Eye2Brain Academy

Sleep: Chronotypes

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Raise of hands for those that get the “norm” 8-10 hours of sleep. When does your body cue you to fall asleep and wake up? Try not to confuse this as when you think you should go to sleep and when your alarm wakes you up. If you could stay up until midnight and sleep until 8, would your lifestyle allow you to do so? What about sleeping for 7 hours at night and 1 hour during the afternoon?

A podcast that I found by Peter Attia, The Drive, episode 221 Understanding sleep and how to improve it, describes chronotypes: the time of day when you feel the most awake, when you are hungry, etc. People that report having insomnia may not truly be an insomniac…what if their chronotype simply does not match their current lifestyle? After a brain injury, as many of us manage on a day to day in our professional careers, someone may have been able to compensate their mismatched chronotype/lifestyle before an injury. Now, they are telling you all of their symptoms and that they are sleeping all the time. Well, think about it. Has their chronotype changed? Is it the same as pre-injury and they are unable to tolerate the mismatch now? We are excited to have an open discussion below on this topic, so make sure you put your comments in the box below!

Follow this link for a more in depth definition of chronotypes: https://www.sleepfoundation.org/how-sleep-works/chronotypes

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Nutrition & Concussion Part 2: Gluten Case Study

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Welcome back for part 2 of our Nutrition & Concussion series! This post is a case study on a 13 year old female that sustained a concussion playing basketball. She completed treatment and her return to play protocol, although was still complaining of a 5 minute headache on a daily basis. This headache was not associated with any activity in particular, and in fact went away with physical activity. At this time, with no known cause of the headaches, I had the athlete journal her eating habits for 2 weeks everyday. This included what she ate/drank, when she ate/drank, and when the headache occurred and for how long. We noticed a trend: her headache occurred within 30 minutes after consuming any gluten. I hated to put her on a specific lifestyle change at such a young, influential age, however it was the only thing we had not tried to get rid of her headaches once and for all. The athlete and parent were both more than willing to try going gluten free for 4 weeks to see what happened. Sure enough, the headaches stopped altogether once she substituted her foods with gluten free products. Now, 6 months later, the athlete has completed a gluten re-introduction process and is able to tolerate small amounts of gluten at a time without remorse. She waited until she knew her body was ready (this was a very mindful 13 year old) and listened to her body when it started becoming symptomatic again, by taking out the foods that caused her the headache. With mindfulness and guidance, we can help our athletes reach their goals and change their life long term for the better.

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Nutrition & Concussion: Part 1

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You know the phrase, “you are what you eat”? Well after a severe injury or illness I have found this to be truer and truer for every athlete I work with. After sustaining a concussion, the blood brain barrier becomes compromised and causes a lack of filtration of toxins. This leads to symptoms such as fatigue, brain fog, lack of concentration, poor memory, etc. The brain literally has no moat to protect it! As clinicians we have to educate our athletes on how to restore the blood brain barrier, protect the brain, and give it an optimal environment to heal on its own. Side note: a great professor once said, “The body will heal itself, we just have to give it the tools to do so.” What kind of tools should we have in our toolbox? At Dr. Fitzgerald & Associates, we look at what foods cause inflammation due to the body’s increased inflammatory response after injury. As with orthopedics, concussion injuries also go through the same inflammatory process and some people get stuck in this phase of healing. This is when they need the tools in our tool box to get through the “stuck”. What do these tools look like? For starters, research what foods may cause inflammation. Many of these include gluten, dairy, nightshades, and caffeine. It takes a special kind of artist to guide someone through dietary changes, especially to make sure they are getting enough protein and fats which is what the brain and blood brain barrier are made of. Really challenging someone to focus on what they can eat vs. what they cannot, keeping their focus positive vs. negative, is key to improving nutritional habits and concussion symptoms associated with them. Secondly, how do you know they are getting enough protein? See below for recommendations from Houston Methodist Orthopedics & Sports Medicine; it’s a great resource! Craving more on nutrition and concussion? Stay tuned for part 2 of this series: a case study on how cutting out gluten abolished an athlete’s symptoms completely.

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Updating the Return to Play Timeframe

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https://www.news.com.au/sport/rugby/world-rugby-extends-minimum-period-that-a-concussed-player-has-to-sit-out-from-seven-to-12-days/news-story/548dfa4b23cf7dc4bd180d43bb5c7207

The above article is associated with World Rugby and their new announcement requiring all athletes that have been diagnosed with a concussion being sidelined for a minimum of 12 days. Formerly this minimum requirement was 7 days across the world, a standard practice regardless of sport. At Dr. Fitzgerald & Associates Vision In Motion clinic, we see numerous athletes, of all ages, that did not think their head impact was “a big deal”. It was only when they began realizing, days later, that they had a headache with certain tasks of daily living, or that they became dizzy when they sat up from lying down, and that they forgot their neighbor’s name across the street. Just like with delayed onset muscle soreness (DOMS) after exercise, symptoms of a concussion can also be delayed. It is important to gain a thorough history of mechanism of injury, symptom provocation, and discuss nutrition, exercise habits, and sleep hygiene when evaluating and treating a concussion. It is equally as important to utilize the return to play protocol appropriately, and monitor the athlete’s heart rate throughout each phase, since symptom provocation may be delayed up to 24 hours, heart rate will tell you immediately if the athlete will have a side effect from any physical or cognitive activity.

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Using sound waves to balance the vestibular system

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A common question I ask when someone tells me they are dizzy is, “Do you feel like you are moving, or is the world around you moving?” When the answer is “I am moving” then we get the patient’s subjective response on which way they feel a sway, and then we also perform an assessment to get an objective verification of that sway. THEN, we use an app called Tone Pacer with bone conduction headphones to use sound waves to balance the vestibular system and discontinue the balance dysfunction causing dizziness.

Frequencies specific to vestibular canals are 100 Hz for the anterior canals and 500 Hz for the posterior canals. At Vision In Motion, we use an app called Tone Pacer to customize the frequencies used because we can customize it per ear. For example, if a patient demonstrates an anterior sway when the head is positioned up and to the right (left anterior canal and right posterior canal) then we will put 500 Hz on the left ear and 100 Hz on the right ear to activate the opposites of what we just saw. We always perform a dual task when using sound waves for vestibular balance, such as eye hand coordination activities, VOR exercises, and peripheral vision coordination exercises. We may do this anywhere between 5 and 20 minutes per session depending on how the patient tolerates this type of treatment.

Breakdown:

If there is an anterior sway, that means the side the anterior canal activated is overactive. This is why we would apply posterior frequencies to this canal; balance. The same concept is taken if there is a posterior sway and we need to apply anterior frequencies.

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Visual Snow Trajectories

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With the visual snow patients that we have encountered this year and the different treatment outcomes they have individually reported, we have noticed that there may be varying trajectories of why the visual snow occurs. 

  1. Biochemical
    1. Lifestyle
    2. Illness 
  2. Physiological
    1. Injury (i.e. concussion/TBI)

Treatments that have reported the most consistent positive outcomes include combinations of light and sound wave frequencies to increase energy reserves and the energy balance of the autonomic nervous system. Patients that are naturally a calmer demeanor, are not involved in regular exercise, and suffer from a biochemical trajectory seem to take much longer for treatment to have an effect than patients whose visual snow was onset by a concussion. To have more positive outcomes with these patients we discuss:

  1. Regular exercise that does not worsen the intensity of the visual snow. This may be something they have to trial and error.
  2. Nutrition. Are they getting the recommended daily amounts of fruits, vegetables, and protein? What kind of inflammatory foods are currently part of their diet and potentially inhibiting recovery?
  3. Sleep quality and consistency.
  4. Smoking cessation and avoiding alcohol consumption. This naturally increases the stress and sympathetic response of the autonomic nervous system, causing symptoms to worsen and be stuck. 

There is a website that you can ask the patient to use so you can see what they are seeing in their visual snow: https://visionsimulations.com/visual-snow.htm

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Retinal Detachment

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Importance of visual rehabilitation following eye and brain injuries:

The addition of vision rehab early in the recovery process following a TBI or eye injury can significantly impact the short term and long term outcomes and success of safely returning to play and work. 

A recent example: Female high school soccer athlete came in with a history of a retinal detachment (including 3 surgeries). Main symptomatology – decreased reaction time and visual field deficits in the affected eye and the opposite eye due to fast onset of cataract. 

Goals include:

  1. Implementing and being comfortable with protective equipment
  2. Improving reaction time in both central and peripheral fields of available vision
  3. Safe return to ADLs
  4. Preventing further injury/loss of vision 

Within 5 weeks of this athlete performing sports vision training exercises 2x a week in our clinic she has improved her overall reaction time by 2.5 seconds! She no longer has to completely search for a target; she just sees it and responds. For a 15 year old girl with a full life ahead of her this could have been tragic, but because of her attitude and family support she was able to be proactive and take hold of her future. She has not missed a high school soccer game yet.

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Cerebellar Ataxia: What can we do to help?

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We have had multiple patients come in recently presenting with Cerebellar Ataxia. Some of their main symptoms have included balance and swaying with weight bearing activities, double vision, and a lack of spatial awareness. We have experienced good results utilizing full body vibration at varying frequencies, plantar surface vibration with oculomotor tasks, VOR (seated then standing), EHC with proprioceptive stances, prism usage, and crossbody movements with oculomotor tasks. 

Our patients demonstrate improved confidence with walking and less reliance on walking aids within just a couple of sessions utilizing these treatments along with others. We have seen improvements in double vision with using prisms and seeing results last after taking the prisms off.

Just like muscles and soft tissues, the cerebellum needs to move and be challenged so it does not shrink. Regardless of age, hobbies, limitations…

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Nutrition Part 3: Protein Timing

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Everyone in healthcare stresses protein intake, and if they don’t they should! What most don’t tell you is that the timing of protein consumption is also crucial to performance. Case example:

Athlete walks in for concussion rehab at 345 pm AFTER a full day of work. When she was unable to perform word association as well as she has previously, we asked how much protein she has eaten today. Her response sounded mildly defensive, but she did respond with a smile on her face when she said, “I just ate a protein bar on the way here, and had muscle milk for breakfast”. We estimated that this was about 1/4 of what her daily protein intake needed to be for her body weight.

The clinicians had a great discussion with the athlete about the timing of protein consumption. It is most important to start the day off with natural sources of protein and then consuming it evenly throughout the day so that there is no drop in energy level. It is also important to consider how much protein is consumed of an evening, because this increases sleep quality. 

If you are unsure what the definition of a “good” source of protein is, you can always ask us and work collaboratively for positive patient outcomes. 

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Patient Engagement

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Keeping patients engaged in their care can help with patient compliance, leading to better outcomes of care. So what are ways that we can keep them engaged during treatments and when not in our direct care?

Some ways that are successful include: 1) finding out what they are passionate about and helping them to stay active with that activity during recovery. Even if it’s only in small increments. 2) doing our best to keep the atmosphere in the clinic light and welcoming; doing this through fun activities. 3) different conversational techniques, including humor with the appropriate patient population. 4) making the treatment sessions as competitive as the patient is (i.e. If the patient is super competitive in nature then we focus on the scores and how the scores they achieve compare to other scores we’ve seen on the same activities. And if the patient isn’t very competitive, we keep it about how they are feeling with the activities and not the scores as their standard for progress.) Patient engagement is important in keeping them compliant with their care, and giving them the steering wheel in their recovery process. 
These are just a few examples. What are ways that you utilize to keep your patients engaged?

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Golf Master’s 2023

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Did anyone watch the Master’s this weekend? (April 6-9, 2023)

We did. And wow, what a show. It reminds me that even professional athletes are human, in reference to Jon Rahm pulling out a ham sandwich in the middle of the tournament. I will attest, I am not a huge golfer. In fact I have a hard time watching it because I don’t understand when an athlete has good form, bad form, or what a “good” shot looks like. Regardless of that, each professional (and amateur in this year’s tournament) golfer spend countless hours training physically with trainers, mentally, and actually on the golf course. Some also do sports vision training in order to get their eyes to sink the putt, or to use the appropriate force in their swing. Which takes depth perception and eye hand coordination. Sports vision training also strongly utilizes cervical positioning. What kind of sports vision exercises could you do in various cervical positions that are golf specific? 

While you think about that, let me give you some ideas: 

  1. Ball toss with cervical rotation
  2. Chart exercises in side plank. You could also have them do thread the needle with this to really work gaze stabilization after changing direction.
  3. Pursuits with eye hand coordination in cervical rotation at various distances and eye levels.

Although golf seems like a slower paced sport, it’s really not. It takes a significant amount of concentration, technique, and visual endurance to be above average at the sport. Next time you spectate golf, or participate yourself, think about what kind of visual requirements the sport takes and how you as a healthcare professional can improve those skills. Until next time…

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Massive Results

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20 yo college student/club volleyball coach presented to the clinic last week with a symptom score in the upper 20s, with the history of 7 concussions in her last 2 years of high school then went a year and half without 1. A month ago was hit in the face with a volleyball during a practice and got another concussion. Pt family member expressed observed symptoms of migraines and “spacing out” during conversations. The Pt was seen in the clinic 4x this week and received treatments including but not limited to: syntonics (AlphaOmega/MuUpsilon), PEMF mat with Huso sound waves, cervical and facial dry needling, EHC activities, saccadic exercises, and neuro entrainment/meditative therapy with intermittent compression. 

After roughly 4 years of struggling with symptoms from multiple concussions and receiving no formal treatment, the Pt left her appointment today with a symptom score of 1 (headache) and stated that she is feeling better than she has in a few years.
The plan is to continue to treat her concussion and graduate to a return to play protocol so she can continue to exercise and coach volleyball without any worries of symptom provocation.

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Unilateral Nasal Occlusion

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A couple of weeks ago we evaluated a patient that had been diagnosed with a concussion after falling to the ground when slipping her shoes off. She presents with all of the typical high scored symptoms: headache, nausea, visual fatigue, difficulty concentrating, difficulty remembering, but NO SLEEP DYSFUNCTION!!!! Phew, finally one without sleep dysfunction. 

Upon observation, we noticed that one eye was naturally more converged than the other. She was actually unaware that her left eye was set this way and reported no history of visual dysfunction. So…instead of using a binasal occlusion to increase bilateral divergence we decided to try unilateral nasal occlusion with the eye that was struggling the most with divergence. After application to the left eye, the occlusion instantly gave the patient mild headache relief and improved eye hand coordination. She was educated to keep it on until she became visually fatigued and then take it off at home. This patient was compliant and reports taking it off a couple hours after her appointment had ended. 

In order to keep progressing, we had to get this woman back to work. Along with our inter-professional blog post, she is working with her primary care physician on a return to work plan. She works full time utilizing 2 computer monitors to be effective and efficient in her job, however we all understand how this can cause symptom provocation, eye fatigue, and inhibit concussion recovery. We decided to utilize this unilateral nasal occlusion on her glasses during work hours to see if that would help in getting her eyes to work together and avoid over convergence. 

It worked! The patient was able to go from working 3 hours/day last week to 5 hours today (per physician order) with even less symptoms than she had before! She does take the occlusion off after work and continues to demonstrate an increase in visual endurance with eye hand coordination and ocular motor tasks. We plan to continue treating her 2-3x per week until she is asymptomatic and back to work without restrictions. 

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Working Inter-professionally

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In our clinic, we work collaboratively on multiple cases with other healthcare providers to help our patients get better as quickly and safely as possible. Working with doctors of different specialties (i.e. Neurology, sports medicine, orthopedics, etc.), physical therapists, and athletic trainers is essential in returning our patients to normal ADLs and sport participation. The tricky part is getting all involved parties on the same page and keeping them on the same page, that way no one is stepping on the others toes and hindering the advancement of the patient’s recovery process. This can be difficult when days get busy or when one person out of the care team does not communicate care with the other. 

Example: an athlete is being seen for concussion recovery and is attempting to complete a return to play protocol (which is a minimum of 5 days, 24 hours asymptomatic between each day). The athlete also has another injury, unrelated to the concussion, that they are seeing another care provider for. Even though these injuries are unrelated, they do affect the body’s physiological response! To return this athlete to play, we had to put a hold on her other therapy so that it did not affect her ability to finish this 5 day protocol.

Continuing to strengthen communication skills, both written and verbal, is a big factor in keeping everyone working towards that patient’s goal. And then documenting what the patient’s goals are, keeping inter-professional communications in the patient’s electronic or paper chart, and taking the time to look at those charts to remind ourselves of where the patient is at in reaching those established goals.

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