Eye2Brain Academy

Sleep: Chronotypes

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

Nutrition & Concussion Part 2: Gluten Case Study

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.

Nutrition & Concussion: Part 1

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.

Updating the Return to Play Timeframe

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.

Nutrition Part 3: Protein Timing

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. 

Patient Engagement

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?

Golf Master’s 2023

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…

Massive Results

 

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.

Unilateral Nasal Occlusion

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. 

Working Inter-professionally

 

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.

Happy Friday from Dr. Fitzgerald!

 

Good morning everyone! Hope your Friday is happy and healthy. I spoke about the z-vibe as a tool to help get patients in a better position to be able to do more therapy. Vibration as a whole, and utilizing the z-vibe, allows us to  contribute to improved outcomes. This is a very powerful tool in helping patients with balance issues. We will be starting the monthly webinars with emphasis on therapy protocols. Stay tuned for those protocols and how to implement them in your practice. With nearly 7.8 million people a year reporting concussion, there is absolutely plenty of folks that need our help. And with the literature supporting that vision is affected in 90% + of folks, we are in big demand. And anyone helping in concussion management, I do not know how we can do treatment without a thorough eye exam. Keep posted. Happy Friday!!

Cerebral Spinal Fluid Leak Case Study

 

Now 70 year old male tells his story of an injection gone wrong…7 and a 1/2 years ago he went in for a lumbar spine epidural and he ended up with a cerebral spinal fluid leak. This has caused constant, 24/7, headaches that are reported to be all over the head and very severe. 

After being evaluated by Dr. Fitzgerald, OD at Dr. Fitzgerald & Associates, he was referred to complete a Multi-Sensory Reset Therapy (the Vision In Motion Pinnacle Program for those of you that know of it). Throughout the 12 day program, he was dry needled by an Athletic Trainer 2-3 x per week to relieve head pressure and allow the cerebral spinal fluid to flow. The patient states that he felt the largest impact from dry needling than he ever has with any other treatment. 

He continues to receive treatment 1-2x per week during the 1 month period between the end of the MSRT program and his re-assessment with Dr. Fitzgerald, OD. These sessions consist of eye hand coordination exercises, specifically noted benefits from tossing a ball with a partner, and dry needling. 

This patient continues to report improvements in his chronic headaches; that they now occur only at the end of the day. AND that some times he goes days without one at all! Can you imagine going through the trauma that this man has, understanding that he will always be in pain due to the injection gone wrong, and then wake up without headaches multiple days in a row?! That is the power of combining treatments appropriately, utilizing your medicine team, and incorporating a 360 degree health program. 

Intricate Work Comp Concussion Case

3/9/2023 Concussion Case Study

 

30 y.o. Female sustains a concussion while holding a child during a co-treat speech therapy session. As the child extended to avoid cueing from another therapist, our patient extended to avoid him and her chair fell back resulting in contact with her head against the wall. 

 

This patient attempted to continue working without limitations for 2 weeks after being diagnosed with a concussion. Due to severe symptoms of blurred vision, headache, nausea, dizziness, sleep dysfunction, difficulty remembering, difficulty concentrating she was put on workman’s compensation and referred to Dr. Fitzgerald & Associates for concussion rehabilitation. Her baseline post-injury Right Eye Assessment is as follows:

 

Began with a total symptom score of 32/96 upon beginning concussion rehabilitation. The patient began treatment utilizing the eyes with syntonic light frequency therapy to balance the autonomic nervous system. We were then able to progress to peripheral vision exercises, taking the strain off of her lack of convergence. As her symptoms progressively decreased, she was able to tolerate eye hand coordination exercises, depth perception exercises, and all exercises forcing the eyes to team together with all movements. She was cleared to return to work by her work comp MD for 4 hours per day, multiple days per week. From 1/4/2023 to 1/27/2023 she attempted this schedule, while also doing concussion management around various work hours. This caused stress to her visual and emotional systems due to using her computer to document therapies done with children under duress. 

 

Due to the consistent symptom score of about 24/96, she began our Multi-Sensory Reset Therapy (Pinnacle Program) for 1 hour per day x 12 days in a row; discontinuing work until further notice. This helped to continue to balance her autonomic nervous system, continue to work toward her eyes working effectively and efficiently together, and decrease her emotional response to stressful situations. She continued concussion management with an Athletic Trainer 3x per week upon completion of this 12-day program. 

 

Two months after her initial visit, her Right Eye Assessment looks like:

This demonstrates that the patient now needs an increased amount of vestibular integration to reduce symptoms. 

 

Utilization of compression, weighted lei, and going shoes off to increase proprioception have improved vestibular responses. She also benefited from sound wave therapy, whether it be standing on a vibration plate or utilizing sound waves over both ears. As of 3/8/2023, she arrived at rehabilitation with a total symptom score of 11 and left at a 4/96…! She has improved sleep quality, zero blurry vision, and is able to perform body weight exercises and walking based cardio exercises without symptom provocation. 

 

She has been back to work for 1 week at 4 hours per day, every morning, with a maximum of 2 patients per day to allow ample documentation time before going home. The patient reports no symptom change or increase with work stimuli now. Below is her Right Eye Assessment from 3/6/2023:

This patient still has some working to do in order to return to her normal, or new normal after concussion. However she has demonstrated significant improvement in every trajectory of concussion.

Hockey Puck Case Study

Case Study:
Professional hockey player takes a puck to his right zygomatic arch during a game. He has a clear laceration from the impact. After a trip to the ER for 3 stitches and x-rays, he is clear of any fractures. Dr. Fitzgerald & Associates was able to rule out any retinal damage 2 days after the injury occurred.
At this time the athlete complains of headache pressure around the right eye and zygomatic bone. He was treated with syntonics to balance the autonomic nervous system, the PEMF mat for inflammation, and dry needling around the injury site utilizing homeostatic and symptomatic points. He states that the combination of treatments completely resolved his symptoms of pressure and that he now had mild pressure on the opposite side of his face.
Thanks to this treatment he was able to be cleared of any concussion and play in the games the following week. His Athletic Trainer and equipment manager did make him wear a fishbowl mask around his entire face, attached to his helmet. Due to inter-professional care this athlete, and others, have been able to return to competition so much faster than when working with just one individual.