Autonomic Dysfunction After Brain Injury - An Interview with Dr. John McClaren - Part 2 | E12

Dr. John McLaren shares his functional neurology approach to treating autonomic dysfunction and concussions, exploring cutting-edge therapies and personalized rehabilitation strategies for complex brain injuries.

• Detailed explanation of how jump rope training can improve neuroplasticity by synchronizing upper and lower body timing
• Discussion of PEMF devices and hyperbaric oxygen therapy for improving vasomotion and blood flow to the brain
• Examination of heat intolerance as a manifestation of autonomic dysfunction due to impaired sweating response
• Exploration of the five-minute sustained hand grip test to measure sympathetic nervous system function
• Implementing gradual, individualized return-to-activity protocols with 20% reductions when symptoms appear
• Insights on how Long COVID can create setbacks by further disrupting autonomic nervous system function
• Techniques for using fine motor activities to stimulate cerebellar activation without overwhelming the system

Dr. McClaren can be found at: Advanced Chiropractic & Neurology in Omaha Nebraska

Advanced Chiropractic & Neurology Facebook Page

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Chapters

• 0:00 Introduction to Dr. John McLaren
• 2:15 Jump Ropes and Neuroplasticity Discussion
• 5:04 PEMF and Hyperbaric Oxygen Therapies
• 11:31 Heat Intolerance and Autonomic Dysfunction
• 16:18 Graded Exercise for Concussion Recovery
• 30:19 Head-Eye Vestibular Motion Therapy Techniques
• 36:23 Long COVID and Concussion Recovery Setbacks
• 46:25 Contact Information and Closing

Transcript

Dr. Ayla Wolf: 0:01

Welcome back to the Life After Impact podcast. This is part two of my conversation with Dr John McLaren, an expert in traumatic brain injuries, concussion, recovery and autonomic nervous system dysfunction, practicing near Omaha, Nebraska in this episode, after geeking out about jump ropes. We continue to explore his Functional Neurology approach to treating autonomic dysfunction and concussions. We discuss the use of pulsed electromagnetic frequency devices to improve vasomotor activity and the use of hyperbaric oxygen therapy, where he takes it one step further and shares how specific examination findings such as the pupillary light reflex and a five minute sustained hand grip test further help him to differentiate who truly is a good candidate for hyperbaric oxygen therapy. We discuss heat intolerance as a manifestation of autonomic dysfunction due to a loss of normal sweat response the use of compression gear and the importance of therapist guided gradual return to activity and exercise as it's appropriate for the individual and we touch upon head eye vestibular motion, a functional therapy that utilizes eye movements, head movements and vestibular activation as part of neuro rehabilitation, and then we touch upon long-COVID as a possible setback in people's recovery due to inflammatory consequences and further insult to the autonomic nervous system. Thank you so much for listening to the podcast. If you have topics you would like us to explore, please text us using the link in the show notes, or send us an email at lifeafterimpact@gmail.com

Sophia Bouwens: 1:48

Welcome 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, and I'm here with Dr Ayla Wolf, and we will be your guides to living your best life after impact.

Dr. Ayla Wolf: 2:15

Yeah, I had just a major geek moment the other day. I was listening to a podcast. It was a CrossFit podcast, and they were interviewing a guy who teaches like jump rope classes, and all of a sudden he launched into what, from my perspective, was a functional neurology explanation of why jump roping is so important to toning the autonomic nervous system and talking about how some people are more upper body dominant, and other people are lower body dominant. But when you jump rope, you've gotta sync up your timing of your wrist with the timing of your feet and your jump and so, you know, basically he just launched into this whole neurological reasoning for why jumping rope was this way of creating better neuroplasticity, in terms of how the coordination between your upper body and your lower body. And, of course, in my mind, I'm like, "and then we have the inferior olive which is all about timing, and that goes into the cerebellum"

Dr. John McClaren: 3:16

Put the metronome to the jump rope and see what happens. Right? Yeah,

Dr. Ayla Wolf: 3:20

metronome and a jump rope like that could be a magical therapy right there.

Dr. John McClaren: 3:26

We might have just, you know, call it the Wolf-McLaren jump rope.

Dr. Ayla Wolf: 3:29

Let's work on that,

Dr. John McClaren: 3:31

yeah, but you throw in the vestibular aspects as well, right? I mean, that's, it's like, this big thing, and not to mention the proprioceptive bombardment from lumbosacral spine, which is one of the reasons I don't jump rope as much as I probably should, that I suck at it, you know, it's like, yeah, I know it's a great activity. And that's the cool thing about CrossFit, you know, or any of these athletic endeavors, it's, it's motion at a higher level. You know, we look at gait all the time, but you go, okay, the gait... Okay, how do I jump rope? How do I jump rope with a dual task, or something like that? That could be a really, really nice, high end way to test. And I know, one of the things you, you know, you had mentioned in the questions leading into today, was how, what can people do at home? And these are things you know, you can integrate your activities of daily living in to to how to rehabilitate yourself as well.

Dr. Ayla Wolf: 4:24

Yeah, and I think that you mentioned you've got a PEMF device, and so do I. And one of the things that I really have spent a lot of time researching and wrote about in my book was the importance of vasomotion within the, you know, cardiovascular system and the arteries and even within the brain too. And so I think that you know, one of the things that the PEMF devices are so helpful for is restoring that healthy vaso motion, and especially when you've got somebody who maybe has dysautonomia and exercise intolerance and can't necessarily. Necessarily move their body at the high level that they maybe were used to, you know, something like that can really come in and support that system in that way too.

Dr. John McClaren: 5:11

Absolutely, it's so interesting. And a lot of people, you know, they like hyperbaric oxygen therapy for these kind of things as well, because, again, you're increasing blood oxygen concentration. Yeah, the pulsed EMF, vasomotion remodeling, you know, kind of in that neuronal pool because of that and so on. Yeah, you want to heal white matter. I mean, those are two of the best modalities that you could potentially use, for sure. And of course, just like anything else, be judicious, right? Have a biomarker. Everybody says that, well, what's the protocol? And I think you've probably found this with your PEMF too. There aren't necessarily standardized protocols, right?

Dr. Ayla Wolf: 5:46

Yeah. I mean, a lot of times it's like, let's just start you out really, really light and just very slowly bring you up, and then, you know, kind of cycle through. But yeah. And you know, some people like with mine, you know, they'll lay on it at a level one, and they'll say, Oh, wow. I can just really feel like, you know, all of this stuff happening in my body. Well, me, I have to have it on level seven before I even feel anything.

Dr. John McClaren: 6:09

it's interesting, yeah, yeah, you know, you boost the field strength off, and you can vary your field intensities and things like that. It's, it's fascinating stuff. And, and that's the thing, I think there, you know, there will be established research parameters for this stuff on top of everything else, as we go, same with hyperbaric. You know, that that's the thing. There are a lot of people, again, talking about, what's great for everybody? Nothing's great for everybody all the time, right? If it was, we'd all, you know, if hyperbaric was the thing to do for dysautonomia with concussions, we'd have like, 10 hyperbarics in our office, and everybody would be doing that all day long, I mean, and before I really, really understood the dynamics of, you know, this, especially this sympathetic activation being important, you know, I was putting a lot of people in hyperbaric and getting mixed results because Sometimes it's too much of a stimulus for that parasympathetic system. You're really driving vagal systems and and, you know, they come out there, like I feel great, and then, and then they'd have a hard time for a little while. And now, when I understand it, do I have pupillometry that's appropriate for the stimulus? Do I have, you know, one of these, we do this hand grip test and see, do I have adequate activation of that sympathetic system to be able to handle a stimulus? You talk about sweating. And one of the things I mean, what sweating is most important function, dissemination of body heat, right? What's one of the things these people with dysautonomia tell you, I suck in the heat, yep, you know, I can't wait for fall, yeah, because they can't disseminate heat properly, because they don't have activation of the sympathetic system appropriate for it.

Dr. Ayla Wolf: 7:52

and I think that's something that people also, you know, kind of miss is the fact that it's not a teeter totter. It's not that when parasympathetic activity is high, that sympathetic then is, by default, low. You know, these are two completely separate arms of the nervous system doing their own things. And so there can be maybe a relative excess of sympathetic compared to parasympathetic, or you can have it where there is actual decreased parasympathetic and increase sympathetic. And so we do have to look at it not as a teeter totter, but as two separate output systems that can be independently doing their own thing, but we need both of them to be appropriately responsive.

Dr. John McClaren: 8:36

Yeah it's just like when you test balance. It's context specific weighting, right? I want my brain to be able to stand on a perturbed surface with eyes closed. Then I want to be able to do things with eyes open. Then I want to be able to do things on a normal surface and and the brain will re weight the systems according to the context and the demands of that context. It's the same thing with the autonomics. Again, I need to digest I need to digest the stake, and then I need to fight off the intruder, or whatever it is, relatively quickly. And then, and then, you know, once the intruders fought off, I got to finish digesting, go back to what I was doing, yeah, and then, and then, hopefully, go to bed. And do it again the next day, these kind of things. Yeah, it's exactly what it is that's what the brain does when it works the way that it should is it can take every system that it communicates with, and it can weight it appropriate to the current demands, but the background processes work appropriately. And in order to do all that, you have to have fuel, oxygen, vasomotor activity, exactly, all of those things and you want it comes down to it, everybody will ask, well, what is a symptom of autonomic nervous system dysfunction? Anything they can come in with, because if I can't fuel my frontal lobe, I'm going to have executive dysfunction, right? If I can't fuel my vestibular system, I'm going to be dizzy, or we'll have some kind of translational issues, or have background contamination throw me off, or any of these kind of things. If I can't fuel my cerebellum, I'm gonna have maybe some of these, like speech issues, or some of these issues in cognition as well. Or activity coordinations of motor activity won't be super well, you know, you'll see miscoordination And like, what the way a hamstring contracts, or things like that, you know, things that you're doing in your postural assessment. And again, blood and oxygen. Every neuron needs it. Blood oxygen and activation, right?

Dr. Ayla Wolf: 10:33

And for everybody, that can look completely different in terms of how to get in there and start stimulating, yeah. So you mentioned you've got your hyperbaric, you've got your PEMF, or you do you also do like the NormaTec compression gear. Or like, are you doing compression? Or what else are you integrating?

Dr. John McClaren: 10:50

I haven't used that. I haven't used that in my office. I will have people use compression where, you know, even if it is just a simple compression stocking, like you'd get, if you're a runner. You know, a lot of marathon runners wear compression wear, because it's smart. When you're doing, you know, tons of miles, you're going to get some blood pooling and, you know, interstitial issues as things happen, but, but that kind of where it works really well for people who have autonomic nervous system dysfunction, particularly those like orthostatic phenotypes, you know, because the thing is, I can't get blood out of my legs back into my head with those types of guys, the POTS, those kind of things. So the compression wear is super helpful. But I'm not, you know, I'm not using that. I use some photobio modulation in my office, the PEMF, the hyperbaric and the rest of what I do is, is kind of this, you know, some aspects of myofascial release that are neural, exam guided and head eye, vestibular, motion therapy aspects. You know, I like Focus Builder. People use focus builder a lot. No disclosures there. I do some mentoring for them. But I'm not a stock owner. I wish I was. I just think it's one of the best programs for a functional neurologist to use in their practice and with their patients, because you can do all of these things with it, you know, from metronome timing to pursuits to saccades to roll applications when you've got role playing issues and and all these kind of things. So I really, really like it, and I use that in my head, eye vestibular motion approach. I have a lot of people, you know, they'll simple things, you know, they take some fine motor activity home, they take a board that I made that's got some targets on it, they'll do some saccades, or some gaze holding, or some pursuits, in addition to what we do in the office. That's, that's kind of where it is. It's kind of a nuts and bolts approach with, you know, with some accoutrement for sure. Yeah.

Dr. Ayla Wolf: 12:35

Are you currently seeing a lot of people where maybe they had a concussion, then they got long COVID, and then they had all their concussion symptoms come back.

Dr. John McClaren: 12:45

yeah. I mean, you get any of these things, and that's one of the things we talked about, long COVID, definitely a contaminator or, you know, mold issues, lime, those kind of things, you know, where maybe they've had a concussion, and then this kind of thing comes on, yeah, it looks like a second concussion for a lot of these people, or a third or a fourth or a fifth or or things like that. And they're, they're different animals, because you're seeing, you know, different aspects of activation in the inflammasome. You're seeing a skewing of the microglial axis and things like that. That is a little different, because there's a pathogen or something like that that comes in, but you see that stuff, you know, the inflammasome activation, the changes in cerebral blood flow that happen with with a TBI as well. So, boom. Second insult, you know, sometimes it kind of goes back to a flare up of their old issues. Sometimes they come in with new or additional problems, and it's sometimes it's harder to deal with, you know, I had, I had a guy that had a long COVID, got a concussion, you know, so, like, We stabilized him with his long-COVID, then he got a concussion, then we stabilized the concussion, and then he got COVID again. And it just was, like, starting over, yeah,

Dr. Ayla Wolf: 13:58

which is so frustrating for the patient. But I think one of the things I always try to say, when, when stuff like that happens, is, you know, if you got better, once you can get better again, right? Like we got you better, and we'll, we just have to start back, you know, a couple steps backwards, but we're now, we're just going to keep going forwards again, yeah,

Dr. John McClaren: 14:19

and that's a lot of times what happens. You

Dr. Ayla Wolf: 14:20

I think that with COVID, the other kind of unique just find you probably scaled the rehab back, you know, to square one, or maybe even square zero, from where they were in and, you know, sometimes, you know this guy in particular, he had been going for like, a couple years before he found me the first time, right? So it's like, Hey, you're already here. We're like, two years ahead of where we were when all this stuff started for you, so we're going to be fine. We've got you. And that's the thing, I think, with with these autonomic nervous system, people who have that affectation in their TBI, whether it's with these other contaminating aspects or not, you really do judiciously, have to encourage them to because. Maybe they've been through, you know, some of those other tests, or they've been to a medical provider who kind of told them, you know, your testing isn't really that bad, or whatever it is. I don't really, you know, it's in your head kind of stuff, right? You know, they've maybe been a little gaslit or something like that. So they're discouraged when they already come in and it's like, you know, I'm just going to see you because my wife drug me in here. You know, you're the last thing I could find on the internet. I've tried everything else, or or whatever it is, and then, you know, you start to see, hey, you know, we've, we found test XYZ, we've done some things. We've improved, you you know. And listening a lot of times, they just want to be heard, right? You know, so, so listen to them talk about how your examination maybe fits some of the things they're seeing. And sometimes you may see the exam get better, and they still feel like crap. And, well, that's that happens. You know? That happens for sure. thing was just the severe amount of damage to mitochondria that some people are experiencing so that they are very, very fatigued. And it's, you know, I use the phrase, you know, of, you know, sometimes you gotta spend money to make money. And it's kind of the same thing where, you know, our muscles are such a powerhouse for creating mitochondria. It's like, okay, I know you're tired, but you actually gotta, use it a little bit in order to create more mitochondria. And so that process can be really a struggle for people, because, like you said, every single day the goal post moves in terms of what somebody can handle.

Dr. John McClaren: 17:42

And maybe, you know, they have a day where they feel pretty damn good. And then they try to do everything, you know, that they've been missing out on for months, two months, year. Or, you know, it's like, my wife has this list for me and I really wanted to get to it. And then they pay, you know, the Piper for it, so to speak, for a while. And that's part of the deal, too. It's like, how when can I get back to physical activity, you know, all these kind of things after, traumatic brain injury, or after, you know, a long-COVID affectation, where they've been out of action for a little while. And that's, I mean, it's like, you know, most people just crave kind of feeling normal, right? It's like, I want to, you know, I want to feel like I did before all this happened, and they start to get a little bit of a taste of that, because the rehabilitation is working. And then, and then, yeah, they'll, they'll do too much. I've been guilty of that as well with orthopedic injuries or whatever else. You know, it's like, why? How did you break your back? Well, I tried to squat 600 pounds four weeks after knee surgery. You know, stupid, right? You know, you've been there. Yeah, I got hit in the head. I'm fine. Let's roll, you know?

Dr. Ayla Wolf: 18:44

I completely understand, you know, it's funny, I think I suffered from feeling like I was invincible for far too long. And I think that that reality check was hard for me to recognize, like, No, you're not invincible. Maybe you shouldn't follow your friends as they huck themselves off that cliff on mountain bikes.

Dr. John McClaren: 19:06

It looks fun. And, you know, you get a little bit of that. You know, that's the thing. Our brain loves dopamine, you know, you want a little bit of that dopamine. It's a, it's a nice, natural way to get a dopamine hit, you know. And it's something, you go, look what I mean. That's and like, with you, it's like, what can't you do? You know? You go, that's another thing I can do that a lot of people can't. And you We thrive on being able to do some of these things that we think, you know, we can do better than a lot of other people as humans, whether it's hang drywall fast, or, you know, have the best garden on the block, or the best lawn on the block, or squat 800 pounds, or, you know, whatever it is, and you go, Hey, I just want to, I just want to maximize my human experience as much as I can, because we're only here for so long.

Dr. Ayla Wolf: 19:52

Well, I'm an Aries, so I have to try everything at least once.

Dr. John McClaren: 19:56

Yes! What else could I do today? Should read a book and go to bed.

Dr. Ayla Wolf: 20:05

So when it comes to exercise, and obviously, with both, you know, the fatigue from long-COVID And the autonomic dysfunction and the exercise intolerance that people experience after a concussion, do you help people to really dial in this kind of gradual graded exercise program. And how do you do that with people?

Dr. John McClaren: 20:30

Yeah, I think. And again, the athlete, everybody, I like to say this, everybody's an athlete, right? But your athletics might be your garden, or whatever it is. The thing you know, John Leddy - his work is really, really good for this. You know, the old, the old thought process was cocoon people and and then it's like, that's like, the worst friggin thing you can do is sit in the dark room and not expose yourself to the world. Like you said, you need to get back into the world and start to do some stuff, because if you don't use it, you lose it. So he, he did this work in 2013 on graded cardiovascular activity. As a measure for, you know, how recovered you are, and as a measure for rehabilitating people. So, you know the thing, you know that the buffalo treadmill test came out of this. You know, a lot of people are starting to do those. I've got athletic trainers in town doing them now. You know, which is great. You know, it's like, oh, they failed their BTT, can I send them over? Yeah, please send them over, because that's a measure of autonomic nervous system function as well. Again, you got a treadmill, or you don't even need a treadmill. You can walk and see what happens, right? So what's the symptom load somebody comes in with, okay, you know, XYZ, you know, rate it scale one to 10. Okay, I want to start to do some things. And you know, I can at least dilate my pupil a little bit. Now okay, we've got some sympathetic activation so we can get blood to the brain and the body. When you do some certain activity, I maybe will have them do a Timed Up and Go test and see if I get pupillary dilation when they do that, because that'll tell me. Okay, yeah, you can go for a walk. Now, you know that kind of thing, real, good. You know, the Timed Up and Go test. You have them walk 10 meters, you know, see how fast they can do it. And again, you can measure some of these other neurological metrics associated with it that will do. And then, you know, what's your symptom load? You know, rate it one to 10. Get on the treadmill. When do your symptoms start to tick up? You know, okay, at x miles an hour out of a heart rate of X, okay, let's stop see if it comes back down. Does it come back down? Cool? Okay, let's reduce the load by 20% do it again. Do the symptoms come back up? Or are you good? You're good. That's where you're going to exercise until we assess you again and see things happen. You know, if you do it again tomorrow and you get the headache at that 20% lower number, we lower it again by 20% whatever it is, you know, whether it's the treadmill or if they want to ride a bike or if they want to play the trumpet, all these kind of things. I just had one of those this week. The high school guy, concussed, super like, super like, jazz band trumpet wants to play. Well, okay, once we, once we establish, you've got an autonomic nervous system that's at least in the game, you know. And the cool thing about this guy, like, he could do the Valsalva to play the trumpet, fine. I'm like, thank God. You know, he had a lot of things that I was glad, you know, were good, like he didn't have a big issue in his near point of convergence or accommodation. He had the ability to tolerate a Valsalva without getting a headache. I'm like, we're going to be fine. You know, those things you really, really like to see, but, but that's the thing. Take that lower it by 20% if you don't get symptoms. That's where you're exercising for the day, whether it's gardening, you know, doing farmers carries weight. Lifting, same thing, lower the weight by 20% if you don't get a headache or you don't get clenching of the job, whatever you're bringing me, right, whatever you're bringing me, if you don't get that, if you don't get cold. You know,

Dr. Ayla Wolf: 24:00

it was really fascinating. One of the things that, in hindsight, I recognized as kind of an autonomic symptom, because a lot, all, you know, a lot of my concussions were mild in the sense that I walked away from them, I continued to do whatever I was doing, and then the symptoms were just kind of these, like lingering things that I kept, kind of like thinking were related to something else entirely. Well, one of the things that I figured out, kind of in hindsight, was that whenever I would go mountain biking, a lot of the trails that I would go on was always a steep uphill climb first, before you got to the super fun screaming downhill. And what I found was that I would start out my ride, I'd be feeling totally fine, and then all of a sudden my heart rate would get to a certain point, and it was like some a switch got flipped, and all of a sudden my thoughts would turn so negative, and I would just be like, I hate mountain biking. Why am I doing this? I'm terrible at this. Why do I even bother? I don't want to be here, and I'm just like, paddling up this mountain, just angry. And in hindsight, I was like, that was my threshold before my autonomic nervous system just had some kind of limbic thing kick in. Just the whole thing fell apart.

Dr. John McClaren: 25:14

You go fully mesolimbic, and it's like, Man, I don't really hate this. Do I do it? Do I want to do this anymore? And you go, Man, if only I could have lowered the grade by 20%

Dr. Ayla Wolf: 25:24

But I couldn't make the mountain flatter!

Dr. John McClaren: 25:28

Yeah, that's the problem, you know, you go, No, I want that trail, damn it. That's my favorite trail. I don't want to go to that like, crappy John McLaren trail.

Dr. Ayla Wolf: 25:37

Can't I just get a ride to the top so I can just go down?

Dr. John McClaren: 25:40

Yeah, put the ski lift in and, you know, you know, take your bike with you, right? But it makes sense, and that's the same thing, whether it is, you know, the gardening or or whatever it is that somebody really, really loves and they want to do, there's, there's an autonomic nervous system component to being able to do anything where, even if you're playing video games, you know, if that's all you want to do, I get a lot of kids that ask that, you know, video. Video games are killing me. Well, there's a lot of things going on, visual stimulus, a lot of eye movement, a lot of vestibular activation and things like that, which, again, you know, we've already talked about, you need fuel and oxygen for the process. And a lot of times it could be your primary autonomic nervous system dysfunction that's not allowing these, you know, these people, to be able to do that

Dr. Ayla Wolf: 26:23

well. And I think what you're highlighting is where Functional Neurology really excels in that the way that you're looking at each of these patients is so completely individualized, whether you're talking about a professional weightlifter or somebody who just wants to garden or somebody who's playing video games or somebody who just needs to carry groceries up a flight of stairs, you know, functional neurology really excels in being able to take that one single individual person and say, What are you struggling with now? And how do we get you a little bit better so that you can do life better in whatever way that looks like for you? And I think that's what I really love about it is, is the flexibility and then also the creativity in saying, you know, if the goal is to get you to garden, then that might completely change what kind of therapies we're actually using or doing, as opposed to the power lifter.

Dr. John McClaren: 27:14

Well, for sure, and sometimes you you know, that's the great thing about this stuff, that's one, one thing Professor Carrick, from the first time I ever saw him, do a case. What if there's one thing I can do for you. What do you want it to be? Right? What a great question. Sometimes you might not get it, but at least I know where this person is, you know. And then you meet people. And again, you've said this before on the podcast. You meet people where they are, you go to them where they are, and you make it work. Maybe, maybe we go do your head, eye, vestibular motion therapy in the garden, or a garden, or I simulate a garden with a projector on my office wall, or whatever it is, because, you know, it's like, I feel pretty good when I do your gaze stability exercises here, or when I'm in my house, where my walls are kind of plain, but then you get outside and it's like there's different visual context To the activity, right? Or whatever it is, visual, vestibular, you know, maybe, maybe it's like, they need to wear different shoes, you know, there's something in that that's causing the breakdown. And you can bring the rehabilitation to the place they want to be, the power lifter. You can bring the rehabilitation into the gym. I've got a Brock string and a saccade board and all this stuff right by my squat rack. So, you know, I'm doing, like, you know, head tilts and all this kind of stuff between sets. And, you know, it's like, well, you know, does it help?

Dr. Ayla Wolf: 28:32

I Yeah, no, that's hilarious. Mean, sometimes in between sets, when I'm at CrossFit, I'm like, I need to do some Yes, yes, gaze stabilizers. Like, you know, let's, let's fire down this vestibulospinal pathway before I start doing my power cleans.

Dr. John McClaren: 28:47

Yep, I wish I brought my OPK strip in, because I feel like I'm a little forward, or, you know, something like that right?

Dr. Ayla Wolf: 28:53

Yeah. I mean being able to understand how the system is wired and how to stimulate it so that you can create, you know, the appropriate response is, is really the name of the game here. And like I said, I just, I love the the creativity that I see with all the different functional neurologists that I that I talk to in terms of what they're doing in their practice. And like you said, even like having someone do their therapies in the gym or in the garden or in the swimming pool, it makes a huge difference. I mean, we're, you know, like you said, it's all about context.

Dr. John McClaren: 29:28

Yeah, that's the thing. What do you want to do? Let's make you better at it, yeah? And let's make you better at it, and not compromise yourself along the way. Ideally, is the good thing, right? Yeah, we want to be well rounded humans, and that's what we want to see in our exams all the time. But, yeah, you know, really what it comes down to. It, if you, if you can get people to handle the activity that makes them the most happy, they're going to be a satisfied person. They're going to refer you more people than you probably wanted them to refer you and and all these kind of things. And it's, it's just the way to organically build a practice just listen to people give them the best version of yourself that you can and do these kind of things, and they're going to be, they're going to be really happy. They're going to have a successful rehabilitation and and, you know, the thing too, a lot of times, people will ask me, How long do I have to do this stuff? You know, do I do I need to do this stuff forever? And I'm like, well, some of it, you probably should. You know, I had that when I had my shoulder surgery last year. It was I had that epiphany where it's like, you might, my therapist asked, you know, what do you do for your warm up before bench press? It's like, one plate, two, plate, three, plate. And she just rolls her eyes at me, you know? And it's like, what what? You know, that's, that's just what I've done, you know? Now it's like, I've got this 20 minute routine of old man warm ups before I lift that I'll do for the rest of my life, because I want to stay healthy, you know, in my shoulders, and I do neuro axis work and things like that. Again, I wasn't doing that stuff before. And I'll tell people that, you know, it's like you should probably, as long as you have a brain, do some of these things for the rest of your life. And the thing too. You know, that's to go back to, you know, the the case where the guy had, you know, the COVID, the concussion and the COVID, if people continue to do some of these things, look at Joe Clark's research. It's preventative. You do these things and you have an event, you are way less susceptible than if you don't do these things and have an event, right? You know, if you're doing some eye movement training or some reaction time training, or some aspect of balance training, and you get hit in the head, or you get your COVID or your influenza A or these kind of things, your nervous system is going to be hardened so that it minimizes the damage, right? That's the thing. It's, it's like, you know, it's the same thing as lifting weights or doing CrossFit. Now, like, we're doing this one, because we want to, you know, we want to look and feel good now, but I want to be able to get off the toilet when I'm eating right? Everybody says it now, why are you training so I can get off the floor later?

Dr. Ayla Wolf: 31:56

Well, and I think too, that just the very nature of what we're doing all day long, in terms of the neuro rehab with our patients is like, when I'm having them doing saccades or pursuits, it's like I'm also I'm looking at their eyes, so I'm also getting a pursuit in a saccade, and as I'm watching them do what I want them to do, and it's like, as I'm moving their arm in a figure eight, my arm's moving in a figure eight.

Dr. John McClaren: 32:19

You're doing complex movements too, and it's and it's unique. You know, you're getting a different activation with every person because they're stiff and heavy in different different ways. Your cerebellum is like, yeah, you know, I want to come to work today!

Dr. Ayla Wolf: 32:32

Yeah. And so it's like if I've got someone looking at a Brock string and I'm pointing at the beads, well, I'm kind of doing the Brock string myself in that moment. And honestly, I feel like that is activating my brain all day long, literally, just by working with my patients. It's like my brain is getting its own active activity,

Dr. John McClaren: 32:50

absolutely, yeah, and that's the thing. I mean, you look at, you talk to some of these people at, like, iscn or, or, you know, what other things we get together, clinical gems. Or, you know, whatever it is, when you get a big group of people who've been doing some of this work a really long time together. You know, you get some of these people that are in there six, seven decades of life. One, they're still working. Two, they're sharp as tacks.

Dr. Ayla Wolf: 33:14

So you mentioned you use a lot of the head eye vestibular therapy as part of creating better balance and integrity within the the system. What you know, what other types of therapies or things are you incorporating in a lot of your rehab when it comes to people that have dysautonomia as part of their presentation?

Dr. John McClaren: 33:38

Things I love. I really like to have people use fine motor activity. I just have found when you bring in some of those lateral cerebellar aspects, you know, coin rolling is one of the big ones. And, you know, Carrick got me onto this, like everything, right, you know, and the thought process is, how do I activate the brain in a way that is judicious and doesn't bias that system too much one way or the other, because what am I trying to do? As you said, I want to get the top down stuff, to talk to the vagus, or talk to the IML, to get it to do what it's supposed to do. Those neurons, generally, when you have a TBI, themselves aren't damaged unless you've got a significant shear or an intracranial bleed or things like that. It's the connections, those white matter connections that get, you know, damage you get the road construction, so to speak, is going on. And, you know, now I've really, I've only got one lane when I should have three or or so on when I'm driving, the fine motor activity is great, because you don't get a super high level of activation in those brain stem centers, like the nucleus track to solitaires, where you can suppress an already suppressed sympathetic system by doing some of these big, complex movements and things like that, which works in some cases really, really well. If I wanted to drive more those parasympathetic aspects, I might do a little more complex movements, because I get an activation of that NTS, I get some vagal activation to suppress the IML, a little more increasing circular output. Really good for that, right? So, you know, fine motor activity is really, really good. I get these. You can use, like a poker chip or a 50 cent piece, like a quarter with some of these people, is almost too small. I got these, you know, I've got one, you know, it's, it says I was caught being good today. You know, it's about the size of a 50 cent piece, and you just have people roll it, and it works super duper well. And I mean, you people see me do it, it's like, well, I've been doing this every day for three years. Don't feel like you should do it. It's been part of my whole process of getting that brain to be better. So I'm pretty fluent with it. You know, on a good day, I can do a dime. And that's another way you can scale the therapy, you know, make give them different weighted objects that are maybe that size, because, again, the cerebellum likes that novelty, and it helps to drive into some of those autonomic activating centers, the locus coeruleus, so to speak. You know, one of those areas that's very important to autonomic modulation. It's got, like, 313 different parts of the brain. Screen that pop into that little thing, and if it doesn't work really well, that's when you see these dysautonomia phenotypes. I may, again, if I can get some pupillary dilation on like a cognitive task, or I don't see them fail doing dual tasking on their balance, I might have them do some saccades. You know, I like very small amplitude saccades. Generally, when I start these with dysautonomia patients who are a little less stable, I like to move away from center because it's easier to put the brakes on. You want people not to overshoot when they do saccades really early. It's harder to put the brakes on when you cross the nose than it is when you go away from the nose, that kind of thing. So we'll put them, you know, maybe on a 45 where we combine the machinery for vertical and horizontal saccades, because, again, it's a little nicer on brain activation. That's why you see all these carrot brain exercises on the 40 fives. It's vertical and horizontal machinery working together. So it takes a little less blood and oxygen to get that thing going. You'll see this all the time. And people who have dysautonomia, you know, you have them do saccades horizontally in the exam. And it's like, my god, I can't do that. And then they can do the verticals a little bit better, or vice versa, usually your vertical a little better than horizontal. And when you look at Professor Carrick's work that he did on, you know, these, these 40,000 different groups, stratified by age and all that, he found the vertical movements tend to be a little more accurate than the horizontal movements overall. Have you seen it?

Dr. Ayla Wolf: 37:33

Was the one where he was really stratifying it by age range, sex, yeah. Kind of normative values really need to change based on not only age, but also gender. Yeah, that's huge,

Dr. John McClaren: 37:47

Yeah. And you see how women do some things a lot better than men, and vice versa, and, and, you know, concussed women perform better than regular men on a lot of things, and, you know, and not so well on others, you know, but it, but it's interesting. And when you, when you look at this research that comes out, you you start to tailor your exam expectations to that, and you can tailor your rehabilitation toward that, where, you know, if I'm dealing with a female patient with dysautonomia, I may do a little better with some saccades than I will with some pursuits. With a male, I might do a little better with some pursuits and some saccades, because they perform a little better in those tasks, even in a TBI, you know, kind of context, even after more than one. So, you know, we use, we use some really small, subtle activations, you know, maybe you loop in some of those other things, like the, you know, the vagal nerve stimulation, if I want to drive it a little bit, or things like that. I'll use the mini stem device, or something that's like an SSEP on the tongue or on the trigeminal system. Those kind of things are really, really nice. Again. I want to see dilation on my pupillometry. Before I do a lot of that, I want to see, we'll do the hand grip test where, you know, we're looking at, you know, are we going with Ewing and Clark 16 on our diastolic, or do we want to see the full 20? The whole thing, you know, when we do this hand grip test, you know, we're, we're getting a maximum hand grip. We're finding out that's kind of our baseline. We're going to 30% of that. We're sustaining that for five minutes. We're checking the blood pressure every minute. You know, in corata and all these people found that that diastolic number was the number that is the the one that matters, the authoritative one for the autonomic nervous system. If I at three minutes, can't get my my diastolic pressure to rise, depending on what source you read, between 16 and 20 millimeters of mercury, you know, then I know I'm not activating my sympathetic nervous system super well. So you're going to be really, really judicious in how you drive your rehabilitation with these dysautonomia phenotypes, you know. And then, and then, and then, can I get it there? And then, can I sustain it? You know, you'll see this, and you'll see it on the pupils all the time. Well, they got the T-75 yay. But then it goes right back down into a full blown constriction. And, you know, I got to the 16 to 20 beats, or millimeters of mercury. And then minutes four and five, it goes right back down. You know, those are people. It's like, you can introduce some of these things a little more than people that can't do it at all, but you still have to be really judicious. And you know, just, just start small. Maybe again, to kind of go back to a topic you guys have discussed really well, maybe we'll do some aspects of apophyseal glides in the cervical spine. We'll do some manipulation in the rib cage to maximize oxygen capacities and things like that, because that cervical spine has so much to do with how that autonomic nervous system activates.

Dr. Ayla Wolf: 40:31

And I think everything you're saying, one of the really important take home here is a lot of people, when they are booking kind of that initial appointment, they're like, why do you need so much time with me to do your initial assessment? And this is why, because looking at the autonomic nervous system and even asking that question of, does this person even have enough sympathetic output to be able to handle the therapy? And if they don't, I need to back down on my therapy. And so it's like the reason we need that time with the patient up front to do all of our invest. To gate of work is because it matters. You know, how they're performing on this pupil test really, is actually indicative of what we are not, are aren't going to do, as far as their therapy, or what we know that their system can or can't handle, at least as a starting point,

Dr. John McClaren: 41:20

yeah, and that's why, that's why I love that pupilometry app, because I can take that four or five, six times. Really apply a therapy and see what happens. And it's not as fatiguing to people as some of the other things we might do are, you know, it's hard to and if you take a blood pressure 12 times during exam, that can contaminate itself over time too, right? You'll, you'll see, you know, a significant change just by doing it multiple times on the same arm in a time period that's relatively small, so it's not as good a data. The pupils, they're very quick to respond to therapy. I mean, again, when we're doing brain rehabilitation, you're seeing brain able to replicate proteins in a nanosecond. So you can really, really quickly add stability or detract from stability. You know, really, quickly, depending on on the person and how they do. So, yeah, it's like, why are you doing this again? Well, you know, if I'm going to give you a saccade to the left, I want to make sure that it doesn't cause you, you know, a negative outcome. And because if I'm going to send you homeless stuff, if I'm not doing and we all practice a little differently, too, but if I'm not seeing you in a three times a day intensive model for five days. Maybe I'm sending some things home with you, and I'm bringing you back in again in a few days or a week, or something like that. Or I'm checking on you via telemedicine with my people ometry, if you've got that app you know, or I've got some other things where you know you're you've got somebody with you who can take blood pressures bilaterally, and tell me what the response is after a few days of therapy where, you know, you can't get to me. I mean, they're coming from a few hours away, maybe to see you. You know that that kind of thing, I'm sure you're getting that a lot, where it's like they're coming from, I mean, all over, all over the state, or even farther than that, you know they're gonna maybe go home and take this stuff home, and I want to make sure that the outcome is as positive as possible, do the least amount of negative that you can do, and do as much positive as you can do with your rehabilitation. So, you know, we'll loop some of those things in, you know, I like looking at joint position errors in the cervical spine and using that as a rehabilitative model. There's so many ways you can do that. You can have people do, you know, head laser things with eyes open. You can have them do it eyes closed. Those things are really, really good with these autonomic nervous system phenotypes, where the neck is really involved. And again, using the neck gives you some more positive activation. Again, as long, as long as we know it with diligence, that it's good strengthening of the neck. You know, that's one of those. I think you guys touched on that too. You know, I think you're doing your best to correct the joint position errors. Is good. Before you get into a ton of heavy strengthening in the neck, you're going to get neck strengthening with general resistance training to some degree. But if you really want to specifically attack the neck, just make sure they aren't really, really skewed on their joint position errors. But you can do them together. You can do them in concert, because a lot of times the strengthening helps with the joint position error processing as well, along with the the manual modalities and so on.

Dr. Ayla Wolf: 44:19

Well, man, I think we covered a lot of a lot of information. Why don't you let people know kind of where they can find you, and now that you're back on social media, yeah,

Dr. John McClaren: 44:27

yeah, yeah. So yeah, back to Facebook. I've got a clinic profile. We're Advanced Chiropractic and Neurology PC. We're located, like you said, in suburban Omaha. We're located in La Vista Nebraska. My website is www.Omahaspinecare.com, curated by a friend of mine. A long time ago, I was going to write it something different. He's like, No, make it something people understand, John. 402-597-2869, is our office number. You can feel free to reach out to me there or on Facebook. I've got a personal profile, the office profile. Instagram, I think I've got like four followers since I came back. So you know, you can look for me there if you want.

Dr. Ayla Wolf: 45:05

Okay, well, now I'll put all of that in the show notes so that the links are there too. Yeah, perfect. Well, I appreciate your time, and thank you so much for coming on the show. Always a pleasure to talk to you. I love geeking out with you.

Dr. John McClaren: 45:18

The pleasure is all mine. Thank you so much for the invite. I really, really am honored to be here. Good.

Dr. Ayla Wolf: 45:22

Well we'll have to do it again. Yeah, yeah,

Dr. John McClaren: 45:24

I'm in. For sure, yeah, for sure, I'm in, yeah.