Dr. Brewer brings his expertise as a neuro-optometrist to explain how visual processing problems are often overlooked in concussion recovery despite causing significant symptoms. He shares insights on integrating visual, vestibular, and proprioceptive systems to create lasting improvements for patients with post-concussion syndrome.
• 20/20 vision only measures clarity, not eye tracking or binocular function
• Many post-concussion symptoms stem from poor integration between sensory systems
• Light sensitivity can come from multiple causes including dry eyes
• Cervical (neck) issues can cause visual problems and vice versa
• Too many sensory errors overwhelm the cerebellum, causing fatigue and emotional dysregulation
• Standard vision therapy exercises can worsen symptoms if they don't address the right problems
• Peripheral vision processing often becomes impaired after concussion
• The brain's ability to filter information is compromised, creating sensory overload
• Integrating multiple sensory systems creates more significant improvement than treating each in isolation
You can find Dr. Brewer at Diverge Performance in Boise, Idaho, or online at divergeperformance.com.
Instagram: @divergeperformance
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Dr. Wolf's book Concussion Breakthrough: Discover the Missing Pieces of Concussion Recovery is now available on Amazon!
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Paul Brewer (00:00):
Yeah, but, and another thing too, is if you
(00:03):
have too many errors, it's likeif the vestibular system is
pulling the body one way thevision is pulling the body,
another way you get this pushand pull all day long, right? So
it's better to have them worktogether than doing this all day
long, which can make the brainreally tired and make you
fatigued.
Dr. Ayla Wolf (00:22):
Welcome to Life after impact, the concussion
recovery Podcast. I'm Dr AylaWolf, and I will be hosting
today's episode where we helpyou navigate the often
confusing, frustrating andoverwhelming journey of
concussion and brain injuryrecovery. This podcast is your
go to resource for actionableinformation, whether you're
dealing with a recentconcussion, struggling with post
(00:45):
concussion syndrome, or justfeeling stuck in your healing
process. In each episode, wedive deep into the symptoms,
testing treatments andneurological insights that can
help you move forward withclarity and confidence. We bring
you leading experts in the worldof brain health, functional
neurology and rehabilitation toshare their wisdom and
(01:05):
strategies. So if you're feelinglost, hopeless or like no one
understands what you're goingthrough, know that you are not
alone. This podcast can be yourguide and partner in recovery,
helping you build a better lifeafter impact.
All right, Dr Brewer, welcome tolife after impact, the
concussion recovery Podcast. I'mso excited to have you on here.
(01:28):
You are an expert in workingwith people with concussions
from an optometry lens, and youare really on the cutting edge
of combining a lot of vestibularand sensory integration into the
vision therapy work that you do.
So I'm so excited to be able topick your brain and have you
share some insights into thework that you do and the
(01:51):
clinical experience that youhave in working with people with
post concussion syndrome. Sowelcome to the show. Thank you.
Yeah, you have a practice inIdaho. You're originally from
Hawaii. Correct, correct,
Dr. Paul Brewer (02:05):
yeah, I'm originally from Hawaii. My roots
are in the islands, and I met mywife in Hawaii. And my wife is
actually from Idaho, so we movedup here to be closer to her
family, which, that's, you know,starting a practice up in Idaho,
in Boise, yeah,
Dr. Ayla Wolf (02:20):
yeah. Well, it's a beautiful area.
Dr. Paul Brewer (02:22):
Have you been?
Dr. Ayla Wolf (02:24):
Yeah? I, well, I lived in Oregon, so I was very
close, and so I got to, youknow, make some, make some quick
little trips here and there. So,yeah, a very beautiful area.
I've been to Joseph Oregon,which is like, in the south or
northeast corner of the state,and I feel like that's just like
(02:45):
this little hidden gem in thiscountry that not many people
know about.
Dr. Paul Brewer (02:48):
I've been through there. We were up in
like Moscow, or whatever, for mydaughter's gymnastics me, and
then when we drove down fromthere, we passed through Joseph,
Dr. Ayla Wolf (02:59):
yeah, yeah, such a great little part of the
country. So tell me a little bitabout how you ended up
specializing in post concussionsyndrome, or people with
concussions, and maybe some ofthe kind of unique things that
you bring to your practice inthat regard.
Dr. Paul Brewer (03:17):
That's good question. So, like, I don't have
this, like, crazy, cool story,like, I came out of my mom's
belly and, like, literally, Istarted loving concussions. You
know, like, every doctor seemsto have that story of, like, oh
yeah, since I was a kid, I likethis and that, right? I mean, it
was never even on my mind,actually, like, I mean, growing
up in Hawaii, I played a lot ofsports. I actually had a lot of
(03:40):
concussions, but it never dawnedon me that, oh yeah, you could
do something for concussion. Imean, it had a ton of
undiagnosed concussions. Fact,when I speak on concussions, I
show this video of me when I'm ateenager. I'm skateboarding on
the seal really fast. Get somespeed wobbles. I bounce off my
board, hit the telephone pole,bounce off the ground, hit my
head, and like, you know, Imean, so I'm not, like, a
(04:02):
stranger to concussions, so Ibut I also knew how it at the
time, I didn't know, but now Ido know how much it actually
affected my performance. Mystory was a little different
than a lot of people that haveconcussions. A lot of people,
like, when they get concussions,they get messed up. They mean
their life falls apart. In mycase, I mean, I always had
(04:25):
deficits. I didn't know I was Ihad, but I was good compensator.
So a lot of people cancompensate, but does that mean
that they're actually it'sactually good for them? So I
compensated really well. I mean,I played four sports in high
school. We did I did a sport incollege, and, you know, I was a
biochem major, had pretty muchstraight A's. That was one of
(04:46):
the ones where I was flyingunder the radar. But I didn't
realize how much work I had toput into studying and everything
else. I just didn't realize. Ithought that was just normal.
And as I, you know, went intoTom. To school, I learned more
about visual rehabilitation, andat the time, you know, they, you
know, the diagnose me withconvergence insufficiency, which
(05:07):
is a pretty common eye conditionthat can be diagnosed when they
have binocular issues. Andthey're like, Oh yeah, you have
this issue. And if you do thistherapy, you'll be better. And I
remember, in my mind, I was afirst year, and I remember,
like, all these, like, thirdyears crowding around me because
they thought it was really coolthat had this you know, thing,
you know, convergenceinsufficiency, which isn't
(05:29):
really that big of a thinganyways, but like they, you
know, when, when you're instudent, anything that you see
as abnormal is really cool. AndI was getting kind of pissed off
because there was telling me allthis stuff before they explained
it to me. I'm like, Hey, so holdon, guys, what's going on? And
they finally said, oh, yeah, youhave this issue that's affecting
your performance. And I'm like,really? And I've been to the eye
doctor every year my lifebecause I had contacts. And I'm
(05:52):
like, why didn't the doctor evertell me this? You know? I'm
thinking my head, like, Wait, ifI actually did this therapy when
I was a teenager, I would havebeen able to study better, you
know? Like, I mean, or I wouldhave been able to do even better
or study more efficiently. Andthis dawn, I'm like, Man, I
really wish my doctor told methat. And that's kind of that
point in time where I had thispassion of learning more about
(06:14):
the rehabilitation versus justlike glasses and contacts. And
that's just, you know, that'simportant thing too, as well.
But it really made me excitedabout learning about the brain
and the neurology of the brainback in my first year of
optometry school. I mean, whenyou go to school, you learn kind
of this, like basic,foundational stuff, and you
don't really learn a lot ofthis, like neurology per se, in
(06:37):
school. And that's why, like,you know, institutes like the
Carrick and others and so forth,you know, they they give these
courses post doctorate to beable to put you at a different
level. And, you know, I learneda lot in school, don't get me
wrong. I mean, I learned a lotabout visual rehabilitation, but
most of my learning came fromafter school. But it was that
passion I had that like I couldactually help other people. I
(06:57):
could actually help peoplerecover quicker and perform
better, and I had my own storyand how it kind of helped me.
And in reality, you know, thevision therapy I did in school
really helped me, but whatbrought me to another level is
when we started incorporatingother sensory integration, like
vestibular and and so forth, andthat kind of helped me even
(07:17):
recover even better. I think Idon't even answer, did I even
answer the question. I think Itotally went on a totally, yeah,
Dr. Ayla Wolf (07:23):
you did. You did.
No, I was curious, kind of what,what your interest was,
specifically with concussionsand vision rehab in that regard
was. And yes, you think it's
Dr. Paul Brewer (07:32):
really cool. It really is super cool, like it's
it's so cool to see that thebrain is plastic. It's so cool
to see that we can do things toactivate the brain to recover
and perform better where, youknow, like, 15 years ago even, I
mean, not even 15, even morethan that, but like, and even
(07:53):
now, people are like, Well, youcan't do anything with the brain
once it's hurt, it's hurt, andit's cool to be able to see
that. In fact, I had a patientthat I just finished, you know,
we just did a few sessions. And,like, literally, for the last
like, two years, they've been,they've been to every single
doctor, I mean, and in twofunctional neurologists defense,
(08:14):
I mean, they, there was reallyno one they saw for that here,
because they did see, like, theylike acupuncturists and
chiropractors and so forth. Butthen it's the same thing as
saying, Oh, they saw optometristin each of our professions,
there's different types ofspecialties and like, so he
didn't really see any functionaltype doctors in any of our
professions, right? So they'rekind of pushed and pulled to all
(08:36):
these different areas. Andfinally, the doctors like, you
know what? You just have to dealwith your business. You have to
deal with this, you know, like,and so they just live their
life, and they, I don't know howeven they found me, they found
me, whatever, for a reason,maybe a referral, or online, or
whatever. And they came in, andwe started doing some sessions,
and literally, after about likefour sessions in, they're like,
(08:57):
Oh my gosh. Like, they saw ahuge difference their life. They
said they were going to makebetter eye contact with people.
They can actually walk outsidefor long periods of time to be
able to, like, enjoy thescenery, versus, like, shutting
down and so, like, it was coolto see that so quickly. And I
think if I just really just didmy own thing, like to say this
(09:19):
vision only, it probably wouldhave taken longer, but in
integrating all the differentparts of the brains and doing
different types of therapiesreally helped them get to a
place where they were happier,quicker and more efficient.
Yeah, yeah.
Dr. Ayla Wolf (09:34):
And that's, that's amazing, and always such
a good feeling when you can, youknow, not only like, start to
help people, but then actuallyfind ways of doing it really
quickly and getting those kindof immediate wins, because
that's what encourages people tostay the course and recognize
that there is room to improve,which is always giving people
(09:55):
that hope is so important forsure. Can you talk a little bit
about so. You know, my myexperience with so many of the
patients that come to see me,when I ask them about who have
you been to, who has assessedyou? Many of them say, Well, I
was having, you know, lightsensitivity or blurry vision. I
went to my eye doctor, and theytold me that my vision was fine.
(10:18):
And so we have this kind ofdifference between visual acuity
versus eye movements and how thetwo eyes are working together.
So can you maybe talk about forour listeners, the difference
between visual acuity versus eyemovement disorders or
dysfunction within how the twoeyes are are moving or moving
and communicating together andwhy so many of these eye
(10:41):
movement disorders are maybegetting missed in a standard
exam.
Dr. Paul Brewer (10:46):
For sure, yeah, and in reality, in a stat, in a
standard exam, in reality, theydoctors should be testing eye
movements. They should betesting eye focusing and eye
teaming. In some cases, it mightbe brushed through really
quickly. So let's talk about,we'll talk about acuity. We'll
talk about eye tracking, eyemovements. We'll talk about
binocular vision. Then when?
Then we'll talk about, like,I'll maybe go over one test on
(11:08):
how we do it and why it might bemissed. Does that make sense
perfect? So the first thing isvisual acuity. So like most
people think visual acuity aslike perfect vision. So when you
when you hear 2020 that's thecoin term, 2020 you have 2020
vision. And when people say, Oh,I have 2020 vision. In fact,
most of my patients say thisevery single time when they come
(11:29):
in, oh, yeah, 2020 vision. Ihave perfect vision. I'm like,
the first thing I usually askpeople is, like, what? What is
your understanding of 2020 andmost people again, will say, Oh,
perfect vision, or crystal clearvision, or whatever, right? And
in reality, you can have betterthan perfect vision, because you
can have like 2010 vision. Soall the numbers refer to as
(11:50):
like. The top number 20 refersto looking at the chart from 20
feet away, so the chart will becalibrated at 20 feet. And the
bottom number refers to the sizeof letter. So 2020, is a certain
size. 2010 is half the size.
2040 is double the size. Sothat's all it refers to. Is the
clarity of vision. So clarity ofvision is that one the first
(12:11):
step in the whole visualprocessing pathway. Now you can
have clear vision, or 2020vision, or even 2010 vision, but
have imperfect vision ordysfunctional vision. So I get
this a lot from patients.
They're like, Oh, yeah, 2020vision. There's nothing wrong
with my vision. In fact, a lotof times they're like, oh, like,
one of my things on myquestionnaire is about
headaches, and they're like, oh,I don't think it's related to
(12:33):
vision. I'm like, I just askhim. I'm like, a little snarky
about it too. I'm like, I'mlike, How do you know it's not
related to vision? You know,like, and they kind of sit
there, like, thinking they'relike, Oh, actually, I don't
know, because people just blurtthese things out of their mouth
all the time, right? Same thingwith perfect vision. And in
(12:53):
reality, you can have the clearvision, but you might have poor
eye tracking or eye movement. Solet's talk about eye movements.
So there's different types ofeye movements. One is, can you
keep your eyes fixated? And alot of people say gaze stability
or fixations. But can you keepyour eyes just steady on a
target? And in reality, you cannever keep your eyes fixated on
(13:14):
target perfectly, like with nomovement, because always eye
movements. But even when youhave gaze stability, there's all
these little micro saccades,what we call them, all these
little different movements. Andyour eyes are constantly moving,
because if they don't, then youwon't your actually, eyes will
get like, your vision will getdark. So it has to constantly
(13:35):
move to refresh. They call itphotoreceptors in the back of
the eye, so that it's to refreshthose photoreceptors so they
don't like bleach out, or theydon't like over activate. So
that's fixation. So can you keepyour eyes steady on a target?
But people that have poor gazestability could have brain
dysfunction or issues with likethe cerebellum or other parts of
(13:56):
the brain that can cause theseissues with keeping your eyes
stable. So if you can't keepyour eyes stable, what happens
to the clarity of vision. Ifyour eyes are all over the
place, right, you're going tohave blurry vision. So sometimes
people will have the perfectprescription, they'll have the
perfect pair of glasses. But,like, my vision is kind of
(14:16):
blurry. It kind of fluctuatesright? So that could be a gaze
stability issue, and thatusually goes hand in hand with,
like, the vestibular system andso forth, where, if you have
poor communication between thosesystems, you might have poor eye
tracking or eye focusing, whichcan cause this fluctuation of
the clarity of vision, whichcauses blurry vision. That's the
(14:36):
eye tracking part. But the otherpart of eye tracking is not only
fixation, but there's two otherelements, one is saccades, and
one is pursuits. So we're notgoing to go over all the
neurology at that. It take toolong, but saccades are basically
like, can you jump from one spotto the next spot? So can you go
from this spot to that spotaccurately? So someone that has
(14:57):
poor saccades may look at thisfinger here, and then when you
look at that, figure they go wayout here. Yeah. Right? So they
can't fixate, and they can'tsaccade or move their eye from
one spot to the next. That'sanother type of eye movement.
And the third type of eyemovement is pursuits. Can you
actually track a moving targetsmoothly? But there's different
(15:18):
types of machines that canobviously test for this. You can
do gross testing just by using atarget, and that's ways of
actually testing to see if theeyes move or not. Again, you can
have clear vision but have poortracking. Another element of
vision is eye focusing. It'scalled accommodation. So eye
focusing, there's actually alens in your eye, so this is
(15:38):
your eyeball in the middle ofthe eye. There's this lens
that's like oval shaped, and itacts as a magnifier. So when
you're looking far away, thatlens is about this shape, and it
actually has a power to it. Butfor this example, we're going to
say that power is zero rightnow. So when you're looking far
away, the power is zero. Andthen when you go up close, when
(15:59):
you're looking at your hand orsomething close up, about arm's
length or closer, there's thesemuscles that automatically
contract. It's controlled by theparasympathetic system. Those
muscles contract, and the lenschanges shape. And when the lens
goes like this, it changes themagnification power. So, you
know, I have those magnifiersthat can magnify things up
(16:19):
close. That's what the lens inyour eye does, and that's what
eye focusing does. So thatchanges shape. So if you have
dysfunction in the neuro and theneural pathways or the muscle,
the lens can't do its job, andthat's why people will have like
when they look up close, oh,it's blurry. Now, as you age,
that lens in your eye actuallygets thicker and less flexible.
(16:40):
So although the neurology worksand the muscles work, when you
hit about 40 or so that lensesdoesn't do this anymore. It goes
like this, er, like little bylittle, right? So it can't
magnify anymore. You don't havethat magnification power as you
used to, and that's why you haveto put readers on. So you know,
those over the counter readerslike plus one plus two and so
(17:01):
forth, plus one, two. Those aremagnification powers, so those
leaders compensates for whatyour lens can't do anymore. But
when you're younger than 40,like earlier in your life, if
you have eye focusing problemsup near, it's not necessarily
the lens, it's the muscle or theneuropathy going to the muscle,
and that's something you canrehab. And in reality, like the
(17:22):
vestibular system and othersystems can actually cause
issues with that as well. That'seye focusing. The next thing is
eye teaming, or binocularity. Sothat's how your eyes team
together. So eye tracking, youreye movements, is like this, or
like that. Binocular vision isgoing like this, in and out. So
when you go out, that'sdivergence, when you go and
(17:42):
that's convergence, that's whatthat's what binocular vision is.
And there's all these differentlevels of it, but given the
time, I probably can go over allof them, but, um, there's
different tests to testbinocular vision, right? So one
bread and butter test everyoneshould be doing is the cover
test, where you cover one eye,you see what the eye does. Cover
(18:02):
the other eye, see what this eyedoes when it's looking at a
target. Then you do analternating cover test, where
you see what the eyes are doingwhen you alternate. So if
there's a lot of movement, theymight have like a strabismus or
an euphoria. And what that meansis that the eyes are aligned
together. So I guess we talkedabout screening. So going back
(18:22):
to the whole screening part, whydid things get missed? Right?
Some people might just do aquick cover. That's like, boom,
boom, boom, boom. Like twoseconds, and that's done where
you might have to actually holdit longer to see if there's
anything going on. There's waysof actually missing it if you go
too quickly, or if you justdon't do the test. But a lot of
(18:43):
times people brush to thembecause they're looking for
really, really bad stuff, andnot these, like, like, kind of
like, these more mild cases thatcould be like, causing issues
where people but they don'tlike, it's not like killing
them, if that makes sense. Sosomeone could have, like, a
little convergence insufficiencyand like me, and function
(19:03):
totally fine, where, if myvision was really bad, like my
convergence issue was really,really bad, I probably wouldn't
be to compensate for it, andthat's maybe why I got missed
for so many years.
Dr. Ayla Wolf (19:17):
One of the questions that I often ask my
patients when they say that theyhave blurry vision is, I ask
them, do you notice your blurryvision like most frequently when
you're changing your gaze fromsomething, say, far away to
something near or vice versa, asa way of trying to tease that
piece out of you know, is yourblurry vision there all the
time, or is it just that whenyou are shifting your focus from
(19:40):
a Near target to a far target,or vice versa, that that shift
in focus actually takes you acouple extra seconds to bring
that target in, and that helpsme to kind of clue into that
binocular vision piece of it.
Dr. Paul Brewer (19:53):
and that's that part could either be like a eye
teaming issue, or it could bethe eye focusing issue, right?
So we talked about going backto. Focusing? Do they have the
power to be able to focus upclose? Do they have the facility
to be able to focus far andnear, back and forth? So there's
all these different elements,and that's a good question to
ask, because then it kind ofteases out. Okay, what test
(20:14):
should I do? Should I do afacility test to see how well
they can focus far and near. Itest how well their eyes can
actually focus individually andso forth.
Dr. Ayla Wolf (20:25):
Yeah. And then you also, like we mentioned
earlier, when, when you'reassessing people, you're also
bringing in a kind of cervicaland a vestibular component. So
maybe talk a little bit abouthow you, you know, put more of
this functional twist on some ofthese classical exams.
Dr. Paul Brewer (20:44):
Oh, for sure.
Yeah. So this is good, a goodcase. I just, uh, bring it up. I
mean, I just like to just showthe videos, but I didn't get
permission for the patient toshare it. So, like, it'd be kind
of cool to see it. But like, sothis patient comes in, right?
And, like, full on, has, like,an, like, it's called an
intermittent extratropia. Solike, the eyes tend to go out,
like this, like that. And it wasa huge one. So I was doing the
(21:05):
cover that was, like, a lot oftimes you just see a little bit
her when I could do cover test,it was like, Don't, don't,
don't. Like, really bad, right?
And in her case, she had a,like, a really bad distributor
to dizziness, to get vertigo andso forth, right? And in her
case, like when I did someintegration stuff, which, time
(21:31):
wise, I'm not going to go overall those details, but like when
we integrated the vision of aserver system, basically what
happened is, when I did thecover test, again, it was almost
aligned as a little movement. Soin my opinion, in that case,
part of the eye alignment issue,not part of a big part of that
one was actually a visualspecific integration issue,
(21:52):
where sometimes, if we did theintegration and they still have
this huge angle, we know maybeit's more a visual pathway
issue. So that's kind of oneexample of, like, why it's
important to the other tests.
Like, I think every doctorshould be doing posturography.
They should do balance testing.
They should be, maybe even havea vng or do some kind of eye
(22:13):
tracking test. And then theyshould also test how, like, the
cervical positions actuallyaffect eye alignment, because if
you're turned this way andsuddenly your eyes aren't
aligned anymore, or they can'ttrack, or they can't focus, that
could be a cervicogenic issue.
It could be errors in theproprioception the neck that are
causing errors in the systemwhere the vision can't
(22:35):
compensate. But the reason why Ithink it's important is because
I look at like, vision,vestibular, proprioception as
like three maps, but they'reintertwined, like Google, Google
Maps. Like, you know, if you'redriving, you're following a
Google map on a road trip. Canyou imagine, like, if you're
following the Google Maps, andsuddenly the path is like the
like, the actual directions forthe path on the map. I think
(22:58):
this is the map, and thedirections suddenly go like this
now, and now you're seeing twodifferent maps, but the
direction is not on the samemap. That'd be a lot harder to
follow that map. Some people cancompensate and still deal with
it, but a lot of people willbreak down and probably get a
car accident, right? So the samething with the vision and other
sensory systems, if they're notcommunicating as a team, as a
(23:19):
family, and why we call ohana?
If they're not ohana, thenbasically there's going to be
more errors in the system, andthere's a point where if there's
too many errors in the system,the brain or the cerebellum
can't correct for those errors,which causes mismatches, which
causes or adaptive ormaladaptive behavior or
(23:42):
adaptations, or it causesinjury, or so forth, right? So
that's kind of what I look atnow. Is like, well, how does
each of these systems affecteach other? So before just
targeting each systemindividually, how can you
integrate the systems togetherinto one so they're working as a
team? And then from there, yousee how you can actually train
each one.
Dr. Ayla Wolf (24:03):
Yeah, I love that. I often talk about it like
a math equation. You've gotthese different sensory systems,
and they all need to be kind offeeding your brain the same
information, but in differentformats. But it needs like one
plus one plus one needs to equalthree, otherwise you've got this
mismatch. And then that drivesthe dizziness, the headaches,
the neck pain, all the things,
Dr. Paul Brewer (24:24):
but and another thing too, is if you have too
many errors, it's like if thevestibular system is pulling the
body one way the vision ispulling the body another way,
you get this push and pull allday long, right? So it's better
to have them work together thandoing this all day long, which
can make the brain really tiredand make you fatigued. So, like,
a good example is a cerebellum,right? So cerebellum does a lot
(24:47):
of cool things. Like, it does itdeals with like, like, movement
error correction, motorcoordination. It does with
planning and thinking. It doeswith immune modulation. It deals
with emotions. Yeah, so thoseare things that the cerebellum
deals with. So think about likethis control center in the back
of the brain, this little smallbrain that's helping all these
(25:09):
sensory systems integrate, in asense, right? If you have too
many errors that little smallbrains, like, I can't do this
anymore. So what happens yourbrain sits down and you're like,
I hate this. I get dizziness.
You have walking issues. Itaffects so many parts of the
body. But in fact, anotherpatient I just had recently,
like, we worked on all thisstuff, and I remember, agree
(25:29):
this finished therapy, and she'stelling me, she's like, man, you
know, I got really kind of,like, I had all these emotional
fluctuations during therapy whenI was doing all these exercises
you're assigning me. And I'mlike, and I told her why, and
she's like, Oh, that makes totalsense. But the cool thing she
said is that, like, I feel moreemotional, sound now than I did
before. Awesome. Yeah, so, andI'm not, I'm not, I'm not a
(25:55):
therapist, I'm not a, you know,a psychologist or anything like
that. But I think when youintegrate systems, people can
adapt better and compensatebetter and be able to control
their emotions and so forth.
Yeah,
Dr. Ayla Wolf (26:10):
you're taking all the errors away and just letting
the brain able, like it's able,to then do its job. One of the
questions I wanted to ask you isabout the cervical ocular
reflex. Can you talk a littlebit about that?
Dr. Paul Brewer (26:24):
It goes back to those three maps again, right?
You know, cervicalproprioception, or somatic you
get somatosensory input rightfrom the proprioception, vision
and vestibular and and, myopinion, I think vestibular is
foundational in stabilizing theproprioceptive pathway and the
visual pathway. So when you lookat these reflexes, it's really
(26:46):
like kind of an integration,like even the VOR reflex, the
vestibular ocular reflex. Allthose three systems are
communicating together to helpeach other out, but to also
stabilize each other. So in somecases, it could be an eye issues
causing neck issues. Other casescould be neck issues causing eye
(27:06):
issues. So there's times where Iwe firm because they may have a
subluxated joint, and I have tosend them to this person to work
on that, but they might havethese underlying vestibular
issues. And a lot of cases, too,when you talk about neck
adjustments or manual therapy onthe in the cervical region,
sometimes you might have to dosome vestibular integration to
(27:29):
stabilize the vision and thevestibular before they do that
actual manipulation or manualtherapy, or even Acupuncture, or
whatever you want to do, right?
Because sometimes, if you don'thave that sound stability
between the systems. It doesn'tmatter what you do. It's kind of
like when you get a massage, andthen, like, literally an hour
later, like, why am I soreagain? You know? I mean, like,
you feel all good, and thensuddenly everything gets all
(27:50):
tight again. It's really comesdown to is, we call it in
Polynesia, no fefe. No fefemeans no fear. So we want to get
people to the point where theyhave no fear. And what does that
mean? If they're fearful,they're going to be in this
fight and fight kind ofsituation, or they're going to
be in a survival mode. And ifthey're in a survival mode,
they're going to always belocked up. They're gonna have
(28:12):
that constant startle reflex,really, like this, you know,
like kind of like that, wherethey have everything contracted
and road forward to protect alltheir vital organs and so forth.
So if you're in this constantfear mode, then you're going to
have neck issues. The neckissues are going to cause visual
issues. But a roundabout way oftalking about this reflex we're
looking at reallyfoundationally. Can you are they
(28:34):
in the survival mode or in theperformance mode? And we want
people to be in the performancemode, and there's going to be
this ebb and flow betweeneverything, but obviously we
want people to be more on thatperformance side, so that
they're not that's when they'regoing to have issues with the
neck, issues with the eyes,issues with the vestibular so
first thing, obviously, goingback to the full foundation
level, we have to look at theautonomic system, because if
(28:57):
they have This autonomy and soforth. It's hard to have a
stable communication between thevision, the vestibular and so
forth. Now, at the same time,those systems will affect the
automaticity of the body aswell, because if you have
underlying visual vestibularintegration issue that can
cause, you know, autonomicdysfunction, and cause immune
(29:17):
issues and cause gut issues andcause like even like emotional
issues, like we said before. Soin reality, like we're when
we're looking at these systemsand tests, we have to see how,
like, the neck and the movementof the neck and the body will
affect your visual pathway toeye movements. So sometimes the
(29:40):
person that maybe be turned thisway might have way better eye
movements versus lookingstraight ahead. So we know that
there's something going on withthat cervical region or the body
that could be affecting thevisual pathway, and they all run
through the same thing. I mean,the same like cerebellum
controls the air correction.
Than all of them. The frontallobes control the, you know,
(30:02):
contralateral movements. So likein reality, you got the same
parts of the brain that areaffecting the kind of different
pathways. So they all work as ateam. And going back to the
reflex, right? If you if youhave poor reflex or poor
communication, you're going tohave errors in one of the
systems. Yeah.
Dr. Ayla Wolf (30:22):
And then I think you brought up that important
point, that when you have lotsof errors in these different
systems, it can actually tax theautonomic nervous system and
drive some of these dysautonomiatype symptoms as well. Talk a
little bit about lightsensitivity. You know, when we
were talking earlier, I reallyliked what you said about light
sensitivity, the term itselfalmost being as vague as when
(30:46):
people say, I have pain, in thesense that it can mean a lot of
different things to differentpeople. So talk a little bit
about when someone says, I havelight sensitivity, what other
questions you ask, or what it isthat you're thinking in terms
of, like a differentialdiagnosis.
Dr. Paul Brewer (31:00):
That's a good question. So, yeah, light
sensitivity can mean so manythings. It's photosensitivity is
the name for photophobia. Sothere's all these different
terms for I don't like light youknow, for me, when I'm when I
hear someone come in, I'm like,Oh my gosh, that means
absolutely in my head. I'm like,thinking, okay, that means
absolutely nothing. Let's justdo the test right, because it
(31:24):
could be so many differentthings. So dry eyes can cause
license sensitivity, because ifyou have a poor tear film, so
you got your eyeball, eyeball,tear foam on eyeball. If this
tear film is unstable, it causesexposure to the front of the eye
to air, and when there'sexposure, there's a trigeminal
nerve. It's like the sensorynerve, it gets stimulated,
(31:45):
pretty crazy. And when it getsstimulated, you feel that
burning sensation or achiness orwhatever. And then the brain's
like, oh, I don't like that.
Throws the fire engine on,lacquer around, produces all
this tears, and suddenly get allthis wateriness, right? So a lot
of people are like, Oh, my eyesaren't dry. They're watery, but
watery eyes are typically prettyhallmark for either allergies or
(32:06):
dryness. So like, that's onething that can cause the
licensivity, because when youhave all this over stimulation,
it's hard to focus. It could bea gaze stability issue, like we
mentioned before, if you havepoor gaze stability that can
cause light sensitivity. Itcould be a poor people or
effect. So the people is thatblack circle that's the people,
(32:27):
and the muscles around the iriscan either contract or die, like
it big when it contracts, that'sa parasympathetic response, or
rest and digest, but not reallyrest and digest, but and then
when it gets dilated. It can beit's a sympathetic response. So
when you're outside,automatically, your eyes
constrict, kind of like anaperture in a camera to let less
(32:48):
light in, because if it'sbright, it gets smaller, so
there's less light coming in.
But if you have poorautomaticity in this, and it
goes like more like this,slowly. Or sometimes they have
what's kind of poor sustainedpeople are with contraction. So
they go like this, and thensuddenly goes like that. It
can't sustain. So you have this,like, evident flow of light
(33:12):
coming in and out, so the braincan't process that, which can be
light sensitivity as well.
There's all these differentthings. Those are, like, one of
many things that could be thatcan cause these issues with
light sometimes even, like, oh,go ahead, yeah.
Dr. Ayla Wolf (33:27):
Sensitivity to flicker as well, which you have
basically a test where you canmeasure if somebody's extra
sensitive to the flickering oflights Correct.
Dr. Paul Brewer (33:36):
Yeah. So I guess going back to the light
sensitivity too, like, it couldbe an eye teaming thing. So
people have, like, a it's got anintermittent extratropia. So
sometimes their eyes go out.
Sometimes it doesn't that.
Sometimes the symptoms for thatis light sensitivity too. So
they're closed when I whenthey're outside, and they're
more sensitive light so there'sall these things that can cause
it. So basically, I guess whatwe're looking at is, like, it's
not, like, okay, they have lightsensitivity that creates a great
(33:57):
symptom, right? What's actuallycausing it. So, like, that's the
same thing with red eye. Like,oh, you have red eye. It could
be allergy, it could bebacteria, it could be viral, it
could be so many differentthings. It could be an autonomic
dysfunction. It could beinflammatory. So there's all
these different things thatcould be so when someone comes
in with lights and severe redeye, I'm like, okay, great.
(34:18):
Let's just do the test and seewhat's going on with the body,
right? The same thing with theflicker rate. Like people that
have concussions, they mighthave poor processing of like
flicker rate. So like, when wesay flicker rate, that's like
hertz. So when you look at likea fluorescent light, now I
might, I'm pulling numbers onthe area now, so I can't
remember the numbers. I alwayshave to look them up. But like a
fluorescent light might be like,I don't know, 60 Hertz or
(34:41):
whatever, but if your braincan't process those hurts, or if
it's kind of dysfunctional,fluorescent lights, might, the
flicker rate of a fluorescentlight or a TV might bother them.
So that's a whole brain thing aswell. So things like that can
actually affect you. So iflights bother you, you. It could
be a flicker frequency, likeprocessing issue, it could be a
(35:05):
dryness issue, and so forth.
Dr. Ayla Wolf (35:08):
Got it, and then you have this very cool tool
where it flickers at differentfrequencies. And then you have
your patient look at it andbasically tell you when they see
the flicker start, and then whenthey see it go away, and that
tells you kind of if their rangeof perception of that flicker is
kind of within a normal range,correct, correct,
Dr. Paul Brewer (35:31):
yeah, because concussions can actually affect
that. And so, like the test,what it does is, like it
flickers, where you actually seea flicker, right? So sometimes,
when you have a fluorescentbulb, or whatever, you'll see
that kind of flickering of thelight. So it's flickering at a
lower Hertz. The faster it goes,the harder it is to eventually
see. So eventually, when it's awritten number, where it's
(35:52):
flickering so fast, and evenwhen you see light that it's not
flickering, it's stillflickering. It's just flickering
at such a high speed that yourbrain and eyes can't see
anymore. And sometimes peoplehave, like, a higher issue, or
they see like, they have such ahigher, like flicker rate, where
they're seeing pretty mucheverything. So all these little
(36:13):
nuances of the light can botherthem. It's like over stimulating
them. That goes back to wholeerror correction, like there's
already so much your brain canhandle and so much your breaking
filter. I guess, going back tothe whole concussion thing, this
podcast is about like a lot oftimes concussions affects the
brain's ability to correct errorand filter information. So when
(36:35):
it can't filter information, itcan't correct errors anymore, or
at a reduced rate. That's whereyou have all those symptoms,
like licensivity, dizziness andso forth. That's what it comes
down to, is like being able to,like, filter we can't. People
that have brain issues, theycan't filter out information. So
now, like, instead of seeinglike parts of things, now, like,
(36:56):
everything's coming into theirbrain, their brains like, oh my
gosh, what's going on? In fact,I, in my opinion, your vision
itself like there's so muchinformation just looking around
you, like I'm looking at this,there's all this stuff around
me, like I'm right in front ofthis huge window where I'm
looking outside too. If my braincouldn't filter all this out,
all this information will becoming in. I'll just go system
(37:17):
overload. So the brain is reallygood at filtering out certain
information coming in where it'sgood at picking out the most
important things. That's calleda perceptual like a perception
span. So perception span is theability for the brain to like
taking critical information andapply it. People that can't do
that either can't see anything,or they see too little, or they
(37:40):
see too much, and then thatcreates this filtering issue,
kind of a funnel effect, whichcan cause more errors and cause
symptoms and so forth.
Dr. Ayla Wolf (37:50):
And I would imagine a lot of the visual
motion sensitivity that peopleexperience, part of it is their
brain failing to kind of filterout the unnecessary information,
and therefore their brain isjust bombarded with every single
thing that's moving in theenvironment.
Dr. Paul Brewer (38:07):
Yep, that's that's, like, that's part of the
equation filtering and errorcorrection, right? So, like,
there's too much informationcoming in, brain can't filter
it. There's too much errors,brain can't correct for it.
Thus, the motion sensitivity,
Dr. Ayla Wolf (38:20):
And when you're incorporating a lot of the
visual and vestibular andproprioceptive information by
kind of cleaning up a lot ofthose errors, then, as a outcome
of that, I imagine you're seeingthat the visual motion
sensitivity is also improving
Dr. Paul Brewer (38:38):
Correct Yep. So if we can give the brain
specific activity. So, you know,through testing, we like, okay,
these are the pathways that areefficient. These are the
exercises that work for thispatient, and by activating that
part of the brain it we're notlike fixing them, and we never
fix anyone. But when we givetheir brain activity, their
(39:00):
brain can interpret informationin a different way. So we're
helping the brain be able tointerpret the incoming
information in a different way,be able to filter in a different
way, and be able to correcterror in a different way. Is
ultimately what it comes downfoundationally. In fact, a good
example of to explain thispathway, it's called the odor
(39:21):
loop. So the odor loop wasactually developed by a guy in
the Air Force way back when, andimplicitly, it's an input
processing output, butultimately his the odor loop is
input, or like observation. Solike all the incoming sensory
information from vestibular tovision and so forth. Then you
(39:44):
have and then you haveorientation mechanism in the
brain. So the orientationsegment is based off, like from
the info coming in. You're goingto process and package it in a
certain way, based off yourgenetics, based off previous
experience, trauma. Based off,even religion, cultural views,
because all that modes howyou're going to bias yourself to
(40:05):
the incoming information. Andthat's the orientation. Then it
goes to a decision makingprocess. And that decision
making process is like, do youdecide what to do? Like, am I
going to if the ball is flyingat my face, am I going to let it
hit my face? Am I going to moveout of the way? Am I going to
catch it? That's the decision.
And then the motor response, theaction. So observation,
orientation, decision action,Oda loop action is basically
(40:29):
what you're going to do, likethe actual motor movement
itself. Then there's obviouslythese feedback loops that go
back and forth, that go in acycle. I I kind of coined this
term called Vision decisionaction, and because I said,
firstly, you made all thesensory as vision. So vision
decision is that orientationdecision together in action. So
that's kind of what I explain topeople when we're actually
(40:51):
explaining this loop. So whenyou're in a car, you have all
this input coming in. Can wechange the orientation and
decision making processes to beable to again, correct error, be
able to filter out informationand be able to make better
decisions
Dr. Ayla Wolf (41:09):
and do it in an appropriate timeframe as well,
I'm sure, because obviously,visual processing and reaction
time are key components of allof that. I know that there's
some interesting research andtalking about when, when people
have concussions, they may notnecessarily have like, a full on
peripheral visual loss in acertain visual field, but the
(41:32):
way that their brain isprocessing peripheral vision can
change. Can you talk a littlebit about that?
Dr. Paul Brewer (41:38):
That's a That's a good question. So, like,
there's a difference betweenactual loss nerve damage, right?
Like something's broken and hasa stroke and there's black
stroke, yeah, and even those, itmight be like a temporary loss.
So the question is, is it acompletely permanent loss? It
doesn't matter what you do, it'sgoing to always be dark at that
(41:58):
spot, right? So a good exampleof like glaucoma. Glaucoma
affects your peripheral vision.
It affects your peripheralvision, and so when you have
really severe glaucoma, this isall you see. Eventually, if you
don't get it treated, or youdon't slow down the process,
that's like permanent loss. Likeit pretty much doesn't matter
what you do, you're not going toget the full extent anymore,
where in concussions, you mighthave either a temporary loss or
(42:22):
a constriction. So, like I kindof differentiate permanent and
constriction. So when you have aconstricted visual field or
partially, it's not like youhave a black spot here. You
still have all this stuff here,but your brain can't process it
as well as it used to. So whenyou have poor peripheral
(42:43):
processing, it actually affectsyour central processing. So they
work out in the hand. There'sthese two different loops that
kind of work separately, butthey stabilize each other. So
when you have poor peripheralprocessing, that leads to gaze
stability issues, it leads toeye tracking issues, it leads to
visual sensitivity and so forth.
(43:08):
So constriction is a differentthing, where you don't have
permanent loss, where you canactually rehab that pretty well
and easily.
Dr. Ayla Wolf (43:15):
And are you rehabbing that by giving people
different exercises?
Dr. Paul Brewer (43:21):
In that case, it kind of depends. I mean,
sometimes, sometimes they mightneed a vestibular integration,
like, like, do visual vestibularintegration exercises I see a
lot of times where you do that,where you're integrating the two
systems together, and it opensup to periphery, because now
they have better processing.
Sometimes you might have to dolike, stuff like, where you're
doing a peripheral centralintegration with like, it's
(43:42):
called like vectograms orstereopsis, or like depth
perception type S, or exercises.
So like, you have thesepolarized glasses on, you see
this 3d image. And by working onthe eye teaming together with
peripheral processing that helpsopen up the periphery. So
(44:05):
really, it's not like you'redoing something to make it open
up. You're just giving the brainan activity to be interpret the
incoming informationdifferently. So one example
someone can do is like they canactually look straight ahead,
and instead of like, looking upat the lines of the corners of
the room, so like, say thatpicture behind me right pretend
(44:26):
like that's the actual wall theback of the room. Instead of me
looking up at each part of it.
I'm using my I'm lookingstraight at I'm using my
peripheral and I'm using myperipheral vision to follow the
edge of that painting. I'm notmoving my eyes at all. I'm just
using my peripheral vision.
Okay? I see the, I see the topcorner. It's like, kind of
(44:47):
bluish. I see the, you know, thetop right corner over here, it's
red. And so forth. By using yourperipheral vision, so there's
activities you can do to kind ofopen up the periphery. That's
just one of many. Yeah,
Dr. Ayla Wolf (44:58):
yeah, yeah. And.
That sparked another comment, Ithink, that you had made in one
of the courses that I had thehonor of taking with you, where
you were saying, like, whenpeople have that kind of
peripheral visual dysfunction,if they're doing, like,
potentially the wrong exercise,or where they're doing a lot of
exercises focusing onconvergence, where you're
(45:20):
training them to actually justfocus on one target that's
really up close. You canactually be kind of like
training the problem, so tospeak, if part of their actual
problem is that they're nottheir brain is ignoring all of
this peripheral information. Andso I think that really teases
out the fact that this type ofvision therapy is incredibly
(45:41):
complex, because everybody'sissues are very different, and
people need very different type,you know, types of exercises.
There's not like, hey, let'sjust run everybody through all
these different exercises. Yeah,
Dr. Paul Brewer (45:56):
that's actually a good point you brought up. So,
like, vision therapy, right?
Like, you go online, you'relike, oh, I have an it should go
online. The first thing you'reprobably going to see is pencil
push ups and bead string orBrock string, right? So a lot of
these docs would like, likethat, just random sign, oh, just
do pencil push ups, just doBrock string, and you'd be fine,
right? And reality, if you havea divergence issue, so they
(46:19):
diverging your eyes out. But youhave good convergence you could
it can have the same symptom asa convergence insufficiency,
where you have issues focusingup close and so forth. So
someone's like, oh, yeah, justdo all this convergence stuff
over and over again. So you'remaking that convergence issue
even stronger, but you're makingthat divergence worse, which can
make the problem even worse. Sothat's the thing. A lot of
(46:41):
people just say, Oh, just douchepencil push ups, broad screens,
like it could be so manydifferent things. So in some
cases it might actually help thesituation, but in a lot of
cases, it may not. That's thebiggest thing is that people go
online they like and there's alot of good information online.
Don't get me wrong, because Iuse online for a lot of stuff
too, but it's about finding outwhere the deficiencies are
(47:02):
first, because certainactivities can make it worse by
going too focal or too centraltoo quickly, where you have to
be opening up the periphery tostabilize the central area.
Another example is even like,like, I get us a lot too.
There's a lot of greatfunctional guys out there,
physical therapists andchiropractors and and so forth,
you know, everyone. So I'll geta patient where, literally, you
(47:22):
know, they've they do vestibulartherapy. They call, I went to a
vestibular therapist, and theirextended visitor therapy is
either walking on a balance beamor getting spin in a chair or
doing a bunch of like, crackingstuff like this, right? And in
reality, those are great things,but that's not what they needed.
(47:43):
They needed a specific path tobe activating their vestibular
visual system, to get them thebrain processing things
differently, versus randomlyjust throwing them all over the
place. I see that time and timeagain with that kind of stuff as
well.
Dr. Ayla Wolf (47:59):
Yeah. I mean, it really all comes down to having
the right type of exam and theright person to be able to
diagnose what that particularindividual is struggling with,
to then be able to find theright types of exercises.
Dr. Paul Brewer (48:14):
Yeah, for sure.
I mean, that's, that's the thingtoo. Like, and I'm still
learning a ton, right? I'm like,I don't think I'll ever be a
master of stuff, but, like, I'mconstantly learning, so all the
times I'll call I'll call it myfunctional neurologist, friends,
you know, colleagues and like,Okay, I have this case. This is
what I'm doing. What am I doing?
Wrong, right? And they'll giveme such good information that's
super awesome. Like, I havepeople in every single field,
(48:37):
like MDs, chiropractors,physical therapists were like, I
might have a case that I needhelp on, and I'm usually calling
out a state, because therepeople in other states I call
I'm like, and I'll share mycase, and sometimes they'll call
me up and share their case too,as well. So we have this good
collaborative team where, wherewe're all really good at we're
(48:57):
doing, but at the same time,we're all learning still. And I
think that's the key. Is that wehave to always learn. If you get
to the point where you think youknow everything, then that's
where you're going to startfailing. I think that's why I
can go the same lecture over andover again, and I learned
something new. In fact, a lot ofthese ones again with the
characters doing so if that, youknow, like you listen to these
videos over and over again,every time I listen to it again,
(49:17):
I'm learning something new.
Because the first five times Ididn't catch something that I
caught the fifth time. You knowexactly,
Dr. Ayla Wolf (49:24):
exactly. And there's so much about the brain
that we're still figuring out.
So it's impossible for anybodyto say that they've got it all,
that they've got it all figured
Dr. Paul Brewer (49:33):
Well for sure.
Yeah, it's hard. I mean, it'sout.
like every person's a newpuzzle. It's like putting a
puzzle together every singletime, but it's a different
picture.
Dr. Ayla Wolf (49:43):
Yeah, I mean, I learn new things from my
patients every single day,because every single person
walks in with their own kind ofunique, unique set of issues
that you've got to then figureout. So in terms of kind of
wrapping up, is there advicethat you could give somebody
who's. Out in the world who'smaybe had an initial eye exam
(50:03):
told their vision was normal,they're still struggling with
visual symptoms. What would yousay to that that individual,
Dr. Paul Brewer (50:10):
that's a good question, like, probably, like,
go find either a functionaloptometrist, like a neuro
optometrist, or a functionalneurologist, or something that
maybe you can do more testing,and it's not like anything that
the doctor is doing wrong. Imean, like, it's kind of like,
this is a good example. I go tomy primary care right, like, and
it's like, they couldn't do somuch, and sometimes you just got
(50:33):
to find a specialist that candiagnose your issue. Like, I had
a good example. Like, I surfedmy whole life, literally, and in
my ears, I have what's calledexternal auditory exit ptosis,
which is like this, bone growthinside the canal. It's not it's
on the outside of the eardrum.
But when you're in the ocean, alot the it basically closes off
the bone growth and closes offthe canal. So it's super small.
(50:54):
My right ear was, like,literally, 97% occluded, right?
So I go to my primary care andthen like, Oh yeah, you have an
ear infection. Give me yourdrops. Like, you know, it feels
like it's getting better, butnot really. I'm like, what's
going on? Like, I like, I wentto Hawaii. I was visiting
Hawaii, and I used to dive allthe time. I dove, like,
literally, three feet in theocean. I'm like, Oh my gosh,
(51:14):
this hurt. This is weird. And Iwent back to my primary care.
When I got back, they're like,Oh yeah, everything's fine.
You're good. I'm like, and Ihave, like, I have a otoscope,
you know, but you can't otoscopeyour own ear. And I follow
online to have these videolines. And this is bad, like,
saying this, like, as a fresher,got found, but, like, I get this
video otoscope, I just look in,I'm like, Oh my gosh, my
(51:35):
freaking ears, like, like, 95%occluded, you know, this is
crazy. And then so I sent anappointment with the ENT, which
is a specialist now, right? AndI go into the anti office, and
I'm like, you know, the MA isgetting my history. And I'm
like, oh, yeah, I think I have a95% external auditory exitosis.
And I can see that Ma's face,like, you just Google that,
like, in her head, you know, yousee, like her face, like she's
(51:58):
like, You're so stupid. I'mlike, okay, whatever. I just see
her face, like, that disgust,and I kind of, like, tone it
down a little bit. I'm justlike, whatever. And then the
doctor comes in. He's like, Ohmy gosh, you're totally right.
Like, yeah, it's totallyclueless how to get surgery on
it, because that's only way toget rid of it. But that's a good
that's a good example, right?
Like, it's not, I don't blame, Idon't blame my primary care, I
(52:21):
don't blame and I don't blameanyone. It is what it is, you
know, like, there's only so muchpeople can do as doctors, I
think as patients, we have to bemore forgiving, because we
expect the doctor to know everylittle thing. And in reality, if
you're not specialized insomething, you're not going to
know it. So my advice is, bemore forgiving to your doctor,
and maybe ask them, like, hey,is there someone you can refer
(52:43):
me to? So a lot of times, thosedoctors will know the
specialists in town. Or you can,like, go online and look at the
different sites, like, you know,the Carrick side, or Nora or
whatever. Like, there's aoptometric rehab site that you
can look up doctors in yourstate. But at the same time,
just because you're trained inany situation in any
institution, doesn't mean thatthey're a good doctor either,
(53:04):
right? So you can have all thefellowships and all the things
in the world, but does it makeyou a good doctor still? So
that's one caveat, that when youdo look up these people, it may
not be the situation for you, ormaybe it might might be the
right fit for you from thedoctor. So that's, I guess, my
biggest advice I give people,for the patient side and for the
doctor side, you know, I justsay, continue learning. Like,
(53:26):
literally, like, don't stoplearning. Because if you stop
learning, then you don't there'salways going to be changes in
research and changes in how wetreat people. And if you're
doing things 20 years back, itmay not be as effective today.
Dr. Ayla Wolf (53:39):
Yeah, yeah, wise words. Well, let me ask you one
question. Where can people findyou?
Dr. Paul Brewer (53:46):
Diverge performance is the my instagram
handle the website's divergedperformance.com as well.
Dr. Ayla Wolf (53:54):
Okay, perfect.
Well, I could put that in theshow notes, and then your
practice is in Boise, Idaho.
Dr. Paul Brewer (54:00):
Boise, yep, uh huh.
Dr. Ayla Wolf (54:01):
Okay. Super Excellent. Yeah. Thank you so
much. Thank you for coming onthe show and for giving us a lot
of insights into what isincredibly complex. And I hope
to have you back on where I canpick your brain some more on
other specific topics that wedidn't get to today. So thank
you so much.
Dr. Paul Brewer (54:21):
Yeah, thank you.
Dr. Ayla Wolf (54:25):
Medical disclaimer, this video or
podcast is for generalinformational purposes only and
does not constitute the practiceof medicine or other
professional health careservices, including the giving
of medical advice. No doctorpatient relationship is formed.
The use of this information andmaterials included is at the
(54:45):
user's own risk. The content ofthis video or podcast is not
intended to be a substitute formedical advice diagnosis or
treatment, and consumers of thisinformation should seek the
advice of a medical professionalfor any and all health. Related
issues, a link to our fullmedical disclaimer is available
in the notes you.
Yeah, but, and another thing too, is if you
(00:03):
have too many errors, it's likeif the vestibular system is
pulling the body one way thevision is pulling the body,
another way you get this pushand pull all day long, right? So
it's better to have them worktogether than doing this all day
long, which can make the brainreally tired and make you
fatigued.
Dr. Ayla Wolf (00:22):
Welcome to Life after impact, the concussion
recovery Podcast. I'm Dr AylaWolf, and I will be hosting
today's episode where we helpyou navigate the often
confusing, frustrating andoverwhelming journey of
concussion and brain injuryrecovery. This podcast is your
go to resource for actionableinformation, whether you're
dealing with a recentconcussion, struggling with post
(00:45):
concussion syndrome, or justfeeling stuck in your healing
process. In each episode, wedive deep into the symptoms,
testing treatments andneurological insights that can
help you move forward withclarity and confidence. We bring
you leading experts in the worldof brain health, functional
neurology and rehabilitation toshare their wisdom and
(01:05):
strategies. So if you're feelinglost, hopeless or like no one
understands what you're goingthrough, know that you are not
alone. This podcast can be yourguide and partner in recovery,
helping you build a better lifeafter impact.
All right, Dr Brewer, welcome tolife after impact, the
concussion recovery Podcast. I'mso excited to have you on here.
(01:28):
You are an expert in workingwith people with concussions
from an optometry lens, and youare really on the cutting edge
of combining a lot of vestibularand sensory integration into the
vision therapy work that you do.
So I'm so excited to be able topick your brain and have you
share some insights into thework that you do and the
(01:51):
clinical experience that youhave in working with people with
post concussion syndrome. Sowelcome to the show. Thank you.
Yeah, you have a practice inIdaho. You're originally from
Hawaii. Correct, correct,
Dr. Paul Brewer (02:05):
yeah, I'm originally from Hawaii. My roots
are in the islands, and I met mywife in Hawaii. And my wife is
actually from Idaho, so we movedup here to be closer to her
family, which, that's, you know,starting a practice up in Idaho,
in Boise, yeah,
Dr. Ayla Wolf (02:20):
yeah. Well, it's a beautiful area.
Dr. Paul Brewer (02:22):
Have you been?
Dr. Ayla Wolf (02:24):
Yeah? I, well, I lived in Oregon, so I was very
close, and so I got to, youknow, make some, make some quick
little trips here and there. So,yeah, a very beautiful area.
I've been to Joseph Oregon,which is like, in the south or
northeast corner of the state,and I feel like that's just like
(02:45):
this little hidden gem in thiscountry that not many people
know about.
Dr. Paul Brewer (02:48):
I've been through there. We were up in
like Moscow, or whatever, for mydaughter's gymnastics me, and
then when we drove down fromthere, we passed through Joseph,
Dr. Ayla Wolf (02:59):
yeah, yeah, such a great little part of the
country. So tell me a little bitabout how you ended up
specializing in post concussionsyndrome, or people with
concussions, and maybe some ofthe kind of unique things that
you bring to your practice inthat regard.
Dr. Paul Brewer (03:17):
That's good question. So, like, I don't have
this, like, crazy, cool story,like, I came out of my mom's
belly and, like, literally, Istarted loving concussions. You
know, like, every doctor seemsto have that story of, like, oh
yeah, since I was a kid, I likethis and that, right? I mean, it
was never even on my mind,actually, like, I mean, growing
up in Hawaii, I played a lot ofsports. I actually had a lot of
(03:40):
concussions, but it never dawnedon me that, oh yeah, you could
do something for concussion. Imean, it had a ton of
undiagnosed concussions. Fact,when I speak on concussions, I
show this video of me when I'm ateenager. I'm skateboarding on
the seal really fast. Get somespeed wobbles. I bounce off my
board, hit the telephone pole,bounce off the ground, hit my
head, and like, you know, Imean, so I'm not, like, a
(04:02):
stranger to concussions, so Ibut I also knew how it at the
time, I didn't know, but now Ido know how much it actually
affected my performance. Mystory was a little different
than a lot of people that haveconcussions. A lot of people,
like, when they get concussions,they get messed up. They mean
their life falls apart. In mycase, I mean, I always had
(04:25):
deficits. I didn't know I was Ihad, but I was good compensator.
So a lot of people cancompensate, but does that mean
that they're actually it'sactually good for them? So I
compensated really well. I mean,I played four sports in high
school. We did I did a sport incollege, and, you know, I was a
biochem major, had pretty muchstraight A's. That was one of
(04:46):
the ones where I was flyingunder the radar. But I didn't
realize how much work I had toput into studying and everything
else. I just didn't realize. Ithought that was just normal.
And as I, you know, went intoTom. To school, I learned more
about visual rehabilitation, andat the time, you know, they, you
know, the diagnose me withconvergence insufficiency, which
(05:07):
is a pretty common eye conditionthat can be diagnosed when they
have binocular issues. Andthey're like, Oh yeah, you have
this issue. And if you do thistherapy, you'll be better. And I
remember, in my mind, I was afirst year, and I remember,
like, all these, like, thirdyears crowding around me because
they thought it was really coolthat had this you know, thing,
you know, convergenceinsufficiency, which isn't
(05:29):
really that big of a thinganyways, but like they, you
know, when, when you're instudent, anything that you see
as abnormal is really cool. AndI was getting kind of pissed off
because there was telling me allthis stuff before they explained
it to me. I'm like, Hey, so holdon, guys, what's going on? And
they finally said, oh, yeah, youhave this issue that's affecting
your performance. And I'm like,really? And I've been to the eye
doctor every year my lifebecause I had contacts. And I'm
(05:52):
like, why didn't the doctor evertell me this? You know? I'm
thinking my head, like, Wait, ifI actually did this therapy when
I was a teenager, I would havebeen able to study better, you
know? Like, I mean, or I wouldhave been able to do even better
or study more efficiently. Andthis dawn, I'm like, Man, I
really wish my doctor told methat. And that's kind of that
point in time where I had thispassion of learning more about
(06:14):
the rehabilitation versus justlike glasses and contacts. And
that's just, you know, that'simportant thing too, as well.
But it really made me excitedabout learning about the brain
and the neurology of the brainback in my first year of
optometry school. I mean, whenyou go to school, you learn kind
of this, like basic,foundational stuff, and you
don't really learn a lot ofthis, like neurology per se, in
(06:37):
school. And that's why, like,you know, institutes like the
Carrick and others and so forth,you know, they they give these
courses post doctorate to beable to put you at a different
level. And, you know, I learneda lot in school, don't get me
wrong. I mean, I learned a lotabout visual rehabilitation, but
most of my learning came fromafter school. But it was that
passion I had that like I couldactually help other people. I
(06:57):
could actually help peoplerecover quicker and perform
better, and I had my own storyand how it kind of helped me.
And in reality, you know, thevision therapy I did in school
really helped me, but whatbrought me to another level is
when we started incorporatingother sensory integration, like
vestibular and and so forth, andthat kind of helped me even
(07:17):
recover even better. I think Idon't even answer, did I even
answer the question. I think Itotally went on a totally, yeah,
Dr. Ayla Wolf (07:23):
you did. You did.
No, I was curious, kind of what,what your interest was,
specifically with concussionsand vision rehab in that regard
was. And yes, you think it's
Dr. Paul Brewer (07:32):
really cool. It really is super cool, like it's
it's so cool to see that thebrain is plastic. It's so cool
to see that we can do things toactivate the brain to recover
and perform better where, youknow, like, 15 years ago even, I
mean, not even 15, even morethan that, but like, and even
(07:53):
now, people are like, Well, youcan't do anything with the brain
once it's hurt, it's hurt, andit's cool to be able to see
that. In fact, I had a patientthat I just finished, you know,
we just did a few sessions. And,like, literally, for the last
like, two years, they've been,they've been to every single
doctor, I mean, and in twofunctional neurologists defense,
(08:14):
I mean, they, there was reallyno one they saw for that here,
because they did see, like, theylike acupuncturists and
chiropractors and so forth. Butthen it's the same thing as
saying, Oh, they saw optometristin each of our professions,
there's different types ofspecialties and like, so he
didn't really see any functionaltype doctors in any of our
professions, right? So they'rekind of pushed and pulled to all
(08:36):
these different areas. Andfinally, the doctors like, you
know what? You just have to dealwith your business. You have to
deal with this, you know, like,and so they just live their
life, and they, I don't know howeven they found me, they found
me, whatever, for a reason,maybe a referral, or online, or
whatever. And they came in, andwe started doing some sessions,
and literally, after about likefour sessions in, they're like,
(08:57):
Oh my gosh. Like, they saw ahuge difference their life. They
said they were going to makebetter eye contact with people.
They can actually walk outsidefor long periods of time to be
able to, like, enjoy thescenery, versus, like, shutting
down and so, like, it was coolto see that so quickly. And I
think if I just really just didmy own thing, like to say this
(09:19):
vision only, it probably wouldhave taken longer, but in
integrating all the differentparts of the brains and doing
different types of therapiesreally helped them get to a
place where they were happier,quicker and more efficient.
Yeah, yeah.
Dr. Ayla Wolf (09:34):
And that's, that's amazing, and always such
a good feeling when you can, youknow, not only like, start to
help people, but then actuallyfind ways of doing it really
quickly and getting those kindof immediate wins, because
that's what encourages people tostay the course and recognize
that there is room to improve,which is always giving people
(09:55):
that hope is so important forsure. Can you talk a little bit
about so. You know, my myexperience with so many of the
patients that come to see me,when I ask them about who have
you been to, who has assessedyou? Many of them say, Well, I
was having, you know, lightsensitivity or blurry vision. I
went to my eye doctor, and theytold me that my vision was fine.
(10:18):
And so we have this kind ofdifference between visual acuity
versus eye movements and how thetwo eyes are working together.
So can you maybe talk about forour listeners, the difference
between visual acuity versus eyemovement disorders or
dysfunction within how the twoeyes are are moving or moving
and communicating together andwhy so many of these eye
(10:41):
movement disorders are maybegetting missed in a standard
exam.
Dr. Paul Brewer (10:46):
For sure, yeah, and in reality, in a stat, in a
standard exam, in reality, theydoctors should be testing eye
movements. They should betesting eye focusing and eye
teaming. In some cases, it mightbe brushed through really
quickly. So let's talk about,we'll talk about acuity. We'll
talk about eye tracking, eyemovements. We'll talk about
binocular vision. Then when?
Then we'll talk about, like,I'll maybe go over one test on
(11:08):
how we do it and why it might bemissed. Does that make sense
perfect? So the first thing isvisual acuity. So like most
people think visual acuity aslike perfect vision. So when you
when you hear 2020 that's thecoin term, 2020 you have 2020
vision. And when people say, Oh,I have 2020 vision. In fact,
most of my patients say thisevery single time when they come
(11:29):
in, oh, yeah, 2020 vision. Ihave perfect vision. I'm like,
the first thing I usually askpeople is, like, what? What is
your understanding of 2020 andmost people again, will say, Oh,
perfect vision, or crystal clearvision, or whatever, right? And
in reality, you can have betterthan perfect vision, because you
can have like 2010 vision. Soall the numbers refer to as
(11:50):
like. The top number 20 refersto looking at the chart from 20
feet away, so the chart will becalibrated at 20 feet. And the
bottom number refers to the sizeof letter. So 2020, is a certain
size. 2010 is half the size.
2040 is double the size. Sothat's all it refers to. Is the
clarity of vision. So clarity ofvision is that one the first
(12:11):
step in the whole visualprocessing pathway. Now you can
have clear vision, or 2020vision, or even 2010 vision, but
have imperfect vision ordysfunctional vision. So I get
this a lot from patients.
They're like, Oh, yeah, 2020vision. There's nothing wrong
with my vision. In fact, a lotof times they're like, oh, like,
one of my things on myquestionnaire is about
headaches, and they're like, oh,I don't think it's related to
(12:33):
vision. I'm like, I just askhim. I'm like, a little snarky
about it too. I'm like, I'mlike, How do you know it's not
related to vision? You know,like, and they kind of sit
there, like, thinking they'relike, Oh, actually, I don't
know, because people just blurtthese things out of their mouth
all the time, right? Same thingwith perfect vision. And in
(12:53):
reality, you can have the clearvision, but you might have poor
eye tracking or eye movement. Solet's talk about eye movements.
So there's different types ofeye movements. One is, can you
keep your eyes fixated? And alot of people say gaze stability
or fixations. But can you keepyour eyes just steady on a
target? And in reality, you cannever keep your eyes fixated on
(13:14):
target perfectly, like with nomovement, because always eye
movements. But even when youhave gaze stability, there's all
these little micro saccades,what we call them, all these
little different movements. Andyour eyes are constantly moving,
because if they don't, then youwon't your actually, eyes will
get like, your vision will getdark. So it has to constantly
(13:35):
move to refresh. They call itphotoreceptors in the back of
the eye, so that it's to refreshthose photoreceptors so they
don't like bleach out, or theydon't like over activate. So
that's fixation. So can you keepyour eyes steady on a target?
But people that have poor gazestability could have brain
dysfunction or issues with likethe cerebellum or other parts of
(13:56):
the brain that can cause theseissues with keeping your eyes
stable. So if you can't keepyour eyes stable, what happens
to the clarity of vision. Ifyour eyes are all over the
place, right, you're going tohave blurry vision. So sometimes
people will have the perfectprescription, they'll have the
perfect pair of glasses. But,like, my vision is kind of
(14:16):
blurry. It kind of fluctuatesright? So that could be a gaze
stability issue, and thatusually goes hand in hand with,
like, the vestibular system andso forth, where, if you have
poor communication between thosesystems, you might have poor eye
tracking or eye focusing, whichcan cause this fluctuation of
the clarity of vision, whichcauses blurry vision. That's the
(14:36):
eye tracking part. But the otherpart of eye tracking is not only
fixation, but there's two otherelements, one is saccades, and
one is pursuits. So we're notgoing to go over all the
neurology at that. It take toolong, but saccades are basically
like, can you jump from one spotto the next spot? So can you go
from this spot to that spotaccurately? So someone that has
(14:57):
poor saccades may look at thisfinger here, and then when you
look at that, figure they go wayout here. Yeah. Right? So they
can't fixate, and they can'tsaccade or move their eye from
one spot to the next. That'sanother type of eye movement.
And the third type of eyemovement is pursuits. Can you
actually track a moving targetsmoothly? But there's different
(15:18):
types of machines that canobviously test for this. You can
do gross testing just by using atarget, and that's ways of
actually testing to see if theeyes move or not. Again, you can
have clear vision but have poortracking. Another element of
vision is eye focusing. It'scalled accommodation. So eye
focusing, there's actually alens in your eye, so this is
(15:38):
your eyeball in the middle ofthe eye. There's this lens
that's like oval shaped, and itacts as a magnifier. So when
you're looking far away, thatlens is about this shape, and it
actually has a power to it. Butfor this example, we're going to
say that power is zero rightnow. So when you're looking far
away, the power is zero. Andthen when you go up close, when
(15:59):
you're looking at your hand orsomething close up, about arm's
length or closer, there's thesemuscles that automatically
contract. It's controlled by theparasympathetic system. Those
muscles contract, and the lenschanges shape. And when the lens
goes like this, it changes themagnification power. So, you
know, I have those magnifiersthat can magnify things up
(16:19):
close. That's what the lens inyour eye does, and that's what
eye focusing does. So thatchanges shape. So if you have
dysfunction in the neuro and theneural pathways or the muscle,
the lens can't do its job, andthat's why people will have like
when they look up close, oh,it's blurry. Now, as you age,
that lens in your eye actuallygets thicker and less flexible.
(16:40):
So although the neurology worksand the muscles work, when you
hit about 40 or so that lensesdoesn't do this anymore. It goes
like this, er, like little bylittle, right? So it can't
magnify anymore. You don't havethat magnification power as you
used to, and that's why you haveto put readers on. So you know,
those over the counter readerslike plus one plus two and so
(17:01):
forth, plus one, two. Those aremagnification powers, so those
leaders compensates for whatyour lens can't do anymore. But
when you're younger than 40,like earlier in your life, if
you have eye focusing problemsup near, it's not necessarily
the lens, it's the muscle or theneuropathy going to the muscle,
and that's something you canrehab. And in reality, like the
(17:22):
vestibular system and othersystems can actually cause
issues with that as well. That'seye focusing. The next thing is
eye teaming, or binocularity. Sothat's how your eyes team
together. So eye tracking, youreye movements, is like this, or
like that. Binocular vision isgoing like this, in and out. So
when you go out, that'sdivergence, when you go and
(17:42):
that's convergence, that's whatthat's what binocular vision is.
And there's all these differentlevels of it, but given the
time, I probably can go over allof them, but, um, there's
different tests to testbinocular vision, right? So one
bread and butter test everyoneshould be doing is the cover
test, where you cover one eye,you see what the eye does. Cover
(18:02):
the other eye, see what this eyedoes when it's looking at a
target. Then you do analternating cover test, where
you see what the eyes are doingwhen you alternate. So if
there's a lot of movement, theymight have like a strabismus or
an euphoria. And what that meansis that the eyes are aligned
together. So I guess we talkedabout screening. So going back
(18:22):
to the whole screening part, whydid things get missed? Right?
Some people might just do aquick cover. That's like, boom,
boom, boom, boom. Like twoseconds, and that's done where
you might have to actually holdit longer to see if there's
anything going on. There's waysof actually missing it if you go
too quickly, or if you justdon't do the test. But a lot of
(18:43):
times people brush to thembecause they're looking for
really, really bad stuff, andnot these, like, like, kind of
like, these more mild cases thatcould be like, causing issues
where people but they don'tlike, it's not like killing
them, if that makes sense. Sosomeone could have, like, a
little convergence insufficiencyand like me, and function
(19:03):
totally fine, where, if myvision was really bad, like my
convergence issue was really,really bad, I probably wouldn't
be to compensate for it, andthat's maybe why I got missed
for so many years.
Dr. Ayla Wolf (19:17):
One of the questions that I often ask my
patients when they say that theyhave blurry vision is, I ask
them, do you notice your blurryvision like most frequently when
you're changing your gaze fromsomething, say, far away to
something near or vice versa, asa way of trying to tease that
piece out of you know, is yourblurry vision there all the
time, or is it just that whenyou are shifting your focus from
(19:40):
a Near target to a far target,or vice versa, that that shift
in focus actually takes you acouple extra seconds to bring
that target in, and that helpsme to kind of clue into that
binocular vision piece of it.
Dr. Paul Brewer (19:53):
and that's that part could either be like a eye
teaming issue, or it could bethe eye focusing issue, right?
So we talked about going backto. Focusing? Do they have the
power to be able to focus upclose? Do they have the facility
to be able to focus far andnear, back and forth? So there's
all these different elements,and that's a good question to
ask, because then it kind ofteases out. Okay, what test
(20:14):
should I do? Should I do afacility test to see how well
they can focus far and near. Itest how well their eyes can
actually focus individually andso forth.
Dr. Ayla Wolf (20:25):
Yeah. And then you also, like we mentioned
earlier, when, when you'reassessing people, you're also
bringing in a kind of cervicaland a vestibular component. So
maybe talk a little bit abouthow you, you know, put more of
this functional twist on some ofthese classical exams.
Dr. Paul Brewer (20:44):
Oh, for sure.
Yeah. So this is good, a goodcase. I just, uh, bring it up. I
mean, I just like to just showthe videos, but I didn't get
permission for the patient toshare it. So, like, it'd be kind
of cool to see it. But like, sothis patient comes in, right?
And, like, full on, has, like,an, like, it's called an
intermittent extratropia. Solike, the eyes tend to go out,
like this, like that. And it wasa huge one. So I was doing the
(21:05):
cover that was, like, a lot oftimes you just see a little bit
her when I could do cover test,it was like, Don't, don't,
don't. Like, really bad, right?
And in her case, she had a,like, a really bad distributor
to dizziness, to get vertigo andso forth, right? And in her
case, like when I did someintegration stuff, which, time
(21:31):
wise, I'm not going to go overall those details, but like when
we integrated the vision of aserver system, basically what
happened is, when I did thecover test, again, it was almost
aligned as a little movement. Soin my opinion, in that case,
part of the eye alignment issue,not part of a big part of that
one was actually a visualspecific integration issue,
(21:52):
where sometimes, if we did theintegration and they still have
this huge angle, we know maybeit's more a visual pathway
issue. So that's kind of oneexample of, like, why it's
important to the other tests.
Like, I think every doctorshould be doing posturography.
They should do balance testing.
They should be, maybe even havea vng or do some kind of eye
(22:13):
tracking test. And then theyshould also test how, like, the
cervical positions actuallyaffect eye alignment, because if
you're turned this way andsuddenly your eyes aren't
aligned anymore, or they can'ttrack, or they can't focus, that
could be a cervicogenic issue.
It could be errors in theproprioception the neck that are
causing errors in the systemwhere the vision can't
(22:35):
compensate. But the reason why Ithink it's important is because
I look at like, vision,vestibular, proprioception as
like three maps, but they'reintertwined, like Google, Google
Maps. Like, you know, if you'redriving, you're following a
Google map on a road trip. Canyou imagine, like, if you're
following the Google Maps, andsuddenly the path is like the
like, the actual directions forthe path on the map. I think
(22:58):
this is the map, and thedirections suddenly go like this
now, and now you're seeing twodifferent maps, but the
direction is not on the samemap. That'd be a lot harder to
follow that map. Some people cancompensate and still deal with
it, but a lot of people willbreak down and probably get a
car accident, right? So the samething with the vision and other
sensory systems, if they're notcommunicating as a team, as a
(23:19):
family, and why we call ohana?
If they're not ohana, thenbasically there's going to be
more errors in the system, andthere's a point where if there's
too many errors in the system,the brain or the cerebellum
can't correct for those errors,which causes mismatches, which
causes or adaptive ormaladaptive behavior or
(23:42):
adaptations, or it causesinjury, or so forth, right? So
that's kind of what I look atnow. Is like, well, how does
each of these systems affecteach other? So before just
targeting each systemindividually, how can you
integrate the systems togetherinto one so they're working as a
team? And then from there, yousee how you can actually train
each one.
Dr. Ayla Wolf (24:03):
Yeah, I love that. I often talk about it like
a math equation. You've gotthese different sensory systems,
and they all need to be kind offeeding your brain the same
information, but in differentformats. But it needs like one
plus one plus one needs to equalthree, otherwise you've got this
mismatch. And then that drivesthe dizziness, the headaches,
the neck pain, all the things,
Dr. Paul Brewer (24:24):
but and another thing too, is if you have too
many errors, it's like if thevestibular system is pulling the
body one way the vision ispulling the body another way,
you get this push and pull allday long, right? So it's better
to have them work together thandoing this all day long, which
can make the brain really tiredand make you fatigued. So, like,
a good example is a cerebellum,right? So cerebellum does a lot
(24:47):
of cool things. Like, it does itdeals with like, like, movement
error correction, motorcoordination. It does with
planning and thinking. It doeswith immune modulation. It deals
with emotions. Yeah, so thoseare things that the cerebellum
deals with. So think about likethis control center in the back
of the brain, this little smallbrain that's helping all these
(25:09):
sensory systems integrate, in asense, right? If you have too
many errors that little smallbrains, like, I can't do this
anymore. So what happens yourbrain sits down and you're like,
I hate this. I get dizziness.
You have walking issues. Itaffects so many parts of the
body. But in fact, anotherpatient I just had recently,
like, we worked on all thisstuff, and I remember, agree
(25:29):
this finished therapy, and she'stelling me, she's like, man, you
know, I got really kind of,like, I had all these emotional
fluctuations during therapy whenI was doing all these exercises
you're assigning me. And I'mlike, and I told her why, and
she's like, Oh, that makes totalsense. But the cool thing she
said is that, like, I feel moreemotional, sound now than I did
before. Awesome. Yeah, so, andI'm not, I'm not, I'm not a
(25:55):
therapist, I'm not a, you know,a psychologist or anything like
that. But I think when youintegrate systems, people can
adapt better and compensatebetter and be able to control
their emotions and so forth.
Yeah,
Dr. Ayla Wolf (26:10):
you're taking all the errors away and just letting
the brain able, like it's able,to then do its job. One of the
questions I wanted to ask you isabout the cervical ocular
reflex. Can you talk a littlebit about that?
Dr. Paul Brewer (26:24):
It goes back to those three maps again, right?
You know, cervicalproprioception, or somatic you
get somatosensory input rightfrom the proprioception, vision
and vestibular and and, myopinion, I think vestibular is
foundational in stabilizing theproprioceptive pathway and the
visual pathway. So when you lookat these reflexes, it's really
(26:46):
like kind of an integration,like even the VOR reflex, the
vestibular ocular reflex. Allthose three systems are
communicating together to helpeach other out, but to also
stabilize each other. So in somecases, it could be an eye issues
causing neck issues. Other casescould be neck issues causing eye
(27:06):
issues. So there's times where Iwe firm because they may have a
subluxated joint, and I have tosend them to this person to work
on that, but they might havethese underlying vestibular
issues. And a lot of cases, too,when you talk about neck
adjustments or manual therapy onthe in the cervical region,
sometimes you might have to dosome vestibular integration to
(27:29):
stabilize the vision and thevestibular before they do that
actual manipulation or manualtherapy, or even Acupuncture, or
whatever you want to do, right?
Because sometimes, if you don'thave that sound stability
between the systems. It doesn'tmatter what you do. It's kind of
like when you get a massage, andthen, like, literally an hour
later, like, why am I soreagain? You know? I mean, like,
you feel all good, and thensuddenly everything gets all
(27:50):
tight again. It's really comesdown to is, we call it in
Polynesia, no fefe. No fefemeans no fear. So we want to get
people to the point where theyhave no fear. And what does that
mean? If they're fearful,they're going to be in this
fight and fight kind ofsituation, or they're going to
be in a survival mode. And ifthey're in a survival mode,
they're going to always belocked up. They're gonna have
(28:12):
that constant startle reflex,really, like this, you know,
like kind of like that, wherethey have everything contracted
and road forward to protect alltheir vital organs and so forth.
So if you're in this constantfear mode, then you're going to
have neck issues. The neckissues are going to cause visual
issues. But a roundabout way oftalking about this reflex we're
looking at reallyfoundationally. Can you are they
(28:34):
in the survival mode or in theperformance mode? And we want
people to be in the performancemode, and there's going to be
this ebb and flow betweeneverything, but obviously we
want people to be more on thatperformance side, so that
they're not that's when they'regoing to have issues with the
neck, issues with the eyes,issues with the vestibular so
first thing, obviously, goingback to the full foundation
level, we have to look at theautonomic system, because if
(28:57):
they have This autonomy and soforth. It's hard to have a
stable communication between thevision, the vestibular and so
forth. Now, at the same time,those systems will affect the
automaticity of the body aswell, because if you have
underlying visual vestibularintegration issue that can
cause, you know, autonomicdysfunction, and cause immune
(29:17):
issues and cause gut issues andcause like even like emotional
issues, like we said before. Soin reality, like we're when
we're looking at these systemsand tests, we have to see how,
like, the neck and the movementof the neck and the body will
affect your visual pathway toeye movements. So sometimes the
(29:40):
person that maybe be turned thisway might have way better eye
movements versus lookingstraight ahead. So we know that
there's something going on withthat cervical region or the body
that could be affecting thevisual pathway, and they all run
through the same thing. I mean,the same like cerebellum
controls the air correction.
Than all of them. The frontallobes control the, you know,
(30:02):
contralateral movements. So likein reality, you got the same
parts of the brain that areaffecting the kind of different
pathways. So they all work as ateam. And going back to the
reflex, right? If you if youhave poor reflex or poor
communication, you're going tohave errors in one of the
systems. Yeah.
Dr. Ayla Wolf (30:22):
And then I think you brought up that important
point, that when you have lotsof errors in these different
systems, it can actually tax theautonomic nervous system and
drive some of these dysautonomiatype symptoms as well. Talk a
little bit about lightsensitivity. You know, when we
were talking earlier, I reallyliked what you said about light
sensitivity, the term itselfalmost being as vague as when
(30:46):
people say, I have pain, in thesense that it can mean a lot of
different things to differentpeople. So talk a little bit
about when someone says, I havelight sensitivity, what other
questions you ask, or what it isthat you're thinking in terms
of, like a differentialdiagnosis.
Dr. Paul Brewer (31:00):
That's a good question. So, yeah, light
sensitivity can mean so manythings. It's photosensitivity is
the name for photophobia. Sothere's all these different
terms for I don't like light youknow, for me, when I'm when I
hear someone come in, I'm like,Oh my gosh, that means
absolutely in my head. I'm like,thinking, okay, that means
absolutely nothing. Let's justdo the test right, because it
(31:24):
could be so many differentthings. So dry eyes can cause
license sensitivity, because ifyou have a poor tear film, so
you got your eyeball, eyeball,tear foam on eyeball. If this
tear film is unstable, it causesexposure to the front of the eye
to air, and when there'sexposure, there's a trigeminal
nerve. It's like the sensorynerve, it gets stimulated,
(31:45):
pretty crazy. And when it getsstimulated, you feel that
burning sensation or achiness orwhatever. And then the brain's
like, oh, I don't like that.
Throws the fire engine on,lacquer around, produces all
this tears, and suddenly get allthis wateriness, right? So a lot
of people are like, Oh, my eyesaren't dry. They're watery, but
watery eyes are typically prettyhallmark for either allergies or
(32:06):
dryness. So like, that's onething that can cause the
licensivity, because when youhave all this over stimulation,
it's hard to focus. It could bea gaze stability issue, like we
mentioned before, if you havepoor gaze stability that can
cause light sensitivity. Itcould be a poor people or
effect. So the people is thatblack circle that's the people,
(32:27):
and the muscles around the iriscan either contract or die, like
it big when it contracts, that'sa parasympathetic response, or
rest and digest, but not reallyrest and digest, but and then
when it gets dilated. It can beit's a sympathetic response. So
when you're outside,automatically, your eyes
constrict, kind of like anaperture in a camera to let less
(32:48):
light in, because if it'sbright, it gets smaller, so
there's less light coming in.
But if you have poorautomaticity in this, and it
goes like more like this,slowly. Or sometimes they have
what's kind of poor sustainedpeople are with contraction. So
they go like this, and thensuddenly goes like that. It
can't sustain. So you have this,like, evident flow of light
(33:12):
coming in and out, so the braincan't process that, which can be
light sensitivity as well.
There's all these differentthings. Those are, like, one of
many things that could be thatcan cause these issues with
light sometimes even, like, oh,go ahead, yeah.
Dr. Ayla Wolf (33:27):
Sensitivity to flicker as well, which you have
basically a test where you canmeasure if somebody's extra
sensitive to the flickering oflights Correct.
Dr. Paul Brewer (33:36):
Yeah. So I guess going back to the light
sensitivity too, like, it couldbe an eye teaming thing. So
people have, like, a it's got anintermittent extratropia. So
sometimes their eyes go out.
Sometimes it doesn't that.
Sometimes the symptoms for thatis light sensitivity too. So
they're closed when I whenthey're outside, and they're
more sensitive light so there'sall these things that can cause
it. So basically, I guess whatwe're looking at is, like, it's
not, like, okay, they have lightsensitivity that creates a great
(33:57):
symptom, right? What's actuallycausing it. So, like, that's the
same thing with red eye. Like,oh, you have red eye. It could
be allergy, it could bebacteria, it could be viral, it
could be so many differentthings. It could be an autonomic
dysfunction. It could beinflammatory. So there's all
these different things thatcould be so when someone comes
in with lights and severe redeye, I'm like, okay, great.
(34:18):
Let's just do the test and seewhat's going on with the body,
right? The same thing with theflicker rate. Like people that
have concussions, they mighthave poor processing of like
flicker rate. So like, when wesay flicker rate, that's like
hertz. So when you look at likea fluorescent light, now I
might, I'm pulling numbers onthe area now, so I can't
remember the numbers. I alwayshave to look them up. But like a
fluorescent light might be like,I don't know, 60 Hertz or
(34:41):
whatever, but if your braincan't process those hurts, or if
it's kind of dysfunctional,fluorescent lights, might, the
flicker rate of a fluorescentlight or a TV might bother them.
So that's a whole brain thing aswell. So things like that can
actually affect you. So iflights bother you, you. It could
be a flicker frequency, likeprocessing issue, it could be a
(35:05):
dryness issue, and so forth.
Dr. Ayla Wolf (35:08):
Got it, and then you have this very cool tool
where it flickers at differentfrequencies. And then you have
your patient look at it andbasically tell you when they see
the flicker start, and then whenthey see it go away, and that
tells you kind of if their rangeof perception of that flicker is
kind of within a normal range,correct, correct,
Dr. Paul Brewer (35:31):
yeah, because concussions can actually affect
that. And so, like the test,what it does is, like it
flickers, where you actually seea flicker, right? So sometimes,
when you have a fluorescentbulb, or whatever, you'll see
that kind of flickering of thelight. So it's flickering at a
lower Hertz. The faster it goes,the harder it is to eventually
see. So eventually, when it's awritten number, where it's
(35:52):
flickering so fast, and evenwhen you see light that it's not
flickering, it's stillflickering. It's just flickering
at such a high speed that yourbrain and eyes can't see
anymore. And sometimes peoplehave, like, a higher issue, or
they see like, they have such ahigher, like flicker rate, where
they're seeing pretty mucheverything. So all these little
(36:13):
nuances of the light can botherthem. It's like over stimulating
them. That goes back to wholeerror correction, like there's
already so much your brain canhandle and so much your breaking
filter. I guess, going back tothe whole concussion thing, this
podcast is about like a lot oftimes concussions affects the
brain's ability to correct errorand filter information. So when
(36:35):
it can't filter information, itcan't correct errors anymore, or
at a reduced rate. That's whereyou have all those symptoms,
like licensivity, dizziness andso forth. That's what it comes
down to, is like being able to,like, filter we can't. People
that have brain issues, theycan't filter out information. So
now, like, instead of seeinglike parts of things, now, like,
(36:56):
everything's coming into theirbrain, their brains like, oh my
gosh, what's going on? In fact,I, in my opinion, your vision
itself like there's so muchinformation just looking around
you, like I'm looking at this,there's all this stuff around
me, like I'm right in front ofthis huge window where I'm
looking outside too. If my braincouldn't filter all this out,
all this information will becoming in. I'll just go system
(37:17):
overload. So the brain is reallygood at filtering out certain
information coming in where it'sgood at picking out the most
important things. That's calleda perceptual like a perception
span. So perception span is theability for the brain to like
taking critical information andapply it. People that can't do
that either can't see anything,or they see too little, or they
(37:40):
see too much, and then thatcreates this filtering issue,
kind of a funnel effect, whichcan cause more errors and cause
symptoms and so forth.
Dr. Ayla Wolf (37:50):
And I would imagine a lot of the visual
motion sensitivity that peopleexperience, part of it is their
brain failing to kind of filterout the unnecessary information,
and therefore their brain isjust bombarded with every single
thing that's moving in theenvironment.
Dr. Paul Brewer (38:07):
Yep, that's that's, like, that's part of the
equation filtering and errorcorrection, right? So, like,
there's too much informationcoming in, brain can't filter
it. There's too much errors,brain can't correct for it.
Thus, the motion sensitivity,
Dr. Ayla Wolf (38:20):
And when you're incorporating a lot of the
visual and vestibular andproprioceptive information by
kind of cleaning up a lot ofthose errors, then, as a outcome
of that, I imagine you're seeingthat the visual motion
sensitivity is also improving
Dr. Paul Brewer (38:38):
Correct Yep. So if we can give the brain
specific activity. So, you know,through testing, we like, okay,
these are the pathways that areefficient. These are the
exercises that work for thispatient, and by activating that
part of the brain it we're notlike fixing them, and we never
fix anyone. But when we givetheir brain activity, their
(39:00):
brain can interpret informationin a different way. So we're
helping the brain be able tointerpret the incoming
information in a different way,be able to filter in a different
way, and be able to correcterror in a different way. Is
ultimately what it comes downfoundationally. In fact, a good
example of to explain thispathway, it's called the odor
(39:21):
loop. So the odor loop wasactually developed by a guy in
the Air Force way back when, andimplicitly, it's an input
processing output, butultimately his the odor loop is
input, or like observation. Solike all the incoming sensory
information from vestibular tovision and so forth. Then you
(39:44):
have and then you haveorientation mechanism in the
brain. So the orientationsegment is based off, like from
the info coming in. You're goingto process and package it in a
certain way, based off yourgenetics, based off previous
experience, trauma. Based off,even religion, cultural views,
because all that modes howyou're going to bias yourself to
(40:05):
the incoming information. Andthat's the orientation. Then it
goes to a decision makingprocess. And that decision
making process is like, do youdecide what to do? Like, am I
going to if the ball is flyingat my face, am I going to let it
hit my face? Am I going to moveout of the way? Am I going to
catch it? That's the decision.
And then the motor response, theaction. So observation,
orientation, decision action,Oda loop action is basically
(40:29):
what you're going to do, likethe actual motor movement
itself. Then there's obviouslythese feedback loops that go
back and forth, that go in acycle. I I kind of coined this
term called Vision decisionaction, and because I said,
firstly, you made all thesensory as vision. So vision
decision is that orientationdecision together in action. So
that's kind of what I explain topeople when we're actually
(40:51):
explaining this loop. So whenyou're in a car, you have all
this input coming in. Can wechange the orientation and
decision making processes to beable to again, correct error, be
able to filter out informationand be able to make better
decisions
Dr. Ayla Wolf (41:09):
and do it in an appropriate timeframe as well,
I'm sure, because obviously,visual processing and reaction
time are key components of allof that. I know that there's
some interesting research andtalking about when, when people
have concussions, they may notnecessarily have like, a full on
peripheral visual loss in acertain visual field, but the
(41:32):
way that their brain isprocessing peripheral vision can
change. Can you talk a littlebit about that?
Dr. Paul Brewer (41:38):
That's a That's a good question. So, like,
there's a difference betweenactual loss nerve damage, right?
Like something's broken and hasa stroke and there's black
stroke, yeah, and even those, itmight be like a temporary loss.
So the question is, is it acompletely permanent loss? It
doesn't matter what you do, it'sgoing to always be dark at that
(41:58):
spot, right? So a good exampleof like glaucoma. Glaucoma
affects your peripheral vision.
It affects your peripheralvision, and so when you have
really severe glaucoma, this isall you see. Eventually, if you
don't get it treated, or youdon't slow down the process,
that's like permanent loss. Likeit pretty much doesn't matter
what you do, you're not going toget the full extent anymore,
where in concussions, you mighthave either a temporary loss or
(42:22):
a constriction. So, like I kindof differentiate permanent and
constriction. So when you have aconstricted visual field or
partially, it's not like youhave a black spot here. You
still have all this stuff here,but your brain can't process it
as well as it used to. So whenyou have poor peripheral
(42:43):
processing, it actually affectsyour central processing. So they
work out in the hand. There'sthese two different loops that
kind of work separately, butthey stabilize each other. So
when you have poor peripheralprocessing, that leads to gaze
stability issues, it leads toeye tracking issues, it leads to
visual sensitivity and so forth.
(43:08):
So constriction is a differentthing, where you don't have
permanent loss, where you canactually rehab that pretty well
and easily.
Dr. Ayla Wolf (43:15):
And are you rehabbing that by giving people
different exercises?
Dr. Paul Brewer (43:21):
In that case, it kind of depends. I mean,
sometimes, sometimes they mightneed a vestibular integration,
like, like, do visual vestibularintegration exercises I see a
lot of times where you do that,where you're integrating the two
systems together, and it opensup to periphery, because now
they have better processing.
Sometimes you might have to dolike, stuff like, where you're
doing a peripheral centralintegration with like, it's
(43:42):
called like vectograms orstereopsis, or like depth
perception type S, or exercises.
So like, you have thesepolarized glasses on, you see
this 3d image. And by working onthe eye teaming together with
peripheral processing that helpsopen up the periphery. So
(44:05):
really, it's not like you'redoing something to make it open
up. You're just giving the brainan activity to be interpret the
incoming informationdifferently. So one example
someone can do is like they canactually look straight ahead,
and instead of like, looking upat the lines of the corners of
the room, so like, say thatpicture behind me right pretend
(44:26):
like that's the actual wall theback of the room. Instead of me
looking up at each part of it.
I'm using my I'm lookingstraight at I'm using my
peripheral and I'm using myperipheral vision to follow the
edge of that painting. I'm notmoving my eyes at all. I'm just
using my peripheral vision.
Okay? I see the, I see the topcorner. It's like, kind of
(44:47):
bluish. I see the, you know, thetop right corner over here, it's
red. And so forth. By using yourperipheral vision, so there's
activities you can do to kind ofopen up the periphery. That's
just one of many. Yeah,
Dr. Ayla Wolf (44:58):
yeah, yeah. And.
That sparked another comment, Ithink, that you had made in one
of the courses that I had thehonor of taking with you, where
you were saying, like, whenpeople have that kind of
peripheral visual dysfunction,if they're doing, like,
potentially the wrong exercise,or where they're doing a lot of
exercises focusing onconvergence, where you're
(45:20):
training them to actually justfocus on one target that's
really up close. You canactually be kind of like
training the problem, so tospeak, if part of their actual
problem is that they're nottheir brain is ignoring all of
this peripheral information. Andso I think that really teases
out the fact that this type ofvision therapy is incredibly
(45:41):
complex, because everybody'sissues are very different, and
people need very different type,you know, types of exercises.
There's not like, hey, let'sjust run everybody through all
these different exercises. Yeah,
Dr. Paul Brewer (45:56):
that's actually a good point you brought up. So,
like, vision therapy, right?
Like, you go online, you'relike, oh, I have an it should go
online. The first thing you'reprobably going to see is pencil
push ups and bead string orBrock string, right? So a lot of
these docs would like, likethat, just random sign, oh, just
do pencil push ups, just doBrock string, and you'd be fine,
right? And reality, if you havea divergence issue, so they
(46:19):
diverging your eyes out. But youhave good convergence you could
it can have the same symptom asa convergence insufficiency,
where you have issues focusingup close and so forth. So
someone's like, oh, yeah, justdo all this convergence stuff
over and over again. So you'remaking that convergence issue
even stronger, but you're makingthat divergence worse, which can
make the problem even worse. Sothat's the thing. A lot of
(46:41):
people just say, Oh, just douchepencil push ups, broad screens,
like it could be so manydifferent things. So in some
cases it might actually help thesituation, but in a lot of
cases, it may not. That's thebiggest thing is that people go
online they like and there's alot of good information online.
Don't get me wrong, because Iuse online for a lot of stuff
too, but it's about finding outwhere the deficiencies are
(47:02):
first, because certainactivities can make it worse by
going too focal or too centraltoo quickly, where you have to
be opening up the periphery tostabilize the central area.
Another example is even like,like, I get us a lot too.
There's a lot of greatfunctional guys out there,
physical therapists andchiropractors and and so forth,
you know, everyone. So I'll geta patient where, literally, you
(47:22):
know, they've they do vestibulartherapy. They call, I went to a
vestibular therapist, and theirextended visitor therapy is
either walking on a balance beamor getting spin in a chair or
doing a bunch of like, crackingstuff like this, right? And in
reality, those are great things,but that's not what they needed.
(47:43):
They needed a specific path tobe activating their vestibular
visual system, to get them thebrain processing things
differently, versus randomlyjust throwing them all over the
place. I see that time and timeagain with that kind of stuff as
well.
Dr. Ayla Wolf (47:59):
Yeah. I mean, it really all comes down to having
the right type of exam and theright person to be able to
diagnose what that particularindividual is struggling with,
to then be able to find theright types of exercises.
Dr. Paul Brewer (48:14):
Yeah, for sure.
I mean, that's, that's the thingtoo. Like, and I'm still
learning a ton, right? I'm like,I don't think I'll ever be a
master of stuff, but, like, I'mconstantly learning, so all the
times I'll call I'll call it myfunctional neurologist, friends,
you know, colleagues and like,Okay, I have this case. This is
what I'm doing. What am I doing?
Wrong, right? And they'll giveme such good information that's
super awesome. Like, I havepeople in every single field,
(48:37):
like MDs, chiropractors,physical therapists were like, I
might have a case that I needhelp on, and I'm usually calling
out a state, because therepeople in other states I call
I'm like, and I'll share mycase, and sometimes they'll call
me up and share their case too,as well. So we have this good
collaborative team where, wherewe're all really good at we're
(48:57):
doing, but at the same time,we're all learning still. And I
think that's the key. Is that wehave to always learn. If you get
to the point where you think youknow everything, then that's
where you're going to startfailing. I think that's why I
can go the same lecture over andover again, and I learned
something new. In fact, a lot ofthese ones again with the
characters doing so if that, youknow, like you listen to these
videos over and over again,every time I listen to it again,
(49:17):
I'm learning something new.
Because the first five times Ididn't catch something that I
caught the fifth time. You knowexactly,
Dr. Ayla Wolf (49:24):
exactly. And there's so much about the brain
that we're still figuring out.
So it's impossible for anybodyto say that they've got it all,
that they've got it all figured
Dr. Paul Brewer (49:33):
Well for sure.
Yeah, it's hard. I mean, it'sout.
like every person's a newpuzzle. It's like putting a
puzzle together every singletime, but it's a different
picture.
Dr. Ayla Wolf (49:43):
Yeah, I mean, I learn new things from my
patients every single day,because every single person
walks in with their own kind ofunique, unique set of issues
that you've got to then figureout. So in terms of kind of
wrapping up, is there advicethat you could give somebody
who's. Out in the world who'smaybe had an initial eye exam
(50:03):
told their vision was normal,they're still struggling with
visual symptoms. What would yousay to that that individual,
Dr. Paul Brewer (50:10):
that's a good question, like, probably, like,
go find either a functionaloptometrist, like a neuro
optometrist, or a functionalneurologist, or something that
maybe you can do more testing,and it's not like anything that
the doctor is doing wrong. Imean, like, it's kind of like,
this is a good example. I go tomy primary care right, like, and
it's like, they couldn't do somuch, and sometimes you just got
(50:33):
to find a specialist that candiagnose your issue. Like, I had
a good example. Like, I surfedmy whole life, literally, and in
my ears, I have what's calledexternal auditory exit ptosis,
which is like this, bone growthinside the canal. It's not it's
on the outside of the eardrum.
But when you're in the ocean, alot the it basically closes off
the bone growth and closes offthe canal. So it's super small.
(50:54):
My right ear was, like,literally, 97% occluded, right?
So I go to my primary care andthen like, Oh yeah, you have an
ear infection. Give me yourdrops. Like, you know, it feels
like it's getting better, butnot really. I'm like, what's
going on? Like, I like, I wentto Hawaii. I was visiting
Hawaii, and I used to dive allthe time. I dove, like,
literally, three feet in theocean. I'm like, Oh my gosh,
(51:14):
this hurt. This is weird. And Iwent back to my primary care.
When I got back, they're like,Oh yeah, everything's fine.
You're good. I'm like, and Ihave, like, I have a otoscope,
you know, but you can't otoscopeyour own ear. And I follow
online to have these videolines. And this is bad, like,
saying this, like, as a fresher,got found, but, like, I get this
video otoscope, I just look in,I'm like, Oh my gosh, my
(51:35):
freaking ears, like, like, 95%occluded, you know, this is
crazy. And then so I sent anappointment with the ENT, which
is a specialist now, right? AndI go into the anti office, and
I'm like, you know, the MA isgetting my history. And I'm
like, oh, yeah, I think I have a95% external auditory exitosis.
And I can see that Ma's face,like, you just Google that,
like, in her head, you know, yousee, like her face, like she's
(51:58):
like, You're so stupid. I'mlike, okay, whatever. I just see
her face, like, that disgust,and I kind of, like, tone it
down a little bit. I'm justlike, whatever. And then the
doctor comes in. He's like, Ohmy gosh, you're totally right.
Like, yeah, it's totallyclueless how to get surgery on
it, because that's only way toget rid of it. But that's a good
that's a good example, right?
Like, it's not, I don't blame, Idon't blame my primary care, I
(52:21):
don't blame and I don't blameanyone. It is what it is, you
know, like, there's only so muchpeople can do as doctors, I
think as patients, we have to bemore forgiving, because we
expect the doctor to know everylittle thing. And in reality, if
you're not specialized insomething, you're not going to
know it. So my advice is, bemore forgiving to your doctor,
and maybe ask them, like, hey,is there someone you can refer
(52:43):
me to? So a lot of times, thosedoctors will know the
specialists in town. Or you can,like, go online and look at the
different sites, like, you know,the Carrick side, or Nora or
whatever. Like, there's aoptometric rehab site that you
can look up doctors in yourstate. But at the same time,
just because you're trained inany situation in any
institution, doesn't mean thatthey're a good doctor either,
(53:04):
right? So you can have all thefellowships and all the things
in the world, but does it makeyou a good doctor still? So
that's one caveat, that when youdo look up these people, it may
not be the situation for you, ormaybe it might might be the
right fit for you from thedoctor. So that's, I guess, my
biggest advice I give people,for the patient side and for the
doctor side, you know, I justsay, continue learning. Like,
(53:26):
literally, like, don't stoplearning. Because if you stop
learning, then you don't there'salways going to be changes in
research and changes in how wetreat people. And if you're
doing things 20 years back, itmay not be as effective today.
Dr. Ayla Wolf (53:39):
Yeah, yeah, wise words. Well, let me ask you one
question. Where can people findyou?
Dr. Paul Brewer (53:46):
Diverge performance is the my instagram
handle the website's divergedperformance.com as well.
Dr. Ayla Wolf (53:54):
Okay, perfect.
Well, I could put that in theshow notes, and then your
practice is in Boise, Idaho.
Dr. Paul Brewer (54:00):
Boise, yep, uh huh.
Dr. Ayla Wolf (54:01):
Okay. Super Excellent. Yeah. Thank you so
much. Thank you for coming onthe show and for giving us a lot
of insights into what isincredibly complex. And I hope
to have you back on where I canpick your brain some more on
other specific topics that wedidn't get to today. So thank
you so much.
Dr. Paul Brewer (54:21):
Yeah, thank you.
Dr. Ayla Wolf (54:25):
Medical disclaimer, this video or
podcast is for generalinformational purposes only and
does not constitute the practiceof medicine or other
professional health careservices, including the giving
of medical advice. No doctorpatient relationship is formed.
The use of this information andmaterials included is at the
(54:45):
user's own risk. The content ofthis video or podcast is not
intended to be a substitute formedical advice diagnosis or
treatment, and consumers of thisinformation should seek the
advice of a medical professionalfor any and all health. Related
issues, a link to our fullmedical disclaimer is available
in the notes you.
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