Questions, Terms and Concepts
Communication between providers and patients is very important. Discussions involving brain often become confusing, especially when it comes to clinical applications of neurophysiology.
Therefore, the following is a list of some of the terms, concepts or metaphors that are used at Brain Centers NW. The intent is to help the patients of Brain Centers NW gain a better understanding of the applications being used, tests, and reports that are implemented in clinical practice.
These terms may or may not be unique to Brain Centers NW. I encourage comment, criticism or expansion of these terms or concepts, but please understand that this is directed to patients and clients and not the medical community.
Comprehensive Evaluation / Functional Neurology
What is a functional neurology approach for brain health?
What I look for is how various brain systems or regions are functioning. This assessment is partly to do with symptoms being experienced, partly to do with how your level of function compares to others and partly how one side of you compares to the other (e.g. reflexes). If you think about brain like a bunch of muscles, you might say that I’m like a personal trainer for the brain and nervous system.
Muscle is muscle for the most part and neurons are neurons for the most part. They do what they do because of the information they receive and how they are networked with other regions or systems. For example a bicep and a tricep are the same, they are both muscles, they are just on the opposite side of the joint and therefore have a different consequence when they shorten. There is a different result if the bicep contracts and inhibits the tricep (i.e. flexion of the arm) compared to the opposite (i.e. extension of the arm) or if both were to contract at the same time with equal force maintaining a fixed angulation of the joint. Which one shortens or contracts is based on the message sent. The muscles are interdependent, they influence one another. The brain is similar in that regions work with other regions to get a given outcome. When the assessment of the “strength” of these brain muscle regions are viewed as weak they are exercised in the same way you might exercise a weak muscles.
As part of assessment the “fatigability” of brain regions will be evaluated. Consider that doing something that is healthy, is only healthy if the degree of challenge is not over powering, that is to say it does not exceed the “metabolic capacity”. For example while starting to walk or jog maybe healthy, suddenly dropping an unconditioned person into the Boston marathon would not be healthy, to the contrary it could be disastrous. The amount of rehab a given individual can take at any one time is dependent on the health of that system. When I say “exceeding metabolic rate” or “fatigability” of a system or regions this is the concept I am referencing. Another way to think of it is would be like an exercise for muscle. How much weight can my brain lift and how many reps can it do before it “fails”. This is an evaluation of the endurance or health of that system. It would be expected that with an appropriate level of repetition that the system would get stronger, healthier with greater endurance.
Functional neurology is not specific to chiropractic, naturopathic or medical. It is a way of thinking, evaluating and treating humankind. While one of the pioneers of this approach is in fact a chiropractor, Dr. Carrick, he is not alone. There are many others taking a functional approach to healthcare, among them are medical physicians, naturopathic physicians, osteopathic physicians and optometrists.
The curious thing is that individuals within a given profession may be unaware or their perspective does not allow for this manner of thinking. The ability to do so is testament to our different brains as what we can process and how we process information. As an example, I have had the experience of explaining myself to a medical neurologist once who thought what I was saying was interesting but that it was not science and was at best theoretical. One only has to read “The Clinical Science of Neurologic Rehabilitation” by Bruce Dobkin, M.D. who is a medical neurologist and was the medical director at UCLA to realize that while the terms may vary, this is not a profession specific approach and its roots are science based. It is simply applied clinical neurophysiology with the intent of restoring or gaining higher levels of function to maximize our human potential.
A Typical Visit
What is a typical visit like?
The time that a visit takes is dependent on what you are looking for. A simple balance check will only take a few minutes. A full baseline testing including balance, interactive metronome, videonystagmography will take sixty to ninety minutes. If a functional neurological evaluation is to be done as well with history and examination it will take two to three hours total. Many of the exam procedures are the same as what a medical neurologist might do but the interpretation of the findings will potentially be different. It is a question of perspective, disease versus function. Please see other pages for interactive metronome, sports, functional neurology, vision, balance to get a better appreciation of testing options.
I have been asked, “Are you testing today or will it be rehab?” The answer is “Yes”. Unlike other healthcare appointments, this approach requires constant evaluation. From these examinations clinical hypotheses are generated and then strategies are applied based on neurophysiological principles. If the application is of benefit changes are expected immediately. We do not examine the patient and then put them on a two to three week course of treatment before retesting. We want to know that clinical applications are making the appropriate changes immediately. Can you imagine being given the wrong treatment and continuing with that treatment for weeks before re-evaluation? Doesn’t make much sense now does it?
Baseline Brain Testing
Why is it important to have a baseline of present brain function?
When you are looking at function of a system the best thing to compare your present findings too are your previous findings. When athletes experience a head injury and are only relying on symptoms they may be misguided to return to play too soon or conversely may be missing game day because of a symptom that appears to be brain related but may actually be coming from their neck (e.g. headaches).
By testing various aspects of function (e.g. balance, eye movements, attention, motor coordination, range of motion, muscle tone) you have a before and after picture that gives the provider, parent, athlete more “windows” whether or not a return to pre-injury status has been reached. The other benefit is that asymptomatic issues like a mild balance deficit that is affecting their performance can be easily managed not only elevating their game but potentially preventing injury.
The idea of baseline testing is to know what a person’s present level of function is. The information obtained can either be used to proactively intercede if a relative functional deficit is discovered, which can exist without symptoms, or can be used as a benchmark of function in the event of a head injury. Think of baseline testing as you might blood pressure monitoring or baseline labs that you get on a yearly physical.
To illustrate the advantage of acquiring this information I will use a metaphor of a “mental push up”. Let’s say that in order to function within their given sport or academic level a person needs to be able to do 10 mental pushups. This level of function ensures that they do not experience any symptoms. Now let’s say they experience a concussion and drop to a theoretical 8 mental push up capacity. Understanding that we are symptomatic when a stress is greater than our ability to handle it, this person would experience symptoms when trying to perform to the level that requires 10 mental pushups.
When we rely on symptoms alone, we end up letting the player return to play once they are asymptomatic, which only means they can perform 10 mental pushups. But what if prior to injury they could perform 15 mental pushups? As a parent would you want them at the level of 10 mental pushups or back to their 15 mental pushups or perhaps still higher at 17 or 20 mental pushups?
The only way to know how many “mental push-ups” they can perform is to do baseline testing. There are various levels of baseline testing. The more “windows” examined the greater the understanding of your child’s level of function.
Benefits to Athletes
How would my child benefit as an athlete?
There isn’t a sport that does not require balance, focus, eye-foot or eye-hand coordination, timing or agility. The functional approach to testing and performance enhancement elevates all of these necessary functions. The difference between being average and competing and being the best and dominating requires the edge that is provided by optimizing these skills. So training will increase their thought process, reaction time, coordination, stability of joints, quickness, concentration, visual tracking. It isn’t a question of having these attributes or not, it is not a destination it is how well do you want them functioning. You can always be smarter, stronger, faster etc. It is just a question of how good do you want to be?
Why is it that Formula 1 race car, post race, is re-evaluated and “tuned up” but athletes undergo traumas throughout a competition and receive no re-evaluation or “tune up” until they are complaining about something. That makes as much sense as waiting until the engine is on fire before you respond to alterations in the engines performance. Research has shown that functional and even structural changes can occur without overt symptoms. We know that a compromised brain is at greater risk of injury, so why not ensure that all cylinders are firing perfectly at all times?
Protection Through Function
All things being equal, if one knee is stronger than the other and they both sustained the same degree of trauma, we would assume that the stronger knee would have a better outcome to that physical stress.
We know that those with migraines, ADHD, anxiety or dyslexia have a worse prognosis in the event of a concussion than those without this diagnosis. We know, through imaging studies, that these diagnoses are associated with relative deficits of function of certain areas of brain or “brain muscles”.
If that is true, and neurons are neurons, it might also be true that any area of brain that is relatively weaker would have a worse prognosis in the event of a concussion. For example, if the areas of brain associated with visual tracking are “weak” and it is this area that is concussed than it may be true that the prognosis would be worse than if that weakness was not present.
Perhaps, when we pay attention only to symptoms post concussion rather than level of function we allow an individual to return to play with a lower level of function or “weakness” increasing the probability of a subsequent concussion. If we increased the level of function perhaps we increase the relative protection of the brain. Perhaps, brain training and functional optimization could act as an “internal helmet” and mitigate the consequences of a traumatic brain injury.
Note the author is not making a known evidence based claim, rather it is a clinical hypothesis. However, clinical cases seem to support this contention.
“Windows” to Function
I will often say that I cannot open you and probe at your various areas of brain, therefore I must look through as many “windows” into your brain and nervous system as possible to have as clear a picture as possible. There are countless “windows” that reveal what is going on inside and the degree of clarity of that window is dependent on the observer’s capacity to see it and understand it, in that moment and how it relates to all that is transpiring at that moment.
A window is a physical manifestation that reflects the relative “strength” of what is going on within the nervous system. A few examples of the countless hundreds of windows include: gait, strength, tone of muscle, reflexes, eye movements, balance, coordination, attention, emotion, thought processing, likes / dislikes, musicality, sensory processing, heart rate and rhythm, pupils, respiration, blood pressure, posture.
Obviously, brain is not muscle. This analogy is used to communicate the idea that like the body, the brain is made of various “muscles” and that these muscles, like the muscles of the body, work in concert with one another. Moreover, like the muscles of the body these “brain muscles” can be exercised, strengthened and consequently can function at higher levels.
The strength and endurance of “brain muscles” are tested by looking at how quickly they respond to a stimulus and how long it takes them to fail. For example, when looking at the pupils we can look at how fast they respond to light and how long they take to fail. We can also compare one side to the other, to understand their relative strength and endurance. This is what I am referring to when I say the “rate of summation and fatigue”.
Now, when we are looking at the pupils for example, what is noted may be related to the pupils themselves or maybe a “window” into the areas of brain that perform the function of dilation and constriction or still further a “window” into the areas that fire into the areas that perform this function.
The key points to understand is that we are looking at how fast things respond and how quickly they fail and that the entire neural network and relevant relationships are considered with each test or “window”. Lastly, that like muscle the brain’s function is dependent on how much and what kind of exercise it gets.
When you are given exercises or when I am evaluating your brain’s functions I look at fatigue. This is a key concept to understand. When it comes to brain training, just because a little bit of an exercise is good does not mean that a lot of it is better. “Brain muscle” needs to be challenged but not fatigued to point of symptom provocation. The function of a given system or “muscle” tends to fail prior to symptom provocation.
Note that the signs will vary and the number of repetitions or sets of an exercise that you can perform should change over time, reflecting that the system is getting stronger. You need to be aware of signs of fatigue when performing home exercises and communicate the results to ensure that we are attaining suitable level of challenge. To facilitate this process, patients are asked to fill out daily journals of their exercises and any issues. These journals are automatically sent to the provider for review allowing for adjustments in care if need be.
Continuum of Health and Function
The “continuum of health” or perhaps the “continuum of function”, is to say that, health or function is not an “either or” state; it is not “have or have not” but rather a dynamic state within a range from a very poor disease and symptomatic state to no symptoms and beyond to a higher functioning level wherein higher levels of “stress” to the system could be handled due to the relative increased “strength” of the system. It is to say that, one’s function can be significantly greater than simply being at a state without symptoms. Some have argued that being “well” has nothing to do with symptoms.
Symptoms vs. Function
When one is symptomatic, it only means that the level of structure or function is not capable of handling the degree of stress being applied. On the other hand, a lack of symptoms only implies that the structure or function in question is at a minimum handling the given level of stress being applied. For example, if you sprained your ankle it would be sore with any weight bearing. Once the symptoms are gone, while standing for example, do we say that the ankle is returned to its previous normal healthy state? Of course not. It only means that it can handle that degree of stress (i.e. standing). So the ankle is rehabbed or strengthened, to handle the level of function required for that individual’s needs (e.g. running, cutting, jumping).
Symptoms only mean that your level of function is less than than the degree of stress being applied. A stress challenges a system and will increase the strength of the system so long as it is not greater than the system’s ability to respond. At Brain Centers NW this concept is applied to brain, wherein the level of function is challenged to increase its relative strength so that at times of greater stress it will not begin to fail and directly exhibit symptoms (e.g. confusion) or indirectly (e.g. manifestations within the body).
Many of the tests or diagnostics employed are standard tests that you would see performed during most neurological exams. What is perceived as significant, however, is where things may differ. When you are examining somebody from a disease model you rightfully have a higher point or threshold before you label something as abnormal. A “normal” finding could be interpreted to mean “common” or not significant enough to suggest pathology. But common and true normal are not one in the same.
It is often the case that a common yet abnormal finding is ignored because a lack of understanding of how this common but abnormal finding could be eliminated. From a functional standpoint we are looking for differences, side to side, top to bottom and relative to people we’ve seen before. Additionally, the finding itself is appreciated within the context of a picture that is created by all the findings as a whole. That is to say, does a pattern exist that would suggest weakness within a given network of assemblies of neurons?
This primarily true when looking at “physiological lesions” or soft lesions rather than hard lesions. For example, if you were doing a finger to nose test and you missed your nose by half an inch with the left hand but not the right, this might not be significant from a pathological standpoint but it does say to me that the structures responsible for the function on the left side did not perform to the degree that the structures on the right side performed. Now if something simple could be done to increase the function of the structures on the left side, I would imagine most would prefer that reality or honing of that function.
Your Brain Has “Needs”
A brain needs food, oxygen and exercise. The first two are transported via the arterial system. The food that we eat and our cardiovascular fitness influences our brain integrity and function. Exercise for a neuron is dependent on the other neurons that it is connected to. Neurons require constant stimulation to survive and they depend on one another to do so. When one area of brain begins to falter the areas that it is connected to will in turn begin to decrease in function. In medicine this concept is termed “diaschisis”.
Each neuronal assembly is a node within a network wherein the firing of one node increases the probability of firing the nodes that it is connected to. Like a muscle when a neuron is “fired” upon, if it is of sufficient input, whether that is an excitatory or inhibitory stimulus, it will result in protein replication within the cell. This is similar in a sense to our body muscles.
It is this protein replication, and the negative charge of protein that helps stabilize the neuron. A neuron without stimulus and subsequent protein replication will become weak and “unhealthy”. Therefore, at Brain Centers NW our goal is to “exercise” these various “brain muscles” to help maintain their health and integrity. Think of us like a “brain gym” and the doctors as personal trainers or coaches for the brain.
One of the intents at Brain Centers NW is to come up with individualized exercise plans that challenge the “weaker” areas of brain or generally try to increase the relative function of various “brain muscles”. These exercises are “neuro scientifically based interventions”. That is, these exercises are based off of the information that the scientific community has gleaned from imaging studies (e.g. PET or SPECT scans), information from known disease states as it relates to the function and structure of areas of brain (e.g. Parkinson’s) and the known result of injuries to various aspects of brain and the consequences of those injuries.
Because these are theory based therapies or exercises, we measure or examine the level of function and expect that level of function or strength to increase with the application or exercise. If there is no improvement in function than two possibilities include: the exercise is not addressing the correct muscle or not enough “weight” has been put on the bar. That is, the exercise was not enough of a challenge or stress for the system to respond and become “stronger”.
Ablative vs. Physiological Lesion
An ablative lesion refers to disease states or injuries wherein the connections are cut or interrupted between pools of neurons, “the road is out” (e.g. multiple sclerosis, stroke, tumors). Sometimes ablative lesions are referred to as hard lesions and physiological lesions are referred to as “soft” lesions.
A physiological lesion on the other hand, is referred to when we are talking about the relative strength or function of an area of the nervous system. Unlike, ablative lesions the road between dynamic neuronal assemblies or nodes of neurons are intact.
These physiological lesions can be a consequence of a lack of appropriate food or exercise (i.e. substrate or activation). The lack of exercise or input can be a result of an ablative lesion. For example, if a person suffers an injury to the right frontal cortex, physiological changes in the left cerebellum can be noted (i.e. diaschisis) by virtue of their connection to one another. Physiological lesions are expected to change or improve when appropriate exercise strategies are employed.
This term is flip flopped depending on the source. At Brain Centers NW, a hemisphericity refers to the relative weaker half of the brain. It is my understanding that other professions (e.g. psychology) that the opposite is true and that hemisphericity refers to the stronger hemisphere. It should be understood that while one might be said to have a “right hemisphericity” it does not mean that relative weaknesses are not found on the left side. It is a general term of function or pattern only, the reality is both hemispheres are connected and involved in most if not all activities.
Brain – An Integrated System
It is often thought that brain functions exist in a given area and that this area is independent of the other areas. This is rarely if ever the case. Brain functions have areas that are key to that given function but that given region is dependent on all the areas that it is connected to.
That is to say, input A may not bring area B to threshold as a consequence of deficits of input from area B and C, thereby the given function of A may not be realized or at least may be altered qualitatively or quantitatively (e.g. sight, sounds, taste, memory).
Within this notion of brain operating in a network or web of nodes is the reality that midline structures relate to midline structures, intermediate relate to intermediate and lateral relate to lateral. Therefore, if a lower level midline structure fires, comes to threshold, there is a possibility of the areas above and below it firing as well. From an evolutionary standpoint, midline structures are older structures and lateral structures are newer structures. Generally speaking, old connects to old and new connects to new.
Are you covered by insurance?
The insurance company practices can be very convoluted. Regardless of what an insurance carrier tells you, there is no guarantee of payment. Ultimately, your coverage verification is your responsibility and you are encouraged to verify for yourself, as sometimes the information we are told is inaccurate. Different services or situations influence whether your care would be considered “medically necessary” and therefore covered. There is no cost to you to do a “meet and greet” and review your insurance and my approach to your care.
Insurance is about “disease” management not wellness, maintenance and anything remotely out of the ordinary will be considered “experimental” and will be rejected. Some forms of therapy or assessment, like the interactive metronome, balance testing with vestibular technologies, functional videonystagmography assessment or any functional neurology rehabilitation services may not be covered.