Dr. Jimmy P. Transcript

Okay, hi everyone. Just start off by thanking Concussion Box for having me. This is a pretty exciting opportunity. I get to speak about one of my favorite subjects. So, my name is Jimmy, and I’m a physical therapist, Doctor of Physical Therapy, here in San Diego. I have my own practice. It’s a mobile practice, meaning that I drive to patients’ homes to see them. The thing is, I had my practice in the bay for about two, three years before I relocated here to San Diego about six weeks ago. So I’m kind of starting over, still looking for my ideal patients right now, which are concussion patients, for sure.

So, let’s take it back a little bit, and I can give you guys some background on how I got into concussion rehab and why I enjoy it so much. So when I went to PT school, I think I was, like most people, I thought I wanted to do, like, standard orthopedics, back pain, double pain, and athletes. And then it didn’t take long for me to realize that, actually, I was much more interested in neurology. And then, so, when I started at the neurological journey, it was mostly I was really enjoying things like Stroke, Parkinson’s, some of these more gross motor neurological diseases, but that was very physically taxing on my body. You don’t get to work really hard. And then pretty much as soon as I got out of school, I started having health issues. I became a chronic pain patient, and then two years later, I became a chronic migraine patient. So, my working diagnosis is, for me, is like fibromyalgia and chronic migraine. So it’s 30 out of 30 headache days a month for six years. So I effectively had a headache for six years with a lot of other neurological symptoms. 

So, given that I was dealing with all that, I wasn’t able to sustain working with those previous populations I mentioned. So I had to think really hard about how I wanted to transition and pivot. And I knew I didn’t want to really go back to orthopedics, low back pain, elbow pain, these things. I enjoy it, but I don’t want it to be what I do primarily. And then given that I had this history with headaches, and it came with like, it was a different disease process, because it is migraine. I should mention, I’ve had concussions in the past as well, and we can get into that. And let me just tell you, I’m a healthcare provider. And then, when I had those concussions in the past, I did not take good care of myself, you know, and I knew better. So bit of a lesson learned for me. But, you know, I became this chronic headache patient, and it became a big part of my life. 

And so, yeah, so I didn’t want to go back to orthopedics. I really wanted to stick with neurology. So I did kind of brainstorm ways that I could stick in the neurological world without compromising my own health. And that’s how I landed on vestibular therapy and concussion therapy, because, generally speaking, these people, you know, they have high levels of disability, but in terms of motor planning, a lot of times, they’re, they’re okay, they can walk, you know, they can sit up and down by themselves. And so it was almost born out of necessity, but I think with my history of chronic headaches, it really also made it very, very personal, because I have, you know, headaches, I have dizziness, I can, I can empathize with my patients a lot. So it’s a different disease process, but there is overlap. So, I have issues with, like, ocular motor issues, issues with keep, like, keeping my eyes. I do get motion sick, especially with head turns. 

But I’ve come a long way. You know, I was on disability for two years to running my own business. So, for anyone who’s listening, who’s listening, who’s dealing with thought, you know, I just want you to know there is hope. And I also want people to know that there’s, there’s a lot more options than you might realize. So getting back to the specialty, so it was, my specialty is vestibular therapy, so dealing with dizziness, vertigo, and then headaches also, and so concussion is the perfect blend and intersection of those two disorders, right? Those two classes of disorders, because, naturally, concussions come with a lot of things, like nausea, dizziness, you know, vestibular issues, among other things.

I lost my train of thought there, yeah, concussion comes with all those things, oh, and then, of course, concussion comes with headache, right? That’s a very primary discussion. So this is kind of just train of thought, but let’s talk about headaches in general for a second. So, people with concussions, you definitely fall into this class. Because I don’t think you realize how big this community is, right? I think you may be learning, starting to learn that, okay, post-concussion syndrome, concussion patients, okay? This is, this is, there are a lot of people in this, but then I want you to kind of expand beyond that, right? See some adjacent groups, and then if you look at the, there’s a document called the International Classification of Headache Disorders. And then if you look in this document, actually there, there exist over 300 headache disorders in the world, so it’s very, very taxing. And then if you look at migraine, migraine is the most disabling, well, besides maybe post-concussion syndrome, but you know, one of the most disabling headaches, and it’s still the second leading cause of disability in the world. So headaches really affect the large swath of the population, but, you know, it doesn’t get the attention it deserves. And I think headache patients, including post-concussion patients and concussion patients, are definitely underrepresented. 

So I think some of you have probably heard of this, concussion is like snowflakes, right? We call them a snowflake injury, because no two are the same. You think about it, you know, it comes from this rapid acceleration and deceleration of the brain that damages the neurons in the brain on the Microscopic level that, you know, we can’t really see on MRI, we can’t see on imaging. So the brain is kind of like this black box, right? It’s all this information from the outside. Systems go in, and then it processes that information, and then what it spits out is your sense of balance, any sensations of pain, and then that gets disrupted with the post-concussion syndrome. And, we don’t have any accurate way to image and know, or any markers that we can look for that we know. Okay, like, you know this concussion is going to result in this, we just don’t know. So it really is just dependent on how the patient presents. So I think they’re starting to update these, but generally, I still go by the six different concussion phenotypes. 

So there’s the cervical phenotype. So when you think about, it takes about 19 G’s of force to cause a concussion, but it only takes four G’s of force to cause a neck injury. So any kind of concussion is usually going to be coupled with the neck injury, and the neck actually has a really large role to play in your sense of balance as well. So when you think about your inner ears and your head, the inner ears are what provide your brain information with where your head is oriented in space. So that’s important for balance. And then your head, you know, naturally sits on your neck.

So if your neck is having issues, and your neck doesn’t know where it is in space, that jumbles the information in the brain, and then that can cause dizziness. So it’s like, when you have a concussion, you know, we know there’s going to be some neck involvement. We know there’s going to be this central brain involvement. The question is, is the dizziness coming more from the neck, or is it coming more from the brain, or is it coming from the ears? Right? So it’s an interesting puzzle that we have to figure out, because all these symptoms are really well integrated. 

And then moving on to the next one, I think about ocular motor deficits. So ocular motor means issues with eye movements. And I think as a clinician, what you have to be aware of is, you have to be aware of the different kinds of eye movements. So I think this is where patients get kind of jumbled up. They’re like, well, I saw my, I saw my optometrist, and he said my eyes are fine. And then I want to make this very clear, there’s a big difference between sight and vision. So sight is does I think of it, I’m not an optometrist, so I’m sure I got some of this wrong, but like when I think of sight, I think of the structural integrity of your eye. Is your eye structurally sound that it’s receiving visual information properly from the environment. 

And then, when I think of vision, I think of, okay, is your brain coordinating your eyes properly? Because you have, you know, news flash, you have two eyes, right? So, and sometimes they get conflicting information. They’re supposed to work in a certain way, so that objects stay in focus, and that can be disrupted, right, if your eyes are not working together properly. And then the second part is, how is your brain interpreting that visual information? You have to remember that the image that goes into our eyes from the environment, it is actually upside down, and then our brain takes that image and flips it upside down for us. So, it’s a big part of the treatment is knowing the different kinds of eye movements that make up our visual system, and knowing the different processes between, behind each eye movement. So I can give you an example really quick. Some of you are probably familiar with the vestibulo-ocular reflex, just a fancy word, meaning that you can keep an object in focus as you turn your head. And this neurological process is what we would call peripheral, so gross simplification is, you know, the information from the ears coordinates with some certain sense sensors centers in your brain stem. So it’s not so central brain, and it’s modulated there, right? Versus something like we call a smooth pursuit, where, if I move my hand, and you’re able to just keep eyes, keep your eyes, checking my hand without moving your head. That’s called a smooth pursuit. But we know that’s, that’s a central, that’s a central process, right? It’s much more. It’s deeper, higher up in the brain. 

So kind of knowing, and that’s just two different kinds of eye movements that we assess and we look at a lot more, so knowing the path of the, not the path of physiology, knowing the processes and neurological reflexes that go into those eye movements that’s really going to drive your treatment, and seeing which eye movements are especially difficult. Going on from that, you know, I think about vestibular problems. So vestibular means your inner ear, right again, your brain is not interpreting the information from your inner ear correctly. But what we also have to remember with a concussion is, it does not always come from a blow to the head. Yeah, let me, let me restate that actually, concussion doesn’t have to come from a blow to the head. It can come from a hard blow to the body. What it really is, the concussion comes from, is when there’s the rapid acceleration and deceleration of the head or the brain. And that can totally happen if you get slammed really hard and your rag doll in you head snaps back and forth, you can totally catch a concussion that way.

But going back to the vestibular, most concussions are still because of a blow to the head. And if you get a blow to the head to the side, what you can have is something we call a labyrinthian concussion. And what that means is that the concussion is resulting in actually damage to your inner ear structures. So again, we have to tease out, okay, how much is happening, you know, at the inner ear, or how much is happening centrally? Yeah. So ocular, yeah. And then so we did cervical, ocular motor, vestibular, thinking about cognition. So cognition is going to be impaired after you sustain a concussion, right? I think, I think intuitively, we all understand that, and you need to work on it, right? You need to work on the concussion. You know, where cognition, you know it becomes after concussion with these brain fogs. You’ll, you’ll notice it’s much harder to do things, much harder the focus and part of that is because your cognitive level has decreased, so you can’t really be doing something, and kind of thinking about things as well. The layering of the thinking and the physical action of doing something, it becomes very difficult for the brain to integrate these both together. And the way we treat that, is we train your cognitive ability. And you know, as physical therapists, we can do this to some degree, very effectively in most cases. 

But of course, sometimes when this is really the primary driver, then we have to refer out to somebody like a neuropsych, who’s better equipped, or speech, who’s better equipped to handle that. Post-traumatic migraine, that’s the rarest form of, you know, type that we see with post-concussion people. Well, I think the correct term now is persistent concussion. So that just speaks to just how fast things are changing in the concussion world. It’s changing all the time. And as a health care provider, you know, even I have a hard time keeping up. So for anyone else who’s overwhelmed by all this information, just know that you’re not alone. But post-traumatic migraine, that’s when people start experiencing migraine symptoms with their concussion, so things like light sensitivity, sound sensitivity. 

And when I think of post-traumatic migraine, I’m thinking it’s a brain that’s gone haywire. And the reason, I think, you know this is just my personal opinion. The reason why it’s gone haywire is that all the information that’s coming from all your other sensory systems that we talked about already, your eyes, your ears, your brain’s just not processing it correctly, and it’s just too much. And then it overreacts, and then it causes these issues. And then, because, you know, the brain is integrated with everything, and it affects all systems of your body. So in addition to light sensitivity, sound sensitivity, you know, you could find, you know, we call these like dysautonomias, right? So things like heart palpitations, you know, digestive issues, blood pressure issues, you know, that’s also all part of the equation. 

So when it gets really complicated like that, especially with post-traumatic migraine, I think that’s when we really have to start considering pharmaceuticals. You know, you should always have a doctor on board, always a neurologist on board, along with your therapy, I think. But generally speaking, yeah, if you have post-traumatic migraine, that’s when I think we really have to be working very closely with the doctor. And then finally, there’s the mood and anxiety portion. So having the concussion is going to make you more prone to anxiety, not just because you had this life-changing event, but because it structurally changes, neurochemically changes your brain, that it just makes you more prone to these things. So, so that’s a good one to end on, because, you know, naturally having this concussion is very life changing, and it’s very normal to be very anxious about what it all means, but the good news is that we’re getting better and better at treating it and it’s being shown to be very effective, right? And that’s another reason why I like treating concussions. People get better. 

So, you know, I mentioned, I treat a lot of headaches, and generally I get good results. But with migraine, you know, the research is just it’s just not as comprehensive as concussion disorders. For migraine, you know, you have to pull a lot from other disorders to try to make it work, try to find different things that can work for the patient. It’s not the case with concussion. We have really good studies, we have really good guidelines, and now it’s just a matter of the medical community catching up and keeping up pace with the research. You know, when you think about, when I think about concussions, most of the research it kind of started coming out around 2010 that’s when you know attitudes are starting to change, that people were starting to realize, oh, what you can treat a concussion. It’s not just sitting in a dark room. You know, there is an active rehab process that helps people get better sooner, and helps reduce their risk of future concussions. So that research started, started around 2010, and it’s only gone up ever since. But what we have to remember is there’s a concept called medical inertia, and it takes medical practice about, you know, I think on average, 12 to 15 years to catch up with medical research, right, for people to learn these things and for these things to get implemented. So medical, the medical community, regards to concussion, is, I feel like just starting to catch on. It’s finally kind of out there, right? But it’s mostly still not, so, you know, doing my line of work, I meet a lot of people, and when I tell them I treat concussion, they, they’re they always, there’s a look on their face. They’re like, what like? What are you going to what are you going to do for a concussion? Right?

It’s a very detrimental, it’s a very detrimental framework to have, because we know that an active rehab process leads to better outcomes and reduce risk of developing persistent concussions from so actually adhering to that old process of, you know, totally passive treatment, cocooning yourself in a dark room, hoping things will get better, you’re actually doing harm to your patient. And with the interventions, you know, with the research you know, they’re finding earlier intervention, the earlier it is, the better. So I think the neurological, the Academy of neurological physical therapy, just came out with an abstract, think, a few months ago, very recently, and it’s saying, you know, concussion rehab, this starts within 48 hours of the initial injury, leads to better outcomes. So 48 hours, right? You know, people, people with concussion, they’re getting to therapy too late, right? 

Personally, I’ve never seen, I’ve never seen anyone within 48 hours. And you know, I think it’s a testament to just how ingrained this cocooning strategy is to modern society. Because even if I saw a patient at 48 hours and I would still be a little nervous, right? Because I still kind of, I’m still kind of, we still have our biases and, but the research is very clear, right? The sooner you start, the better. And, you know, I do this, but even at 48 hours to be, you know, like I said, I’d be kind of nervous. So that’s why I really like concussion, like, kind of, I was nerding out a little bit. It’s so interesting. There’s so many different presentations. It’s just such a puzzle. It’s just very mentally stimulating work. It’s incredibly rewarding. And the best part, though, the best part is that it works, right? You know, there’s, there’s nothing more discouraging than working with someone on a very obscure, rare diagnosis, and you’re just, you’re doing your best, but you’re just not sure, like, you know, is this going to work? But it’s different with a concussion. It’s like, okay, we know if we implement these things, we know if we do a good evaluation and pinpoint where the problem is, we can get very, very good results.

So I talked already about kind of the systems impairments that we look at, and then what we also have to really think about with concussion is what we have to think a lot about with concussion is also aerobic, so exertional tolerance. So a lot of people, when they think about concussions, they just think, oh, vestibular, vestibular, vestibular gets the most attention. They almost equate the two, and they do go hand in hand. But the thing you have to remember that is, concussion rehab is not vestibular rehab. I’m going to repeat that. So, concussion rehab is not vestibular rehab. There’s a lot more to it. 

There’s just all these different things that are also involved. So I think, I think they’re, I think concussion is a very unique framework, because it intersects the vestibular part and the headache part. And so you end up doing a lot of treatments that are vestibular and neurology-based. But then you also have to, because all the neck involvement, you do end up doing a lot of orthopedic work. So it’s kind of a mix of both worlds. And I lost my train of thought again with it, oh yeah, exertional tolerance, so this is one of the most important things that we need to address. Because after you get a concussion, the first thing, one of the first things that goes down is the brain flow to the brain. So you know, you can go for as far as to say that after a concussion, your brain actually becomes a hypoxic environment, meaning there’s not enough oxygen to the brain.

 And so what do you need to what do you need in order for your brain to heal, right? And the natural answer is, you need blood flow, right? So this is one of my top priorities, is kind of starting this aerobic program, and you need to do it in a smart way. You can’t just say, Okay, well, just go do, just go do 20 minutes of aerobic exercise a day. Just, just go and do that, and just have that as a blanket prescription for everybody. It doesn’t work. It needs to be tailored to you. We need to know what your current tolerance is, how far, how much we can push at a time.

And we do that actually, very accurately. We have certain tests that we use to determine what heart rate you should be working at, and then using that as a guide, we use that to gradually increase your heart rate to the point that you’re at a better, you have better tolerance to aerobic activity, better tolerance to exertion. So that’s also critical. I actually think that’s foundational for all of these, lot of these things. So you know, if you’re dealing with everything else, you know you could be doing all the right interventions. But if we’re not getting the brain properly perfused, it’s just that much harder for your brain to make those changes.

And we know for the brain, that aerobic stress,  it proves neuroplasticity. So there’s a there’s a neurochemical called BDNF, brain-derived neurotrophic factor. I hope I got that right, otherwise, I’m gonna sound really dumb, but we’ll see. But BDNF and that has a large role to play in neuroplasticity, and for those who are maybe unfamiliar, I imagine most listeners are familiar who aren’t familiar with neuroplasticity, that just means your brain’s ability to adapt and change.

So it’s really important that we have this aerobic program kind of expanding upon that, we’re starting to see BDNF, we start thinking a lot about for different neurological diseases also, so things like stroke, you know, more severe brain injuries, more severe traumatic brain injuries, Parkinson’s, and we’re actually starting to see HIT, high intensity training being implemented in a lot of neurological populations, because the intensity really drives that BDNF, really drives to those plastic changes in the brain, and just really helps people. (I’ll just start over.) Okay, so after you have a concussion, the first thing you need to do is you definitely need to go seek care. Okay, a concussion is a serious injury. Okay, so you need, you need medical oversight. You know you can go straight to a physical therapist, right? Especially if a direct access in your country, like I think that’s highly recommended, because you should still go to your physician, right? Because you want to make sure there’s nothing more sinister going on. But the reason you really want to go to your physical therapist and be that have that be really high priority is because physical therapy or active rehabilitation is the gold standard for treating concussion. 

There’s no medication that they can give you that’s really going to tackle this in the most comprehensive way that physical therapy and concussion rehab can. So seek care, start early. You know, cocooning, the practice of just being in a dark room, hoping things will get better. I think that still has a role to play in the first 24to 48 hours. I think that’s smart. But after that, you know, you should be trying to see somebody. And you know, I just, I just wish more people knew. I wish more physicians knew, because most people you know their first point of contact after concussion is generally going to see a physician, and it’s just, it’s just, not there yet. 

You know it’s just, a lot of physicians are still unclear that this is even an option. Many people have never even heard of concussion rehab, and I’m lucky. I feel very fortunate that I’m in this space, that I have this knowledge, that I can help people with. So I think that’s the biggest thing is, uh, establish care, uh, seek out your support system, and then if you are an athlete or you’re a student who got it from school? You need you, you need your healthcare providers to coordinate with your school. Because, first of all, they need to advocate for you. So, whether they need to write you a disability a letter or anything, for you, they have two accommodations at school. And if you’re a parent listening, and you know, you guys are very enthusiastic about your kids playing sports or anything, what you have to remember is that the protocols, the recommendations are after you get a sustained concussion and you go back, you have to ensure that you get returned to learn before you do return to play.

So return to learn. Same thing. You have accommodations from the school. So say, for example, you have a really hard time with busy environments like, you know, and schools get busy, right? People are walking all over the place, after, after, after class, kind of different classes. So maybe you need, like, an accommodation, like you need to leave class five minutes early so you can walk in a quiet hallway, right? So these are the things you have to think about, longer test taking times, whatever we can do, and then we need to get that back to on track, back normal first. That’s, that’s our priority, okay? And then after return to learn, and this is by design, right? This is, this is what’s going to ensure that you have the best recovery. And then after that, then you can go to return to play, so going back to your sport, and when you go back to your sport, that doesn’t mean you’re just going to get thrown in, like coach is going to put you on the field. That means that we need to have a gradual program for you. So maybe you start out, you go for to practice for half an hour, and then you go for an hour, and then we have to have the accommodations there too. So you need to have these plans in place to maximize your chance of recovery, because what you don’t want to do is, and what most people do is, they go back too early, and then if you go back to early, what’s going to happen, is you haven’t addressed all these, this dysfunctions that got picked up with your concussion, all these changes they’re leaving. If they’re, and they’re unaddressed, you’re at much higher risk for getting another concussion, and we call that second impact syndrome, and that’s going to compound on the last one, and so it’s just going to make your recovery that much more difficult. You know, I think part of the concussion recovery is, yes, we want to get you better faster. Yes, we want to make you less likely to develop persistent concussion syndrome. But beyond that is we want to build resilience in your system as well. Right? 

You’ve, you’ve effectively entered this group where you are more likely to get concussion. Like, you know, sorry, it’s just the hard truth, after you have had a concussion, you’re just at higher risk. And actually, you know, for expanding on that, for any injury in the body, I’m just gonna, I’m just gonna ask the audience this question, so, what do you think is the highest risk factor for an injury?

And then so people are thinking, you know, you guys didn’t verbalizing answers…

Okay, so the highest risk factor for any injury is a previous injury. Yeah. So this, this applies to anything, but especially for concussion. If you had a concussion, that just makes you more at risk for concussion for the future. So please take care of yourself. Please go through a good plan of care. You’d be surprised how effective it is. You won’t regret doing it. You know. You know your body is the most precious commodity you have, right? So you really want to take good care of it, and don’t rush back to play too soon. Make sure you have a plan, have a team.