Latest / The Driven Athlete / Headaches, Stress Connections, & Treatments w/ Dr. James Ghattas | Ep 54

Transcript

Headaches, Stress Connections, & Treatments w/ Dr. James Ghattas | Ep 54 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: That sounds good.
• 0:16
  Speaker 1: Yeah, nice, what's up y'all?
• 0:20
  Speaker 1: It's your man, dr Kyle.
• 0:22
  Speaker 1: We got Dr Gaddis back in the house with us.
• 0:24
  Speaker 1: Thanks for coming in, man.
• 0:26
  Speaker 1: I know you're a busy dude.
• 0:28
  Speaker 2: It's all good man, it's nice to get a little break.
• 0:31
  Speaker 1: Yeah, from the clinical patient side, nerd out on some stuff.
• 0:34
  Speaker 1: Yeah, nerd out a little bit Good.
• 0:36
  Speaker 1: And headaches we're going to nerd out on headaches this time.
• 0:40
  Speaker 1: Your neurology background has served you well in diving into this subject matter.
• 0:46
  Speaker 1: Yeah Right, because you did a neuro, a lot of post-med school neuro training Word certified in neurology.
• 0:53
  Speaker 2: So I did four years of neurology residency.
• 0:55
  Speaker 1: Yeah, it's crazy.
• 0:56
  Speaker 2: Which is, you know it's fun.
• 0:58
  Speaker 2: Well, it's hard work.
• 0:59
  Speaker 2: Yeah, I didn't realize this going into it, but neurology call is like one of the most busiest calls, like second to cardiologists, because they're always getting chest pain call and you know, heart attack and stuff like that.
• 1:12
  Speaker 2: So the second most common emergency in the emergency room is a stroke.
• 1:16
  Speaker 2: I didn't know that.
• 1:17
  Speaker 2: Okay, there you go.
• 1:18
  Speaker 2: Yeah, so very, very busy training and then outside of like acute neurologic stuff in the hospital you have your outpatient neurology and a big proportion I would say 30 of the volume of your traditional neurology practice is headaches interesting.
• 1:36
  Speaker 1: Yeah, what of the what encompasses the other 70?
• 1:41
  Speaker 2: the other 70 would be things like epilepsy, so seizure disorders there's a whole host of different seizure disorders and then you have stroke.
• 1:53
  Speaker 2: You have to have outpatient care for stroke.
• 1:56
  Speaker 2: That's a big one.
• 1:57
  Speaker 2: From there it's like cognitive disorders which fall on a fall on a massive spectrum of things outside of just dementia.
• 2:08
  Speaker 2: But anyone with cognitive disorders and you got to figure figure out what's causing it, is it a dementia?
• 2:13
  Speaker 2: Is it not a dementia?
• 2:14
  Speaker 2: Is it something that's going to cause dementia?
• 2:16
  Speaker 1: Parkinson's, huntington's disease yeah, those all Okay.
• 2:19
  Speaker 2: Those fall under movement disorders.
• 2:21
  Speaker 1: Yeah.
• 2:22
  Speaker 2: And movement disorders have overlap with dementia right so parkinson's huntingtons, um, you know things like louis, body dementias, certain types of strokes can cause movement disorders, and then there's pure movement disorders like cervical dystonia and you know essential tremors, things like that interesting, uh, and then outside of it is a lot of like we don't know what's happening.
• 2:44
  Speaker 1: Ask the neurologist, yeah yeah, yeah, that's interesting man.
• 2:49
  Speaker 1: A four-year residency, and then you flipped the tables and then went orthopedics.
• 2:52
  Speaker 2: Yeah, well, not before I did pain management, so left neurology I shouldn't say left neurology Graduate neurology and then joined a pain management fellowship where it was unique because where I trained was one of the only neurology residencies that also hosted a pain management fellowship.
• 3:08
  Speaker 2: Every other pain management fellowship is either anesthesiology based or physical medicine, rehab based, which makes sense.
• 3:14
  Speaker 2: Pm&r guys these are musculoskeletal masters, and anesthesia guys are procedural masters.
• 3:20
  Speaker 2: They can put a needle anywhere it needs to go and they're also very familiar with the OR and procedural complications and things like that.
• 3:29
  Speaker 2: So neurology I was fortunate enough to get a lot of procedural training in my neurology residency, so it was kind of a natural progression.
• 3:38
  Speaker 2: But most neurologists, other than doing spinal taps, never really put their hands on a needle, so it's not typical for a neurologist to go into pain management.
• 3:47
  Speaker 1: Interesting.
• 3:48
  Speaker 2: Even more or less typical for a neurologist turned pain management doctor to go orthobiologics.
• 3:54
  Speaker 2: Yeah right so, and that I think I was able to make that transition because I'm a DO yeah, I have that osteopathic background and we learned a lot of physical and we really hammered down musculoskeletal anatomy.
• 4:07
  Speaker 2: So, yeah, I had some knowledge to pull back on basically Totally.
• 4:13
  Speaker 1: That's perfect.
• 4:14
  Speaker 1: It was an easier transition.
• 4:15
  Speaker 1: Yeah, Before we continue, remind everybody where you're at with your practice.
• 4:19
  Speaker 2: Yes, palm Beach Regenerative, sport and Spine yeah, just down the road next to Renegades.
• 4:24
  Speaker 2: Yep, yep, yep, yeah, it's off Palm Beach, lakes Boulevard and Village Boulevard and we're in a nice little office building there.
• 4:31
  Speaker 2: It has a little putt-putt green on the front.
• 4:33
  Speaker 2: Oh, cool yeah.
• 4:34
  Speaker 2: And we do non-surgical regenerative orthopedics, any sort of musculoskeletal care, entirely autologous, meaning using your own tissues, like platelets, bone marrow, concentrate which has your stem cells in it, and in some cases we use other stuff like prolotherapy, adipose things like that, pretty much whatever we need to tailor your treatment without using toxic corticosteroids and anti-inflammatories and so on.
• 5:04
  Speaker 1: Right For the goal of regenerating tissue and orthopedic dysfunctions.
• 5:09
  Speaker 1: Orthopedic issues Exactly Awesome.
• 5:12
  Speaker 1: Well, that's amazing.
• 5:13
  Speaker 1: And you just opened your practice a couple months, six months ago.
• 5:15
  Speaker 1: How long has it been now?
• 5:16
  Speaker 1: We just started month four, man Four, month four Awesome, that's awesome.
• 5:21
  Speaker 1: What a journey, I know A journey.
• 5:27
  Speaker 1: I learned a lot about how to build cabinets and lay down marble in the process.
• 5:30
  Speaker 1: That's good, getting a jack of all trades.
• 5:31
  Speaker 1: So today we want to talk about headaches, right, something that you mentioned before, passionate about and have a lot of exposure with.
• 5:40
  Speaker 1: Let's break down some of the types first.
• 5:43
  Speaker 1: Yeah, so I know some of the ones that we've been exposed to and very common things Hangovers, yeah, hangovers.
• 5:50
  Speaker 1: What is the cure for that Water?
• 5:52
  Speaker 1: Yeah, hangovers, real quick.
• 5:54
  Speaker 1: Yeah, explain that.
• 5:56
  Speaker 2: Hangover is two things.
• 5:57
  Speaker 2: It's dehydration, so your brain literally shrunk a little bit because it doesn't have enough water in it, and so it's tugging on the meninges, it's tugging on the wrapping of the brain, yeah, and that hurts.
• 6:08
  Speaker 2: It's also a buildup of one of the breakdown components of alcohol, which is called acetyl aldehyde, which is pretty toxic, and so that causes irritation of the nerves.
• 6:18
  Speaker 2: So, yeah, those two things Drink a bunch of water, get some sleep.
• 6:23
  Speaker 2: Electrolytes Electrolytes are good, yeah, because with a hangover and with dehydration you get this almost like hypertonicity of the muscles, especially in the neck, and so it's kind of tugging on the fascial planes of the skull and so that can give you headaches.
• 6:38
  Speaker 2: So take some magnesium and some Pedialyte and lay down with a pillow under your neck and drink a bunch of water and hopefully it goes away.
• 6:46
  Speaker 1: Watch some Netflix, watch some rom-coms?
• 6:47
  Speaker 1: Yeah, exactly, I'm loved.
• 6:52
  Speaker 1: I promise that's good to know.
• 6:53
  Speaker 1: Okay, cool, yeah.
• 6:54
  Speaker 1: So headaches we got a plethora of types of headaches which would indicate maybe causes and then how do we treat it?
• 7:05
  Speaker 1: Right um, cluster headaches, tension headaches, cervicogenic headaches, which is more orthopedic, kind of related um the migraine, right um, and then other ones that you were mentioned before.
• 7:17
  Speaker 1: There's types of headaches that um are a little more sinister than others yeah, right, yeah well, first, quick though, let's break down cluster versus tension, versus cervicogenic headaches.
• 7:28
  Speaker 2: Yeah.
• 7:28
  Speaker 2: So I think the easiest way to compartmentalize headaches is to think of at least this is how they teach you in neurology training is migranous and non-migranous.
• 7:37
  Speaker 2: Okay, with the migranous headaches that's kind of like the mother-of-all headaches and you're going to see mostly migraine headaches and those are.
• 7:47
  Speaker 2: They have some typical features, things like sensitivity to light and sound.
• 7:53
  Speaker 2: They can be unilateral or bilateral.
• 7:56
  Speaker 2: Typically they're unilateral, but they can switch sides.
• 8:00
  Speaker 2: That's an important feature.
• 8:01
  Speaker 2: Nausea is an important feature of migraines.
• 8:01
  Speaker 2: That's an important feature.
• 8:03
  Speaker 2: Nausea is an important feature of migraines and there's like a stereotypical form, meaning it's like you kind of most patients will know oh, this is my migraine.
• 8:12
  Speaker 2: Yeah, they recognize it, versus like they can tell if it's a tension headache or something.
• 8:17
  Speaker 1: I've also heard that they can tell it's coming about like the aura that comes with it.
• 8:21
  Speaker 1: Yeah, Is that something you dove into?
• 8:26
  Speaker 2: Yeah, aura that comes with it.
• 8:27
  Speaker 2: Yeah, is that something you dove into some?
• 8:27
  Speaker 2: Yeah, so some migraines have a very distinct aura, which is like you know.
• 8:30
  Speaker 2: They can get audio visual phenomenon or kind of other autonomic symptoms like rising gut feeling or sense of doom, things like that, okay.
• 8:41
  Speaker 2: Or they can get what we call scotoma, like like wiggly lines, that kind of you know, almost like you know, when you look at a hot desert road and it's shimmering, that sort of happens.
• 8:51
  Speaker 2: Or they can get like humming or whooshing or tinnitus in the ears.
• 8:54
  Speaker 2: That sort of lets them know it's happening.
• 8:56
  Speaker 2: Those are obvious auras.
• 8:59
  Speaker 2: But an aura is separate from what we call a prodrome, and a prodrome is like a whole other host of symptoms that sort of.
• 9:10
  Speaker 2: How do I say this?
• 9:12
  Speaker 2: If you can imagine like a tsunami, what's the earliest sign that a tsunami is coming?
• 9:17
  Speaker 1: The water gets retracted.
• 9:18
  Speaker 2: Yeah, water goes all the way out, and that may happen hours or days before the tsunami actually gets there.
• 9:24
  Speaker 2: And so a prodrome is kind of like that.
• 9:25
  Speaker 2: It's like your body starts telling you symptoms that there's a headache coming, and it could be very subtle, it could just be some fatigue, it could be yawning, it could be like an upset stomach, difficulty concentrating or sleep disruptions.
• 9:39
  Speaker 2: Those are all prodromes, and so very intuitive migraineurs, people with migraines, will recognize like, oh you know, I've been having, you know, upset stomach and a hard time.
• 9:52
  Speaker 2: I've been like fogginess for the last couple of days.
• 9:54
  Speaker 2: I know a migraine is coming and so they'll be able to, you know, nip it in the bud.
• 9:58
  Speaker 1: Yeah.
• 9:59
  Speaker 2: So those are prodromes which are separate from auras, but they're not mutually exclusive.
• 10:03
  Speaker 1: Yeah, yeah, understood, interesting, okay.
• 10:05
  Speaker 1: So cluster versus tension headaches?
• 10:08
  Speaker 1: I've heard it's some stress related.
• 10:12
  Speaker 1: I've heard symptoms of like behind the eyeball like tightness, For cluster or for tension.
• 10:18
  Speaker 1: You tell me Well it's a little bit of both.
• 10:20
  Speaker 1: Okay.
• 10:21
  Speaker 1: Well, that's what we're here, yeah.
• 10:22
  Speaker 2: Okay, so outside it's a little bit of both.
• 10:25
  Speaker 2: Okay, well, that's what we're here.
• 10:27
  Speaker 2: Yeah, so outside of migraines you have these non-migrenous headaches and cluster headaches, and tension headaches are all non-migrenous.
• 10:35
  Speaker 2: Cluster headache actually falls into a unique subgroup of headaches, all on its own, called TACs, t-a-c or trigeminal autonomic cephalalgia, which is a mouthful.
• 10:45
  Speaker 2: So trigeminal meaning it's emanating probably from the trigeminal nerve system.
• 10:50
  Speaker 2: Autonomic meaning it exhibits features of your autonomic nervous system, which is like the involuntary part of your nervous system.
• 10:59
  Speaker 2: And then cephalalgia is just a fancy way of saying head hurts, head problem, head pathology yeah, exactly.
• 11:04
  Speaker 2: And so all those headaches have very distinct features, and one of them is they're always side locked, meaning you always get it on one side of the head, never switches sides.
• 11:16
  Speaker 2: Another distinct feature is they always have some sort of autonomic feature, meaning there's either flushing, so like change in vasomotor tone you know the motor tone of the blood vessels in your face tearing, runny nose, drooling or salivation, or like a blown pupil or a constricted pupil.
• 11:38
  Speaker 2: So all these things are features of your involuntary nervous system, so like sweating, salivation, crying you know the people tone and things like that.
• 11:46
  Speaker 2: So those things change.
• 11:48
  Speaker 2: Um, everything outside of that, uh, it varies in severity, frequency and duration.
• 11:58
  Speaker 2: So, like cluster headache we all know cluster headache is cluster headaches like the most severe Its duration could be anywhere from, like you know, a few hours to a few days and it typically happens in a seasonal pattern, meaning you know it may only happen a few times a year, but it's like always in the spring or it's always right before wintertime or something like that.
• 12:19
  Speaker 2: Have they dove into why that is.
• 12:22
  Speaker 2: They have, and I probably knew at some point and I think it has something to do with, like hormone profiles and your how your hormones sort of change in response to barometric changes and light changes and the circadian rhythm and and so on.
• 12:35
  Speaker 2: Interesting, uh, so I guess you could tie that back to the pineal gland.
• 12:40
  Speaker 2: Uh, and a certain nucleus in the pituitary gland which is sensitive to their circadian rhythm?
• 12:47
  Speaker 2: Interesting, yeah, so cholesterol headache is the most famous one because it typically affects I don't know why like high-functioning males.
• 12:58
  Speaker 2: That's what I've heard.
• 12:59
  Speaker 1: Yeah, it's always like your 35-year-old attorney, or something like that, probably under a lot of pressure, under a lot of stress, a lot of stress.
• 13:06
  Speaker 2: Which stress doesn't help anything.
• 13:08
  Speaker 2: Yeah, it doesn't help.
• 13:10
  Speaker 2: It literally makes every neurologic condition worse.
• 13:12
  Speaker 2: Yeah, so like when somebody says, oh, I think it's stress, I'm like, yeah, yeah, yeah, but what else is it?
• 13:15
  Speaker 2: Yeah, totally.
• 13:17
  Speaker 1: Something interesting I heard about stress like cause.
• 13:20
  Speaker 1: Eventually, once you work through all the types and stuff, asking like, what are the causes?
• 13:24
  Speaker 1: And then how do you treat these things right?
• 13:27
  Speaker 1: Headaches, migraines, all these things?
• 13:28
  Speaker 1: Yeah, what I've heard about stress is like the difference between stress versus anxiety.
• 13:32
  Speaker 1: Stress being, um, it usually comes about with from, uh, a lack of action.
• 13:37
  Speaker 1: So there's like a lot of options and, uh, not taking action.
• 13:41
  Speaker 1: Yeah, which, from an entrepreneur standpoint, or from a parent standpoint, or from a job and career.
• 13:46
  Speaker 1: It's like a lack of clarity then on what exactly would be the next best step to do, not unwilling to do it, but there's this inaction and not doing what to do.
• 13:56
  Speaker 1: So then imagine going home and be like I have so much to do and I've done nothing right, stress, inaction, and then anxiety.
• 14:03
  Speaker 1: I've always told was like it's the concern that I'm not going to be able to handle problems as they arise in the future.
• 14:10
  Speaker 1: Another one, another part of that would be another form of like being scattered, and then paralysis by analysis of like I have so many things and again, I don't know what choice to make.
• 14:24
  Speaker 1: Yeah, you're like, what do I start with?
• 14:28
  Speaker 1: Yeah, am I using my time wisely, exactly that.
• 14:29
  Speaker 1: And then that leads to like the future, future framing concern that I'm not gonna handle things as they arise in the future.
• 14:35
  Speaker 1: Like I'm so nervous, I'm worried, a worry ward right, we're a worrier.
• 14:39
  Speaker 1: I'm worried that, like, if this happens, I'm open to handle it.
• 14:41
  Speaker 1: So I thought I was.
• 14:43
  Speaker 1: I'm like, like, okay, how can I play this to my own life?
• 14:44
  Speaker 1: So it's interesting you say that.
• 14:47
  Speaker 1: That like imagine a high pressure someone ascending in their career, uh, stress, anxiety, pressure on career, and uh, a young individual that's trying to progress through that yeah, that makes another pen by the way, by any chance.
• 15:03
  Speaker 2: I was like I haven't kind of thoughts, yeah, that I want to jot down.
• 15:04
  Speaker 2: Okay, thank you.
• 15:04
  Speaker 2: I don't understand, ty.
• 15:05
  Speaker 2: Do you have another pen by the way, by any chance?
• 15:05
  Speaker 2: I have kind of thoughts that.
• 15:05
  Speaker 1: I want to jot down.
• 15:06
  Speaker 1: Ty, do you have one over there?
• 15:09
  Speaker 1: Can you toss me one?
• 15:14
  Speaker 2: Sorry, I didn't mean to disrupt the flow there.
• 15:16
  Speaker 2: Totally blow everything.
• 15:18
  Speaker 1: Exploding head syndrome.
• 15:23
  Speaker 2: I guess I could have just typed it on my no, you're good, All right, oh, thanks.
• 15:29
  Speaker 2: All right, sorry, no, I totally blew off your train of thought.
• 15:37
  Speaker 2: All right, sorry, no, I totally blew off your train of thought.
• 15:40
  Speaker 1: So well, what you're saying was is uh, cluster headaches, very famous, are very identifiable with, and it seems to affect males that um are wanting to be high performer, high achievers, under a lot of stress and stuff um, which makes total sense.
• 15:57
  Speaker 2: you know, yeah, and so when you're under a lot of stress, I think we sort of it's easy to lose sight of the other things, that sort of.
• 16:08
  Speaker 2: So yeah, okay, when somebody has got this like cluster headache, they're a successful person and they lead a stressful lifestyle.
• 16:15
  Speaker 2: What is it about the stressful lifestyle that's going to cause them to have a headache?
• 16:19
  Speaker 2: And it could be well.
• 16:20
  Speaker 2: If you're under a tremendous amount of stress, first thing that goes is your sleep.
• 16:23
  Speaker 2: You know whether it's voluntary or involuntary, meaning like you have so much work to do that you're pulling all-nighters.
• 16:29
  Speaker 2: Well, you're not sleeping.
• 16:30
  Speaker 2: Or if you're, you know you're working up until the wee hours of the night and then you just have to all of a sudden turn off the lights and go straight to bed and you're just laying there.
• 16:39
  Speaker 1: Ruminating yeah.
• 16:41
  Speaker 2: Just with your eyes wide open in the dark, thinking about everything.
• 16:43
  Speaker 1: Or waking up in the middle of night and being like I'm looking at the ceiling.
• 16:46
  Speaker 1: I can't sleep.
• 16:47
  Speaker 2: Yeah, exactly, and then you're trying to sleep and then grinding Dang it.
• 16:52
  Speaker 1: I've actually.
• 16:52
  Speaker 1: Unfortunately, that's never really been a problem.
• 16:54
  Speaker 1: Usually, if I'm lacking sleep, it's because I either do the revenge sleep against myself.
• 16:59
  Speaker 1: I'm like I'm staying up and watching football.
• 17:01
  Speaker 1: I'm not going to bed, like no.
• 17:03
  Speaker 1: And then I'm like gosh, I went to bed or playing all-nighters.
• 17:06
  Speaker 1: It's usually my thing.
• 17:07
  Speaker 1: I fortunately have not had the lack of insomnia type things of not going to sleep.
• 17:13
  Speaker 2: Yeah, man, I mean, for me it's like when I have tasks that need to get done, it's hard to get them done during the day, because you know there are things demanding your attention during the day.
• 17:22
  Speaker 2: And so the only time I get you know, a couple hours of just uninterrupted time is like two in the morning.
• 17:28
  Speaker 1: Wow.
• 17:29
  Speaker 2: You end up staying up pretty late, you know, yeah, so you have the sleep issues.
• 17:34
  Speaker 2: Then there are physical issues.
• 17:36
  Speaker 2: So, depending on like your line of work, most successful people now are well, I shouldn't say most, but like, classically a successful career is usually a desk oriented career where you're sitting at a desk a lot and so you're not really exercising, you're not physically using your body, and so now you've got physical complaints that might be waking you up at night, like if you're laying in bed and your back is hurting or your knees are hurting because you just sit all day.
• 18:03
  Speaker 2: You know that's also going to keep you up and yeah.
• 18:06
  Speaker 2: And then there's like the, the future prospective stuff that's.
• 18:09
  Speaker 2: You're just thinking about constantly Right.
• 18:12
  Speaker 1: Totally Interesting point about that.
• 18:13
  Speaker 1: Real quick, about sleep too, that I just heard it was, I came across an article.
• 18:17
  Speaker 1: It was like when we sleep and we wake up in the middle of night and then you start like catastrophizing of, like well, what is this totally doesn't work, and then we're gonna be this is gonna tank and then this is gonna fail and then like we're gonna be in debt and living on the street forever.
• 18:31
  Speaker 1: You know, like those kind of thoughts in your head like this isn't going to work, um, what I heard he told me, if you've heard this when you're sleeping, um, your frontal lobe, your frontal cortex, is the main executive decision making and weighing through options and decisions, right, and like a higher level cognition.
• 18:50
  Speaker 1: And then the amygdala and other basal ganglia are like the autonomic and or fight or flight and like anyway, the frontal cortex is still asleep at 3 am or2 am when you wake up, but then the amygdala, at being one of them, is still ready to go and there's no.
• 19:06
  Speaker 1: And that's where, like a lot of the um fear, I guess, fear-based, appropriate, fear-based survival skills are involved.
• 19:13
  Speaker 1: Yeah, um, and instinctive things, and that's firing all on all cylinders still.
• 19:19
  Speaker 1: But the executive decision-making.
• 19:21
  Speaker 1: Your frontal cortex isn't there to inhibit.
• 19:22
  Speaker 1: It's not online and not a lot.
• 19:24
  Speaker 1: Not alive yet and not aligned and not filtering.
• 19:26
  Speaker 1: Okay, what's reality?
• 19:28
  Speaker 1: Let's not jump off a cliff.
• 19:29
  Speaker 1: Let's wait through the options here.
• 19:31
  Speaker 1: Most likely it's not going to happen.
• 19:32
  Speaker 1: That's not awake, yeah.
• 19:33
  Speaker 1: So then that's firing and full blown and like dominating the thought process, as the amygdala, which is like we're going to, we're going to die, everything's going to die, we're going to fail, we're going to be on the street forever.
• 19:43
  Speaker 1: My daughter and my son are going to be eating from trash cans, you know.
• 19:47
  Speaker 2: Yeah, that's actually a really good observation.
• 19:49
  Speaker 2: So, um, like our conscious brain functions in a top down and then our unconscious brain functions in a bottom-up method, that makes sense.
• 19:58
  Speaker 2: Top down, meaning your the cortex, which is the most evolutionarily new or advanced brain, is sort of in charge and it's dictating down what needs to happen.
• 20:09
  Speaker 2: So it's, you know, like you just said, it's like rationalizing, yeah, um, a good way to illustrate this is like people who have traumatic brain injury or they have damage to the cortex, you know that top-down mechanism is not working properly.
• 20:27
  Speaker 2: Yeah, and so, on a functional MRI where we can see, you know, sort of the direction of neuronal activity, yeah, of neuronal activity, you can see that there's more of this bottom-up sort of.
• 20:40
  Speaker 2: You know, the stimulus is coming from the deeper lobes of the brain and the more autonomic areas, like the amygdala, and then it goes up and then there's no like reciprocity, there's no signal back down saying like shh.
• 20:50
  Speaker 1: Yeah, relax.
• 20:51
  Speaker 2: Yeah, so those people are irritable and moody and then they have chronic pain and things like that.
• 20:56
  Speaker 2: So all those primitive brain functions are kind of left unchecked.
• 21:00
  Speaker 2: Yeah, that's really interesting.
• 21:02
  Speaker 2: Another thing to think about is we have this like the.
• 21:07
  Speaker 2: You know, when you turn on a computer, you press the button and then you hear it boot up and it goes through a boot up process.
• 21:12
  Speaker 2: Our brain is kind of the same way.
• 21:14
  Speaker 2: So when we sort of come up out of unconsciousness, we have a booting up system and it arises from something called the reticular activating system and it sits deep in our brainstem.
• 21:25
  Speaker 2: It's like this meshwork of neurons and it basically, when we wake up, it starts from there and goes up.
• 21:31
  Speaker 2: So literally the lights blossom up like so Cool.
• 21:34
  Speaker 2: Last thing to come online is our conscious brain.
• 21:36
  Speaker 2: Right, I know many people, myself included, who we may get up and look conscious and until we have coffee we're not conscious.
• 21:44
  Speaker 1: I was gonna say like is that similar than when you first wake up?
• 21:48
  Speaker 1: Most people aren't exactly pleasant.
• 21:51
  Speaker 1: Yeah, like an irritability, grogginess, and let me wake up a little bit is that the same thing as a tbi, where it's like my executive decision-making cortex skills haven't been woken up yet.
• 22:02
  Speaker 1: So my basal ganglia system.
• 22:05
  Speaker 2: Yeah, it's definitely on that spectrum, maybe not as drastic, but it's definitely on that spectrum.
• 22:09
  Speaker 1: Probably not going to say to a I wouldn't recommend to a spouse be like.
• 22:13
  Speaker 1: I can tell you're still in your TBI stage right now.
• 22:18
  Speaker 2: So until you wake up, we can have a conversation later.
• 22:19
  Speaker 2: Yeah, you're a little encephalopathic.
• 22:20
  Speaker 2: Let's put an EEG on and diagnose that Gosh.
• 22:24
  Speaker 1: Not ideal.
• 22:27
  Speaker 2: And so we use this in practice a lot in the hospital when somebody comes in or has altered mental status or encephalopathy, and we can test the various features status or encephalopathy.
• 22:39
  Speaker 2: And we can test the various features.
• 22:40
  Speaker 2: We can test cortical functions, like talking to them and see if they attend to you and answer questions and follow commands and so on.
• 22:46
  Speaker 2: And you can get pretty granular with it, like what?
• 22:48
  Speaker 2: Granular meaning, like having a full conversation with somebody.
• 22:50
  Speaker 2: Obviously they're fully conscious, versus talking to them and they are following some commands but they'll follow midline commands.
• 22:59
  Speaker 2: Meaning like close your eyes but they won't give you a thumbs up on the right or the left.
• 23:03
  Speaker 2: So it's like there's some laterality and symmetry to it.
• 23:07
  Speaker 2: So you're more likely to follow midline commands than you are like lateral commands Interesting.
• 23:13
  Speaker 2: Also, you know, trying to see if someone responds to a verbal stimulus.
• 23:18
  Speaker 2: If I'm across the room and I'm shouting is very different than me coming right up to your ear and whispering.
• 23:24
  Speaker 2: that'll wake you right up yeah so it's like there's certain stimuli that will kind of localize how much of your brain is online, cortically meaning on the outside.
• 23:31
  Speaker 2: Then, as you go deeper, there's, um, you know, brainstem reflexes.
• 23:36
  Speaker 2: You know, are they moving their face, are their pupils reacting, dilating, are they swallowing?
• 23:40
  Speaker 2: So that kind of gives me like a topographic map of what parts of their brain are online or offline.
• 23:49
  Speaker 1: Yeah, interesting.
• 23:50
  Speaker 2: So, going back to my earlier point, that reticular activating system, it starts from the bottom and goes up, so basically in the middle of the night.
• 23:59
  Speaker 2: If you sort of wake up, that means that that reticular activating system has kind of come online enough for you to be uh, conscious, like not sleeping, I guess but not fully functional and and cognitive.
• 24:15
  Speaker 2: And so what ends up happening is like if, if you have, you know, pain, things that bother you throughout the day, then all of a sudden in the middle of the night you're like, oh my God, my back hurts so bad, or my knee, and that's another reason why patients who have bone swelling, like bone marrow edema, or in like bone marrow cysts that form underneath the cartilage and arthritis, like bone on bone arthritis, they wake up with a lot of pain.
• 24:42
  Speaker 2: It's a very like distinct feature of this bone marrow edema, and that's because the inside of our bone is innervated by our sympathetic fight or flight nervous system, and so if that is something that is hurting and it's in pain and you wake up in the middle of the night but you're not totally on there, you're getting this unopposed signal from your bone marrow that's saying like something's wrong, and so you get this.
• 25:07
  Speaker 2: You know a lot of pain but, then when they wake up and they start moving around, it's like not so much, their conscious nervous system is sort of suppressing.
• 25:13
  Speaker 1: It's uncompeted with non-dampened, just fight or flight, Exactly.
• 25:20
  Speaker 1: Another interesting moment, like the reticular activating system blossoming, maybe just enough to get conscious and then it dwindles back down and getting back to sleep, Um sleep paralysis.
• 25:28
  Speaker 2: Super interesting Is that something that I've.
• 25:30
  Speaker 2: Have you battled that before?
• 25:31
  Speaker 2: No, I have a friend who has, but I haven't had to deal with that.
• 25:34
  Speaker 1: Very interesting.
• 25:35
  Speaker 1: Yeah, have have you?
• 25:36
  Speaker 1: Yeah, really.
• 25:37
  Speaker 1: Yeah, yeah, big time.
• 25:37
  Speaker 1: I've heard a lot of spiritual, terrifying right.
• 25:39
  Speaker 1: Yeah, there's like it depends on where you're at in the spectrum with this, but there's a lot of spiritual indications with this implications as well.
• 25:45
  Speaker 1: Yeah, the thought being like, if you're in this boat, what I kind of suppressing your body but you're conscious but you can't activate against it.
• 25:57
  Speaker 1: Have you ever heard that?
• 25:58
  Speaker 1: You haven't heard before.
• 25:59
  Speaker 1: Yeah, google it.
• 26:00
  Speaker 1: It's really interesting, google this.
• 26:08
  Speaker 1: This is some thoughts on this, you know.
• 26:09
  Speaker 1: And then, because usually during a sleep paralysis episode, people have vision, they see, really messed up, they see the scary things, demons sitting on their chest.
• 26:14
  Speaker 1: Well, yeah, exactly, think about like a demon sitting in your chest, that's particularly.
• 26:18
  Speaker 1: They're like hovering over you and compressing you.
• 26:20
  Speaker 1: So, as an example, if somebody there's a lot of episodes of people saying I've seen aliens or ghosts and demons or whatever scary stuff, where I'm thinking about something very bad during sleep paralysis episodes that's interesting, right, but I don't know why I'm not on that, but um, I mean that is pretty well, because the sleep paralysis is a disconnect and, like the, it's like a dyssynchrony of like your systems coming online.
• 26:44
  Speaker 2: It's like you're booting up, like microsoft word is trying to open up before windows does, and I don't know why I keep going back to the pc, but it makes total sense yeah, um, so like I get that part, but like I never understood why people have these.
• 26:57
  Speaker 2: They see these apparitions.
• 26:59
  Speaker 1: I was wondering, from a neurological standpoint, where sleep paralysis is just maybe your RAC getting open, but not enough.
• 27:09
  Speaker 2: It has to do with.
• 27:10
  Speaker 2: There's a couple of different enzymes and pathways that are involved with reestablishing motor tone when you wake up.
• 27:18
  Speaker 2: So when you're in REM sleep you know you're basically your motor cortex like the part of your brain that controls your muscle activity is just decoupled from the rest of your body.
• 27:28
  Speaker 2: And that's how we know you're in REM sleep is because we can actually put an electrode in your muscles and during REM sleep there would be no muscle tone.
• 27:36
  Speaker 2: But once there's muscle tone, we know you're not in REM sleep anymore.
• 27:40
  Speaker 2: Interesting, and you can correlate it with like EEG findings.
• 27:42
  Speaker 2: Huh, yeah.
• 27:43
  Speaker 1: That's really cool.
• 27:44
  Speaker 2: Yeah, so what's happening with sleep paralysis is that you're waking up before your motor system has finished coupling.
• 27:52
  Speaker 1: Yeah.
• 27:52
  Speaker 2: And so you've?
• 27:53
  Speaker 2: You're literally paralyzed, you can't move.
• 27:55
  Speaker 2: That's really interesting, you've you literally paralyzed, you can't move.
• 27:57
  Speaker 2: That's now why that goes hand in hand with, like you know, apparitions and, and you know, visions and things like that I have no idea, but that is very intriguing, super intriguing.
• 28:05
  Speaker 2: It's one of those things where I, I think subconsciously, I'm like afraid to look into it.
• 28:09
  Speaker 1: It's like I don't want to know.
• 28:10
  Speaker 1: I'm gonna leave that alone.
• 28:11
  Speaker 1: I'm not gonna open that death book.
• 28:13
  Speaker 1: Yeah, um, I, but they're interesting, like there was.
• 28:17
  Speaker 1: I've had plenty episodes of sleep paralysis, just like I'm like I'm kind of awake and but I'm trying to move, but I can't right.
• 28:23
  Speaker 1: That's what the that's how I just can't move, I can't make it happen.
• 28:26
  Speaker 1: I'm like I move, you know, get up.
• 28:28
  Speaker 1: But there was one time in college where I was, I was, I got to campus early.
• 28:32
  Speaker 1: It was in the fall for fall football camp and I was there and had early meetings the next day and I was in.
• 28:36
  Speaker 1: I was wiped.
• 28:37
  Speaker 1: You know I have two a day.
• 28:38
  Speaker 1: It's like exhausting.
• 28:39
  Speaker 1: Um, and this place I was temporarily sleeping at, um, was near all the bars of this campus, um, and I was there before.
• 28:47
  Speaker 1: A lot of students were there.
• 28:48
  Speaker 1: I'm like weeks ahead of time and I'm like I sleep in my house, this house I'm sleeping at, and uh, I'm upstairs and I had this sleep paralysis episode.
• 28:56
  Speaker 1: Oh no, the lights turn on downstairs.
• 28:58
  Speaker 1: So like my hallway light through my door, you know, illuminates the behind the door and I'm like I have a roommate who's with me, right, he's downstairs in his own room and I'm like, ok, he's by him, yeah.
• 29:11
  Speaker 1: But I'm like I want to get up and ask, but I can't move.
• 29:13
  Speaker 1: Like what the heck I?
• 29:14
  Speaker 1: But I can't move, like what the heck, I'm not, I'm paralysis, I literally can't move.
• 29:16
  Speaker 1: And then I hear footsteps come up the stairs just like boom, boom, boom, and I'm like he usually doesn't wake up in the middle and I don't even know what time it is.
• 29:25
  Speaker 1: I can't move right, but I'm like looking and I'm just absolute paralysis.
• 29:30
  Speaker 1: The door opens oh my god, yeah, the steps keep going up the stairway, getting closer, getting louder.
• 29:35
  Speaker 1: Stops.
• 29:35
  Speaker 1: Does the door creak?
• 29:36
  Speaker 1: There's like a shadow of legs underneath the door frame, right Over the light.
• 29:42
  Speaker 1: Door knob twists, door opens and I'm like in bed on my stomach-like side.
• 29:48
  Speaker 1: I'm kind of like looking and I'm like get up and move.
• 29:51
  Speaker 1: Like move, I need to get out.
• 29:53
  Speaker 1: You ever see Kill Bill?
• 29:54
  Speaker 1: Yeah yeah, yeah, he wakes up from a coma.
• 29:56
  Speaker 1: Move your big toe, yeah, move your big toe.
• 29:59
  Speaker 1: And I couldn't move.
• 29:59
  Speaker 1: Oh, my gosh.
• 30:01
  Speaker 1: Door closes, person leaves Light, turns off Wait there was a person in the doorway.
• 30:07
  Speaker 2: There was a person.
• 30:08
  Speaker 1: Yeah, door closes, light turns off and then the bedroom next to me that door opens, closes and I wake up the next morning and I was like ready for you know the day to start.
• 30:27
  Speaker 1: It's like 6am and I'm like, was that a real episode?
• 30:28
  Speaker 1: Or like what?
• 30:29
  Speaker 1: I remember this happened and I couldn't move and they're like oh yeah, and I went to the door next to me and there was somebody sleeping in the bed and they're at the bedroom and I thought it was my roommate.
• 30:36
  Speaker 1: I thought he just came up a little night and I was like, oh, it's probably him.
• 30:39
  Speaker 1: And he was kind of turned away and I couldn't see and I wasn't going to go in there and like, but it kind of looked like him and I was like I'm probably my roommate, you know.
• 30:46
  Speaker 1: So then I leave, I come back at 5 PM after a whole day of everything, and I see my roommate he was, he was on the team and I was like dude, did you wake up last night and go upstairs?
• 30:54
  Speaker 1: And he's like no, I was downstairs the whole time and I was like somebody came in our house last night then, cause it wasn't I woke up in the morning when I was conscious that a dude was sleeping in his bed, oh, yeah.
• 31:04
  Speaker 1: So I was like what, if I don't know, maybe it was on purpose that I didn't wake up, cause I'm at, like I'm, you know, at this point with football player, not in the best mindset of life, right, yeah, had I woken up, bad things could have happened.
• 31:19
  Speaker 1: You know, not gonna just like have a rational conversation like at that point.
• 31:24
  Speaker 1: You know what I mean.
• 31:25
  Speaker 1: Oh gosh, yeah, I know, but a good thing I didn't wake up.
• 31:27
  Speaker 1: Could he have been sleepwalking?
• 31:28
  Speaker 1: Um, he doesn't, he usually didn't do that.
• 31:31
  Speaker 1: Okay, and I also heard also too, if I'm at the time, it sounded like the front door opened outside, you know, oh, night walker, yeah, so like the front door opened from the street door closed, kitchen light went on, hallway light went on, stairs up noise, opened my door and then fell asleep.
• 31:50
  Speaker 1: It was some drunk guy that came up from the bars who probably thought this was his house.
• 31:53
  Speaker 1: He's like oh wow, what a nice bed.
• 31:55
  Speaker 1: Yeah, this is great.
• 31:56
  Speaker 1: He's a military cool.
• 31:57
  Speaker 1: Is it cool if I sleep here?
• 31:58
  Speaker 1: Guys, I got to get my resistance, so I'm good, yeah, but anyway, sleep.
• 32:02
  Speaker 1: Paralysis story real quick.
• 32:03
  Speaker 1: That that is very interesting.
• 32:05
  Speaker 1: Yeah, I've had a lot of episodes, a lot not like every night, but like a handful of sleep paralysis episodes like that.
• 32:13
  Speaker 1: It's pretty crazy.
• 32:14
  Speaker 2: It is interesting, like if you were to have been awake, like what could have?
• 32:19
  Speaker 2: Well, what?
• 32:19
  Speaker 2: I would have been like a home intruder.
• 32:20
  Speaker 2: Would it have been a conflict?
• 32:22
  Speaker 1: 100, so it's a good thing I didn't wake up.
• 32:24
  Speaker 1: Yeah, maybe it was on purpose.
• 32:25
  Speaker 1: If you just wanted to nap, yeah, exactly, it's like yo let me sleep, I'm just tired man, too much alcohol.
• 32:30
  Speaker 1: He's like can I get in bed?
• 32:31
  Speaker 1: Yeah, is there a room in there?
• 32:33
  Speaker 1: Oh man, but over a little bit.
• 32:34
  Speaker 1: Oh man, but okay anyway.
• 32:37
  Speaker 1: Headaches, yeah, headache, where are we with this?
• 32:39
  Speaker 1: Headaches Okay, lack of sleep, causing stress, causing lack of sleep, causing more stress because you're not sleeping well.
• 32:45
  Speaker 1: Yeah, snowballs.
• 32:48
  Speaker 2: When you don't sleep you don't drain out toxic proteins and misfolded proteins.
• 32:55
  Speaker 2: So recently they sort of Interesting they proteins and misfolded proteins.
• 32:58
  Speaker 2: So recently they sort of flew it onto something called the glial lymphatic system, which is basically like a lymphatic system, which is what our body uses to drain stuff and present antigens and all that.
• 33:06
  Speaker 2: But we have one in our brain but it's not like its own system.
• 33:10
  Speaker 2: It's sort of rents space from the veins and it kind of comes online at night from the veins Okay, and it kind of comes online at night, so especially in REM sleep.
• 33:19
  Speaker 2: And so at night when you get into REM sleep and you stay in REM sleep long enough, this glial lymphatic system sort of turns on.
• 33:26
  Speaker 2: I don't remember exactly how they were able to distinguish that.
• 33:29
  Speaker 2: It like turns on, I think it like expresses different proteins in certain channels open so that they can pass things across the blood-brain barrier, but it drains out the accumulation of oxidation throughout the day.
• 33:43
  Speaker 2: So as we are conscious and we do things and we are exposed to radiation and we drink things like this and whatnot, we build up oxidation and oxidation builds up toxic byproducts and they kind of linger in the brain because they have no way of getting out.
• 33:56
  Speaker 2: Until you go to bed you reach REM sleep, this glial lymphatic system activates byproducts and they kind of linger in the brain because they have no way of getting out.
• 33:58
  Speaker 2: Until you go to bed you reach REM sleep, this glial lymphatic system activates and then you can drain out those byproducts.
• 34:05
  Speaker 2: And one of the things in those byproducts are misfolded proteins and those proteins can, if they don't drain out appropriately, they can accumulate over the years and it's one of like the key uh causations of neurocognitive disorders and dementias.
• 34:22
  Speaker 2: It's just accumulation of plaques yeah or neurofibrillary tangles.
• 34:26
  Speaker 2: Yeah, it's like that.
• 34:27
  Speaker 2: So yeah, that could.
• 34:28
  Speaker 2: That also has interesting plays a role in headaches huh, yeah, that's, I mean.
• 34:32
  Speaker 1: That makes total sense.
• 34:33
  Speaker 1: So achieving REM sleep is super super important man yeah, how do you do that?
• 34:37
  Speaker 1: How do you achieve REM sleep?
• 34:40
  Speaker 2: dark, cold quiet.
• 34:41
  Speaker 2: That's what I've heard.
• 34:42
  Speaker 2: Yeah, dark, cold, quiet.
• 34:43
  Speaker 2: Uh, so the room has to be dark.
• 34:45
  Speaker 2: It has to be cool to help your body temperature go down.
• 34:49
  Speaker 2: If you want to help that along, you can like take a hot shower before you go to bed, because it's not the, the temperature that matters, it's the delta.
• 34:56
  Speaker 2: So it's like how many degrees has your body changed?
• 34:59
  Speaker 2: It has to change, yeah.
• 35:00
  Speaker 2: So whether you like to sleep in 77 degrees or 73 degrees, it doesn't matter, so long as, like, you got cooler to get there.
• 35:07
  Speaker 2: Interesting Dark, cold quiet.
• 35:11
  Speaker 2: Oh, quiet.
• 35:11
  Speaker 2: Yeah, so phones, tvs, kick the dog out.
• 35:15
  Speaker 1: Yeah, yeah.
• 35:16
  Speaker 2: Interruption, you know sometimes.
• 35:17
  Speaker 2: And, like you, tvs kick the dog out.
• 35:18
  Speaker 2: Yeah, yeah, interruption, you know sometimes, and, like you know, I toss a little bit when I sleep, so like I feel bad for my fiance, so I'll like Go sleep on the couch some nights Also, because I'm on call a lot at night, so like if.
• 35:30
  Speaker 2: I get called, she gets woken up.
• 35:31
  Speaker 2: So I don't want to do that, so I'll sleep outside.
• 35:33
  Speaker 2: Yeah, so yeah, dark, cold, quiet.
• 35:35
  Speaker 2: With the quiet thing, you know, it's more than just noises and lights, it's like even devices.
• 35:42
  Speaker 2: So I don't charge my phone in my room anymore.
• 35:46
  Speaker 2: I just I put it out.
• 35:47
  Speaker 2: Either I don't charge it or I just put it out in the in the kitchen.
• 35:49
  Speaker 2: Um, because when you charge your phone at night and it's connected to wifi, that's when all this like data exchange and all this stuff is happening.
• 35:57
  Speaker 2: It's like syncing with the cloud and talking to the government.
• 36:00
  Speaker 1: Yeah, Like hey, guess what he was doing today.
• 36:03
  Speaker 2: Yeah, exactly, and so you know it's.
• 36:05
  Speaker 2: It's like, yeah, it's not, it's non-ionizing radiation, but it's radiation nonetheless, and like it affects your brainwaves.
• 36:11
  Speaker 2: I mean we can see it on an EEG, like when you have somebody hooked up to an EEG in the ICU and they are next to all the hospital machinery, like it disrupts the study.
• 36:22
  Speaker 2: We see the influence of all this electromagnetic stuff and so we have to like tell people, move the machines away, no cell phones, things like that Interesting.
• 36:33
  Speaker 1: So imagine having a supercomputer just blasting off next to your head all night.
• 36:35
  Speaker 1: Yeah, that's a great point.
• 36:36
  Speaker 2: Yeah, so starting.
• 36:36
  Speaker 2: Well, it's my alarm clock dang it.
• 36:37
  Speaker 2: Yeah, all right, you gotta go old school.
• 36:38
  Speaker 1: Yeah, old school, yeah that one, yeah, which is the worst, which is also good, though.
• 36:42
  Speaker 1: So dark, cold, quiet, yeah, and um, yeah, that makes total sense.
• 36:46
  Speaker 1: What about?
• 36:46
  Speaker 1: What do you hear about?
• 36:47
  Speaker 1: Grounding of?
• 36:49
  Speaker 1: Like a grounding blanket?
• 36:50
  Speaker 2: I've been hearing about that more lately.
• 36:52
  Speaker 2: Actually, one of my patients literally just told me about that, like last week.
• 36:54
  Speaker 2: Yeah, well, it's like touching the ground, like it has, like some you know, metallic thread in or something yeah, it's threaded with like metal coils and then you plug it into the wall.
• 37:05
  Speaker 1: Oh yeah, like the outlet, like an outlet, and then you sleep on it.
• 37:08
  Speaker 1: Um, I'm down to try anything new yeah, right but I've I've definitely have been exposed to some articles and studies and stuff about like grounding in general, of like being actually barefoot, like skin on earth, yeah and uh, just the electromagnetic transfer of energy from the earth and there's a benefit to the humans I 100 agree with that the studies.
• 37:31
  Speaker 1: Like it's not, like it's not woo woo, you know like this is like science, yeah and like it's a benefit for our bodies for that stuff, and I was like, oh, I like, okay, cool, I'm in.
• 37:40
  Speaker 1: So it was like you need to just sleep on the earth.
• 37:42
  Speaker 1: You know, you can imagine getting eaten up, I bug, I could be the worst, you know.
• 37:46
  Speaker 1: But, um, anyway, like bring an element of like that electromagnetic benefit in a bedsheet and you sleep on the bedsheet all night and it's plugged into an outlet in the wall.
• 37:56
  Speaker 2: That's interesting.
• 37:56
  Speaker 2: Hopefully you don't get a power surge.
• 37:58
  Speaker 1: Right, exactly that.
• 38:00
  Speaker 1: We're really charged.
• 38:01
  Speaker 2: I know that there's some.
• 38:01
  Speaker 2: There's some truth to what direction you sleep at, like at night, meaning cardinal direction has some influence on your brainwaves.
• 38:10
  Speaker 2: So, oh man, I'm going to butcher this, but I know that if you are sleeping north-south is better than sleeping east-west.
• 38:20
  Speaker 1: Okay.
• 38:20
  Speaker 2: Meaning if your head and feet are on the north-south pole, it is more conducive to the natural direction of electricity flow in your brain than it is to sleep east-west.
• 38:31
  Speaker 2: So, like electricity flow in our brain in general, like the summation of it is up-down and the magnetic poles are up-down, so it's better to sleep like that because it lines up with that versus against it.
• 38:46
  Speaker 2: Because of that cause and you can again, you can see this on an EEG you can see, like, the difference in the brainwaves.
• 38:50
  Speaker 1: That yeah egs are pretty cool.
• 38:52
  Speaker 1: That's really cool.
• 38:53
  Speaker 1: Yeah, interesting.
• 38:55
  Speaker 1: What about white noise for sleeping?
• 38:56
  Speaker 1: Don't do it really absolutely don't do it.
• 38:59
  Speaker 2: White noise is a fallacy in my opinion.
• 39:01
  Speaker 1: Well, it's not my opinion.
• 39:02
  Speaker 1: It's true, not my opinion.
• 39:04
  Speaker 2: It's just empirical evidence so, like your brain has this really cool way of increasing the resolution of a signal, right.
• 39:14
  Speaker 2: So, like, if you hear something and you really want to like focus in on it, your brain does this cool thing.
• 39:22
  Speaker 2: Where, like it, will you know whatever neurons get activated are being activated, but then your brain will immediately suppress all the neurons around it and so you get this like clear, isolated stimulus yeah, hyper-focused, hyper-focused, hyper-focused stimulus of neurons, and there's no distraction, there's no noise around it.
• 39:42
  Speaker 2: So your brain is suppressing what's around it.
• 39:46
  Speaker 2: Now imagine if you are sleeping and you have this noise that is the exact same frequency, same pattern, same pitch and volume, all night long.
• 39:59
  Speaker 2: You're basically turning on this one little subset of neurons and you're shutting down everything around it for hours, and so eventually you do that long enough, those neurons atrophy, and so eventually you do that long enough those neurons atrophy.
• 40:11
  Speaker 2: So, especially in kids, you do not want to use white noise in children, babies, because it has been shown to suppress language development and cognitive development, especially language development, because you're activating their auditory cortex.
• 40:25
  Speaker 2: So don't use white noise around kids Interesting.
• 40:28
  Speaker 2: And it also, like your brain is very sensitive to artificial sounds.
• 40:32
  Speaker 2: So, like you know, if you're looping some sort of white noise machine like your brain knows that this is like a distinct loop and it'll wake you up and it's just white noise.
• 40:43
  Speaker 1: I've heard that it helps to mimic, like for babies, right, because we definitely have used white noise the entire life of my kids so far.
• 40:52
  Speaker 1: Um, sorry, yeah, well, I'm like you're destroying, yeah, you're destroying your children.
• 40:58
  Speaker 1: Um, they, it's like what we've read is like to mimic the environment of like the womb yeah and then the shushing of like the aortic, descending aorta and the mom's belly and also amyloid fluid to mimic that it helps calm them down and soothe soothe the kiddos, it's it is right.
• 41:16
  Speaker 2: It is correct in concept, but is incorrect in practicality.
• 41:20
  Speaker 2: So, by concept, yes, you're trying to mimic the womb.
• 41:23
  Speaker 2: The womb is great, but what we know as the womb, as the like wishing, noises.
• 41:27
  Speaker 2: We know that because, like we're hearing it through an ultrasound or we're like hearing it through a microphone, but what the baby's feeling is not noise, the baby's feeling vibration.
• 41:36
  Speaker 2: So what would be more appropriate is like a warm blanket that vibrates got it.
• 41:41
  Speaker 1: That's the womb, I see, yeah they're not, they're not hearing anything inside their ears aren't even developed enough yet yeah, uh, interesting, okay, all right, well, moving on.
• 41:50
  Speaker 1: So, um, yeah, back to headaches.
• 41:52
  Speaker 1: We're on number two.
• 41:53
  Speaker 1: All right now, number two tension headaches.
• 41:56
  Speaker 1: Okay, compared to cluster tension headaches.
• 42:00
  Speaker 2: Uh like, for me tension headache is a big, broad term, uh, that encompasses any sort of musculoskeletal etiology or cause of a headache, okay, and then tension headaches are often triggers for other headaches.
• 42:16
  Speaker 1: Okay.
• 42:17
  Speaker 2: So the classic tension headache is like muscle spasm in the back of the neck or tightness in the back of the neck and what you're getting is tension along the fascia or that kind of covering of the scalp, especially along it's like pinning points.
• 42:33
  Speaker 2: So you know, the fascia and the scalp kind of has pinning points along the sutures or like the I don't know, basically where the bones of your cranium come together.
• 42:44
  Speaker 2: Those like little squiggly lines are the sutures and the fascia, like tacks down there, and so you can get tension there Interesting.
• 42:51
  Speaker 2: The classic example I like to use is like if you have a shirt like so and you take one side of the shirt and you do this, you're going to see these like tension lines and so you might feel the pain along those tension lines, but not necessarily here.
• 43:07
  Speaker 2: Yeah, so like you're feeling those pain along tension lines on your scalp.
• 43:15
  Speaker 2: Interesting so cervicogenic headaches then, which is a neck related?
• 43:16
  Speaker 2: Yeah, I think that falls out underneath.
• 43:17
  Speaker 2: Fall that into a tension?
• 43:18
  Speaker 1: headache.
• 43:18
  Speaker 1: Interesting, yeah, cervical headaches, from our understanding, like what very common with upper cervical dysfunction, pain um, and especially our instability of the neck um, and a lot of pain in the neck.
• 43:30
  Speaker 1: We see, yeah, creating cervicogenic headaches is related.
• 43:33
  Speaker 2: Yeah.
• 43:34
  Speaker 1: Prolonged sitting, prolonged standing, all that stuff, yeah, so it falls underneath tension headaches.
• 43:39
  Speaker 2: Yeah, I think a cervicogenic headache would fall into a tension headache, because cervicogenic headaches cause tension headaches.
• 43:45
  Speaker 1: Yeah, got it, yeah Interesting.
• 43:47
  Speaker 1: And then migraines, yeah.
• 43:49
  Speaker 2: Right Got it Interesting.
• 43:49
  Speaker 1: And then migraines, yeah.
• 43:50
  Speaker 1: Right the mother of all, the, the mother of migraines.
• 43:52
  Speaker 1: Yeah, exactly.
• 43:53
  Speaker 2: So migraines is, and you know what?
• 43:56
  Speaker 2: You'd probably have to check me on this now because, like, the migraine discipline is evolving especially rapidly, especially now, whereas, like just like 60 years ago, people thought migraines were like a psychiatric disorder.
• 44:10
  Speaker 2: They're just like, you're crazy.
• 44:16
  Speaker 2: Go back back to work now we know it's real and now we know that it some oftentimes is associated with, like other genetic vascular disorders that are associated with strokes and things like that.
• 44:23
  Speaker 2: So it's definitely real, um, and then we know a lot of treatments to you know, or we know how to target some of its mechanisms basically.
• 44:31
  Speaker 2: So, in general, like the 30,000 foot view of a migraine, it's an inflammatory state of the brain and brain stem and then that inflammatory state releases a lot of toxic proteins into the central nervous system and then from there it can cause vasomotor dysfunction, so disruption of, like, the tone of the arteries.
• 44:55
  Speaker 1: Yeah, the blood pressure.
• 44:56
  Speaker 2: Yeah, so, as history dictates, you know, the first things that we would target to treat migraines was the vasomotor tone.
• 45:05
  Speaker 2: So we would use things like beta blockers, you know things that kind of help relax the arteries and so on, and that seemed to help.
• 45:10
  Speaker 2: So we're use things like beta blockers, things that kind of help relax the arteries and so on, and that seemed to help.
• 45:14
  Speaker 2: So we're like, okay, migraines are a blood vessel thing.
• 45:16
  Speaker 2: Well, then you take it back one step further and now we know that, okay, there's this general inflammatory state and there's nerve irritation and nerve overexcitation.
• 45:26
  Speaker 2: So we started using, like anti-epileptics and things like that, and SSRIs, like antidepressant medications, because it would tend to calm down the excitation of nerves, and that seemed to help.
• 45:38
  Speaker 2: So we're like, oh, it's a neuroexcitation disorder which went hand in hand with what causes an aura, and an aura is basically this, what we call a wave of depolarization, or just like this wave of activation across the surface of the brain.
• 45:55
  Speaker 2: Um, and depending where that wave propagates from or to, dictates like what kind of aura you get, whether it's visual or audio or whatever.
• 46:01
  Speaker 2: Um, and then from there we decided to discover that there are these specific proteins that have multiple effects on multiple different systems in the brain and they get released at the beginning of a migraine and then that sort of ramps up like the pain part of a migraine so long after the prodrome, but right before the pain part of a headache or migraine.
• 46:24
  Speaker 2: A classic one is called CGRP calcitonin gene-related peptide and this is a protein that's kind of ubiquitous in the body it's in our guts, it's in our muscles, it's in our heart and it's in our brain and, for whatever reason, it is released in incredibly high volumes during a migraine.
• 46:44
  Speaker 2: And we know now that if you either block the protein or you block its receptor, you can stop it migraines, and so that's kind of like the newest class of migraine medication which is making a huge impact.
• 46:59
  Speaker 1: That's a good impact.
• 47:00
  Speaker 1: Good impact, yeah.
• 47:01
  Speaker 2: Cool.
• 47:01
  Speaker 2: They're either blocking the CGRP protein itself or they're blocking the CGRP receptors.
• 47:08
  Speaker 2: Some examples are like Amovig, q-lipta, ubrel v.
• 47:14
  Speaker 2: Like all these new they're all new medications so what causes that cg?
• 47:19
  Speaker 1: what was it again?
• 47:19
  Speaker 1: Cgrp, cgrp, cgrp, protein, yeah, in the first place.
• 47:24
  Speaker 1: Well, it's a natural proliferating and like becoming a problem.
• 47:29
  Speaker 1: In that moment, that's, I don't actually Like one step back again.
• 47:36
  Speaker 2: Yeah you know, yeah, we know.
• 47:38
  Speaker 2: It kind of emanates from blood vessels, especially deep in the brainstem.
• 47:43
  Speaker 2: What triggers that?
• 47:45
  Speaker 2: There's some.
• 47:46
  Speaker 2: The general school of thought is like If you're in a pro-inflammatory state, then you can't really get rid of it, you can't really suppress the production of it.
• 48:00
  Speaker 2: Or you have like an accumulation and then once it reaches like a critical mass, then it goes into a migraine.
• 48:05
  Speaker 1: So it would be stopping the inflammatory response at the beginning.
• 48:08
  Speaker 2: Yeah, exactly.
• 48:09
  Speaker 1: Which could be a lot of factors, and I imagine stress being one of them.
• 48:14
  Speaker 2: Yeah, I mean.
• 48:15
  Speaker 2: That's why, like when we are evaluating someone who's presenting with migraine, we have to figure out what their triggers are and a lot of times, like the typical triggers are like sugar, caffeine, alcohol, especially like red wine, certain cheeses, certain perfumes, citrus, of all things.
• 48:37
  Speaker 2: So like there are these like triggers, so we think that it could be like a form of an allergy, right?
• 48:42
  Speaker 1: Yeah.
• 48:42
  Speaker 2: You have a sensitivity or an allergy to something, but your allergy is expressing itself inside your central nervous system, and so you get this migraine Interesting.
• 48:50
  Speaker 1: Wow, that's really cool, yeah, that we are, y'all are finding out like this information.
• 48:54
  Speaker 2: You know that the researchers and stuff- yeah, like when I was in residency, this was like breaking news and now it's like common practice, but it's still like it's evolving, evolving, cool.
• 49:06
  Speaker 1: So uh, remind me again tacs tacs trigeminal autonomic cephalalgia.
• 49:10
  Speaker 2: This is how we ended up on cluster headache.
• 49:11
  Speaker 1: Okay, got it yeah, cool, good, we took we, we tackled that already To interject one more thing.
• 49:18
  Speaker 2: So yeah, you have your classic cluster headache, which is something interesting about cluster headache.
• 49:22
  Speaker 2: It is considered a deadly headache not because the headache itself can kill you, but because the most common cause of death in people with cluster headache is suicide.
• 49:32
  Speaker 1: Interesting.
• 49:32
  Speaker 1: It's that bad.
• 49:34
  Speaker 2: Wow, it's that bad wow, it's that bad.
• 49:35
  Speaker 1: I mean that I like I can piece that together.
• 49:37
  Speaker 1: You know, over the stress and pressure and stuff involved with people that are in the demographic, you know well it's, it's, it's the, the pain itself.
• 49:47
  Speaker 2: The pain oh it's the pain, it's the pain itself is so severe and it's so resistant to treatment that people will resort to suicide.
• 49:55
  Speaker 1: Interesting yeah.
• 49:56
  Speaker 1: Wow, that is scary, super scary yeah.
• 50:00
  Speaker 2: Okay, one of the other TACs.
• 50:01
  Speaker 2: Uh, like I said earlier, like they they sort of vary in like, uh, frequency, duration, severity, things like that, and they go all the way from headaches that can last months to headaches that are literally instantaneous.
• 50:14
  Speaker 2: There's something called like Suna and Sunk like a sudden unilateral.
• 50:18
  Speaker 2: I forgot what the N stands for cranial tics or something, but basically it's like a lightning bolt.
• 50:28
  Speaker 2: It lasts like less than a moment.
• 50:30
  Speaker 2: And it is so severe that it, like just you know, stops you in your tracks.
• 50:34
  Speaker 2: You're like what was that?
• 50:35
  Speaker 1: Yeah, yeah.
• 50:36
  Speaker 2: And then they can happen once, rarely, or they can happen in, like lightning storms and then stop.
• 50:41
  Speaker 1: So really really weird headaches.
• 50:43
  Speaker 1: Yeah, man, that's a, that's great, that's intense, yeah.
• 50:46
  Speaker 1: Then you mentioned pressure headaches.
• 50:48
  Speaker 2: Yeah, pressure headaches meaning, is there a problem with the, you know, the pressure of fluid inside your cranium?
• 50:55
  Speaker 2: So increased intracranial pressure is usually a more foreboding sign, because things that increase your intracranial pressure, other than like your blood pressure, could be like a tumor, something obstructing the flow of CSF in your brain, trauma, bleeding, things like that.
• 51:12
  Speaker 2: So Okay, gotcha.
• 51:13
  Speaker 2: And those headaches tend to get better when they're sitting up and worse when they're in your brain trauma, bleeding things like that.
• 51:16
  Speaker 2: Okay, gotcha.
• 51:17
  Speaker 2: And those headaches tend to get better when they're sitting up and worse when they're laying down.
• 51:22
  Speaker 1: More pressure available when you're not gravity dependent.
• 51:26
  Speaker 2: Yeah, so like someone with an increased pressure headache, their headaches are worse in the morning because they've been laying down all night.
• 51:32
  Speaker 1: Yeah, that makes sense.
• 51:32
  Speaker 2: Low pressure headache is the opposite problem.
• 51:34
  Speaker 2: Not enough pressure.
• 51:36
  Speaker 2: And so the most common cause, at least in the US, is post-procedural, or what we call a CSF leak, meaning somebody's got you know an epidural, whether from you know, prior to labor or from a pain management injection.
• 51:48
  Speaker 2: You can leak cerebrospinal fluid into the tissue and then the pressure goes down and the brain is literally trying to sink down into the bottom of your skull and that pulls on the meninges and pulls on the nerves.
• 52:03
  Speaker 2: Uh, and that's very, very painful.
• 52:05
  Speaker 2: And those headaches get better when you lay down and they get worse when you sit up.
• 52:09
  Speaker 2: Yeah, wow, but it's like it's like a drastic difference, like you're fine laying down and then when you sit up you like you're seeing stars and you're just like you're going to pass out because your brain is like sagging down, like gravity's pulling on it.
• 52:20
  Speaker 1: Yeah, Wow, yeah.
• 52:21
  Speaker 1: And then meningitis headache is a classic sign of symptom and usually teenagers right or like adolescents for meningitis.
• 52:30
  Speaker 2: Oh, yeah, yeah.
• 52:31
  Speaker 2: So meningitis falls into what I call the star of death headaches.
• 52:37
  Speaker 2: These are headaches that can be lethal, basically, and within meningitis you have viral meningitis, which is inflammation of the meninges from a viral infection Tend to be less harmful, self-limiting, you just give supportive care Tylenol fluids, steroids, things like that, some cases antivirals but it goes away.
• 52:55
  Speaker 2: Bacterial meningitis can be lethal fast.
• 53:00
  Speaker 2: So classic signs of that oh, classic signs of that is what we call meningismus, which is like when you put tension on the meninges, the body tends to do certain reflexes, like if you pull down on the neck.
• 53:16
  Speaker 2: Like the body tends to do certain reflexes, like if you pull down on the neck, like the knees come up to the chest in order to reflexively take tension off the meninges, the dura.
• 53:23
  Speaker 1: Yeah, exactly what are some signs and symptoms?
• 53:25
  Speaker 1: From my understanding of bacterial meningitis, it's more adolescents than teenagers as like a danger.
• 53:33
  Speaker 2: It can happen.
• 53:33
  Speaker 2: So the most vulnerable are your neonates and your very elderly?
• 53:38
  Speaker 2: Oh, okay, because they are immune, compromised, I see.
• 53:40
  Speaker 2: And then there's like typical bacteria that affect neonates and typical bacteria that affect the elderly, and then there's a whole different type of set of bacteria that can affect adolescents and young adults.
• 53:52
  Speaker 2: Okay, I would say the neonates and the elderly are the most vulnerable.
• 53:56
  Speaker 2: Yeah, got it.
• 54:00
  Speaker 1: Um, and then the uh exploding head syndrome.
• 54:03
  Speaker 2: Yeah, exploding head syndrome is literally what it sounds like it just people will just report that they feel like their head's exploding and they don't.
• 54:13
  Speaker 2: There's like no abnormalities on tests and things like that.
• 54:16
  Speaker 2: So you know that's.
• 54:17
  Speaker 2: We just call it exploding head syndrome, and then I think it's treated with uh like benzodiazepines, yeah, things like clonazepam and lorazepam wow, yeah uh and oh, there's a couple other cool ones.
• 54:30
  Speaker 2: There's post-coital headaches uh, these, for some reason, uh, very few unfortunate people get like debilitating headaches whenever they climax.
• 54:41
  Speaker 2: Okay, like right, that climax, okay, uh, and it has something to do with this like sudden shift from your sympathetic to parasympathetic nervous system which is you know, a distinct feature of of a climax yeah and like all the different, you know blood vessel changes, that happens with that.
• 54:57
  Speaker 2: They just get these horrible headaches, which is a distinct feature of a climax, and all the different blood vessel changes that happens with that.
• 55:00
  Speaker 2: They just get these horrible headaches.
• 55:01
  Speaker 1: It's a bummer.
• 55:01
  Speaker 1: Yeah, it is a bummer.
• 55:02
  Speaker 1: I imagine there's also a pressure shift of blood pressure right.
• 55:06
  Speaker 2: Yeah, yeah, you're suddenly going from elevated blood pressure to just yeah, yeah, yeah.
• 55:11
  Speaker 1: Interesting, that's a bummer man.
• 55:14
  Speaker 1: Man, that's crazy.
• 55:16
  Speaker 1: They correlate that.
• 55:17
  Speaker 1: How do they test that in research?
• 55:18
  Speaker 1: Yeah, exactly, that's tough, that's a tough one.
• 55:24
  Speaker 1: Orthopedics of cranial cervical instability, upper cervical instability and then headaches that can come with that of like neck pain.
• 55:40
  Speaker 1: But upper cervical instability being like upper ligamentous dysfunction, upper ligamentous instability of like um the c1, c2 and c1, c0.
• 55:49
  Speaker 1: Yeah, uh, a lot of ligaments um the transverse ligament of the dens right, um I've also heard jefferson's fracture right can be a upper cervical instability issue that might be go miss misdiagnosed at the beginning jefferson's fracture a c1 four-point burst fracture, oh, just like, okay, c1 fracture, but from like an axial load, you know compression fracture, but and that doesn't like show up right away, you know like symptoms I see.
• 56:17
  Speaker 1: But anyway, what are some distinct features of those Upper cervical instability?
• 56:22
  Speaker 1: Yes, headaches.
• 56:25
  Speaker 2: Interestingly enough, one of the guys that I trained with, he sort of is a pioneer in this and he made this like heat map for upper cervical instability symptoms, meaning like it's a whole bunch of words.
• 56:38
  Speaker 2: Those words are symptoms and the size of the word represents gotcha.
• 56:42
  Speaker 2: Uh, you know how common it is.
• 56:44
  Speaker 2: Yeah, the most common one is obviously headache, um, and then it's followed closely by dizziness, um, neck pain, tinn ringing in the ears, and then a whole host of other things like feeling off balance, tachycardia, upset stomach, anxiety, stuff like that.
• 57:08
  Speaker 1: Interesting.
• 57:09
  Speaker 2: Okay, those heat maps are really interesting, yeah, just the font is like larger for the more frequent symptoms.
• 57:18
  Speaker 2: Yeah, it a good.
• 57:18
  Speaker 2: It's a great way for, like you know, people like me to just kind of quickly understand, like, ah yes yes, exactly, I'm a very visual, visual learner, you know.
• 57:25
  Speaker 1: Yeah, it's like oh, now I see.
• 57:26
  Speaker 1: Now I got it all right.
• 57:27
  Speaker 1: So then people are battling these headaches at home.
• 57:30
  Speaker 1: What do you do like?
• 57:30
  Speaker 1: Do you like ibuprofen um, tylenol, acetaminophen, right?
• 57:35
  Speaker 1: What are the options?
• 57:39
  Speaker 2: So the type of headache dictates the treatment, meaning in migraine.
• 57:45
  Speaker 2: The sort of classic approach to treating migraines is you have rescue meds and you have preventative meds, and so anybody comes in with migraine, depending on how frequent they get it.
• 57:58
  Speaker 2: If they're getting headaches or migraine headaches more than a certain amount of times in a month, or they're having a certain amount of migraine days in a month because migraines can last more than one day, then you would offer them a rescue med and then a preventative med and those types of medications.
• 58:17
  Speaker 2: And then the rescue meds range anywhere from supplements like folic acid and magnesium all the way to your typical over-the-counter anti-inflammatories like ibuprofen, tylenol, things like that.
• 58:26
  Speaker 2: But you have to be careful about medication overuse headaches.
• 58:29
  Speaker 2: And then they get into more advanced ones like the triptans and the ergots, to more.
• 58:36
  Speaker 2: You know advanced ones like the Triptans and the Ergots and you know these are like intranasal, or they can be IV or they can be, you know, under the tongue dissolvable.
• 58:41
  Speaker 2: Those are rescue meds.
• 58:43
  Speaker 2: Now there's this newer class of the CGRPs are being formulated as rescue meds.
• 58:49
  Speaker 2: So that's pretty cool.
• 58:50
  Speaker 2: And then after that you have like the preventative meds and there's a whole host of preventative meds all the way from, like, old school blood pressure meds to antidepressants, to anti-seizure medications.
• 59:01
  Speaker 2: Botox is a very important one and that works on an interesting, a couple of different interesting mechanisms.
• 59:07
  Speaker 2: And then and then you have these newer class of the CGRP inhibitors.
• 59:11
  Speaker 2: So that's migraine as a like wrapped up in a box, um, tension headache.
• 59:18
  Speaker 2: You know I always have some disagreements, but conventionally tension headaches are treated with anti-inflammatories, muscle relaxers.
• 59:25
  Speaker 2: But I think that is an ignorant approach because you're not looking at why the person's having tension.
• 59:29
  Speaker 2: Um, you should be.
• 59:31
  Speaker 2: We should be treating the cause, whether it's dehydration, electrolyte abnormalities, sleep deprivation.
• 59:35
  Speaker 2: Is it a cervical problem that we're just misdiagnosing as a tension headache?
• 59:40
  Speaker 2: Right, so that's that.
• 59:43
  Speaker 2: Then the autonomic encephalologists, like cluster headache and like Suna Sancta and all these other autonomic ones, they do well with what's called calcium channel blockers.
• 59:56
  Speaker 2: So these are classic blood pressure medications that work on the motor tone of arteries and they basically prevent vasoconstriction, which is part of the pathophysiology of those.
• 1:00:14
  Speaker 2: And then you have certain anti-inflammatories, like indomethac, those, and then you have certain anti-inflammatories like endomethacin, which is a very powerful anti-inflammatory and for some reason that one works really really well for those, and heated high flow oxygen.
• 1:00:26
  Speaker 2: So you get this.
• 1:00:27
  Speaker 2: Like you know, it's like a nasal cannula but it's big and the air is humidified and warmed and it is just blasted in at like 30 liters a minute.
• 1:00:35
  Speaker 2: So oxygen can cause vasoconstriction as well.
• 1:00:40
  Speaker 2: So heated high-flow oxygen, calcium channel blockers, anti-inflammatories and, in some cases, botox, things like that Interesting.
• 1:00:49
  Speaker 2: What were the other ones?
• 1:00:51
  Speaker 2: We did attention to that?
• 1:00:52
  Speaker 2: Oh, cranial cervical instability.
• 1:00:53
  Speaker 1: Yeah, well, yeah, you got to, sometimes surgical, sometimes just stabilize the heck out of stuff.
• 1:00:58
  Speaker 2: Yeah.
• 1:00:59
  Speaker 1: Stability training, postural endurance, stability.
• 1:01:01
  Speaker 1: I wouldn't recommend aggressive manual therapy for upper cervical instability.
• 1:01:07
  Speaker 1: Right, there's been a lot of controversy around practitioners that will do neck cracking manip, neck cracking, you know manipulations aggressively.
• 1:01:18
  Speaker 2: Yeah.
• 1:01:18
  Speaker 1: And then vertebral artery dissection.
• 1:01:21
  Speaker 1: Yeah, but just.
• 1:01:22
  Speaker 1: And if they're not, if they're not a candidate for it, you know that's just not a good.
• 1:01:24
  Speaker 1: They're not, that's not for them.
• 1:01:26
  Speaker 2: Well, intolerance to therapy cranial cervical therapy is one of our indicators that somebody has true cranial cervical instability Right, that somebody has true cranial cervical instability Right.
• 1:01:36
  Speaker 2: And so you know, if somebody is getting better, we're like okay, they might have some cervical instability or a very mild degree of cranial cervical instability, but it's responding to therapy.
• 1:01:45
  Speaker 1: Great, let's ride that train.
• 1:01:46
  Speaker 2: If they're getting worse, they can't tolerate it, or it's just not helping.
• 1:01:49
  Speaker 2: Then we have to think okay, structurally it's not fit enough to handle the therapy, or the ligaments are too lax, or something Exactly.
• 1:01:58
  Speaker 2: And so, from there, our next sort of diagnostic step is getting what's called a digital motion x-ray, a DMX, not the wrapper, although that would be hilarious.
• 1:02:08
  Speaker 1: We're going to go see DMX.
• 1:02:09
  Speaker 1: He's like stand here, yeah, exactly.
• 1:02:12
  Speaker 2: So a digital motion x-ray is basically?
• 1:02:15
  Speaker 2: It's a live x-ray where the patient is asked to go through specific ranges of motion like extension, flexion, side bending, rotation, jaw opening, closing and then not neck side bending but head side bending with the mouth open, so that we can see C1, C2 and the dens.
• 1:02:35
  Speaker 2: And what we're looking for there, number one, is are they maintaining that normal lordosis of the spine and is there segmental instability when they're moving around, Meaning when they flex and extend, like are there certain facet joints that are gapping?
• 1:02:51
  Speaker 2: Are things sliding around?
• 1:02:52
  Speaker 2: Yeah, and then particular attention to the first three levels.
• 1:02:56
  Speaker 2: You know, when they're flexing and extending, a lot of times in an unstable patient that axis, the C2, will start, it'll like move in and out, or the C1 will start moving in and out in relation to C2.
• 1:03:09
  Speaker 2: And that causes a lot of troublesome neurologic symptoms because you can cause transient compression of the vertebral arteries, the spinal arteries, a lot of the nerves that are exiting through those delicate little foramen right there.
• 1:03:22
  Speaker 1: Or myelopathy symptoms.
• 1:03:24
  Speaker 2: Yeah, you can get myelopathy symptoms and really severe ones.
• 1:03:26
  Speaker 2: What's tricky is that a lot of people can have craniosacral instability but not be a candidate for surgery.
• 1:03:31
  Speaker 2: A lot of people can have craniosympathetic instability but not be a candidate for surgery.
• 1:03:35
  Speaker 2: Reasonably so, because the surgery for that is like pretty intense, like they're bolting your head onto your neck, yeah, so you know surgeons aren't excited to do that.
• 1:03:46
  Speaker 2: So what ends up happening is a lot of people have craniosympathetic instability but it's not enough to warrant.
• 1:03:52
  Speaker 2: Yeah, so they, they don't, they're left with no options.
• 1:03:54
  Speaker 2: Um, there is at the centeno schultz clinic out in in colorado and also I think, uh, no, no, I'm thinking something different.
• 1:04:05
  Speaker 2: So in in colorado, um, they developed a procedure called the percutaneous um cervical ligament injections or percutaneous injection of cervical ligaments I was gonna say is there like a regenerative option?
• 1:04:18
  Speaker 2: And there's only a handful of people in the world that do this, and three of them are in Denver, colorado.
• 1:04:23
  Speaker 2: They developed this procedure slowly over time it's still and it's like experimental phases, but at this point they've treated about 15,000 patients, wow, and basically what they're doing is they are injecting bone marrow concentrate.
• 1:04:38
  Speaker 1: Okay.
• 1:04:38
  Speaker 2: Much like the bone marrow concentrate that I do in my clinic.
• 1:04:40
  Speaker 2: Right but they are injecting it into the alar and transverse ligaments and then whatever other supporting cervical, cranial cervical structures.
• 1:04:49
  Speaker 2: They are like the atlantooccipital ligaments and the myodural bridge in the back and all these other important ligaments.
• 1:04:54
  Speaker 2: Cool, the technique that they use is very novel.
• 1:04:58
  Speaker 2: Nobody else is doing this.
• 1:04:59
  Speaker 2: It's a trans oral technique.
• 1:05:01
  Speaker 2: Um, wow, I'll send you a picture.
• 1:05:03
  Speaker 1: Are they under anesthesia, I assume, or okay?
• 1:05:06
  Speaker 2: yeah, they're under anesthesia and you know they had to.
• 1:05:10
  Speaker 2: They developed this like custom 3d printed mouthpiece to sort of hold the mouth open and then they have, you know, like this very specific uh antiseptic protocol to make sure that you're not tracking mouth bacteria in there.
• 1:05:23
  Speaker 2: So, um, and then you have to be very, very skilled at driving a needle, because what, literally, middle meters away from these ligaments is your brainstem.
• 1:05:31
  Speaker 2: So, um, wow, and so I was fortunate enough to like see and work with these folks and and, uh, I didn't do any myself because it's I would lose sleep, uh, it's just incredibly high risk.
• 1:05:46
  Speaker 2: So, yeah, as a trainee, I wasn't really in the position to do that, but so they go through the mouth they go through the mouth and they introduce the needle.
• 1:05:53
  Speaker 2: Yeah, they go on either side of the dens, so like if you have c1 here or if, like c1 is like a ring, like so, and you have the dens like this, there are two little holes on either side of the dens and they call that the something hiatus.
• 1:06:09
  Speaker 2: I think it's called, like the paradens hiatus, dense hiatus or something.
• 1:06:17
  Speaker 2: Anyways, they can.
• 1:06:17
  Speaker 2: That's where they sort of guide the needles through those tiny little holes, and what's on the other end of those tiny little holes is the transverse ligament, and so they can inject them there and then they can also get the alar ligament.
• 1:06:26
  Speaker 2: They can go above and below C1.
• 1:06:28
  Speaker 2: Very like technically challenging procedure, yeah, I imagine.
• 1:06:34
  Speaker 2: But they're basically addressing the root cause of cranial cervical instability, and it is laxity and instability, whether it's unilateral or bilateral, whether it's congenital or acquired.
• 1:06:44
  Speaker 2: They're addressing the laxity in these ligaments and tightening the head back down onto the skull.
• 1:06:49
  Speaker 2: Yeah, yeah, yeah it's incredible.
• 1:06:51
  Speaker 1: That's really cool.
• 1:06:51
  Speaker 1: What results Been pretty promising.
• 1:06:54
  Speaker 2: Yeah, results have been promising Of.
• 1:06:55
  Speaker 2: That's really cool.
• 1:06:56
  Speaker 2: What results Been pretty promising?
• 1:06:57
  Speaker 2: Yeah, results have been promising.
• 1:06:57
  Speaker 2: Of course it varies with what kind of pathology you're treating.
• 1:06:59
  Speaker 2: You know, someone who is otherwise healthy, doesn't have a congenital ligament disorder, had a traumatic, you know, maybe a motor vehicle accident, and they get seen sooner than later, tend to have the best outcomes Maybe one treatment and they're good.
• 1:07:13
  Speaker 2: The other side of the spectrum is someone with like Ehlers-Danlos.
• 1:07:22
  Speaker 2: They have a congenital collagen vascular disorder.
• 1:07:23
  Speaker 2: They have lax ligaments at baseline and so they may need repeated treatment, which does have an additive effect with time got it.
• 1:07:29
  Speaker 1: Yeah, that's.
• 1:07:29
  Speaker 1: I mean, that makes total sense too.
• 1:07:30
  Speaker 1: Yeah, yeah, because I was mentioned I was gonna bring.
• 1:07:33
  Speaker 1: I was on my head thinking, ehlers-danlos, I'm like, what do you do for that?
• 1:07:36
  Speaker 2: Yeah, so just repetitive treatments that can wean out over a long time horizon, yeah, and usually it comes down to just like a maintenance.
• 1:07:45
  Speaker 2: Yeah, you know they get a certain amount of benefit for a certain amount of time with every treatment, and then they'll know They'll say, oh, it's coming back.
• 1:07:53
  Speaker 1: Time to get my PICL injection.
• 1:07:54
  Speaker 1: Wow, yeah, yeah, interesting, all right.
• 1:07:57
  Speaker 1: Last question Headaches from concussion.
• 1:07:59
  Speaker 1: Concussions, it'll be a whole different discussion.
• 1:08:02
  Speaker 1: Let's do that.
• 1:08:02
  Speaker 1: Next podcast is on athletes and concussion and treatment for that.
• 1:08:05
  Speaker 1: Okay, but headaches, post-concussion super common.
• 1:08:12
  Speaker 2: Yeah.
• 1:08:13
  Speaker 1: Right, what things should we look out for for athletes?
• 1:08:19
  Speaker 1: Um, having headaches, you know, uh, from a contact sport Cause we're knowing that, like from the concussion stuff that's come out recently, over the last decade, it's like they're a lot more common than we had thought otherwise.
• 1:08:29
  Speaker 1: Not like you got knocked out Right or like no, you have a you know, you got you know woozy and dizzy, and now that was a concussion.
• 1:08:36
  Speaker 1: Imagine it was like all these minor micro concussions are happening consistently.
• 1:08:39
  Speaker 1: But yeah, what should we look out for for that?
• 1:08:42
  Speaker 1: I feel like this is a concern Go.
• 1:08:44
  Speaker 2: Yeah, Obvious signs obviously, like you know, altered consciousness that's the biggest one.
• 1:08:49
  Speaker 2: More subtle things are anterograde or retrograde memory loss meaning retrograde, meaning you're missing events that happened before the injury, and anterograde meaning, like you know, I got knocked out or I got hit and I don't really remember anything until I got home later that night.
• 1:09:14
  Speaker 2: That's anterograde Got hit and I don't really remember anything until I got home later that night.
• 1:09:16
  Speaker 2: That's answer grade.
• 1:09:16
  Speaker 2: So, and those can be subtle too, because it's kind of like browning out in a sense, you know you're conscious, but you're like missing events.
• 1:09:25
  Speaker 2: So that's one Sleep disturbances, anxiety, mood changes, especially like irritability.
• 1:09:34
  Speaker 1: Irritability is a big one Um vomiting.
• 1:09:38
  Speaker 2: Yeah, I mean, yeah, vomiting is a goes.
• 1:09:40
  Speaker 2: Is up there with like loss of consciousness, somebody who's vomiting, then you know that they had a pretty significant injury.
• 1:09:45
  Speaker 2: Got it Interesting I'm thinking more in the realm of like minor TBI.
• 1:09:49
  Speaker 2: So, this is what we see.
• 1:09:50
  Speaker 2: You'll see a lot more of this and most of these go undiagnosed, like I was recently watching um.
• 1:09:55
  Speaker 2: You know that show on Amazon called like GT.
• 1:09:58
  Speaker 2: Uh, it's, it's the guys from the BBC.
• 1:10:01
  Speaker 2: Um, what was that car show on the BBC for like the longest time, top gear.
• 1:10:06
  Speaker 2: Thank you.
• 1:10:07
  Speaker 1: Yeah.
• 1:10:08
  Speaker 2: Uh, these are.
• 1:10:09
  Speaker 2: These are the guys that used to do top gear.
• 1:10:10
  Speaker 2: They did this show called grand tour and it's basically top gear, but without the bbc's influence.
• 1:10:15
  Speaker 2: Uh, and they recently did an episode where, like they're in the arctic or something like that, and one of the guys, james may, slams his car into the wall at like high speeds and you can see it on the camera.
• 1:10:27
  Speaker 2: I mean, he was like whipped around laterally, his head hit the opposite b pillar like it was bad, and then they just like carried on filming like nothing happened, and I was like this guy just had a TBI and he's probably got some.
• 1:10:39
  Speaker 2: He's definitely got whiplash, he might have some craniosacral instability at this point and he's just like Anyways, so minor TBI symptoms is going to be anything that affects, like the cranial senses, so disturbances and smell.
• 1:10:54
  Speaker 2: So disturbances in smell.
• 1:10:55
  Speaker 2: You know, complete anosmia is a bad sign because that means you could have sheared off the olfactory nerves, that sort of go from the brain and penetrate the skull and go into your nose and so when the brain does this and the nerves go through these little skull holes in the skull, it like shears the nerves off.
• 1:11:09
  Speaker 2: So anosmia is one and anosmia is dangerous because it will affect memory formation and cognition down the road, because smell is like a very primitive sense for hours and it's literally your smell.
• 1:11:23
  Speaker 1: neurons sit right next to your amygdala and the hippocampus and the mesial temporal lobe probably why people have a lot of strong emotions and memory with uh, drinking, like drinking, like you know, very um prominent liquor.
• 1:11:37
  Speaker 1: It's like I can't drink Goldschlager anymore.
• 1:11:40
  Speaker 1: Like you know, coconut rum can't even smell it.
• 1:11:43
  Speaker 1: I'll get sick.
• 1:11:44
  Speaker 1: Spring break of 98.
• 1:11:46
  Speaker 2: Yeah, so anosmia is one um, blurry vision, a double vision.
• 1:11:52
  Speaker 2: So double vision is more like Frank double vision If they're seeing two images side by side or on top of each other at an angle.
• 1:11:58
  Speaker 2: It means that they may have placed so much traction on one of the cranial nerves that it's affecting the motor movement of the eye.
• 1:12:04
  Speaker 2: The most vulnerable one is cranial nerve six, the abducens nerve.
• 1:12:08
  Speaker 2: It comes out from the back of the brainstem no, sorry, it comes out from the front of the brainstem, but further down it goes on this long journey all the way up and then goes over this like kind of sharp bony cliff and then goes to the eye and it can get tugged on and get damaged and so the eye has the inability to look out and so now it falls in.
• 1:12:26
  Speaker 2: So you have this eye that kind of looks like this.
• 1:12:28
  Speaker 1: Yeah.
• 1:12:36
  Speaker 2: Interesting.
• 1:12:36
  Speaker 2: The opposite is one of the fourth cranial nerve, the trochlear nerve, comes out of the back of the brain, some wraps around and goes to the front and it is responsible for making your eye go like down and to the inside, and so when that gets disrupted the eye kind of goes out at an angle.
• 1:12:45
  Speaker 2: Gotcha, that's eye stuff, blurry vision.
• 1:12:48
  Speaker 2: You know Hearing you can get a lot of subtle hearing loss, not obvious enough for someone to detect with like spoken conversation, right.
• 1:13:02
  Speaker 2: What they'll complain of is like in a crowd I can't hear the person I'm talking to anymore, so they lose that like resolution got it what's?
• 1:13:07
  Speaker 2: Really special about our hearing system is that we're able to hone in on certain sounds.
• 1:13:11
  Speaker 2: It goes back to that white noise thing.
• 1:13:13
  Speaker 2: It's like you know your brain is trying to pay attention to something, so it'll suppress other stuff around it to focus.
• 1:13:18
  Speaker 2: Yeah, yeah but if the quality of signal from the ear coming is is bad, or if the uh processing centers are messed up, then you kind of lose that stability yeah, that makes sense, yeah yeah, and then um how much time we can probably wrap it up.
• 1:13:31
  Speaker 1: Yeah, okay, yeah we'll have to get into.
• 1:13:33
  Speaker 1: This is really interesting with concussions and stuff we can spend more time a whole podcast on just that, that's.
• 1:13:38
  Speaker 1: Uh, yeah, that's, I mean, it's super interesting.
• 1:13:40
  Speaker 1: I um, I'm just reflecting on, like, because I had a couple bad concussion.
• 1:13:45
  Speaker 1: I think too I had one bad one.
• 1:13:47
  Speaker 1: Yeah, that I remember as a sophomore and then, and I don't remember, I had the anterior um grade, uh, amnesia oh yeah, I just after that I couldn't remember anything, yeah, and before that I had a little, I don't know, man, that was so long ago, yeah.
• 1:14:01
  Speaker 1: But yeah, I mean, and also I wonder if, like vertigo, right, yeah, I've heard a lot of correlation of like sports, soccer, all the heading.
• 1:14:13
  Speaker 1: I didn't you know, if you think about like headers, you know, oh gosh, it's so much, it's so bad.
• 1:14:16
  Speaker 1: You know, yeah, I was like all the time Football, of course, hockey, lacrosse, but Military Military A shockwave from artillery.
• 1:14:26
  Speaker 1: Yeah, military, totally All this stuff, military Jumping out of airplanes, but vertigo symptoms where the inner ear gets affected, but then also the eye gaze stability, yeah, and then something I've struggled with for a while is eye gaze.
• 1:14:39
  Speaker 2: Yeah, oh, you must work with that.
• 1:14:41
  Speaker 2: I'm sure you work with that to some degree.
• 1:14:42
  Speaker 2: Is that more like a niche?
• 1:14:44
  Speaker 1: It is a niche.
• 1:14:44
  Speaker 1: We do see some of it.
• 1:14:45
  Speaker 1: Vertigo, vestibular rehab there is rehab for that.
• 1:14:49
  Speaker 1: Just a heads up.
• 1:14:49
  Speaker 1: We talked to a lot of patients where they're like I'm still waiting in a test if I have vertigo, and I'm like do you feel it?
• 1:14:55
  Speaker 1: Yeah, like you know you're there cause you have vertigo.
• 1:14:57
  Speaker 1: What, like what's this test going to tell you?
• 1:14:59
  Speaker 1: You know you that you have it, okay, now what are you going to do about it, though?
• 1:15:03
  Speaker 2: Yeah, like what's the actual?
• 1:15:04
  Speaker 2: Analyze the results in a way that affects therapy.
• 1:15:06
  Speaker 2: What?
• 1:15:06
  Speaker 1: are you actually going to do to treat the vertigo vestibular?
• 1:15:09
  Speaker 1: My wife was that, which is she presented at a national conference today on vertigo, vestibular and concussion rehab, which is really interesting as in isolating which semicircular canal was involved.
• 1:15:20
  Speaker 1: And then how do you treat it versus a COR cervical ocular reflex versus a VOR vestibular ocular reflex or eye gaze stability?
• 1:15:28
  Speaker 1: So where do you treat, how do you treat that?
• 1:15:30
  Speaker 1: There's exercises and habituation exercises to improve the sensory conflict between all those things and habituate and desensitize things that's so cool.
• 1:15:45
  Speaker 1: Yeah, it's really interesting.
• 1:15:46
  Speaker 1: So anyway, other than meds, it's like that's the only route to go.
• 1:15:48
  Speaker 1: There is actual treatment for vertigo vestibular, which is really interesting, but anyway we'll have to talk about concussions a full length.
• 1:15:56
  Speaker 2: Yeah, because we didn't even get into the cognitive stuff for the corticals, right exactly, yeah, exactly.
• 1:16:01
  Speaker 1: But anyway, man, that's.
• 1:16:02
  Speaker 1: I appreciate you coming in, that's really cool.
• 1:16:04
  Speaker 1: Well, we'll deep dive in that.
• 1:16:05
  Speaker 1: Yeah, I'm sure you got a busy day, rest of today seeing patients and stuff.
• 1:16:08
  Speaker 1: Yeah, got an afternoon.
• 1:16:09
  Speaker 1: Yeah, productive, awesome.
• 1:16:11
  Speaker 1: Well, if people want to reach out to you, how, what's the best, they can hit you up.
• 1:16:14
  Speaker 2: So you can hit me on myself no, I'm kidding Our website, palmbeachregencom.
• 1:16:21
  Speaker 2: And then you can.
• 1:16:24
  Speaker 2: Our main line is a line that you can text too, and then you can look at me on Instagram docregen D-O-C-R-E-G-E -N.
• 1:16:32
  Speaker 2: Yeah, it's probably the two best ways.
• 1:16:36
  Speaker 1: Awesome.
• 1:16:37
  Speaker 1: Well, reach out if you have any questions.
• 1:16:38
  Speaker 1: And, uh, if, if you need any regenerative orthopedic care, he's your guy.
• 1:16:42
  Speaker 1: We have a good relationship.
• 1:16:43
  Speaker 1: We send people back and forth, so we're always recommending Dr Gaddis, Um, and if you have any questions, definitely reach out to us.
• 1:16:48
  Speaker 1: We'd love to answer some questions, at least get a deep dive on what you have going on and if we're the right ones to help you Dr Gaddis is, or other people, other folks in the area we can at least chat and give you a right direction and also ideas for the podcast, right Comments, questions concerns, conflicting opinions, and then we're always open to discussion.
• 1:17:04
  Speaker 1: What's this?
• 1:17:06
  Speaker 2: That is the American Academy of Neurology.
• 1:17:08
  Speaker 2: Issue on headaches oh, wow, and it breaks down all the headaches that are out there.
• 1:17:12
  Speaker 1: Cool, I'll skim through this little light reading at night to continuum research on headaches for the neurology department.
• 1:17:21
  Speaker 1: Awesome, Cool, Awesome man and uh.
• 1:17:24
  Speaker 1: But anyway, I'll reach out to you in the questions and we'll catch y'all next time.