Brain Hub Podcast

Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy. Hello and welcome to the Brainhub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the owner of Brain Hub Clinics in Sydney. Matthew: Good day Carlo, how are you going? Carlo: Good day Matt, good to be here today. Matthew: Indeed.  So what has been happening latterly I hear that Brain Hub has moved premises and you have no got two locations in Sydney where people can come along and see you. Carlo: That is correct, since our last podcast Matt I have since left the previous location in Annadale and now set up two very central locations scattered throughout Sydney, one in Leichhardtand the other one in Gladesville.  So I have been practising here for almost seven, nine years now. So I have got my roots firm in this area for both where I live, where I studied, where I went to school, where my kids attend school and where I have worked for the last seven, nine years as well as from the Lower North Shore of Sydney where it seems we have a number of patients that travel from the Northern beaches or from the North West that come to see us.  So at these two locations we are offering the same services, the same dizziness, balance and sort of treatments for those neurological based conditions.  We are offering all the services that we were offering previously and we have expanded to incorporate the services of massage therapist, acupuncturists, medical doctors, psychologists are all part of our team.  So I would say the move is great for our patients, we are able to offer more services from our central locations. Matthew: Yes, that sounds great, certainly with the psychology and so forth with dealing with a lot of those vestibular cases and balance cases that can certainly have an aspect particularly with anxiety.  So that probably ties in quite well with what we are going to talk about today.  Basically we got scheduled to go into a bit more deeply about dizziness and obviously with that vertigo, dizziness and vertigo are obviously very common conditions that you see a lot of in your practice Carlo, do you want to tell us a bit about what dizziness is and say how it differs from vertigo and things like that? Carlo: Sure, I would say out of the conditions that our clinics sees dizziness is certainly the most common and the most prevalence symptom that people call us up and seek some help with.  First of all dizziness is often very loosely described, people will come into the office saying that they have dizziness, and they will describe it in some way when we ask them a few more questions as to can you describe it a little bit further, when does is happen, what exactly do you experience, what are you not experiencing, the definition of dizziness comes out a little bit more.  Dizziness is one of those poorly defined conditions that we often need to tease out a little further. So I often say that the differences between dizziness and vertigo is this, is that dizziness is always described as a perception, it is a very none specific term but it is described as an unsteadiness, a light headiness or a giddiness rather than one perceiving that they are moving.  So it is more of an impaired or altered sensation of themselves, not necessarily a sensation that they are moving.  That sensation of movements is typically described as vertigo or as an impairment or a sensation of poor orientation is often described as dizziness and we often want to tease that out a little further as the clinician because the causes of it and obviously how we can help people with it varies quite considerably. So we certainly want to ask these questions as something that we teach in our cause to practitioners is to really elicit the correct diagnosis from a number of questions that we ask clients. Matthew: Right, so clearly it is a different sort of thing there, what are some of the more common causes of the vertigo component if that is a little bit more easily defined? Carlo: Sure, vertigo is often described or defined by two different categories and again as clinicians we want to put someone into one of these categories because again the prognosis, the diagnosis and the management varies considerably.  Those two categories are whether they have something wrong with their inner ear and that can be the little balance receptors in their ear or the nerves that connects the inner ear to the brain and that is described as a peripheral disorder.  So a peripheral disorder is something that affects the nerve or the inner ear on the outside.  A central disorder is really something that affects the brain and the brain only.  So again they are very distinct and something that we want to be clear with.  An example of a peripheral vertigo is classically BPPV which is Benign Paroxysmal Positional Vertigo. It is part of the common cause of dizziness, it is where the little calcium crystals, the little calcium carbonate otherwise known as otoconia in the inner ear, these little canals in the ear becomes dislodged for various reasons, they move into the canals and as they move through the canals and as we move our heads the brain perceives that the world is spinning or we are spinning.  So we get momentary periods of dizziness or vertigo where we feel that the room is spinning. Anyone who has had this will certainly confirm how unpleasant it can be, they often fall to the floor because they feel the room is spinning around or that they are spinning within the room.   So that is a classic condition, a peripheral vertigo condition and another two classical conditions are infections in the inner ear, I know two main types, on is called neuritis which is information of a portion of the nerve that affects only the balance parts and then we have labyrinthitis.  Labyrinthitis is infection of the nerve in the ear that affects both the balance part as well as the hearing part, so people will also get some tinnitus which is ringing sounds in the ear, they might get fullness in the ear which is a discomfort or a full sensation or they also may get some deafness and that is indicative of labyrinthitis.  And that can happen through a number of infectious problems that we get in our ear nose and throat or even in their respiratory systems as well.  So those are our main peripheral vertigo conditions.  I guess some of the most central conditions, those that are affecting the brain shall include things like migraine associated vertigo or vertiginous migraine where people who often get migraines, the classical head and head pain conditions can also get vertigo and a senseless spinning with their migraines.  So that is often described as vertiginous migraine or migraine associated vertigo.  Those are the common disorders that people can get.  Another one is described as Meniere’s, Meniere’s really should be included in the peripheral disorders those affecting the inner ear, unfortunately with Meniere’s it is quite a debilitating disease that as people get dizziness they get tinnitus which is that ringing sound and they also can get deafness and fullness in the ear as well and that can last hours if not days when they have it and they can also get attack every so often and that has been associated with dietary problems or immune problems, salt intake amongst others as well.  So I guess those are the more common vertigo conditions to answer your question Matt. Matthew: Yes, so I suppose what comes out there is all of those have that perception of movement and the speeding type of sensation that you are describing.  What are sort of some of the causes perhaps of dizziness where you get these less well defined symptoms and conditions themselves don’t really have names as much as my understanding anyway of the dizziness, do you want to tell us a little bit more about that? Carlo: I think probably the three main dizziness conditions that are reported and we see in our practice include cervicogenic dizziness and that by definition is dizziness that comes from basically a neck that is not working too well, their joints in the upper neck are very strong connections with the balance parts of the brain, with their balance parts of the brain, with their visual parts of the brain amongst others and when the upper neck is not working for instance from a whiplash injury or a concussion or arthritis, poor posture, injuries of any sort many chiropractics or physical therapists will see this patients present to their to their practice. They often can have dizziness associated with these cervicogenic or neck related conditions.  Unfortunately through the work that we can do with the neck and with balance and visual retraining we can really help these people.  So cervicogenic dizziness is one that we need to include.  Another is described as a light headedness or a presyncope. Presyncope basically means it is almost that fainting state where someone from a seated position may stand up quickly or they may lying down or they may sit up quickly, that change in blood pressure, the blood pressure change is not first enough or great enough to combat the change in gravity as opposed as it goes from a sit to a standing position.  Basically parts of the brain don’t get enough blood supply to it as the body changes in gravity.  So what happens is that they get a little light headed and they get a little oozy in their head and this is a very common symptom particularly those with age and the elderly, they may say to you I feel a little lightheaded, I feel a little dizzy when I get up, well this is the reason for it.  It is often described as an orthostatic hypertensive problem or presyncope problem where basically the cardiovascular system or the part of the brain that controls the cardiovascular system aren’t working as well as they should and for that reason they get a little lightheaded and they report it as a sense of dizziness.  Medication is also another cause of that as well.  I guess finally the other form of dizziness that we tend to see a fair bit in our office is what we call or describe as a persistent postural perceptual dizziness, it is a big word, big title, shorter name is 3PD which is persistent postural perceptual dizziness.  And expanding on that name, persistent meaning that it can unfortunately stay with you for some time, postural meaning that your posture and movement of your body can often exacerbate these symptoms, perceptual is an interesting term because it means that the patient will always perceive they have these dizziness symptoms but in fact as a clinician when we examine them we often may find very little wrong with them and we may go into a full series of balance tests that involve ocular or eye movement tests, blood pressure tests, balance tests and by and large these people may look relatively ok, or what happens is because they have had these problems for so long just like a chronic pain patient their brain actually rewires itself a little bit to perceive that they have these dizziness symptoms in the absence of actually having any real problems, any physical problems I should say.  The way in which we typically help people like these apart from some of the rehabilitation that we may provide is additionally work with other councillors or psychologists particularly those that use cognitive behaviour therapy and help them through emotional or rather behavioural strategies overcome some of these perceptual persistence symptoms.  So I guess they are other main causes of dizziness that we see commonly in our office. Matthew: I am sure that many people when they get things like dizziness and vertigo one of the things that sort of jumps to their mind is that they are having a stroke or have a brain tumour or something like that, and most of the time it is one of the sort of less causes that you have referred to.  These can be a cause though of dizziness and vertigo and how can people tell if it is something they need to seek urgent attention for? Carlo: It is a great question Matt, often it could be difficult, difficult for even clinicians, often I get calls from new clients or people interested in the work that we do, they have a bout of severe dizziness and vomiting overnight or over the weekend they present it to the emergency department and often get dismissed from the hospital because nothing serious has happened.  One of the things that I indicated to clients as well as teach other practitioners is look for other symptoms that may indicate that something more serious is occurring.  If it is, if you do get dizziness and you are vomiting you may think that the world is ending even though it may be relatively benign people often think the worst and I certainly don’t begrudge them in thinking that.  But if it is a dizziness condition and it is affecting only the ear and they have BPPV or they have got one of the infectious complaints or they have an attack of Meniere’s it affects only the inner ear, there are no effects on other parts of the body.  So that being said we shouldn’t see any other signs or symptoms outside of the inner ear.  To give you an example, if someone has trouble talking, swallowing, chewing that is typically not a good sign, if someone has troubles with incontinence, they have troubles holding their bowel or bladder that is not a good sign, they have pins and needles in their hands or feet that is generally not a good sign.  That being said, also anxiety and panic attacks can also cause that same symptom.  If they have troubles walking or they have weakness in their hands or they have weakness in their feet, additionally that is not a good sign.  So if anyone has dizziness and they present with any of those difficult with chewing, swallowing, talking, unable to move their hands, unable to move their legs, get funny sensations impacts the body or they have altered bowel and bladder control I would typically say that is not a great sign and it is pretty best that they seek emergency care.  Fortunately though the series causes of dizziness are relatively rare which is great but for the average person who may not know otherwise I can certainly understand why they would think the worst. Matthew: Yeah, so they really need to just be sure, go and get checked and most of the time it is not going to be anything serious but it is really something you don’t want to walk around with isn’t it? Carlo: Exactly and so much on the side of consciousness but  you are not getting any of these other symptoms you could be fairly confident that it is not anything of serious notes but certainly if you are concerned more than that seek first aid care immediately. Matthew: What are some of the treatment that can be done for vertigo and dizziness? Carlo: Treatment for vertigo and dizziness always depend on what the cause is.  I mentioned earlier the differences between and inner ear problem to a nerve problem to a brain related problem or a neck related problem or a cardiovascular related problem.  So your first step should always be seeking care and assessment with an appropriate trained person who can dissect and really tease out which one of those causes is the case.  So in my office we spend sometimes almost up to two hours on an initial consultation whereby we go through a very comprehensive examination, we ask all the right questions, they help tease out which one of these is potentially causing it and then we do an examination that looks at balance, looks at spinal control, looks at eye movement, looks at inner ear, looks at other brain function and then we say okay based upon that this is more or likely what you are suffering from.  And then from that this is what we can do and these are our expectations.  Some conditions are very favourable to the sort of work that we do, conditions like BPPV I would say in terms of the migraine associated vertigo we get some great results and other conditions we can help manage it very effectively.  So with BPPV you can almost get a nine percent resolution in symptoms after the first one or two visits purely from the work that we do which is great for the patient so that they can get back on their feet and feeling better again pretty quickly.  Treatments involve many things from specific head movements that we may do to exercises that involve the eyes, balance exercises, neck related exercises, dietary advice, lifestyle advice. Again I guess it is somehow difficult question to answer that unless we knew what their condition was but certainly our goal is to accurately diagnose what is going on and for the vast majority of people we can certainly help them and for some people we can help them tremendously, very quickly to a point where they are all back to normal.  For others they have more complicated cases whereby we can help manage their symptoms, we can help lessen the frequency or the severity of their symptoms and sometimes we need to co-manage with various other specialities like medical doctors, ENTs, nutritionists or naturopaths as well as psychologists for some of those conditions that we mentioned earlier.  So there is many things that we can do and there is very few people that we are unable to help which is great. Matthew: Yeah, so it sounds like this might be something we might want to look into in more detail in the future, no doubt we will cover some of these conditions perhaps in more depth in upcoming episodes.  Is there anything else you would like to add in closing? Carlo: Just the basic summary, with dizziness be sure to seek the assistance and care of someone who looks at it from a very integrated perspective.  There is many reasons why someone would have dizziness as we spoke of today, so it makes sense to have a practitioner to go through all the systems that are involved because sometimes it can be just a change in medication that causes it or it could be because they have a recent ankle sprain and that in itself has changed the mechanics of their body which has then changed the way the brain integrates this information.  It could be that they have had a recent ear infection or it could be that they have got anxiety and fear and that that is perpetuating their dizziness.  So there is never a one size fits all approach to this so be sure to see someone who can look at it from a very integrated perspective. The team at Brain Hub certainly attempts to do that, we work with people and if we feel that we don’t cover all those bases we certainly work with the appropriate people to make sure that we do. Matthew: Well, if you have got any questions about today’s episode or if you would like to leave a comment or anything else like that please pop along to brainhub.com.au/blog, on that website as well you will find all the contact details for the practice should you want to get in touch with Carlo and book an appointment or anything like that.  In addition to that you will also find a full transcript of today’s episode, if you want to have a read through be sure to subscribe on iTunes, Stitcher or whatever other platform you are using to listen to so that you don’t miss any future episodes.  So until next time take care.   Thanks for listening to the Brainhub Podcast, for more information and to subscribe visit brainhub.com.au. References 1: van Leeuwen RB, van der Zaag-Loonen H. Dizziness and neck pain: a correct diagnosis is required before consulting a physiotherapist. Acta Neurol Belg. 2016 Sep 6. 2: Martins E Silva DC, Bastos VH, de Oliveira Sanchez M, Nunes MK, Orsini M, Ribeiro P, Velasques B, Teixeira SS. Effects of vestibular rehabilitation in the elderly: a systematic review. Aging Clin Exp Res. 2016 Aug;28(4):599-606. 3: Hillier S, McDonnell M. Is vestibular rehabilitation effective in improving dizziness and function after unilateral peripheral vestibular hypofunction? An abridged version of a Cochrane review. Eur J Phys Rehabil Med. 2016 Jul 12. 4: Ribeiro KM, Freitas RV, Ferreira LM, Deshpande N, Guerra RO. Effects of balance Vestibular Rehabilitation Therapy in elderly with Benign Paroxysmal Positional Vertigo: a randomized controlled trial. Disabil Rehabil. 2016 Jun 24:1-9. 5: Dommaraju S, Perera E. An approach to vertigo in general practice. Aust Fam Physician. 2016 Apr;45(4):190-4. 6: Edlow JA, Newman-Toker D. Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo. J Emerg Med. 2016 Apr;50(4):617-28. 7: Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016 Apr;263 Suppl 1:S82-9. 8: Tjernström F, Zur O, Jahn K. Current concepts and future approaches to vestibular rehabilitation. J Neurol. 2016 Apr;263 Suppl 1:S65-70. 9: Grill E, Penger M, Kentala E. Health care utilization, prognosis and outcomes of vestibular disease in primary care settings: systematic review. J Neurol. 2016 Apr;263 Suppl 1:S36-44. 10: Ouchterlony D, Masanic C, Michalak A, Topolovec-Vranic J, Rutka JA. Treating Benign Paroxysmal Positional Vertigo in the Patient With Traumatic Brain Injury: Effectiveness of the Canalith Repositioning Procedure. J Neurosci Nurs. 2016 Apr;48(2):90-9; 11: Liu Y, Wang W, Zhang AB, Bai X, Zhang S. Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: A network meta-analysis. Laryngoscope. 2016 Apr;126(4):951-5. 12: Schlick C, Schniepp R, Loidl V, Wuehr M, Hesselbarth K, Jahn K. Falls and fear of falling in vertigo and balance disorders: A controlled cross-sectional study. J Vestib Res. 2016;25(5-6):241-51. 13: Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015 Aug;33(3):577-99, viii. 14: Arnold SA, Stewart AM, Moor HM, Karl RC, Reneker JC. The Effectiveness of Vestibular Rehabilitation Interventions in Treating Unilateral Peripheral Vestibular Disorders: A Systematic Review. Physiother Res Int. 2015 Jun 25. 15: Jahn K, Kressig RW, Bridenbaugh SA, Brandt T, Schniepp R. Dizziness and Unstable Gait in Old Age: Etiology, Diagnosis and Treatment. Dtsch Arztebl Int. 2015 Jun 5;112(23):387-93. 16: Furman JM, Balaban CD. Vestibular migraine. Ann N Y Acad Sci. 2015 Apr;1343:90-6. 17: Hain TC. Cervicogenic causes of vertigo. Curr Opin Neurol. 2015 Feb;28(1):69-73.   Dr Carlo Rinaudo (Chiropractor and PhD candidate) is the clinic director of Brain Hub, a clinic in Sydney focussed on helping people with dizziness and vertigo conditions, poor balance, whiplash and concussion symptoms. The clinic and its practitioners use a range of modalities to help assess and manage these conditions and/or symptoms. Vestibular rehabilitation therapy and other brain-based therapies are primarily utilised, along with standard Chiropractic and physical therapy techniques. The growing evidence showing support for the management of these conditions comes primarily from the physical therapy and clinical neuroscience fields, rather than chiropractic specific. Fortunately, Dr Rinaudo with post-graduate training both in Australia and from overseas is experienced to translate this knowledge into clinical practice. Additionally, he is currently undertaking a PhD from the University of New South Wales (UNSW) and Neuroscience Research Australia (www.neura.edu.au)  in Vestibular Therapy, more specifically clinical trials on how to help people with dizziness and vertigo conditions. He is working alongside leading researchers and Neurologists in the field. Additionally, the benefits expected from his PhD research will be used to further validate the use of vestibular rehabilitation therapy for other related conditions like whiplash and concussions. Dr Rinaudo is a frequent speaker at national events, as well as lecturer in the field of vestibular rehabilitation and dizziness conditions to other health practitioners.  

Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy. Hello and welcome to the Brainhub Podcast my name is Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the owner of Brain Hub Clinics in Sydney. Matthew: G’day Carlo, how are you doing? Carlo: G’day Matt, glad to be here. Matthew: You sound you are a bit under the weather I believe it was a fairly big weekend in terms of some conferences that you were speaking at and so forth.  Apologies to the listeners today, Carlo was saying he is a bit bunged up, but you want to tell us a little bit about what you have been up to and what has been going on? Carlo: Yes, thanks Matt.  I apologise to the listeners to my very nasal and stuffy voice.  It has been a busy few months, most our listeners are aware that I have been presenting a series of seminars to practitioners across Australia on the vestibular and balance therapy which has been extraordinarily well received and we still have got some more planned for Perth, and Tasmania as well which is fantastic.  But over the weekend I was very fortunate to present to several hundred people practitioners, patients and parents at the international forum held by MINDD which is a rights initiative, it has been around now for about ten years, set up to help parents and adults and children and practitioners learn more about various chronic and nutritional, metabolic, immune, neurological and development disorders that unfortunately plaque many of us. Matthew: Indeed.  What did you chat about when you were speaking there? Carlo: I was very fortunate to be part of the teaching of a faculty there over the weekend.  My talk was on a problem that most people there were very familiar with which relates to gut function.  The direction which I took this was quite different than what most people are probably used to or exposed to.  My talk was on a brain based or a top down approach in helping people’s gut function, immunity and inflammatory conditions.  Whereas most of them have been exposed to very directed care to the gut through naturopathic or integrated medicine or other forms of health structures in getting the body to work to help the body, whereas my talk was get the brain to work better to help the gut to work better.  And it was quite novel for a lot of them and it was really well received.  I had a lot of parents and practitioners come up to me afterwards and share their thoughts and they were quite pleased that there was a different approach to problem unfortunately suffer from. Matthew: Yes, it’s a very common problem these days unfortunately.  What you are saying is a bit of a great segway into today’s topic which is we are looking at vagal stimulation for the treatment of brain disorders and other disorders within the body.  This isn’t a topic that I know much about so I am actually very interested to hear what you have got to say as I am sure our listeners will.  Do you want to start by maybe giving us an overview of what the vagus nerve is, where it’s located etc? Carlo: Before I get to the vagus nerve I will take a step back and talk about a part of the brain which the vagus nerve originates from, it’s called a brainstem, within this brainstem are many control centres and they record the autonomic nervous system.  There are many nucleo parts of the autonomic nervous system that sit within the brain stem.  The autonomic brain stem in itself is divided into two parts, there is sympathetic, that brain that helps coordinate our body and our response when we are under stress or when we are under attack and that’s very important and equally important is the flipside to that which our parasympathetic, our parasympathetic system is involved with our rest and digest, it’s involved with the part of the body that helps us to recover, repair, it helps digest foods, it helps us think, so it’s really the antagonist to the flight and flight the rest and digest.  That parasympathetic portion of the autonomic nervous system is controlled by the vagus nerve.  I need to step back a little bit to talk about the vagus nerve and I think with that in mind it’s pretty a little easier for us to discuss.  The vagus nerve is actually a cranial nerve so it’s one of the twelve cranial nerves that come out of our brain and supply various parts of our face and body.  So this cranial nerve, the vagus nerve is often referred to as the wondering nerve because in fact I think it’s the longest nerve in our body because it comes out of our brainstem, that lower part of the brain almost near where ears and top part of the neck would sit and it runs down through the neck into the torso and it supplies our hearts, it supplies our bronchial tubes, it supplies our guts.  The vagus nerve its job is to slow down heart rate, to slow down our breath rate, it’s also there to increase our gut function.  So it helps gut motility which means we can move matter through our gut effectively and quickly. It also supplies a lot of our organs which include our pancreas, our gull bladder and other parts of the digestive track to produce enzymes.  People are unaware enzymes are needed to break down food. So our vagus nerve helps organs to secrete enzymes which help break down food.  That’s pretty important for us to survive and to be able to absorb the all the nutrients that we need.  Another function it does is it supplies the lining of our gut.  In the lining of our gut we have got two important things, we have got a lot of our immune system which is why a good healthy gut not only equates to a healthy immune system but also the vagus nerve supplies the cells on the lining of that gut that helps keep them together.  It’s really important so our gut doesn’t become leaky and undigested, unbroken down foods are not allowed to be absorbed into our bloodstream.  So if you have good vagus activity the epithelium or the lining of that gut is tight and none of the undigested food is allowed to be absorbed into our bloodstream, which is really important.  So the vagus nerve is really really important and interestingly also it’s described as a bidirectional nerve meaning it sends information from our brain down to our organs but equally it’s sensory which means it detects what’s going on in our organs and tells our brain what’s happening.  So it also detects different problems and stresses in our organs and let’s our brain know hey say something is wrong we need to do something appropriate to make sure that it works well.  So it’s one of those incredibly important nerves in our body and research is now showing the value of understanding it in the therapeutic window that it has to offer as well. Matthew: Yes, I remember reading a paper that was talking about if there is damage to vagal function that you lose your gut lining very quickly, is that correct. Carlo: Yeah, it is. Some of the research that has been produced recently has linked poor vagus nerve activity with leaky gut syndrome, with irritable bowel syndrome, with chronic inflammatory bowel disease and there are many people out there that unfortunately suffer from these condition and I am pretty confident they are not getting a brain based approach a vagal nerve approach to help in the gut work. They are attending to it by getting some herbs or some nutritional products for their gut, they may be seeing a gastroenterology to help repair whatever is going on inside.  I am not going to take away from the value of that but equally that may only be a symptom to the brain not working particularly well.  The talk that I gave to two hundred and fifty plus people I hope sparked that thought pattern that oh maybe I should look at the other component to my gut which the top down the brain based effects and then that could be a nice adjunct to what I am currently doing.  So I think that many people were pleased and took that away. Matthew: What you are saying is there are a number of conditions that can benefit from this.  How would somebody know that they might have vagal problem that’s causing it and is it the case that everybody with irritable bowel syndrome would be a potential candidate for this treatment and if so or if not what would give them some clues that maybe they need to look into this further? Carlo: What I would often say to people is it really depends on what your examination and your assessment findings are.  So examinations or assessments that you could do to find whether or not your vagal tone is low or you have asymmetry in your autonomic nervous system.  Unfortunately there is no blood tests I think at the moment, cortisol level which is a salivary test that can look at what one of your stress hormones and that relates to your sympathetic systems.  So remember if your sympathetic system is high, unfortunately in the life that we lead, we tend to lead a very sympathetic dominant state.  So things like cortisol levels will tend to reflect that and if that’s high you could almost be safe to say that your vagal tone is going to be low as a by product of that.  Symptoms and history are the hallmark of any assessment, so any skilled practitioner should be able to ascertain that they get a good sense of where you are at based upon detailed history and examination.  But one of the, I guess the gold standard to determine autonomic dysfunction is heart rate variability where we are not just looking at your heart rate of 55 beats per minute but we are looking at the variability and most people will be quite surprised to hear the variability in your heart rate you can measure with an ECG machine or you can measure with a low cost, low tech device that you can put on your finger or as a chest strap and you can measure the variability in your heart rate.  Like this is a good idea whether you are sympathetic or para-sympathetic dominant.  Remember the vagus nerve is a by-product of the para-sympathetic nerves.  Additionally there are examinations we can look at, one is gag reflex, so the vagus nerve supplies the back of the throat, so we can look at how the throat functions when we will stroke it to elicit gag reflex whether it’s there, whether it’s asymmetrical, whether the left side or the right side works better.  We also look at other autonomic nerve system signs like pupil size is another classic sign or an autonomic imbalance.  For instance with a sympathetic or a fight or flight state our pupils are typically large, when we are in a rest and digest state our pupils are typically low.  So we may see that asymmetrically as well through the use of an ophthalmoscope.  We may look at the difference in size of the vein to artery size in the back of the retina.  We can look at other measures of brain function that give us an idea of what control do they have on the brainstem.  So I wouldn’t say it’s a simple question to answer but a detailed and thorough assessment will always give you the best way to detect if there is a problem and then from that the practitioner should then be able to tell a specific prescribed program based upon those results to help alleviate and manage those symptoms and that’s something that we do in our office all the time. Matthew: Right, so when you are talking about putting together a protocol what sort of thing is involved in vagal stimulation, is it an electrical thing or do you do reflex stimulation or how does it work? Carlo: There is a three pronged attack for us, we first we look at the higher brain because the higher brain has a huge influence on the brainstem.  So we want to make sure that the rest of the brain is doing well because without it, if there is an injury like a concussion or anthology like stroke, cerebral palsy or there is just a lack of attention and focus in the brain, it’s going to have a negative on the vagus nerve and other parts of the brainstem.  Firstly we want to make sure that those areas are working well, that’s for another discussion in itself, but in terms of the vagus nerve there is another two ways which we help, one is an in office program of using a specific current that we apply to the outer ear and the outer ear is one of the only part that the vagus nerve actually has in contact with the skin the rest of it’s obviously very deep.  And whilst there are invasive techniques that attach a pacemaker inside the body, clip a little stimulator on the nerve and that’s something that we do in our office and certainly then people have that but there is a transcutaneous or a surface mounted electrode that can be attached to one’s ear with a specific device we can use to apply very gentle and light constant current that can directly affect that vagus nerve.  And our clinic doctor has been really favourable to helping people with a number of different conditions with this particular device. Matthew: Right, because I was going to say are there ways of going about it but it’s not necessarily something that you want to rush in and start doing vagal stimulation itself, you can look at the whole brain in its context. Carlo: Certainly, like anything else I think the success of what you do will always depend upon the accuracy of what you are trying to do.  I try and apply cookbook approach to something that’s off the shelf and apply it, it will give like its results but I often say to people if you are going to spend some time and effort on something do it properly, get some proper direction.  The stimulator in the brain based therapy are things that we provide in our office and certainly we do it with a program, additionally we also prescribe some homework to people to do and there are some great home based vagal nerve exercises that are great as an adjunct to what we provide, please understand that it’s an adjunct.  There is little harm in trying to do it but the success of it, I haven’t seen as good unless you can combine it with other modalities. Matthew: Right, so when you are you looking at that what types of things are you doing, is it things like gargling and so forth? Carlo: Definitely, I think gargling is actually one of the best vagus nerve exercises that you can do.  It’s something that we encourage a lot of our patients to do. It’s advisedly the things that we recommend which include blowing a balloon, sucking through a straw or chewing food and gargling. When we recommend these things to people invariably they say ah I can’t do that, I choke on food or I can’t blow up a balloon or I gag on food because when it hits like my throat I just choke on it.  It’s exactly these people that this sort of therapy can be extraordinarily beneficial, in fact we work with a lot of children in collaboration with speech pathologists, speech pathologists often note that their abilities to use their tongue and mouth when they enunciate and pronounce letters and words is vastly improved when they have had some vagal nerve exercises and stimulation because now they their throats and their tongue and their back of their throat are all are working better.  So it has many flowing effects and it’s something that feature pretty strongly in our office. Matthew: It makes you wonder then the people who are snorers and have sleep apnoea and so forth all to do with low muscle tone in the throat, has there been much research done of that aspect of it? Carlo: It’s a great question I do have some patients with sleep apnoea that I have work with some holistic dentist that’s still in progress.  We are just looking for subtleties in the presentation that may give you better real results but in theory it makes sense, it makes sense that when someone sleeps they have poor throat tone which is vagus nerve and as a result their voice box and their throat you can get that sound that occurs as air passes through, the turbulence can be heard of as gaggling or very throaty sound or even a snoring.  So I have not seen any data on it, I would be curious to follow that up but in theory it does make sense. Matthew: One thing that I have heard about with vagus stimulation is using it from a brain plasticity point of view, is that something that you really sort of factor in do you into your equation or is that something that you haven’t looked into so much. Carlo: So what I have discussed so far is probably more than input into the brainstem and down into the rest of the body but equally understand that there is never a one single direction path, it always goes different directions.  So once we stimulate the brainstem through the vagal nerve stimulation or during our exercises you will always have an upward effect to the rest of the brain.  So what we find is those that have fear, anxiety and even depression and the research has shown this, and I can talk about that in a moment, that if we can stimulate the vagus nerve it has been shown to actually help alleviate a lot of the symptoms that are associated with some of these conditions.  It allows us in our office to provide additional care or adjunctive care to help with some of their other concerns.  So whilst I am certainly not saying this is going to cure their depression or their anxiety it certainly gives us a platform to be able to give better leverage in providing a care to other parts of the body but the research is also saying that it may actually have more of a direct effect and what I see in my office as well. Matthew: Well, that’s very interesting, if somebody wants to get help with this type of thing, what should they do? Carlo: Our office we are certainly taking and seeing patients with these sorts of conditions or symptoms of these conditions and they include children, adults and we always start with a comprehensive examination on where and what the problem is and we feel that the best person or at least part of the team that can help them we certainly make that recommendation.  If we feel that the condition is best assessed by someone else then we also make that call.  But I think it’s an area that’s often overlooked, it’s an area that’s now getting more traction and people are starting to see that the vagus nerve is an incredible window to helping various parts of the brain.  If I may just take a moment to highlight some of the research that’s coming out at the moment.  I think initially vagal nerve stimulation was shown to be very effective with people with seizures and help reduce the intensity or frequency of seizures and that has been well documented for some years, depression, chronic pain, inflammatory disorders like the subtleties disease and rheumatoid arthritis.  Its effect is becoming more substantiated in research and in clinically in our office we are seeing it more and more.  So I think almost no matter what condition someone presents to our office with is something that we certainly look at and it might well be part of the program of care. Matthew: That’s very interesting and particularly the whole epilepsy aspect and so forth.  Well that really wraps up what we are going to talk about today, I mean it’s always great to sort of look at this cutting edge treatments and see how they can be applied but is there anything you would like to mention in closing Carlo? Carlo: I think the main point I want to talk about is look at the brain, just because you may have symptoms in other parts of the body it doesn’t necessarily mean that that’s where the problem is.  So I encourage people to work with people that have a very holistic approach, a very integrated approach to healthcare and the work that we do at our office in our Brain Hub Clinics certainly is a reflection of that and I guess my studies in neuroscience and a PhD in neuroscience is a testament that understanding how the brain operates will give people hopefully more answers and more solutions to the health problems.  So call into our office to register on our website or our phone number and we are happy to have a chat with you as to how we could help you. Matthew: That would be good as always if anybody has any questions that they want to ask about what we have covered today it will be on what Carlo has just mentioned pop along to brainhub.com.au/blog and post your questions below today’s episode, we will more than happy to pop in there and answer those and you can contact the practice by calling 1300 770 197 or by using the contact details on brainhub.com.au particularly if you are outside Australia, I believe that number only works if you are inside Australia. Carlo: That’s correct yes. Matthew: That’s correct, don’t worry, that’s the trouble with this 1300 numbers but we have got plenty of contact information on the website.  If you like the work that we are doing on the Brainhub Podcast do leave us a four or five review on iTunes or your favourite podcasting platform but until next time take care.   Thanks for listening to the Brainhub Podcast, for more information and to subscribe visit brainhub.com.au. References 1: Liu J, Fang J, Wang Z, Rong P, Hong Y, Fan Y, Wang X, Park J, Jin Y, Liu C, Zhu B, Kong J. Transcutaneous vagus nerve stimulation modulates amygdala functional connectivity in patients with depression. J Affect Disord. 2016 Aug 11;205:319-326. 2: He B, Lu Z, He W, Huang B, Jiang H. Autonomic Modulation by Electrical Stimulation of the Parasympathetic Nervous System: An Emerging Intervention for Cardiovascular Diseases. Cardiovasc Ther. 2016 Jun;34(3):167-71. 3: Cha WW, Song K, Lee HY. Persistent Geotropic Direction-Changing Positional Nystagmus Treated With Transcutaneous Vagus Nerve Stimulation. Brain Stimul. 2016 May-Jun;9(3):469-70. 4: Trevizol AP, Shiozawa P, Taiar I, Soares A, Gomes JS, Barros MD, Liquidato BM, Cordeiro Q. Transcutaneous Vagus Nerve Stimulation (taVNS) for Major Depressive Disorder: An Open Label Proof-of-Concept Trial. Brain Stimul. 2016 May-Jun;9(3):453-4. doi: 5: Holle-Lee D, Gaul C. Noninvasive vagus nerve stimulation in the management of cluster headache: clinical evidence and practical experience. Ther Adv Neurol Disord. 2016 May;9(3):230-4. 6: Frøkjaer JB, Bergmann S, Brock C, Madzak A, Farmer AD, Ellrich J, Drewes AM. Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. Neurogastroenterol Motil. 2016 Apr;28(4):592-8. 7: Schoenen J, Roberta B, Magis D, Coppola G. Noninvasive neurostimulation methods for migraine therapy: The available evidence. Cephalalgia. 2016 Mar 29. Dr Carlo Rinaudo (Chiropractor and PhD candidate) is the clinic director of Brain Hub, a clinic in Sydney focussed on helping people with dizziness and vertigo conditions, poor balance, whiplash and concussion symptoms. The clinic and its practitioners use a range of modalities to help assess and manage these conditions and/or symptoms. Vestibular rehabilitation therapy and other brain-based therapies are primarily utilised, along with standard Chiropractic and physical therapy techniques. The growing evidence showing support for the management of these conditions comes primarily from the physical therapy and clinical neuroscience fields, rather than chiropractic specific. Fortunately, Dr Rinaudo with post-graduate training both in Australia and from overseas is experienced to translate this knowledge into clinical practice. Additionally, he is currently undertaking a PhD from the University of New South Wales (UNSW) and Neuroscience Research Australia (www.neura.edu.au)  in Vestibular Therapy, more specifically clinical trials on how to help people with dizziness and vertigo conditions. He is working alongside leading researchers and Neurologists in the field. Additionally, the benefits expected from his PhD research will be used to further validate the use of vestibular rehabilitation therapy for other related conditions like whiplash and concussions. Dr Rinaudo is a frequent speaker at national events, as well as lecturer in the field of vestibular rehabilitation and dizziness conditions to other health practitioners.

Welcome to BrainHub Podcast where you will discover the top news and tips on keeping your brain healthy. Hello and welcome to the BrainHub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the owner of Brain Hub Clinic in Sydney. Matthew: Good day Carlo, how are you doing? Carlo: Great Matthew, excuse my rusty voice this morning after two weekends of presenting seminar content it’s a little husky today. Matthew: Yes, I was going to ask you a little bit about that, you have been doing some seminars for practitioners on the treatment of vestibular disorders, that’s, for those who aren’t practitioners the balance system within the body, do you want to tell us a little bit about how that went? Carlo: Yeah, thanks Matt, we were fortunate that we presented to approximately a hundred practitioners in Sydney and Melbourne over two day weekend, we explored vestibular system and how important it’s to many clinical conditions that practitioners see in their office.  We went through an examination and management of people suffering from a range of balance conditions like vertigo, cervical dizziness and other vestibular or balance based conditions. Matthew: I know, I was at the Melbourne one and I found it to be extremely interesting and the feedback that I believe you got from a lot of people was that the seminars were very well received so hopefully you will doing a lot of those soon. Carlo: Yeah, thanks Matt, we had very favourable comments from a lot of the practitioners and really pleasant to hear they are experience in their own clinic and how they have translated some of the content that we have covered into obtaining favourable patient outcome which is only one of the goals that we set out in putting this on and we have just announced that we are hitting over to Perth so those people in WA who would have also heard of this seminar series. Matthew: Yeah that’s great, I am sure we are going to talk a little bit more about vestibular dysfunction and so forth in coming episodes, this is obviously our fourth episode and so far we have looked at the effects of concussion on the brain and how to prevent concussion, how to improve recovery through pre-season screenings and so on and in our last episode we talked about how sugar can have a negative impact on the brain.  So if you haven’t had a chance to listen to those episodes be sure to visit brainhub.com.au/blog and you can find all those episodes there.  Alternatively if you subscribe on iTunes or Stitcher be sure that you won’t miss any episodes that way.  If you like the show be sure to leave us a four or five star review on iTunes, it gives us some nice feedback, it gives us a nice warm fuzzy feeling but also helps others find our podcast as well.  So it’s really great for them, it’s really for us and hopefully you get a nice feeling out if it as well.  So it could be wonderful if you could.  This month we are going to be talking about whiplash, whiplash might seem like an odd topic, there was a great deal of information and awareness raised in the 1980s and 1990s about the effects on the neck and the long term damage that it can cause but the increase in there in that knowledge on brain function has meant that we have discovered impacts on the brain that really weren’t appreciated before.  So Carlo, do you want just to give us some background about whiplash and what it’s and what makes it such an important injury? Carlo: Yes, thanks Matt, most of us as you have mentioned historically we think of whiplash as being a neck related injury, technically it’s referred to as an acceleration or deceleration or a hyperflexion-hyperextention injury.  Basically what that means is that we have got this big mass, this ball namely our skull sitting on this thin and fragile structure namely our neck and whenever there is a stop start shearing force on the body as if we were tackled or involved in a car accident this big mass just gets flung forwards and backwards or in sideways at times and it has been shown that because of the acceleration deceleration type movement a lot of the muscular musculoskeletal structures within the neck and the ligaments, the muscles, the disk and in severe cases even the bones themselves can be damaged both in acutely so when the injury happens there is a sprain, strain, sometimes even a fracture of those areas.  We have seen in practice and many people have seen in practice that over a long period of time those injuries whether they are small bingos or large motor vehicle accidents can actually lead to other mechanical spinal degeneration based injuries, arthritis and other conditions like that.  So we see the effects of it, we see the effects on the neck as a mechanical influence on the upper back and suddenly we need to be aware of those type of injuries. Matthew: Yes indeed, I know the trigger for these injuries is often quite small as well, I remember reading something that as little as sort of ten kilometres an hour can trigger some sort of whiplash injury in the neck. Carlo: You are exactly correct, small low speeds have been shown to have the basis of early stages of whiplash disorders and interestingly people think of whiplash, you know, your head has to hit a steering wheel or has to hit the pillar for it to be considered a whiplash and that’s not the case. Even pushing someone from behind or in a little dodging car bingo from behind people can often experience whiplash associated symptoms from such a small innocuous based incident. Matthew: Indeed, that sort of puts a bit of dump going to the fanfare and jumping in the dodging cars. Carlo: I guess another thing is that our neck fortunately has the capacity to protect itself, we are not as fragile as it may be but these reflexes can only operate at a certain speed and a lot of these injuries that the body sustains is basically too fast for those protective reflexes to occur.  So the neck is somewhat susceptible and as I mentioned small instances can contribute to lasting problems. Matthew: Yes, now we know of course that the neck and the rest of the spine and other tissues of the neck have a big impact on the brain the logical conclusion is that because of these neck injuries that it’s going to affect the brain function, do you want to tell us a little bit about how the brain relates to whiplash and so forth? Carlo: Yeah, definitely.  Obviously if there is a head trauma associated with the whiplash, your head hits the steering wheel or the pillar or you have been tackled and your head hits the floor there can no doubt be concussion or mild traumatic brain injury components but that aside injury to the neck whether it be from a traumatic injury like a whiplash or even we are noticing now from poor posture or degeneration of the neck has an influence on the brain.  I subscribe to a lot of the research performed by a group of physiotherapists based at University of Queensland and led by physiotherapist Julie Treleaven, she has really shown how when there is a dysfunction in the neck the joints in the neck and the muscles in the neck it not only gives you neck pain but it actually has strong influences to other parts of the brain and can cause symptoms.  So basically the information from the neck fires up into the brain and influences the balance senses of our brain, it influences eye movement, it influences the autonomic parts of our brainstem and these are the parts that the heart rate, blood pressure, gut function, respiration originates from, the neck and influence areas of the brain that have regulation on our emotions, fear, anxiety, as well as posture.  So with these connections what they are finding now is if the neck is disturbed through a whiplash injury then people can suffer from a range of symptoms and they include dizziness and steadiness, headaches, visual changes, they have trouble following a moving target or they have troubles reading and they can have auditory problems, they might have some hearing difficulties as well, they may have cognitive difficulties like poor memory, they are unable to focus and have concentration, they may have fatigue, may have sleep disturbances.  So what we find is someone who has had whiplash based injury such as a car accident or sporting injury will typically complain of a number and sometimes all of these symptoms to various grades.  It’s really important that we as clinicians or even as patients or someone who suffer this that we don’t simply look at the neck, whilst it’s important and that area needs to be attended to and there is a number of people that can do so but I guess what we are seeing now is a that unless you start assessing and managing these other connected symptoms and signs you are not going to get to the root of the problem and persistence in symptoms can be there. Matthew: I suppose that kind of links in that one of the big problems in the past with whiplash has been the tendency to sort of develop chronic pain syndromes from it.  I suppose that ties in with what you are saying in terms of you have the secondary effects within the brain that need to be addressed as well.  Can you dive in a little bit more about the chronic pain aspects and why that’s the case and how the management of whiplash has changed because you see a number of people with whiplash in your clinic, don’t you? Carlo: That’s true, yeah, a good portion of our patients have suffered whiplash whether be in the sport field or motor vehicle accidents, we have got practitioners and doctors that tend to send clients to us because of the more complete aspect of what we do and going back to your question about chronicity, I find that chronic pain from whiplash really can come from several angles one of which I have touched on that the practitioner may not look at the full picture.  They simply look at  ok you suffered a neck injury so let’s manage the neck function and whilst this certainly needs to happen it’s certainly not the only thing, because of those connections between the neck, the eyes, the balance system and other parts of the brain your assessment really should involve all movement analyses.  It really should involve measuring balance and posture, you should look at vestibular or inner ear function, we often test memory and cognitive capacity because people find that they have got brain fog, they don’t have that capacity to focus on their task, they are quite sleepy, their performance at work suffers.  So we measure these things, we also look at blood pressure, heart rate and other things that gives us a good snapshot or window of function to how their body is going.  So unless you address these and once you identify them obviously the management should be based upon those findings and unless you can address that as part of your rehabilitation plan then chronicity of pain will tend to happen because you manage their neck they may feel better but unless you are addressing these other things the pain will return or dysfunction will return and it’s that dysfunction that actually contributes to chronic pain.  So my strong advice to people with whiplash based problems is really find someone to look across all those aspects which is well researched and there is evidence to show that they are linked.  And another aspect that can contribute to chronic pain and something that we see with people with dizziness and that can include cervicogenic or neck related dizziness is fear and anxiety.  A lot of people who have had these injuries are fearful of getting into a car or fearful that their balance is not right and that can cause further problems.  So we often work with psychologists or other practitioners that may use an assortment of therapies, cognitive behaviour therapy that can help manage people’s expectations, people’s fear and anxiety and unless sometimes you address those things no matter how good you are with your manual therapy or rehabilitation therapy those symptoms can persist and form further chronic problems.  So we often encourage people, we work with a team of other elite practitioners who can help us on these things.  So basically be broad with your scope, understand the connection between the neck and other parts of the brain and ensure that your therapists involve that and secondly ensure that you are working with people who can help from a cognitive, behavioural and even on an emotional perspective. Matthew:  Yes, I think gone are the days of people being told that it’s all in your head, it used to be a very common thing and unfortunately there probably still are some practitioners out there who tend to think of that but those who are at the forefront of this research and the forefront of practice really do understand that it’s an aspect that’s involving someone’s emotionality and that it’s valid as any physical symptoms that the patient has. Carlo: Very much so and sometimes you could clear up any physical symptoms that may have happened a result of the injury but if the patient still lives in that fear, anxiety or sensitised world then that would still perceive symptoms irrespective of what actually has happened or is happening.  So at times you really need a collective approach. Matthew: Exactly, I remember when we were studying neurology that one of the things that our teacher said was that you don’t actually have to have any pain in the limb for example, you can feel pain in your finger but it doesn’t mean that that’s where the pain is, all it means is that you are perceiving pain in your brain, that it doesn’t actually have to be anything wrong with your finger.  And that isn’t to say that you are just imagining it, it’s that there are problems within the brain and that needs to be dealt with just as much. Carlo: Very much so, I describe to the patients those things have been really wired in your brain, there is no more inputs and outputs and how we interpret things has been skewed for whichever reason, there is many reasons for that probably another podcast in its own but things are really wide and what we need to do is help change that.  Neuroplasticity which is how the brain changes based upon its environment is both a good thing and can be a negative thing as well.  So having a practitioner that understands that’s really important.  So I would strongly encourage any patient or a parent of a patient who has experienced altered sensations and altered perceptions of pain as well as whiplash injuries then they would certainly seek care from someone who is open and understanding of these underlying processes.  Medication is not the answer here, standardised very segmental therapy on an area where pain is believed to be is not the answer, you need a more global way of thinking and managing these sorts of concerns. Matthew: Well at Brain Hub we do offer assessment for whiplash as well as a variety of other conditions.  So if you are based in Australia and you would like some advice the telephone number is 1300770197 or you can visit our website which is brainhub.com.au and there is full contact details available there.  Otherwise Carlo was there anything else you wanted to add. Carlo: No, no, I think for practitioners who want to know more about this Brain Hub has just concluded Sydney and Melbourne seminars, we are about to hit over to Perth and probably other states throughout the year, the information has been recorded and will be available at some other stage for practitioners to be well versed in what we have just discussed.  For patients that have suffered these sorts of issues, as Matt said, contact the website or our phone number and we will put you into contact with the best people to help overcome some of these concerns. Matthew: Great, well thank you very much for listening and until next time take care.   Thanks for listening to the BrainHub Podcast, for more information and to subscribe visit brainhub.com.au. References 1: Coppieters I, Malfliet A. Chronic Whiplash-Associated Disorders: Reorganization of the Brain? EBioMedicine. 2016 Aug 9. pii: S2352-3964(16)30359-0. 2: Treleaven J, Peterson G, Ludvigsson ML, Kammerlind AS, Peolsson A. Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: A prospective randomized study comparing three exercise programs. Man Ther. 2016 Apr;22:122-30. 3: Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015 Jul;43(3):274-84. 4: Yokota J, Shimoda S. [Neuro-otological Studies of Patients Suffering from Dizziness with Cerebrospinal Fluid Hypovolemia after Traffic Accident-associated Whiplash Injuries]. Brain Nerve. 2015 May;67(5):627-34. 5: Takasaki H, Treleaven J, Johnston V, Van den Hoorn W, Rakotonirainy A, Jull G. A description of neck motor performance, neck pain, fatigue, and mental effort while driving in a sample with chronic whiplash-associated disorders. Am J Phys Med Rehabil. 2014 Aug;93(8):665-74. 6: Craton N, Leslie O. Is rest the best intervention for concussion? Lessons learned from the whiplash model. Curr Sports Med Rep. 2014 Jul-Aug;13(4):201-4. 7: Treleaven J, Takasaki H. Characteristics of visual disturbances reported by subjects with neck pain. Man Ther. 2014 Jun;19(3):203-7. 8: Nijs J, Meeus M, Cagnie B, Roussel NA, Dolphens M, Van Oosterwijck J, Danneels L. A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Phys Ther. 2014 May;94(5):730-8. 9: Roitman P, Gilad M, Ankri YL, Shalev AY. Head injury and loss of consciousness raise the likelihood of developing and maintaining PTSD symptoms. J Trauma Stress. 2013 Dec;26(6):727-34. 10: Bexander CS, Hodges PW. Cervico-ocular coordination during neck rotation is distorted in people with whiplash-associated disorders. Exp Brain Res. 2012 Mar;217(1):67-77. 11: Treleaven J. Dizziness, unsteadiness, visual disturbances, and postural control: implications for the transition to chronic symptoms after a whiplash trauma. Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S211-7. 12: Treleaven J, Jull G, Grip H. Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders. Man Ther. 2011 Jun;16(3):252-7. 13: Evans RW. Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review. Headache. 2010 Apr;50(4):716-24. 14: Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache. 2010 Apr;50(4):699-705. 15: Treleaven J. A tailored sensorimotor approach for management of whiplash associated disorders. A single case study. Man Ther. 2010 Apr;15(2):206-9. 16: Elliott J, Sterling M, Noteboom JT, Treleaven J, Galloway G, Jull G. The clinical presentation of chronic whiplash and the relationship to findings of MRI fatty infiltrates in the cervical extensor musculature: a preliminary investigation. Eur Spine J. 2009 Sep;18(9):1371-8. 17: Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009 May;39(5):364-77. Dr Carlo Rinaudo (Chiropractor and PhD candidate) is the clinic director of Brain Hub, a clinic in Sydney focussed on helping people with dizziness and vertigo conditions, poor balance, whiplash and concussion symptoms. The clinic and its practitioners use a range of modalities to help assess and manage these conditions and/or symptoms. Vestibular rehabilitation therapy and other brain-based therapies are primarily utilised, along with standard Chiropractic and physical therapy techniques. The growing evidence showing support for the management of these conditions comes primarily from the physical therapy and clinical neuroscience fields, rather than chiropractic specific. Fortunately, Dr Rinaudo with post-graduate training both in Australia and from overseas is experienced to translate this knowledge into clinical practice. Additionally, he is currently undertaking a PhD from the University of New South Wales (UNSW) and Neuroscience Research Australia (www.neura.edu.au)  in Vestibular Therapy, more specifically clinical trials on how to help people with dizziness and vertigo conditions. He is working alongside leading researchers and Neurologists in the field. Additionally, the benefits expected from his PhD research will be used to further validate the use of vestibular rehabilitation therapy for other related conditions like whiplash and concussions. Dr Rinaudo is a frequent speaker at national events, as well as lecturer in the field of vestibular rehabilitation and dizziness conditions to other health practitioners.

Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy. Hello and welcome to the Brainhub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the owner of Brain Hub Clinic in Sydney. Matthew: Hi Carlo, how are you doing? Carlo: Great Matt, thanks for having me on today. Matthew: It’s always a pleasure that’s for sure.  This month we had Brain Awareness Week which is an event which is organised by the Dana Foundation which is based in the United States.  They focus upon brain awareness and brain research, now obviously being the Brain Hub Podcast all our episodes are about the brain but today we are going to be taking a look specifically at how to look after your brain from a nutritional point of view and within that we are really going to be looking in detail at the effects of sugar upon the brain.  Now, in recent years there has been a trend towards highlighting the damaging effects of sugar on your health, there was a film that came out recently called That Sugar Film which highlighted how with the move away from including fat within our diet with the whole idea that fat was related to heart disease and things like that and manufacturers had to replace the nice taste that fat supplied with something else and most of the time that something else ended up being sugar.  Now, we could probably do a whole episode on why we should be including more fats in our diet and we probably will at some stage in the future but today we are going to focus on sugar.  So first of all Carlo, what role does sugar play in our brains. Carlo: Ok, sugar, if we sit back for a second the neuron or sort of the nerve cells of the brain have a very high demand for energy compared to any other part of the body.  It needs and requires the most amount of energy to perform its activities and the energy source that it relies on typically is glucose or sugar.  So we need a constant source of sugar for our brains to function properly.  Interestingly whilst the brain actually only counts for about two percent of our total body weight, it consumes about twenty percent of the energy.  So we are certainly dependent upon it and we need a very constant supply of glucose or sugars to be able to maintain properly and because the brain is so dependent upon it, any deviation away from the low or a high state can be a precursor of the brain not functioning properly and diseases can occur later on. Matthew: Right, so the brain really is very dependent on sugars for energy then? Carlo: Extraordinarily. Matthew: Yes and why is sugar so damaging for the brain?  What is it about it? Carlo: Well, in short it can be toxic in high amounts, as I said, sugar is required but when it’s in huge supplies or an oversupply it can become quite toxic and that sugar is both in a natural form just sucrose or sort of the worst type which is the fructose or sort of the high fructose corn syrups that we often see in our products.  What it does to the brain in many things one of which it’s highly addictive, there has been many studies that have shown that our brain or the brain on addicts whether it be alcohol, a drug or nicotine addicts lights up or shows activity similar to those people that crave sugars.  So there have shown the similarity in brain function and what’s used to what’s not used from the person who crave sugars and a person who is addictive to a lot of the things that we sociably think is not being particularly good.  What it does do with the brain is typically we see people who have brain fog where a lot of the proteins that are involved with developing and communicating within the brain it adversely affects the activities of these proteins, so people often get brain fog.  We also can get over eating, so the hypothalamus which is a part of the brain that controls our appetite, when it gets affected by sugars it doesn’t alert the body to say hey you have had enough sugars in your consumption you better stop.  So people actually when they consume sugar don’t get that feeling of I am full, so they actually continue eating which is very different to those that consume fats and proteins, when you consume fats and proteins, our brain tells us, okay you have had enough we are full at the moment, that’s enough for these meals but when you have sugars you don’t actually get that sensation.  It also affects the way we learn, our memory and some studies are now showing that it could even be a precursor to things like dementia and cognitive decline. Matthew: Ok, so I suppose that links in quite interestingly perhaps from an evolution point of view when you talk about how the hypothalamus doesn’t inhibit the uptake of sugar or not and inhibit the uptake of sugar, but you know what I meant, in that perhaps when we were out living in the plains and we were trying to survive, if we came across the starchy fruit it was in our interest to stuff as much of that into our bodies as we possibly could and store it away so as to have some reserves as we go into winter and so forth.  Well, that’s perhaps less so for eating meats and fats, is that your understanding? Carlo: Yeah, exactly.  I guess we can pretty talk about some of the suggesting and recommendations with dietary changes and how are going back to some of those more primitive styles of eating but energy is required for us to revolve as a human species and sugars and carbohydrates are definitely a source of that but it’s a source that in modern world has changed.  We are now not eating a lot of the whole carbohydrates, the unrefined carbohydrates that are actually quite good for us, a lot of those natural forms, we are having now far more processed foods and carbohydrates in just about everything that we eat and you just have to look at the consumption of sugars in soft drinks and packaged foods, I read a stat recently that we consume five times the amount of sugars that we should normally be consuming in a Western diet and that’s pretty frightening and a lot of links to that, it’s not only brain function which is what we are talking about today, you know, in a lot of obesity, in a lot of childhood disorders that we are seeing, developmental to behavioural and a lot of adult conditions that are equally being linked too. Matthew: Yes, you mentioned about the sugar being toxic and there is this concept of excitotoxicity out there where potentially too much sugar could drive the brain too hard, is that the case? Carlo: Yeah, so we spoke that sugars obviously help the metabolism of our nerve cells but again like anything else there is a threshold or a tolerance which everything operates in a nice level, you exceed that then the cells can actually start to produce free radicals and these free radicals are actually quite toxic to the cell itself and this term called excitotoxicity where free radicals form, the cell deforms in its shape, it starts losing its function and it becomes very easily excited, for lack of a better word, where a small amount of stimulus that normally should be well tolerated now becomes too much of a stimulus and that’s very much in line with a lot the conditions that we can see like for migraines to seizures and other conditions that are involved with excitotoxicity. Matthew: Yes indeed.  Now, many of our listeners have probably heard of things called type 2 diabetes and even metabolic syndrome and all insulin resistance.  What are these conditions and how do they impact upon the brain and sugar regulation and so forth? Carlo: It starts from, you know, we ingest foods and say in this case carbohydrates, carbohydrates if you are not aware are things like breads and pastas and sugars from fruits and vegetables and so on, so they are deemed as a carbohydrate.  So our digestive system breaks it down with various enzymes that are either in our mouth or in our gut, it breaks it down to a smaller molecule or a smaller fragment that the digestive system can absorb, so it passes from the intestines into our blood stream but the sugar in our blood now is not ideal.  So what happens is as the blood sugar levels increase, our pancreas which is an organ in our abdominal area secretes insulin which is a protein, it’s secreted into the blood streams, insulin then sort of latches onto to the glucose and it moves the glucose from our blood where it’s not ideal into our muscles and other areas where once it’s there that glucose, that sugar is then used as fuel where it’s burned along with oxygen to produce energy.  With that sort of framework, type 2 diabetes is basically a progressive condition, a condition that we develop, it’s not something that we are born with or though there is a genetic component to it.  It’s something that we develop generally through our lifestyle where the body becomes resistant to one or two things, our body cannot produce insulin as well. So we either become insulin resistant or our pancreas no longer produces insulin as well. So we either become insulin resistant or our pancreas no longer produces enough insulin to meet the demand and this is what we describe as sort of type 2 diabetes and as I said it’s very lifestyle based, something that we develop throughout our lives and what was once thought as only an old person or older persons’ disorder, we are seeing that now kids in teens, it’s becoming an epidemic in our society.  Metabolic syndrome is a collection of disorders, so it’s not a disorder itself but it’s a collection. There are various criteria that the medical fraternity use to classify one of which is abdominal fat, so you need to have a large abdomen, a lot of fatty deposits around the abdomen area, you need to have high blood pressure or hypertension, you need to have abnormal cholesterol or LDL level in your blood tests and generally you are either a diabetic or pre-diabetic.  So metabolic syndrome is a combination of at least three of those by classification to be classified as a metabolic syndrome. Matthew: Right, so it sounds quite complex. Carlo: Oh yeah, it’s something that obviously a medical practitioner or specialist, I think a medical practitioner would certainly be the first person to diagnose that, first he assesses it and diagnoses it appropriately and then offer you a lifestyle or sometimes medication to help combat that. Matthew: Right, ok, so given the increase in sugar in our diet and these other conditions like type 2 diabetes where there is issues with even if you are having a normal amount of sugar you are potentially getting issues with regulation of those levels.  The potential for damage to our brains has increased, besides directly reducing that sugar intake what can people do to reduce the effects on their brains? Carlo: Moderation is always best, we are certainly not advocating a no carbohydrate diet but I would encourage people to look at good quality carbohydrates, look at foods that aren’t processed, looked at raw foods, low carbohydrates, look at whole meal foods, things that have a lower GI or glycemic index foods and I often encourage patients to be well versed, stack in some books or join forums or look online at what defines a low or a high glycemic food and particularly for your family, the kids you want to be looking at things that have a low glycemic, so you get that constant sugar hit or short sugar delivery I should say rather than the higher hit you get from high glycemic food.  Also be aware of educating yourself that low fat is not necessarily good, so if they are taking out fats they normally need to make it taste better by lighting it up with high sugars and generally with high salts at the same time.  So getting educated about reading the label and what a normal daily intake should look like, look at the ingredients, you know, when you start seeing things like high fructose corn syrup and agave syrup, those sort of things are damned good to the person but aren’t good at all, in fact the high fructose corn syrup the American FDA is on the border of actually defining it as being a toxic ingredient which should be banned, companies are looking at ways of covering it up with calling it something else but probably another discussion.  I guess other things, things like fruit juices, people go to the health food bar and get fruit juices of watermelon and apple and pineapple, again they taste great, don’t get me wrong, but we should be looking at maybe substituting fruit juices for vegetable juice, some are still quite sweet, they have the nutrients in there that make it more digestible and make them more tolerable.  Look at again low glycemic fruits, so look at berries as opposed to say pineapple or watermelon and obviously have the whole fruit rather than just the juice, there is many properties including fibre which make that sugar delivery more tolerable. As you said, you know, avoid over processed foods because we want to have more raw foods and whole foods in our diet.  Have plenty of fat in our diet with the exception of trans fats or oxygenated fats.  So we want to increase our omega 3 fatty acids, things like salmon and nuts and flax seed are really good in themselves but they also counter against fructose’s harmful effects particularly with kids substituting a lot of the sweet things like lollis with macadamias and nuts and cashews and better alternatives as well as the berries are great way of helping.  Make sure you have protein in your diet and there is a push now I mentioned this earlier that paleo diets which are high in nuts and seeds, high in proteins, good quality proteins that are generally fed and reducing a lot of the high glycemic carbohydrates and I think a big thing now that I would suggest here also is don’t have artificial sweeteners, we are talking about excitotoxicity I don’t think you need to sweeten with any of those artificial sweeteners in my opinion and I think it’s well documented as well are actually more harmful to the brain as those found in many products than sugar itself.  So I would actually put them on top of in terms of severity than sugar. So please don’t substitute sugar for a sweetening product but also, you know, you want to reduce natural sugars at the same time as well. Matthew: Yes, so the artificial sweeteners you mean yes, I was reading an article recently, it was sort of talking about how these artificial sweeteners actually change they have got bacteria as well, so with all the talk that’s coming out now about how the gut brain axis and how gut health affects what’s happening in your brain, you know, that they are potentially coming at it from two ways there.  You mentioned about increasing fats, does that even include saturated fats and cholesterol? Carlo: My opinion on this I think there is now a shift in the last few years away from avoiding animal fats, so what that means is that we should be including more animal fats in our diet and I include if you want to have dairy I think certainly you can have a full fat dairy, that includes things like batter and good quality animal fats that you will find in meats.  When I say good quality fats I mean sources that are from grass fed meats as opposed to maybe grain fed meats, there is a lot of good fats in there that our brain requires as well.  So that’s my opinion and something that I think we are moving more towards now in the media and certainly research is showing that to be the case as well. Matthew: Yes, so I suppose that links back in with what you were talking about with trans fatty acids in terms of these saturated fats when they get heated they tend to turn into these trans fatty acids and become damaging at that stage. Carlo: Yes, another word you might see on the ingredient list is hydrogenated fats and it’s those hydrogenated fats and oxidised fats and the trans fats which are not to be confused with saturated fats, there are the ones that could be really avoided because once the fat gets oxidised or it’s hydrogenated it becomes quite toxic to the body. Matthew: Good, well I think that kind of wraps up what we are going to talk about today, was there anything else you wanted to touch on? Carlo: No, look I think it’s a great topic, it’s something that when I start working with clients on getting their body and brains to work better we certainly look at diet because it can be an uphill battle for me to help them if they are feeding their bodies the wrong thing and I think many times we certainly go through it and some of the other suggestions that I made are also included in that discussion to help people  ensure that they get the most out of their care, ensuring that they get most out of their exercise and they get benefits from what we do.  You know, even just cleaning this up with a lot of people when we see it with kids parents and patients report back general improvement, not only in the health but also their brain function. Matthew: Some great advice there, I mean, so if we are going summarise today’s episode we would really be advising people to reduce their sugar intake unless you are diabetic in which case you should speak to your medical practitioner before acting on any advice like that and we would also be saying that you need to be potentially increasing the good fats within your diet, trying to include things like complex carbohydrates if you are going to include sugars in your diet so that you get that sustained sugar relays rather than direct sugar hits and be looking at other energy sources like proteins and so forth.  So if you have got any questions about today’s episode on brain health or just that in general be sure to live a comment at this episode which can be found at brainhub.com.au/blog.  In addition you will also find a full transcript of today’s episode, so be sure to subscribe on iTunes, Stitcher or whatever platform that you are listening to so that you don’t miss any upcoming episodes but do be sure to pop along to our blog as well to catch that additional information.  So until next time take care and we will see you then.   Thanks for listening to the Brainhub Podcast, for more information and to subscribe visit brainhub.com.au.

Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy. Matthew: Hello and welcome to the Brainhub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo, a chiropractor and the owner of the Brain Hub Clinic in Sydney. Hi Carlo. Carlo: Hi Matt, great to be here today, how are you? Matthew: I am great thanks, yourself. Carlo: Awesome, thank you. Matthew: Today we are going to be talking again about concussion in particular about using preseason screenings in combating concussions.  Now, we did go into concussion quite a bit in our first episode where we reviewed Will Smith’s new movie called Concussion.  So if you haven’t heard that episode be sure to check it out at brainhub.com.au/blog. Preseason screening for concussion has become a bigger thing in recent years, given the time of year in the Southern Hemisphere when people are starting to move into sports where they are more likely to sustain some sort of head impact or concussion.  We are going to touch on why that is the case but first Carlo perhaps you could give us an overview of what a concussion is. Carlo: Certainly, a concussion I guess is the most conform of a traumatic brain injury and it is often correctly labelled as a mild traumatic brain injury. The term mild means that it is obviously, it is a closed head injury so there is no open wound but more importantly it’s an injury that results from some sort of mechanical impact where the soft brain which is often described as the consistency of jelly often hits the inside of the skull causing it to shear or compress as it moves around within the skull cavity. With concussions we typically see more of a change in the way the brain functions and how processes and thoughts and movements and so on rather than any change in the structure of the brain.  People see this with MRIs and CT scans, typically after concussion you don’t see any structural change on a scan but you certainly do see changes in the way the brain functions. Matthew: Right. So why do you think that this has become such a big deal in recent years, I mean obviously this has been happening for as long as people have been having head impacts, why are we certainly so much more aware of it? Carlo: I think for two reasons, there are short term and there are long term effects to the concussion both of which have been played out in the players as well as obviously in the media.  With some of the short term effects that many parents of children, players and even coaches are seeing and these include things like poor memory, brain fog, poor attention and concentration, headaches, dizziness, poor balance, difficult reading, nausea, poor sleep, I mean, these are all the things that parents note.  So it is not being dismissed now as being ah well, you just sleep it off and you will be fine, I think parents are becoming more aware of it and these are some of the short term effects.  The long term effects of concussion are also being played out at the moment in the media from the Concussion movie as we spoke previously as well as some of the high profile litigation cases against American Football and even Aussie Rules.  People are suffering from chronic traumatic encephalopathy where essentially the brain after multiple head injuries turns to marsh and there has been many links to early deaths and suicides and also to things Alzheimer’s and dementia have been to linked to as well.  So I guess to answer your question Matt, it’s becoming a big deal because of what parents and coaches are seeing on a day to day basis but also some of the long term effects that medical practitioners and some of the deaths and long term conditions are seen. Matthew: Cool. Or not cool in this case. So that sort of gives us a really good idea about why these are important. Can you tell us then what are preseason screenings? Carlo: Preseason screens are a series of tests that are typically performed on an athlete to gauge their baseline performance and what it’s like before the season starts or before they start preseason training. It gives us an idea of where they are at typically ideally when they are healthy without sustaining any injuries and then we can use that as a measure of just how much impairment they may have and also what their capacity for them to return to play is like. Matthew: Right. So why wouldn’t you just use say a normal database, you touched there on the idea of individual capacity but and for those listeners who aren’t familiar with the idea of a normal database, that is where quite often manufacturers of a certain bit of equipment will collate a lot of data from large number of tests they do and work out what is “normal” for that particular piece of equipment.  As clinicians we often check people against those databases to work out if they are at normal.  Why can’t we just do that when we are looking at these preseason screenings? Carlo: Great question the best way to answer that would be there is a lot of subtlety and individuality in each person. That one person compared to a large database and used later for a comparison is not sensitive, they are not specific to that person.  So we always recommend that the best control is themselves.  So we want to see, when I say relative change in that person, so comparing to how they are “as normal” during season and after an injury is really important and as I said earlier, it allows us to see how suitable someone is to return back to play because they might start at an extraordinary high level, they have an injury and if figures like cognitive scores or the behavioural scores or the balance scores drop relatively to where they started but they still might fit in the normal range and that may go undetected but yet parents might say look my son is just not focused at school, I am getting some bad reports from teachers.  So what a preseason test enables us to do is to see where they are at and then compare them to a later point and we have always got that as a reference. Matthew: Right. I suppose that really highlights an aspect that is so true when you are looking at these functional brain conditions isn’t it that in that we are really talking about subtleties with these as opposed to gross deficits which will probably be showing up as structural deficits on an MRI or something like that whereas we are talking about subtlety here aren’t we? Carlo: Exactly and be aware of those subtleties and looking for them and as you said making a comparison is the key and I guess this where at times if someone were to present to a medical specialist or a doctor doing a quick screen or a comparative test to a normative database they might be given the all clear but we know through our experience and what research is going to show and this a lot of subtle things you need to be aware of and there is no better way to highlight that in comparing to how they work prior to this injury and this is why we certainly encourage a lot of people to get preseason tests because it is search a valuable data that even for subsequent needs you can plot on the graph and we can plug with our results in a declined or improved scene in people’s performance from preseason to throughout the season but also season one, two, three, four and five and some will say it is incredibly important. Matthew: Right, do you want to talk us through then how you would actually conduct this baseline screening in your clinic and what tests do you do?  Are they sort of intrusive or painful etc? Carlo: These two types of tests that we do one of which is a real quick screen which we can do in a club or even on the sideline if we need to but the more comprehensive one is the one that we perform in our office.  It is about an hour and a half long test, we go through a computerised and standardised cognitive tests which helps look at various forms of memory, the ability to switch tasks to perform various tasks at once, looks at attention and various performances like that.  So that is a great way to measure up someone’s memory and cognitive function.  Two, we also look at people’s balance and we have a computerised posturography device which very accurately measures the ability to stay still or combat different surfaces eyes open, eyes closed and we are looking at how they react to various conditions and it is a great way to see how balanced and coordinated their body is. An area that we use and again research is showing more validity is looking at eye movements, there are very subtle discrepancies or problems with eye movements after a concussion or a brain injury and this might be the ability for them to follow a smooth target for their eyes to jump from side to side accurately and with speed or even just to be able to fix at a certain point and not have their eyes flicker off that point.  We use various high end diagnostic equipment, video electronystagmography, video head impulse test devices which have cameras attached to these goggles and accurately measure eye movements and there are some low tech devices like the King-Devick test and other forms of eye tracking.  So we use those as well as the physical practices as a chiropractic we also look at spinal and limb movement and function and how one controls their body and that gives us a really good idea of their spine and joints control. Matthew: Right, so based on what you are saying a lot of the testing then is testing the frontal lobes with the cognitive testing that you were talking about and then also the balance aspects. Are there particular components of concussion that make those areas of the brain more susceptible to injury or is it just that they are good ones to test. Carlo: Well I think because of the typically the mechanics of the injury where people typically get hit front on and this is also seen with whiplash injury for people suffering from motor vehicle accidents where the front of the head gets hit by something whether it will be helmet or another person and this side of injury of the brain, remember that jelly like structure normally impacts the inside of the front of the skull as well as the back of the skull and often there are shearing or rotational forces involved in which the brain stem and the cerebellum are areas that are likely to be involved and bruised, for lack of a better word, in concussions and it is these areas where a lot of our balance, a lot of our memory and our lot of our higher function like attention concentration and eye movement originate from.  So it just so happens that the areas that get affected and the areas of the brain that coordinate these functions and that testing is really targeting these areas of the brain. Matthew: Well obviously that testing is quite involved and obviously very necessary.  If a coach or team manager who is listening to this how would they go about getting their team tested?  Is it something that you always have to do in the clinic or like you said can you travel to a club room and still get an effective baseline test for somebody? Carlo: With our experience with local clubs we provide two levels of testing one of which is a screen only can take fifteen twenty minutes where we place individuals through a quick balance test, we look at their eye movements and we can do a very quick cognitive memory recall test.  And from this we get a sense of where they are at.  So we can note that down again that is a good preseason test that we can do.  If any of these come out lagging further attention like they are falling when they are attempting to stand on one leg or there are movements are showing a lot of breakdown and they are unable to focus on a certain point or they are having troubles recalling certain events that you would expect them to remember then it is our recommendation at that stage to the parent or club to say I think little Joey needs some more detailed assessment.  We will then arrange that assessment to happen in our clinic. Matthew: I think that perhaps brings up another important point as well in that you can with this preseason testing actually pick up problems that people weren’t aware of in the first place and given that people are more susceptible to sustaining another concussion if they have these balance or awareness issues, you are having a preventative from that point of view as well? Carlo: Exactly you mentioned a subsequent injury, second impact syndrome is a real problem where the brain after having received an injury it is prone to receive a second injury with less of an impact and the consequences both in symptoms and management become more challenging and we strongly encourage that clubs managers take a proactive and I guess a responsible step in ensuring that their team members particularly kids are properly checked and screened which helps identify risk factors in players, obviously it also helps identify the safe time and stage for a player who has been injured to return back to the sport.  For parents I would say if your club is not doing this ask, best practice and evidence now in sports management is recommending this from our top level down, so be sure to get on the case and if not then approach us and we will be happy to contact clubs, we do talks and presentations to clubs on this exact topic. Matthew: So I think that has covered the topic of preseason screening very well and given our listeners a good overview of the reasons why they should be doing it and what is involved, if they want more information they can just contact you via our websites which is brainhub.com.au, just go to the contact page and fill out the enquiry form there or the phone numbers on the website as well, Carlo: Our number is 1300 770 197 Matthew: Great, excellent, well that wraps us our episode today, the transcript will be available at brainhub.com.au/concussions-screening or if you just want to go to brainhub.com.au/blog you will see the most recent episodes there.  So until next time take care and we will see you then.   Thanks for listening to the Brainhub Podcast, for more information and to subscribe visit brainhub.com.au.

Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy. Matthew: Hi, welcome to the Brainhub Podcast where we discuss the latest in neuroscience and brain health.  I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the head clinician and owner of Brain Hub Clinic in Sydney Australia. Carlo: Hi Matthew, how are you? Matthew: I am great Carlo, yourself? Carlo: Very good thank you. Matthew: This is obviously our first podcast, what we are going to be doing today and in subsequent episodes of this podcast is that we are going to be diving into the field of neuroscience and brain health.  The thing about neuroscience and brain health is that it is a rapidly expanding field, there is thousands of papers published each month on neuroscience and aspects of brain health and so forth as a full time clinician it is a really full time job just to keep up with that sort of rapidly emerging field. What we are going to do in this podcast is distil that information and present it to you in an easily digestible form, ideally it is going to give you practical tips for improving your brain performance and longevity.  Do you have anything to add on that aspect Carlo? Carlo: Yeah, I mean, it is a great point, i think translating some of the research that can be quite technical at times into small chunks that other clinicians or more important for this media is for our patients to understand what is happening in research and how really it relates to the presenting conditions or symptoms.  So we have to be very informative to them. Matthew: Excellent, well research is a bit of a thing that is quite dear to your heart, isn’t it?  I believe you are currently doing a PhD, do you want to tell us just a little bit about which institution you are running with and so forth. Carlo: Sure, I guess PhD is travelling down a very small rabbit hole, very very deep so I hope to come up the other end with a lot of information and expertise in them in a particular small area although it, the vestibulo-ocular reflex is a very important area of the vestibular rehabilitation.  For those who aren’t aware vestibular rehabilitation is all about retraining and regaining ones balance, reducing symptoms like dizziness and vertigo.  I am very fortunate that my research is part of a world leading lab in vestibular research at Neuroscience Research Australia, or NeuRA which is affiliated with the University of New South Wales and fortunately my lab is also tied in with John Hopkins University, School of Medicine in Baltimore in the States.  So I have got some great supervisors and team members as part of their research group.  Our research focuses on a very important reflex that we all have called the VOR or vestibulo-ocular reflex which its job is essentially to stabilize our vision when we move our head or we move our body.  Very important, so when it doesn’t work our eyes and our inner ears where we have these movement detectors don’t talk to each other particularly well causing our vision and our balance to be affected. And what our studies focused on is doing clinical trials on patients with poor balance and using a novel rehabilitation device that we have developed hoping to retrain these reflex so people feel better.  So it is very much tied in with the Brain Hub clinic but it is also a very expanding and exciting area of neuroscience that a lot of physical therapists, chiropractors and even medical practitioners see in their practices because dizziness disorders makes up a relatively large and significant portion of patients that we see. Matthew: Yes and I know that some of the research is coming out and talking about how these vestibular deficits can be responsible with problems with cognition and clear thought and memory and all sorts of aspects like that which ties in well with the concussion aspect that we are going to talk about later doesn’t it but I know the Brain Hub Clinic that you run deals with a lot of issues like concussion and I think some people might sort of say well you are dizziness and balance clinic. How does that relate to other aspects like migraine, whiplash and concussion when you are doing a lot of vestibular rehabilitation.  Do you want to tell us a bit of the Brain Hub Clinic and the work you do and so forth? Carlo: Sure, as you mentioned I am the clinic director of Brain Hub which is a very specific hub clinic that deals with dizziness and concussion and we hope people with a range of vertigo and poor balance conditions which will also include whiplash, vertiginous migraine and obviously the point of today’s talk is those that suffer from post concussive symptoms.  There is a strong link between all of them, they are not random conditions or symptoms that I feel like that I want to help people with but they are often related.  There is obvious commonality between the areas of the brain that is affected and the connections between these areas are also known.  So we often find people with concussions symptoms will have balance problems, will have vertiginous or vertigo based problems, they will have problems when walking, they will be unbalanced, they will have eye movement symptoms and also have cognition problems like poor memory, anxiety and fear.  Now if we look at a patient that has a chronic dizziness that is not a concussion patient but a chronic dizziness patient they will often have the similar signs and symptoms, they will have poor memory, brain fog, fear and anxiety, they will have problems with their eyes.  So we often see a commonality in signs and symptoms what we often describe as comorbidity between a lot of these conditions.  So our practice helps people with concussion symptoms while using specific vestibular rehabilitation and also brain based rehabilitation and the research now is showing good signs that these form of assessment as well as treatment is actually proving very beneficial to those that have suffered from concussion problems. Matthew: Excellent yes, that ties in very well with what look at today which is the Concussion movie and for those who are not familiar with it is a movie that has been released in the USA it hasn’t come out in Australia yet so we haven’t had the benefit of actually seeing it yet. We have seen the trailers, we have read posts about the movie and obviously we are both very familiar with concussion itself but we are going also look at some of the bigger issues behind the movie and how it is all stuff is flaring up in the US, the reaction of the public to the film and the way that sports and so forth are dealing with the issue of concussion within the larger picture.  So what I will do first is I am just going to quickly give you a summary of the film so that those who haven’t much about it or aren’t familiar with it have got a bit of background so that they are not going in completely blind to watch what we are talking about.  This is a film, which has been as you say starring Will Smith, it is basically a movie about an accomplished pathologist, Dr. Bernard Omalu who is a Nigerian person who is practicing medicine within the United States and he is a pathologist that is working for one of the local counties in the United States in America.  Prompted by the death of a famous football player at the age of fifty this Dr. Bernard Omalu undertakes research that leads to the discovery of the condition known as Chronic Traumatic Encephalopathy.  So Carlo, do you want to just give us a quick bit of background on what is Chronic Traumatic Encephalopathy is or CTE? Carlo: Sure it is a very devastating condition or disease that often results from repeated head injuries, how I describe it to patients who unfortunately by definition we can’t diagnose it at this stage until someone has died.  But when we start seeing early signs of it what I often describe the patients something that we want to avoid is where the brain after these repeated injuries turns to marsh. The brain shrivels in size and a post-mortem examination show the brain to be much smaller in size, almost bruised as I said it almost looks like marsh in post autopsies.  At the moment aren’t any markers that we could use while someone is alive to help identify it, some preliminary test or research is showing that things like functional magnetic resonance imaging or FMRI, external tractography where they are able to look at how viable healthy and alive are some of this parts of the brain as well as even some markers in blood tests are showing promise to maybe giving people when alive a sign that all is not too well. Basically this CTE happened as I said from repeated injuries and repeated concussions, it takes many years to develop, some of the signs and symptoms of it are brain fog, dementia, Alzheimer’s, depression is probably one of the most common sign and this is thought to lead to why suicide levels in people with CTE is extraordinary high. You only have to look at, I think the best example of this and particularly as it relates to the movie is studies are being done in NFL players, the stats are scary, when you look deep into some of the stats and I can understand why the NFL the National Football League in the States probably didn’t want this movie to be promoted is almost a hundred per cent of former players that have since died they perform post-mortem autopsies on them and as I said almost a hundred percent of these patients of the former players actually have developed CTE.  So it doesn’t look great for people that have had repeated injuries and this is why we try to check out a lot of our patients particularly our kids in sports to wear appropriate headgear or maybe choose an appropriate sport that doesn’t involve repeated head traumas. Matthew: Yes, when you talk about a hundred people of people, is that people who have died of natural causes as well or those who have say died of unnatural courses like suicide? Carlo: Suicide, yes, I think both, a relatively high percentage I think two to three times the average rate in society of mental illness and suicide are generally reported in this population. So they tend to die either of both sorts of conditions, both in suicidal and normal history they are both detected CTE. Matthew: So that is quite damning isn’t it, so I suppose a little take away there is even though you may not be getting symptoms from having some sort of brain damage from chronic repetitive trauma you can still have brain changes going on that you are not aware of. Carlo: Exactly and some of the subtle warning signs are something that as clinicians we want to educate our patients and in particular our sporting people, I think if we could focus on some of the early detection of some of the subtle signs potentially through reparative or preventative means can maybe slow down that process or halt it in some ways. Matthew: Good that is some good news for those who have potentially had some head trauma in the past. I suppose what you have been saying they are linked in very well with the film in terms of precipitating episodes that cause this doctor to get into investigating the CTE further is the fact that there are several suicides, you know, there is this trend showing up.  I suppose one of the whole premises of the film is that the way the American Football is played, players basically bang their heads together or their helmet together as part of the offensive nature of the play like the offensive as the defensive and so forth and that chronic repetitive trauma is what causes the brain damage.  It is easy for us perhaps in Australia and other parts of the world where American Football isn’t that common to think that well this doesn’t apply to us but research is suggesting that any sort of repeated head impact whether that be concussion in Australian Rules Football or heading the ball repeatedly in soccer is going to affect the brain. That is the case is it? Carlo: Correct, AFL in Australia and Rugby League there are some cases and some case studies that are now coming to light over the last several years that have shown former players with confirmed CTE.  So it is not isolated to only NFL I think just the numbers and obviously the intensity which they play in and they just had a lot of head collisions that are part and parcel of the game are more prevalent in that sport but it certainly has been seen in soccer, IFL, NRL and also boxing, I mean. let’s keep in point boxing is, if you just look at it, I mean, we often cringe looking at boxing thinking that has got to hurt, well, later in life it does hurt.  So it is something that even in our clinic we do see boxers with concussion which is really described as a mild traumatic brain injury and those that have had repeated head concussions which essentially you can look at boxing as being CTE is probably likely to happen in the number of elite and amateur boxers.  Interestingly we also see people with blast injuries in the military and the armies and armed forces are starting to see the early warning signs of post-concussion syndromes including PTST or post traumatic stress disorders in returned and active military and the though is that they are suffering very similar conditions. Matthew: Yes, I know in the United States that has been a big driver because of the large military involvement the number varies around the world, a lot of their colleagues in the States do report seeing a lot of military and you are saying the same trend here in Australia? Carlo: Yes in Australia from the returned military personnel that I have seen, they often when reporting to the doctors or specialist it is very much an unknown condition so there is a push amongst those people to make it known amongst the medical fraternity and there are a few clinics including ours that actually can help identify, if not a name to it, can put a list of symptoms and more importantly can put a regime of therapy, rehabilitation therapy to help people overcome a lot of the symptoms associated with this. Matthew: Yes, that so that sounds great, I suppose perhaps of one of the big issues, the movie is that this film movie has basically flopped in the United States as far as I am aware and the reception to it has been very poor, we have a lot of people who perhaps are very passionate about football and the last thing they want to see is it will end up being something just like touch football as opposed to the heavy type of contact sport.  Does that sort of fit in with your thoughts about what some of the resistance to these concepts are coming up against an endurance of the condition and a desire of fans not to see these sports watered down. Carlo: Exactly, I think in particular with the medical fraternity because mild traumatic brain injury or concussions is not seen on any image, if you would do an MRI or a CT scan as long as it is not an open wound which is not by definition not a traumatic brain injury anywhere or a concussion, if I would get an image nothing would be seen so it is hard for someone to say aah that is what you have got because I can see it on an image. It is really a combination of symptoms, so it is not turned into structural injury, it is turned a functional injury nowadays.  So the difference between the two as I said a structural will be seen on a scan and it is very identifiable.  A functional image is something with, obviously it is not identified on any structural image but there are symptoms associated with how the person is functioning and typically dis-functioning.  So the common symptoms maybe they just have troubles reading or they have got some brain fog or I have this sleepy or that muscle achy or lethargic, the balance is not right.  So a lot of these things appear to be vague symptoms and something that doctors see on a lot of their patients.  So it is hard to say well that is what you have got based upon those but the criteria now and the guidelines and standards say that we need to identify, we need to observe, assess the signs and this is why some of the testing that we do and the research they are showing can help identify some of these early concussion signs and they include posture, so we look at how someone’s balance and posture is, whether they can walk in a straight line, whether they can stand on one leg with eyes open or eyes closed. We look at their eye movement functions, are they able to focus on a particular point, are they able to track a moving object either slowly or fast, can they look at a visual stimulus as a passers-by accurately.  So these are all now becoming quite big markers of concussion so the guidelines are catching up, they are not quite there yet put as a protocol, as an international standard but I think we are not far from that being developed at this point. Matthew: Yes, so I think probably some of the resistances or part of the challenge perhaps rather than the resistance is either it takes years of clinical expertise to be able to see the subtle changes in eyes or eye movement and posture changes and so forth or the need for fairly expensive equipment in order to do that which isn’t practical or reasonable when you are dealing with even a large AFL law in a real game to have that sort of by the side of the pitch to be testing people though it maybe some of the balance place test to be coming in a little bit more.  But it is something that really something that really needs to be done in a specialised facility and that is part of the problem? Carlo: Year, as you said, for you to be able to quantitate accurately how they are functioning then you need equivalent equipment so to be able to assess that and unfortunately this equipment is not that cheap or readily available to a lot of clinics.  So there are side line testing measures that a physical therapist or a medical practitioner or even a trainer can perform on the side line are showing some degree of correlation and they are good tests and certainly not the best and but on a side line it is better than nothing. So that is often what they use as a side line testing but if symptoms persist past the natural history of a concussion which is within a week, if they persist it is generally that time when a more dedicated balance and dizziness concussion clinical laboratory is generally recommended where most of these equipment are available and testing can be performed. Matthew: Indeed and there is also a push towards getting a baseline testing done, where pre season people are getting themselves screened so that if they do get a dong on the head they have then got some normal measurements for them in order to be tested further. Carlo: Exactly, baseline testing is something that we promote in our practice to a lot of local sporting teams to, just say get a baseline as to where they are at and all comparison should be made back to the person.  So as they go throughout the season if they get a dong on the head or get their bell rung then we can then test them and measure the performance at that time relative to how they were at the beginning of the season or preseason. And then we don’t return them to play or allow them to return back to training and play itself until we are satisfied that they have met as close to if not at the same level that they were preseason.  So it is a great thing and we are encouraging, we are working with a lot of local teams to advocate this sort of testing as a way of really getting a baseline and understanding as to where each team member is at the beginning of the season. Matthew: So I think particularly when you are dealing with kids with local clubs and so on, if kids should get better over the space of a season, shouldn’t they, if they are coming to you and they have preseason testing and they are worse after getting a knock on the head and you at very least want to get them back to their preseason level because that is where they were six months ago or whatever and the natural evolution of a child’s development is that they should be getting better, they should be better than when the baseline testing was done, certainly not worse. Carlo: Exactly, and parents often bring their kids in or are referred by the coaching staff because they have noticed not only is their performance deteriorated in terms of balance, in terms of the general performance of that sport but parents might say my son is just not sleeping well, he is sleeping excessive or is just waking up at night and is always tired, the teachers have commented that his report cards have deteriorated, he is losing focus, he is irritable, his concentration has worsened.  So there is a lot of things that parents note, parents are pretty good at noting at noting some subtle signs in teenagers and they are not the normal teenage things, obviously can’t be that but in such a period of time following a head trauma the correlation is got to be there and it is during that stage when parents drag the kids in and say look I need my son or daughter assessed, please let’s find out what is going on. Matthew: Absolutely, I suppose we kind of covered some kind of really good stuff today, we probably need to wind up there, we will no doubt come back to the issue of concussion and how it is being dealt with and further practical tips as we go through the podcast series.  I suppose some practical takeaway ideas for people are that if you are involved in any sort of contact sport you really should be looking at getting baseline testing done at the start of the season.  Also if you have had a concussion and you have got symptoms that are persisting beyond a week then you really need to be looking at getting some sort of assessment done as well and also if you are involved in a sport that has lots of contact maybe you need to reconsider it particularly if you have multiple concussions already and you are a little bit concerned that you might be even developing some of the early signs of chronic traumatic encephalopathy.  Does that kind of summarise it for you, is there any other tips you would like to add. Carlo: No, it is great Matt, I think if all those points could be disseminated and taken on board by our listeners, it starts with education, I think going back to the movie if there is anything that I feel weren’t appraise from the movie would be the ability for the information to get out in awareness of that concussion in the media.  I think if we can get this information out to players, military and the general public I think it is great. Matthew: Yes, I definitely agree with you there.  So that winds up our episode today, don’t forget to subscribe so that you don’t miss any of our upcoming episodes, if you are on iTunes you can very easily do that from the iTunes platform.  If you are listening to us on Android we are going to be syndication this through platforms like the Google Library and Stitcher and other platforms like that, so be sure to subscribe and also subscribe to the newsletter on the Brainhub website so that you can be sure that you keep up to date with any of our latest posts and blog post as well as any podcast episodes.  If you would like any further advice please don’t hesitate to get in touch with us via brainhub.com.au, that web address brainhub.com.au it is all one word for brainhub.  And any sort of closing points that you would like to make? Carlo: No, I think we have summarised it quite well I hope it is helpful to people in the awareness of head concussions. Matthew: Good, thank you very much.  We will see you all soon   Thanks for listening to the Brainhub Podcast, for more information and to subscribe visit brainhub.com.au.