, absolutely. Okay. Dr. Ayla Wolf DAOM: 24:07 Well, let's switch gears a little bit and talk about technology because you also have well, so you you're using virtual reality, which is kind of highest tech out there at the moment. And then you also have an app which is using technology. Talk about how your research is focusing on technology and the pros and cons of technology, because some people, again, going back to light sensitivity or screen sensitivity, that kind of becomes a barrier. Absolutely. Dr. Melissa Biscardi PhD: 24:40 And there are actually a couple of variables when it comes to VR that should be considered. One is a lot of the headsets were designed for the male head. And so the headset size matters. If you think about putting the headset on, if the headset is not the right size, then the visual stimuli is going to be a little bit off. So that in and of itself can create a mismatch and unpleasant experience and likely not a you know a productive uh session. Dr. Ayla Wolf DAOM: 25:15 The other Was that problematic in your study since you had more women than men? Dr. Melissa Biscardi PhD: 25:20 So the headset itself was uh pretty good, I want to say, but the other uh variable, it's called interpupillary distance, um, and which is the distance between your pupils essentially that the headset is calibrated to. And headsets can have a fixed distance, and that's what we used. The distance was 63 millimeters, and just for uh context, a female will have usually between I want to say 54 and 60 millimeters, and a male will be more 60 to 65. Those aren't the exact numbers, but just to um put it in perspective. Dr. Ayla Wolf DAOM: 26:05 So it was And you're saying this is the distance between the two, like the center of the pupil? Dr. Melissa Biscardi PhD: 26:11 Yes, exactly. And how then all the images are presented to the person based on that interpupillary distance. And when there's a large enough mismatch on what the goggles are programmed to and the person, again, that can create like a visual mismatch on on what they what they're seeing. Um, so in a perfect world, someone would be using a headset that has an automatic adjustment because those are available now. The the thing is, of course, the more financially accessible models use a fixed um distance. And then as there are more uh ways to calibrate it, it costs a little bit more money. But yeah, so if you're out there looking for a headset to use with your patients, it's is worth it to invest in one that will adjust the interpupillary distance, especially working in vulnerable populations. You really should do, you know, everything you can to make sure the technology is not going to be what's triggering their symptoms anymore. Right. Well, kids too have smaller heads. Yes, yes. So I don't work a lot with kids, but I I do every once in a while, and the headset is always way too big for them. Which is funny because it's a gaming headset, and kids like it. So I don't know if they're kid-sized headsets, maybe. So one thing or a few things in the clinic, there's only so much we can do and so much we can simulate uh in the space. And in virtual reality, we could literally, it's limitless uh what we can do. So maybe make it a grocery store or a sporting event. Um, so that can be helpful, right? And also, so making it transferable to the real world, making it a little bit more fun than moving around the clinic, depending on what your clinic is like, because there are some fun clinics out there. Dr. Ayla Wolf DAOM: 28:14 Sure. Dr. Melissa Biscardi PhD: 28:14 But rather than just looking at dots on a wall, exactly making it more um engaging and really personalized. Most VR will also allow you to track the eye movements, which is good. So you kind of get a dual purpose. In research, it has shown that patients prefer VR to traditional rehab, like whether that's for so that hasn't been done in um concussion, but for stroke rehab. I think there was one for vestibular rehab, and it does make sense, like having a fun rehab uh experience is it's also gonna help with neuroplasticity and change, right? When it when it's engaging. So uh those are the pros. Another one would be there aren't trained a lot of trained clinicians everywhere. So when you have a technology that can essentially help you see more patients, I think that can be that can be helpful. Okay, you have any questions about that? Sorry. I don't just want to like ramble and ramble and ramble. Dr. Ayla Wolf DAOM: 29:16 Well, so maybe explain kind of how VR works in terms of like obviously there's different companies, there's different software, there's different technologies within VR. So can you talk about kind of that's those specifics? Sure. Dr. Melissa Biscardi PhD: 29:30 Um, so yes, there's a variety of different VR platforms and and how they work on the more simple end. You can have VR where what is happening in the VR is very simple. So for example, a Brock string, but in VR. Um what else? Oh, like objects coming at you and you having, we did this one, objects coming at you and you're looking at them to explode them. So that would be like a random cicade. Um, just doing the OPK stripes or some an optokinetic stimulus, maybe a car is driving by in VR. So very uh simple and not too much depth. And then you can have literally going through a grocery store, but so this is interesting. So going through a grocery store, but your body is not moving, but you're moving with your eyes. So here's an example where there might end up being a mismatch because the what the visual system is perceiving versus what the vestibular system is perceiving is not quite the same. These are the things we have to watch out for, definitely as clinicians, because you're, you know, maybe you're really trying to improve the eye movements, but you're causing a problem at the same time. Um what are some other ones? Groceries, I use a grocery store a lot. Definitely driving. Dr. Ayla Wolf DAOM: 30:59 Um are there programs specific for improving peripheral vision? Because I know peripheral visual loss or deficits or dysfunction are common too after concussion. Dr. Melissa Biscardi PhD: 31:10 Yes. So there is uh one company, it's called the Reflex, and they and that use you can use a bunch of different headsets, but I know it does it works on the MetaQuest goggle, which I want to say is kind of the midline for a price range. Um, and then the neuroflex, which is what we used in in my research, has peripheral vision. I think it basically works on um everything, I would say. Dr. Ayla Wolf DAOM: 31:41 Got it. So you have the neuroflex. Okay. Dr. Melissa Biscardi PhD: 31:45 I'm getting the reflex though, because the one thing with the the one thing with the reflex is it also has hand um controllers. I did a try. I did like 20 different exercises on this device um and tolerated it. But I think the more you can have the patient doing, then the more transferable it's going to be. Because just sitting there in a VR, moving your eyes, even if you're in a grocery store, it still isn't that transferable. So if we can bring in some body movements that we're getting closer. We're getting closer to the grocery store. Dr. Ayla Wolf DAOM: 32:23 Sure. And then you decided to build an app yourself called the Brain Toolkit. So talk a little bit about um how you utilized that and kind of what that process was of creating your own app. Dr. Melissa Biscardi PhD: 32:38 Yes. So um at least five years ago, I noticed a gap in my clinical practice. And part of this is because I'm an Android user. So there really wasn't a lot available. And actually, one day I had a computer programmer patient, and I gave him the dots, you know, the post-it notes, and he made for himself dots. And I was like, oh my gosh, I'm gonna do that. So then I made the first version of the app, which was very simple, just had gaze stability, OPK, cicades pursuits, hemistim. And shared it with my colleagues and asked for feedback, and slowly it just kept growing and growing and growing into this um I don't a good monster that it is right now. And now, you know, I it's available for iOS or Android, which I think is very it's very helpful. Um, so there are you know all the different eye movements that you can assess or give homework. It doesn't track your eyes. And then some things from memory. Oh yeah, memory cicades, which I love, a short-term memory one. I don't even know all the things that are on it. Oh, a trailmaking like. So I call it brainy trail, but that one is good for again testing and training, um, sort of focus, executive functioning. And then I added a whole assessment battery so you can assess balance, reaction time, subjective visual vertical, and trail trail making, and then get some findings. And I think as a practitioner, especially a new practitioner coming in, you don't usually have the money to invest in the eye goggles and and all this and a force plate. And so it allows those assessments uh to be done, and then you can send the results to yourself. And it's actually pretty cool. You get a little map of the sway if you do the balance test. So it's definitely been um a co-design with the community. And uh, so that's how that that came to be. Dr. Ayla Wolf DAOM: 34:53 Okay. When did you add the balance assessment component? Is that fairly new? So what when was that added? Dr. Melissa Biscardi PhD: 35:00 Probably this year, maybe let's say in January. And it's really cool because, well, you can do eyes open, eyes closed, you know, feet together, one foot, the other foot, tandem, and then it gives you centimeters of sway. I tried to validate it against the B tracks. Um, so I can't say it's you know accurate to the millimeter, but you get you get a good picture, and it tells you the centimeters of sway, it gives you the sway pattern, which is nice to visualize too, especially for the patient. And then and then you can send the results. So the exciting, I'm hoping it will be well, it will be out by the time this airs, is that there is the ability to track your performance in the assessments over time. So a little graph is going to be there. It will be the data stored in the user's phone. So there's no data centers involved, which is way better for everyone. And then if they want to, you know, share the results, they can. So I think that will be fun too, because we we like to see how we're doing over time. And it's not only about recovery, it's like, how am I doing today? How am I doing in three months? Dr. Ayla Wolf DAOM: 36:15 Exactly. Exactly. So that's phenomenal that you now have that whole balance component built in and people can track that over time and save that on their own personal device. Yes, and then export it. That's great. Dr. Melissa Biscardi PhD: 36:27 So I think I think that's super helpful. So if there's anything you ever want added, you know, just say the word all right. Yes, yes. A lot of the subjective visual vertical, for example, that was suggested by someone. So, because we all have, we all realize different things. Like, oh, it'd be nice if I had this in my practice in this app. Yeah. Dr. Ayla Wolf DAOM: 36:51 Well, I mean, I have to have like 12 different apps all in one folder because I have to have like right now, I have a different subjective visual vertical app, and I've got a different one for balance and a different one for this, and so yeah. Dr. Melissa Biscardi PhD: 37:02 Yeah, and thinking I was like, let's try and get everything under one little button. Dr. Ayla Wolf DAOM: 37:10 Right. Yeah. A uh a convergence uh tracker one would be great. Dr. Melissa Biscardi PhD: 37:15 I know. I was thinking about that, and I know there's another company that does it by having the dot jump towards the person. I don't know. I sh I could try it out. Stay Dr. Melissa Biscardi PhD: 37:30 tuned. Dr. Ayla Wolf DAOM: 37:31 Well, yeah, yeah, for sure. And then you mentioned the trail making like test. Do you call it the brainy test? The brainy trail. The brainy trail. You have something called the brainy method. So what is that? What is that? Dr. Melissa Biscardi PhD: 37:45 Brain, I like to use the the brainy word, the brain. Um, so basically, what it is is thinking about having a process versus a protocol. So instead of getting hung up on when I see X, I do Y, really thinking through the recovery process with a patient. So starting with the baseline, what is the baseline regulation looking like? Like how are those autonomics, how is the sleep, the diet, um, any mental health support? Because we need those foundations before we we get into anything else. And then looking at, well, the personalized deficits that are happening and creating active interventions for them that we slowly scale up. And then, and that's an iterative process over time, and then integration into the real world, maybe using VR first, but maybe not. And then actually, okay, we're doing these whatever post-it notes. We have people on the Brock string, perturbed surfaces, but then moving it, integrating it into their life. And then performance over time, because I always say concussion recovery is the first step, right? And then then there's the rest of it. There's neuroperformance over our whole lifetime. And that's harder to sell, I will say. Like we are very reactive as humans, but I definitely have some patients that after a concussion, they are really interested in their brain health. And it's definitely a biased sample because those people choose to check in. But those people do better with time, which is the opposite of what people, the media, whoever, the media would have us think that we decline. But actually, I see those patients get better on their test results year after year. So it should just goes to show you neuroplasticity, right? How much capacity uh the brain has for not just healing but improving. And then the why is you or the patient. It's all personalized. Um, even, for example, in my research, there had to be some parameters, for example, what was even available to us on the VR, but then doing whatever we can to make it um personalized and more meaningful to the person in front of us. And there's definitely more of that happening in care these days, but just making sure that it's always at the front of our minds. Dr. Ayla Wolf DAOM: 40:30 Yeah. Well, I think you bring up a really good point here, which is that essentially you're transitioning some patients out of a concussion recovery program because they've gotten better into a brain optimization program. And so essentially that's kind of an interesting progression because a lot of people want to say, okay, well, you know, when am I going to get better? Or when can I stop coming to see you, right? Like we're kind of actively trying to put ourselves out of business every day by getting people better. Yes. But then sometimes, you know, there is a place to say that continuing to come in and kind of work on things for maintenance and for optimization is it still has a place. And that can be difficult because some clinics are very much focused on concussion recovery. Other clinics are very much focused on like sports optimization or CEO optimization, right? They kind of market themselves as like we're an optimizer clinic. When you try to kind of do both things, I guess it can be a little tricky and confusing and convoluted. Dr. Melissa Biscardi PhD: 41:38 Absolutely. And I do think like my clinic is called Concussion Rehab. So people are like, okay, I'm done with you. unknown: 41:46 Right. Dr. Melissa Biscardi PhD: 41:47 I don't fit the name of the clinic anymore. Um, but yeah, I do see it as, or at least even if it's not with us, you know, we we hope people um are empowered to know that um we have more capacity than sure than sometimes we give ourselves credit for. Dr. Ayla Wolf DAOM: 42:09 Yeah. I mean, I'll never get tired of the the videos circulating on Facebook of like the 80-year-old lady doing balance beam routines. Yes, exactly. Dr. Melissa Biscardi PhD: 42:18 And I always say, like, because people will say, is it just age? Um, and I'm like, Mills, you want to have the highest uh level of functioning as your comparison, right? There are people running marathons in their 80s, 90s, balance mean that gymnast, maybe it's a single you're talking about. Dr. Ayla Wolf DAOM: 42:39 Probably. Dr. Melissa Biscardi PhD: 42:40 Right. So it's like, let's use that as you know, who we're associating with with aging. Dr. Ayla Wolf DAOM: 42:47 Exactly. Yeah. Well, and I have chickens and I live out in the country. So like I go to the feed store to get my 50-pound bags of chicken feed. And when I was there the other day, it was like there was this young woman working behind the counter ringing me up, and then she like shouts to the other woman in the back, like, hey, she needs four bags of chicken feed. Well, the other lady in the back was like 70 years old, but yeah, I mean, she's she was a farmer, right? So, like, it was no big deal for the 70-year-old to just go and grab four 50-pound bags of chicken feed and throw them on a dolly and wheel them out to my car. And it's like, meanwhile, I'm standing there feeling bad. I'm like, Let me help you. But to her, it was like, I do this all day long. It's not a big deal. Dr. Melissa Biscardi PhD: 43:30 That's amazing. Yeah, and that's what our bodies used to be exposed to all the time. Dr. Ayla Wolf DAOM: 43:36 Yeah. So physical labor jobs instead of desk jobs. Dr. Melissa Biscardi PhD: 43:40 Yes. And I mean, when you think about it, like how long have we really been chained to our desks? It isn't that long in terms of the life, the lifespan of humans. So I don't, I think we're in um we're We're in an interesting time because well, I do think people are getting less healthy. I hate to say that, but we're just exposed to so much more that is not natural for for what we've been exposed to in the past, whether it be chemicals or all who knows, all this the EMF and and stress. We the stress used to be running from a bear, but now we have other stress and it affects healing, right? Dr. Ayla Wolf DAOM: 44:36 Yeah. I think maybe what another way to frame it too is it is becoming harder or more of a what feels like a full-time job to be aware of all the things that could be detrimental to our health and to try to avoid them or compensate for them or make adjustments in our life to you know not have those things affect us as much. Dr. Melissa Biscardi PhD: 44:57 Absolutely. And we all have our individual um like tolerance to different exposures as well. So, and that's why I think that technology will not take over when it comes to health and clinical practice, because healing traditionally has involved another human. Like there's a human component to healing and helping. And even today, this morning, I was at the doctor's office and she came in and I was thinking, there isn't like I don't want to be talking to a robot about my health, right? There's a human component of healing and like biologically that I think will always be important in care. So maybe we'll we have the technological tools, and I'm sure the tools will be able to pick up every single autonomic um marker, but having someone there and seeing that you're struggling and validating, um, yeah, I think that will continue to be important. And and especially as humans were becoming more isolated, right? Um we're just all online. So I I don't think um I don't think technology can completely replace care. What do you think about that? Dr. Ayla Wolf DAOM: 46:16 I agree. I think that if we can use technology to prevent medical errors and to kind of fix that part of the healthcare system and to aid in diagnostics, I think it's only going to be able to make doctors more efficient and more helpful to their patients and to maybe be able to see more people too. But to be able to just automate parts of the job that were just eating up time, like that's really, I think, where technology is the most helpful. Dr. Ayla Wolf DAOM: 46:46 Yeah. Well, what's next for you? I mean, you've wrapped up your PhD, you've got your your app, The Good Monster. Yes. Uh what's next? Dr. Melissa Biscardi PhD: 46:58 So the first next thing is going to be finishing the analysis, like that second analysis, um, and publishing knock on wood that. Um, so that we'll look more at, you know, letting you guys all know about the um improvements in your point of convergence and all the self-reported um outcomes that people were experiencing. And then what else am I going to be up to? I'm going to go to Portugal and then I want to go to Hawaii. So I'll have some self-care. And I'm going to keep developing the app. Actually, this is a really exciting time. Yesterday, I just learned I had applied for a grant, which essentially would allow me to have access to students that need a project to do. And so they're going to help me add to the app that it will send nice reports to the clinician. So instead of just like uh whatever screenshot of the results. And so I hope that's going to be taking place over the next six months. So that will take my my energy. And you can also give your two cents, but I went without a clinician platform to start at least to avoid honestly. I just want to avoid data centers. So we'll see. Once that, once that's available, you can you can give me your feedback. But yeah, I'm trying to develop the app into being the best it can be and then and then my clinical practice. Dr. Ayla Wolf DAOM: 48:43 Amazing. Do you think that you want to continue to do research after you wrap up all of your research and data that you did during the PhD program? So I'm not sure. Dr. Melissa Biscardi PhD: 48:54 I feel like um with one foot in. So I do, or one toe. I don't see myself running trials. Um, you know, the unfortunate thing with research is it takes so long, right? Like this trial took let's say four years or or three and a half, really. But yeah, it just takes so long to get the answer. I think there are this is uh a conversation, like there are more efficient ways. We don't need randomized controlled trials for everything. Um so I think I would more like to kind of consult or help recruit, but not go through the all the invisible work, applying for grants and and all of that. Right. Dr. Ayla Wolf DAOM: 49:37 Yeah, I hear that. Dr. Melissa Biscardi PhD: 49:39 And that's the thing I know in what would you call it? Just like talking on the internet, it's always like, but is there a randomized controlled trial for that? And it's like there's actually not that level of evidence for a lot of things, even some surgeries, right? Dr. Ayla Wolf DAOM: 50:00 So we yeah, we have to appreciate other evidence as well. Yep, absolutely. Amazing. Okay, well, have fun in Portugal. Tell me all about it. I'll let you know how it is. Okay. And we'll connect. I'll see all your Instagram posts from the beach. Yes. Okay, bye. Dr. Ayla Wolf DAOM: 50:24 Medical disclaimer. 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