She couldn't finish a workout without crashing. 3 Days Later, she could

[00:00:00]So, I hear we got a story. I know who it's about and I got some Everybody pay attention because we're going to have a little bit of learning right afterwards on this. So, be ready.

[00:00:09]>> So, we're going to run over a patient case. We had this patient in not that long ago. Her primary complaint was fatigue and exercise intolerance. So, she would get out of breath and really tired doing things that previously she didn't have any problem with. So, for example, she used to be able to walk her kids to the pool without an issue, and now she was getting out of breath, just walking them to the bus stop. Um, and she noticed that she used to be able to do an exercise class for 45 minutes, no problem. And then as her symptoms started getting worse, she'd struggle to do half an hour. and then afterwards she'd have to rest for a couple hours just to feel like she could do something else after that. So that's kind of where she's starting. Um also she had some brain fog which this particular patient tons of education hadn't struggled with stuff in the past and she'd noticed that her productivity had really dropped. She was working on a master's program and she's really struggling to get stuff done, struggling to help her kids with program with their homework because of the brain fog.

[00:01:22]So, we went through we did her normal exam. We some of the things we noticed and I'm going to go a little bit more into some of these. I'll touch on um just a couple to start. So, she had a really decreased cervical range of motion. So when we test head positions on the Doppler, we have people put their heads in a bunch of your normal head positions. So like flexion, extension, rotation. When we had her do some of these, she couldn't even really get into the range of motion that we wanted to.

[00:01:53]Yep. Protraction and retraction. Dr. Kaiser showing some of those, but all of her range of motion was pretty decreased. The muscles in her neck were super tight, and that was also limiting some of that motion. And then some of our other bedside tests, we noticed some decrease in coordination on the right side. And then when we did the tilt, she had cerebral hyper profusion kind of isolated more to that left side, a little bit on the right side where she dropped below the levels. I won't show you the chart this week, but if you've been around, you've seen that. So much lower levels on the left. And then when we had her do that, the extension that she did have, we also noticed a decrease on the left when she was sitting.

[00:02:41]>> And then >> So what walk through real quick? Sorry to interrupt you.

[00:02:45]>> So you'd mentioned that we had some coordination problems. What does that when you say coordination problems, how can people think about that? What does that mean?

[00:02:58]So when for example what we're doing when we're testing so we'll have people take and touch their um nose to a finger back and forth and that should be relatively coordinated but she was getting some kind of tremors in the end not quite finding the target coordinating where that is. If we have her do different tasks like moving her hands back and forth like this, it would be floppy and not quite coordinated. So, you should be able to do that movement nice and smooth. But we noticed that on one side it was way less coordinated than the other. It just didn't look as smooth a little bit. The timing was off >> and there'd be some head.

[00:03:44]>> So, yeah. So, we're getting So, that lack of coordination is kind of like there's a wobble in it, right? So the the feedback loop isn't quite running hot, let's say. So if we compare that to you said you noticed that we noticed that on the right side. Yeah.

[00:04:00]>> Okay. And then you'd mentioned there were some changes in profusion.

[00:04:04]Can you walk us through the coralate for those those things? So I think that would be really helpful for everybody to hear.

[00:04:11]So if we're looking at this big picture, a lot of times the coordination stuff when we see problems with that, that'll be our cerebellum.

[00:04:20]And it's interesting that we had those tests come up on the right side because the right cerebellum correlates with the function of the left brain. So when we see decrease in the profusion to the left brain and also decrease to the coordination of the cerebellum on the right, we're starting to see sort of a tie-in between the two where the left brain's not getting the blood flow that it needs to run the task that it wants to run and also some of the coordination on a corresponding pathway right before that.

[00:04:52]>> Yeah. Yeah. So when we say left brain, we're kind of like using that as a shorthand for saying the left side of the cerebral cortex. And the left side of the cerebral cortex has a map for the entire right side of the body. So it's like all the sensory stuff on the right side is going to be integrated over here. It's going to cross over and then when it kicks out the motor program again, it kicks it out over that opposite side. So it's a really useful coralate to be able to understand how that coordination of the hand is going to couple to what's going to happen with we're going to talk about in a minute is going to couple with activities of gate and trunkal activity and in the leg and then that just helps us understand where in that mapping system things are affected which things are good which things are not as good and off and running. Thanks for sharing that with us.

[00:05:39]Okay. And then also on the tests, we do a test. I don't know if we've shared one of these yet, but we test cacods, which is quick eye movements back and forth. So if I tell you to look at this point and then look at this point and go back and forth between those, that's what a cacod is.

[00:05:58]So we want the eyes to jump smoothly from one to the other. and we have a little device that'll take and measure that and give us graphs so we can see that. So, I'm going to share what hers looked like to start and kind of talk through what's happening and then we'll look at what that looked like a couple days later to see what the changes are after we did a little bit of treatment with her.

[00:06:25]So, I'm gonna share my screen.

[00:06:28]>> I'm gonna take this question because it's pertinent to what we're just talking to. It's from not another pale spoony.

[00:06:33]I'm always confused by the mirroring where a left hand is affected by the right brain. I'm both lightheaded on the left side of my head and have tremors on the left side. Shouldn't one of them be right side? Not necessarily. So this is important. So number one, the right side of your brain has got a little unlock because it carries a little bit of a correlated map for both sides. It's a little fail safe that we have. But when we think about the overlap, you can think about it like I don't know if anybody grew up with those old sheets like my math teacher used to have the overhead transparency sheets that they just write on with markers and then put another one over top and write on them. But if you think about those overlays, you're thinking about the neurology is going to cross, but the profusion is going to be unilateral. So it's going to affect everything on that one side. So we can see cases where depending on what causes what if it if the profusion is going to be more problematic this is super general but if the profusion is more problematic we may see that it's going to affect things not only uh contraterally but ipssilaterally as well because we're knocking out the whole system we may affect anterior circulation posterior circulation the whole deal but when we see things where we're actually creating a sensory barrage that is skewing activity in the brain it's going to change the cerebral blood flow based on the activity that's coming from the sensory system and that helps us to be able to refine the diagnosis of which one becomes kind of the you know the tail wagging the dog or the dog wagging the tail. So that's actually a really important point because we can't just say like oh my tremors over here and then just quickly say everything must be on the other side. We have to overlay what is happening from looking at the neurological pathways and then looking at the vascular that's over top of that and then put them together. So great question. You are we ready? Did we do it?

[00:08:25]>> So what we have here is a picture of the um position on this side and then the or the velocity on the left and then the phase on the right. So we're going to look at the left side one first.

[00:08:44]This is showing how we have from the start of the sacad at the beginning to the end of the sacad on the other side and increase in velocity as it should.

[00:08:55]So this it should speed up and then it should slow down as it comes to the target. So going um across >> that's really good. But we got to establish what is a sakad because I think that is a madeup word that no no one should ever say. What is it?

[00:09:12]>> Good point. So the quick eye movement when you're jumping from one target to the next target.

[00:09:18]>> Yeah. So if you look from one thing to another thing, it's a certain type of movement comes from the frontal eye fields. But it's really important one because it's different than anything else. It's a shift. So your eyes are actually jumping to a target in space, which means it's got to be able to know where it's going before it even leaves, right? So it's throwing a dart there.

[00:09:38]Once that dart leaves your hand, you can't change it. It's going to land. And so that's what you're looking at with these these graphs. So we see the graphs are both eyes, but it's both eyes that are landing on the left target and they're both eyes that are landing on a right target. They're both about 20° apart. So it's just literally like, you know, you picture the people at the tennis match looking back and forth.

[00:10:00]That's what we're doing. And we're measuring how well someone can land their eyes on that target. And then also like how quickly they react to be able to notice that target and then get the machinery of their eyes to get over there. That's like a processing component. And then the third is we look at kind of like how does that look when it's going? Does it take the normal arc like normal speed arc to be able to get there or does it have stops and starts along the way? Like how is your brain organizing that? And that's what you're seeing in these two graphs. Now go ahead and explain it from there for me.

[00:10:35]>> Okay. So, what we should see on this left one is it should be one beautiful peak going up and then back down to the other side. And our red one is the left eye when we see the eyes going to the left. And then the green is when we see things going to the right. So, if you know boats or airplanes, they always have the red light on the left and the green light on the right. That's kind of how that correlates with this. But those should be one peak up and one peak down.

[00:11:03]And you can see how in hers it goes up and then there's a little bump in here and then it comes down on the other side. And we also see that same little bump looking shape on the other one. So the other one instead of being the speed of the eyes, it shows the position of the eyes. So along the bottom we've got degrees and it should land at about 20.

[00:11:25]You can see that hers go a little bit past that. So her sacods are actually those quick eye movements are overshooting where the target is and then coming back a little bit.

[00:11:37]So she's going too far. She doesn't have a great um jump from one point to the other cleanly. And then when we see that jump or that little bump in the middle that makes it look like an M, we call that an omnipause intrusion.

[00:11:51]So a lot of times when that pops up, we actually see people who are recruiting their head in the middle of their Oh, I have [clears throat] a >> give yourself thumbs up. I like that.

[00:12:04]Yeah. So that little bump in the green one is just an indicator that we're having some some asynchrony in the way that the eyes and the head are be able to communicate with each other. So it actually changes the trajectory of the eye movement. This is really helpful because we're looking at okay, we've got this coordination error that's kind of unilateral and it's seems to be affecting the the way that we're able to peruse the brain and we also have this tightness in the neck and those things all make sense because the quality of your eye movement and the quality of your head movement are going to be contingent on how well your eyes and your neck are able to coordinate with each other. So that's kind of exactly what uh the data is showing us here. So what's next?

[00:12:46]So, next, even if you can't even if you don't understand anything that we just said and you just see the pictures here, I'm going to scroll to the um other one, which unfortunately might be a little bit difficult >> to see if you can two finger scroll that thing and hope it works.

[00:13:19]Can you click on the white part?

[00:13:23]>> Um, oh, there you go. I got it.

[00:13:26]>> Okay.

[00:13:27]>> So, you can see in this one, this is only after 3 days. And interest, it's interesting to note that we actually didn't have her practice these cicods at all between the first one and the second one. We did a couple other things with her eyes, but we mostly took and worked on her neck and then some gay stability stuff. And you can see that this velocity one is now more of a nice easy peak. And that M that was in the middle of that second one is no longer that there. It's now more of what we like to see where it goes right from the start and lands smoothly over here. And she's now landing closer to that 20. So she's not overshooting it as much as she was before. Yeah, these are beautiful. So that kind of like semicircle is exactly what that should look like on the right one. And then there's no big, you know, she said nice a nice sledding hill there on the left. So that's perfect. And you can see where the the greens and the red overlay each other. Nice.

[00:14:25]>> Okay. So I'm going to stop sharing my screen now and go back and then give you just a couple of updates on how she's doing otherwise. Am I out of the screen share now?

[00:14:38]You're doing great.

[00:14:40]>> You and me.

[00:14:42]>> So then after all, so we had all of these objective testing and they got so much better. She completely cleared up the orthostatic cerebral hyper profusion. So her profusion was good for the entirety of the tilt test. and she told us that she while she was here decided that she was going to do a whole workout class at the end of the day and felt wonderful, didn't have to rest for hours afterwards and was able to wash her hair, which she was super excited about. So, we loved sharing those wins with her while she was here.

[00:15:19]>> Yeah, that's pretty cool. And just super bright personality, wonderful to be around. So, that always makes it makes it fun and easy. So, we're always lucky to have We're very lucky to get to meet the people we get to meet on this journey. So, it's been pretty great.

[00:15:33]>> Awesome. I'm going to share real quick.

[00:15:34]You hang out with me for just another minute. I want to share on my screen.

[00:15:38]Let's see if I can Let's see if I can beat you in speed. What do you think?

[00:15:43]>> I think it would be hard to not beat me [laughter] in speed.

[00:15:46]>> You think so?

[00:15:48]I'm going to go with this whole window and we are going to go with this one.

[00:15:56]Let's go.

[00:15:58]Okay. So, you guys may or may not be able to read this well, but what we're pointing out here is this really important piece of the correlation.

[00:16:07]We're always talking about cerebral blood flow, right? That is that's just part of our party. But what uh not another pale spoony pointed out that's really really helpful is this interplay between understanding is that cerebral blood flow the causal problem or is there something that's happening in the system that then shows up as this lack of profusion and then we get symptoms that are secondary to that.

[00:16:34]Right? So this is one of those cases and what you're what you can see is this correlation between looking at outcomes in the pre cerebral profusion. We didn't show you that but they're there. Um we're just short on time. But that correlate is really important because those sacads can become a training tool in some instance in some instances but they can also become a measurement tool.

[00:17:00]Right? So we're able to see that we didn't do anything to try to manipulate making her better at doing sakods. But by stimulating the pathway of choice and being able to stimulate that portion of the brain, then we can see that the outcome is that the whole system runs smoother. The cacods improve and then that ties into what we see with that cerebral profusion. So it gives us ways to triangulate them together. So what we know that's pretty amazing that we've known forever you can see I don't know if you can see this or not but this study was published in 1994 Joe Diffy time. So this is basically just showing that when you do cacods, when you do visual fixation, just holding your eyes steady, that you can measure cerebral blood flow to the point where we use it to to like qualify what areas of the brain we're stimulating, which is amazing. So this is in 1994.

[00:17:57]So at that time they were able to say hey when we do these cacods we can see the increased profusion into these areas in the posterior parietal cortex the extra stri cortex the frontal eye fields and this is both during reflexive and rememberance cicods and then there's additional activation in the supplementary motor area the cerebellum the phalamus the midbrain right so why do I bother bringing this up I bring it up because in order for those sacads to generate it means we have to have a pathway it's active through that whole system.

[00:18:30]And what's amazing is by looking at these different tests, it gives us ways to understand where in that pathway things are becoming errored. And then how do we stimulate things that are pre-synaptic, which means like you think about it like a train station. We want to do things that are earlier on like before your stop so that when we fire that signal up there, it's able to change the activity in the stop we're trying to change it or in the the portion of the pathway we want to change. And you can see that really well when we look at eye movements, specifically sacads.

[00:19:08]And then we can see that again here. So this is another one. Hopefully this will pop up. Oh, it's reverifying. Great.

[00:19:15]Hopefully it'll kick back on. Yeah. So this is doing a PET study looking at cerebral blood flow as well. And again you can see this activity in the frontal eye fields and posterior parietal cortex are associated with these activities. So if you are someone that is having trouble being able to direct blood flow to the brain, we can use these eye movement strategies to be able to stimulate those particular components, which is beautiful. Or if we're trying to talk about things that are presinaptic to it, we can use stimulus through other parts of the body, the vestibular system, through eye head movement, through neck proprioception, and we can measure the outputs in these other systems that are part of those pathways. And then the third one I pulled up here was this is looking at pupil dilation and microcods. We don't have to talk specifically about microcodads, but it's a certain type of movement, but they're tied to the dynamics of arousal and attention.

[00:20:13]And so, this is really helpful because this study basically show, you know, when you're in a crowded room and you're trying to pay attention to something, but if it's super noisy, it makes it harder to pay attention, right?

[00:20:26]So, you got to put more effort into it.

[00:20:28]And so, that's what this study looked at. It said, "We're going to ask you to read. We're going to do these visually mediated tasks for people that are healthy. But when you do that, we're going to have a high listening environment and a low listening environment, meaning a lot of noise, not very much noise. And what they did was they looked at microcods and they looked at pupil dilation as a way to understand how much arousal has to take place or how much effort or cognitive load is being used to be able to deal with that extraneous noise. Most of you probably recognize that like oh that's a thing for me right like the more complicated environment is I'm in the grocery store.

[00:21:11]I'm at I'm out to lunch. I'm going to Starbucks with Cam.

[00:21:15]Those are more busy environments.

[00:21:17]Whether that's through listening, auditory stimulus, but it could also be visual stimulus, could be motion, could be motion of your own body. All of these things increase the amount of potential noise in the system, which means that your body has to use more, your brain has to use more cognitive load, has to use more energy to do the same task. So when we look at these cases where we see there's this processing error, all the things that would then go with that that would add load make that more difficult. So we've got exercise class, we've got doing homework, we've got all of these things that are too much load.

[00:21:56]But if we can improve that processing speed so that something is of normal intensity doesn't feel huge. Now you're able to be able to generate enough load to be able to do that. And we can see that as measured through pupilary responses and through eye movement responses that help us know if we're on the right track. So you can see these two correlations where when we see the eye movements improving. Now you might understand why we get super excited because we know that that activity of the brain is improving and we expect to see those challenges get less and less and that's what we're seeing here in this case.