Advanced TMS for Concussion and Brain Dysfunction with Dr. Glen Zielinski | E29

Dr. Glen Zielinski from Northwest Functional Neurology in Lake Oswego, OR, joins us to talk about how he’s using cutting-edge, image-guided transcranial magnetic stimulation (TMS) technology to treat more than just depression. With neuro-navigated TMS, he's able to target specific brain regions with millimeter precision—and he's not stopping there.

Dr. Zielinski walks us through how he customizes every treatment using detailed neurodiagnostic testing, identifying exactly where and why the brain isn't functioning properly. Instead of using generic protocols, he fine-tunes TMS treatment plans based on individual brain mapping.

We also dive into:

• How the default mode network and salience network are key players in emotional dysregulation after concussion
• Why combining TMS with targeted neurological rehab exercises leads to stunning outcomes—like a 96% response rate and remission rates in the high 80s
• The use of TMS for dystonias, dysautonomia, movement disorders, and more
• Key contraindications you need to know before considering TMS

Whether you’re a patient exploring new treatment options or a clinician wanting to deepen your understanding of brain-targeted therapies, this episode is packed with insight you won’t want to miss.

Dr. Zielinski's Website: Northwest Functional Neurology
Youtube channel: @northwestfunctionalneurolo5250

Get 20% off your first order of Puori protein with code LIFEAFTERIMPACT by following this link.

Chapters

• 0:00 Inhibitory Control and Post-Concussion Challenges
• 2:30 The Five-Day Intensive Treatment Model
• 3:37 Evolution of TMS Technology
• 5:35 Anti-Saccade Testing and DLPFC Function
• 11:34 TMS Results and Integration with Therapies
• 17:54 The Four-Step Neurological Recovery Approach
• 23:07 Targeting Specific Neural Pathways with TMS
• 28:46 Contraindications and Special Considerations

Transcript

Dr. Glen Zielinski: 0:00

Because if you can't inhibit what's happening around you, if you can't inhibit all the visual stimulation, if you can't inhibit all the auditory stimulation, you know, Costco is like our final exam for our patients, because that's the most overwhelming circumstance that we can put anybody in in terms of visual and auditory and cognitive paths to someone. If you can't inhibit that kind of stuff, you can't function in the world.

Dr. Ayla Wolf: 0:23

Welcome to Life After Impact the concussion recovery podcast. I'm Dr Ayla Wolf and I will be hosting today's episode, where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information, whether you're dealing with a recent concussion, struggling with post-concussion syndrome or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing, treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies.

Dr. Ayla Wolf: 1:08

So if you're feeling lost, hopeless or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. All right, Dr. Glen Zielinski, welcome to Life After Impact the concussion recovery podcast. You are a chiropractic physician and board certified functional neurologist with an absolutely beautiful clinic in Lake Oswego, oregon, and I brought you onto the show today to talk about your integration of transcranial magnetic stimulation with all of your other tools, techniques, therapies specifically for people with traumatic brain injuries. So welcome to the show and thank you for being here.

Dr. Glen Zielinski: 1:53

Hey, happy to be here.

Dr. Ayla Wolf: 1:55

Yeah, so tell me a little bit about your clinic. I know that you do five-day intensives primarily. Is that correct?

Dr. Glen Zielinski: 2:04

Yeah, generally, that's probably the majority of our business at this point.

Dr. Ayla Wolf: 2:08

Yeah, so you get to spend a whole week with people and really get to see them from beginning to end. And tell me a little bit about your integration of the technology, especially that TMS, and when did you bring that into your clinic and what has that looked like or how has that evolved over time?

Dr. Glen Zielinski: 2:26

All right. Well, so we have been using TMS in our practice since, I think, 2018 or early 2019. We've gone through a couple of different TMS systems. Currently we're using a system by a company called mag venture and the beauty of that is that our unlike most tms, where the process just largely comes down to doing finding a motor threshold on somebody by you know, moving this coil around and figuring out where your thumb twitches and saying, okay, here's the primary motor cortex, the areas that we want to stimulate. Now we're just going to measure based on landmarks and hope for the best, hope that we're getting close. We now have a system that's neuro-navigated, which means we use this MRI database. We upload a brain MRI, it feeds it into this AI thing, it stretches it out and morphs the AI brain into a way that allows us to identify any area on the cortex that we want to simulate and hit it within like half a millimeter, which is pretty fantastic. So that's given us some pretty dramatic increases in terms of what we can and can't treat with TMS.

Dr. Glen Zielinski: 3:36

Traditional TMS is largely used to just stimulate the dorsolateral prefrontal cortex, which is a critically important area. I mean, it's a massively important node in the default mode network and in the salience network and it's sort of like the apex of cognition within the frontal lobe. Just about everything runs into the DLPFC and just about everything is stimulated one way or another by the DLPFC and, as a consequence, it's an area that is impacted almost inevitably in concussion. There's research that shows that by the time you've had two significant hits, you've got a problem with your DLPFC. People are looking at DLPFC problems as now a biomarker of post-concussion syndrome, as in if you don't show some dysfunction in that system, then you've got problems, something beyond just concussion. There's something else going on. Now. Traditional TMS just simulates that and if you go to see your average TMS clinic, they're just going to do left DLPFC because that's the only protocol that they've been trained in.

Dr. Glen Zielinski: 4:38

Your average psychiatric practice is just doing that and that alone right, and that is very relevant for a lot of patients, but by no means all patients right. There's tons of people that have problems, on the right side, for example, and if you have a right DLPFC lesion then that's not exactly helpful. You may even be making somebody worse by doing that kind of stimulus. So the key is with TMS you need to understand first of all what it is that you're trying to accomplish, and it's not as simple as the sort of traditional psychiatric. Do a PHQ-9 depression scale and see if your scores are low, and if they're low then let's see TMS.

Dr. Glen Zielinski: 5:18

What we do is based, first of all, on some pretty heavy neurodiagnostics, and the neurodiagnostics that we engage in are I mean, we address every conceivable system. We do something like 50-odd discrete tests that give us objective data on what's going on with somebody's brain before we even start any kind of therapy, and one of the things that we pay quite a bit of attention to is anti-sachetometry. Now, sachetometry is a system that I helped develop for this company called Interacoustics, which does video and asthmography testing, and video and asthmography is infrared cameras. You're tracking your pupils, you're seeing various different types of stimulation take place on a screen and the system basically just records eye movements in response to the different types of stimulus. This is probably the best way to see really what's going on with somebody's brain after a concussion, because all of the systems that tend to be impacted by all the rotational shearing forces that happen when your head gets snapped around, we can see function in all of those systems by looking at eye movements, because eye movements all start in the same part of the brain stem, which is an area that takes it. That's sort of like the apex of all the rotation. I mean, if you just think of a concussion is like if your brain's like a big cauliflower and the brain stem is the stock of the cauliflower. Um, all the maps that your brain uses to make sense out of where you are in the world, they all live in different parts of the cortex but they integrate right in the middle of the pons and the midbrain, which is basically the stalk of the cauliflower. And getting concussed is like you grab the stalk of the cauliflower and just snap it really fast and all these rotational shearing forces go right where you're holding, which means right where you put all those maps together. And that's also the areas that not only control all your autonomic nervous system but also the areas that basically generate all of your eye movements.

Dr. Glen Zielinski: 7:09

And different types of eye movements coming from different parts of the brain can show you a ton about what's happening in the different parts of the brainstem and cerebellum and parietal lobe and frontal lobe and basal ganglia and all the pathways in between that have a tendency to be affected by these things. And it's one thing to be able to see that somebody has a problem on an image and it's another thing entirely to see under what sets of circumstances those pathways fatigue and fail, what kind of stimulus pushes them over the edge, what makes them melt down, and so on and so forth, and that can give you like a massive amount of information about what's happening with somebody's brain after a concussion. And it doesn't just show you what's wrong. It shows you if you understand what you're looking at, it shows you what to do about it, how to get somebody better. Right Now there is a specific eye movement called a saccade, which is a fast jump from target to target. And this is how you build your environmental map.

Dr. Glen Zielinski: 7:57

Saccades come from your frontal lobe through your basal ganglia into your midbrain and down into the pons. So basically, that whole brainstem pathway is being driven by descending frontal lobe output. And again, frontal lobe is cognition, executive function and so on and so forth. Right, everything that people like to think of as consciousness is mostly frontal lobe, and when you talk about people having cognitive problems, you're talking about some kind of a frontal lo, frontal deficit in most cases Now. So again, a saccade is moving from target to target, going towards something that's called a prosaccade. An antisaccade is a whole other ball of wax. An antisaccade is you have a target and your brain has a reflex that wants to make you move towards that target, but you have to be able to inhibit that reflex and then you have to be able to move your eyes in the opposite direction. Now that is a higher-level executive function task that comes from specifically an area called the dorsolateral prefrontal cortex, the DLPFC, and generating antipsychots with stimulus on the right is a function of the left DLPFC and vice versa.

Dr. Glen Zielinski: 9:00

Um, there is a ton of new emerging evidence around how anti-saccades get messed up when somebody has concussion. I mean, I presented on that at the Barony Society meeting in Madrid a couple of years ago, at the biggest vestibular conference in the world. The whole idea of anti-saccades is they're not just about you being able to not look at a target, they're about response inhibition. All right, and response inhibition is essentially if you're capable of listening to me, it's because you're inhibiting the sound of the birds chirping behind my head Right, or the sensation of your butt on the chair that you're sitting on and all this other sensory input that's just there at all times. And if you can't inhibit, then you sort of become a slave to the environment and you get what we like to call squirrel brain, in the sense that you're in the middle of squirrel, you know, and you can't inhibit environmental stimulation.

Dr. Glen Zielinski: 9:55

Now that's massively problematic when people get into complicated sensory environments, because if you can't inhibit what's happening around you, if you can't inhibit all the visual stimulation, if you can't inhibit what's happening around you, if you can't inhibit all the visual stimulation, if you can't inhibit all the auditory stimulation. You know, costco is like our final exam for our patients, because that's the most overwhelming circumstance that we can put anybody in in terms of visual and auditory and cognitive tasks and so on and so forth. If you can't inhibit that kind of stuff, you can't function in the world. And that's why people find inevitably that they get into complicated sensory environments and they have meltdowns. So an anti-saccade very specifically looks at your ability to inhibit the world and if it doesn't work, then good luck, right, okay, so anti-saccades come from the dorsolateral prefrontal cortex and traditional TMS is basically geared towards stimulating the DLPFC directly.

Dr. Glen Zielinski: 10:48

So if you're not familiar with TMS, it's this big MRI-strength magnet with a very focal beam, you place it directly over your DLPFC. With traditional TMS it's the weirdest sensation in the world. It feels like somebody's snapping you in the forehead with an elastic band but it sounds like somebody's drilling a mallet into your head with a big wooden stake. Like it's just crazy. But most people don't have any problem with it. I mean, there is the odd person that can't tolerate the stimulus, but I mean we have more patients that fall asleep in the chair during TMS than we do, people that can't handle it. But the point is that it directly stimulates that pathway. It directly stimulates the dorsolateral prefrontal cortex from through your skull and it lights it up like a Christmas tree.

Dr. Glen Zielinski: 11:34

So when TMS was first presented, when it first got its FDA approval, the thing about TMS was that if you looked at the response rate of SSRIs the antidepressant medications that most people go on if they have chronic refractory depression the response rate on an SSRI is something like 22% for the first med and then it's something like 14% for the second med and like 3% or 4% for the third med, with response being 50% improvement or better. And if you haven't% for the third med, with response being 50% improvement or better, and if you haven't responded by the third med, almost inevitably you're not responding. Okay, and what that means is that the majority of the depressed population don't respond to meds right. They just don't have the benefit that everybody's supposed to get. So TMS was originally studied looking at that population, and they put together a six week protocol. You basically get 18 minutes worth of STEM five days a week for six weeks. The research on that showed something like a 68% response rate and a 48% remission rate, which is dramatically better than you can get from any medication.

Dr. Ayla Wolf: 12:43

And in a short period of time.

Dr. Glen Zielinski: 12:45

Yeah, exactly, exactly right Now. Yeah, the thing is and this is a really important thing to understand depression is not a TMS deficiency. Depression is not a DLPFC lesion. Depression is a problem with networks. Okay, depression is something that involves your whole brain. You can have one area that's critical for that function, but that doesn't mean it's coming from that area. It means that that area is, you know, an apex, involved in a lot of pathways, lots of stuff basically summates in that area. But that doesn't mean that's where the problem is.

Dr. Glen Zielinski: 13:19

Now the thing is, when you start looking at what happens with concussions, if you just look at, like classic depression, that happens, you know, refractory depression, with post-concussion syndrome, which is the majority of people that have been significantly concussed, the majority of people that have been significantly concussed. If you look at that it's, I mean you can have that problem and the injured areas of your brain or brainstem or cerebellum or frontal lobe can be just about anywhere and you can still wind up in a situation where your DLPFC is not firing very well, not because it itself was directly lesioned, so much as that. Everything runs in there. They did this thing called the Connectome Project a few years back, where the imaging technology had reached the point where now we can not only see what different parts of the brain do but how they all connect. And the DLPFC is essentially the most connected part of the entire system. Everything runs in there and it affects just about everything and it affects just about everything and, as a consequence, if you have shearing forces or diffuse axonal injury or damage somewhere, it's almost inevitable that it's going to influence what happens in the DLPFC at some point. Okay Now, with that system being a critical node in again the default mode network, the salience network, there's a few different ways to look at what those systems mean.

Dr. Glen Zielinski: 14:31

The way that I usually explain it to patients even though this isn't like strictly accurate is just to say that you know your default mode network is sort of like resting emotional tone between thoughts and you want that to be positive and when it's not working very well it becomes negative. And your salience network is how you build emotional context around information and you want to be able to integrate that stuff appropriately and normal. You're walking down the street and stuff happens and you're like, wow, stuff happened and you keep walking. And when those systems don't work very well, you're like walking down the street. Wow, stuff happens and you just immediately default to this negative self-talk and it's like and what is it about me that makes all this stuff keep happening? And now I'm going to catastrophize and die alone and unloved or whatever, right? And that's a circumstance where people just can't successfully integrate that kind of information correctly because of those networks not working very well, and that sets people up for chronic depression and chronic anxiety and PTSD and catastrophizing and so on and so forth. All right, so the point I'm trying to make is that you can affect those systems by directly stimulating it and it'll help in some cases. If that's where the integrated problem is, if it's on the other side of the brain, well then you need to understand that, and if it's in other areas that are feeding into that, you need to understand that as well.

Dr. Glen Zielinski: 15:44

Now, we've been doing TMS as part of our neurorescue program for years. Right, we've been looking at doing TMS as an integrated therapy within all of our I shouldn't say all, but within the majority of the patients that we work with with post-concussion syndrome, and we were, and we probably still will, publish on this at some point. We just got way too busy and never quite got around to it. But we tracked our first 300 patients, that we did this with the first 300 in week-long intensive therapies. That involved us doing TMS and, like I said, traditional TMS, like 68 response rate. Our response rates were like 96% I think, and our remission rate was in the high 80s, you know. And that's doing TMS twice a day over one week coupled with the rest of the therapy, and that's the whole point, right, because it's not just about being able to stimulate that one area, it's about getting your entire brain to light back up and integrate correctly.

Dr. Glen Zielinski: 16:44

Okay, and that requires being able to map out everything that's wrong, where everything has the problem, and then coming up with an appropriate protocol to be able to fix whatever it is that you find right. And that kind of pivots towards our general approach with everything. Our general approach is, I mean, we sort of follow the same heuristic, the same plan with every patient and the pieces are different for everybody, but the concepts are exactly the same for everyone. We start with really intense neurodiagnostics so we can see exactly where the problem is, which systems are working, which ones are having a hard time keeping up, what we need to do in order to facilitate them, and then from there, once we've identified the tissue that we've decided that we want to go after step one we do something to build metabolic capacity in that system. And step one is that's like oxygen therapies or laser therapies or LEDs, all these things that one way or another allow us to build energy and metabolic capacity within those systems.

Dr. Glen Zielinski: 17:40

Step two is find some way to directly stimulate those pathways. And if we're talking about something like, say, a problem in the DLPFC, tms is the perfect way to do that. Okay, but if we're talking about a brainstem system, then we're talking about doing like trigeminal electrical stimulus. Or if it's like a vestibular lesion, we're talking about putting somebody in a gyro stem or an omni-ax and spinning them off axis in a way that's going to directly activate or integrate particular vestibular receptors.

Dr. Glen Zielinski: 18:06

And then from there, the next step is find some way to exercise that pathway, and that is, you know, eye exercises, inner ear things, balance exercises, whatever. It is that we're trying to facilitate, cognitive exercises, you know whatever. And then from there the last step is find some way to integrate it. And integrating it for us means everything from doing all these exercises on, you know, touch screens with all these cognitive things that we can integrate eyes with body, with vestibular systems, with cognition, with emotional regulation to taking them out on our big gym floor. Since you were out, you probably haven't seen this, but I added an extra like 1,200 square feet. We've got like 50 lane or 50 foot turf, four lanes and like a full gym and all this kind of stuff, and that's allowed us to basically start doing all kinds of more kinetic, dynamic things and make up physical exercises for people along the way to help integrate all that kind of stuff.

Dr. Glen Zielinski: 19:00

And the point is that tms is a fantastic stimulus. It's a fantastic way to directly hit some very specific pathways in ways that you just can't get. You can't stimulate any other way, but you can certainly exercise them in other ways. Okay, so like, for example, one of the things that we have people doing all the time now is we'll go and do all of our diagnostics and see exactly oh, there's a hummingbird behind me. We'll go and see exactly where all of the like, what parts of our system we want to facilitate, and if we decide, say, this person has a problem with their right dorsolateral prefrontal cortex, we'll basically do TMS to facilitate that cortex while they're staring at a screen that we have positioned to give perfect field of view for their eyes and give them anti-saccade eye exercises which directly stimulate that pathway as well.

Dr. Glen Zielinski: 19:58

So one of the things that's important to understand about the research on TMS is there's a difference between stimulating a pathway and facilitating and integrating a pathway. And if you have some cells that aren't working very well and you get those cells working better but they're not talking to the other parts of the system that they were originally integrating with, then you didn't make that much of a change. You made some change but you didn't make the change that you want. And there's a lot of research that we've seen on TMS for specific conditions where it's like, yeah, it looks like it helps somewhat, but it's not a game changer. Conditions where it's like, yeah, it looks like it helps somewhat, but it's not a game changer. And we do it and we incorporate it with an exercise that specifically stimulates that pathway in somebody's life changes in real time. You know like we see that all the time.

Dr. Ayla Wolf: 20:38

So so, essentially, by stacking neuro specific neuro rehab exercises while people are getting the TMS, you're not only activating the area but you're integrating it with the other hubs where it's speaking to and you're basically seeing phenomenal results when, again, the research that's only looking at one thing is maybe getting less of an effectiveness.

Dr. Glen Zielinski: 22:12

Oh, absolutely. I mean, see, this is one of the problems with trying to do research on brains, right? And this isn't just specific to TMS, I mean, this is just welcome to neuro research, right? Um, if you want to be able to say that, say, hyperbaric oxygen makes a change for somebody and we do hvac all the time, hvac is super helpful if you want to be able to say that hyperbaric oxygen made a change in somebody with a brain injury, you have to study only hyperbaric oxygen. You have to make sure this person isn't getting any other stimulus, otherwise it's confounding, and so on and so forth. And people say it's a lousy study and they throw it out.

Dr. Glen Zielinski: 22:45

Now, hbot by itself, the only thing HBOT does is get more oxygen into the tissue and that's great. But if you don't do anything to exercise that tissue, to build it back up so that it can integrate and it can actually start performing the functions that it needs, it's not going to make that much of a change. And that's why most of the research on HBOT is equivocal. But what we see all the time is that if we put somebody in an HBOT and we kind of juice up their oxygenation and then we go and start doing exercises, we can push them a lot harder, we can push them a lot farther before their systems start to fatigue and, as a consequence, we can get a much bigger change. So as part of an integrated protocol, things like that can be fantastically helpful. And TMS kind of works the same way. Tms is a stimulus and you can juice up a pathway and get it firing a little bit better for a few hours. Then it's kind of backwards started, right.

Dr. Glen Zielinski: 23:36

So this is something that's important to understand about neuro rehab, right? Neuro rehab is nothing like physical rehab. With physical rehab you push a muscle to fatigue, you push it to the point where it fails. It comes back stronger, right. If you drive a neuron anaerobically and you push it to the point where it fatigues and crashes, you just wave goodbye to that neuron. Neurons don't go anaerobic and survive, right.

Dr. Glen Zielinski: 23:57

So the idea is that what you need to do with rehab is small bits of stimulus that don't exceed any fatigue thresholds. So you want to think if this is how high I want to get this pathway firing and it's firing down here, you have to make sure that you're only getting up to around this level of the fatigue threshold so that you're not blowing something up, because you've talked about fragile pathways, right, and but, more importantly, that wasn't exactly the point I was trying to make. If you, if you look at what happens where, if here's where we're trying to get this pathway firing and it's down here, right, and we give it exactly the right stimulus and exactly the right exercises and we get right up to exactly the fatigue ability we want, you're good for two hours and then you're back where you started, because you didn't change the pathway. The only thing that you did was sensitize receptors in the pathway. You created what's called a receptor potentiation. You get it firing a little bit better, but that degrades, that wears off, and this is one of the things that has got the entire neuro rehab world gravitating towards the intensive outpatient model. Everybody does this now, from every rehab hospital down to every rational clinic, right? The idea is if you can stimulate it again before that receptor potential wears off. That's how you start turning on all these genetic responses within the cells that say I need to build more protein, I got to keep up. That's how you actually make something better, right? You generate what's called long-term potentiation with high frequency stimulus. You generate what's called long-term potentiation with high-frequency stimulus over short periods of time, right.

Dr. Glen Zielinski: 25:25

And if you look at even just within TMS, okay, there's a protocol that Stanford just came out with where they've suddenly figured out hey, you know what's great, doing intensive therapy, so instead of this like six-week, we'll hit you for five days a week, kind of thing. They're doing intensive stimulus, they're doing five sessions a day for five days and they're getting better outcomes, right. But again, that's still just stimulating that one pathway and that's not the same thing as using it to facilitate everything. And one of the things that's really great about TMS is that you don't just have to use it for the dorsolateral prefrontal cortex, so for, for example, we see people that have got problems with particular motor patterns. Okay, they've had strokes or they've had some kind of really significant catastrophic injury or whatever, and you know they lose control of one part of their body.

Dr. Glen Zielinski: 26:12

Um, we found that by being able to go in and precisely activate the parts of the parietal lobe where those areas send their initial sensory input to, and facilitating that with some directed TMS and then so that they can start to get a better representation of their body and they can start to control it better, so we see lots of improvement from doing that and then going specifically to the different parts of the motor cortex that allow you to drive exactly those outputs that can be spectacularly helpful.

Dr. Glen Zielinski: 26:40

So there's actually a bunch of research just on things like athletic performance. If you want to throw a jump shot, you can do TMS before you go and practice your jump shot and then, as a consequence, your jump shot improves much faster than it would otherwise. I mean there's all kinds of stuff around that. We have been for the last few years, years seeing this really really massive number of people with dystonias, so like cervical dystonias, movement disorders and so on and so forth, and we found that by going in and finding the precise part of the sensory or motor strip in the brain that is driving their dystonia and inhibiting it with TMS, because you can not only accelerate the function of something but you can slow down the function of something depending on the frequency of activation you do 10 hertz is excitatory, 1 hertz is inhibitory. Within the TMS world, by doing an inhibitory stimulus we can actually get some of these weird motor patterns to calm down.

Dr. Ayla Wolf: 27:39

Oh, wow.

Dr. Glen Zielinski: 27:40

And when you see somebody walking in doing this and then you do TMS and then they're just kind of like that and they're like what happened, you know, I mean that's fun, we like that. Yeah, I mean I could go on. We see a lot of people with dysautonomia. I mean there's tons of patients that we see all the time that come in with dysautonomia. You know, like postural orthostatic tachycardia syndrome and things like that. They tend to respond fantastically well to TMS because there's this huge part of the tachycardic component of that, the sympathetic activation. That's about how well your frontal lobe is talking to your basal ganglia so that your basal ganglia can chill your midbrain out, and if that doesn't work, your sympathetic system fires really high and they get super high heart rates and lightheaded and stuff like that. Directly stimulating the parts of the system that activate the basal ganglionic pathways in these cases can be tremendously helpful as well.

Dr. Glen Zielinski: 28:37

So my point is that we've seen benefit in just about every condition that we treat with TMS. But again, the key is being able to target it specifically to the condition, and I think the main reason that we get the outcomes that we get with that therapy is because we're tailoring it entirely based on our diagnostics. It's not the same thing as just saying, hey, you should go and do TMS at the TMS clinic down the street because they will do left dorsolateral prefrontal cortex excitatory. That's it. That's all, because that's generally the only thing they know how to do, and if you happen to be exactly the person that needs that, it can still give you a great outcome, but if you're not, then it might not.

Dr. Ayla Wolf: 29:18

Yeah, Now did you just say that you can actually target the basal ganglia because that's super deep in the brain. But are you able to get that far in with the magnetic?

Dr. Glen Zielinski: 29:26

there are. There are different types of coils that you can use for basal ganglionic activation. So basal ganglionic stuff is called deep stimulus. It's deep dms. There's an older system floating around called brain sway and the brain sway is sort of like. It's kind of non-specific but it is still deep. Um, that doesn't quite give you the ability to target right or left, it just kind of hits that that depth of the brain and gives you some benefit. Um, that was originally the first one that was FDA approved for treating OCD and various basal ganglion conditions.

Dr. Glen Zielinski: 30:02

But since then there's other coils that have come out that allow you to get deeper penetration with like a traditional system. So most traditional TMS is like a little figure eight coil or it's like hoop coil. The deep ones, they're kind of V-shaped and they allow you to get some deeper penetration. The deep ones, they're kind of V-shaped and they allow you to get some deeper penetration. No-transcript. So we were doing a lot of deep TMS for a while and we rarely find the need to do it now. For the most part we're just doing superficial stuff but but just being extremely precise with what we're going to target.

Dr. Ayla Wolf: 30:51

Yeah, are you seeing Parkinson's patients too?

Dr. Glen Zielinski: 30:54

Oh yeah, lots of them, and we find that helpful in many, many cases. The thing about Parkinson's is that when you're talking about a neurodegenerative disorder, it really depends on when we get to them and how much degeneration they've already experienced. Because the thing about TMS is that it is a stimulus and, as with all types of stimulus, you have to be really careful to make sure that you're not overstimulating a system Because, like I said before, if you take a neuron and you fire it faster than it can handle, you can blow it up. And with people, like with Parkinsonian patients, depending on what we see in our diagnostics we don't always go straight there. It's fairly common that we'll build their systems up for a while doing other types of therapies and get them to the point where they can actually handle that kind of stimulus. And again, we find it really helpful and for things like tremors and stuff like that, it can be spectacularly beneficial yeah, that's incredible yeah, it's fun, thank you for sharing all of that amazing information.

Dr. Ayla Wolf: 31:59

So, outside of maybe you know what you just mentioned in terms of a Parkinson's patient maybe needing to be built up first, are there certain people with TBI that come in? What would be a contraindication for using it, or are there any that you see?

Dr. Glen Zielinski: 32:17

Well, there are a couple of frank contraindications for TMS. One is you need to have no seizure history, right, and and then another is you know metal in your head. So anybody that's that's had you know that has like surgical clips or has like a vp shunt or anything like that. That idea now, when they say metal, what they mean is something that's you. Now, when they say metal, what they mean is something that's ferromagnetic. So if you, there are some people that have metal, that isn't an issue, it's not a problem, right, um, but the thing that is that I do also frequently find to be a little bit of a problem for people and this isn't a contraindication, it just kind of slows down how fast we can start to apply that.

Dr. Glen Zielinski: 33:00

People that have like hyperacusis, um, I mean, tms makes a bit of noise, right, and everybody does tms with hearing protection it's not like it's insanely loud, but you know. But it's like about an 85, maybe 88 decibel noise, you know. So it's loud enough to mess with people if they're already having lots of difficulty with auditory input, right, and and still, the majority of those patients, just with some hearing protection they still do fine and we can generally dive in. But every once in a while we run up against somebody that just needs to be stabilized a lot more before we can start doing that got it that makes sense.

Dr. Ayla Wolf: 33:49

this was part one of my conversation with Dr. Glen Zielinski from northwest functional neurology Got it that makes sense. And superior canal dehiscence. He also describes at length how he won several architectural awards for his clinic design and the great lengths that he and his architects went to to create a healing space, taking into account the different colors that were used and the types of shapes and spaces that are most calming and healing to the nervous system of people who are struggling with traumatic brain injuries and other neurological disorders. If you have certain topics you'd like us to cover in future episodes, you can click the send us a text link at the top of the show notes or email us at lifeafterimpact at gmailcom. Thank you so much and we'll see you next time. Thank you so much and we'll see you next time.

Dr. Ayla Wolf: 34:41

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