March 31, 2025 • 45 mins
Dr. John McLaren shares his functional neurology approach to treating autonomic dysfunction and concussions, exploring cutting-edge therapies and personalized rehabilitation strategies for complex brain injuries.
• Detailed explanation of how jump rope training can improve neuroplasticity by synchronizing upper and lower body timing
• Discussion of PEMF devices and hyperbaric oxygen therapy for improving vasomotion and blood flow to the brain
• Examination of heat intolerance as a manifestation of autonomic dysfunction due to impaired sweating response
• Exploration of the five-minute sustained hand grip test to measure sympathetic nervous system function
• Implementing gradual, individualized return-to-activity protocols with 20% reductions when symptoms appear
• Insights on how Long COVID can create setbacks by further disrupting autonomic nervous system function
• Techniques for using fine motor activities to stimulate cerebellar activation without overwhelming the system
Dr. McClaren can be found at: Advanced Chiropractic & Neurology in Omaha Nebraska
Advanced Chiropractic & Neurology Facebook Page
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Ayla Wolf (00:01):
Welcome back to the Life After Impact podcast.
This is part two of myconversation with Dr John
McLaren, an expert in traumaticbrain injuries, concussion,
recovery and autonomic nervoussystem dysfunction, practicing
near Omaha, Nebraska in thisepisode, after geeking out about
jump ropes. We continue toexplore his Functional Neurology
(00:23):
approach to treating autonomicdysfunction and concussions. We
discuss the use of pulsedelectromagnetic frequency
devices to improve vasomotoractivity and the use of
hyperbaric oxygen therapy, wherehe takes it one step further and
shares how specific examinationfindings such as the pupillary
light reflex and a five minutesustained hand grip test further
(00:47):
help him to differentiate whotruly is a good candidate for
hyperbaric oxygen therapy. Wediscuss heat intolerance as a
manifestation of autonomicdysfunction due to a loss of
normal sweat response the use ofcompression gear and the
importance of therapist guidedgradual return to activity and
exercise as it's appropriate forthe individual and we touch upon
(01:12):
head eye vestibular motion, afunctional therapy that utilizes
eye movements, head movementsand vestibular activation as
part of neuro rehabilitation,and then we touch upon
long-COVID as a possible setbackin people's recovery due to
inflammatory consequences andfurther insult to the autonomic
(01:32):
nervous system. Thank you somuch for listening to the
podcast. If you have topics youwould like us to explore, please
text us using the link in theshow notes, or send us an email
at lifeafterimpact@gmail.com
Sophia Bouwens (01:48):
Welcome to the life after impact podcast, where
we do a deep dive into allthings concussion and brain
injury related. We talk aboutall the different symptoms that
can follow brain injury,different testing methods,
different types of specialistsout there, and different
therapies available. I'm SophiaBowens, and I'm here with Dr
Ayla Wolf, and we will be yourguides to living your best life
(02:12):
after impact.
Dr. Ayla Wolf (02:15):
Yeah, I had just a major geek moment the other
day. I was listening to apodcast. It was a CrossFit
podcast, and they wereinterviewing a guy who teaches
like jump rope classes, and allof a sudden he launched into
what, from my perspective, was afunctional neurology explanation
of why jump roping is soimportant to toning the
(02:36):
autonomic nervous system andtalking about how some people
are more upper body dominant,and other people are lower body
dominant. But when you jumprope, you've gotta sync up your
timing of your wrist with thetiming of your feet and your
jump and so, you know, basicallyhe just launched into this whole
(02:58):
neurological reasoning for whyjumping rope was this way of
creating better neuroplasticity,in terms of how the coordination
between your upper body and yourlower body. And, of course, in
my mind, I'm like, "and then wehave the inferior olive which is
all about timing, and that goesinto the cerebellum"
Dr. John McClaren (03:16):
Put the metronome to the jump rope and
see what happens. Right? Yeah,
Dr. Ayla Wolf (03:20):
metronome and a jump rope like that could be a
magical therapy right there.
Dr. John McClaren (03:26):
We might have just, you know, call it the
Wolf-McLaren jump rope.
Dr. Ayla Wolf (03:29):
Let's work on that,
Dr. John McClaren (03:31):
yeah, but you throw in the vestibular aspects
as well, right? I mean, that's,it's like, this big thing, and
not to mention theproprioceptive bombardment from
lumbosacral spine, which is oneof the reasons I don't jump rope
as much as I probably should,that I suck at it, you know,
it's like, yeah, I know it's agreat activity. And that's the
cool thing about CrossFit, youknow, or any of these athletic
(03:52):
endeavors, it's, it's motion ata higher level. You know, we
look at gait all the time, butyou go, okay, the gait... Okay,
how do I jump rope? How do Ijump rope with a dual task, or
something like that? That couldbe a really, really nice, high
end way to test. And I know, oneof the things you, you know, you
had mentioned in the questionsleading into today, was how,
(04:14):
what can people do at home? Andthese are things you know, you
can integrate your activities ofdaily living in to to how to
rehabilitate yourself as well.
Dr. Ayla Wolf (04:24):
Yeah, and I think that you mentioned you've got a
PEMF device, and so do I. Andone of the things that I really
have spent a lot of timeresearching and wrote about in
my book was the importance ofvasomotion within the, you know,
cardiovascular system and thearteries and even within the
brain too. And so I think thatyou know, one of the things that
(04:48):
the PEMF devices are so helpfulfor is restoring that healthy
vaso motion, and especially whenyou've got somebody who maybe
has dysautonomia and exerciseintolerance and can't
necessarily. Necessarily movetheir body at the high level
that they maybe were used to,you know, something like that
can really come in and supportthat system in that way too.
Dr. John McClaren (05:11):
Absolutely, it's so interesting. And a lot
of people, you know, they likehyperbaric oxygen therapy for
these kind of things as well,because, again, you're
increasing blood oxygenconcentration. Yeah, the pulsed
EMF, vasomotion remodeling, youknow, kind of in that neuronal
pool because of that and so on.
Yeah, you want to heal whitematter. I mean, those are two of
the best modalities that youcould potentially use, for sure.
(05:31):
And of course, just likeanything else, be judicious,
right? Have a biomarker.
Everybody says that, well,what's the protocol? And I think
you've probably found this withyour PEMF too. There aren't
necessarily standardizedprotocols, right?
Dr. Ayla Wolf (05:46):
Yeah. I mean, a lot of times it's like, let's
just start you out really,really light and just very
slowly bring you up, and then,you know, kind of cycle through.
But yeah. And you know, somepeople like with mine, you know,
they'll lay on it at a levelone, and they'll say, Oh, wow. I
can just really feel like, youknow, all of this stuff
happening in my body. Well, me,I have to have it on level seven
(06:06):
before I even feel anything.
Dr. John McClaren (06:09):
it's interesting, yeah, yeah, you
know, you boost the fieldstrength off, and you can vary
your field intensities andthings like that. It's, it's
fascinating stuff. And, andthat's the thing, I think there,
you know, there will beestablished research parameters
for this stuff on top ofeverything else, as we go, same
with hyperbaric. You know, thatthat's the thing. There are a
lot of people, again, talkingabout, what's great for
(06:33):
everybody? Nothing's great foreverybody all the time, right?
If it was, we'd all, you know,if hyperbaric was the thing to
do for dysautonomia withconcussions, we'd have like, 10
hyperbarics in our office, andeverybody would be doing that
all day long, I mean, and beforeI really, really understood the
dynamics of, you know, this,especially this sympathetic
(06:54):
activation being important, youknow, I was putting a lot of
people in hyperbaric and gettingmixed results because Sometimes
it's too much of a stimulus forthat parasympathetic system.
You're really driving vagalsystems and and, you know, they
come out there, like I feelgreat, and then, and then they'd
have a hard time for a littlewhile. And now, when I
understand it, do I havepupillometry that's appropriate
(07:17):
for the stimulus? Do I have, youknow, one of these, we do this
hand grip test and see, do Ihave adequate activation of that
sympathetic system to be able tohandle a stimulus? You talk
about sweating. And one of thethings I mean, what sweating is
most important function,dissemination of body heat,
right? What's one of the thingsthese people with dysautonomia
(07:39):
tell you, I suck in the heat,yep, you know, I can't wait for
fall, yeah, because they can'tdisseminate heat properly,
because they don't haveactivation of the sympathetic
system appropriate for it.
Dr. Ayla Wolf (07:52):
and I think that's something that people
also, you know, kind of miss isthe fact that it's not a teeter
totter. It's not that whenparasympathetic activity is
high, that sympathetic then is,by default, low. You know, these
are two completely separate armsof the nervous system doing
their own things. And so therecan be maybe a relative excess
(08:15):
of sympathetic compared toparasympathetic, or you can have
it where there is actualdecreased parasympathetic and
increase sympathetic. And so wedo have to look at it not as a
teeter totter, but as twoseparate output systems that can
be independently doing their ownthing, but we need both of them
to be appropriately responsive.
Dr. John McClaren (08:36):
Yeah it's just like when you test balance.
It's context specific weighting,right? I want my brain to be
able to stand on a perturbedsurface with eyes closed. Then I
want to be able to do thingswith eyes open. Then I want to
be able to do things on a normalsurface and and the brain will
re weight the systems accordingto the context and the demands
of that context. It's the samething with the autonomics.
(08:58):
Again, I need to digest I needto digest the stake, and then I
need to fight off the intruder,or whatever it is, relatively
quickly. And then, and then, youknow, once the intruders fought
off, I got to finish digesting,go back to what I was doing,
yeah, and then, and then,hopefully, go to bed. And do it
again the next day, these kindof things. Yeah, it's exactly
(09:20):
what it is that's what the braindoes when it works the way that
it should is it can take everysystem that it communicates
with, and it can weight itappropriate to the current
demands, but the backgroundprocesses work appropriately.
And in order to do all that, youhave to have fuel, oxygen,
vasomotor activity, exactly, allof those things and you want it
(09:43):
comes down to it, everybody willask, well, what is a symptom of
autonomic nervous systemdysfunction? Anything they can
come in with, because if I can'tfuel my frontal lobe, I'm going
to have executive dysfunction,right? If I can't fuel my
vestibular system, I'm going tobe dizzy, or we'll have some
kind of translational issues, orhave background contamination
(10:05):
throw me off, or any of thesekind of things. If I can't fuel
my cerebellum, I'm gonna havemaybe some of these, like speech
issues, or some of these issuesin cognition as well. Or
activity coordinations of motoractivity won't be super well,
you know, you'll seemiscoordination And like, what
the way a hamstring contracts,or things like that, you know,
things that you're doing in yourpostural assessment. And again,
(10:28):
blood and oxygen. Every neuronneeds it. Blood oxygen and
activation, right?
Dr. Ayla Wolf (10:33):
And for everybody, that can look
completely different in terms ofhow to get in there and start
stimulating, yeah. So youmentioned you've got your
hyperbaric, you've got yourPEMF, or you do you also do like
the NormaTec compression gear.
Or like, are you doingcompression? Or what else are
you integrating?
Dr. John McClaren (10:50):
I haven't used that. I haven't used that
in my office. I will have peopleuse compression where, you know,
even if it is just a simplecompression stocking, like you'd
get, if you're a runner. Youknow, a lot of marathon runners
wear compression wear, becauseit's smart. When you're doing,
you know, tons of miles, you'regoing to get some blood pooling
and, you know, interstitialissues as things happen, but,
(11:12):
but that kind of where it worksreally well for people who have
autonomic nervous systemdysfunction, particularly those
like orthostatic phenotypes, youknow, because the thing is, I
can't get blood out of my legsback into my head with those
types of guys, the POTS, thosekind of things. So the
compression wear is superhelpful. But I'm not, you know,
I'm not using that. I use somephotobio modulation in my
office, the PEMF, the hyperbaricand the rest of what I do is, is
(11:35):
kind of this, you know, someaspects of myofascial release
that are neural, exam guided andhead eye, vestibular, motion
therapy aspects. You know, Ilike Focus Builder. People use
focus builder a lot. Nodisclosures there. I do some
mentoring for them. But I'm nota stock owner. I wish I was. I
just think it's one of the bestprograms for a functional
(11:57):
neurologist to use in theirpractice and with their
patients, because you can do allof these things with it, you
know, from metronome timing topursuits to saccades to roll
applications when you've gotrole playing issues and and all
these kind of things. So Ireally, really like it, and I
use that in my head, eyevestibular motion approach. I
have a lot of people, you know,they'll simple things, you know,
(12:19):
they take some fine motoractivity home, they take a board
that I made that's got sometargets on it, they'll do some
saccades, or some gaze holding,or some pursuits, in addition to
what we do in the office.
That's, that's kind of where itis. It's kind of a nuts and
bolts approach with, you know,with some accoutrement for sure.
Yeah.
Dr. Ayla Wolf (12:35):
Are you currently seeing a lot of people where
maybe they had a concussion,then they got long COVID, and
then they had all theirconcussion symptoms come back.
Dr. John McClaren (12:45):
yeah. I mean, you get any of these things, and
that's one of the things wetalked about, long COVID,
definitely a contaminator or,you know, mold issues, lime,
those kind of things, you know,where maybe they've had a
concussion, and then this kindof thing comes on, yeah, it
looks like a second concussionfor a lot of these people, or a
(13:05):
third or a fourth or a fifth oror things like that. And
they're, they're differentanimals, because you're seeing,
you know, different aspects ofactivation in the inflammasome.
You're seeing a skewing of themicroglial axis and things like
that. That is a littledifferent, because there's a
pathogen or something like thatthat comes in, but you see that
stuff, you know, theinflammasome activation, the
(13:27):
changes in cerebral blood flowthat happen with with a TBI as
well. So, boom. Second insult,you know, sometimes it kind of
goes back to a flare up of theirold issues. Sometimes they come
in with new or additionalproblems, and it's sometimes
it's harder to deal with, youknow, I had, I had a guy that
had a long COVID, got aconcussion, you know, so, like,
(13:50):
We stabilized him with hislong-COVID, then he got a
concussion, then we stabilizedthe concussion, and then he got
COVID again. And it just was,like, starting over, yeah,
Dr. Ayla Wolf (13:58):
which is so frustrating for the patient. But
I think one of the things Ialways try to say, when, when
stuff like that happens, is, youknow, if you got better, once
you can get better again, right?
Like we got you better, andwe'll, we just have to start
back, you know, a couple stepsbackwards, but we're now, we're
just going to keep goingforwards again, yeah,
Dr. John McClaren (14:19):
and that's a lot of times what happens. You
Dr. Ayla Wolf (14:20):
I think that with COVID, the other kind of unique
just find you probably scaledthe rehab back, you know, to
square one, or maybe even squarezero, from where they were in
and, you know, sometimes, youknow this guy in particular, he
had been going for like, acouple years before he found me
the first time, right? So it'slike, Hey, you're already here.
We're like, two years ahead ofwhere we were when all this
(14:42):
stuff started for you, so we'regoing to be fine. We've got you.
And that's the thing, I think,with with these autonomic
nervous system, people who havethat affectation in their TBI,
whether it's with these othercontaminating aspects or not,
you really do judiciously, haveto encourage them to because.
Maybe they've been through, youknow, some of those other tests,
(15:02):
or they've been to a medicalprovider who kind of told them,
you know, your testing isn'treally that bad, or whatever it
is. I don't really, you know,it's in your head kind of stuff,
right? You know, they've maybebeen a little gaslit or
something like that. So they'rediscouraged when they already
come in and it's like, you know,I'm just going to see you
because my wife drug me in here.
You know, you're the last thingI could find on the internet.
(15:26):
I've tried everything else, oror whatever it is, and then, you
know, you start to see, hey, youknow, we've, we found test XYZ,
we've done some things. We'veimproved, you you know. And
listening a lot of times, theyjust want to be heard, right?
You know, so, so listen to themtalk about how your examination
maybe fits some of the thingsthey're seeing. And sometimes
(15:46):
you may see the exam get better,and they still feel like crap.
And, well, that's that happens.
You know? That happens for sure.
thing was just the severe amountof damage to mitochondria that
some people are experiencing sothat they are very, very
fatigued. And it's, you know, Iuse the phrase, you know, of,
(16:11):
you know, sometimes you gottaspend money to make money. And
it's kind of the same thingwhere, you know, our muscles are
such a powerhouse for creatingmitochondria. It's like, okay, I
know you're tired, but youactually gotta, use it a little
bit in order to create moremitochondria. And so that
process can be really a strugglefor people, because, like you
(16:32):
said, every single day the goalpost moves in terms of what
somebody can handle.
Dr. John McClaren (16:38):
And maybe, you know, they have a day where
they feel pretty damn good. Andthen they try to do everything,
you know, that they've beenmissing out on for months, two
months, year. Or, you know, it'slike, my wife has this list for
me and I really wanted to get toit. And then they pay, you know,
the Piper for it, so to speak,for a while. And that's part of
the deal, too. It's like, howwhen can I get back to physical
activity, you know, all thesekind of things after, traumatic
(17:00):
brain injury, or after, youknow, a long-COVID affectation,
where they've been out of actionfor a little while. And that's,
I mean, it's like, you know,most people just crave kind of
feeling normal, right? It'slike, I want to, you know, I
want to feel like I did beforeall this happened, and they
start to get a little bit of ataste of that, because the
rehabilitation is working. Andthen, and then, yeah, they'll,
(17:21):
they'll do too much. I've beenguilty of that as well with
orthopedic injuries or whateverelse. You know, it's like, why?
How did you break your back?
Well, I tried to squat 600pounds four weeks after knee
surgery. You know, stupid,right? You know, you've been
there. Yeah, I got hit in thehead. I'm fine. Let's roll, you
know?
Dr. Ayla Wolf (17:40):
I completely understand, you know, it's
funny, I think I suffered fromfeeling like I was invincible
for far too long. And I thinkthat that reality check was hard
for me to recognize, like, No,you're not invincible. Maybe you
shouldn't follow your friends asthey huck themselves off that
cliff on mountain bikes.
Dr. John McClaren (18:02):
It looks fun.
And, you know, you get a littlebit of that. You know, that's
the thing. Our brain lovesdopamine, you know, you want a
little bit of that dopamine.
It's a, it's a nice, natural wayto get a dopamine hit, you know.
And it's something, you go, lookwhat I mean. That's and like,
with you, it's like, what can'tyou do? You know? You go, that's
another thing I can do that alot of people can't. And you We
(18:25):
thrive on being able to do someof these things that we think,
you know, we can do better thana lot of other people as humans,
whether it's hang drywall fast,or, you know, have the best
garden on the block, or the bestlawn on the block, or squat 800
pounds, or, you know, whateverit is, and you go, Hey, I just
want to, I just want to maximizemy human experience as much as I
(18:45):
can, because we're only here forso long.
Dr. Ayla Wolf (18:48):
Well, I'm an Aries, so I have to try
everything at least once.
Dr. John McClaren (18:52):
Yes! What else could I do today? Should
read a book and go to bed.
Dr. Ayla Wolf (19:01):
So when it comes to exercise, and obviously, with
both, you know, the fatigue fromlong-COVID And the autonomic
dysfunction and the exerciseintolerance that people
experience after a concussion,do you help people to really
dial in this kind of gradualgraded exercise program. And how
(19:23):
do you do that with people?
Dr. John McClaren (19:26):
Yeah, I think. And again, the athlete,
everybody, I like to say this,everybody's an athlete, right?
But your athletics might be yourgarden, or whatever it is. The
thing you know, John Leddy - hiswork is really, really good for
this. You know, the old, the oldthought process was cocoon
people and and then it's like,that's like, the worst friggin
(19:46):
thing you can do is sit in thedark room and not expose
yourself to the world. Like yousaid, you need to get back into
the world and start to do somestuff, because if you don't use
it, you lose it. So he, he didthis work in 2013 on graded
cardiovascular activity. As ameasure for, you know, how
recovered you are, and as ameasure for rehabilitating
(20:06):
people. So, you know the thing,you know that the buffalo
treadmill test came out of this.
You know, a lot of people arestarting to do those. I've got
athletic trainers in town doingthem now. You know, which is
great. You know, it's like, oh,they failed their BTT, can I
send them over? Yeah, pleasesend them over, because that's a
measure of autonomic nervoussystem function as well. Again,
you got a treadmill, or youdon't even need a treadmill. You
can walk and see what happens,right? So what's the symptom
(20:28):
load somebody comes in with,okay, you know, XYZ, you know,
rate it scale one to 10. Okay, Iwant to start to do some things.
And you know, I can at leastdilate my pupil a little bit.
Now okay, we've got somesympathetic activation so we can
get blood to the brain and thebody. When you do some certain
activity, I maybe will have themdo a Timed Up and Go test and
(20:51):
see if I get pupillary dilationwhen they do that, because
that'll tell me. Okay, yeah, youcan go for a walk. Now, you know
that kind of thing, real, good.
You know, the Timed Up and Gotest. You have them walk 10
meters, you know, see how fastthey can do it. And again, you
can measure some of these otherneurological metrics associated
with it that will do. And then,you know, what's your symptom
(21:13):
load? You know, rate it one to10. Get on the treadmill. When
do your symptoms start to tickup? You know, okay, at x miles
an hour out of a heart rate ofX, okay, let's stop see if it
comes back down. Does it comeback down? Cool? Okay, let's
reduce the load by 20% do itagain. Do the symptoms come back
(21:37):
up? Or are you good? You'regood. That's where you're going
to exercise until we assess youagain and see things happen. You
know, if you do it againtomorrow and you get the
headache at that 20% lowernumber, we lower it again by 20%
whatever it is, you know,whether it's the treadmill or if
they want to ride a bike or ifthey want to play the trumpet,
all these kind of things. I justhad one of those this week. The
(22:00):
high school guy, concussed,super like, super like, jazz
band trumpet wants to play.
Well, okay, once we, once weestablish, you've got an
autonomic nervous system that'sat least in the game, you know.
And the cool thing about thisguy, like, he could do the
Valsalva to play the trumpet,fine. I'm like, thank God. You
know, he had a lot of thingsthat I was glad, you know, were
(22:21):
good, like he didn't have a bigissue in his near point of
convergence or accommodation. Hehad the ability to tolerate a
Valsalva without getting aheadache. I'm like, we're going
to be fine. You know, thosethings you really, really like
to see, but, but that's thething. Take that lower it by 20%
if you don't get symptoms.
That's where you're exercisingfor the day, whether it's
gardening, you know, doingfarmers carries weight. Lifting,
(22:45):
same thing, lower the weight by20% if you don't get a headache
or you don't get clenching ofthe job, whatever you're
bringing me, right, whateveryou're bringing me, if you don't
get that, if you don't get cold.
You know,
Dr. Ayla Wolf (22:56):
it was really fascinating. One of the things
that, in hindsight, I recognizedas kind of an autonomic symptom,
because a lot, all, you know, alot of my concussions were mild
in the sense that I walked awayfrom them, I continued to do
whatever I was doing, and thenthe symptoms were just kind of
these, like lingering thingsthat I kept, kind of like
(23:17):
thinking were related tosomething else entirely. Well,
one of the things that I figuredout, kind of in hindsight, was
that whenever I would gomountain biking, a lot of the
trails that I would go on wasalways a steep uphill climb
first, before you got to thesuper fun screaming downhill.
And what I found was that Iwould start out my ride, I'd be
feeling totally fine, and thenall of a sudden my heart rate
(23:39):
would get to a certain point,and it was like some a switch
got flipped, and all of a suddenmy thoughts would turn so
negative, and I would just belike, I hate mountain biking.
Why am I doing this? I'mterrible at this. Why do I even
bother? I don't want to be here,and I'm just like, paddling up
this mountain, just angry. Andin hindsight, I was like, that
(24:01):
was my threshold before myautonomic nervous system just
had some kind of limbic thingkick in. Just the whole thing
fell apart.
Dr. John McClaren (24:10):
You go fully mesolimbic, and it's like, Man,
I don't really hate this. Do Ido it? Do I want to do this
anymore? And you go, Man, ifonly I could have lowered the
grade by 20%
Dr. Ayla Wolf (24:20):
But I couldn't make the mountain flatter!
Dr. John McClaren (24:24):
Yeah, that's the problem, you know, you go,
No, I want that trail, damn it.
That's my favorite trail. Idon't want to go to that like,
crappy John McLaren trail.
Dr. Ayla Wolf (24:33):
Can't I just get a ride to the top so I can just
go down?
Dr. John McClaren (24:36):
Yeah, put the ski lift in and, you know, you
know, take your bike with you,right? But it makes sense, and
that's the same thing, whetherit is, you know, the gardening
or or whatever it is thatsomebody really, really loves
and they want to do, there's,there's an autonomic nervous
system component to being ableto do anything where, even if
you're playing video games, youknow, if that's all you want to
(24:57):
do, I get a lot of kids that askthat, you know, video. Video
games are killing me. Well,there's a lot of things going
on, visual stimulus, a lot ofeye movement, a lot of
vestibular activation and thingslike that, which, again, you
know, we've already talkedabout, you need fuel and oxygen
for the process. And a lot oftimes it could be your primary
autonomic nervous systemdysfunction that's not allowing
(25:17):
these, you know, these people,to be able to do that
Dr. Ayla Wolf (25:19):
well. And I think what you're highlighting is
where Functional Neurologyreally excels in that the way
that you're looking at each ofthese patients is so completely
individualized, whether you'retalking about a professional
weightlifter or somebody whojust wants to garden or somebody
who's playing video games orsomebody who just needs to carry
groceries up a flight of stairs,you know, functional neurology
(25:40):
really excels in being able totake that one single individual
person and say, What are youstruggling with now? And how do
we get you a little bit betterso that you can do life better
in whatever way that looks likefor you? And I think that's what
I really love about it is, isthe flexibility and then also
the creativity in saying, youknow, if the goal is to get you
(26:01):
to garden, then that mightcompletely change what kind of
therapies we're actually usingor doing, as opposed to the
power lifter.
Dr. John McClaren (26:10):
Well, for sure, and sometimes you you
know, that's the great thingabout this stuff, that's one,
one thing Professor Carrick,from the first time I ever saw
him, do a case. What if there'sone thing I can do for you. What
do you want it to be? Right?
What a great question. Sometimesyou might not get it, but at
least I know where this personis, you know. And then you meet
people. And again, you've saidthis before on the podcast. You
meet people where they are, yougo to them where they are, and
(26:33):
you make it work. Maybe, maybewe go do your head, eye,
vestibular motion therapy in thegarden, or a garden, or I
simulate a garden with aprojector on my office wall, or
whatever it is, because, youknow, it's like, I feel pretty
good when I do your gazestability exercises here, or
when I'm in my house, where mywalls are kind of plain, but
(26:53):
then you get outside and it'slike there's different visual
context To the activity, right?
Or whatever it is, visual,vestibular, you know, maybe,
maybe it's like, they need towear different shoes, you know,
there's something in that that'scausing the breakdown. And you
can bring the rehabilitation tothe place they want to be, the
power lifter. You can bring therehabilitation into the gym.
(27:15):
I've got a Brock string and asaccade board and all this stuff
right by my squat rack. So, youknow, I'm doing, like, you know,
head tilts and all this kind ofstuff between sets. And, you
know, it's like, well, you know,does it help?
Dr. Ayla Wolf (27:28):
I Yeah, no, that's hilarious. Mean,
sometimes in between sets, whenI'm at CrossFit, I'm like, I
need to do some Yes, yes, gazestabilizers. Like, you know,
let's, let's fire down thisvestibulospinal pathway before I
start doing my power cleans.
Dr. John McClaren (27:43):
Yep, I wish I brought my OPK strip in, because
I feel like I'm a littleforward, or, you know, something
like that right?
Dr. Ayla Wolf (27:49):
Yeah. I mean being able to understand how the
system is wired and how tostimulate it so that you can
create, you know, theappropriate response is, is
really the name of the gamehere. And like I said, I just, I
love the the creativity that Isee with all the different
functional neurologists that Ithat I talk to in terms of what
(28:10):
they're doing in their practice.
And like you said, even likehaving someone do their
therapies in the gym or in thegarden or in the swimming pool,
it makes a huge difference. Imean, we're, you know, like you
said, it's all about context.
Dr. John McClaren (28:24):
Yeah, that's the thing. What do you want to
do? Let's make you better at it,yeah? And let's make you better
at it, and not compromiseyourself along the way. Ideally,
is the good thing, right? Yeah,we want to be well rounded
humans, and that's what we wantto see in our exams all the
time. But, yeah, you know,really what it comes down to.
It, if you, if you can getpeople to handle the activity
(28:44):
that makes them the most happy,they're going to be a satisfied
person. They're going to referyou more people than you
probably wanted them to referyou and and all these kind of
things. And it's, it's just theway to organically build a
practice just listen to peoplegive them the best version of
yourself that you can and dothese kind of things, and
(29:06):
they're going to be, they'regoing to be really happy.
They're going to have asuccessful rehabilitation and
and, you know, the thing too, alot of times, people will ask
me, How long do I have to dothis stuff? You know, do I do I
need to do this stuff forever?
And I'm like, well, some of it,you probably should. You know, I
had that when I had my shouldersurgery last year. It was I had
that epiphany where it's like,you might, my therapist asked,
(29:26):
you know, what do you do foryour warm up before bench press?
It's like, one plate, two,plate, three, plate. And she
just rolls her eyes at me, youknow? And it's like, what what?
You know, that's, that's justwhat I've done, you know? Now
it's like, I've got this 20minute routine of old man warm
ups before I lift that I'll dofor the rest of my life, because
I want to stay healthy, youknow, in my shoulders, and I do
(29:47):
neuro axis work and things likethat. Again, I wasn't doing that
stuff before. And I'll tellpeople that, you know, it's like
you should probably, as long asyou have a brain, do some of
these things for the rest ofyour life. And the thing too.
You know, that's to go back to,you know, the the case where the
guy had, you know, the COVID,the concussion and the COVID, if
people continue to do some ofthese things, look at Joe
(30:08):
Clark's research. It'spreventative. You do these
things and you have an event,you are way less susceptible
than if you don't do thesethings and have an event, right?
You know, if you're doing someeye movement training or some
reaction time training, or someaspect of balance training, and
you get hit in the head, or youget your COVID or your influenza
(30:28):
A or these kind of things, yournervous system is going to be
hardened so that it minimizesthe damage, right? That's the
thing. It's, it's like, youknow, it's the same thing as
lifting weights or doingCrossFit. Now, like, we're doing
this one, because we want to,you know, we want to look and
feel good now, but I want to beable to get off the toilet when
I'm eating right? Everybody saysit now, why are you training so
I can get off the floor later?
Dr. Ayla Wolf (30:52):
Well, and I think too, that just the very nature
of what we're doing all daylong, in terms of the neuro
rehab with our patients is like,when I'm having them doing
saccades or pursuits, it's likeI'm also I'm looking at their
eyes, so I'm also getting apursuit in a saccade, and as I'm
watching them do what I wantthem to do, and it's like, as
(31:12):
I'm moving their arm in a figureeight, my arm's moving in a
figure eight.
Dr. John McClaren (31:16):
You're doing complex movements too, and it's
and it's unique. You know,you're getting a different
activation with every personbecause they're stiff and heavy
in different different ways.
Your cerebellum is like, yeah,you know, I want to come to work
today!
Dr. Ayla Wolf (31:28):
Yeah. And so it's like if I've got someone looking
at a Brock string and I'mpointing at the beads, well, I'm
kind of doing the Brock stringmyself in that moment. And
honestly, I feel like that isactivating my brain all day
long, literally, just by workingwith my patients. It's like my
brain is getting its own activeactivity,
Dr. John McClaren (31:46):
absolutely, yeah, and that's the thing. I
mean, you look at, you talk tosome of these people at, like,
iscn or, or, you know, whatother things we get together,
clinical gems. Or, you know,whatever it is, when you get a
big group of people who've beendoing some of this work a really
long time together. You know,you get some of these people
that are in there six, sevendecades of life. One, they're
still working. Two, they'resharp as tacks.
Dr. Ayla Wolf (32:10):
So you mentioned you use a lot of the head eye
vestibular therapy as part ofcreating better balance and
integrity within the the system.
What you know, what other typesof therapies or things are you
incorporating in a lot of yourrehab when it comes to people
that have dysautonomia as partof their presentation?
Dr. John McClaren (32:34):
Things I love. I really like to have
people use fine motor activity.
I just have found when you bringin some of those lateral
cerebellar aspects, you know,coin rolling is one of the big
ones. And, you know, Carrick gotme onto this, like everything,
right, you know, and the thoughtprocess is, how do I activate
(32:54):
the brain in a way that isjudicious and doesn't bias that
system too much one way or theother, because what am I trying
to do? As you said, I want toget the top down stuff, to talk
to the vagus, or talk to theIML, to get it to do what it's
supposed to do. Those neurons,generally, when you have a TBI,
themselves aren't damaged unlessyou've got a significant shear
(33:16):
or an intracranial bleed orthings like that. It's the
connections, those white matterconnections that get, you know,
damage you get the roadconstruction, so to speak, is
going on. And, you know, nowI've really, I've only got one
lane when I should have three oror so on when I'm driving, the
fine motor activity is great,because you don't get a super
high level of activation inthose brain stem centers, like
(33:38):
the nucleus track to solitaires,where you can suppress an
already suppressed sympatheticsystem by doing some of these
big, complex movements andthings like that, which works in
some cases really, really well.
If I wanted to drive more thoseparasympathetic aspects, I might
do a little more complexmovements, because I get an
activation of that NTS, I getsome vagal activation to
(34:00):
suppress the IML, a little moreincreasing circular output.
Really good for that, right? So,you know, fine motor activity is
really, really good. I getthese. You can use, like a poker
chip or a 50 cent piece, like aquarter with some of these
people, is almost too small. Igot these, you know, I've got
one, you know, it's, it says Iwas caught being good today. You
(34:22):
know, it's about the size of a50 cent piece, and you just have
people roll it, and it workssuper duper well. And I mean,
you people see me do it, it'slike, well, I've been doing this
every day for three years. Don'tfeel like you should do it. It's
been part of my whole process ofgetting that brain to be better.
So I'm pretty fluent with it.
You know, on a good day, I cando a dime. And that's another
way you can scale the therapy,you know, make give them
different weighted objects thatare maybe that size, because,
(34:44):
again, the cerebellum likes thatnovelty, and it helps to drive
into some of those autonomicactivating centers, the locus
coeruleus, so to speak. Youknow, one of those areas that's
very important to autonomicmodulation. It's got, like, 313
different parts of the brain.
Screen that pop into that littlething, and if it doesn't work
really well, that's when you seethese dysautonomia phenotypes. I
(35:06):
may, again, if I can get somepupillary dilation on like a
cognitive task, or I don't seethem fail doing dual tasking on
their balance, I might have themdo some saccades. You know, I
like very small amplitudesaccades. Generally, when I
start these with dysautonomiapatients who are a little less
stable, I like to move away fromcenter because it's easier to
(35:26):
put the brakes on. You wantpeople not to overshoot when
they do saccades really early.
It's harder to put the brakes onwhen you cross the nose than it
is when you go away from thenose, that kind of thing. So
we'll put them, you know, maybeon a 45 where we combine the
machinery for vertical andhorizontal saccades, because,
again, it's a little nicer onbrain activation. That's why you
see all these carrot brainexercises on the 40 fives. It's
(35:48):
vertical and horizontalmachinery working together. So
it takes a little less blood andoxygen to get that thing going.
You'll see this all the time.
And people who havedysautonomia, you know, you have
them do saccades horizontally inthe exam. And it's like, my god,
I can't do that. And then theycan do the verticals a little
(36:09):
bit better, or vice versa,usually your vertical a little
better than horizontal. And whenyou look at Professor Carrick's
work that he did on, you know,these, these 40,000 different
groups, stratified by age andall that, he found the vertical
movements tend to be a littlemore accurate than the
horizontal movements overall.
Have you seen it?
Dr. Ayla Wolf (36:29):
Was the one where he was really stratifying it by
age range, sex, yeah. Kind ofnormative values really need to
change based on not only age,but also gender. Yeah, that's
huge,
Dr. John McClaren (36:43):
Yeah. And you see how women do some things a
lot better than men, and viceversa, and, and, you know,
concussed women perform betterthan regular men on a lot of
things, and, you know, and notso well on others, you know, but
it, but it's interesting. Andwhen you, when you look at this
research that comes out, you youstart to tailor your exam
expectations to that, and youcan tailor your rehabilitation
(37:03):
toward that, where, you know, ifI'm dealing with a female
patient with dysautonomia, I maydo a little better with some
saccades than I will with somepursuits. With a male, I might
do a little better with somepursuits and some saccades,
because they perform a littlebetter in those tasks, even in a
TBI, you know, kind of context,even after more than one. So,
you know, we use, we use somereally small, subtle
(37:25):
activations, you know, maybe youloop in some of those other
things, like the, you know, thevagal nerve stimulation, if I
want to drive it a little bit,or things like that. I'll use
the mini stem device, orsomething that's like an SSEP on
the tongue or on the trigeminalsystem. Those kind of things are
really, really nice. Again. Iwant to see dilation on my
pupillometry. Before I do a lotof that, I want to see, we'll do
(37:48):
the hand grip test where, youknow, we're looking at, you
know, are we going with Ewingand Clark 16 on our diastolic,
or do we want to see the full20? The whole thing, you know,
when we do this hand grip test,you know, we're, we're getting a
maximum hand grip. We're findingout that's kind of our baseline.
We're going to 30% of that.
We're sustaining that for fiveminutes. We're checking the
(38:08):
blood pressure every minute. Youknow, in corata and all these
people found that that diastolicnumber was the number that is
the the one that matters, theauthoritative one for the
autonomic nervous system. If Iat three minutes, can't get my
my diastolic pressure to rise,depending on what source you
read, between 16 and 20millimeters of mercury, you
(38:28):
know, then I know I'm notactivating my sympathetic
nervous system super well. Soyou're going to be really,
really judicious in how youdrive your rehabilitation with
these dysautonomia phenotypes,you know. And then, and then,
and then, can I get it there?
And then, can I sustain it? Youknow, you'll see this, and
you'll see it on the pupils allthe time. Well, they got the
T-75 yay. But then it goes rightback down into a full blown
(38:51):
constriction. And, you know, Igot to the 16 to 20 beats, or
millimeters of mercury. And thenminutes four and five, it goes
right back down. You know, thoseare people. It's like, you can
introduce some of these things alittle more than people that
can't do it at all, but youstill have to be really
judicious. And you know, just,just start small. Maybe again,
to kind of go back to a topicyou guys have discussed really
(39:12):
well, maybe we'll do someaspects of apophyseal glides in
the cervical spine. We'll dosome manipulation in the rib
cage to maximize oxygencapacities and things like that,
because that cervical spine hasso much to do with how that
autonomic nervous systemactivates.
Dr. Ayla Wolf (39:27):
And I think everything you're saying, one of
the really important take homehere is a lot of people, when
they are booking kind of thatinitial appointment, they're
like, why do you need so muchtime with me to do your initial
assessment? And this is why,because looking at the autonomic
nervous system and even askingthat question of, does this
person even have enoughsympathetic output to be able to
(39:49):
handle the therapy? And if theydon't, I need to back down on my
therapy. And so it's like thereason we need that time with
the patient up front to do allof our invest. To gate of work
is because it matters. You know,how they're performing on this
pupil test really, is actuallyindicative of what we are not,
are aren't going to do, as faras their therapy, or what we
(40:12):
know that their system can orcan't handle, at least as a
starting point,
Dr. John McClaren (40:16):
yeah, and that's why, that's why I love
that pupilometry app, because Ican take that four or five, six
times. Really apply a therapyand see what happens. And it's
not as fatiguing to people assome of the other things we
might do are, you know, it'shard to and if you take a blood
pressure 12 times during exam,that can contaminate itself over
time too, right? You'll, you'llsee, you know, a significant
(40:37):
change just by doing it multipletimes on the same arm in a time
period that's relatively small,so it's not as good a data. The
pupils, they're very quick torespond to therapy. I mean,
again, when we're doing brainrehabilitation, you're seeing
brain able to replicate proteinsin a nanosecond. So you can
really, really quickly addstability or detract from
(40:58):
stability. You know, really,quickly, depending on on the
person and how they do. So,yeah, it's like, why are you
doing this again? Well, youknow, if I'm going to give you a
saccade to the left, I want tomake sure that it doesn't cause
you, you know, a negativeoutcome. And because if I'm
going to send you homelessstuff, if I'm not doing and we
all practice a littledifferently, too, but if I'm not
(41:19):
seeing you in a three times aday intensive model for five
days. Maybe I'm sending somethings home with you, and I'm
bringing you back in again in afew days or a week, or something
like that. Or I'm checking onyou via telemedicine with my
people ometry, if you've gotthat app you know, or I've got
some other things where you knowyou're you've got somebody with
you who can take blood pressuresbilaterally, and tell me what
(41:41):
the response is after a few daysof therapy where, you know, you
can't get to me. I mean, they'recoming from a few hours away,
maybe to see you. You know thatthat kind of thing, I'm sure
you're getting that a lot, whereit's like they're coming from, I
mean, all over, all over thestate, or even farther than
that, you know they're gonnamaybe go home and take this
stuff home, and I want to makesure that the outcome is as
(42:04):
positive as possible, do theleast amount of negative that
you can do, and do as muchpositive as you can do with your
rehabilitation. So, you know,we'll loop some of those things
in, you know, I like looking atjoint position errors in the
cervical spine and using that asa rehabilitative model. There's
so many ways you can do that.
You can have people do, youknow, head laser things with
eyes open. You can have them doit eyes closed. Those things are
(42:25):
really, really good with theseautonomic nervous system
phenotypes, where the neck isreally involved. And again,
using the neck gives you somemore positive activation. Again,
as long, as long as we know itwith diligence, that it's good
strengthening of the neck. Youknow, that's one of those. I
think you guys touched on thattoo. You know, I think you're
doing your best to correct thejoint position errors. Is good.
(42:49):
Before you get into a ton ofheavy strengthening in the neck,
you're going to get neckstrengthening with general
resistance training to somedegree. But if you really want
to specifically attack the neck,just make sure they aren't
really, really skewed on theirjoint position errors. But you
can do them together. You can dothem in concert, because a lot
of times the strengthening helpswith the joint position error
processing as well, along withthe the manual modalities and so
(43:11):
on.
Dr. Ayla Wolf (43:15):
Well, man, I think we covered a lot of a lot
of information. Why don't youlet people know kind of where
they can find you, and now thatyou're back on social media,
yeah,
Dr. John McClaren (43:23):
yeah, yeah.
So yeah, back to Facebook. I'vegot a clinic profile. We're
Advanced Chiropractic andNeurology PC. We're located,
like you said, in suburbanOmaha. We're located in La Vista
Nebraska. My website iswww.Omahaspinecare.com, curated
by a friend of mine. A long timeago, I was going to write it
something different. He's like,No, make it something people
understand, John. 402-597-2869,is our office number. You can
(43:46):
feel free to reach out to methere or on Facebook. I've got a
personal profile, the officeprofile. Instagram, I think I've
got like four followers since Icame back. So you know, you can
look for me there if you want.
Dr. Ayla Wolf (44:01):
Okay, well, now I'll put all of that in the show
notes so that the links arethere too. Yeah, perfect. Well,
I appreciate your time, andthank you so much for coming on
the show. Always a pleasure totalk to you. I love geeking out
with you.
Dr. John McClaren (44:14):
The pleasure is all mine. Thank you so much
for the invite. I really, reallyam honored to be here. Good.
Dr. Ayla Wolf (44:18):
Well we'll have to do it again. Yeah, yeah,
Dr. John McClaren (44:20):
I'm in. For sure, yeah, for sure, I'm in,
yeah.
Welcome back to the Life After Impact podcast.
This is part two of myconversation with Dr John
McLaren, an expert in traumaticbrain injuries, concussion,
recovery and autonomic nervoussystem dysfunction, practicing
near Omaha, Nebraska in thisepisode, after geeking out about
jump ropes. We continue toexplore his Functional Neurology
(00:23):
approach to treating autonomicdysfunction and concussions. We
discuss the use of pulsedelectromagnetic frequency
devices to improve vasomotoractivity and the use of
hyperbaric oxygen therapy, wherehe takes it one step further and
shares how specific examinationfindings such as the pupillary
light reflex and a five minutesustained hand grip test further
(00:47):
help him to differentiate whotruly is a good candidate for
hyperbaric oxygen therapy. Wediscuss heat intolerance as a
manifestation of autonomicdysfunction due to a loss of
normal sweat response the use ofcompression gear and the
importance of therapist guidedgradual return to activity and
exercise as it's appropriate forthe individual and we touch upon
(01:12):
head eye vestibular motion, afunctional therapy that utilizes
eye movements, head movementsand vestibular activation as
part of neuro rehabilitation,and then we touch upon
long-COVID as a possible setbackin people's recovery due to
inflammatory consequences andfurther insult to the autonomic
(01:32):
nervous system. Thank you somuch for listening to the
podcast. If you have topics youwould like us to explore, please
text us using the link in theshow notes, or send us an email
at lifeafterimpact@gmail.com
Sophia Bouwens (01:48):
Welcome to the life after impact podcast, where
we do a deep dive into allthings concussion and brain
injury related. We talk aboutall the different symptoms that
can follow brain injury,different testing methods,
different types of specialistsout there, and different
therapies available. I'm SophiaBowens, and I'm here with Dr
Ayla Wolf, and we will be yourguides to living your best life
(02:12):
after impact.
Dr. Ayla Wolf (02:15):
Yeah, I had just a major geek moment the other
day. I was listening to apodcast. It was a CrossFit
podcast, and they wereinterviewing a guy who teaches
like jump rope classes, and allof a sudden he launched into
what, from my perspective, was afunctional neurology explanation
of why jump roping is soimportant to toning the
(02:36):
autonomic nervous system andtalking about how some people
are more upper body dominant,and other people are lower body
dominant. But when you jumprope, you've gotta sync up your
timing of your wrist with thetiming of your feet and your
jump and so, you know, basicallyhe just launched into this whole
(02:58):
neurological reasoning for whyjumping rope was this way of
creating better neuroplasticity,in terms of how the coordination
between your upper body and yourlower body. And, of course, in
my mind, I'm like, "and then wehave the inferior olive which is
all about timing, and that goesinto the cerebellum"
Dr. John McClaren (03:16):
Put the metronome to the jump rope and
see what happens. Right? Yeah,
Dr. Ayla Wolf (03:20):
metronome and a jump rope like that could be a
magical therapy right there.
Dr. John McClaren (03:26):
We might have just, you know, call it the
Wolf-McLaren jump rope.
Dr. Ayla Wolf (03:29):
Let's work on that,
Dr. John McClaren (03:31):
yeah, but you throw in the vestibular aspects
as well, right? I mean, that's,it's like, this big thing, and
not to mention theproprioceptive bombardment from
lumbosacral spine, which is oneof the reasons I don't jump rope
as much as I probably should,that I suck at it, you know,
it's like, yeah, I know it's agreat activity. And that's the
cool thing about CrossFit, youknow, or any of these athletic
(03:52):
endeavors, it's, it's motion ata higher level. You know, we
look at gait all the time, butyou go, okay, the gait... Okay,
how do I jump rope? How do Ijump rope with a dual task, or
something like that? That couldbe a really, really nice, high
end way to test. And I know, oneof the things you, you know, you
had mentioned in the questionsleading into today, was how,
(04:14):
what can people do at home? Andthese are things you know, you
can integrate your activities ofdaily living in to to how to
rehabilitate yourself as well.
Dr. Ayla Wolf (04:24):
Yeah, and I think that you mentioned you've got a
PEMF device, and so do I. Andone of the things that I really
have spent a lot of timeresearching and wrote about in
my book was the importance ofvasomotion within the, you know,
cardiovascular system and thearteries and even within the
brain too. And so I think thatyou know, one of the things that
(04:48):
the PEMF devices are so helpfulfor is restoring that healthy
vaso motion, and especially whenyou've got somebody who maybe
has dysautonomia and exerciseintolerance and can't
necessarily. Necessarily movetheir body at the high level
that they maybe were used to,you know, something like that
can really come in and supportthat system in that way too.
Dr. John McClaren (05:11):
Absolutely, it's so interesting. And a lot
of people, you know, they likehyperbaric oxygen therapy for
these kind of things as well,because, again, you're
increasing blood oxygenconcentration. Yeah, the pulsed
EMF, vasomotion remodeling, youknow, kind of in that neuronal
pool because of that and so on.
Yeah, you want to heal whitematter. I mean, those are two of
the best modalities that youcould potentially use, for sure.
(05:31):
And of course, just likeanything else, be judicious,
right? Have a biomarker.
Everybody says that, well,what's the protocol? And I think
you've probably found this withyour PEMF too. There aren't
necessarily standardizedprotocols, right?
Dr. Ayla Wolf (05:46):
Yeah. I mean, a lot of times it's like, let's
just start you out really,really light and just very
slowly bring you up, and then,you know, kind of cycle through.
But yeah. And you know, somepeople like with mine, you know,
they'll lay on it at a levelone, and they'll say, Oh, wow. I
can just really feel like, youknow, all of this stuff
happening in my body. Well, me,I have to have it on level seven
(06:06):
before I even feel anything.
Dr. John McClaren (06:09):
it's interesting, yeah, yeah, you
know, you boost the fieldstrength off, and you can vary
your field intensities andthings like that. It's, it's
fascinating stuff. And, andthat's the thing, I think there,
you know, there will beestablished research parameters
for this stuff on top ofeverything else, as we go, same
with hyperbaric. You know, thatthat's the thing. There are a
lot of people, again, talkingabout, what's great for
(06:33):
everybody? Nothing's great foreverybody all the time, right?
If it was, we'd all, you know,if hyperbaric was the thing to
do for dysautonomia withconcussions, we'd have like, 10
hyperbarics in our office, andeverybody would be doing that
all day long, I mean, and beforeI really, really understood the
dynamics of, you know, this,especially this sympathetic
(06:54):
activation being important, youknow, I was putting a lot of
people in hyperbaric and gettingmixed results because Sometimes
it's too much of a stimulus forthat parasympathetic system.
You're really driving vagalsystems and and, you know, they
come out there, like I feelgreat, and then, and then they'd
have a hard time for a littlewhile. And now, when I
understand it, do I havepupillometry that's appropriate
(07:17):
for the stimulus? Do I have, youknow, one of these, we do this
hand grip test and see, do Ihave adequate activation of that
sympathetic system to be able tohandle a stimulus? You talk
about sweating. And one of thethings I mean, what sweating is
most important function,dissemination of body heat,
right? What's one of the thingsthese people with dysautonomia
(07:39):
tell you, I suck in the heat,yep, you know, I can't wait for
fall, yeah, because they can'tdisseminate heat properly,
because they don't haveactivation of the sympathetic
system appropriate for it.
Dr. Ayla Wolf (07:52):
and I think that's something that people
also, you know, kind of miss isthe fact that it's not a teeter
totter. It's not that whenparasympathetic activity is
high, that sympathetic then is,by default, low. You know, these
are two completely separate armsof the nervous system doing
their own things. And so therecan be maybe a relative excess
(08:15):
of sympathetic compared toparasympathetic, or you can have
it where there is actualdecreased parasympathetic and
increase sympathetic. And so wedo have to look at it not as a
teeter totter, but as twoseparate output systems that can
be independently doing their ownthing, but we need both of them
to be appropriately responsive.
Dr. John McClaren (08:36):
Yeah it's just like when you test balance.
It's context specific weighting,right? I want my brain to be
able to stand on a perturbedsurface with eyes closed. Then I
want to be able to do thingswith eyes open. Then I want to
be able to do things on a normalsurface and and the brain will
re weight the systems accordingto the context and the demands
of that context. It's the samething with the autonomics.
(08:58):
Again, I need to digest I needto digest the stake, and then I
need to fight off the intruder,or whatever it is, relatively
quickly. And then, and then, youknow, once the intruders fought
off, I got to finish digesting,go back to what I was doing,
yeah, and then, and then,hopefully, go to bed. And do it
again the next day, these kindof things. Yeah, it's exactly
(09:20):
what it is that's what the braindoes when it works the way that
it should is it can take everysystem that it communicates
with, and it can weight itappropriate to the current
demands, but the backgroundprocesses work appropriately.
And in order to do all that, youhave to have fuel, oxygen,
vasomotor activity, exactly, allof those things and you want it
(09:43):
comes down to it, everybody willask, well, what is a symptom of
autonomic nervous systemdysfunction? Anything they can
come in with, because if I can'tfuel my frontal lobe, I'm going
to have executive dysfunction,right? If I can't fuel my
vestibular system, I'm going tobe dizzy, or we'll have some
kind of translational issues, orhave background contamination
(10:05):
throw me off, or any of thesekind of things. If I can't fuel
my cerebellum, I'm gonna havemaybe some of these, like speech
issues, or some of these issuesin cognition as well. Or
activity coordinations of motoractivity won't be super well,
you know, you'll seemiscoordination And like, what
the way a hamstring contracts,or things like that, you know,
things that you're doing in yourpostural assessment. And again,
(10:28):
blood and oxygen. Every neuronneeds it. Blood oxygen and
activation, right?
Dr. Ayla Wolf (10:33):
And for everybody, that can look
completely different in terms ofhow to get in there and start
stimulating, yeah. So youmentioned you've got your
hyperbaric, you've got yourPEMF, or you do you also do like
the NormaTec compression gear.
Or like, are you doingcompression? Or what else are
you integrating?
Dr. John McClaren (10:50):
I haven't used that. I haven't used that
in my office. I will have peopleuse compression where, you know,
even if it is just a simplecompression stocking, like you'd
get, if you're a runner. Youknow, a lot of marathon runners
wear compression wear, becauseit's smart. When you're doing,
you know, tons of miles, you'regoing to get some blood pooling
and, you know, interstitialissues as things happen, but,
(11:12):
but that kind of where it worksreally well for people who have
autonomic nervous systemdysfunction, particularly those
like orthostatic phenotypes, youknow, because the thing is, I
can't get blood out of my legsback into my head with those
types of guys, the POTS, thosekind of things. So the
compression wear is superhelpful. But I'm not, you know,
I'm not using that. I use somephotobio modulation in my
office, the PEMF, the hyperbaricand the rest of what I do is, is
(11:35):
kind of this, you know, someaspects of myofascial release
that are neural, exam guided andhead eye, vestibular, motion
therapy aspects. You know, Ilike Focus Builder. People use
focus builder a lot. Nodisclosures there. I do some
mentoring for them. But I'm nota stock owner. I wish I was. I
just think it's one of the bestprograms for a functional
(11:57):
neurologist to use in theirpractice and with their
patients, because you can do allof these things with it, you
know, from metronome timing topursuits to saccades to roll
applications when you've gotrole playing issues and and all
these kind of things. So Ireally, really like it, and I
use that in my head, eyevestibular motion approach. I
have a lot of people, you know,they'll simple things, you know,
(12:19):
they take some fine motoractivity home, they take a board
that I made that's got sometargets on it, they'll do some
saccades, or some gaze holding,or some pursuits, in addition to
what we do in the office.
That's, that's kind of where itis. It's kind of a nuts and
bolts approach with, you know,with some accoutrement for sure.
Yeah.
Dr. Ayla Wolf (12:35):
Are you currently seeing a lot of people where
maybe they had a concussion,then they got long COVID, and
then they had all theirconcussion symptoms come back.
Dr. John McClaren (12:45):
yeah. I mean, you get any of these things, and
that's one of the things wetalked about, long COVID,
definitely a contaminator or,you know, mold issues, lime,
those kind of things, you know,where maybe they've had a
concussion, and then this kindof thing comes on, yeah, it
looks like a second concussionfor a lot of these people, or a
(13:05):
third or a fourth or a fifth oror things like that. And
they're, they're differentanimals, because you're seeing,
you know, different aspects ofactivation in the inflammasome.
You're seeing a skewing of themicroglial axis and things like
that. That is a littledifferent, because there's a
pathogen or something like thatthat comes in, but you see that
stuff, you know, theinflammasome activation, the
(13:27):
changes in cerebral blood flowthat happen with with a TBI as
well. So, boom. Second insult,you know, sometimes it kind of
goes back to a flare up of theirold issues. Sometimes they come
in with new or additionalproblems, and it's sometimes
it's harder to deal with, youknow, I had, I had a guy that
had a long COVID, got aconcussion, you know, so, like,
(13:50):
We stabilized him with hislong-COVID, then he got a
concussion, then we stabilizedthe concussion, and then he got
COVID again. And it just was,like, starting over, yeah,
Dr. Ayla Wolf (13:58):
which is so frustrating for the patient. But
I think one of the things Ialways try to say, when, when
stuff like that happens, is, youknow, if you got better, once
you can get better again, right?
Like we got you better, andwe'll, we just have to start
back, you know, a couple stepsbackwards, but we're now, we're
just going to keep goingforwards again, yeah,
Dr. John McClaren (14:19):
and that's a lot of times what happens. You
Dr. Ayla Wolf (14:20):
I think that with COVID, the other kind of unique
just find you probably scaledthe rehab back, you know, to
square one, or maybe even squarezero, from where they were in
and, you know, sometimes, youknow this guy in particular, he
had been going for like, acouple years before he found me
the first time, right? So it'slike, Hey, you're already here.
We're like, two years ahead ofwhere we were when all this
(14:42):
stuff started for you, so we'regoing to be fine. We've got you.
And that's the thing, I think,with with these autonomic
nervous system, people who havethat affectation in their TBI,
whether it's with these othercontaminating aspects or not,
you really do judiciously, haveto encourage them to because.
Maybe they've been through, youknow, some of those other tests,
(15:02):
or they've been to a medicalprovider who kind of told them,
you know, your testing isn'treally that bad, or whatever it
is. I don't really, you know,it's in your head kind of stuff,
right? You know, they've maybebeen a little gaslit or
something like that. So they'rediscouraged when they already
come in and it's like, you know,I'm just going to see you
because my wife drug me in here.
You know, you're the last thingI could find on the internet.
(15:26):
I've tried everything else, oror whatever it is, and then, you
know, you start to see, hey, youknow, we've, we found test XYZ,
we've done some things. We'veimproved, you you know. And
listening a lot of times, theyjust want to be heard, right?
You know, so, so listen to themtalk about how your examination
maybe fits some of the thingsthey're seeing. And sometimes
(15:46):
you may see the exam get better,and they still feel like crap.
And, well, that's that happens.
You know? That happens for sure.
thing was just the severe amountof damage to mitochondria that
some people are experiencing sothat they are very, very
fatigued. And it's, you know, Iuse the phrase, you know, of,
(16:11):
you know, sometimes you gottaspend money to make money. And
it's kind of the same thingwhere, you know, our muscles are
such a powerhouse for creatingmitochondria. It's like, okay, I
know you're tired, but youactually gotta, use it a little
bit in order to create moremitochondria. And so that
process can be really a strugglefor people, because, like you
(16:32):
said, every single day the goalpost moves in terms of what
somebody can handle.
Dr. John McClaren (16:38):
And maybe, you know, they have a day where
they feel pretty damn good. Andthen they try to do everything,
you know, that they've beenmissing out on for months, two
months, year. Or, you know, it'slike, my wife has this list for
me and I really wanted to get toit. And then they pay, you know,
the Piper for it, so to speak,for a while. And that's part of
the deal, too. It's like, howwhen can I get back to physical
activity, you know, all thesekind of things after, traumatic
(17:00):
brain injury, or after, youknow, a long-COVID affectation,
where they've been out of actionfor a little while. And that's,
I mean, it's like, you know,most people just crave kind of
feeling normal, right? It'slike, I want to, you know, I
want to feel like I did beforeall this happened, and they
start to get a little bit of ataste of that, because the
rehabilitation is working. Andthen, and then, yeah, they'll,
(17:21):
they'll do too much. I've beenguilty of that as well with
orthopedic injuries or whateverelse. You know, it's like, why?
How did you break your back?
Well, I tried to squat 600pounds four weeks after knee
surgery. You know, stupid,right? You know, you've been
there. Yeah, I got hit in thehead. I'm fine. Let's roll, you
know?
Dr. Ayla Wolf (17:40):
I completely understand, you know, it's
funny, I think I suffered fromfeeling like I was invincible
for far too long. And I thinkthat that reality check was hard
for me to recognize, like, No,you're not invincible. Maybe you
shouldn't follow your friends asthey huck themselves off that
cliff on mountain bikes.
Dr. John McClaren (18:02):
It looks fun.
And, you know, you get a littlebit of that. You know, that's
the thing. Our brain lovesdopamine, you know, you want a
little bit of that dopamine.
It's a, it's a nice, natural wayto get a dopamine hit, you know.
And it's something, you go, lookwhat I mean. That's and like,
with you, it's like, what can'tyou do? You know? You go, that's
another thing I can do that alot of people can't. And you We
(18:25):
thrive on being able to do someof these things that we think,
you know, we can do better thana lot of other people as humans,
whether it's hang drywall fast,or, you know, have the best
garden on the block, or the bestlawn on the block, or squat 800
pounds, or, you know, whateverit is, and you go, Hey, I just
want to, I just want to maximizemy human experience as much as I
(18:45):
can, because we're only here forso long.
Dr. Ayla Wolf (18:48):
Well, I'm an Aries, so I have to try
everything at least once.
Dr. John McClaren (18:52):
Yes! What else could I do today? Should
read a book and go to bed.
Dr. Ayla Wolf (19:01):
So when it comes to exercise, and obviously, with
both, you know, the fatigue fromlong-COVID And the autonomic
dysfunction and the exerciseintolerance that people
experience after a concussion,do you help people to really
dial in this kind of gradualgraded exercise program. And how
(19:23):
do you do that with people?
Dr. John McClaren (19:26):
Yeah, I think. And again, the athlete,
everybody, I like to say this,everybody's an athlete, right?
But your athletics might be yourgarden, or whatever it is. The
thing you know, John Leddy - hiswork is really, really good for
this. You know, the old, the oldthought process was cocoon
people and and then it's like,that's like, the worst friggin
(19:46):
thing you can do is sit in thedark room and not expose
yourself to the world. Like yousaid, you need to get back into
the world and start to do somestuff, because if you don't use
it, you lose it. So he, he didthis work in 2013 on graded
cardiovascular activity. As ameasure for, you know, how
recovered you are, and as ameasure for rehabilitating
(20:06):
people. So, you know the thing,you know that the buffalo
treadmill test came out of this.
You know, a lot of people arestarting to do those. I've got
athletic trainers in town doingthem now. You know, which is
great. You know, it's like, oh,they failed their BTT, can I
send them over? Yeah, pleasesend them over, because that's a
measure of autonomic nervoussystem function as well. Again,
you got a treadmill, or youdon't even need a treadmill. You
can walk and see what happens,right? So what's the symptom
(20:28):
load somebody comes in with,okay, you know, XYZ, you know,
rate it scale one to 10. Okay, Iwant to start to do some things.
And you know, I can at leastdilate my pupil a little bit.
Now okay, we've got somesympathetic activation so we can
get blood to the brain and thebody. When you do some certain
activity, I maybe will have themdo a Timed Up and Go test and
(20:51):
see if I get pupillary dilationwhen they do that, because
that'll tell me. Okay, yeah, youcan go for a walk. Now, you know
that kind of thing, real, good.
You know, the Timed Up and Gotest. You have them walk 10
meters, you know, see how fastthey can do it. And again, you
can measure some of these otherneurological metrics associated
with it that will do. And then,you know, what's your symptom
(21:13):
load? You know, rate it one to10. Get on the treadmill. When
do your symptoms start to tickup? You know, okay, at x miles
an hour out of a heart rate ofX, okay, let's stop see if it
comes back down. Does it comeback down? Cool? Okay, let's
reduce the load by 20% do itagain. Do the symptoms come back
(21:37):
up? Or are you good? You'regood. That's where you're going
to exercise until we assess youagain and see things happen. You
know, if you do it againtomorrow and you get the
headache at that 20% lowernumber, we lower it again by 20%
whatever it is, you know,whether it's the treadmill or if
they want to ride a bike or ifthey want to play the trumpet,
all these kind of things. I justhad one of those this week. The
(22:00):
high school guy, concussed,super like, super like, jazz
band trumpet wants to play.
Well, okay, once we, once weestablish, you've got an
autonomic nervous system that'sat least in the game, you know.
And the cool thing about thisguy, like, he could do the
Valsalva to play the trumpet,fine. I'm like, thank God. You
know, he had a lot of thingsthat I was glad, you know, were
(22:21):
good, like he didn't have a bigissue in his near point of
convergence or accommodation. Hehad the ability to tolerate a
Valsalva without getting aheadache. I'm like, we're going
to be fine. You know, thosethings you really, really like
to see, but, but that's thething. Take that lower it by 20%
if you don't get symptoms.
That's where you're exercisingfor the day, whether it's
gardening, you know, doingfarmers carries weight. Lifting,
(22:45):
same thing, lower the weight by20% if you don't get a headache
or you don't get clenching ofthe job, whatever you're
bringing me, right, whateveryou're bringing me, if you don't
get that, if you don't get cold.
You know,
Dr. Ayla Wolf (22:56):
it was really fascinating. One of the things
that, in hindsight, I recognizedas kind of an autonomic symptom,
because a lot, all, you know, alot of my concussions were mild
in the sense that I walked awayfrom them, I continued to do
whatever I was doing, and thenthe symptoms were just kind of
these, like lingering thingsthat I kept, kind of like
(23:17):
thinking were related tosomething else entirely. Well,
one of the things that I figuredout, kind of in hindsight, was
that whenever I would gomountain biking, a lot of the
trails that I would go on wasalways a steep uphill climb
first, before you got to thesuper fun screaming downhill.
And what I found was that Iwould start out my ride, I'd be
feeling totally fine, and thenall of a sudden my heart rate
(23:39):
would get to a certain point,and it was like some a switch
got flipped, and all of a suddenmy thoughts would turn so
negative, and I would just belike, I hate mountain biking.
Why am I doing this? I'mterrible at this. Why do I even
bother? I don't want to be here,and I'm just like, paddling up
this mountain, just angry. Andin hindsight, I was like, that
(24:01):
was my threshold before myautonomic nervous system just
had some kind of limbic thingkick in. Just the whole thing
fell apart.
Dr. John McClaren (24:10):
You go fully mesolimbic, and it's like, Man,
I don't really hate this. Do Ido it? Do I want to do this
anymore? And you go, Man, ifonly I could have lowered the
grade by 20%
Dr. Ayla Wolf (24:20):
But I couldn't make the mountain flatter!
Dr. John McClaren (24:24):
Yeah, that's the problem, you know, you go,
No, I want that trail, damn it.
That's my favorite trail. Idon't want to go to that like,
crappy John McLaren trail.
Dr. Ayla Wolf (24:33):
Can't I just get a ride to the top so I can just
go down?
Dr. John McClaren (24:36):
Yeah, put the ski lift in and, you know, you
know, take your bike with you,right? But it makes sense, and
that's the same thing, whetherit is, you know, the gardening
or or whatever it is thatsomebody really, really loves
and they want to do, there's,there's an autonomic nervous
system component to being ableto do anything where, even if
you're playing video games, youknow, if that's all you want to
(24:57):
do, I get a lot of kids that askthat, you know, video. Video
games are killing me. Well,there's a lot of things going
on, visual stimulus, a lot ofeye movement, a lot of
vestibular activation and thingslike that, which, again, you
know, we've already talkedabout, you need fuel and oxygen
for the process. And a lot oftimes it could be your primary
autonomic nervous systemdysfunction that's not allowing
(25:17):
these, you know, these people,to be able to do that
Dr. Ayla Wolf (25:19):
well. And I think what you're highlighting is
where Functional Neurologyreally excels in that the way
that you're looking at each ofthese patients is so completely
individualized, whether you'retalking about a professional
weightlifter or somebody whojust wants to garden or somebody
who's playing video games orsomebody who just needs to carry
groceries up a flight of stairs,you know, functional neurology
(25:40):
really excels in being able totake that one single individual
person and say, What are youstruggling with now? And how do
we get you a little bit betterso that you can do life better
in whatever way that looks likefor you? And I think that's what
I really love about it is, isthe flexibility and then also
the creativity in saying, youknow, if the goal is to get you
(26:01):
to garden, then that mightcompletely change what kind of
therapies we're actually usingor doing, as opposed to the
power lifter.
Dr. John McClaren (26:10):
Well, for sure, and sometimes you you
know, that's the great thingabout this stuff, that's one,
one thing Professor Carrick,from the first time I ever saw
him, do a case. What if there'sone thing I can do for you. What
do you want it to be? Right?
What a great question. Sometimesyou might not get it, but at
least I know where this personis, you know. And then you meet
people. And again, you've saidthis before on the podcast. You
meet people where they are, yougo to them where they are, and
(26:33):
you make it work. Maybe, maybewe go do your head, eye,
vestibular motion therapy in thegarden, or a garden, or I
simulate a garden with aprojector on my office wall, or
whatever it is, because, youknow, it's like, I feel pretty
good when I do your gazestability exercises here, or
when I'm in my house, where mywalls are kind of plain, but
(26:53):
then you get outside and it'slike there's different visual
context To the activity, right?
Or whatever it is, visual,vestibular, you know, maybe,
maybe it's like, they need towear different shoes, you know,
there's something in that that'scausing the breakdown. And you
can bring the rehabilitation tothe place they want to be, the
power lifter. You can bring therehabilitation into the gym.
(27:15):
I've got a Brock string and asaccade board and all this stuff
right by my squat rack. So, youknow, I'm doing, like, you know,
head tilts and all this kind ofstuff between sets. And, you
know, it's like, well, you know,does it help?
Dr. Ayla Wolf (27:28):
I Yeah, no, that's hilarious. Mean,
sometimes in between sets, whenI'm at CrossFit, I'm like, I
need to do some Yes, yes, gazestabilizers. Like, you know,
let's, let's fire down thisvestibulospinal pathway before I
start doing my power cleans.
Dr. John McClaren (27:43):
Yep, I wish I brought my OPK strip in, because
I feel like I'm a littleforward, or, you know, something
like that right?
Dr. Ayla Wolf (27:49):
Yeah. I mean being able to understand how the
system is wired and how tostimulate it so that you can
create, you know, theappropriate response is, is
really the name of the gamehere. And like I said, I just, I
love the the creativity that Isee with all the different
functional neurologists that Ithat I talk to in terms of what
(28:10):
they're doing in their practice.
And like you said, even likehaving someone do their
therapies in the gym or in thegarden or in the swimming pool,
it makes a huge difference. Imean, we're, you know, like you
said, it's all about context.
Dr. John McClaren (28:24):
Yeah, that's the thing. What do you want to
do? Let's make you better at it,yeah? And let's make you better
at it, and not compromiseyourself along the way. Ideally,
is the good thing, right? Yeah,we want to be well rounded
humans, and that's what we wantto see in our exams all the
time. But, yeah, you know,really what it comes down to.
It, if you, if you can getpeople to handle the activity
(28:44):
that makes them the most happy,they're going to be a satisfied
person. They're going to referyou more people than you
probably wanted them to referyou and and all these kind of
things. And it's, it's just theway to organically build a
practice just listen to peoplegive them the best version of
yourself that you can and dothese kind of things, and
(29:06):
they're going to be, they'regoing to be really happy.
They're going to have asuccessful rehabilitation and
and, you know, the thing too, alot of times, people will ask
me, How long do I have to dothis stuff? You know, do I do I
need to do this stuff forever?
And I'm like, well, some of it,you probably should. You know, I
had that when I had my shouldersurgery last year. It was I had
that epiphany where it's like,you might, my therapist asked,
(29:26):
you know, what do you do foryour warm up before bench press?
It's like, one plate, two,plate, three, plate. And she
just rolls her eyes at me, youknow? And it's like, what what?
You know, that's, that's justwhat I've done, you know? Now
it's like, I've got this 20minute routine of old man warm
ups before I lift that I'll dofor the rest of my life, because
I want to stay healthy, youknow, in my shoulders, and I do
(29:47):
neuro axis work and things likethat. Again, I wasn't doing that
stuff before. And I'll tellpeople that, you know, it's like
you should probably, as long asyou have a brain, do some of
these things for the rest ofyour life. And the thing too.
You know, that's to go back to,you know, the the case where the
guy had, you know, the COVID,the concussion and the COVID, if
people continue to do some ofthese things, look at Joe
(30:08):
Clark's research. It'spreventative. You do these
things and you have an event,you are way less susceptible
than if you don't do thesethings and have an event, right?
You know, if you're doing someeye movement training or some
reaction time training, or someaspect of balance training, and
you get hit in the head, or youget your COVID or your influenza
(30:28):
A or these kind of things, yournervous system is going to be
hardened so that it minimizesthe damage, right? That's the
thing. It's, it's like, youknow, it's the same thing as
lifting weights or doingCrossFit. Now, like, we're doing
this one, because we want to,you know, we want to look and
feel good now, but I want to beable to get off the toilet when
I'm eating right? Everybody saysit now, why are you training so
I can get off the floor later?
Dr. Ayla Wolf (30:52):
Well, and I think too, that just the very nature
of what we're doing all daylong, in terms of the neuro
rehab with our patients is like,when I'm having them doing
saccades or pursuits, it's likeI'm also I'm looking at their
eyes, so I'm also getting apursuit in a saccade, and as I'm
watching them do what I wantthem to do, and it's like, as
(31:12):
I'm moving their arm in a figureeight, my arm's moving in a
figure eight.
Dr. John McClaren (31:16):
You're doing complex movements too, and it's
and it's unique. You know,you're getting a different
activation with every personbecause they're stiff and heavy
in different different ways.
Your cerebellum is like, yeah,you know, I want to come to work
today!
Dr. Ayla Wolf (31:28):
Yeah. And so it's like if I've got someone looking
at a Brock string and I'mpointing at the beads, well, I'm
kind of doing the Brock stringmyself in that moment. And
honestly, I feel like that isactivating my brain all day
long, literally, just by workingwith my patients. It's like my
brain is getting its own activeactivity,
Dr. John McClaren (31:46):
absolutely, yeah, and that's the thing. I
mean, you look at, you talk tosome of these people at, like,
iscn or, or, you know, whatother things we get together,
clinical gems. Or, you know,whatever it is, when you get a
big group of people who've beendoing some of this work a really
long time together. You know,you get some of these people
that are in there six, sevendecades of life. One, they're
still working. Two, they'resharp as tacks.
Dr. Ayla Wolf (32:10):
So you mentioned you use a lot of the head eye
vestibular therapy as part ofcreating better balance and
integrity within the the system.
What you know, what other typesof therapies or things are you
incorporating in a lot of yourrehab when it comes to people
that have dysautonomia as partof their presentation?
Dr. John McClaren (32:34):
Things I love. I really like to have
people use fine motor activity.
I just have found when you bringin some of those lateral
cerebellar aspects, you know,coin rolling is one of the big
ones. And, you know, Carrick gotme onto this, like everything,
right, you know, and the thoughtprocess is, how do I activate
(32:54):
the brain in a way that isjudicious and doesn't bias that
system too much one way or theother, because what am I trying
to do? As you said, I want toget the top down stuff, to talk
to the vagus, or talk to theIML, to get it to do what it's
supposed to do. Those neurons,generally, when you have a TBI,
themselves aren't damaged unlessyou've got a significant shear
(33:16):
or an intracranial bleed orthings like that. It's the
connections, those white matterconnections that get, you know,
damage you get the roadconstruction, so to speak, is
going on. And, you know, nowI've really, I've only got one
lane when I should have three oror so on when I'm driving, the
fine motor activity is great,because you don't get a super
high level of activation inthose brain stem centers, like
(33:38):
the nucleus track to solitaires,where you can suppress an
already suppressed sympatheticsystem by doing some of these
big, complex movements andthings like that, which works in
some cases really, really well.
If I wanted to drive more thoseparasympathetic aspects, I might
do a little more complexmovements, because I get an
activation of that NTS, I getsome vagal activation to
(34:00):
suppress the IML, a little moreincreasing circular output.
Really good for that, right? So,you know, fine motor activity is
really, really good. I getthese. You can use, like a poker
chip or a 50 cent piece, like aquarter with some of these
people, is almost too small. Igot these, you know, I've got
one, you know, it's, it says Iwas caught being good today. You
(34:22):
know, it's about the size of a50 cent piece, and you just have
people roll it, and it workssuper duper well. And I mean,
you people see me do it, it'slike, well, I've been doing this
every day for three years. Don'tfeel like you should do it. It's
been part of my whole process ofgetting that brain to be better.
So I'm pretty fluent with it.
You know, on a good day, I cando a dime. And that's another
way you can scale the therapy,you know, make give them
different weighted objects thatare maybe that size, because,
(34:44):
again, the cerebellum likes thatnovelty, and it helps to drive
into some of those autonomicactivating centers, the locus
coeruleus, so to speak. Youknow, one of those areas that's
very important to autonomicmodulation. It's got, like, 313
different parts of the brain.
Screen that pop into that littlething, and if it doesn't work
really well, that's when you seethese dysautonomia phenotypes. I
(35:06):
may, again, if I can get somepupillary dilation on like a
cognitive task, or I don't seethem fail doing dual tasking on
their balance, I might have themdo some saccades. You know, I
like very small amplitudesaccades. Generally, when I
start these with dysautonomiapatients who are a little less
stable, I like to move away fromcenter because it's easier to
(35:26):
put the brakes on. You wantpeople not to overshoot when
they do saccades really early.
It's harder to put the brakes onwhen you cross the nose than it
is when you go away from thenose, that kind of thing. So
we'll put them, you know, maybeon a 45 where we combine the
machinery for vertical andhorizontal saccades, because,
again, it's a little nicer onbrain activation. That's why you
see all these carrot brainexercises on the 40 fives. It's
(35:48):
vertical and horizontalmachinery working together. So
it takes a little less blood andoxygen to get that thing going.
You'll see this all the time.
And people who havedysautonomia, you know, you have
them do saccades horizontally inthe exam. And it's like, my god,
I can't do that. And then theycan do the verticals a little
(36:09):
bit better, or vice versa,usually your vertical a little
better than horizontal. And whenyou look at Professor Carrick's
work that he did on, you know,these, these 40,000 different
groups, stratified by age andall that, he found the vertical
movements tend to be a littlemore accurate than the
horizontal movements overall.
Have you seen it?
Dr. Ayla Wolf (36:29):
Was the one where he was really stratifying it by
age range, sex, yeah. Kind ofnormative values really need to
change based on not only age,but also gender. Yeah, that's
huge,
Dr. John McClaren (36:43):
Yeah. And you see how women do some things a
lot better than men, and viceversa, and, and, you know,
concussed women perform betterthan regular men on a lot of
things, and, you know, and notso well on others, you know, but
it, but it's interesting. Andwhen you, when you look at this
research that comes out, you youstart to tailor your exam
expectations to that, and youcan tailor your rehabilitation
(37:03):
toward that, where, you know, ifI'm dealing with a female
patient with dysautonomia, I maydo a little better with some
saccades than I will with somepursuits. With a male, I might
do a little better with somepursuits and some saccades,
because they perform a littlebetter in those tasks, even in a
TBI, you know, kind of context,even after more than one. So,
you know, we use, we use somereally small, subtle
(37:25):
activations, you know, maybe youloop in some of those other
things, like the, you know, thevagal nerve stimulation, if I
want to drive it a little bit,or things like that. I'll use
the mini stem device, orsomething that's like an SSEP on
the tongue or on the trigeminalsystem. Those kind of things are
really, really nice. Again. Iwant to see dilation on my
pupillometry. Before I do a lotof that, I want to see, we'll do
(37:48):
the hand grip test where, youknow, we're looking at, you
know, are we going with Ewingand Clark 16 on our diastolic,
or do we want to see the full20? The whole thing, you know,
when we do this hand grip test,you know, we're, we're getting a
maximum hand grip. We're findingout that's kind of our baseline.
We're going to 30% of that.
We're sustaining that for fiveminutes. We're checking the
(38:08):
blood pressure every minute. Youknow, in corata and all these
people found that that diastolicnumber was the number that is
the the one that matters, theauthoritative one for the
autonomic nervous system. If Iat three minutes, can't get my
my diastolic pressure to rise,depending on what source you
read, between 16 and 20millimeters of mercury, you
(38:28):
know, then I know I'm notactivating my sympathetic
nervous system super well. Soyou're going to be really,
really judicious in how youdrive your rehabilitation with
these dysautonomia phenotypes,you know. And then, and then,
and then, can I get it there?
And then, can I sustain it? Youknow, you'll see this, and
you'll see it on the pupils allthe time. Well, they got the
T-75 yay. But then it goes rightback down into a full blown
(38:51):
constriction. And, you know, Igot to the 16 to 20 beats, or
millimeters of mercury. And thenminutes four and five, it goes
right back down. You know, thoseare people. It's like, you can
introduce some of these things alittle more than people that
can't do it at all, but youstill have to be really
judicious. And you know, just,just start small. Maybe again,
to kind of go back to a topicyou guys have discussed really
(39:12):
well, maybe we'll do someaspects of apophyseal glides in
the cervical spine. We'll dosome manipulation in the rib
cage to maximize oxygencapacities and things like that,
because that cervical spine hasso much to do with how that
autonomic nervous systemactivates.
Dr. Ayla Wolf (39:27):
And I think everything you're saying, one of
the really important take homehere is a lot of people, when
they are booking kind of thatinitial appointment, they're
like, why do you need so muchtime with me to do your initial
assessment? And this is why,because looking at the autonomic
nervous system and even askingthat question of, does this
person even have enoughsympathetic output to be able to
(39:49):
handle the therapy? And if theydon't, I need to back down on my
therapy. And so it's like thereason we need that time with
the patient up front to do allof our invest. To gate of work
is because it matters. You know,how they're performing on this
pupil test really, is actuallyindicative of what we are not,
are aren't going to do, as faras their therapy, or what we
(40:12):
know that their system can orcan't handle, at least as a
starting point,
Dr. John McClaren (40:16):
yeah, and that's why, that's why I love
that pupilometry app, because Ican take that four or five, six
times. Really apply a therapyand see what happens. And it's
not as fatiguing to people assome of the other things we
might do are, you know, it'shard to and if you take a blood
pressure 12 times during exam,that can contaminate itself over
time too, right? You'll, you'llsee, you know, a significant
(40:37):
change just by doing it multipletimes on the same arm in a time
period that's relatively small,so it's not as good a data. The
pupils, they're very quick torespond to therapy. I mean,
again, when we're doing brainrehabilitation, you're seeing
brain able to replicate proteinsin a nanosecond. So you can
really, really quickly addstability or detract from
(40:58):
stability. You know, really,quickly, depending on on the
person and how they do. So,yeah, it's like, why are you
doing this again? Well, youknow, if I'm going to give you a
saccade to the left, I want tomake sure that it doesn't cause
you, you know, a negativeoutcome. And because if I'm
going to send you homelessstuff, if I'm not doing and we
all practice a littledifferently, too, but if I'm not
(41:19):
seeing you in a three times aday intensive model for five
days. Maybe I'm sending somethings home with you, and I'm
bringing you back in again in afew days or a week, or something
like that. Or I'm checking onyou via telemedicine with my
people ometry, if you've gotthat app you know, or I've got
some other things where you knowyou're you've got somebody with
you who can take blood pressuresbilaterally, and tell me what
(41:41):
the response is after a few daysof therapy where, you know, you
can't get to me. I mean, they'recoming from a few hours away,
maybe to see you. You know thatthat kind of thing, I'm sure
you're getting that a lot, whereit's like they're coming from, I
mean, all over, all over thestate, or even farther than
that, you know they're gonnamaybe go home and take this
stuff home, and I want to makesure that the outcome is as
(42:04):
positive as possible, do theleast amount of negative that
you can do, and do as muchpositive as you can do with your
rehabilitation. So, you know,we'll loop some of those things
in, you know, I like looking atjoint position errors in the
cervical spine and using that asa rehabilitative model. There's
so many ways you can do that.
You can have people do, youknow, head laser things with
eyes open. You can have them doit eyes closed. Those things are
(42:25):
really, really good with theseautonomic nervous system
phenotypes, where the neck isreally involved. And again,
using the neck gives you somemore positive activation. Again,
as long, as long as we know itwith diligence, that it's good
strengthening of the neck. Youknow, that's one of those. I
think you guys touched on thattoo. You know, I think you're
doing your best to correct thejoint position errors. Is good.
(42:49):
Before you get into a ton ofheavy strengthening in the neck,
you're going to get neckstrengthening with general
resistance training to somedegree. But if you really want
to specifically attack the neck,just make sure they aren't
really, really skewed on theirjoint position errors. But you
can do them together. You can dothem in concert, because a lot
of times the strengthening helpswith the joint position error
processing as well, along withthe the manual modalities and so
(43:11):
on.
Dr. Ayla Wolf (43:15):
Well, man, I think we covered a lot of a lot
of information. Why don't youlet people know kind of where
they can find you, and now thatyou're back on social media,
yeah,
Dr. John McClaren (43:23):
yeah, yeah.
So yeah, back to Facebook. I'vegot a clinic profile. We're
Advanced Chiropractic andNeurology PC. We're located,
like you said, in suburbanOmaha. We're located in La Vista
Nebraska. My website iswww.Omahaspinecare.com, curated
by a friend of mine. A long timeago, I was going to write it
something different. He's like,No, make it something people
understand, John. 402-597-2869,is our office number. You can
(43:46):
feel free to reach out to methere or on Facebook. I've got a
personal profile, the officeprofile. Instagram, I think I've
got like four followers since Icame back. So you know, you can
look for me there if you want.
Dr. Ayla Wolf (44:01):
Okay, well, now I'll put all of that in the show
notes so that the links arethere too. Yeah, perfect. Well,
I appreciate your time, andthank you so much for coming on
the show. Always a pleasure totalk to you. I love geeking out
with you.
Dr. John McClaren (44:14):
The pleasure is all mine. Thank you so much
for the invite. I really, reallyam honored to be here. Good.
Dr. Ayla Wolf (44:18):
Well we'll have to do it again. Yeah, yeah,
Dr. John McClaren (44:20):
I'm in. For sure, yeah, for sure, I'm in,
yeah.
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