Life After Impact: The Concussion Recovery Podcast
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Life After Impact: The Concussion Recovery Podcast
Autonomic Dysfunction After Brain Injury - An Interview with Dr. John McClaren - Part 1 | E11
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Dr. John McClaren shares his journey into specializing in brain injury rehabilitation and explains how autonomic nervous system dysfunction affects many TBI patients, often going undiagnosed despite causing significant symptoms.
• Personal connection to TBI after his father's severe train accident which inspired his specialization
• Conventional autonomic testing (QSART, tilt table) often has 6-month waiting lists, delaying treatment
• Autonomic nervous system functioning requires responsiveness - like a high-performance sports car - needing both acceleration and braking capabilities
• Simple bedside assessments can reveal autonomic dysfunction without lengthy waits
• Pupillary light reflex testing using smartphone apps provides millisecond-precision measurements
• Blood pressure differences between sides and positions offer valuable diagnostic information
• Heart examination with position changes can detect subtle autonomic abnormalities
• White matter connections between brain regions drive proper autonomic function
• Current focus on vagus nerve may miss the bigger picture of central autonomic network dysfunction
• New imaging techniques like DTI now allowing visualization of damaged neural connections
Dr. McClaren can be contacted at Advanced Chiropractic & Neurology in Omaha Nebraska.
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What you're looking at for people who are getting these reflex tests done. Those are the things they're going to do the QSART testing and the tilt table test, which you know we're going to orthostatically challenge you and see what happens to your blood pressure and your heart rate over time. And do the responses occur normally, or do I get, you know, a huge rise in my heart rate and a drop in my blood pressure when I become upright, which is not, you know, the response that you want to have, and it's got to meet a certain criteria which they change. You know they move the goalposts all the time on this stuff too. You know, used to be 30 beats a minute, now some people are saying 40, you know, because it's like one.
Dr. John McClarenDo we have so many people, especially in this post COVID era, that have autonomic nervous system dysfunction? You know, and you know again what we know not function, you know, and you, you know again, we, you know, not to get ahead of ourselves on topic there, but you combine some of these things, which is the human experience, you know, oh boy
Podcast Introduction & Dr. McLaren
Dr. John McClarenright.
Sophia BouwensWelcome to the Life After Impact podcast, where we do a deep dive into all things concussion and brain injury related. We talk about all the different symptoms that can follow brain injury, different testing methods, different types of specialists out there and different therapies available. I'm Sophia Bowens, I'm here with Dr Ayla Wolf and we will be your guide to living your best life after impact.
Dr. Ayla WolfWelcome to the Life After Impact podcast, where today we have Dr John McLaren on the show. And Dr McLaren, you've been in private practice since 2002 outside of Omaha, Nebraska, correct?
Dr. John McClarenCorrect.
Dr. Ayla WolfAnd you have a diplomat in chiropractic neurology. You also completed a very intense program and earned a fellowship by the American Board of Brain Injury and Rehabilitation. And then, if that wasn't enough, you actually went back to school. You already have a doctorate degree, but you went back to school. You got a master's degree in clinical neuroscience, where you spent a lot of time studying traumatic brain injuries as well as dysautonomia, and then you earned your master's in clinical neuroscience. You're on the faculty of the Carrick Institute, You've had the honor of presenting at the International Symposium of Clinical Neuroscience and you specialize in your practice in brain injuries, concussions and different neurological disorders. So I'm thrilled to have you on the show as one of my teachers. I find you to be just a wealth of information and so generous in sharing your information. So thank you so much for being here.
Dr. John McClarenThat is about the greatest introduction I could ever ask for. Thank you so much for the kind words. And yeah, I've done. I've done all that. I guilty as charged. My wife would say it's just because you're bored or you know things like that. But but the thing that is great about clinical practice, and when you get into this stuff, you just, you know, you dip your toes in a little bit and it's like, oh, I'll just go to, you know I even me, you know, it's like I'll just go to the first TBI seminar, I'll get some guidelines. I already kind of know what I'm doing. And then I'm like I don't know what I'm doing at all. So here I am, you know, like I said, you know sucking that from the fire hose, trying to get more, and you know you're in over your head and it's it's definitely something you can never, you can never know enough in this practice. Same with you, you're super duper credentialed and you just keep going and I am so excited for your book.
Dr. John McClarenThank you Personally and for my patients and anybody else that I'd refer to. So put me on the list.
Dr. Ayla WolfThank you for that. And you are so right, I think. Every single patient comes in and presents with their own unique challenges. That forces us to constantly be learning more and it's
Dr. McLaren's Personal TBI Connection
Dr. Ayla Wolfnever ending. I mean, even with my book. I referenced papers that were published in January of 2025 in my book. Like I mean, it's just the amount of new stuff coming out is so good it is, and that's the thing you go.
Dr. John McClarenOne more paper I remember when I did my long COVID class I found a paper I think it was that week or the week before that got published and it's like hey guys, this is hot off the press. I don't even have a citation for it yet. So it's the way it goes. For sure, you find stuff all the time, and it's kind of nice when assertions you make in your research get validated kind of at the last second, like that too.
Dr. Ayla WolfIt's really, really fun. Oh yeah, absolutely. You know things like patterns that you were seeing or things that you observed. All of a sudden, someone publishes a research paper on it and you go okay, so I'm not crazy, I really am. You know, seeing this correctly.
Dr. John McClarenYeah, I'm not the only person that saw this, or you find stuff that was way, way buried in the weeds and it. You know, for some reason it wasn't really spoken about a lot, but then you know a lot with the olfaction and the long COVID, that was really really big and it was nice to see that, because olfaction, you know I always said it's kind of like the redheaded stepchild of our. You know it's a vestigial sense, it doesn't mean much, and then COVID happens and everybody's like well, I guess olfaction is probably pretty important for cognitive function.
Dr. Ayla WolfYes, I mean the amount of anxiety that people were having when they couldn't smell and I think people don't realize, you know, when you can't smell, you don't know if your house is on fire, and that you know not knowing can create tons of anxiety when you aren't, when you lose that sense to when you lose that sense, oh for sure, yeah.
Dr. John McClarenOr you know even simple things like well, the baby's got a loaded diaper and you know stuff like that, you just go, geez, it's like I don't want to smell it, but you kind of want to know for the kid right, Right. You do need to know if the diaper change needs to happen.
Dr. Ayla WolfYeah, yeah, exactly, yes. Well, I did read a study that said that 55% of people, after a traumatic brain injury, have changes in their smell that lasted, for you know, up to a year afterwards. I've certainly had patients that have experienced a loss of smell longer than that. So you know also with brain injuries, that loss of smell can be a symptom as well. Why don't you give us some of your background in terms of what led you to not only study chiropractic but then to specialize in neurology specifically?
Dr. John McClarenYou got it, yeah. So how did I get here, so to speak? And you know the thing, and in listening to you guys in the podcast and in our discussions from before too, we always, you know, when we kind of choose our healthcare profession, we have kind of a horse in the race, you know, so to speak, or things like that. I was a high school student at Cornhusker Boys State. The Boys and Girls State programs are these legion programs that they do for like leadership development and things like that for high school, like juniors going into senior year. I was at Cornhusker Boys State, my you know junior going into my senior year, and I get a call from my mom.
Dr. John McClarenYou know, your dad was in an accident, you know, and I think you know I had some friends in the room and we were meeting with one of my friends who was like this gubernatorial candidate and no-transcript. One train ran into the other this wreckage goes everywhere and my dad was in an oncoming train and his conductor jumped off the train and dad was thrown off the train as these things collided, landed on his head, his neck and so on. Luckily he was not paralyzed Worse, you know. You know gets up, you know see stars, claws his way up the hill, this kind of thing, and you know they run for their lives, they get away far enough and they just watch the carnage happen. And then you know, ambulances come in and they transport them to North Platte, which is, you know, a central Nebraska town. That's kind of got the hub for emergency services and things like that. And his doctor in North Platte was our like childhood, my childhood doctor. He'd moved on and so it was kind of nice to get a familial connection. Nebraska is small like that. I grew up in Western Nebraska so then, you know, I became intimately familiar with the world of traumatic brain injury.
Dr. John McClarenIt took a little while for my dad to get the diagnosis. He's diagnosed with a traumatic brain injury, ptsd, which you know some of the things we're going to be talking about today. You know all these kind of things. He had a neck injury as well, which I have loved the way you guys have talked about neck injury on the podcast so far. I mean, you know, chef's kiss, you guys nail that stuff super well.
Dr. John McClarenAnd this is dad. He ends up having four vertebra fused and, you know, had a neuropsychologist who got, you know, the diagnosis correct for him and you know, and the thing I saw with my dad, as you know, I went on. I was a powerlifter in college. I didn't know that I was going to be a health care guy at that time when dad got hurt, but I was. You know, stem was kind of my path. It was STEM or it was politics and I'm glad I went to STEM and not politics. You know, with the boy state thing and I had. I was a collegiate power lifter. I had a shoulder injury, had a chiropractor. That I found via this muscle media you remember Muscle media magazine back in the day.
Dr. Ayla WolfI started working in a health food store that was managed by a bodybuilder when I was like 15 years old, so we probably had it laying around.
Dr. John McClarenYeah, it's around there. Bill Phillips would do the challenge and he'd give his cord anyway to these guys. You know. Yeah, they had an article on on active release technique at the time and I'd had the shoulder injury and the orthos couldn't figure out what to do and you know, it's like we can open you up and go in and I was nationally ranked as a power lifter and the shoulder thing kind of took me down a few places.
Dr. John McClarenSo I went to this ART chiropractor and it's like that is what I want to do with my life. I didn't know at the time how it would tie in with a traumatic brain injury, until later, you know. So I decided chiropractic school, is it? I
Journey to Neurological Specialization
Dr. John McClarenenroll at Parker, my sister lived in Dallas. That's why I chose Parker. You know everybody will say my chiropractic school is the best because it's because my sister lived in Dallas and I I wanted to have family close by for professional school, just because sometimes it's like man, I I'd have a home-cooked steak or something like that, or somebody to listen to me cry when I'm struggling.
Dr. Ayla WolfOr to quiz you with the note cards.
Dr. John McClarenAll that, yeah, here, throw them at her when I miss. She got good at dodging them. So I chose Dallas and I went to Parker and my friend Haney Helmy my first trimester in school, you know and Haney and Glenn Zielinski, you know, glenn, you know those guys were like tri six at the time I was tri one and these guys, you know they. They were like you got to see this Professor Carrick guy and they showed me a couple of the short shorts videos where he's running around on the stage, you know, and he's getting these people with Parkinson's to get up out of chairs and all these kinds of things. And he had a. He had a patient on one of the case studies they showed me that was a traumatic brain injury patient. I'm like, tell me more and. And they did and and they got me hooked and and you know, we, we started a, we, they started a neurology club and I just went and you know, same thing. It's like, give me all you got. So so I start to learn some things. Go home Maybe some of this stuff.
Dr. John McClarenMy dad had residuals. This is I went to chiropractic school in 98, you know. So I'd go home for breaks, like you know, as as these guys kind of introduced me to some of the principles of examination and treatment. You know, let's, let's try it with dad. You know, dad's balance is terrible, eyes closed. You know, when he tips his head back, things like that He'd had, he'd had some fusion in his neck and things like that too.
Dr. John McClarenSo it's, it's one of those really complicated cases. It's like right away I got a cool TBI case before I even leave school whenever I want, you know, and he was, he liked it because it helped him. You know, he noticed differences right away. And again, I'm hooked. They started the diplomate on campus my seventh trimester at Parker. You know, at the time it was a nine trimester program. So you know, my last year they started the program on campus. Again, dr Klotzik and Dr Peter Percoco were there as my instructors and you know, like module one I had like 35 pages of handwritten notes and if you've seen my handwriting, that's like terrible. So then I was in.
Dr. Ayla WolfYeah. For sure, and so how do people find you in your community? And I actually lived in Omaha for about six months, by the way, when I was an infant.
Dr. John McClarenOh, how about that? I didn't know that.
Dr. Ayla WolfMy dad got transferred there for work for like six months, so obviously I have no recollection of it but I did live in Omaha.
Dr. John McClarenYou don't remember the flat plains?
Dr. Ayla WolfNope, I just remember that we have home videos where there's just like really trippy music playing in the background. I was like dad, what were you into?
Dr. John McClarenThat's kind of awesome. Yeah, yeah, yeah. What did Omaha introduce him to? Music? Wise, right? That's cool. That's cool. Yeah, I've been in practice. You nailed it. I've been in practice for 23 years now and you know it was just last month we celebrated, kind of the birthday of the practice, which is awesome. In my wildest dreams couldn't have imagined it going as well as it has, of course, hiccups and bumps and bruises and all sorts of things, but it's just, it's been awesome. I haven't had to do, we just brought in some new stuff. You know, I've got I've got some things that I've never marketed for that I really want to expose people to a little more and brought in some new stuff. But I haven't done any marketing or or you know those kinds of outreach things, since the yellow pages were like a way to actually find people you know, to date myself.
Dr. John McClarenRight, you know, that's you know. And yellow pages don't work anymore.
Dr. Ayla WolfIt's tough when you're so busy with patients you don't have the time to then also be a marketing executive for your own company no-transcript, that kind of thing or whatever.
Dr. John McClarenSo you don't have to, you don't have to bother them with it, even though they're super great at taking care of people. So it's like, yeah, let's, let's get back on. And I, just today, you know, and so you know, you start posting things like here, here's another hyperbaric treatment, or here's some pulse EMF that we're offering for you know, all the stuff you would offer that for now, like, like my, you know, and, of course, because I've been dead for four years on Facebook, nobody, nobody's watching me anymore or anything anyway. And then today I took the wife and kids to brunch before this and I posted a food picture because I'm like I haven't seen a food picture since I've been on Facebook. More engagement with that than any of my work stuff.
Dr. Ayla WolfI totally, I totally know that, like I will post, you know, a link to a blog that I think is just so rich with information and it gets like one like. And then I post a picture of my dog and it gets like 55 likes and you're just like all right, the animals win every time.
Dr. John McClarenEverybody's like I want to hug him. You know that kind of thing. Yeah, yeah, I know I'm giving you the like on the post and you're like well, that that's great, but it doesn't help. No-transcript my practice, especially early on. You know, and you see movement disorder cases and TBI cases and you do some things. You know, and there wasn't a Facebook forum for collaboration like there is now or any that kind of stuff. So you know it's like I'd call the one or two people I knew and they're like I don't know. You know, and we just kind of learned to try. You know what would an optokinetic do in this situation or things like that. And then you know the TBI fellowship program starts and I found out how behind I was a lot of other people when I first got into that, because you know we have so many people in this care trained. You know variety of disciplines between you know like you know your acupuncturists, the physical therapists that are doing it. You know the nurse, nurse and nurse practitioner people that are doing it. I mean you'll get Melissa Biscardi's work. You know those kind of things, just amazing and even medical doctors that really are fascinated with this kind of work. So you know, a lot of it originally was a lot of doctors at chiropractic, you know, and then Professor Carrick built the bridges and here it is. It's like, hey, you know, we're not the only people that can do this stuff there. Hey, we're not the only people that can do this stuff. There's an evidence base for it and I think it's impressed so many varieties of people and you can really tie it into whatever kind of practice you want. So I just think we have people that are trained really well. I've gotten to where Carla Mellenbacher made a connection for me with somebody
Building a Specialized TBI Practice
Dr. John McClarenwho's a speech language pathologist in our community, you know, in that they went out to see her when she was out in California for TBI Because, again, you know, I wasn't marketing that, I was in TBI and they live in my community. So Carla's like go see John when you get back home. And the thing organically grew. Tammy got me involved with the Brain Injury Alliance, you know, and I've spoken at their state annual conference. I've done a lot of their support group work and things like that. So it really kind of got me into that community. I've done some collabs at the hospital up there where we've rounded with each other. I've rounded with them. They've come and rounded with me and a lot of times now you know some of the SLPs that are doing a lot of the TBI work up there speech and language pathologists they get a ton of this stuff, you know, and they get a ton of really complex TBIs.
Dr. John McClarenAnd sometimes the thing and again, you know, a lot of people are doing TBI work now in a variety of professions because there's so much of it out there and there's such a need but people have a tendency to not blend things together because of, you know, differences in training and things like that. And that's the thing Professor Carrick has kind of showed us is we can blend principles from every specialty together into what he calls head-eye vestibular motion therapy or you know those kinds of things. So it's like, hey, john, I got one, I'm I've done X, y, z, can I send them over? And of course it's like, well, yeah, please, some of them are really, really tough, you know, and I get why there there's struggles there for sure. So so that's one of the ways I've kind of become known in the community.
Dr. John McClarenA lot of it is referral, you know from, from internal patients. It's like, hey, my cousin's sister's brother had a TBI, can they come see you? And it's like, well, yeah, of course I'm here, and that's the thing I think people don't want, these cookie cutter approaches. You know that, that you can find that, that, you know, just like any modality on its own, you kind of get that 80, 10, 10 rule. You know, maybe it works for 80% of people, 10% of people it somewhat works for, and 10% are your, your non-responders, that need to move on to something else.
Dr. Ayla WolfShort answer.
Dr. Ayla WolfYou get a lot of people in the community who know your specialty and and so one of the things that I I know you worked really hard on was this presentation on long COVID that you taught for the Carrick Institute and I know a huge part of that was a deep dive into autonomic nervous system dysfunction, and so I wanted to have you maybe talk a little bit about autonomic nervous system dysfunction that you see, not only with long COVID, but also that is one of the things that when patients come to me, that I often find has been the thing that's been undiagnosed until they come in and I start paying attention to it, and so a lot of, at least in where I live, I know there's like a three to six month waiting list for people when they get referred to these conventional big hospitals for their autonomic reflex testing.
Dr. Ayla WolfSo it's great that we have some really great tools that we can do bedside that you know don't have a six-month waiting list or don't require, you know, some super high tech and why don't you talk a little bit about you know somebody comes in to see you A lot of times. The autonomic assessment is really the cornerstone or the foundation of what we're looking at here. So maybe talk a little bit about how frequently you do see that in people that are having these lingering post-concussion symptoms, and then how you're assessing it.
Dr. John McClarenThere are so many things that we can do. I mean, you talk about QSART testing or tilt table testing and things like that, you know, and one of the things like you, you know not to not to make it sound like I'm a super genius you sent me a list of topics ahead of time so I could kind of get in there and do a little bit
Autonomic Testing and Assessment Methods
Dr. John McClarenof research on my own. And I thought, you know, let's look at QSART testing, your qualitative, you know, pseudomotor axon testing, where you know we're putting somebody in conditions and seeing what the sweat response is right, you know, and I thought let's see if that actually has a body of literature associated with TBI. I mean, did you go out and look for that QSART testing TBI like Google, scholar, pubmed, that?
Dr. Ayla Wolfkind of thing. I did not look for a specific link between those two. What'd you find?
Dr. John McClarenWell, I wanted to see it. I wanted to see it because, again, that's the thing what you're looking at for people who are getting these reflex tests done. Those are the things they're going to do the QSART testing and the tilt table test, which, you know, we're going to orthostatically challenge you and see what happens to your blood pressure and your heart rate over time. And do the responses occur normally, or do I get, you know, a huge rise in my heart rate and a drop in my blood pressure when I become upright, which is not, you know, the response that you want to have, and it's got to meet a certain criteria, which they change. You know they move the goalposts all the time on this stuff too. You know, used to be 30 beats a minute, now some people are saying 40, you know, because it's like one. Do we have so many people, especially in this post COVID era, that have autonomic nervous system dysfunction? You know, and you, you know again what we. You know not to get ahead of ourselves on topic there, but you combine some of these things, which is the human experience, you know, oh boy, right. But yeah, you know, people go and they get this stuff done and they get results that maybe aren't conclusive or things like that.
Dr. John McClarenIf you know, yeah, I've waited six months to get in. I was going to come see you but I figured I'd wait until I had a diagnosis before I would. And you go, that's six months of rehab. We lost. You know that kind of a thing and and and again.
Dr. John McClarenYou know, with traumatic brain injury you can make progress throughout the lifetime of the person, right? You know the old conventional wisdom of you know, and again, the goalpost move it's your. Six months is your recovery window. A year is your recovery window. Two years is your recovery window, right, and now it's like man. You know it's a lifetime recovery process that you can have as long as you keep working at it, and some of it is slow and some of it's long. But people get frustrated and you wait six months for a diagnosis and it just stinks. So I went out and I looked at that. Let's go to PubMed, let's go to Google Scholar and let's see if there aren't a lot of sources out there that link the QSART testing to being significant for dysautonomia associated with traumatic brain injury. Same with the tilt table test.
Dr. Ayla WolfI found it really interesting because I had a patient who came in and she had a lot of symptoms. She had had three concussions and I started working with her and she had gotten a referral to go do all the autonomic reflex testing. But she had a six month wait list and so she came in with a lot of symptoms. Well, I got to treat her for six months and then by the time she went to do all of the autonomic reflex testing, it was everything was normal, except for the QSART. However, there was a little note on the bottom that said this test can be impacted by certain medications, and there was, you know.
Dr. Ayla WolfI think a certain medication she was on that might have actually thrown it off. And there was, you know, I think, a certain medication she was on that might have actually thrown it off.
Dr. Ayla WolfBut you know, when we, you know way back in, like beginning of clinical neuroscience training, you know we talk about this concept of sweating, as you know, being increased sympathetic activity that can sometimes be uneven. Some people might actually say I sweat more in my right armpit than my left armpit, and so, even from a Chinese medicine perspective, sweating is a very important thing that we pay attention to, whether it's, you know, cold clammy hands or hot clammy hands, or if people have spontaneous sweating. You know. So, in from a Chinese medicine perspective, the whole sweating thing is an important thing that we do pay attention to. But you know, it's only one small piece of the autonomic pie, obviously. And so you know, I've, I think that a lot of this conventional testing, like you said, sometimes it's a little, it leaves people kind of with more questions than answers, I think.
Dr. John McClarenFor sure, yeah, for sure, and that's the thing. Or they get an inconclusive test, or or, yeah, they get some of those things where it's like, well, it's probably your medicine, it's not your, it's not your TBI. And that's the thing I see a lot, especially like if litigation's involved, they'll try to blame anything but the TBI. You know, I had a guy that was like, oh, it's diabetic neuropathy, you know, because he had like numb hands and feet. He had a myelopathic injury to his neck In addition to his TBI. He had like an A1C of 5.7. I'm like, thanks for that, you know, independent medical examiner for saying that. But that's the thing.
Dr. John McClarenA lot of these conventional tests they're waiting on for a really long time. I'm so glad your patient came in and got the rehab, you know it's like, oh, darn you, you passed your test. That means you know you high five and go well, let's just keep doing what we're doing. Then you don't need that stuff anymore, right, you don't? You don't need to wait for the next test to try to validate how you feel, you know, because that's ultimately what matters, right? People are coming in because they feel crappy and they want to feel better and they think, you know, because of whatever, whatever it is that they got to you that maybe you can help them. So you know, when we're looking at these things, yeah, how much do you sweat. You know and and and things that'll happen to. You know, if I've got some dysautonomia and I'm doing some things that I should sweat when I'm doing, what'll happen is instead I don't sweat and my hands and my feet and my nose and all these other things get really really cold, which, again you go in Chinese medicine. That's definitely not good. And again, in functional neurology. We know that's not good and you know you see these things where and that's one of the things in a lot of the training that we get.
Dr. John McClarenYou know the autonomic nervous system. Everybody talks about how, like it's parasympathetic, good, sympathetic, bad. Too much sympathetic activity is bad, absolutely. But a lot of times you know that kind of a model you're going. You need a sympathetic nervous system to take the load of clothes up the stairs and like not pass out, or you know things like that. Or to run around and chase your kid or something like that. You need to dilate some blood vessels and you need to get the lungs to expand at a little higher rate and you need, you know, pupillary dilation. So, as we're talking about these things, people who are trained like us are already going.
Dr. John McClarenYeah, now I know how we're crafting our examination that we're going to do at the bedside for this. So you know that that's one of the things like what do we do in our practices for testing. You know, and when somebody comes to see me, the first thing especially, you know you can look at like a Rivermead post-concussive score, especially if it's six months or later after they've had the TBI, because it's valid six months or later, right, you know, some of these other inventories you can look at are really good to kind of point you toward well, we've got some autonomic types of symptoms. But before I do any, you know, pursuit or saccade or vestibular testing or things like that, the first thing I want is a baseline people test before I contaminate it with my exam, right? So I'm going to come in and I use the reflex people app, but no disclosures. I have like a hundredth of a hundredth of a thousandth of a piece of stock on it because they offered it when you. You know it was like you get, you get a free month if you buy like a share or something. So I do have a tiny amount of share in it, but you know it's it's more, just because I think it's.
Dr. John McClarenIt's a fabulous piece of technology and and again, professor Kirk introduced us to this and we're getting a lot of data on what should happen with your people and you can use this thing. You know tons of different ways. The way, the way I use it at the beginning of my assessment is you know it'll, it'll come in, it'll flash. You should see a pupil constrict when it's exposed to light. You should see it dilate, you know, to 75% of its original size relatively quickly, and you should see it maintain. And the app gives you, you know, constriction speed metrics, dilation speed metrics, latency metrics, things that with my pen light I am not as good at. You know you can pick a lot of stuff up.
Dr. Ayla WolfI mean it's taking 30 frames a second when it does that. We can't do that with the naked eye.
Dr. John McClarenThese guys aren't doing 30 frames a second, that's for sure. Or maybe they're doing it, but it sure ain't processing up here. You know I wish, yeah, so it it. It gives you a lot of information and you can kind of segregate that into. You know some left brain versus right brain types of aspects in regard to autonomic. You know activations and so on and so forth. But you know those are things you should see. You get a pupillogram. How smooth is it? You know how much does it constrict, dilate? Do they maintain that throughout the process? That's the first thing I'm doing before I do really anything else other than maybe gabbing with somebody a little bit.
Dr. Ayla WolfSo we'll get some pupils, we'll get some blood pressures bilaterally, metrics are actually very narrow as far as, like, what's considered a normal latency between
Reading Pupillary Responses and Blood Pressure
Dr. Ayla Wolfthe light flashing and the pupil constricting, you know, and so, though, again like those windows of time that are measured in milliseconds, very hard to see with the naked eye if you just shine a pen light in someone's eye.
Dr. Ayla Wolfso I also love that that app that pupillary light reflex for that reason, is to be able to capture a latency down to a certain millisecond. You know, and knowing that the normal reference range is so narrow, you do start to be able to see. You know, this orchestra between the parasympathetic and sympathetic nervous systems in this test that takes 15 seconds to do.
Dr. John McClarenThat's beautiful. The orchestra word is exactly what it is. It's this fine waltz between the systems right when, if they work appropriately, odds are good. You know that patient's not going to have as big of a symptom load, or they're maybe not even going to come see you because they feel pretty good if it works like it's supposed to. You know. And then, yeah, you get in and you grab your sphygmometer and your your stethoscope and you take your blood pressures. You know what happens on the left side versus the right side. Then you compare it. You know, and that's the great thing about this, you go, I've got different metrics that I can compare.
Dr. John McClarenAnd then you start to go does this make sense? Do we have medications on board that can maybe contaminate some of our data, which? You go, well, there are some medications that can influence pupillary reactions. There are others that can influence your blood pressure findings, but it's really hard to find medications that influence everything equally. So you can go, well, I've got and again, even if they're on medications, these systems should adapt relatively well. Sometimes that's why they're taking the medication is to get the system to adapt well, and if it's why they're taking the medication is to get the system to adapt. Well, and if it's still not working, then you know, depending on your scope of practice and your relationship with your patient and your providers, you can give them that data. You can go, hey, you know, maybe the dose or the medicine isn't appropriate for this patient because we're still seeing XYZ and it could be ruining or contaminating or causing a problem with our rehabilitation coefficients and so on.
Dr. John McClarenJust communicating with other providers, which, again, when you ask, how do people find you and how do you build this kind of practice, that's one of the best ways because they go. Well, you're not just, you know, you're not just banging away on people willy nilly, you're actually collecting some data and there's some care. You know these primary practice people. They're really busy and a lot of times they don't have the time to do this stuff. If they, if they know how to do it Sometimes they're, again, not trained like this, but they appreciate it and they go wow, that's a nice, you know, that's a nice approach that you take. I've got five others that are just like this patient who had a traumatic brain injury. They were, they were maybe on the same bridge or you know something like that, where the multi-car pileup happens and you know they do. They become impressed with the way you know people, especially that are care trained, really start to approach these kinds of things and they go.
Dr. John McClarenI never referred to an acupuncturist before, but I'm so glad I did. Or I never referred to a doctor or chiropractic before. I always thought you guys were, you know, weirdos or whatever. And you know it turns out I was the weirdo for not doing it all this time. I you know, and it helps.
Dr. Ayla WolfWell, and I see a lot of patients, you know, when they have things like postural orthostatic tachycardia syndrome, a lot of times they end up taking themselves off the medications they're given because of the side effects that they experience. And a lot of doctors are very upfront and saying listen, you know, we don't have a great pharmaceutical solution to fix this and so let's just try this. And a lot of doctors are also kind of humbly approaching it and saying you know what, like we're not so good at treating this, and we know that. But here it. And saying you know what, like, we're not so good at treating this, and we know that. But here, try this, and if it helps, great, but if it doesn't, like, then you know, don't take it.
Dr. Ayla WolfBasically, and so well they know that you know a lot of their medical.
Dr. Ayla WolfYou know approaches are kind of a trial and error and you know the way that I. I think the autonomic nervous system is so complex and when you try to control one small arm of it with a drug it usually doesn't equate to a good outcome. And I think you know that's what I see play out quite often and I you know, like you said, you know people kind of demonize the sympathetic nervous system and say parasympathetic good, sympathetic bad. But the way that I like to describe it is like like your autonomic nervous system turns you into a high performance sports car and so when you want to, you know, slam on the brakes and come to a screeching halt, you can. Or if you want to go zero to 60 in 0.5 seconds, you hit the gas pedal and your system can do that. And so it's like it's that ability to modulate for whatever's appropriate in the moment. And in some cases, if you're power lifting, you got to have that sympathetic output, otherwise you're not going to be a good power lifter.
Dr. John McClarenYeah, or you're snorting all these salts and doing all these other things to try to get it to activate. And and know, I had a buddy man, he would. He would just literally have his training partner hit him with a two by four just to get that sympathetic. You know, and I'm like you know, and some of them, you hear it, it's like, oh my God, I'm like I'm out of the gym. I'm like I'm like if you guys slap me like that, I'm gonna slap you back. And I'm like if you guys slap me like that, I'm going to slap you back and I'm out. These kind of things. I'm like don't smack me. I'm like, tell me nice things, give me some validation. You're a really good lifter, john, you're going to lift. I'm not the tough love guy with that. Don't corporately punish me before my lift.
Dr. John McClarenBut yeah, you see people do this stuff all the time and it's just fascinating. And yeah, you know, that's the great thing is we've got these tools that are relatively inexpensive to assess it in a very thorough fashion. You know, this orthostatic testing
Vagus Nerve Oversimplification
Dr. John McClarenis really a great thing to do. You can, you can check blood pressures in those different positions, you know, and if a lot of this to people kind of go how do I save time? You know, and I think the thing too, if you really want to do a service in this autonomic nervous system in your TBI community, you've got to be willing to spend a little bit of time and it's okay. Maybe you don't do your whole exam in one visit, or something like that with people, because if you're trying to fit a TBI exam into a 30-minute window, I can't do it.
Dr. Ayla WolfIt doesn't work.
Dr. John McClarenI mean, professor Carrick can probably do it in two minutes because he has it when he looks at you walk. But you know, I mean for me it's like, especially with some of this, yeah, you get, you know, the pupillometry is pretty quick, blood pressures are pretty quick, but you could. You got to spend some time and and you've got to try some different therapies and kind of see what happens as well so you can do a pull. I mean you've got to pull socks. If you don't have a blood pressure cuff and a stethoscope and a pull socks, don't do this kind of work, right, I mean? And we should all have those things, probably after a professional school or things like that. The pull socks, you know, get a good one. Don't buy the $20 junkie one off Amazon or from Walgreens nothing against Walgreens but get a good one like a non or you know something like that.
Dr. John McClarenMy brother was a critical care nurse for a really long time and he's like, don't you know, and they, these are guys, those measurements, you know their life and death for for the things that they're doing. You know he was a flight nurse. He's a nurse, anesthetist now and he's like you really want good equipment if you're going to do that stuff. And again, professor Carrick would say the same thing Get a good pulse ox, you know. Get a good stethoscope and auscultate the heart too. You know.
Dr. John McClarenYou can find so much with regards to the autonomic nervous system by what happens with heart sounds. You know not only you know. Is there a murmur or something like that which you should find? If they have autonomic nervous systems, do they have a primary cardiovascular issue? But you can listen to your S1 and S2 sounds. Have them turn the head just like we would in a post-geographic exam. You go. Well, if I turn the head to the left and I've got differences in S2 splitting or you know some muffling of an S1 sound or things like that, then I know those are things that aren't supposed to normally happen.
Dr. John McClarenA whole lot with physiology. Right Now I've got a deviation from what and that's the thing like we get normal physiology in our schooling. What is a deviation from that? Is that related to how I get blood and oxygen to my body? That's what your autonomic nervous system does. Yeah, you know. And, like I said, I just got back on social media. I mean, I go down my feed and everybody's got a way to activate the vagus, right, it's the new hypoglycemia, right. You know it's like everybody's firing that vagus up, you know, due to the cold plunge, and breathe this way and eat these foods and all these kind of things. And you know that's great that people are talking about it. You know, I I see like Nate Kaiser's post he did the dysautonomia program for the Carrick Institute. You know he's like. You know he kind of takes some of these things and he's like, yeah, but Right.
Dr. Ayla WolfWell, and you know when I've taught different classes, because you know you have the auricular branch of the vagus nerve, so a lot of acupuncturists are really into auricular acupuncture for that reason, and so a lot of times I kind of have to say like hey guys, the vagus nerve does not have a brain of its own, like it's not making its own decisions here, and so what you really need to understand is the connections of the vagus nerve into all these different parts of the central autonomic network, and that you actually need to be paying maybe a little bit more attention to what's happening above the vagus nerve.
Dr. John McClarenIt's ideal, right? Yeah, you know it's like don't look at me down here, look at me up here. Right, it matters, right, it really does. And sometimes it's okay. You have to with some of these people where they've got this phenotype that sympathetic nervous system is really really overactive. Those pupils are, you know, constricting and then dilating, like really really big and really really fast. The heart rate's really high, the blood pressure is a little high. You've got a, you know, a huge discrepancy between left side and right side blood pressures. Again, these are all things, like you know.
Dr. John McClarenThe primary question was how do we examine these? As people are listening, they can go. So I'm checking blood pressures on both sides. I'm checking blood pressure lying down versus seated, versus standing. You can go ahead and check blood pressure in dual task settings if you really want to. Again, how much time do you want to spend on it? But you should do some of these aspects for sure. What does the heart rate do when I change positions? And you know those are things. When people see that those things break down, you know, here they go.
Dr. John McClarenThey may need some vagal nerve stimulation until you get those connections, those drivers of the vagal activity, to work the way that they're supposed to, which, when they've got a traumatic brain injury. That's what they're telling you is. Hey, you know I've got some issues. A lot of that really is rooted in those white matter connections. Right, you get this white matter connectivity. I'm really excited there's a clinic in town now, an MRI and imaging center. They do DTI. It's commercially available, yeah, so it's like I am going to be sending you more than
White Matter Connections & Adaptation
Dr. John McClarenyou probably want to deal with, right, just because the work they're doing with that. We're looking at these connections between the cerebral they're doing with that. We're looking at these connections between the cerebral cortex and the brainstem. We're looking at the connections between the cerebellum and the brainstem. How does the cerebellum drive into these centers? How does the cortex drive in? Because you should get some activation of inhibition, of inhibition and so on and so forth, so that that orchestra plays the way that it's supposed to. Yeah, inhibition and so on and so forth, so that that orchestra plays the way that it's supposed to.
Dr. John McClarenYeah, I want to be the Ferrari that you're talking about. I want to be able to rest and digest when I want and somebody breaks in I've had the big steak and somebody breaks into my house. I want to be ready right away. I want to go. I'll come back in 20 minutes once this thing's digested. I've got to get slapped in the back by my buddy with the two by four so I can fight you out of my house. You know those kind of things, so you know that's. That's the thing. I want that system to be primed and ready to go. And of course I mean there's a lot of ways for, for athletic optimization. I think a lot of the strategies they're doing may be unknowingly helping to harness these aspects, or knowingly, you know, to get them to work like they're supposed to, or knowingly, you know, to get them to work like they're supposed to.
Dr. Ayla WolfThis was part one of my interview with Dr John McLaren. The second half of our conversation will be available next week. If you have a specific topic you would like to learn more about, please leave us a message, either by clicking the send us a text link in the show notes or emailing us at lifeafterimpact at gmailcom. You can also follow us on Instagram at lifeafterimpact, and sign up for our latest news and announcements by going to lifeafterimpactcom. Thanks so much for listening to today's show. Medical Disclaimer. This video or podcast is for general informational purposes only. Thank you. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice, diagnosis or treatment, and consumers of this information should seek the advice of a medical professional for any and all health-related issues. A link to our full medical disclaimer is available in the notes.
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