August 4, 2025 • 35 mins
Dr. Glen Zielinski from Northwest Functional Neurology in Lake Oswego, OR, joins us to talk about how he’s using cutting-edge, image-guided transcranial magnetic stimulation (TMS) technology to treat more than just depression. With neuro-navigated TMS, he's able to target specific brain regions with millimeter precision—and he's not stopping there.
Dr. Zielinski walks us through how he customizes every treatment using detailed neurodiagnostic testing, identifying exactly where and why the brain isn't functioning properly. Instead of using generic protocols, he fine-tunes TMS treatment plans based on individual brain mapping.
We also dive into:
- How the default mode network and salience network are key players in emotional dysregulation after concussion
- Why combining TMS with targeted neurological rehab exercises leads to stunning outcomes—like a 96% response rate and remission rates in the high 80s
- The use of TMS for dystonias, dysautonomia, movement disorders, and more
- Key contraindications you need to know before considering TMS
Whether you’re a patient exploring new treatment options or a clinician wanting to deepen your understanding of brain-targeted therapies, this episode is packed with insight you won’t want to miss.
Dr. Zielinski's Website: Northwest Functional Neurology
Youtube channel: @northwestfunctionalneurolo5250
Get 20% off your first order of Puori protein with code LIFEAFTERIMPACT by following this link.
Dr. Wolf's book Concussion Breakthrough: Discover the Missing Pieces of Concussion Recovery is now available on Amazon!
What topics do you want to hear more about? What questions do you have? Email us at lifeafterimpact@gmail.com
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Website: lifeafterimpact.com
Medical disclaimer: this video or podcast is for general informational purposes only, and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice diagnosis or treatment. Consumers of this information should seek the advice of a medical professional for any and all health related issues.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Glen Zielinski (00:00):
Because if you can't inhibit what's
happening around you, if youcan't inhibit all the visual
stimulation, if you can'tinhibit all the auditory
stimulation, you know, Costco islike our final exam for our
patients, because that's themost overwhelming circumstance
that we can put anybody in interms of visual and auditory and
cognitive paths to someone.
If you can't inhibit that kindof stuff, you can't function in
(00:21):
the world.
Dr. Ayla Wolf (00:23):
Welcome to Life After Impact the concussion
recovery podcast.
I'm Dr Ayla Wolf and I will behosting today's episode, where
we help you navigate the oftenconfusing, frustrating and
overwhelming journey ofconcussion and brain injury
recovery.
This podcast is your go-toresource for actionable
information, whether you'redealing with a recent concussion
(00:44):
, struggling withpost-concussion syndrome or just
feeling stuck in your healingprocess.
In each episode, we dive deepinto the symptoms, testing,
treatments and neurologicalinsights that can help you move
forward with clarity andconfidence.
We bring you leading experts inthe world of brain health,
functional neurology andrehabilitation to share their
(01:05):
wisdom and strategies.
So if you're feeling lost,hopeless or like no one
understands what you're goingthrough, know that you are not
alone.
This podcast can be your guideand partner in recovery, helping
you build a better life afterimpact.
All right, Dr.
Glen Zielinski, welcome to LifeAfter Impact the concussion
(01:26):
recovery podcast.
You are a chiropracticphysician and board certified
functional neurologist with anabsolutely beautiful clinic in
Lake Oswego, oregon, and Ibrought you onto the show today
to talk about your integrationof transcranial magnetic
stimulation with all of yourother tools, techniques,
therapies specifically forpeople with traumatic brain
(01:49):
injuries.
So welcome to the show andthank you for being here.
Dr. Glen Zielinski (01:53):
Hey, happy to be here.
Dr. Ayla Wolf (01:55):
Yeah, so tell me a little bit about your clinic.
I know that you do five-dayintensives primarily.
Is that correct?
Dr. Glen Zielinski (02:04):
Yeah, generally, that's probably the
majority of our business at thispoint.
Dr. Ayla Wolf (02:08):
Yeah, so you get to spend a whole week with
people and really get to seethem from beginning to end.
And tell me a little bit aboutyour integration of the
technology, especially that TMS,and when did you bring that
into your clinic and what hasthat looked like or how has that
evolved over time?
Dr. Glen Zielinski (02:26):
All right.
Well, so we have been using TMSin our practice since, I think,
2018 or early 2019.
We've gone through a couple ofdifferent TMS systems.
Currently we're using a systemby a company called mag venture
and the beauty of that is thatour unlike most tms, where the
(02:51):
process just largely comes downto doing finding a motor
threshold on somebody by youknow, moving this coil around
and figuring out where yourthumb twitches and saying, okay,
here's the primary motor cortex, the areas that we want to
stimulate.
Now we're just going to measurebased on landmarks and hope for
the best, hope that we'regetting close.
We now have a system that'sneuro-navigated, which means we
use this MRI database.
(03:12):
We upload a brain MRI, it feedsit into this AI thing, it
stretches it out and morphs theAI brain into a way that allows
us to identify any area on thecortex that we want to simulate
and hit it within like half amillimeter, which is pretty
fantastic.
So that's given us some prettydramatic increases in terms of
(03:33):
what we can and can't treat withTMS.
Traditional TMS is largely usedto just stimulate the
dorsolateral prefrontal cortex,which is a critically important
area.
I mean, it's a massivelyimportant node in the default
mode network and in the saliencenetwork and it's sort of like
the apex of cognition within thefrontal lobe.
(03:54):
Just about everything runs intothe DLPFC and just about
everything is stimulated one wayor another by the DLPFC and, as
a consequence, it's an areathat is impacted almost
inevitably in concussion.
There's research that showsthat by the time you've had two
significant hits, you've got aproblem with your DLPFC.
People are looking at DLPFCproblems as now a biomarker of
(04:15):
post-concussion syndrome, as inif you don't show some
dysfunction in that system, thenyou've got problems, something
beyond just concussion.
There's something else going on.
Now.
Traditional TMS just simulatesthat and if you go to see your
average TMS clinic, they're justgoing to do left DLPFC because
(04:36):
that's the only protocol thatthey've been trained in.
Your average psychiatricpractice is just doing that and
that alone right, and that isvery relevant for a lot of
patients, but by no means allpatients right.
There's tons of people thathave problems, on the right side
, for example, and if you have aright DLPFC lesion then that's
not exactly helpful.
You may even be making somebodyworse by doing that kind of
(04:58):
stimulus.
So the key is with TMS you needto understand first of all what
it is that you're trying toaccomplish, and it's not as
simple as the sort oftraditional psychiatric.
Do a PHQ-9 depression scale andsee if your scores are low, and
if they're low then let's seeTMS.
What we do is based, first ofall, on some pretty heavy
(05:21):
neurodiagnostics, and theneurodiagnostics that we engage
in are I mean, we address everyconceivable system.
We do something like 50-odddiscrete tests that give us
objective data on what's goingon with somebody's brain before
we even start any kind oftherapy, and one of the things
that we pay quite a bit ofattention to is
(05:44):
anti-sachetometry.
Now, sachetometry is a systemthat I helped develop for this
company called Interacoustics,which does video and
asthmography testing, and videoand asthmography is infrared
cameras.
You're tracking your pupils,you're seeing various different
types of stimulation take placeon a screen and the system
(06:05):
basically just records eyemovements in response to the
different types of stimulus.
This is probably the best wayto see really what's going on
with somebody's brain after aconcussion, because all of the
systems that tend to be impactedby all the rotational shearing
forces that happen when yourhead gets snapped around, we can
see function in all of thosesystems by looking at eye
movements, because eye movementsall start in the same part of
(06:29):
the brain stem, which is an areathat takes it.
That's sort of like the apex ofall the rotation.
I mean, if you just think of aconcussion is like if your
brain's like a big cauliflowerand the brain stem is the stock
of the cauliflower.
Um, all the maps that yourbrain uses to make sense out of
where you are in the world, theyall live in different parts of
the cortex but they integrateright in the middle of the pons
and the midbrain, which isbasically the stalk of the
(06:50):
cauliflower.
And getting concussed is likeyou grab the stalk of the
cauliflower and just snap itreally fast and all these
rotational shearing forces goright where you're holding,
which means right where you putall those maps together.
And that's also the areas thatnot only control all your
autonomic nervous system butalso the areas that basically
generate all of your eyemovements.
And different types of eyemovements coming from different
(07:11):
parts of the brain can show youa ton about what's happening in
the different parts of thebrainstem and cerebellum and
parietal lobe and frontal lobeand basal ganglia and all the
pathways in between that have atendency to be affected by these
things.
And it's one thing to be ableto see that somebody has a
problem on an image and it'sanother thing entirely to see
under what sets of circumstancesthose pathways fatigue and fail
(07:32):
, what kind of stimulus pushesthem over the edge, what makes
them melt down, and so on and soforth, and that can give you
like a massive amount ofinformation about what's
happening with somebody's brainafter a concussion.
And it doesn't just show youwhat's wrong.
It shows you if you understandwhat you're looking at, it shows
you what to do about it, how toget somebody better.
Right Now there is a specificeye movement called a saccade,
which is a fast jump from targetto target.
(07:54):
And this is how you build yourenvironmental map.
Saccades come from your frontallobe through your basal ganglia
into your midbrain and down intothe pons.
So basically, that wholebrainstem pathway is being
driven by descending frontallobe output.
And again, frontal lobe iscognition, executive function
and so on and so forth.
Right, everything that peoplelike to think of as
(08:15):
consciousness is mostly frontallobe, and when you talk about
people having cognitive problems, you're talking about some kind
of a frontal lo, frontaldeficit in most cases Now.
So again, a saccade is movingfrom target to target, going
towards something that's calleda prosaccade.
An antisaccade is a whole otherball of wax.
An antisaccade is you have atarget and your brain has a
(08:37):
reflex that wants to make youmove towards that target, but
you have to be able to inhibitthat reflex and then you have to
be able to move your eyes inthe opposite direction.
Now that is a higher-levelexecutive function task that
comes from specifically an areacalled the dorsolateral
prefrontal cortex, the DLPFC,and generating antipsychots with
stimulus on the right is afunction of the left DLPFC and
(08:59):
vice versa.
Um, there is a ton of newemerging evidence around how
anti-saccades get messed up whensomebody has concussion.
I mean, I presented on that atthe Barony Society meeting in
Madrid a couple of years ago, atthe biggest vestibular
conference in the world.
The whole idea of anti-saccadesis they're not just about you
(09:22):
being able to not look at atarget, they're about response
inhibition.
All right, and responseinhibition is essentially if
you're capable of listening tome, it's because you're
inhibiting the sound of thebirds chirping behind my head
Right, or the sensation of yourbutt on the chair that you're
sitting on and all this othersensory input that's just there
at all times.
And if you can't inhibit, thenyou sort of become a slave to
(09:48):
the environment and you get whatwe like to call squirrel brain,
in the sense that you're in themiddle of squirrel, you know,
and you can't inhibitenvironmental stimulation.
Now that's massively problematicwhen people get into
complicated sensory environments, because if you can't inhibit
what's happening around you, ifyou can't inhibit all the visual
stimulation, if you can'tinhibit what's happening around
you, if you can't inhibit allthe visual stimulation, if you
can't inhibit all the auditorystimulation.
You know, costco is like ourfinal exam for our patients,
(10:11):
because that's the mostoverwhelming circumstance that
we can put anybody in in termsof visual and auditory and
cognitive tasks and so on and soforth.
If you can't inhibit that kindof stuff, you can't function in
the world.
And that's why people findinevitably that they get into
complicated sensory environmentsand they have meltdowns.
So an anti-saccade veryspecifically looks at your
(10:32):
ability to inhibit the world andif it doesn't work, then good
luck, right, okay, soanti-saccades come from the
dorsolateral prefrontal cortexand traditional TMS is basically
geared towards stimulating theDLPFC directly.
So if you're not familiar withTMS, it's this big MRI-strength
magnet with a very focal beam,you place it directly over your
(10:56):
DLPFC.
With traditional TMS it's theweirdest sensation in the world.
It feels like somebody'ssnapping you in the forehead
with an elastic band but itsounds like somebody's drilling
a mallet into your head with abig wooden stake.
Like it's just crazy.
But most people don't have anyproblem with it.
I mean, there is the odd personthat can't tolerate the
stimulus, but I mean we havemore patients that fall asleep
(11:18):
in the chair during TMS than wedo, people that can't handle it.
But the point is that itdirectly stimulates that pathway
.
It directly stimulates thedorsolateral prefrontal cortex
from through your skull and itlights it up like a Christmas
tree.
So when TMS was first presented,when it first got its FDA
(11:40):
approval, the thing about TMSwas that if you looked at the
response rate of SSRIs theantidepressant medications that
most people go on if they havechronic refractory depression
the response rate on an SSRI issomething like 22% for the first
med and then it's somethinglike 14% for the second med and
(12:01):
like 3% or 4% for the third med,with response being 50%
improvement or better.
And if you haven't% for thethird med, with response being
50% improvement or better, andif you haven't responded by the
third med, almost inevitablyyou're not responding.
Okay, and what that means isthat the majority of the
depressed population don'trespond to meds right.
They just don't have thebenefit that everybody's
supposed to get.
So TMS was originally studiedlooking at that population, and
(12:25):
they put together a six weekprotocol.
You basically get 18 minutesworth of STEM five days a week
for six weeks.
The research on that showedsomething like a 68% response
rate and a 48% remission rate,which is dramatically better
than you can get from anymedication.
Dr. Ayla Wolf (12:43):
And in a short period of time.
Dr. Glen Zielinski (12:45):
Yeah, exactly, exactly right Now.
Yeah, the thing is and this isa really important thing to
understand depression is not aTMS deficiency.
Depression is not a DLPFClesion.
Depression is a problem withnetworks.
Okay, depression is somethingthat involves your whole brain.
You can have one area that'scritical for that function, but
(13:08):
that doesn't mean it's comingfrom that area.
It means that that area is, youknow, an apex, involved in a
lot of pathways, lots of stuffbasically summates in that area.
But that doesn't mean that'swhere the problem is.
Now the thing is, when you startlooking at what happens with
concussions, if you just look at, like classic depression, that
happens, you know, refractorydepression, with post-concussion
syndrome, which is the majorityof people that have been
(13:30):
significantly concussed, themajority of people that have
been significantly concussed.
If you look at that it's, Imean you can have that problem
and the injured areas of yourbrain or brainstem or cerebellum
or frontal lobe can be justabout anywhere and you can still
wind up in a situation whereyour DLPFC is not firing very
well, not because it itself wasdirectly lesioned, so much as
(13:51):
that.
Everything runs in there.
They did this thing called theConnectome Project a few years
back, where the imagingtechnology had reached the point
where now we can not only seewhat different parts of the
brain do but how they allconnect.
And the DLPFC is essentiallythe most connected part of the
entire system.
Everything runs in there and itaffects just about everything
and it affects just abouteverything and, as a consequence
(14:11):
, if you have shearing forces ordiffuse axonal injury or damage
somewhere, it's almostinevitable that it's going to
influence what happens in theDLPFC at some point.
Okay Now, with that systembeing a critical node in again
the default mode network, thesalience network, there's a few
different ways to look at whatthose systems mean.
The way that I usually explainit to patients even though this
(14:33):
isn't like strictly accurate isjust to say that you know your
default mode network is sort oflike resting emotional tone
between thoughts and you wantthat to be positive and when
it's not working very well itbecomes negative.
And your salience network ishow you build emotional context
around information and you wantto be able to integrate that
stuff appropriately and normal.
You're walking down the streetand stuff happens and you're
(14:54):
like, wow, stuff happened andyou keep walking.
And when those systems don'twork very well, you're like
walking down the street.
Wow, stuff happens and you justimmediately default to this
negative self-talk and it's likeand what is it about me that
makes all this stuff keephappening?
And now I'm going tocatastrophize and die alone and
unloved or whatever, right?
And that's a circumstance wherepeople just can't successfully
integrate that kind ofinformation correctly because of
(15:16):
those networks not working verywell, and that sets people up
for chronic depression andchronic anxiety and PTSD and
catastrophizing and so on and soforth.
All right, so the point I'mtrying to make is that you can
affect those systems by directlystimulating it and it'll help
in some cases.
If that's where the integratedproblem is, if it's on the other
side of the brain, well thenyou need to understand that, and
(15:38):
if it's in other areas that arefeeding into that, you need to
understand that as well.
Now, we've been doing TMS aspart of our neurorescue program
for years.
Right, we've been looking atdoing TMS as an integrated
therapy within all of our Ishouldn't say all, but within
the majority of the patientsthat we work with with
post-concussion syndrome, and wewere, and we probably still
(16:03):
will, publish on this at somepoint.
We just got way too busy andnever quite got around to it.
But we tracked our first 300patients, that we did this with
the first 300 in week-longintensive therapies.
That involved us doing TMS and,like I said, traditional TMS,
like 68 response rate.
Our response rates were like96% I think, and our remission
(16:25):
rate was in the high 80s, youknow.
And that's doing TMS twice aday over one week coupled with
the rest of the therapy, andthat's the whole point, right,
because it's not just aboutbeing able to stimulate that one
area, it's about getting yourentire brain to light back up
and integrate correctly.
Okay, and that requires beingable to map out everything
(16:47):
that's wrong, where everythinghas the problem, and then coming
up with an appropriate protocolto be able to fix whatever it
is that you find right.
And that kind of pivots towardsour general approach with
everything.
Our general approach is, I mean, we sort of follow the same
heuristic, the same plan withevery patient and the pieces are
different for everybody, butthe concepts are exactly the
(17:09):
same for everyone.
We start with really intenseneurodiagnostics so we can see
exactly where the problem is,which systems are working, which
ones are having a hard timekeeping up, what we need to do
in order to facilitate them, andthen from there, once we've
identified the tissue that we'vedecided that we want to go
after step one we do somethingto build metabolic capacity in
that system.
And step one is that's likeoxygen therapies or laser
(17:34):
therapies or LEDs, all thesethings that one way or another
allow us to build energy andmetabolic capacity within those
systems.
Step two is find some way todirectly stimulate those
pathways.
And if we're talking aboutsomething like, say, a problem
in the DLPFC, tms is the perfectway to do that.
Okay, but if we're talkingabout a brainstem system, then
we're talking about doing liketrigeminal electrical stimulus.
(17:55):
Or if it's like a vestibularlesion, we're talking about
putting somebody in a gyro stemor an omni-ax and spinning them
off axis in a way that's goingto directly activate or
integrate particular vestibularreceptors.
And then from there, the nextstep is find some way to
exercise that pathway, and thatis, you know, eye exercises,
inner ear things, balanceexercises, whatever.
(18:17):
It is that we're trying tofacilitate, cognitive exercises,
you know whatever.
And then from there the laststep is find some way to
integrate it.
And integrating it for us meanseverything from doing all these
exercises on, you know, touchscreens with all these cognitive
things that we can integrateeyes with body, with vestibular
systems, with cognition, withemotional regulation to taking
(18:38):
them out on our big gym floor.
Since you were out, youprobably haven't seen this, but
I added an extra like 1,200square feet.
We've got like 50 lane or 50foot turf, four lanes and like a
full gym and all this kind ofstuff, and that's allowed us to
basically start doing all kindsof more kinetic, dynamic things
and make up physical exercisesfor people along the way to help
integrate all that kind ofstuff.
(19:00):
And the point is that tms is afantastic stimulus.
It's a fantastic way todirectly hit some very specific
pathways in ways that you justcan't get.
You can't stimulate any otherway, but you can certainly
exercise them in other ways.
Okay, so like, for example, oneof the things that we have
people doing all the time now iswe'll go and do all of our
(19:21):
diagnostics and see exactly oh,there's a hummingbird behind me.
We'll go and see exactly whereall of the like, what parts of
our system we want to facilitate, and if we decide, say, this
(19:51):
person has a problem with theirright dorsolateral prefrontal
cortex, we'll basically do TMSto facilitate that cortex while
they're staring at a screen thatwe have positioned to give
perfect field of view for theireyes and give them anti-saccade
eye exercises which directlystimulate that pathway as well.
So one of the things that'simportant to understand about
the research on TMS is there's adifference between stimulating
a pathway and facilitating andintegrating a pathway.
And if you have some cells thataren't working very well and
you get those cells workingbetter but they're not talking
(20:11):
to the other parts of the systemthat they were originally
integrating with, then youdidn't make that much of a
change.
You made some change but youdidn't make the change that you
want.
And there's a lot of researchthat we've seen on TMS for
specific conditions where it'slike, yeah, it looks like it
helps somewhat, but it's not agame changer.
Conditions where it's like,yeah, it looks like it helps
(20:32):
somewhat, but it's not a gamechanger.
And we do it and we incorporateit with an exercise that
specifically stimulates thatpathway in somebody's life
changes in real time.
You know like we see that allthe time.
Dr. Ayla Wolf (20:38):
So so, essentially, by stacking neuro
specific neuro rehab exerciseswhile people are getting the TMS
, you're not only activating thearea but you're integrating it
with the other hubs where it'sspeaking to and you're basically
seeing phenomenal results when,again, the research that's only
looking at one thing is maybegetting less of an effectiveness
(21:01):
.
Dr. Glen Zielinski (21:02):
Oh, absolutely.
I mean, see, this is one of theproblems with trying to do
research on brains, right?
And this isn't just specific toTMS, I mean, this is just
welcome to neuro research, right?
Um, if you want to be able tosay that, say, hyperbaric oxygen
makes a change for somebody andwe do hvac all the time, hvac
is super helpful if you want tobe able to say that hyperbaric
(21:23):
oxygen made a change in somebodywith a brain injury, you have
to study only hyperbaric oxygen.
You have to make sure thisperson isn't getting any other
stimulus, otherwise it'sconfounding, and so on and so
forth.
And people say it's a lousystudy and they throw it out.
Now, hbot by itself, the onlything HBOT does is get more
oxygen into the tissue andthat's great.
But if you don't do anything toexercise that tissue, to build
(21:46):
it back up so that it canintegrate and it can actually
start performing the functionsthat it needs, it's not going to
make that much of a change.
And that's why most of theresearch on HBOT is equivocal.
But what we see all the time isthat if we put somebody in an
HBOT and we kind of juice uptheir oxygenation and then we go
and start doing exercises, wecan push them a lot harder, we
can push them a lot fartherbefore their systems start to
(22:07):
fatigue and, as a consequence,we can get a much bigger change.
So as part of an integratedprotocol, things like that can
be fantastically helpful.
And TMS kind of works the sameway.
Tms is a stimulus and you canjuice up a pathway and get it
firing a little bit better for afew hours.
Then it's kind of backwardsstarted, right.
So this is something that'simportant to understand about
(22:27):
neuro rehab, right?
Neuro rehab is nothing likephysical rehab.
With physical rehab you push amuscle to fatigue, you push it
to the point where it fails.
It comes back stronger, right.
If you drive a neuronanaerobically and you push it to
the point where it fatigues andcrashes, you just wave goodbye
to that neuron.
Neurons don't go anaerobic andsurvive, right.
So the idea is that what youneed to do with rehab is small
(22:52):
bits of stimulus that don'texceed any fatigue thresholds.
So you want to think if this ishow high I want to get this
pathway firing and it's firingdown here, you have to make sure
that you're only getting up toaround this level of the fatigue
threshold so that you're notblowing something up, because
you've talked about fragilepathways, right, and but, more
importantly, that wasn't exactlythe point I was trying to make.
(23:12):
If you, if you look at whathappens where, if here's where
we're trying to get this pathwayfiring and it's down here,
right, and we give it exactlythe right stimulus and exactly
the right exercises and we getright up to exactly the fatigue
ability we want, you're good fortwo hours and then you're back
where you started, because youdidn't change the pathway.
The only thing that you did wassensitize receptors in the
(23:33):
pathway.
You created what's called areceptor potentiation.
You get it firing a little bitbetter, but that degrades, that
wears off, and this is one ofthe things that has got the
entire neuro rehab worldgravitating towards the
intensive outpatient model.
Everybody does this now, fromevery rehab hospital down to
every rational clinic, right?
The idea is if you canstimulate it again before that
(23:55):
receptor potential wears off.
That's how you start turning onall these genetic responses
within the cells that say I needto build more protein, I got to
keep up.
That's how you actually makesomething better, right?
You generate what's calledlong-term potentiation with high
frequency stimulus.
You generate what's calledlong-term potentiation with
high-frequency stimulus overshort periods of time, right.
And if you look at even justwithin TMS, okay, there's a
(24:17):
protocol that Stanford just cameout with where they've suddenly
figured out hey, you knowwhat's great, doing intensive
therapy, so instead of this likesix-week, we'll hit you for
five days a week, kind of thing.
They're doing intensivestimulus, they're doing five
sessions a day for five days andthey're getting better outcomes
(24:37):
, right.
But again, that's still juststimulating that one pathway and
that's not the same thing asusing it to facilitate
everything.
And one of the things that'sreally great about TMS is that
you don't just have to use itfor the dorsolateral prefrontal
cortex, so for, for example, wesee people that have got
problems with particular motorpatterns.
Okay, they've had strokes orthey've had some kind of really
(24:58):
significant catastrophic injuryor whatever, and you know they
lose control of one part oftheir body.
Um, we found that by being ableto go in and precisely activate
the parts of the parietal lobewhere those areas send their
initial sensory input to, andfacilitating that with some
directed TMS and then so thatthey can start to get a better
representation of their body andthey can start to control it
(25:20):
better, so we see lots ofimprovement from doing that and
then going specifically to thedifferent parts of the motor
cortex that allow you to driveexactly those outputs that can
be spectacularly helpful.
So there's actually a bunch ofresearch just on things like
athletic performance.
If you want to throw a jumpshot, you can do TMS before you
go and practice your jump shotand then, as a consequence, your
(25:42):
jump shot improves much fasterthan it would otherwise.
I mean there's all kinds ofstuff around that.
We have been for the last fewyears, years seeing this really
really massive number of peoplewith dystonias, so like cervical
dystonias, movement disordersand so on and so forth, and we
found that by going in andfinding the precise part of the
(26:04):
sensory or motor strip in thebrain that is driving their
dystonia and inhibiting it withTMS, because you can not only
accelerate the function ofsomething but you can slow down
the function of somethingdepending on the frequency of
activation you do 10 hertz isexcitatory, 1 hertz is
inhibitory.
Within the TMS world, by doingan inhibitory stimulus we can
(26:26):
actually get some of these weirdmotor patterns to calm down.
Dr. Ayla Wolf (26:29):
Oh, wow.
Dr. Glen Zielinski (26:30):
And when you see somebody walking in doing
this and then you do TMS andthen they're just kind of like
that and they're like whathappened, you know, I mean
that's fun, we like that.
Yeah, I mean I could go on.
We see a lot of people withdysautonomia.
I mean there's tons of patientsthat we see all the time that
(26:55):
come in with dysautonomia.
You know, like posturalorthostatic tachycardia syndrome
and things like that.
They tend to respondfantastically well to TMS
because there's this huge partof the tachycardic component of
that, the sympathetic activation.
That's about how well yourfrontal lobe is talking to your
basal ganglia so that your basalganglia can chill your midbrain
out, and if that doesn't work,your sympathetic system fires
really high and they get superhigh heart rates and lightheaded
(27:18):
and stuff like that.
Directly stimulating the partsof the system that activate the
basal ganglionic pathways inthese cases can be tremendously
helpful as well.
So my point is that we've seenbenefit in just about every
condition that we treat with TMS.
But again, the key is beingable to target it specifically
(27:38):
to the condition, and I thinkthe main reason that we get the
outcomes that we get with thattherapy is because we're
tailoring it entirely based onour diagnostics.
It's not the same thing as justsaying, hey, you should go and
do TMS at the TMS clinic downthe street because they will do
left dorsolateral prefrontalcortex excitatory.
That's it.
That's all, because that'sgenerally the only thing they
know how to do, and if youhappen to be exactly the person
(28:00):
that needs that, it can stillgive you a great outcome, but if
you're not, then it might not.
Dr. Ayla Wolf (28:07):
Yeah, Now did you just say that you can actually
target the basal ganglia becausethat's super deep in the brain.
But are you able to get thatfar in with the magnetic?
Dr. Glen Zielinski (28:16):
there are.
There are different types ofcoils that you can use for basal
ganglionic activation.
So basal ganglionic stuff iscalled deep stimulus.
It's deep dms.
There's an older systemfloating around called brain
sway and the brain sway is sortof like.
It's kind of non-specific butit is still deep.
(28:37):
Um, that doesn't quite give youthe ability to target right or
left, it just kind of hits thatthat depth of the brain and
gives you some benefit.
Um, that was originally thefirst one that was FDA approved
for treating OCD and variousbasal ganglion conditions.
But since then there's othercoils that have come out that
allow you to get deeperpenetration with like a
(28:58):
traditional system.
So most traditional TMS is likea little figure eight coil or
it's like hoop coil.
The deep ones, they're kind ofV-shaped and they allow you to
get some deeper penetration.
The deep ones, they're kind ofV-shaped and they allow you to
get some deeper penetration.
No-transcript.
(29:29):
So we were doing a lot of deepTMS for a while and we rarely
find the need to do it now.
For the most part we're justdoing superficial stuff but but
just being extremely precisewith what we're going to target.
Dr. Ayla Wolf (29:41):
Yeah, are you seeing Parkinson's patients too?
Dr. Glen Zielinski (29:44):
Oh yeah, lots of them, and we find that
helpful in many, many cases.
The thing about Parkinson's isthat when you're talking about a
neurodegenerative disorder, itreally depends on when we get to
them and how much degenerationthey've already experienced.
Because the thing about TMS isthat it is a stimulus and, as
(30:06):
with all types of stimulus, youhave to be really careful to
make sure that you're notoverstimulating a system Because
, like I said before, if youtake a neuron and you fire it
faster than it can handle, youcan blow it up.
And with people, like withParkinsonian patients, depending
on what we see in ourdiagnostics we don't always go
straight there.
It's fairly common that we'llbuild their systems up for a
(30:30):
while doing other types oftherapies and get them to the
point where they can actuallyhandle that kind of stimulus.
And again, we find it reallyhelpful and for things like
tremors and stuff like that, itcan be spectacularly beneficial
yeah, that's incredible yeah,it's fun, thank you for sharing
all of that amazing information.
Dr. Ayla Wolf (30:49):
So, outside of maybe you know what you just
mentioned in terms of aParkinson's patient maybe
needing to be built up first,are there certain people with
TBI that come in?
What would be acontraindication for using it,
or are there any that you see?
Dr. Glen Zielinski (31:07):
Well, there are a couple of frank
contraindications for TMS.
One is you need to have noseizure history, right, and and
then another is you know metalin your head.
So anybody that's that's hadyou know that has like surgical
clips or has like a vp shunt oranything like that.
That idea now, when they saymetal, what they mean is
(31:29):
something that's you.
Now, when they say metal, whatthey mean is something that's
ferromagnetic.
So if you, there are somepeople that have metal, that
isn't an issue, it's not aproblem, right, um, but the
thing that is that I do alsofrequently find to be a little
bit of a problem for people andthis isn't a contraindication,
it just kind of slows down howfast we can start to apply that.
(31:50):
People that have likehyperacusis, um, I mean, tms
makes a bit of noise, right, andeverybody does tms with hearing
protection it's not like it'sinsanely loud, but you know.
But it's like about an 85,maybe 88 decibel noise, you know
.
So it's loud enough to messwith people if they're already
having lots of difficulty withauditory input, right, and and
(32:14):
still, the majority of thosepatients, just with some hearing
protection they still do fineand we can generally dive in.
But every once in a while werun up against somebody that
just needs to be stabilized alot more before we can start
doing that got it that makessense.
Dr. Ayla Wolf (32:38):
this was part one of my conversation with Dr.
Glen Zielinski from northwestfunctional neurology Got it that
makes sense.
And superior canal dehiscence.
He also describes at length howhe won several architectural
awards for his clinic design andthe great lengths that he and
his architects went to to createa healing space, taking into
(33:01):
account the different colorsthat were used and the types of
shapes and spaces that are mostcalming and healing to the
nervous system of people who arestruggling with traumatic brain
injuries and other neurologicaldisorders.
If you have certain topicsyou'd like us to cover in future
episodes, you can click thesend us a text link at the top
of the show notes or email us atlifeafterimpact at gmailcom.
(33:25):
Thank you so much and we'll seeyou next time.
Thank you so much and we'll seeyou next time.
Medical Disclaimer.
This video or podcast is forgeneral informational purposes
only and does not constitute thepractice of medicine or other
professional health careservices, including the giving
of medical advice.
No doctor-patient relationshipis formed.
(33:46):
The use of this information andmaterials included is at the
user's own risk.
The content of this informationand materials included is at
the user's own risk.
The content of this video orpodcast is not intended to be a
substitute for medical advice,diagnosis or treatment, and
consumers of this informationshould seek the advice of a
medical professional for any andall health-related issues.
A link to our full medicaldisclaimer is available in the
(34:09):
notes.
Because if you can't inhibit what's
happening around you, if youcan't inhibit all the visual
stimulation, if you can'tinhibit all the auditory
stimulation, you know, Costco islike our final exam for our
patients, because that's themost overwhelming circumstance
that we can put anybody in interms of visual and auditory and
cognitive paths to someone.
If you can't inhibit that kindof stuff, you can't function in
(00:21):
the world.
Dr. Ayla Wolf (00:23):
Welcome to Life After Impact the concussion
recovery podcast.
I'm Dr Ayla Wolf and I will behosting today's episode, where
we help you navigate the oftenconfusing, frustrating and
overwhelming journey ofconcussion and brain injury
recovery.
This podcast is your go-toresource for actionable
information, whether you'redealing with a recent concussion
(00:44):
, struggling withpost-concussion syndrome or just
feeling stuck in your healingprocess.
In each episode, we dive deepinto the symptoms, testing,
treatments and neurologicalinsights that can help you move
forward with clarity andconfidence.
We bring you leading experts inthe world of brain health,
functional neurology andrehabilitation to share their
(01:05):
wisdom and strategies.
So if you're feeling lost,hopeless or like no one
understands what you're goingthrough, know that you are not
alone.
This podcast can be your guideand partner in recovery, helping
you build a better life afterimpact.
All right, Dr.
Glen Zielinski, welcome to LifeAfter Impact the concussion
(01:26):
recovery podcast.
You are a chiropracticphysician and board certified
functional neurologist with anabsolutely beautiful clinic in
Lake Oswego, oregon, and Ibrought you onto the show today
to talk about your integrationof transcranial magnetic
stimulation with all of yourother tools, techniques,
therapies specifically forpeople with traumatic brain
(01:49):
injuries.
So welcome to the show andthank you for being here.
Dr. Glen Zielinski (01:53):
Hey, happy to be here.
Dr. Ayla Wolf (01:55):
Yeah, so tell me a little bit about your clinic.
I know that you do five-dayintensives primarily.
Is that correct?
Dr. Glen Zielinski (02:04):
Yeah, generally, that's probably the
majority of our business at thispoint.
Dr. Ayla Wolf (02:08):
Yeah, so you get to spend a whole week with
people and really get to seethem from beginning to end.
And tell me a little bit aboutyour integration of the
technology, especially that TMS,and when did you bring that
into your clinic and what hasthat looked like or how has that
evolved over time?
Dr. Glen Zielinski (02:26):
All right.
Well, so we have been using TMSin our practice since, I think,
2018 or early 2019.
We've gone through a couple ofdifferent TMS systems.
Currently we're using a systemby a company called mag venture
and the beauty of that is thatour unlike most tms, where the
(02:51):
process just largely comes downto doing finding a motor
threshold on somebody by youknow, moving this coil around
and figuring out where yourthumb twitches and saying, okay,
here's the primary motor cortex, the areas that we want to
stimulate.
Now we're just going to measurebased on landmarks and hope for
the best, hope that we'regetting close.
We now have a system that'sneuro-navigated, which means we
use this MRI database.
(03:12):
We upload a brain MRI, it feedsit into this AI thing, it
stretches it out and morphs theAI brain into a way that allows
us to identify any area on thecortex that we want to simulate
and hit it within like half amillimeter, which is pretty
fantastic.
So that's given us some prettydramatic increases in terms of
(03:33):
what we can and can't treat withTMS.
Traditional TMS is largely usedto just stimulate the
dorsolateral prefrontal cortex,which is a critically important
area.
I mean, it's a massivelyimportant node in the default
mode network and in the saliencenetwork and it's sort of like
the apex of cognition within thefrontal lobe.
(03:54):
Just about everything runs intothe DLPFC and just about
everything is stimulated one wayor another by the DLPFC and, as
a consequence, it's an areathat is impacted almost
inevitably in concussion.
There's research that showsthat by the time you've had two
significant hits, you've got aproblem with your DLPFC.
People are looking at DLPFCproblems as now a biomarker of
(04:15):
post-concussion syndrome, as inif you don't show some
dysfunction in that system, thenyou've got problems, something
beyond just concussion.
There's something else going on.
Now.
Traditional TMS just simulatesthat and if you go to see your
average TMS clinic, they're justgoing to do left DLPFC because
(04:36):
that's the only protocol thatthey've been trained in.
Your average psychiatricpractice is just doing that and
that alone right, and that isvery relevant for a lot of
patients, but by no means allpatients right.
There's tons of people thathave problems, on the right side
, for example, and if you have aright DLPFC lesion then that's
not exactly helpful.
You may even be making somebodyworse by doing that kind of
(04:58):
stimulus.
So the key is with TMS you needto understand first of all what
it is that you're trying toaccomplish, and it's not as
simple as the sort oftraditional psychiatric.
Do a PHQ-9 depression scale andsee if your scores are low, and
if they're low then let's seeTMS.
What we do is based, first ofall, on some pretty heavy
(05:21):
neurodiagnostics, and theneurodiagnostics that we engage
in are I mean, we address everyconceivable system.
We do something like 50-odddiscrete tests that give us
objective data on what's goingon with somebody's brain before
we even start any kind oftherapy, and one of the things
that we pay quite a bit ofattention to is
(05:44):
anti-sachetometry.
Now, sachetometry is a systemthat I helped develop for this
company called Interacoustics,which does video and
asthmography testing, and videoand asthmography is infrared
cameras.
You're tracking your pupils,you're seeing various different
types of stimulation take placeon a screen and the system
(06:05):
basically just records eyemovements in response to the
different types of stimulus.
This is probably the best wayto see really what's going on
with somebody's brain after aconcussion, because all of the
systems that tend to be impactedby all the rotational shearing
forces that happen when yourhead gets snapped around, we can
see function in all of thosesystems by looking at eye
movements, because eye movementsall start in the same part of
(06:29):
the brain stem, which is an areathat takes it.
That's sort of like the apex ofall the rotation.
I mean, if you just think of aconcussion is like if your
brain's like a big cauliflowerand the brain stem is the stock
of the cauliflower.
Um, all the maps that yourbrain uses to make sense out of
where you are in the world, theyall live in different parts of
the cortex but they integrateright in the middle of the pons
and the midbrain, which isbasically the stalk of the
(06:50):
cauliflower.
And getting concussed is likeyou grab the stalk of the
cauliflower and just snap itreally fast and all these
rotational shearing forces goright where you're holding,
which means right where you putall those maps together.
And that's also the areas thatnot only control all your
autonomic nervous system butalso the areas that basically
generate all of your eyemovements.
And different types of eyemovements coming from different
(07:11):
parts of the brain can show youa ton about what's happening in
the different parts of thebrainstem and cerebellum and
parietal lobe and frontal lobeand basal ganglia and all the
pathways in between that have atendency to be affected by these
things.
And it's one thing to be ableto see that somebody has a
problem on an image and it'sanother thing entirely to see
under what sets of circumstancesthose pathways fatigue and fail
(07:32):
, what kind of stimulus pushesthem over the edge, what makes
them melt down, and so on and soforth, and that can give you
like a massive amount ofinformation about what's
happening with somebody's brainafter a concussion.
And it doesn't just show youwhat's wrong.
It shows you if you understandwhat you're looking at, it shows
you what to do about it, how toget somebody better.
Right Now there is a specificeye movement called a saccade,
which is a fast jump from targetto target.
(07:54):
And this is how you build yourenvironmental map.
Saccades come from your frontallobe through your basal ganglia
into your midbrain and down intothe pons.
So basically, that wholebrainstem pathway is being
driven by descending frontallobe output.
And again, frontal lobe iscognition, executive function
and so on and so forth.
Right, everything that peoplelike to think of as
(08:15):
consciousness is mostly frontallobe, and when you talk about
people having cognitive problems, you're talking about some kind
of a frontal lo, frontaldeficit in most cases Now.
So again, a saccade is movingfrom target to target, going
towards something that's calleda prosaccade.
An antisaccade is a whole otherball of wax.
An antisaccade is you have atarget and your brain has a
(08:37):
reflex that wants to make youmove towards that target, but
you have to be able to inhibitthat reflex and then you have to
be able to move your eyes inthe opposite direction.
Now that is a higher-levelexecutive function task that
comes from specifically an areacalled the dorsolateral
prefrontal cortex, the DLPFC,and generating antipsychots with
stimulus on the right is afunction of the left DLPFC and
(08:59):
vice versa.
Um, there is a ton of newemerging evidence around how
anti-saccades get messed up whensomebody has concussion.
I mean, I presented on that atthe Barony Society meeting in
Madrid a couple of years ago, atthe biggest vestibular
conference in the world.
The whole idea of anti-saccadesis they're not just about you
(09:22):
being able to not look at atarget, they're about response
inhibition.
All right, and responseinhibition is essentially if
you're capable of listening tome, it's because you're
inhibiting the sound of thebirds chirping behind my head
Right, or the sensation of yourbutt on the chair that you're
sitting on and all this othersensory input that's just there
at all times.
And if you can't inhibit, thenyou sort of become a slave to
(09:48):
the environment and you get whatwe like to call squirrel brain,
in the sense that you're in themiddle of squirrel, you know,
and you can't inhibitenvironmental stimulation.
Now that's massively problematicwhen people get into
complicated sensory environments, because if you can't inhibit
what's happening around you, ifyou can't inhibit all the visual
stimulation, if you can'tinhibit what's happening around
you, if you can't inhibit allthe visual stimulation, if you
can't inhibit all the auditorystimulation.
You know, costco is like ourfinal exam for our patients,
(10:11):
because that's the mostoverwhelming circumstance that
we can put anybody in in termsof visual and auditory and
cognitive tasks and so on and soforth.
If you can't inhibit that kindof stuff, you can't function in
the world.
And that's why people findinevitably that they get into
complicated sensory environmentsand they have meltdowns.
So an anti-saccade veryspecifically looks at your
(10:32):
ability to inhibit the world andif it doesn't work, then good
luck, right, okay, soanti-saccades come from the
dorsolateral prefrontal cortexand traditional TMS is basically
geared towards stimulating theDLPFC directly.
So if you're not familiar withTMS, it's this big MRI-strength
magnet with a very focal beam,you place it directly over your
(10:56):
DLPFC.
With traditional TMS it's theweirdest sensation in the world.
It feels like somebody'ssnapping you in the forehead
with an elastic band but itsounds like somebody's drilling
a mallet into your head with abig wooden stake.
Like it's just crazy.
But most people don't have anyproblem with it.
I mean, there is the odd personthat can't tolerate the
stimulus, but I mean we havemore patients that fall asleep
(11:18):
in the chair during TMS than wedo, people that can't handle it.
But the point is that itdirectly stimulates that pathway
.
It directly stimulates thedorsolateral prefrontal cortex
from through your skull and itlights it up like a Christmas
tree.
So when TMS was first presented,when it first got its FDA
(11:40):
approval, the thing about TMSwas that if you looked at the
response rate of SSRIs theantidepressant medications that
most people go on if they havechronic refractory depression
the response rate on an SSRI issomething like 22% for the first
med and then it's somethinglike 14% for the second med and
(12:01):
like 3% or 4% for the third med,with response being 50%
improvement or better.
And if you haven't% for thethird med, with response being
50% improvement or better, andif you haven't responded by the
third med, almost inevitablyyou're not responding.
Okay, and what that means isthat the majority of the
depressed population don'trespond to meds right.
They just don't have thebenefit that everybody's
supposed to get.
So TMS was originally studiedlooking at that population, and
(12:25):
they put together a six weekprotocol.
You basically get 18 minutesworth of STEM five days a week
for six weeks.
The research on that showedsomething like a 68% response
rate and a 48% remission rate,which is dramatically better
than you can get from anymedication.
Dr. Ayla Wolf (12:43):
And in a short period of time.
Dr. Glen Zielinski (12:45):
Yeah, exactly, exactly right Now.
Yeah, the thing is and this isa really important thing to
understand depression is not aTMS deficiency.
Depression is not a DLPFClesion.
Depression is a problem withnetworks.
Okay, depression is somethingthat involves your whole brain.
You can have one area that'scritical for that function, but
(13:08):
that doesn't mean it's comingfrom that area.
It means that that area is, youknow, an apex, involved in a
lot of pathways, lots of stuffbasically summates in that area.
But that doesn't mean that'swhere the problem is.
Now the thing is, when you startlooking at what happens with
concussions, if you just look at, like classic depression, that
happens, you know, refractorydepression, with post-concussion
syndrome, which is the majorityof people that have been
(13:30):
significantly concussed, themajority of people that have
been significantly concussed.
If you look at that it's, Imean you can have that problem
and the injured areas of yourbrain or brainstem or cerebellum
or frontal lobe can be justabout anywhere and you can still
wind up in a situation whereyour DLPFC is not firing very
well, not because it itself wasdirectly lesioned, so much as
(13:51):
that.
Everything runs in there.
They did this thing called theConnectome Project a few years
back, where the imagingtechnology had reached the point
where now we can not only seewhat different parts of the
brain do but how they allconnect.
And the DLPFC is essentiallythe most connected part of the
entire system.
Everything runs in there and itaffects just about everything
and it affects just abouteverything and, as a consequence
(14:11):
, if you have shearing forces ordiffuse axonal injury or damage
somewhere, it's almostinevitable that it's going to
influence what happens in theDLPFC at some point.
Okay Now, with that systembeing a critical node in again
the default mode network, thesalience network, there's a few
different ways to look at whatthose systems mean.
The way that I usually explainit to patients even though this
(14:33):
isn't like strictly accurate isjust to say that you know your
default mode network is sort oflike resting emotional tone
between thoughts and you wantthat to be positive and when
it's not working very well itbecomes negative.
And your salience network ishow you build emotional context
around information and you wantto be able to integrate that
stuff appropriately and normal.
You're walking down the streetand stuff happens and you're
(14:54):
like, wow, stuff happened andyou keep walking.
And when those systems don'twork very well, you're like
walking down the street.
Wow, stuff happens and you justimmediately default to this
negative self-talk and it's likeand what is it about me that
makes all this stuff keephappening?
And now I'm going tocatastrophize and die alone and
unloved or whatever, right?
And that's a circumstance wherepeople just can't successfully
integrate that kind ofinformation correctly because of
(15:16):
those networks not working verywell, and that sets people up
for chronic depression andchronic anxiety and PTSD and
catastrophizing and so on and soforth.
All right, so the point I'mtrying to make is that you can
affect those systems by directlystimulating it and it'll help
in some cases.
If that's where the integratedproblem is, if it's on the other
side of the brain, well thenyou need to understand that, and
(15:38):
if it's in other areas that arefeeding into that, you need to
understand that as well.
Now, we've been doing TMS aspart of our neurorescue program
for years.
Right, we've been looking atdoing TMS as an integrated
therapy within all of our Ishouldn't say all, but within
the majority of the patientsthat we work with with
post-concussion syndrome, and wewere, and we probably still
(16:03):
will, publish on this at somepoint.
We just got way too busy andnever quite got around to it.
But we tracked our first 300patients, that we did this with
the first 300 in week-longintensive therapies.
That involved us doing TMS and,like I said, traditional TMS,
like 68 response rate.
Our response rates were like96% I think, and our remission
(16:25):
rate was in the high 80s, youknow.
And that's doing TMS twice aday over one week coupled with
the rest of the therapy, andthat's the whole point, right,
because it's not just aboutbeing able to stimulate that one
area, it's about getting yourentire brain to light back up
and integrate correctly.
Okay, and that requires beingable to map out everything
(16:47):
that's wrong, where everythinghas the problem, and then coming
up with an appropriate protocolto be able to fix whatever it
is that you find right.
And that kind of pivots towardsour general approach with
everything.
Our general approach is, I mean, we sort of follow the same
heuristic, the same plan withevery patient and the pieces are
different for everybody, butthe concepts are exactly the
(17:09):
same for everyone.
We start with really intenseneurodiagnostics so we can see
exactly where the problem is,which systems are working, which
ones are having a hard timekeeping up, what we need to do
in order to facilitate them, andthen from there, once we've
identified the tissue that we'vedecided that we want to go
after step one we do somethingto build metabolic capacity in
that system.
And step one is that's likeoxygen therapies or laser
(17:34):
therapies or LEDs, all thesethings that one way or another
allow us to build energy andmetabolic capacity within those
systems.
Step two is find some way todirectly stimulate those
pathways.
And if we're talking aboutsomething like, say, a problem
in the DLPFC, tms is the perfectway to do that.
Okay, but if we're talkingabout a brainstem system, then
we're talking about doing liketrigeminal electrical stimulus.
(17:55):
Or if it's like a vestibularlesion, we're talking about
putting somebody in a gyro stemor an omni-ax and spinning them
off axis in a way that's goingto directly activate or
integrate particular vestibularreceptors.
And then from there, the nextstep is find some way to
exercise that pathway, and thatis, you know, eye exercises,
inner ear things, balanceexercises, whatever.
(18:17):
It is that we're trying tofacilitate, cognitive exercises,
you know whatever.
And then from there the laststep is find some way to
integrate it.
And integrating it for us meanseverything from doing all these
exercises on, you know, touchscreens with all these cognitive
things that we can integrateeyes with body, with vestibular
systems, with cognition, withemotional regulation to taking
(18:38):
them out on our big gym floor.
Since you were out, youprobably haven't seen this, but
I added an extra like 1,200square feet.
We've got like 50 lane or 50foot turf, four lanes and like a
full gym and all this kind ofstuff, and that's allowed us to
basically start doing all kindsof more kinetic, dynamic things
and make up physical exercisesfor people along the way to help
integrate all that kind ofstuff.
(19:00):
And the point is that tms is afantastic stimulus.
It's a fantastic way todirectly hit some very specific
pathways in ways that you justcan't get.
You can't stimulate any otherway, but you can certainly
exercise them in other ways.
Okay, so like, for example, oneof the things that we have
people doing all the time now iswe'll go and do all of our
(19:21):
diagnostics and see exactly oh,there's a hummingbird behind me.
We'll go and see exactly whereall of the like, what parts of
our system we want to facilitate, and if we decide, say, this
(19:51):
person has a problem with theirright dorsolateral prefrontal
cortex, we'll basically do TMSto facilitate that cortex while
they're staring at a screen thatwe have positioned to give
perfect field of view for theireyes and give them anti-saccade
eye exercises which directlystimulate that pathway as well.
So one of the things that'simportant to understand about
the research on TMS is there's adifference between stimulating
a pathway and facilitating andintegrating a pathway.
And if you have some cells thataren't working very well and
you get those cells workingbetter but they're not talking
(20:11):
to the other parts of the systemthat they were originally
integrating with, then youdidn't make that much of a
change.
You made some change but youdidn't make the change that you
want.
And there's a lot of researchthat we've seen on TMS for
specific conditions where it'slike, yeah, it looks like it
helps somewhat, but it's not agame changer.
Conditions where it's like,yeah, it looks like it helps
(20:32):
somewhat, but it's not a gamechanger.
And we do it and we incorporateit with an exercise that
specifically stimulates thatpathway in somebody's life
changes in real time.
You know like we see that allthe time.
Dr. Ayla Wolf (20:38):
So so, essentially, by stacking neuro
specific neuro rehab exerciseswhile people are getting the TMS
, you're not only activating thearea but you're integrating it
with the other hubs where it'sspeaking to and you're basically
seeing phenomenal results when,again, the research that's only
looking at one thing is maybegetting less of an effectiveness
(21:01):
.
Dr. Glen Zielinski (21:02):
Oh, absolutely.
I mean, see, this is one of theproblems with trying to do
research on brains, right?
And this isn't just specific toTMS, I mean, this is just
welcome to neuro research, right?
Um, if you want to be able tosay that, say, hyperbaric oxygen
makes a change for somebody andwe do hvac all the time, hvac
is super helpful if you want tobe able to say that hyperbaric
(21:23):
oxygen made a change in somebodywith a brain injury, you have
to study only hyperbaric oxygen.
You have to make sure thisperson isn't getting any other
stimulus, otherwise it'sconfounding, and so on and so
forth.
And people say it's a lousystudy and they throw it out.
Now, hbot by itself, the onlything HBOT does is get more
oxygen into the tissue andthat's great.
But if you don't do anything toexercise that tissue, to build
(21:46):
it back up so that it canintegrate and it can actually
start performing the functionsthat it needs, it's not going to
make that much of a change.
And that's why most of theresearch on HBOT is equivocal.
But what we see all the time isthat if we put somebody in an
HBOT and we kind of juice uptheir oxygenation and then we go
and start doing exercises, wecan push them a lot harder, we
can push them a lot fartherbefore their systems start to
(22:07):
fatigue and, as a consequence,we can get a much bigger change.
So as part of an integratedprotocol, things like that can
be fantastically helpful.
And TMS kind of works the sameway.
Tms is a stimulus and you canjuice up a pathway and get it
firing a little bit better for afew hours.
Then it's kind of backwardsstarted, right.
So this is something that'simportant to understand about
(22:27):
neuro rehab, right?
Neuro rehab is nothing likephysical rehab.
With physical rehab you push amuscle to fatigue, you push it
to the point where it fails.
It comes back stronger, right.
If you drive a neuronanaerobically and you push it to
the point where it fatigues andcrashes, you just wave goodbye
to that neuron.
Neurons don't go anaerobic andsurvive, right.
So the idea is that what youneed to do with rehab is small
(22:52):
bits of stimulus that don'texceed any fatigue thresholds.
So you want to think if this ishow high I want to get this
pathway firing and it's firingdown here, you have to make sure
that you're only getting up toaround this level of the fatigue
threshold so that you're notblowing something up, because
you've talked about fragilepathways, right, and but, more
importantly, that wasn't exactlythe point I was trying to make.
(23:12):
If you, if you look at whathappens where, if here's where
we're trying to get this pathwayfiring and it's down here,
right, and we give it exactlythe right stimulus and exactly
the right exercises and we getright up to exactly the fatigue
ability we want, you're good fortwo hours and then you're back
where you started, because youdidn't change the pathway.
The only thing that you did wassensitize receptors in the
(23:33):
pathway.
You created what's called areceptor potentiation.
You get it firing a little bitbetter, but that degrades, that
wears off, and this is one ofthe things that has got the
entire neuro rehab worldgravitating towards the
intensive outpatient model.
Everybody does this now, fromevery rehab hospital down to
every rational clinic, right?
The idea is if you canstimulate it again before that
(23:55):
receptor potential wears off.
That's how you start turning onall these genetic responses
within the cells that say I needto build more protein, I got to
keep up.
That's how you actually makesomething better, right?
You generate what's calledlong-term potentiation with high
frequency stimulus.
You generate what's calledlong-term potentiation with
high-frequency stimulus overshort periods of time, right.
And if you look at even justwithin TMS, okay, there's a
(24:17):
protocol that Stanford just cameout with where they've suddenly
figured out hey, you knowwhat's great, doing intensive
therapy, so instead of this likesix-week, we'll hit you for
five days a week, kind of thing.
They're doing intensivestimulus, they're doing five
sessions a day for five days andthey're getting better outcomes
(24:37):
, right.
But again, that's still juststimulating that one pathway and
that's not the same thing asusing it to facilitate
everything.
And one of the things that'sreally great about TMS is that
you don't just have to use itfor the dorsolateral prefrontal
cortex, so for, for example, wesee people that have got
problems with particular motorpatterns.
Okay, they've had strokes orthey've had some kind of really
(24:58):
significant catastrophic injuryor whatever, and you know they
lose control of one part oftheir body.
Um, we found that by being ableto go in and precisely activate
the parts of the parietal lobewhere those areas send their
initial sensory input to, andfacilitating that with some
directed TMS and then so thatthey can start to get a better
representation of their body andthey can start to control it
(25:20):
better, so we see lots ofimprovement from doing that and
then going specifically to thedifferent parts of the motor
cortex that allow you to driveexactly those outputs that can
be spectacularly helpful.
So there's actually a bunch ofresearch just on things like
athletic performance.
If you want to throw a jumpshot, you can do TMS before you
go and practice your jump shotand then, as a consequence, your
(25:42):
jump shot improves much fasterthan it would otherwise.
I mean there's all kinds ofstuff around that.
We have been for the last fewyears, years seeing this really
really massive number of peoplewith dystonias, so like cervical
dystonias, movement disordersand so on and so forth, and we
found that by going in andfinding the precise part of the
(26:04):
sensory or motor strip in thebrain that is driving their
dystonia and inhibiting it withTMS, because you can not only
accelerate the function ofsomething but you can slow down
the function of somethingdepending on the frequency of
activation you do 10 hertz isexcitatory, 1 hertz is
inhibitory.
Within the TMS world, by doingan inhibitory stimulus we can
(26:26):
actually get some of these weirdmotor patterns to calm down.
Dr. Ayla Wolf (26:29):
Oh, wow.
Dr. Glen Zielinski (26:30):
And when you see somebody walking in doing
this and then you do TMS andthen they're just kind of like
that and they're like whathappened, you know, I mean
that's fun, we like that.
Yeah, I mean I could go on.
We see a lot of people withdysautonomia.
I mean there's tons of patientsthat we see all the time that
(26:55):
come in with dysautonomia.
You know, like posturalorthostatic tachycardia syndrome
and things like that.
They tend to respondfantastically well to TMS
because there's this huge partof the tachycardic component of
that, the sympathetic activation.
That's about how well yourfrontal lobe is talking to your
basal ganglia so that your basalganglia can chill your midbrain
out, and if that doesn't work,your sympathetic system fires
really high and they get superhigh heart rates and lightheaded
(27:18):
and stuff like that.
Directly stimulating the partsof the system that activate the
basal ganglionic pathways inthese cases can be tremendously
helpful as well.
So my point is that we've seenbenefit in just about every
condition that we treat with TMS.
But again, the key is beingable to target it specifically
(27:38):
to the condition, and I thinkthe main reason that we get the
outcomes that we get with thattherapy is because we're
tailoring it entirely based onour diagnostics.
It's not the same thing as justsaying, hey, you should go and
do TMS at the TMS clinic downthe street because they will do
left dorsolateral prefrontalcortex excitatory.
That's it.
That's all, because that'sgenerally the only thing they
know how to do, and if youhappen to be exactly the person
(28:00):
that needs that, it can stillgive you a great outcome, but if
you're not, then it might not.
Dr. Ayla Wolf (28:07):
Yeah, Now did you just say that you can actually
target the basal ganglia becausethat's super deep in the brain.
But are you able to get thatfar in with the magnetic?
Dr. Glen Zielinski (28:16):
there are.
There are different types ofcoils that you can use for basal
ganglionic activation.
So basal ganglionic stuff iscalled deep stimulus.
It's deep dms.
There's an older systemfloating around called brain
sway and the brain sway is sortof like.
It's kind of non-specific butit is still deep.
(28:37):
Um, that doesn't quite give youthe ability to target right or
left, it just kind of hits thatthat depth of the brain and
gives you some benefit.
Um, that was originally thefirst one that was FDA approved
for treating OCD and variousbasal ganglion conditions.
But since then there's othercoils that have come out that
allow you to get deeperpenetration with like a
(28:58):
traditional system.
So most traditional TMS is likea little figure eight coil or
it's like hoop coil.
The deep ones, they're kind ofV-shaped and they allow you to
get some deeper penetration.
The deep ones, they're kind ofV-shaped and they allow you to
get some deeper penetration.
No-transcript.
(29:29):
So we were doing a lot of deepTMS for a while and we rarely
find the need to do it now.
For the most part we're justdoing superficial stuff but but
just being extremely precisewith what we're going to target.
Dr. Ayla Wolf (29:41):
Yeah, are you seeing Parkinson's patients too?
Dr. Glen Zielinski (29:44):
Oh yeah, lots of them, and we find that
helpful in many, many cases.
The thing about Parkinson's isthat when you're talking about a
neurodegenerative disorder, itreally depends on when we get to
them and how much degenerationthey've already experienced.
Because the thing about TMS isthat it is a stimulus and, as
(30:06):
with all types of stimulus, youhave to be really careful to
make sure that you're notoverstimulating a system Because
, like I said before, if youtake a neuron and you fire it
faster than it can handle, youcan blow it up.
And with people, like withParkinsonian patients, depending
on what we see in ourdiagnostics we don't always go
straight there.
It's fairly common that we'llbuild their systems up for a
(30:30):
while doing other types oftherapies and get them to the
point where they can actuallyhandle that kind of stimulus.
And again, we find it reallyhelpful and for things like
tremors and stuff like that, itcan be spectacularly beneficial
yeah, that's incredible yeah,it's fun, thank you for sharing
all of that amazing information.
Dr. Ayla Wolf (30:49):
So, outside of maybe you know what you just
mentioned in terms of aParkinson's patient maybe
needing to be built up first,are there certain people with
TBI that come in?
What would be acontraindication for using it,
or are there any that you see?
Dr. Glen Zielinski (31:07):
Well, there are a couple of frank
contraindications for TMS.
One is you need to have noseizure history, right, and and
then another is you know metalin your head.
So anybody that's that's hadyou know that has like surgical
clips or has like a vp shunt oranything like that.
That idea now, when they saymetal, what they mean is
(31:29):
something that's you.
Now, when they say metal, whatthey mean is something that's
ferromagnetic.
So if you, there are somepeople that have metal, that
isn't an issue, it's not aproblem, right, um, but the
thing that is that I do alsofrequently find to be a little
bit of a problem for people andthis isn't a contraindication,
it just kind of slows down howfast we can start to apply that.
(31:50):
People that have likehyperacusis, um, I mean, tms
makes a bit of noise, right, andeverybody does tms with hearing
protection it's not like it'sinsanely loud, but you know.
But it's like about an 85,maybe 88 decibel noise, you know
.
So it's loud enough to messwith people if they're already
having lots of difficulty withauditory input, right, and and
(32:14):
still, the majority of thosepatients, just with some hearing
protection they still do fineand we can generally dive in.
But every once in a while werun up against somebody that
just needs to be stabilized alot more before we can start
doing that got it that makessense.
Dr. Ayla Wolf (32:38):
this was part one of my conversation with Dr.
Glen Zielinski from northwestfunctional neurology Got it that
makes sense.
And superior canal dehiscence.
He also describes at length howhe won several architectural
awards for his clinic design andthe great lengths that he and
his architects went to to createa healing space, taking into
(33:01):
account the different colorsthat were used and the types of
shapes and spaces that are mostcalming and healing to the
nervous system of people who arestruggling with traumatic brain
injuries and other neurologicaldisorders.
If you have certain topicsyou'd like us to cover in future
episodes, you can click thesend us a text link at the top
of the show notes or email us atlifeafterimpact at gmailcom.
(33:25):
Thank you so much and we'll seeyou next time.
Thank you so much and we'll seeyou next time.
Medical Disclaimer.
This video or podcast is forgeneral informational purposes
only and does not constitute thepractice of medicine or other
professional health careservices, including the giving
of medical advice.
No doctor-patient relationshipis formed.
(33:46):
The use of this information andmaterials included is at the
user's own risk.
The content of this informationand materials included is at
the user's own risk.
The content of this video orpodcast is not intended to be a
substitute for medical advice,diagnosis or treatment, and
consumers of this informationshould seek the advice of a
medical professional for any andall health-related issues.
A link to our full medicaldisclaimer is available in the
(34:09):
notes.
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