Interdisciplinary Collaboration in the Management of Post Acute Traumatic Brain Injury

Everyday Functional Neurology clinics receive inquiries from patients wanting to receive more information about their programs.  These patients are searching to see if our programs would be beneficial for recovering from TBI, ABI, Post Stroke, Neurological Disease, Illness, Chronic Pain and Neuro-degeneration which has affected their brain health.  Our inquires range from not only our state and region, but also patients searching on a National and International level.

We are commonly asked what makes our therapies unique?  What do you know?  What can you help with? What do you do for therapy?  Have you helped someone like me before?  I have already done this therapy or that therapy, how could your therapy be different?

In this blog article I hope to explain how a chiropractor with training in functional neurology can collaborate with other providers like neuro-optometry for recovery and improved function in their patients.

Due to the complexity of the brain, multiple regions can be affected. Our job as a functional provider is to assess and localize areas of dysfunction in the brain while uncovering all of the oscillating factors that may be playing a role in brain health recovery.  These factors could be structural, neuro-inflammatory or neuro-circuitry based.  Following traumatic brain injury many patients will receive appropriate post acute medical care.  This is then followed up with rehabilitation that may involve psychology, neurology,  physical therapy, occupational therapy, speech therapy, opthalmology, neuro-optometry, chiropractic, functional neurology or other forms of sensory based therapies and modalities that may be beneficial to recovery and improving overall function.

It is not uncommon for patients to present to a chiropractic functional neurology office after seeing some or all of the providers above.  Many patients are referred to our offices from various providers after they have made improvements and seem to be hitting a plateau in their recovery process.  Many providers are open minded and communicate well with our clinics as functional providers.  These providers are interested in referring and collaborating to help their patients achieve full recovery from their injuries. My office receives many referrals from local medical providers, neuro-optometrists and chiropractors.

One of the specialties I would like to highlight in the article is the interdisciplinary collaboration between functional neurology and neuro-optometry.  The visual system is extremely complex and many patients with persistent post concussive symptoms are visual in nature.  Over half of the cerebral cortex is dedicated to vision.  Brain trauma can destabilize the visual world around us and affect our ability to know where we are in space in relation to objects around us.  This system can affect our head and neck positioning, posture, balance as well as overall cognitive functioning.  To make things simple—if the visual system is affected there can be symptoms noted that seem to be non-related to vision.  A large percentage of the visual pathways integrate into reflexive systems along with autonomic systems.  They also have integration with the vestibular system, auditory system and even the proprioceptive system.

To have a stable, accurate visual world it is also imperative that the integration between these systems is fine tuned and coherent allowing for vision to be dynamic, flexible and adaptable with changes in sensory input that we have to deal with on a day to day basis.  When these systems are not fine tuned this leads to a massive use of energy which takes away from higher level cognitive processing.  In my mind, having a neuro-optometric assessment by a trained functional vision provider is needed in addition to a functional neurological assessment by a provider who has training in traumatic brain injury rehabilitation.  Furthermore, both the functional neurology provider and the neuro-optometrist have in depth knowledge of that pathways that are involved in traumatic and acquired brain injury and our therapies are complimentary.  It is not uncommon for a functional neurology clinic to immerse a patient into a week to two week intensive rehabilitation program to attempt to build plasticity in impaired neurological networks.

Remember many of our patients have already been seen by other providers including vision therapy, vestibular rehabilitation, physical therapy, chiropractic, upper cervical chiropractic and other alternative heath care modalities.  We work on first stabilizing autonomic function—meaning therapies that are aimed at improving perfusion into the brain and into the gut—integrating all sensory modalities to have a functional cohesive binding of sensory information centrally in the brain to help build appropriate maps of where the body is in space and where space is around us.  For more information on our therapies please read https://www.huffingtonpost.com/entry/how-functional-neurology-helped-improve-my-quality_us_587642d4e4b086a337b6f559

We often see patients 3 times per day for 45-60 minute therapy sessions to build plasticity and stability in these systems.  This helps stabilize patients to allow them to be able to be functional and continue with other therapies that are much needed after our care.  We help patients break through the plateau during our intensive. Specific therapies are developed for each individual based on what circuits are dysfunctional. Therapies with specific frequency and intensity of sensory stimulation are used taking into account patients metabolic threshold. We find the perfect amount of stimulation that a patient can handle and do not push them past their limits.  After their intensive is done, we provide them with at home exercises as well as nutrition advice.  The nutritional advice is based on comprehensive lab work that assess for underlying nutritional and metabolic dysfunction.  By looking at underlying issues we are able to keep the patient moving forward with their progress. Many patients choose to continue working with our offices after their initial immersion into care.

After our intensive therapy in my office we commonly work with neuro-optometry providers with a speciality in brain injury and post trauma vision syndrome. Many times patients have already been seen by ophthalmologists and optometrists which have ruled out underlying pathology.  These functional vision providers can help fine tune the visual system with lenses, prisms and other neuro-vision rehabilitation techniques now that our patient is more functional with stable autonomics from our intensive program.  In my mind, we are locating the circuits which are dysfunctional and improving these systems with our therapies which allows other forms of therapies to integrate more effectively.

For example a convergence insufficiency may be due to an impaired proprioceptive feedback from the cervical spine following traumatic whiplash.  Therapy may involve manual therapy and vestibular-proprioceptive retraining of the cervical spine to improve integration in the cerebellum and midbrain which could be the possible neural site of dysfunction in accommodation and vergence.

With the help of specific prisms or lenses the patient is more functional and can continue to improve now that the central neural site of dysfunction has appropriate integration with the cervical spine, proprioceptive feedback cerebellar activation into the central circuitry. In hopes that continued work doing specific exercises a long with neuro-optometric techniques specific that individual plasticity can occur in the brain.

Another example would be dysfunction in pursuit eye movements.  Pursuit eye movements are the type of movements that allow the eyes to follow a moving target.  The circuitry is complex and involves the brain stem, cerebellum and cerebral hemispheres.  An area in the brain stem involved is the neural integrator which includes the NPH and the medial vestibular nuclei.  The medial vestibular nuclei integrates with the cerebellum and the peripheral vestibular structures.  If neuro-vision therapy with pursuit exercises is not fully integrating these movements back to recovery then utilizing the proprioceptive system and combining a body based movement with activation of the spinal musculature- with a vestibular ocular exercises could be enough to drive plasticity in the brainstem to help improve the gain of pursuits, decrease saccadic intrusions reducing retinal slip and improve the pathology.  Having an in depth understanding of the neuro-circuitry is what allows these types of practitioners to make improvements in symptoms.  The visual system is so complex with its integration with other sensory systems.  This integration occurs to allow us to know where we are in space which affects body positioning and motor output.  This integration translates into maps of ourselves internally to allow us to shunt blood to regions that needs it.  The aspects of dysautonomia if left unaddressed after injury could be the missing piece to recovery.

Both of the above scenarios benefit from combined collaborative care between chiropractic functional neurology and neuro-optometry.

Multiple regions of the brain can be injured with concussion and mTBI.  As a functional provider it is imperative to be able to assess the complex integration of our sensory systems which allow us to know where we are in space.  With sensory input dysfunction there can be changes in multiple levels of the nervous system ranging from optical, ocular motor, accommodative, binocular visual system and early visual processing along the pathways from the retina to the thalamus, superior colliculus, hypothalamus and into the primary visual cortex.

There can be injuries in the pre striate as well as extra striate regions of the communication between V1 and the dorsal and ventral stream systems of the parietal and temporal regions.  With a bedside examination without expensive equipment and with in depth knowledge of these sensory systems the provider can begin to assess these systems and develop strategies for activating regions in the brain to help build plasticity and integration.

Many of these visual pathways are involved in non image forming visual systems which integrate into the autonomic regions in the brainstem and higher cortical integration of increasing complexity moving from the posterior regions in the cortex into the frontal lobes.

We assess various eye movements and link these back to the regions of the brain where they are integrated.  If there is injury to the frontal lobes there may be a deficit in saccadic latency from dysfunction in fronto-pontine activation.  If there is saccadic hypermetria there may be dysfunction in the fastigial nucleus of the cerebellum.  Based on our findings and signs and symptoms presented in front of the examiner, they will begin to develop techniques that may be novel for that specific individual in front of them, to improve function of circuits and improve the quality of life of the patient.   It is not just good enough to know the neural processing and pathways.  It is imperative to be able to to develop rehabilitation strategies based on  observations and integrate these findings into a rehab system for that individual.

In summary, many patients that present to our offices are still suffering from lingering symptoms even after receiving vision rehabilitation, vestibular rehabilitation, cognitive behavioral therapy, manual therapy and have tried multiple medications and supplements for their symptoms.  Many functional neurology offices work with other providers as a interdisciplinary team and can collaborate to ensure that the patient is receiving other forms of therapies that may be needed.  We can not perform all of the therapies that may be needed to help patients achieve full functional status, but communication and speaking a common language with other providers is what we aim to achieve in our clinics. In my office I have seen multiple patients improve with work we do in addition to our collaboration with neuro-optometric providers https://noravisionrehab.com/

Dr. Jeremy Schmoe DC DACNB

mnfunctionalneurology.com

Minnesota Functional Neurology: Center for Brain Health

 

The New Science of Concussions

The Brain Injury Symptom My Doctors Didn’t Understand

https://www.huffingtonpost.com/entry/the-downside-of-functional-neurology-after-brain-injury_us_5a008433e4b0d467d4c226e0

 

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