February 24, 2025 • 32 mins
This episode emphasizes the intricate relationship between neck injuries and concussion recovery, exploring how sensory integration affects patient outcomes. Listeners learn about the importance of tailored therapies, effective communication among care providers, and the necessity of understanding each patient's unique presentation for optimal recovery.
• Understanding the role of functional neurology in treatment
• Importance of sensory integration and balance in recovery
• Where do neck strengthening exercises fit in
• Forward head posture and its implications for patients
• Exploring functional tests for assessment of symptoms
• Dangers of poor communication amongst therapists
• Case study illustrating the connection between cervical dysfunction and dysautonomia
• The significance of tailored therapy approaches
• Insight into the challenges faced in workers’ compensation cases
• Preview of topics for future episodes, including cervical instability and dysautonomia
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Ayla Wolf (00:00):
Honestly, I mean this is where I think functional
neurology excels, because thefunctional neurology perspective
and t t t ishat t i i t c haveathat and be able to understand
the connection between thevestibular system and the ocular
(00:29):
motor system and eyemisalignments and ocular motor,
eye movement disorders, and thenpairing that with the neck
trauma and then pairing all ofthat with the potential
dysautonomia.
Sophia Bouwens (00:43):
Welcome to the Life After Impact podcast, where
we do a deep dive into allthings concussion and brain
injury related.
We talk about all the differentsymptoms that can follow a
brain injury, different testingmethods, different types of
specialists out there anddifferent therapies available.
I'm Sophia Bowens, I'm herewith Dr Ayla Wolf and we will be
(01:05):
your guide to living your bestlife after impact.
Ayla Wolf (01:14):
This episode is a continuation of episode six,
where we continue ourconversation about traumatic
neck injuries and the importanceof approaching them from a
sensory integration perspective.
If you haven't yet listened toEpisode 6, we recommend you go
back and do that first beforecontinuing to Episode 7.
Thanks again for listening toLife After Impact, the
(01:37):
Concussion Recovery Podcast.
We talked about a couple ofthese functional tests where
we're looking at, say, apinwheel testing on the face and
how that can change whether thejaw is open or closed or the
head is turned left or right.
There's also, you know, whenyou're looking at somebody's
balance, if you have somebodystanding on a foam pad, for
(01:58):
example, so you're taking awaytheir ankle proprioception and
you're asking them to rely moreheavily on their vestibular
system.
What we can find, too, is thatas soon as you change somebody's
head position, their balancecan break down, and so most
people, if their head is neutral, or if their head is looking
down, they're going to be morestable, but then a lot of times
(02:21):
what you find is that whensomeone tilts their head
backwards, then they're not asstable.
And so you have to also teaseout the difference between is
this a vestibular issue or isthis a cervical issue or, you
know again, often it's often asensory integration between
those two, which is why thesolution is a combination of
head movements and neckmovements and eye movements and
(02:47):
trying to kind of activate thevestibular system with the head
in different positions and doingdifferent eye exercises.
You've got to, you know, craft atherapy for each individual
person that helps them to feelmore stable in the head
positions where they're unstable.
And I think that sometimes thatalso gets missed, where, if
(03:09):
somebody can pass a basicbalance test, they might think,
oh well, I was, my balance wastested and they said it was fine
.
But then what you realize iswell, as soon as your head is
tilted back into the right,you're falling over.
And so that's, you know, that'swhere we need to start with.
Our therapy, too is actuallycorrecting this imbalance
(03:29):
between when you are activatingyour right posterior
semicircular canal of yourvestibular system and your head
is back into the right, you'refalling over.
So what do we need to do tokind of get this back into
balance too, so that you feelstable in any head position?
And that can be, you know again, a combination of what's going
(03:50):
on with the neck as well aswhat's going on with the
vestibular system.
Sophia Bouwens (03:54):
It's interesting , I think, about neck
strengthening, how that can beso helpful.
We talked in the beginning justhow that is even a preventative
measure for concussion itselfIn recovery.
Do you find that strengtheningthe neck is helpful?
Ayla Wolf (04:08):
I do, and there's some kind of like specific neck
strengthening clinic, like theyhave all these different
machines and this whole program,and so I have actually had
patients that have been referredto go do that and sure enough,
a lot of their symptoms improvewhen they actually strengthen
their neck.
Sophia Bouwens (04:24):
The TRIA neck and back program, I think, is
one of them.
It used to be called physiciansneck and back but now it's a
TRIA program where they just doneck stuff and that's they have
really great machines thatstabilize your neck and prevent
you from using your largermuscle groups, so that you're
actually strengthening thespinal muscles, because
oftentimes when those are weakor there's imbalances, we'll use
(04:47):
larger muscle groups to takeover these actions, that really
these smaller muscles which aremore intricately tied into the
vestibular system or theautonomic system, the visual
system, to get those tostrengthen so they're not being
overridden by those largermuscle groups that don't have
the same integration and withoutthat, key integration.
Ayla Wolf (05:11):
As you mentioned before, we can have a lot of
symptoms coming up for people,yeah, and I think that's where
either clinics like that orphysical therapists that have a
whole arsenal of excellent neckstrengthening exercises that
they can guide people through.
I think all of that is soimportant they can guide people
through.
I think all of that is soimportant.
And you know even, I think whathappens a lot is in today's
society.
People are often on theirphones or their computers and so
(05:32):
they have this forward headposture where they're kind of
jutting their whole headforwards.
I catch myself doing that allthe time.
Sophia Bouwens (05:40):
Me too, and my kids.
I'm like get up, stop doingthat.
And they're like mom, stop it.
Ayla Wolf (05:50):
Yeah, and I think that sets a lot of people up too
for a lot of neck issues, andso that posture piece of it is
also very important.
And then we have also in ourclinic these glasses that we
have people wear that have alaser in the front, and so this
little setup allows us to assessfor what's called a joint
position sense error, where wecan have someone close their
eyes and we turn their head sothe laser is no longer pointing
(06:14):
at the center target, it'slasers off to the side, and they
have to try to line that laserback up on the center target
with their eyes closed, justusing their neck receptors.
Exactly.
And so by assessing the levelof joint position error in all
the different planes of movementyou know up, down, side to side
(06:35):
and diagonals we can start topinpoint, you know which
movements, which positions seemto be the most difficult and
then also use that as atherapeutic kind of biofeedback
tool.
And then what I've also foundis that if somebody's joint
position sense has a lot oferrors in it by doing
acupuncture points on the neck,I often find that after a
(06:57):
treatment there's an immediateimprovement in their joint
position sense.
Testing just based on like evenone acupuncture treatment of
needles along the spine, Becauseit is a sensory stimulus.
Exactly.
Sophia Bouwens (07:09):
Helps can upregulate that.
So for patients struggling withsome post-traumatic neck injury
or concussion-like symptomsafter a head injury, teasing out
the different components thatcan be driving that as far as
visual or neck position, headposition, vestibular, can also
help you really understand whereto start with therapies and how
to progress them.
Ayla Wolf (07:30):
Yeah, and I think that that's where working with
somebody who has a really deepunderstanding of the sensory
integration between all thesesystems and can start to do a
lot of these tests to saywhere's the breakdown happening
and then what kinds of therapiesdo we need to do so that we can
clean up the sensoryintegration that's so important.
(07:51):
Somebody I was talking to who isa personal or, sorry, a
physical therapist at a largerhospital setting and she told me
that there's a division betweenoccupational therapy and
physical therapy where they weresaying, oh no, occupational
therapy is allowed to work withthese types of eye movements,
with their brain injury patients, and then the physical
(08:13):
therapists are only supposed towork with these types of eye
movements with their patients.
And there was kind of this liketurf war happening between the
different departments about whogot to do certain eye movement
rehab and it's like that's nothelpful for the patient when
you're trying to tease out like,like this is all about
integration, right, notseparation, right, and so when
(08:35):
you've got, you know, one siloover here saying we're
responsible for saccade eyemovements and gaze stability and
those people over there areonly supposed to do vestibular
ocular reflex exercises, it'slike this is where the system
kind of falls apart.
And I also think that sometimesthere's a hierarchy to what
needs to be done in the firstplace.
(08:55):
And if you've got somebody thathas a lot of issues with gaze
stability, if you try toimmediately throw them into some
really high level balanceexercises or vestibular ocular
reflex exercises where they'returning their head really fast
but they don't even have gazestability working for them, I
(09:16):
think that that's where peopleget really symptomatic they get
dizzy, they get nauseous, theyget headaches, they don't feel
good, they don't feel likethey're getting better, and so a
lot of people just end upquitting.
They just end up dropping outof a therapy because it makes
them symptomatic.
And that's also where, whenyou've got too many siloed
people who aren't communicatingwith each other, trying to do
different parts of the rehab andnot maybe in the right order,
(09:41):
that can be a problem for thepatient.
Kind of a mess right, that canbe a mess.
Sophia Bouwens (09:45):
So for therapists too, who are out
there trying to help theirpatients and they see only one
level of things, or testing inone area or one plane is fine,
but their symptoms aren'tgetting better, even though
their tests seem to be fine,maybe they could think about
head position or jaw position assomething that might feed into
that, or eye movement componentstoo.
I think that's an importantpiece.
(10:06):
There's so much as therapistswe're trying to manage or trying
to figure out or decipher, andeach patient we see is a
different book, right, so wehave to read that novel and
understand it and then come upwith some way of intervening for
that person that's tailored towhat they need and also taking
into consideration what othertherapists might be doing.
(10:27):
So it can be a lot.
Ayla Wolf (10:30):
It can be a lot, and I think that I run into those
kinds of situations most oftenwhen it is some kind of workers'
compensation case or motorvehicle case, where they've got
one kind of TBI doctoroverseeing them, but then that
doctor is referring them out tooccupational therapy, speech
therapy, physical therapy, andthen all of a sudden those three
(10:53):
aren't necessarily talking toeach other or they're all trying
to kind of tackle their pieceof it without recognizing maybe
that one thing needs to bestable first before the other
thing happens.
And so, and then the patients.
You know they, especially in aworkers' compensation situation,
if they don't follow thedoctor's orders, then they're
seen as non-compliant and thentheir entire case can get thrown
(11:14):
out.
And so it's just when you startto bring kind of like I don't
know if you want to call itpolitics or just insurance, you
know, when you bring insuranceinto the conversation, things
can go sideways real quickly interms of you know people may be
doing therapies they're notready for, or working with too
many different doctors thataren't communicating with each
other about what needs to happen, and it can get very messy.
Sophia Bouwens (11:37):
So, as providers , working to communicate with
the partners that are alsoworking with the patient is
really helpful, really importantfor that patient longevity and
for patients understanding whatis going on for them and maybe
what they are ready for or notready for or what might be
driving symptoms can also behelpful to trust that your team
can know that too, because it'shard as a patient waking up in
(11:58):
the middle of this experience,having to figure out and
navigate all this.
Ayla Wolf (12:02):
Right and honestly, I mean this is where I think
functional neurology excels,because the functional neurology
perspective and training isthat we can't have a situation
where you've got 10 blind peoplefeeling an elephant and all
experiencing just one part ofthe elephant.
You have to actually, you know,have the whole picture right of
(12:25):
sensory integration and be ableto understand the connection
between the vestibular systemand the ocular motor system and
eye misalignments and ocularmotor, eye movement disorders,
and then pairing that with theneck trauma and then pairing all
of that with the potentialdysautonomia and being able to
(12:46):
create and craft a verycomprehensive rehab program that
has, again, very much anindividualized, tailored
approach for that particularindividual.
And so that's where I'm alittle biased in saying that the
training that I've had throughthe Carrick Institute and with
all of the most amazing,brilliant, you know, professors
(13:09):
and chiropractic neurologiststhat have done all of this
research on sensory integrationand spent years and years and
years trying to understand howto see that big picture and have
this very integrated approach.
I think that's where people youknow can get a huge amount of
improvement is when you've gotpeople that have that deep
(13:31):
understanding of how it's allconnected and for patients to
understand that it's not just ado this one thing and it's going
to get better.
Sophia Bouwens (14:00):
Oftentimes there's multiple steps needed,
and partnering across your teamto make sure that the steps are
all in place is important.
Steps are all in place isimportant, absolutely.
Ayla Wolf (14:10):
It's definitely an ongoing dance in terms of, okay,
let me do these differentexercises until this certain
aspect is stable and then we canmove to, kind of the next
complicated thing and try to getthat cleaned up.
And and so it is this, you know, very fascinating dance that
happens between you know, tryingto figure out what parts of the
(14:30):
system need to be brought backinto balance and kind of in what
order or how do we createenough of a therapeutic change
that creates a neuroplasticityto this, this understanding that
a lot of this comes down toneuroplasticity.
And I often tell people that ifthey're doing, for example, a
(14:50):
gaze stability exercise, interms of neuroplasticity, I
always say it makes more sensefor you to do this for 15
seconds five or six times a daythan it is to can only handle
doing it for a short period oftime.
It makes more sense to actuallydo something multiple times
throughout the day and you know,when I'm driving, if I'm at a
(15:20):
stoplight, you know I'll justlook at the red light and I'll
do some.
You know, gaze stabilizationexercises on the red light get
some of my neck strengthening in, you know, like pushing up
against the back of the seat,and so she went driving.
I can like fit some of thesetherapies in, you know, while
I'm at a stoplight, you know.
So there's ways of kind ofincorporating some things into
your daily lifestyle where itdoesn't feel super intrusive or
(15:42):
time consuming which it can be afull time job, recovering from
some of these injuries.
Absolutely.
Sophia Bouwens (15:49):
Well, I think that's amazing how complex the
neck can be, how complex ournervous system is and this
integration between the neck,how important it is to decide or
decipher what might be drivingwhat.
Maybe the diagnosis is right,but we need to figure out what's
driving that diagnosis and howto intervene to help it.
Ayla Wolf (16:07):
I just had a patient come in the other day who was
kind of an interesting case,where she came in because of a
dysautonomia diagnosis and shehad been to the Mayo Clinic.
They ran her through all oftheir autonomic reflex tests and
she passed all of them justfine, except for the Valsalva
maneuver showed that there wassome cardiovagal insufficiencies
(16:30):
happening, and so she basicallywas like, well, I don't know
what to do next.
And so she found me, and as Iwas taking her through all my
tests, what I noticed was thather neck was very, very stiff
and she wasn't moving her headat all.
So when she walked she walkedlike a robot, you know,
stabilizing that neck system.
(16:50):
And so then she's like oh, Iforgot to tell you that I had a
surgery and I had two of myvertebrae fused in my neck, and
her main complaint was dizzinesscertainly be playing into this.
(17:13):
I actually think that thedysautonomia diagnosis might
actually be related to the necksurgery, which caused her for a
long time to walk around withoutever moving her head, and that
she was probably experiencing acertain amount of cervicogenic
dizziness along with adownregulation of her vestibular
system, because she's nevermoving her head and so that
vestibular system is not reallybeing activated in a normal way
(17:34):
as we kind of go through theworld and are looking around and
moving our head and and so Istarted to see this quote
dysautonomia problem as asensory integration problem.
That had very much a lot to dowith her neck and her fear
around moving her head and thisinability to just naturally go
(17:57):
through life and as you'rewalking down the hall to kind of
look up or down, or it's likethere was none of that happening
.
And so when I started to kindof put all this together with
her history, it started to makemore sense that this was not
just an autonomic dysfunctionthat's on its own, that there's
very much a cervical componentto this.
Sophia Bouwens (18:16):
Right, so almost like there's a symptom of the
dysautonomia, but the drivingfactor is coming from the neck
or other components.
Ayla Wolf (18:25):
Yeah, I mean, I can't say for 100% certainty, but
that was my suspicion, and soonce I have this suspicion, then
the quest becomes, okay, like,let's do all these functional
exams, let's collect information, then let's start doing some
treatments on the neck andgetting her more comfortable
with, you know, performing somegaze stability exercises as she
(18:45):
turns her head and graduatingfrom, say, doing that, laying
down to seated, to standing, towalking and, you know, taking
her through these steps to thepoint where she can be
comfortable moving her headwhile she's moving through life.
And if we can get her doingthat, you know, and then
reducing the dizziness, thenideally we would probably expect
(19:09):
to see that these autonomicdysfunctions also start to
correct themselves too, if thisis really as closely linked as I
think it is.
Sophia Bouwens (19:17):
Do you expect that she'll find discomfort
during that process ofrehabilitation or therapy for
that?
Ayla Wolf (19:23):
Well, surprisingly, as I was kind of giving her
different therapies anddifferent exercises in the
office, she was struggling withthe difficulty of them but had
an excellent attitude.
And when I kept checking inwith her to saying, you know,
are you dizzy?
Are you okay?
Is this, you know?
Can you handle this?
You know, she was very muchlike you know, yes, like I can
(19:43):
handle this, I'm doing fine.
And she came in feelinglightheaded and dizzy and so I
was very conscious of likecontinuing to check in with her
and she kept saying, yep, I'mgreat I can do this, like we're
good to go.
Sophia Bouwens (19:56):
I think that makes such a big difference.
Working with patients who areokay with some of the discomfort
and getting through things,knowing that it takes time and a
little bit of, you know,recalibration of these systems,
which will throw you offPatients that are hardworking
and not afraid of that, isreally important.
I find that they have muchbetter outcomes.
Ayla Wolf (20:16):
Yeah, I think it is really important to be aware of
people's fears and their anxiety.
I find that sometimes I'll havesomebody do just like one basic
thing, like let's just turn youin a chair 90 degrees, and all
of a sudden they're like, oh mygosh, I feel lightheaded, dizzy,
nauseous, and that's like theirsymptoms rev up so quickly.
(20:36):
Right, and so it can get reallytricky, because some people are
highly symptomatic like thatyou do one tiny little thing and
it's just like a domino effecton their system.
Yeah, and so it can get tricky.
But I do find that, you know,people's willingness to deal
with a little bit of discomfortis often necessary.
(20:57):
And the way that I often phraseit to people is I pay attention
to how long does it take themto get back to the baseline that
they were at before thattherapy.
So if somebody is practicing,you know, a gaze stability
exercise, my cue to people is tosay you know, tune into your
body, and as soon as you startto feel lightheaded or dizzy, or
(21:21):
your headache, you know, goesfrom a three out of 10 to a five
out of 10, or you become supernauseous, like, take a break,
you know, let's get these thingsto calm down again, and then
maybe they need to do theexercise slower, maybe take a
break you know, let's get thesethings to calm down again and
then maybe they need to do theexercise slower.
Maybe they forgot to breathe,right?
That happens all the time.
People are thinking too hardabout the exercise and then they
forget to breathe and then theyget dizzy and lightheaded and
(21:44):
nauseous, and so a lot of it is.
I think, meeting people withwhere they're at, cuing them
appropriately, getting people toyou know be okay with a little
bit of perhaps dizziness, aslong as they feel safe, right
and understand that the idea isthat with time they're going to
be able to do this exerciselonger or faster without getting
(22:07):
dizzy.
And you see that happen all thetime.
You know people say Okay, Iused to only be able to do three
repetitions of this before Iwould get symptomatic.
Now I can do 15.
Sophia Bouwens (22:17):
Like I can only lift 10 pounds, but now I can
lift 15 pounds.
It's like a weight gaining or astrengthening exercise, but it's
a different component and thatmuscular component is easy for
people to relate to.
We're like if you do a workout,you get sore, that's a good
thing, but if you're too soreyou can set yourself back.
So it's a listening betweenyour symptoms, right, you don't
(22:38):
want to do it so much thatyou're driving yourself up the
wall or really setting yourselfback, right?
So listening to the body andhaving them stop or taper, take
a break when they feel reallysymptomatic, not pushing through
Is that what I'm hearing yousay?
Ayla Wolf (22:54):
Absolutely.
We have to meet each individualwhere they're at in terms of
their metabolic capacity to dothe work, and I think when it
comes to even small, little,tiny eye exercises, those can be
incredibly fatiguing veryquickly, can be incredibly
(23:15):
fatiguing very quickly, and sowe have to educate people to
help them realize that thesemovements might look super
simple, but they're reallyimportant and they can actually
cause a lot of fatigue within asystem that's injured, and so
people do need to keep checkingin with themselves to say how
much can I tolerate?
If I do push myself over theedge, how quickly can I recover
in order to be able to then goagain and do more?
(23:37):
And that that should grow overtime, and that should grow over
time.
Yeah, like you said, just withan exercise program.
Sophia Bouwens (23:42):
Yeah, I mean.
Ayla Wolf (23:43):
I remember when I was training for a trail marathon,
I could barely run one mile.
Wow, when I first startedtraining for that trail marathon
.
Sophia Bouwens (23:51):
Wow, I mean I had.
I can't imagine.
Are you going to do a marathon?
You can barely run a mile, soyou have to work your way up.
Ayla Wolf (23:58):
Yeah, I'm the world's slowest runner.
When I was training for thistrail marathon, someone
convinced me to do at least justa 5k race.
Just a fun run, right?
I got beat by a speed walker ina 5k run, but you still did it.
You got yourself out there andthen did you do the marathon.
(24:19):
I did the marathon.
It was brutal, but after I didit I ended up then moving to
Central Oregon where they havegreat running trails, like
through the forest, and I didfind a lot of enjoyment going
for trail runs and I did get alot better at it, to the point
where there was a six mile loopthrough this one park that I
loved and it just gave me joy torun through the woods for six
(24:41):
miles.
So there was a point in my lifewhere I did get faster and
stronger and better at running.
But I would say at this pointin my life I don't love it.
Sophia Bouwens (24:52):
But at the time you kept at it.
You started where you were andyou this point in my life.
I don't love it, but at thetime you kept at it.
You started where you were andyou were small in the beginning
and you worked your way up tothe point where you were feeling
good, running six miles, whereone mile was brutal.
Ayla Wolf (25:04):
Yeah, that's the stubborn gene in me.
I hate quitting.
Sophia Bouwens (25:08):
That's success, right?
So many of our patients withthat stubborn gene, I find, do
better because they just stickwith it.
Keep at it, yeah.
Ayla Wolf (25:16):
That stubbornness you can use to your advantage, for
sure.
Sophia Bouwens (25:21):
I'm excited for talking about this.
We'll do another episode oncervical instability paper
because there's a lot of likeinternational discussion around
how to approach some of thesethings, not just neck injuries.
What about when the neck isn'tstable enough or strong enough?
How do we help those patientswho might be having neck pain or
(25:41):
headaches, and what can be donefor them?
Ayla Wolf (25:44):
I think that's a really important topic because
the people that have cervicalinstability of varying degrees,
they often have a lot ofsymptoms and a lot of therapies
they're doing may not, might notbe the most appropriate
therapies, but until theyactually have that correct
diagnosis, they don't know that.
And so you do have this categoryof people who have a lot of
(26:06):
symptoms, a lot of neck pain,and they oftentimes are trying
to do things they think they aredoing the right thing and until
they get that diagnosis they'revery confused about why they're
not getting better.
And you know, my heart goes outto people who are trying so
hard to get better but theydon't have the right diagnosis,
they haven't had the right testsand they're just struggling.
(26:28):
I mean, that's really the wholepoint of this podcast and the
book that I wrote is like thisis all troubleshooting for
people.
You know we're trying to do thetroubleshooting for them so
that hopefully we can catchpeople early and they can get
the information they need to goget the right testing so that
they don't spend three yearsstruggling, say, with a case of
(26:50):
cervical instability that theydidn't know was there.
Sophia Bouwens (26:52):
I think your book chapter on traumatic neck
injuries and the concussionbreakthrough book that you wrote
is a great way for people tokind of dive into and
understanding some of the waysthese symptoms might present and
what might be driving them tobe able to navigate that.
Ayla Wolf (27:08):
The tool we have for headache to understand those
better might be helpful tounderstand if it's neck
components or what other thingsmight be driving that, what type
of headache they might even behaving and how these all play
together and so in our nextepisode we'll do a deep dive
into cervical instability andthen from there I think we'll
(27:30):
also kind of start talking aboutdysautonomia, which is the next
chapter in my book, which is ahuge topic, huge topic,
excellent.
Well, hopefully we gave peoplesome things to think about and
if people are finding thisinformation useful, they can
subscribe to our podcast andthere's a link in the show notes
(27:50):
that says click to support theshow so you can subscribe, kind
of at any level of membershipthat feels comfortable for you.
We also have a lot ofinformation on our website,
lifeafterimpactcom.
We've got a blog post we have.
You can subscribe to be thefirst to hear about when my book
comes out.
(28:11):
We also have that freeconcussion headache tool.
So it's a kind of a headachecommunication tool and journal
that people can use to betterexplain to their physicians and
providers what types ofheadaches they're having, what
seems to be working, what's notworking, so that hopefully they
can get better diagnosis, bettercare.
And then, if you have certainquestions or topics you want us
(28:35):
to cover, feel free to shoot usan email at lifeafterimpact, at
gmailcom, and we'd love to hearyour thoughts on what you'd like
us to talk about and cover infuture episodes.
So I think that's it right.
Sophia Bouwens (28:49):
Yeah, thanks for tuning in, for listening.
Stay tuned for our next episodeon cervical instability.
Ayla Wolf (28:55):
Thank, you or treatment, and consumers of this
information should seek theadvice of a medical professional
for any and all health-relatedissues.
(29:36):
A link to our full medicaldisclaimer is available in the
notes.
Honestly, I mean this is where I think functional
neurology excels, because thefunctional neurology perspective
and t t t ishat t i i t c haveathat and be able to understand
the connection between thevestibular system and the ocular
(00:29):
motor system and eyemisalignments and ocular motor,
eye movement disorders, and thenpairing that with the neck
trauma and then pairing all ofthat with the potential
dysautonomia.
Sophia Bouwens (00:43):
Welcome to the Life After Impact podcast, where
we do a deep dive into allthings concussion and brain
injury related.
We talk about all the differentsymptoms that can follow a
brain injury, different testingmethods, different types of
specialists out there anddifferent therapies available.
I'm Sophia Bowens, I'm herewith Dr Ayla Wolf and we will be
(01:05):
your guide to living your bestlife after impact.
Ayla Wolf (01:14):
This episode is a continuation of episode six,
where we continue ourconversation about traumatic
neck injuries and the importanceof approaching them from a
sensory integration perspective.
If you haven't yet listened toEpisode 6, we recommend you go
back and do that first beforecontinuing to Episode 7.
Thanks again for listening toLife After Impact, the
(01:37):
Concussion Recovery Podcast.
We talked about a couple ofthese functional tests where
we're looking at, say, apinwheel testing on the face and
how that can change whether thejaw is open or closed or the
head is turned left or right.
There's also, you know, whenyou're looking at somebody's
balance, if you have somebodystanding on a foam pad, for
(01:58):
example, so you're taking awaytheir ankle proprioception and
you're asking them to rely moreheavily on their vestibular
system.
What we can find, too, is thatas soon as you change somebody's
head position, their balancecan break down, and so most
people, if their head is neutral, or if their head is looking
down, they're going to be morestable, but then a lot of times
(02:21):
what you find is that whensomeone tilts their head
backwards, then they're not asstable.
And so you have to also teaseout the difference between is
this a vestibular issue or isthis a cervical issue or, you
know again, often it's often asensory integration between
those two, which is why thesolution is a combination of
head movements and neckmovements and eye movements and
(02:47):
trying to kind of activate thevestibular system with the head
in different positions and doingdifferent eye exercises.
You've got to, you know, craft atherapy for each individual
person that helps them to feelmore stable in the head
positions where they're unstable.
And I think that sometimes thatalso gets missed, where, if
(03:09):
somebody can pass a basicbalance test, they might think,
oh well, I was, my balance wastested and they said it was fine
.
But then what you realize iswell, as soon as your head is
tilted back into the right,you're falling over.
And so that's, you know, that'swhere we need to start with.
Our therapy, too is actuallycorrecting this imbalance
(03:29):
between when you are activatingyour right posterior
semicircular canal of yourvestibular system and your head
is back into the right, you'refalling over.
So what do we need to do tokind of get this back into
balance too, so that you feelstable in any head position?
And that can be, you know again, a combination of what's going
(03:50):
on with the neck as well aswhat's going on with the
vestibular system.
Sophia Bouwens (03:54):
It's interesting , I think, about neck
strengthening, how that can beso helpful.
We talked in the beginning justhow that is even a preventative
measure for concussion itselfIn recovery.
Do you find that strengtheningthe neck is helpful?
Ayla Wolf (04:08):
I do, and there's some kind of like specific neck
strengthening clinic, like theyhave all these different
machines and this whole program,and so I have actually had
patients that have been referredto go do that and sure enough,
a lot of their symptoms improvewhen they actually strengthen
their neck.
Sophia Bouwens (04:24):
The TRIA neck and back program, I think, is
one of them.
It used to be called physiciansneck and back but now it's a
TRIA program where they just doneck stuff and that's they have
really great machines thatstabilize your neck and prevent
you from using your largermuscle groups, so that you're
actually strengthening thespinal muscles, because
oftentimes when those are weakor there's imbalances, we'll use
(04:47):
larger muscle groups to takeover these actions, that really
these smaller muscles which aremore intricately tied into the
vestibular system or theautonomic system, the visual
system, to get those tostrengthen so they're not being
overridden by those largermuscle groups that don't have
the same integration and withoutthat, key integration.
Ayla Wolf (05:11):
As you mentioned before, we can have a lot of
symptoms coming up for people,yeah, and I think that's where
either clinics like that orphysical therapists that have a
whole arsenal of excellent neckstrengthening exercises that
they can guide people through.
I think all of that is soimportant they can guide people
through.
I think all of that is soimportant.
And you know even, I think whathappens a lot is in today's
society.
People are often on theirphones or their computers and so
(05:32):
they have this forward headposture where they're kind of
jutting their whole headforwards.
I catch myself doing that allthe time.
Sophia Bouwens (05:40):
Me too, and my kids.
I'm like get up, stop doingthat.
And they're like mom, stop it.
Ayla Wolf (05:50):
Yeah, and I think that sets a lot of people up too
for a lot of neck issues, andso that posture piece of it is
also very important.
And then we have also in ourclinic these glasses that we
have people wear that have alaser in the front, and so this
little setup allows us to assessfor what's called a joint
position sense error, where wecan have someone close their
eyes and we turn their head sothe laser is no longer pointing
(06:14):
at the center target, it'slasers off to the side, and they
have to try to line that laserback up on the center target
with their eyes closed, justusing their neck receptors.
Exactly.
And so by assessing the levelof joint position error in all
the different planes of movementyou know up, down, side to side
(06:35):
and diagonals we can start topinpoint, you know which
movements, which positions seemto be the most difficult and
then also use that as atherapeutic kind of biofeedback
tool.
And then what I've also foundis that if somebody's joint
position sense has a lot oferrors in it by doing
acupuncture points on the neck,I often find that after a
(06:57):
treatment there's an immediateimprovement in their joint
position sense.
Testing just based on like evenone acupuncture treatment of
needles along the spine, Becauseit is a sensory stimulus.
Exactly.
Sophia Bouwens (07:09):
Helps can upregulate that.
So for patients struggling withsome post-traumatic neck injury
or concussion-like symptomsafter a head injury, teasing out
the different components thatcan be driving that as far as
visual or neck position, headposition, vestibular, can also
help you really understand whereto start with therapies and how
to progress them.
Ayla Wolf (07:30):
Yeah, and I think that that's where working with
somebody who has a really deepunderstanding of the sensory
integration between all thesesystems and can start to do a
lot of these tests to saywhere's the breakdown happening
and then what kinds of therapiesdo we need to do so that we can
clean up the sensoryintegration that's so important.
(07:51):
Somebody I was talking to who isa personal or, sorry, a
physical therapist at a largerhospital setting and she told me
that there's a division betweenoccupational therapy and
physical therapy where they weresaying, oh no, occupational
therapy is allowed to work withthese types of eye movements,
with their brain injury patients, and then the physical
(08:13):
therapists are only supposed towork with these types of eye
movements with their patients.
And there was kind of this liketurf war happening between the
different departments about whogot to do certain eye movement
rehab and it's like that's nothelpful for the patient when
you're trying to tease out like,like this is all about
integration, right, notseparation, right, and so when
(08:35):
you've got, you know, one siloover here saying we're
responsible for saccade eyemovements and gaze stability and
those people over there areonly supposed to do vestibular
ocular reflex exercises, it'slike this is where the system
kind of falls apart.
And I also think that sometimesthere's a hierarchy to what
needs to be done in the firstplace.
(08:55):
And if you've got somebody thathas a lot of issues with gaze
stability, if you try toimmediately throw them into some
really high level balanceexercises or vestibular ocular
reflex exercises where they'returning their head really fast
but they don't even have gazestability working for them, I
(09:16):
think that that's where peopleget really symptomatic they get
dizzy, they get nauseous, theyget headaches, they don't feel
good, they don't feel likethey're getting better, and so a
lot of people just end upquitting.
They just end up dropping outof a therapy because it makes
them symptomatic.
And that's also where, whenyou've got too many siloed
people who aren't communicatingwith each other, trying to do
different parts of the rehab andnot maybe in the right order,
(09:41):
that can be a problem for thepatient.
Kind of a mess right, that canbe a mess.
Sophia Bouwens (09:45):
So for therapists too, who are out
there trying to help theirpatients and they see only one
level of things, or testing inone area or one plane is fine,
but their symptoms aren'tgetting better, even though
their tests seem to be fine,maybe they could think about
head position or jaw position assomething that might feed into
that, or eye movement componentstoo.
I think that's an importantpiece.
(10:06):
There's so much as therapistswe're trying to manage or trying
to figure out or decipher, andeach patient we see is a
different book, right, so wehave to read that novel and
understand it and then come upwith some way of intervening for
that person that's tailored towhat they need and also taking
into consideration what othertherapists might be doing.
(10:27):
So it can be a lot.
Ayla Wolf (10:30):
It can be a lot, and I think that I run into those
kinds of situations most oftenwhen it is some kind of workers'
compensation case or motorvehicle case, where they've got
one kind of TBI doctoroverseeing them, but then that
doctor is referring them out tooccupational therapy, speech
therapy, physical therapy, andthen all of a sudden those three
(10:53):
aren't necessarily talking toeach other or they're all trying
to kind of tackle their pieceof it without recognizing maybe
that one thing needs to bestable first before the other
thing happens.
And so, and then the patients.
You know they, especially in aworkers' compensation situation,
if they don't follow thedoctor's orders, then they're
seen as non-compliant and thentheir entire case can get thrown
(11:14):
out.
And so it's just when you startto bring kind of like I don't
know if you want to call itpolitics or just insurance, you
know, when you bring insuranceinto the conversation, things
can go sideways real quickly interms of you know people may be
doing therapies they're notready for, or working with too
many different doctors thataren't communicating with each
other about what needs to happen, and it can get very messy.
Sophia Bouwens (11:37):
So, as providers , working to communicate with
the partners that are alsoworking with the patient is
really helpful, really importantfor that patient longevity and
for patients understanding whatis going on for them and maybe
what they are ready for or notready for or what might be
driving symptoms can also behelpful to trust that your team
can know that too, because it'shard as a patient waking up in
(11:58):
the middle of this experience,having to figure out and
navigate all this.
Ayla Wolf (12:02):
Right and honestly, I mean this is where I think
functional neurology excels,because the functional neurology
perspective and training isthat we can't have a situation
where you've got 10 blind peoplefeeling an elephant and all
experiencing just one part ofthe elephant.
You have to actually, you know,have the whole picture right of
(12:25):
sensory integration and be ableto understand the connection
between the vestibular systemand the ocular motor system and
eye misalignments and ocularmotor, eye movement disorders,
and then pairing that with theneck trauma and then pairing all
of that with the potentialdysautonomia and being able to
(12:46):
create and craft a verycomprehensive rehab program that
has, again, very much anindividualized, tailored
approach for that particularindividual.
And so that's where I'm alittle biased in saying that the
training that I've had throughthe Carrick Institute and with
all of the most amazing,brilliant, you know, professors
(13:09):
and chiropractic neurologiststhat have done all of this
research on sensory integrationand spent years and years and
years trying to understand howto see that big picture and have
this very integrated approach.
I think that's where people youknow can get a huge amount of
improvement is when you've gotpeople that have that deep
(13:31):
understanding of how it's allconnected and for patients to
understand that it's not just ado this one thing and it's going
to get better.
Sophia Bouwens (14:00):
Oftentimes there's multiple steps needed,
and partnering across your teamto make sure that the steps are
all in place is important.
Steps are all in place isimportant, absolutely.
Ayla Wolf (14:10):
It's definitely an ongoing dance in terms of, okay,
let me do these differentexercises until this certain
aspect is stable and then we canmove to, kind of the next
complicated thing and try to getthat cleaned up.
And and so it is this, you know, very fascinating dance that
happens between you know, tryingto figure out what parts of the
(14:30):
system need to be brought backinto balance and kind of in what
order or how do we createenough of a therapeutic change
that creates a neuroplasticityto this, this understanding that
a lot of this comes down toneuroplasticity.
And I often tell people that ifthey're doing, for example, a
(14:50):
gaze stability exercise, interms of neuroplasticity, I
always say it makes more sensefor you to do this for 15
seconds five or six times a daythan it is to can only handle
doing it for a short period oftime.
It makes more sense to actuallydo something multiple times
throughout the day and you know,when I'm driving, if I'm at a
(15:20):
stoplight, you know I'll justlook at the red light and I'll
do some.
You know, gaze stabilizationexercises on the red light get
some of my neck strengthening in, you know, like pushing up
against the back of the seat,and so she went driving.
I can like fit some of thesetherapies in, you know, while
I'm at a stoplight, you know.
So there's ways of kind ofincorporating some things into
your daily lifestyle where itdoesn't feel super intrusive or
(15:42):
time consuming which it can be afull time job, recovering from
some of these injuries.
Absolutely.
Sophia Bouwens (15:49):
Well, I think that's amazing how complex the
neck can be, how complex ournervous system is and this
integration between the neck,how important it is to decide or
decipher what might be drivingwhat.
Maybe the diagnosis is right,but we need to figure out what's
driving that diagnosis and howto intervene to help it.
Ayla Wolf (16:07):
I just had a patient come in the other day who was
kind of an interesting case,where she came in because of a
dysautonomia diagnosis and shehad been to the Mayo Clinic.
They ran her through all oftheir autonomic reflex tests and
she passed all of them justfine, except for the Valsalva
maneuver showed that there wassome cardiovagal insufficiencies
(16:30):
happening, and so she basicallywas like, well, I don't know
what to do next.
And so she found me, and as Iwas taking her through all my
tests, what I noticed was thather neck was very, very stiff
and she wasn't moving her headat all.
So when she walked she walkedlike a robot, you know,
stabilizing that neck system.
(16:50):
And so then she's like oh, Iforgot to tell you that I had a
surgery and I had two of myvertebrae fused in my neck, and
her main complaint was dizzinesscertainly be playing into this.
(17:13):
I actually think that thedysautonomia diagnosis might
actually be related to the necksurgery, which caused her for a
long time to walk around withoutever moving her head, and that
she was probably experiencing acertain amount of cervicogenic
dizziness along with adownregulation of her vestibular
system, because she's nevermoving her head and so that
vestibular system is not reallybeing activated in a normal way
(17:34):
as we kind of go through theworld and are looking around and
moving our head and and so Istarted to see this quote
dysautonomia problem as asensory integration problem.
That had very much a lot to dowith her neck and her fear
around moving her head and thisinability to just naturally go
(17:57):
through life and as you'rewalking down the hall to kind of
look up or down, or it's likethere was none of that happening
.
And so when I started to kindof put all this together with
her history, it started to makemore sense that this was not
just an autonomic dysfunctionthat's on its own, that there's
very much a cervical componentto this.
Sophia Bouwens (18:16):
Right, so almost like there's a symptom of the
dysautonomia, but the drivingfactor is coming from the neck
or other components.
Ayla Wolf (18:25):
Yeah, I mean, I can't say for 100% certainty, but
that was my suspicion, and soonce I have this suspicion, then
the quest becomes, okay, like,let's do all these functional
exams, let's collect information, then let's start doing some
treatments on the neck andgetting her more comfortable
with, you know, performing somegaze stability exercises as she
(18:45):
turns her head and graduatingfrom, say, doing that, laying
down to seated, to standing, towalking and, you know, taking
her through these steps to thepoint where she can be
comfortable moving her headwhile she's moving through life.
And if we can get her doingthat, you know, and then
reducing the dizziness, thenideally we would probably expect
(19:09):
to see that these autonomicdysfunctions also start to
correct themselves too, if thisis really as closely linked as I
think it is.
Sophia Bouwens (19:17):
Do you expect that she'll find discomfort
during that process ofrehabilitation or therapy for
that?
Ayla Wolf (19:23):
Well, surprisingly, as I was kind of giving her
different therapies anddifferent exercises in the
office, she was struggling withthe difficulty of them but had
an excellent attitude.
And when I kept checking inwith her to saying, you know,
are you dizzy?
Are you okay?
Is this, you know?
Can you handle this?
You know, she was very muchlike you know, yes, like I can
(19:43):
handle this, I'm doing fine.
And she came in feelinglightheaded and dizzy and so I
was very conscious of likecontinuing to check in with her
and she kept saying, yep, I'mgreat I can do this, like we're
good to go.
Sophia Bouwens (19:56):
I think that makes such a big difference.
Working with patients who areokay with some of the discomfort
and getting through things,knowing that it takes time and a
little bit of, you know,recalibration of these systems,
which will throw you offPatients that are hardworking
and not afraid of that, isreally important.
I find that they have muchbetter outcomes.
Ayla Wolf (20:16):
Yeah, I think it is really important to be aware of
people's fears and their anxiety.
I find that sometimes I'll havesomebody do just like one basic
thing, like let's just turn youin a chair 90 degrees, and all
of a sudden they're like, oh mygosh, I feel lightheaded, dizzy,
nauseous, and that's like theirsymptoms rev up so quickly.
(20:36):
Right, and so it can get reallytricky, because some people are
highly symptomatic like thatyou do one tiny little thing and
it's just like a domino effecton their system.
Yeah, and so it can get tricky.
But I do find that, you know,people's willingness to deal
with a little bit of discomfortis often necessary.
(20:57):
And the way that I often phraseit to people is I pay attention
to how long does it take themto get back to the baseline that
they were at before thattherapy.
So if somebody is practicing,you know, a gaze stability
exercise, my cue to people is tosay you know, tune into your
body, and as soon as you startto feel lightheaded or dizzy, or
(21:21):
your headache, you know, goesfrom a three out of 10 to a five
out of 10, or you become supernauseous, like, take a break,
you know, let's get these thingsto calm down again, and then
maybe they need to do theexercise slower, maybe take a
break you know, let's get thesethings to calm down again and
then maybe they need to do theexercise slower.
Maybe they forgot to breathe,right?
That happens all the time.
People are thinking too hardabout the exercise and then they
forget to breathe and then theyget dizzy and lightheaded and
(21:44):
nauseous, and so a lot of it is.
I think, meeting people withwhere they're at, cuing them
appropriately, getting people toyou know be okay with a little
bit of perhaps dizziness, aslong as they feel safe, right
and understand that the idea isthat with time they're going to
be able to do this exerciselonger or faster without getting
(22:07):
dizzy.
And you see that happen all thetime.
You know people say Okay, Iused to only be able to do three
repetitions of this before Iwould get symptomatic.
Now I can do 15.
Sophia Bouwens (22:17):
Like I can only lift 10 pounds, but now I can
lift 15 pounds.
It's like a weight gaining or astrengthening exercise, but it's
a different component and thatmuscular component is easy for
people to relate to.
We're like if you do a workout,you get sore, that's a good
thing, but if you're too soreyou can set yourself back.
So it's a listening betweenyour symptoms, right, you don't
(22:38):
want to do it so much thatyou're driving yourself up the
wall or really setting yourselfback, right?
So listening to the body andhaving them stop or taper, take
a break when they feel reallysymptomatic, not pushing through
Is that what I'm hearing yousay?
Ayla Wolf (22:54):
Absolutely.
We have to meet each individualwhere they're at in terms of
their metabolic capacity to dothe work, and I think when it
comes to even small, little,tiny eye exercises, those can be
incredibly fatiguing veryquickly, can be incredibly
(23:15):
fatiguing very quickly, and sowe have to educate people to
help them realize that thesemovements might look super
simple, but they're reallyimportant and they can actually
cause a lot of fatigue within asystem that's injured, and so
people do need to keep checkingin with themselves to say how
much can I tolerate?
If I do push myself over theedge, how quickly can I recover
in order to be able to then goagain and do more?
(23:37):
And that that should grow overtime, and that should grow over
time.
Yeah, like you said, just withan exercise program.
Sophia Bouwens (23:42):
Yeah, I mean.
Ayla Wolf (23:43):
I remember when I was training for a trail marathon,
I could barely run one mile.
Wow, when I first startedtraining for that trail marathon
.
Sophia Bouwens (23:51):
Wow, I mean I had.
I can't imagine.
Are you going to do a marathon?
You can barely run a mile, soyou have to work your way up.
Ayla Wolf (23:58):
Yeah, I'm the world's slowest runner.
When I was training for thistrail marathon, someone
convinced me to do at least justa 5k race.
Just a fun run, right?
I got beat by a speed walker ina 5k run, but you still did it.
You got yourself out there andthen did you do the marathon.
(24:19):
I did the marathon.
It was brutal, but after I didit I ended up then moving to
Central Oregon where they havegreat running trails, like
through the forest, and I didfind a lot of enjoyment going
for trail runs and I did get alot better at it, to the point
where there was a six mile loopthrough this one park that I
loved and it just gave me joy torun through the woods for six
(24:41):
miles.
So there was a point in my lifewhere I did get faster and
stronger and better at running.
But I would say at this pointin my life I don't love it.
Sophia Bouwens (24:52):
But at the time you kept at it.
You started where you were andyou this point in my life.
I don't love it, but at thetime you kept at it.
You started where you were andyou were small in the beginning
and you worked your way up tothe point where you were feeling
good, running six miles, whereone mile was brutal.
Ayla Wolf (25:04):
Yeah, that's the stubborn gene in me.
I hate quitting.
Sophia Bouwens (25:08):
That's success, right?
So many of our patients withthat stubborn gene, I find, do
better because they just stickwith it.
Keep at it, yeah.
Ayla Wolf (25:16):
That stubbornness you can use to your advantage, for
sure.
Sophia Bouwens (25:21):
I'm excited for talking about this.
We'll do another episode oncervical instability paper
because there's a lot of likeinternational discussion around
how to approach some of thesethings, not just neck injuries.
What about when the neck isn'tstable enough or strong enough?
How do we help those patientswho might be having neck pain or
(25:41):
headaches, and what can be donefor them?
Ayla Wolf (25:44):
I think that's a really important topic because
the people that have cervicalinstability of varying degrees,
they often have a lot ofsymptoms and a lot of therapies
they're doing may not, might notbe the most appropriate
therapies, but until theyactually have that correct
diagnosis, they don't know that.
And so you do have this categoryof people who have a lot of
(26:06):
symptoms, a lot of neck pain,and they oftentimes are trying
to do things they think they aredoing the right thing and until
they get that diagnosis they'revery confused about why they're
not getting better.
And you know, my heart goes outto people who are trying so
hard to get better but theydon't have the right diagnosis,
they haven't had the right testsand they're just struggling.
(26:28):
I mean, that's really the wholepoint of this podcast and the
book that I wrote is like thisis all troubleshooting for
people.
You know we're trying to do thetroubleshooting for them so
that hopefully we can catchpeople early and they can get
the information they need to goget the right testing so that
they don't spend three yearsstruggling, say, with a case of
(26:50):
cervical instability that theydidn't know was there.
Sophia Bouwens (26:52):
I think your book chapter on traumatic neck
injuries and the concussionbreakthrough book that you wrote
is a great way for people tokind of dive into and
understanding some of the waysthese symptoms might present and
what might be driving them tobe able to navigate that.
Ayla Wolf (27:08):
The tool we have for headache to understand those
better might be helpful tounderstand if it's neck
components or what other thingsmight be driving that, what type
of headache they might even behaving and how these all play
together and so in our nextepisode we'll do a deep dive
into cervical instability andthen from there I think we'll
(27:30):
also kind of start talking aboutdysautonomia, which is the next
chapter in my book, which is ahuge topic, huge topic,
excellent.
Well, hopefully we gave peoplesome things to think about and
if people are finding thisinformation useful, they can
subscribe to our podcast andthere's a link in the show notes
(27:50):
that says click to support theshow so you can subscribe, kind
of at any level of membershipthat feels comfortable for you.
We also have a lot ofinformation on our website,
lifeafterimpactcom.
We've got a blog post we have.
You can subscribe to be thefirst to hear about when my book
comes out.
(28:11):
We also have that freeconcussion headache tool.
So it's a kind of a headachecommunication tool and journal
that people can use to betterexplain to their physicians and
providers what types ofheadaches they're having, what
seems to be working, what's notworking, so that hopefully they
can get better diagnosis, bettercare.
And then, if you have certainquestions or topics you want us
(28:35):
to cover, feel free to shoot usan email at lifeafterimpact, at
gmailcom, and we'd love to hearyour thoughts on what you'd like
us to talk about and cover infuture episodes.
So I think that's it right.
Sophia Bouwens (28:49):
Yeah, thanks for tuning in, for listening.
Stay tuned for our next episodeon cervical instability.
Ayla Wolf (28:55):
Thank, you or treatment, and consumers of this
information should seek theadvice of a medical professional
for any and all health-relatedissues.
(29:36):
A link to our full medicaldisclaimer is available in the
notes.
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