Understanding Traumatic Brain Injury, Concussions & Neurological Care

[0:00] One of the most important things that people need to understand when it comes to traumatic brain injury is that

[0:05] it doesn’t necessarily require a direct impact to the head. It’s any type of internal force that causes the brain to shake inside of the skull,

[0:13] disrupt that electrical activity and the function of the brain and thus subsequently lead to symptoms.

[0:18] Concussion is pretty much a type of mild traumatic brain injury. How much of the field of neurology is detected work?

[0:25] When it comes to a person’s health, you have to be responsible for how you get better in your care.

[0:34] But as a patient, if you’re not willing to comply or listen or follow certain recommendations, it’s futile.

[0:49] Welcome to The Care Cartography, a show about health care and having practical conversations with people who understand the health care system from different angles,

[0:57] from doctors and nurses to administrators and operators to coordinators, advocates and other health care professionals

[1:04] who see where the system works, where it breaks down and what can be done better. I’m your host Andrei Tsagov and today we’re going to talk about neurology,

[1:12] traumatic brain injury, headaches and what really goes on to evaluating patients with neurological symptoms.

[1:19] With us today is Dr. Tamara Green, a board certified neurologist with extensive experience in general neurology,

[1:25] traumatic brain injury, concussions, headaches and neuromuscular medicine. She’s also the founder of Green Neurological and

[1:31] Medical Consulting in Roswell, Georgia, just North Atlanta. Dr. Green, welcome.

[1:36] Hi, thanks for having me. Great to have you. I think our audience will be especially interested in

[1:42] hearing how much of the field of neurology is detected work. Because a lot of times when patients come to see

[1:49] you with headaches or dizziness or cognitive issues, a lot of it is really determining what is at the cause of their problems.

[1:59] Right. So how do you begin evaluating someone like that and

[2:04] what does it take to get to the root of their problems? So the basics that were taught in medical school are history and physical.

[2:14] So welcome your patient in, you collect the history, talk about their symptomatology, what’s going on with them,

[2:21] how long it’s been going on, the severity of it, if it affects their daily life.

[2:26] And after you collect the history, get past medical history to see if there is any

[2:31] potential diseases that they’re currently suffering from that could be related to their symptoms. Also, family history is important to see if there’s a family history of symptoms or

[2:40] similar symptoms that the patient is complaining about. Finally, you do a physical exam. So you try to ascertain what’s going on with the patient as it relates to any

[2:51] potential physical findings you may find on their evaluation. Specifically, their neurologic evaluation. Our exam is a little bit different from other providers.

[2:59] So you do a thorough neurologic exam, assess any abnormalities, and then from there

[3:05] you come up with a game plan, potential diagnosis and potential treatment options as far as as well as, I’m sorry, diagnostic testing for them.

[3:12] So it seems that there’s multiple components, but at least the core three would be their family history and their physical exam that you would have to do with them

[3:20] and then perhaps diagnostic testing to really triangulate what might be an issue. Is that right? Correct.

[3:26] So let’s go back to the beginning. Can you tell us a little bit about yourself and how you became interested in medicine?

[3:32] So I entered medical school and five years

[3:37] ago, joking, but I entered medical school. Initially uncertain as to what I wanted to do.

[3:44] I knew I wanted to do something in the field of medicine. And for those first three and a half years during your 30

[3:50] year rotation, you rotate through different specialties. And when I was going through those rotations,

[3:57] a lot of the residents just didn’t seem happy. So I just thought, great, what am I going to do with my life?

[4:04] And then I did my neurology rotation, my second, the second half of my 30 year medical school, and the residents were happy.

[4:11] They were smiling and they were treating disorders that the one thing I love about neurology is it’s an ever growing field.

[4:18] Unfortunately, because most of the things that we treat, they don’t have cures. And it’s a matter of making sure that your patients have a good quality of life as

[4:27] they’re going through whatever they’re going through. There’s some that do, but there are a lot that do not.

[4:32] Talking to these other residents, seeing how they evaluate patients and seeing their interactions with patients.

[4:39] And then once you actually treat a patient and you actually help them and help them feel better, the patients are just absolutely grateful.

[4:46] So seeing smiling residents, smiling patients, I thought, hey, this would be a good profession for me to be in.

[4:53] And then after that, I did a fourth year away rotation at UT Houston Health Science

[4:58] Center, which kind of further solidified, hey, this is a field that I want to go in.

[5:03] During our conversation earlier, you mentioned that neurology is a growing and changing field.

[5:10] Can you talk a little bit more about that? What does that mean to you? So I love some of the things that are going on in

[5:17] neurology because it’s actually giving patients hope. For example, with Alzheimer’s dementia specifically, initially there were only a

[5:26] couple of prescription medications that were thought to maybe

[5:32] make available certain neurotransmitters or chemicals in the brain to help with the symptoms.

[5:39] But those medications did not slow down the actual process of progression of the disease.

[5:44] So within the past, maybe at least five years or so, there are medications now that

[5:50] have been shown to actually slow the rate of progression for Alzheimer’s dementia. So that’s something that’s new.

[5:57] There are several medications that are coming out to treat MS or multiple sclerosis in various different categories as you look at or as

[6:05] researchers look at the mechanism of action of these different immune factors that can affect the disease.

[6:11] And so there are a lot of additional medications coming out with something like multiple sclerosis.

[6:17] So those are just two prime examples and two diseases where the research is ever growing and evolving to actually give patients

[6:25] hope that they can have a good quality of life. And hopefully on the horizon, there will be other medications to treat the other forms of dementia.

[6:33] Alzheimer’s is the most common, but there are other subsets of dementia that people are not as aware of or not as familiar with, that those subtypes still don’t have a

[6:43] specific treatment that targets their abnormalities. So hopefully as time goes on, research continues to develop.

[6:50] We can also give those patients some hope. That’s fascinating. And it seems to be a wonderful thing that would really improve both the quality of

[6:59] life for a lot of folks who are suffering from that. Absolutely. So you mentioned you’ve done your residency and one of your fellowships in Houston.

[7:07] Correct. So what was that like and how did that shape your outlook both on medicine and neurology?

[7:14] Well, Houston was hot. But residency, back then, it wasn’t as these days, I think they’re not as tough on

[7:27] the residents, but I trained back when they didn’t have an 80-hour work rule.

[7:32] So you’re in the hospital 36 to 40 hours at a time. And it sounds absolutely brutal.

[7:37] It was brutal, but I am grateful for it because it’s during those times that you would see certain pathology and certain things that you go out.

[7:45] That you probably won’t ever see again in your, even in your career.

[7:51] So, yeah, resident, it really helped to, with that training, you not only learn the

[7:59] science behind things, but then you also learn, you know, patient interaction. Physiology was, it primarily focused on patients that had seizure disorder as well

[8:11] as certain more rare diseases, muscle and nerve diseases. And it was interesting.

[8:16] I think during that first fellowship, my mom got diagnosed with something called myasthenia gravis.

[8:22] And myasthenia gravis, it’s an autoimmune disease that attacks the muscles where your body makes antibodies that attacks the muscles.

[8:30] And just so happens, I was during, I was in the middle of that fellowship and one

[8:35] of the diseases that we focus on was myasthenia gravis. And my mom got diagnosed during that time in the middle of that fellowship.

[8:42] So it really helped me to, having that knowledge and having that background really helped to put my mom at ease.

[8:50] He said, hey, you know, this is a disease. It’s something new. It’s autoimmune, but it’s so treatable.

[8:55] And that’s another disease where there’s again other medications that are coming out on the horizon. It’s given patients with myasthenia hope.

[9:02] That must have been surreal to be studying something and then having that your own

[9:07] family being impacted by that same thing. Yeah, it was. And when she, and she had seen a couple of neurologists and so when she started

[9:14] talking about her symptoms and I said, hey, mom, it sounds like you have, you know, myasthenia gravis.

[9:19] And just so happened, one of my mentors that trained me during residency had, my

[9:25] mom was living in Kansas City, well, outside of Kansas City, Missouri. One of the mentors that trained me during

[9:30] residency had taken a position at, up in Kansas. And so, and he’s so kind.

[9:36] I’m forever eternally grateful to him. I sent him an email said, hey, I think this is what’s going on with my mom.

[9:43] They can’t get her in for six months. And there was a simple email. He gives me a call. He says, have her come into my office on Monday.

[9:50] Oh, that’s, that’s, I’m sure your mom must have been relieved to get that right away.

[9:56] Yeah, she absolutely loves him. Dr. Dimashki, he’s watching.

[10:02] Solid plug. Yeah. So you mentioned a clinical neurophysiology.

[10:07] Can you explain in layman’s terms what that means and what that study entails? So physiology refers to the dynamics as to the electrical

[10:18] components of the nervous system, brain and the spinal cord. Neuro, so this neurophysiology, so electrical activity of the brain.

[10:27] One of the major diagnostic tests that we look that we use is EEGs or electroencephalography.

[10:34] It’s common for patients that have seizures. You assess the brainwaves to see if they’re having seizures, what type of seizures.

[10:41] And then the second component, the second diagnostic test is an EMG nerve conduction study or electro myography slash nerve.

[10:48] It’s oftentimes abbreviated NCS or nerve conduction studies. And that assesses the peripheral nervous system.

[10:54] So the muscles and the nerves. So you have the brain and the spinal cord that are part of the central nervous

[10:59] system and all the nerves and muscles that extend from it refers to the peripheral nervous system.

[11:05] And so the fellowship focus primarily on assessing not only the seizure disorder

[11:10] and other different brainwaves and diseases associated with epilepsy, but also the

[11:16] peripheral nervous system, muscle and nerve disorders. What do you think is one of the most common misunderstandings that patients might

[11:22] have in working with you and working with neurologists in general? So it’s oftentimes it’s not hilarious, but it is kind of hilarious when I tell

[11:33] patients I’m a neurologist and they say, oh, you work with the nerves. Well, my nerves are bad.

[11:38] It’s like, well, no, that’s more psychiatry. But, you know, if something’s going on, like do you have a mask?

[11:47] You have seizures, you have migraines. And so what a lot of people don’t know what neurologists treat, which is fine.

[11:55] It’s a matter of just educating patients and letting them know, hey, these are the things or disorders that, you know, that we focus on from a neurologic standpoint.

[12:04] I even when I first went into the field and oh, another misconception is confusing neurology with neurosurgery.

[12:11] And I sometimes will get referrals for a neurosurgical cases and I’ll see the referral to say brain tumor.

[12:18] I’m like, no, well, that’s needed to see a surgeon. Like their malpractice insurance is a lot

[12:23] higher than mine and they make more money than me. But we’ll get you in the right place.

[12:28] So though oftentimes it’s just a matter of educating laypeople as to what specifically that our areas of focus are.

[12:36] And how does your practice differ from that of a neurosurgeon? Again, lower malpractice.

[12:41] They make more money. Oftentimes, or be as your but neurosurgeons, they do surgery.

[12:47] So most neurologists don’t do surgery. Some neurologists do minor procedures.

[12:53] I do a couple of procedures. But did a lot of procedures during my second year fellowship training as far as muscle and nerve biopsies.

[12:59] But neurosurgeons, if you’re looking for resection of a brain tumor or spinal

[13:05] surgery, disc degeneration and things of that nature, those are just two big things that a lot of neurosurgeons focus on.

[13:12] But yeah, they do surgery. We do not in most instances. I guess the name surgery or in a neurosurgeon should have cued everyone off.

[13:23] Ideally. But it’s not always the case. You touched on this just a little bit earlier in the fact that an actual physical

[13:32] exam is a really important part of what you do. How does your exam of a patient differ from, let’s say, a general practitioner?

[13:42] So the neurologic exam itself, there’s seven main components of it.

[13:47] So you have the mental status exam. You know, are they awake or alert? Are they talking? How is their speech?

[13:53] Can they answer questions appropriately? Then there’s a cranial nerve exam and the cranial nerves focus on function of

[14:00] primarily muscles and eyes and everything in the head. And then you have the motor exam.

[14:06] How is your strength? Are they strong? Do you notice asymmetry or are they weaker on one side versus the other?

[14:11] Then the sensory exam assesses their sensation. Do they have a neuropathy, whether have numbness in their feet or numbness in the hands reflexes?

[14:19] So you tap there. Of course, their elbows, knees, ankles to see if they have reflexes, if there’s a

[14:25] symmetry noted, if someone’s hyper reflexic. That can tell you about certain things as far as we trained to learn where is the lesion.

[14:34] Then you assess coordination, their fine motor movements. If they’re doing finger to nose, do they have a tremor?

[14:40] Are they missing the target? Or in cases like Parkinson’s disease, do they have something called bradykinesia where they have slow movements?

[14:48] And then finally, there’s the gait. How are they walking? Are they stumbling? Are they able to do tandem gait?

[14:53] Or some of my patients refer to it the drunk walk. They will walk with one foot in front of the other.

[14:58] Are they able to stand with their eyes closed? So those are the major components of the neurologic exam, which in itself kind of

[15:05] sets us apart from pretty much all the other specialties. There’s not a specialty that really assesses.

[15:13] Of course, some neurosurgeons also incorporate that into their physical exam. But with neurology, those are the main components of our exam.

[15:23] Well, and that does seem very different than I think what most people are typically used to what they expect.

[15:29] And I guess it seems that that’s where the detective work starts. Right. Absolutely. So you mentioned something interesting.

[15:35] It says, where is the lesion? Yes. Can you explain what that is? So when you’re assessing a patient, you start again.

[15:44] The nervous system is divided into the central nervous system, again, the brain and the spinal cord and then the peripheral nervous system.

[15:51] So you as you’re going through your exam, you look for certain findings to point to certain areas.

[15:58] If they have facial asymmetry, that could tell you, OK, there’s something wrong with their cranial nerve, like, for example, stroke patients.

[16:04] So with stroke patients, they will have a lower facial droop versus which is a

[16:09] central nervous system, lesion or something in the brain, versus bells palsy, where the whole side, the entire side of the face will be paralyzed.

[16:17] That indicates a peripheral nerve lesion or their seventh nerve is damaged. If you have somebody that has hyper reflexia, their arms, if you tap the reflexes

[16:27] and their reflexes are really active, that could indicate a lesion again, potentially in the brain.

[16:32] If it’s on one side, the opposite side of the body could have hyper reflexia or if

[16:38] they’re hyper reflexic throughout, that could indicate a spinal cord lesion. You know, if a patient has neuropathy, they can have sensory findings where they

[16:47] have numbness that’s distal or sensory changes past a certain part of their arms and or legs.

[16:53] So once you do an examination or neurologic examination and see those

[16:59] abnormalities, that could tell you, OK, hey, your lesion is likely here or your lesion is likely there.

[17:05] Or hopefully, in a lot of cases, the neurologic examination is normal. You can tell them you can give them some reassurance.

[17:11] Well, it seems that, to translate it into lay terms, it says, where is the problem?

[17:16] Exactly. Absolutely. So given that we have it seems that there are more and more diagnostic tests

[17:25] available and then becoming more and more varied and more prevalent.

[17:31] Why is the physical exam still so important when you have these potentially new and interesting other kind of tests available?

[17:38] So one of the more most important things with regards to diagnostic testing is you

[17:44] with the financial finances and patient’s finances, you don’t want to have them do diagnostic testing unnecessarily.

[17:52] So you don’t want to order an entire scan like their brain in their entire spinal cord because that could cost several thousands of dollars.

[18:01] So once you localize a lesion, then you can narrow it down. OK, this is person need an MRI of their brain if they’re hyper-reflexic all over,

[18:09] whether you need an MRI of their cervical spine versus if they’re just hyper-reflexic in the legs, you can stop at the thoracic spine.

[18:16] So it’s a matter of just not only narrowing down what you are looking for and where you suspect the lesion is.

[18:24] Also, again, it’s important to have that reassurance. Say if a patient has a normal neurologic

[18:30] exam, you can say, hey, your exam is normal. They’re imaging more likely than not. Won’t show anything, but we can do it.

[18:36] Sometimes patients just need that reassurance. But it’s really important to do that physical exam to make sure that you’re not

[18:44] over-ordering tests and putting patients through not only unnecessary testing, costing them unnecessary money, but then sometimes also exposure to radiation.

[18:52] A lot of patients are concerned about that. So that’s a very important thing. Yes, to really to localize the issue and really make

[19:01] diagnostic testing very pointed as opposed to general. Absolutely. So what are some neurological symptoms that

[19:09] patients may minimize, but they shouldn’t overlook? Refractory headaches is an important one.

[19:16] A lot of patients, I see a lot of headache patients. And if you start to treat a patient for headache and the headaches aren’t going

[19:24] away, especially if they just pop up spontaneously, a lot of times, especially patients who are older and they have a strong family history of high blood

[19:32] pressure, that’s one of the first things that I look for. You know, you talk to a patient, you have this headache’s not going away, this is not going away.

[19:38] It’s like, what’s your blood pressure? Well, I don’t know. You check the blood pressure and it’s in the 200s. Oh, wow. So, yeah, I was like, yeah, we got to get that taken care of immediately.

[19:46] I have a patient that I recently had to help her because she was having recurring headaches. And sure enough, I said, what is your blood pressure?

[19:53] She hadn’t checked. And then she calls me and said, hey, I checked it or my I think someone else had checked it for it.

[19:58] It was literally in the 200s and she was fairly 36 years old. Oh, wow. Yeah. So recurring headaches is one definitely referred to as focal neurologic deficit.

[20:08] So there’s one entire side of your body that’s not moving as well as the other.

[20:14] That could definitely be a sign that there’s something going on in the brain. Something I see a lot of the a lot of retired NFL

[20:23] patients, they know like a lot of balance and stiffness. Oftentimes, it’s not something that you want to ignore

[20:30] because then it could lead to something that’s more serious. Gotcha. So when it comes to headaches and high

[20:37] blood pressure, how can why is that a problem? Oh, because it can lead to hemorrhagic stroke.

[20:44] It can lead to both types of stroke ischemic stroke and ischemic stroke refers to if you have a blood clot in an artery or a vessel inside of the brain that cut that

[20:53] cuts off the blood supply and then thus leads to, you know, no blood supply to that area.

[20:58] Thus resulting in a stroke where you can’t move side of your body, your speech is slurred, you can’t talk.

[21:04] So that’s the ischemic stroke. It’s where your blood vessel actually ruptures and

[21:09] you bleed into your brain and hemorrhagic strokes. The most common cause for hemorrhagic stroke is elevated blood pressure and

[21:16] hemorrhagic strokes tend to be a lot more serious than ischemic strokes.

[21:22] I mean, they’re both serious, but hemorrhagic strokes, not uncommonly, the recovered deficits are a lot worse.

[21:29] The recovery time is a lot longer and even more importantly, their risk, their mortality risk or their risk of passing away from the

[21:38] hemorrhagic stroke is a lot higher versus an ischemic stroke. If you have a headache and it doesn’t go away, make sure to take care of that.

[21:46] Yeah, take care of that. Yeah, definitely. Absolutely. And the first thing you do is check your blood pressure to make sure this is fine.

[21:52] So what are your specialties is traumatic brain injury? Yes. So when someone hears traumatic brain injury or TBI, what should they understand?

[22:02] Can you explain in layman’s terms? Traumatic brain injury refers to any type of external force that causes the brain

[22:11] to move inside of the skull and it disrupts brain activity.

[22:17] It can disrupt the electrical activity as far as structural activity. And there’s a misconception that it requires direct trauma to the head.

[22:25] That’s not always the case. So just a rapid acceleration, deceleration can

[22:30] cause because, of course, the skull is a hard surface. The brain is floating around in something called CSF, cerebral spinal fluid.

[22:38] And if the brain, if the head suddenly stops and the skull stops, but the brain is

[22:44] still moving inside of the skull, it can impact that inner surface and thus create those symptoms that

[22:50] refer to as post concussive symptoms. But one of the most important things that people need to understand when it comes

[22:55] to traumatic brain injury is that it doesn’t necessarily require direct impact to the head.

[23:01] It’s any type of internal force that causes the brain to shake inside of the skull, disrupt that electrical activity and the function

[23:08] of the brain and thus subsequently lead to symptoms. So would a concussion fall into that category?

[23:15] Yes, concussion. And that’s another thing sometimes people don’t understand.

[23:20] A concussion is pretty much a type of mild traumatic brain injury. They’re oftentimes thought to be interchangeable.

[23:26] So concussions mild, but there are other obviously more intense types of traumatic brain injury.

[23:33] Absolutely. And but they can still result from the same things. Just is it a different kind of impact, a different kind of force?

[23:41] Yeah. What might cause something to be more serious? So simple gunshot wounds, stab wounds to the head and not uncommon blast injuries.

[23:50] So military servicemen, if they are in the process or if they suffer from a blast

[23:57] injury that caused them to physically get blown away and those are more serious traumatic brain injuries.

[24:05] And unfortunately, something that we saw a lot during my pediatric neurology rotation in the Shaken Baby Syndrome.

[24:11] Oh, no. That’s that’s a very serious, more serious traumatic brain injury that can be extremely detrimental to babies.

[24:19] Patients sometimes hear the term post concussive syndrome. What does that what does that mean?

[24:24] So simply put, post concussion syndrome refers to symptoms that patients suffer from after they have a concussion.

[24:33] It’s simple. In the duration, as far as the symptoms, some patients recover after a couple of weeks. Some patients have symptoms for the data vary.

[24:41] Some some studies say six weeks, some studies say three to six months. About 10 to 15 percent of patients may go on to have symptoms longer than the year.

[24:50] And then that’s referred to as a permanent post concussion syndrome. So and how long permanent should be self explanatory?

[24:58] But does that really mean that that can stay with someone for a long period of time and perhaps for the rest of it?

[25:04] Yeah. And so what the study show that is that if a person is still suffering from post

[25:10] concussive symptoms after a year from their initial injury, the thought is that

[25:15] their symptoms or their injury is likely permanent. And how common is that just in your practice?

[25:21] Approximately 10 in the study show approximately 10 to 15 percent of patients will go on to have a long term appointment permanent post concussive syndrome.

[25:29] And just based on either research or your your experience in your practice, is

[25:34] there anything that is there a common thread between those people who have this fall and the rest of their lives?

[25:43] Honestly, from it depends on the ideology, but you can’t

[25:48] really tell who’s going to have those long term symptoms. Some patients have what you would think to be a

[25:53] pretty mild accident and then they have symptoms long term. Some patients have a pretty detrimental.

[25:59] I saw a patient out last year. This is the sweetest lady and she had an intracranial bleed.

[26:05] She had brain bleeding. And after a couple of months, she recovered pretty quickly. So you can’t really predict who’s going to have what.

[26:13] Of course, the big thing that people are talking about these days is CTE and that’s a whole other talk show.

[26:19] But that’s also an example of something that could be considered a permanent post concussive syndrome or permanent injury.

[26:26] You said something very interesting and as you don’t treat a syndrome, you treat symptoms.

[26:31] Can you explain that? Yeah. So there is a misconception that a post concussive

[26:38] syndrome can be treated with one thing, which is you can’t.

[26:43] In medicine, you have a lot of different subspecialties have their respective

[26:49] syndromes and a lot of providers can tell you. And not uncommonly, some of those syndromes require a multi-disciplinary approach

[26:57] where you have a bunch of different providers. And of course, this is not necessarily it’s kind of related to neurology, but like Down syndrome.

[27:04] Down syndrome patients, they have, of course, cognitive delay. They have cardiac defects.

[27:09] They have sometimes they can have abnormalities of their hormones.

[27:15] So then you not only have to have a neurologist on board, you have to have the cardiologist on board, but then you have to have the endocrinologist on board.

[27:21] So you don’t treat a syndrome, you treat a patient’s symptoms. So once I talk to a patient, hear their symptoms and not try to make sure I address

[27:31] those symptoms individually to get them in. Not uncommonly, you’re treating everything at the same time, but you want them to

[27:40] feel better because not uncommonly, their symptoms can interfere with their activities of daily living. So you want to make sure that you don’t say, OK, let’s do the headaches first.

[27:48] OK, headaches are better. Now let’s take care of the disease. OK, that’s gone. Now take care of the memory issues. You want to make sure that you’re addressing everything all at one time to help to

[27:56] speed that help to accelerate that patient’s recovery. What role would you say things like physical therapy or

[28:04] occupational therapy or vestibular therapy play in TBI recovery?

[28:10] I oftentimes refer to vestibular therapy because patients have inner ear symptoms.

[28:15] So not only do you have the brain that hits the inner surface of the skull, in the

[28:21] inner ear, you have these stones called otoconia. So you have the central nervous system dysfunction when the

[28:27] brain is affected, but the inner ear system can be affected. So those inner ear stones can be dislodged and go into

[28:33] an area of the inner ear called the semicircular canals. There’s a set on each side and the semicircular canals

[28:40] are very important with regards to balance and equilibrium. So a very common symptom that patients will talk

[28:45] patients will talk about is that they have positional dizziness. If they bend over, they get dizzy. They stand up, they get dizzy.

[28:51] They turn their head, they get dizzy. So it’s important to and unfortunately, there’s there are no FDA approved

[28:58] medications for post contructive vestibular symptoms. And so oftentimes we’ll refer for vestibular therapy because a good vestibular

[29:05] therapist will teach them certain exercises to get that equilibrium back in tact and help

[29:11] to help to maintain their balance and improve their balance so that their dizziness is not so bothersome.

[29:17] What is vestibular therapy in layman’s terms? What does it do? They do what we refer to as passive range

[29:23] of motion exercises with the patient’s head. And they work to get those inner ear stones back in tact.

[29:30] Also, they’ll work with patients because patients not uncommonly complain of balance issues. They’ll assess a patient’s balance, see where their abnormalities are and teach

[29:39] them exercises to do at home to help to get their balance back in tact.

[29:44] Occasionally, some patients will get vestibular therapy to help with ringing in the ears.

[29:50] Again, ringing or tinnitus is one of those things that can be very difficult to treat.

[29:56] Sometimes depending on the etiology of the ringing in the ear, sometimes a vestibular therapy can help.

[30:01] Sometimes it may not be as effective for patients. That, in essence, is the goal of vestibular therapy is for

[30:08] to help a patient get their vestibular function back in tact. When it comes to head injuries, why is

[30:14] getting an evaluation care early so important? The most important thing is to help with your recovery so that you recover sooner.

[30:24] And, you know, sometimes patients will they may minimize their symptoms and say, OK, well, no, this is that big deal.

[30:31] It may not be OK, but then three, four months later, they’re still experiencing symptoms and some patients may not know.

[30:38] And it’s a little lifestyle changes that you can make. Staying well hydrated. I tell my my younger patients, my teenagers and my 20 year olds for whatever

[30:47] reason, they don’t like drinking water these days. Like, no, you have to hydrate. Dehydration can aggravate your headaches as well as the dizziness.

[30:55] And you want to feel better. You have to avoid prolonged fasting. You know, prolonged fasting can aggravate the headaches and the dizziness.

[31:02] And then you also want to make sure that they don’t do anything to aggravate those symptoms.

[31:07] I had one patient. He was such a sweet kid, but bless his heart.

[31:12] I think he had an accident on a Thursday or Friday and then decided to go to Six Flags and get on a roller coaster.

[31:19] So not only are we having the brains shake around inside of the skull, but then you’re doing the neck also.

[31:27] It’s so little things that patients don’t know to avoid that could potentially exacerbate their symptoms.

[31:34] So going to ride roller coasters after a head injury. Absolutely not. Absolutely not.

[31:40] So what are some potential red flags after a head injury, big or small, that

[31:46] someone should not avoid or ignore rather? So like I said, the headaches are a big one.

[31:53] One thing that a lot of patients don’t want to ignore are the cognitive deficits,

[32:00] especially if it starts to interfere with your activities of daily living and your job.

[32:06] I have a patient now that’s an accountant. And one of the things she talked about are numbers.

[32:12] Of course, an accountant, numbers are something that’s important with her profession. And she noted that it’s hard for her to remember numbers.

[32:21] And she’s finding herself having to repeat numbers oftentimes inside of her head. And then she’ll just forget them immediately.

[32:28] And it’s when you have certain deficits to start to interfere with your livelihood. Like, of course, no one wants an accountant that can’t count their money.

[32:38] That’s not for the accountant as well as the client. Seems like a bona fide qualification.

[32:45] Exactly. So yeah, you want to make sure that you have that aspect.

[32:50] There are certain things you don’t want to ignore that could interfere with your quality of life.

[32:56] So when it comes to accidents of varying kinds that result in head injuries,

[33:03] it seems that headaches are a very common complaint. Yes. Would that be appropriate to say? Actually, the most common complaint, yes.

[33:10] And so how do you think about headaches in the context of some kind of accident

[33:15] that somebody might have gone through, whether it’s irrespective of how that happened?

[33:21] But how do you think about headaches in that context? So you want to talk to the patient and assess the specifics of the headaches.

[33:30] Where are the headaches located? Are they sharp? Are they throbbing? Do they radiate, Skeleone and 10?

[33:35] What works? Are there medications that help or do not help? Are there other associated symptoms?

[33:40] Do they have sensitivity to light, sensitivity to sound, blurry vision, floaters?

[33:46] All of those things you want to take into consideration before you come up with a treatment plan.

[33:51] So the headaches are located in the back of the head. That’s more also associated with occipital neuralgia.

[33:58] Common manifestation of patients hit their head on the headrest. And I have literally had two patients this week that had hair clips in.

[34:06] And so when they hit their heads, their clips hit the back of their head. One patient’s feet had her clip actually broke.

[34:12] And so now their headaches are primarily in the back of their head. You have a couple of patients that they are,

[34:19] because they’re in pain, they may grit their teeth. The temporalis muscles here on this side are

[34:25] responsible for one of the muscles of mastication. So if they’re getting their teeth, that can cause

[34:30] temporalis tenderness or they can irritate their temporalis muscles. If the headaches are more diffuse, then you’re probably

[34:38] going to focus more on prescription medical management. Because with the occipital neuralgia and the temporalis

[34:44] headaches, you can treat those with simple injections. But if someone has a diffuse headache, unfortunately, short of Botox injections,

[34:52] you can’t inject them all over their head. So you want to collect in history, see if they’re associated symptoms.

[34:57] If they had one patient that had floaters, so she responded well to a lot of medications, that’s one of the medications that we often use for headache prevention.

[35:06] So you actually mentioned Botox for headaches. What other types of procedures or injections might you

[35:12] either recommend or do to someone who’s suffering from headaches? So the three most common ones are the occipital nerve blocks for posterior

[35:20] headaches, the temporalis trigger point injections for patients that have temporalis headaches. And not uncommonly, you can actually feel like a

[35:27] trigger point or spasm in their temporalis muscles. And then there are Botox injections.

[35:33] It’s a series of 31 injections of the muscles around the head and neck that you

[35:40] oftentimes reserve that for patients that have headaches that are refractory to medication, as well as those simple injections.

[35:47] So when it comes to the occipital nerve block, what does that do? And what’s the benefit of that? So I love occipital nerve blocks because they’re quick, they’re simple, and they

[35:57] typically knock out the headaches like that. And so what you do, again, in the back of the head, there are occipital nerves,

[36:04] there’s one on each side where they exit the skull and the occipital nerve actually

[36:09] radiates for to give soft branches to supply sensation to the scalp. And telltale sign is if you press at their cranial cervical junction or where their

[36:19] head and their neck meet, they’ll have tenderness. I jokingly tell patients, I call it the heifer stop sign.

[36:25] So when you press that area, the patient wants to say heifer stop. So if you have that positive sign, then you know that that’s your target.

[36:33] And so once you inject it and literally they walk into your office with a headache,

[36:39] they walk out and they say, man, my headaches gone. Really quick and really simple.

[36:45] So what about trigger points? What how does that differ from the occipital nerve block? And what kind of a patient might benefit from that?

[36:52] So trigger point injections specifically that I mean, they’re different trigger point injections. I’ll do them, of course, in the bigger muscles like the

[36:58] trapezius and some of the semi spinalis muscles in the neck. But specifically temporalis trigger point injections, similar premise.

[37:05] You press on the side of their head. Sometimes you may feel a trigger point or spasm in their temporalis muscles.

[37:11] If their headaches are here, not uncommonly a patient will tell you that I have headaches across here and they come into your

[37:17] office and you press in their temporalis muscles. You press here and then the headache radiates forward because again, the temporalis

[37:24] muscle sits like there’s one on each side. They sit like fans on the side of your head, on the side of your skull.

[37:29] And so if you again find that area of maximal tenderness, potentially the trigger point you inject it again, knocks the headaches out.

[37:36] And the main differences are your targets. So with the trigger point injection, you typically are targeting muscle or the

[37:43] muscle spasm itself, whereas with an occipital neural or occipital nerve block, you’re targeting the occipital nerve, that area

[37:50] of irritation where the nerve is exiting the skull. Not uncommonly because you have muscles that lie on top of that occipital nerve.

[37:59] You have occipitalis muscles that sit on top of them. Those muscles can be tight and tense. And so when you put the needle in, you can

[38:06] hear a crunching sound and muscle is soft tissue. It’s not supposed to make a crunching sound.

[38:11] And you can tell that’s likely where they have a spasm sitting on top of their occipital nerve. It’s irritating it, thus leading to their occipital headaches.

[38:19] And with that nerve block, for example, would that help that patient longer term?

[38:26] Yeah, in oftentimes, in my career, my goal, I tell my patients jokingly, you know,

[38:33] if you come in and get an injection, the next time I’d rather see you is at like Kroger or Publix.

[38:38] I don’t want to if I’ve seen you in my office again for headaches, that means I haven’t done my job.

[38:43] In my career, I’ve only had to repeat it a handful of times because many times you

[38:49] do the injection, depending on the type of medications you use, use a short acting analgesic, a long term, a long acting analgesic, as well as a

[38:58] mild like steroid, topical steroids, so it doesn’t go systemic. So patients don’t have to worry about all the bad side effects that come with oral steroids.

[39:06] But yeah, you do it and you make sure you get that target area. And that’s really important if you’re going to inject someone because, of course,

[39:15] patients oftentimes are nervous because they think, OK, you’re putting a needle in my head and they equate head to skull, like no or head to brain.

[39:21] Like, no, I’m not putting a needle in your brain. Your skull is there. It’s going to protect your brain. My goal is to target those because what happens is those muscles are compressing

[39:31] those sensory nerves or those scalp nerves and irritating them. So my goal is to get rid of their pain and see them out and about in public.

[39:38] So it seems that those are those those types of procedures and treatments are very effective. Yes, very much so.

[39:44] So I think a lot of folks might be surprised to hear the term Botox used in in your

[39:51] line of work, because a lot of times that I think most people associate Botox with beauty spas and that use case.

[39:59] Yes. So why is Botox so effective in treating certain certain types of headaches?

[40:05] So when especially when patients have diffuse headaches, there are refractory to prescription medical management.

[40:11] Botox targets all of those muscles again in the head and neck. So you get the temporalis muscles, the frontalis muscles, the occipitalis muscles.

[40:20] And then oftentimes patients will note tension in their neck. So you also get the neck muscles as well as the trapezius muscles.

[40:27] So you’re helping to relieve a lot of that tension, especially when the headaches are more diffuse.

[40:33] The tension that’s in those muscles that are surrounding their head. And many times, again, once you do a good Botox, if you do it effectively, it

[40:42] knocks it out and just comparing the differences. So when someone does cosmetic Botox, it’s only a few

[40:49] units in certain areas and certain muscles in the face. Whereas with Botox for migraines, that’s again, it’s

[40:56] a series of 31 injections around the head and neck. So it’s a lot more injections. And but the goal, the goal is also different.

[41:03] So with cosmetic Botox, you’re trying to get rid of wrinkles. You know, Botox for migraines or medical

[41:08] Botox, you’re trying to get rid of headaches. And there are other indications like cervical dystonia, hyperhidrosis, but I won’t get into those.

[41:14] But yeah, the goals are different and the treatments are different. But a lot of times for like, especially my female patients, when they come in for

[41:21] Botox for migraines, for medical Botox, I said, hey, you know, got this Botox here.

[41:27] We’re going to take care of your migraines. However, anything else you want to take care of, you’re like, OK, yeah, well, do this and do that.

[41:32] And then I’ll just throw that in for them for free. I’m sure your patients love you for that.

[41:37] Yeah. And I try to make sure that it lasts long enough. It’s like, this lasts like six months where some places you go to certain spas, the

[41:45] Botox effects last four to six weeks, which is not supposed to be the case. But yeah, it’s just wearing off.

[41:50] It’s been a while. So yeah, I try to knock out two birds with one stone, the headaches as well as the wrinkles.

[41:57] Talk about a tremendous selling point. So what should your patients know about the timelines

[42:03] for a Botox treatment for on the headache side, obviously? On the headache side. So if you listen to the commercials, they’ll tell you that

[42:12] it’s indicated for migraines, for chronic migraines. And treatment is recommended every three months.

[42:19] Again, I try to be so when I because with Botox, we

[42:24] have to do something called reconstitution and mix it. I try to mix it so that my patients again don’t have to see me that often.

[42:33] I mean, in some sometimes in some patients, some providers may over deluded just to

[42:38] have them come back sooner and charge more money. But again, I’d rather see my patients smiling at Kroger or in Publix or somewhere else.

[42:47] So the goal is to make sure that when they come in and get the Botox that it really

[42:52] knocks out the headaches and is effective for them. And is it a one time procedure or is it require multiple sessions?

[42:59] It’s usually once every three months. Yeah, but sometimes sometimes I have patients that stretch out four to six months.

[43:06] What about something like a CGRP blocking agents? Is that is that something that you can talk about?

[43:12] Yeah, so see our Casa tonin gene related peptide inhibitors.

[43:17] So those are some newer medications that are on the market that have come about within the past, maybe I guess maybe five to 10 years.

[43:23] And so the CGRP, the actual protein itself, it’s targeted because that protein is

[43:30] thought to what we refer to as a vasodialate or cause blood vessels in the brain to expand.

[43:36] Is the primarily pathophysiology behind migraines or headaches. And so what the CGRP inhibitors do is that they cause those blood vessels.

[43:46] So they inhibit that expansion of those blood vessels, thus limiting a patient’s headache, sometimes for prevention or take as needed.

[43:53] The primary issue with CGRP inhibitors these days is that they’re very expensive.

[43:59] And so if a patient is uninsured or has limited insurance,

[44:05] I typically won’t start with that because they are very expensive upwards to thousands of dollars per dose.

[44:13] I have a patient now that’s on one specifically and it’s an infusion.

[44:18] And I think the if you Google the cost, it’s like twelve thousand dollars per infusion.

[44:24] Wow. So yeah, they but that’s of course that’s infusion. They have the pills, they have the injection. So there are different types of CGRP inhibitors.

[44:31] So I’ll reserve that if I have to, because one of the important things, especially these days,

[44:38] is to make sure that you help the patient as best as you can in multiple ways. You help their headaches as well as your pockets because

[44:44] no one wants to pay thousands of dollars for medication. If they don’t have to have it. Absolutely. So but would you say it’s in your opinion, is this is this effective?

[44:53] Oh yeah, absolutely. Oh yeah, absolutely. I like the patient that I have, the one patient that I’m speaking about specifically.

[45:00] It’s been a game changer for her because she’s been on so many different medications

[45:06] that either didn’t help her migraines or she had side effects. So you have to make sure you document,

[45:13] okay, we tried this, this, this, this and this. So if you’re going to go to a medication that costs twelve thousand dollars,

[45:18] get to make sure you’ve tried all the other things first. But once we got her on that one, she’s been maintained beautifully.

[45:24] Wonderful. So it seems that that’s the kind of the end of the line in terms of treatment options for that particular patient and has worked for her.

[45:29] Yeah. And with this particular patient, she’s on a combination of things. So she’s doing Botox as well as one of the CGRP inhibitors because the oral

[45:37] medications just didn’t work for her or she would have side effects. So let’s let’s talk diagnostic testing.

[45:45] What what what are the most common tests that that you use in evaluating your patients?

[45:50] So I do a lot of traumatic brain injury. So I’ll order a lot of MRIs in depending on a patient symptom.

[45:58] If a patient is telling me that they’re doing better, they’re improving, then that may not be a patient that you necessarily need to order imaging on.

[46:05] But if a patient’s certain red flags and certain symptoms stand out to me that you want to make, especially if they haven’t had any imaging done, if they’re

[46:12] complaining of cognitive issues, if they’re complaining of visual symptoms, if they’re complaining of balance issues,

[46:18] you want to make sure that there’s no evidence of any type of bleeding or structural lesion in their brain. Again, especially if they haven’t had any imaging done.

[46:26] Sometimes I’ll order an EMG nerve conduction study if patients have numbness in their hands. What happens oftentimes when patients are in accidents, their whole steering wheel

[46:34] and a sudden hit will affect their median nerve. So you may get an EMG nerve conduction study.

[46:41] And then there are other tests as far as concussions that are out there that depending on the patient and the symptoms may order.

[46:48] Sometimes patients will have video nystagmographies or eye box testing for their concussion symptoms or they already had it in their test is positive.

[46:56] So then they’re referred to me. So you mentioned eye box. What is that? What is that intended to test?

[47:03] So eye box is one of the few FDA cleared diagnostic tests specifically for a concussion.

[47:10] It’s really simple. You sit down, you and you watch the video for four minutes. And as you’re watching the video, there’s monitoring of your eye movements.

[47:19] And there’s a lot that you can tell with eye movements after a patient has had a concussion, the eyes don’t move the same.

[47:25] There are certain things we look at called saccades or abnormal eye movements or nystagmus if they’re jerky eye movements or if they’re not moving their eyes

[47:33] smooth, if they have interruptions in their eye movements. So you can tell a lot with looking at something like the eye box that even as a

[47:39] neurologist, if you look at their eye movements, it may seem normal. But then you put them in the eye box testing, they’ll detect those minute

[47:46] abnormalities that just you can’t see with the naked eye. And again, using that as a data point to

[47:52] then continue your investigations of detectives. Correct. So what about a VNG? What does that do? And what might that be useful?

[48:02] So VNG or video nystagmography, similar premise, a patient will wear special goggles and look at tracings.

[48:11] And again, it’s monitoring those eye movements and looking for those abnormal eye movements, as I mentioned before, abnormal saccades or nystagmus.

[48:19] Not uncommonly, the VNG is used when patients have vestibular symptoms. So VNG stands for videonystagmography.

[48:25] Nystagmography refers to the study of the vestibular system. So you want to see if they’re if they’re having symptoms like dizziness, if they’re

[48:33] having ringing in the ears, if they’re having balance issues. The goal is to see if their vestibular system is affected in the vestibular system.

[48:42] You have parts in the brain that are responsible for the vestibular system, but then you also have the inner ear structures, as I mentioned earlier.

[48:50] So you want to the VNG can tell you whether they have an abnormality in the brain, in their inner ear system, or sometimes it’s both.

[48:58] And not uncommonly, the VNG or video nystagmography can be abnormal, but their MRI brain can be normal.

[49:04] So it picks up those minute abnormalities that may not be visible on something like a structural, like a scan.

[49:12] And when what when might you recommend that? Again, oftentimes if they have vestibular symptoms, if there’s dizziness, if

[49:17] there’s ringing in the ears, if there are balance issues, those would be good patients and potentially for for VNG.

[49:23] Are there any other kinds of testing, diagnostic testing that you are seeing coming

[49:29] down the pipe, whether it’s experimental at this point, or just coming online that you find interesting or you think might be useful?

[49:38] So there’s a test that’s out now, but it’s typically used in the emergency room.

[49:43] It’s a blood test in the blood test test for two main proteins that test for GFAP.

[49:49] And I think it’s UCHL1, the primary issue with those, I shouldn’t say an issue, but

[49:56] those are typically reserved for emergency room because you’re because those levels are the highest within the first 24 hours.

[50:01] And then they kind of taper off after that. So in the reason that they’re using emergency

[50:07] room is to see whether a patient needs neuroimaging. So those levels are high.

[50:13] Then we’re like, OK, their levels are high. We may need to refer them to a CT scan to make sure they don’t have any type of intracranial lesion or bleeding or anything like that.

[50:20] But if those levels are normal, then more likely than not, especially if it’s done within the first two first 24 hours after

[50:26] injury, that could indicate, OK, this patient’s fine. Unlikely they have concussion. You don’t necessarily need to rush to scan them.

[50:32] But yeah, and there are other blood tests that are in the works that they’re trying to ascertain the best time to assess and test for them so that patients don’t

[50:41] necessarily have to go through anything invasive. You know, just get a simple blood test. And if the levels will high, that could be more consistent with concussion.

[50:49] It’s even a blood test, especially done in an emergency setting, would be a lot less costly. Absolutely, absolutely.

[50:55] The unfortunate thing is by the time they see me, they’re already a few days out from their injury.

[51:01] So the test unfortunately wouldn’t be useful in those situations. But there’s research going on to look for certain proteins that are released in the

[51:10] brain after any type of traumatic brain injury that you could assess long term. So you mentioned that when we spoke earlier that you’re certified in connection

[51:19] with NFL related evaluations and that you’ve you’ve worked with retired NFL players.

[51:24] What has that experience been like for you? It’s been eye opening. And I’m a football fan, I admit it.

[51:34] And seeing these players that you especially some of the ones you grew up watching

[51:40] and then they come into your office and your life. That must be surreal. It is especially the idols and it’s and I’m a Tennessee Titans fan.

[51:49] And so I remember the Super Bowl years back when the Rams were in St. Louis and St.

[51:56] Louis played the Titans in the Super Bowl. I’ve seen a couple of those those St. Louis players. I’ve seen a couple of the Titans players.

[52:03] So it’s been surreal. You know, it’s eye opening. But it’s also humbling.

[52:08] And it’s one of those things that I it’s humbling.

[52:14] I don’t take it for granted because you see these men, they’re strong.

[52:19] And of course, I’m only five feet, 120 pounds. So you got this guy that’s six, seven that’s coming in your office, but he’s not who he used to be.

[52:28] And, you know, you feel for that person, especially seeing them on the screen to being in your office and you feel for them and you want to

[52:34] do what you can to help them because they’re not even there. It’s genuine. Yeah, it’s genuine.

[52:40] And so you just see them and just like, man, let’s see what we can do to help you feel better. So what are some of the unique challenges in

[52:47] evaluating retired former professional athletes?

[52:52] For me, I think and, you know, again, I don’t take the job for granted.

[53:00] And I was raised by my dad. I’m a daddy’s girl and my dad has two brothers.

[53:06] I have three brothers of my own. So you’re used to men that are rough and rugged.

[53:12] And that’s how my family, the men of my family are. They’re mentally men. I’m not going to take a pill unless the limb is falling off.

[53:21] I’m not going to do anything, you know, because it seems very common for men in principle.

[53:26] Chromosome is interesting, but these men are used to toughing it out. And so what you try to do is share with them like,

[53:34] hey, you don’t necessarily have to be so tough and rugged. Let’s talk as a team to see what we can do to get you feeling better.

[53:43] You’re going through this. It’s there. We can’t change it, but let’s see what we can do to help you feel better.

[53:49] And it’s a matter of talking to them. You know, one of the biggest things, Parkinson’s is one of those diagnoses that

[53:55] some of the quite a few retired players are diagnosed with. And, you know, they’re like, I don’t want to take anything.

[54:01] OK, you don’t have to. A couple of months later, I fail. The wife says he’s fallen. Like, OK, are we ready now?

[54:07] So, you know, it can be a humbling experience, not only just for me, but them also to say, hey.

[54:14] And you also want to because some of these guys are still in the public eye, you know, and I know some of them are, you know, football season is coming up.

[54:21] They do a lot of the tailgates. They’re get college football season. Some of their sons are playing college football.

[54:28] And so my goal is to say, hey, I want to make sure that if you’re in the public eye, no one is looking at you and feeling sorry for you.

[54:36] And to be present yourself as normal as possible so that people don’t question you

[54:41] so that the only people that know what’s going on are, you know, your wife, you and me. No one else has to know.

[54:48] So what has that taught you about vulnerability?

[54:55] It’s one of those things where you talk to me. It’s OK to be vulnerable.

[55:01] And again, that, you know, I’m a daddy’s girl. I kind of I grew up as a tomboy.

[55:06] I grew up climbing trees and, you know, fight. Well, I had my cousin and his friends. I grew up. He’s a boy and two of his friends.

[55:14] And I used to fight. So I grew up tough. And, you know, as you get older and things start to happen, you learn, hey, it’s OK

[55:26] to be vulnerable, not just vulnerable, humble, because then people are more willing to help you if you accept that help.

[55:33] And you and a lot of these guys are totally amazed and surprised. Just a little intervention here and there in their life can make a difference.

[55:42] How do you how do you help these these folks who are literal giants to help to heal both mentally and physically?

[55:53] I talk to them. First of all, you talk to them as they’re humans. They’re, you know, they’re men.

[55:58] I don’t I make it a point to because, again, being raised around men, you don’t want to belittle them. You don’t want to baby them.

[56:04] You talk to them like, hey, this is what’s going on. Direct, straightforward to the point. And you make it a team thing.

[56:11] You don’t you can’t. I cannot tell this six, seven, 350 pound man, hey, you’re going to do it.

[56:21] And you can’t do that. And so you make you because they’re used to being on teams.

[56:27] So you talk to them as if you’re part of their team. Hey, these are your options.

[56:34] What sounds good for you? What are you willing to do? What can we do together? What can I do to help you?

[56:39] So you make it a team effort in order to make them feel better. As a neurologist, as a professional, what should the public understand about the

[56:49] long term impact of repeated head trauma? Oh, that’s that’s a heavy question.

[56:56] So I think a couple of days ago, there’s a study. They just published a study that said one and four, because of course they have the

[57:05] studies going on where they did the biopsies in regards to the brain. Some of the retired players have donated their brains to science.

[57:12] And one and four were found to have CTE. Which is? Chronic traumatic encephalopathy or the

[57:18] trauma that results from repeated head trauma. And it’s it’s a serious.

[57:25] It’s it’s serious. It’s there. And depending, you know, if you choose to go

[57:32] into the profession, that’s a risk that you take. And one of the things that, you know, in the program and the they’re talking about

[57:41] their things that are in the research and coming down the pipeline where they’re attempting to lessen this risk, which is absolutely awesome.

[57:51] Unfortunately, the guys that already have it, it’s just a matter of making them feel better.

[57:56] And helping them through what they’re going through. But it’s something that is a risk that’s, you know, as again, football season is

[58:05] coming up on us, you know, high school college and all and beyond and so forth.

[58:12] That’s a risk that you have to be willing to take. But it’s important to take care of yourself, take care of your brain also, you

[58:19] know, and just take care of your body, you know, do the cognitive exercise, this reading.

[58:24] Do things that are simulating. Stay active. I encourage a lot of my retired NFL players, you know, as best as you can and bless their hearts.

[58:31] A lot of them, they’ll come in. They’ve had certain they’ve had several surgeries, their knees or backs or joints.

[58:37] All of these things are aching them and you try to see what you can come up with as

[58:42] a team in order to help them feel better so where they can still remain active and get through the pain.

[58:48] It’s not it’s not easy. It absolutely is not easy, but you just give them strategies to help them cope with that.

[58:55] So let’s talk a little about dementia. You mentioned that earlier. What is the difference between dementia and let’s say Alzheimer’s disease?

[59:03] All right. And that’s a that’s a misconception that there are two different things.

[59:08] So you have a broad category of dementia and underneath dementia, you have different subtypes.

[59:15] So the one that people are most familiar with is Alzheimer’s dementia. There are other subtypes.

[59:21] So there is vascular dementia, which can result if people have ever a person has had multiple strokes.

[59:26] There’s something called FTD or frontal temporal dementia, where there is disinhibition, where they can still be fairly functional.

[59:34] But it affects the frontal lobe and the temporal lobes. The frontal lobe is part of its function

[59:41] is to prohibit you from acting impulsively. And so frontal temporal dementia patients are very impulsive.

[59:50] I jokingly have one patient that I used to treat years ago that had frontal

[59:56] temporal dementia and she would walk in and curse me out. And I’d be a lot of B words, which you have done.

[1:00:02] You can’t take it personal because they’re disinhibited. And her daughter was her daughter.

[1:00:08] Everyone was B words. Her daughter was the staff was my M.A. Everyone was a B. So and so that’s another subtype.

[1:00:15] Then you have Lewy body dementia. There’s a show years ago that I used to love the show that Chelsea Grammer played a

[1:00:22] mayor of Chicago that had Lewy body dementia where he’d have these hallucinations and have a tremor.

[1:00:28] It’s under it. It can have some Parkinsonian features, but the hallucinations is what typically sets it apart from Parkinson’s disease.

[1:00:35] So there are a lot of different types of dementia. Just Alzheimer’s is the most common one. So what are some early signs that families and patients should not ignore?

[1:00:46] So the most important thing is when their cognitive issues interfere with daily

[1:00:53] living, leaving the stove on while they’re cooking and walking away, getting lost while driving to a familiar location.

[1:01:01] If you’re used to going to a certain Kroger every day and all of a sudden you go to Kroger and you can’t get back home, you get lost while driving home.

[1:01:09] Definitely those are very rare flights. Or as far as cooking, putting certain ingredients in the food that don’t belong.

[1:01:17] There’s a commercial out where they show the mom or grandmom putting salt in while she’s making up high.

[1:01:23] So certain things like that where the cognitive deficits interfere with your activities of daily living.

[1:01:29] And people joke and say you may have some word finding difficulty or forget certain people’s names.

[1:01:34] Now my grandmother love it or that she’s 89. Oftentimes I’ll come home and she’ll say, “Hey, girl.”

[1:01:43] Wow, that hurts. She’s 89. Definitely giving an 89-year-old grandmother.

[1:01:49] But she still cooks, she still cleans, and she’s still extremely functional.

[1:01:55] So I don’t take offense that I’m girl occasionally. So you have those.

[1:02:00] There’s a precursor called mild cognitive impairment where you’ll have some word finding difficulty or certain things.

[1:02:05] But that transition from mild cognitive impairment to dementia is when it starts to interfere with activities of daily living.

[1:02:13] Like patients forget to take their medications and blood pressure goes high. So there are all those little things.

[1:02:19] Those are the warning signs that, hey, it’s time to intervene. And by intervene, you mean to see a specialist?

[1:02:24] Absolutely. And hopefully begin on a path to treat the symptoms if possible.

[1:02:30] Absolutely. So what should families do if they’re worried about memory changes in their loved one?

[1:02:38] That’s a hard conversation. And I say that because I’ve seen it as a provider as well as in my family.

[1:02:50] So not uncommonly, the family member may not be receptive to what you’re saying to them.

[1:02:57] I oftentimes encourage, you know, persons and family members. You don’t have to necessarily be gentle and sugarcoat it, but don’t be rough.

[1:03:07] You know, you can’t say, “This is going on!” Or you can’t fuss. You can’t be demeaning.

[1:03:13] You can’t be forceful. Nice sit down, have a conversation. You know, what’s the old show where they would have intervention?

[1:03:22] Where you’re going to have all the family come down and everyone expressed what

[1:03:27] they’ve seen and things that have happened. And I think it’d be a lot more receptive to the person that’s affected versus

[1:03:34] finger pointing and talking to the person as if they’re a child. To be constructive and gentle. Absolutely.

[1:03:41] What are some of the lifestyle choices that someone might make to hopefully decrease their chances of dementia?

[1:03:49] If you’re aware of any studies… Oh yeah, I mean, conservative management. Controlling those risk factors.

[1:03:54] Diabetes, high blood pressure. Making sure that if you’re diagnosed with those disorders, you know, make sure that your numbers are controlled.

[1:04:01] Make sure your blood pressure is controlled. Make sure A1C is good. Cholesterol levels. Make sure that in studies have shown the higher LDLs increases your risk for

[1:04:09] stroke, but it also increases your risk for dementia. In all the things staying active, studies have shown 30 to 45 minutes of cardio

[1:04:18] exercise a day for three to four weeks can help to not only lessen your chances of

[1:04:23] dementia, but if you’re diagnosed, slow that rate of progression. Smoking.

[1:04:28] You know, of course, that’s one of the things that has been shown to, again, increase the worst in those modifiable risk

[1:04:35] factors like high blood pressure and high cholesterol. Cognitive exercises. Reading. I encourage my patients to do Sudoku.

[1:04:42] Luminosity. Those little corny apps that you can download on your phone just to stimulate your brain.

[1:04:47] All of those things can help because, of course, the saying is, if you don’t use it, you lose it. So all of those little things can help with the electrical stimulation and help

[1:04:55] those neurons stay active so that they don’t degenerate. And it’s fun to talk about the retired football players.

[1:05:02] I love them to death because they’ll go to the gym and they’ll spend an hour doing weights. Like, what about your cardio?

[1:05:07] I hate cardio. Well, you’re bulky, but you’re still leaving a cell phone.

[1:05:12] You know, you have to do those little things. I know you hate cardio, but this is what has

[1:05:18] been shown to slow the rate of cognitive decline. So you just incorporate it. You know, baby said, you know, start 10 minutes, 15 minutes, go, you know, and a

[1:05:25] lot of them, their arms are bigger than my body’s. It was like, but yeah, you have to have cardio in there too to help to slow the rate of progression.

[1:05:32] Daily multivitamin, antioxidants and neuroprotective. So all of those are just conservative, everyday lifestyle things people can do to

[1:05:38] not only lessen their chances of developing the disease, but also if you’re having

[1:05:43] those signs to help to slow the rate of progression. And cardio doesn’t necessarily mean hours of hill spreads.

[1:05:50] You started a light jog or bike ride. I say baby steps, you know, but I started working out.

[1:05:57] I would do a little bit of cardio, but, you know, I’ve increased it now. So I was like, OK, as long as I stick with it

[1:06:02] and be consistent, you have to be consistent. You can’t, you know, do two miles one day and

[1:06:08] then your next two miles is four or five months down. You have to be consistent three or four days a week.

[1:06:14] Well, we spoke earlier. You said a very interesting thing. And that is this, that you are the gatekeeper for your care and your health.

[1:06:23] And I’m a participant. Absolutely. What do you mean by that? So when it comes to a person’s health, you have to be responsible for how you get

[1:06:37] better in your care, because as a physician, you know, we’re physicians, we’re not dictators.

[1:06:42] We can give our recommendations until we turn blue in the face. But as a patient, if you’re not willing to comply or listen or follow certain

[1:06:53] recommendations, then it’s, you know, it’s futile. What we’re saying is futile.

[1:06:59] And that’s why I said earlier, I try to when I talk to patients about their care, I give them options.

[1:07:05] I don’t say, well, you’re going to do this. You know, you listen to a patient, you listen to people talk. And I pick up if someone says, well, I don’t like taking medicine.

[1:07:13] I’m like, OK, well, I’m not going to prescribe. You know, that’s the first thing in my hands. I’m like, well, I’m not going to try to prescribe you anything because I know you’re not going to take it.

[1:07:19] You know, you listen to your patients and you give them options. You know, when a patient comes in, for example, with headaches, I said, OK, OK,

[1:07:26] there’s non-prescription medical management. There are supplements I oftentimes recommend. There’s prescription medical management.

[1:07:31] And for patients that are having multiple symptoms like headaches, insomnia,

[1:07:36] anxiety, there are a couple of medications that are my go to. So say, hey, we can potentially treat these three or four

[1:07:44] symptoms with one medication, if you’re willing to try it. If you don’t want to do that, if you don’t want to take any pills at all, then

[1:07:50] that’s when we talk about the injections, occipital nerve blocks, the Botox and the Peralis sugar point injection.

[1:07:56] So you give patients options and you, since the patient is that gatekeeper,

[1:08:02] gatekeeper, I’m sorry, you allow that patient to make an informed decision as to what they feel comfortable doing

[1:08:09] in regards to their health care. In reason. Absolutely. I’ve heard some things where a patient will say, well, I’m going to go and do this.

[1:08:16] Then a couple of weeks later, it’s like, well, that didn’t work. I was like, OK, and you don’t judge, you know, let you try it.

[1:08:23] And it’s kind of like as a parent, you know, your kid is learning to walk, you let them fall a couple of times and they eventually they’ll get it.

[1:08:28] As long as they’re not, you know, like bumping their head or anything. As a parent, I can definitely relate to that.

[1:08:35] Yeah. But my daughter, when she learned to walk, you know, of course, the grandparents would run and get her like, no, no, no.

[1:08:40] You know, first, you know, with me, she’ll fall and I was like, shake it off. And then she learned to get up and just start shaking it.

[1:08:46] So, yeah. So do you see yourself adjusting your recommendations to the patient and what you see in front of you?

[1:08:56] Absolutely. And again, you have to, again, work as a team with your patient.

[1:09:02] If your patient tells you, well, I don’t like taking medications, I don’t want to take medications, then you say, OK, well, we don’t

[1:09:08] have to do meds, especially if there are other options. Let’s potentially try the injections or let’s try these non-prescription options to

[1:09:16] see if that’ll help and give you relief and we’ll go from there. Sometimes it helps, sometimes it doesn’t.

[1:09:21] If it doesn’t help, then you just bring it back up. But you don’t force those options on the

[1:09:26] patients, especially if they’re not comfortable with it. What can a patient do, especially a new patient, to

[1:09:33] prepare better for an appointment to see a neurologist? Oh, that’s simple.

[1:09:38] Know your history. You’re right. Know your medications. Yeah, know your history and know what meds you’re taking, because again, as a

[1:09:49] provider, if there are options, if you’re telling me you have symptoms and there are potential treatment options, but you don’t know what meds you’re on,

[1:09:57] I can’t prescribe something because there’s going to be a risk of drug-drug interaction, which in certain cases can be lethal interactions.

[1:10:05] So, yeah, be in tune with yourself, your body. Know what’s going on.

[1:10:11] Know your history. Know what happened. Know what meds you’re taking. And then as a team, we can make an informed

[1:10:16] decision as to what you’re comfortable with. If you could change one thing, just one thing, about health care in America,

[1:10:26] what would that be? Oh, Lord. So I really wish that everyone in health care could get on one accord.

[1:10:40] Oftentimes, it seems like everyone’s fighting against each other. So we have the health insurance companies that are

[1:10:47] denying the medications from the pharmaceutical companies. The pharmaceutical companies may have the medications too expensive.

[1:10:53] Then you have insurance companies denying treatment for doctors. Once we recommend a treatment, the insurance companies could deny it.

[1:11:01] Then you have the hospital systems, which have prices that can be pretty expensive.

[1:11:06] Subsequently, us as treating doctors, we’re like, hey, that’s too expensive and that shouldn’t happen.

[1:11:13] There’s a lot of division in health care, which is unfortunate. I wish the American health care system could, all of us could meet in a room and

[1:11:25] come up with a solution to help America as far as their health. The country would be such a healthier place if we could all find a way to allow

[1:11:37] patients to be healthy and to live long lives, but still be productive members of society.

[1:11:44] Of course, everyone has their business. I understand that, but financial gain should not be the ultimate goal.

[1:11:54] Healthy Americans should be the ultimate goal. That’s a very noble one. It’s a very noble one. And it seems that aligning all the different constituencies is possible.

[1:12:05] You think it’s possible? Well, maybe, maybe, maybe not in our lifetime. Yeah, exactly.

[1:12:11] But that would be a wonderful goal. If you could have just one takeaway from this conversation that we’ve had for

[1:12:21] someone to take home with them and hopefully benefit themselves, what would that be?

[1:12:27] What would that takeaway be? Neurology is an ever-growing field.

[1:12:34] It’s an unfortunately, patients are scared when they have to see a neurologist

[1:12:41] because they think that’s their brain and they may know someone that has been affected by a neurologic disorder and that scares them.

[1:12:50] It’s not something to fear. If you’re having neurologic symptoms, don’t be afraid.

[1:12:55] Don’t be scared. There’s a vast amount of options to help

[1:13:02] you get through whatever you’re going through. So if you notice something, talk to someone. If you’re scared to make the phone call, have someone else make the phone call for

[1:13:10] you and you can start their process of growth in preserving your brain and your body.

[1:13:15] Dr. Green, thank you very much for sitting down with me to have this conversation.

[1:13:21] Really appreciate your time. Thanks for having me. Thank you very much for watching. We hope you found this to be interesting and helpful.

[1:13:28] Please like and subscribe. And if you’d like some more information about Dr. Green and Green Neurological and Medical Consulting, that information appears below.

[1:13:36] Thank you very much.