Dr. Helena Esmonde  00:00

And what's really fascinating is that both enjoyment and just having a dual task, meaning something else to think about, time and again, has been shown to improve balance better than just like I'll call a more straightforward balance activity by itself, as well as to reduce dizziness.

 

Dr. Ayla Wolf  00:18

Welcome to Life after impact, the concussion recovery Podcast. I'm Dr Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go to resource for actionable information, whether you're dealing with a recent concussion, struggling with post concussion syndrome or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. All right. Dr Helena esmondi, thank you so much for coming on to the life after impact podcast.

 

Dr. Helena Esmonde  01:25

Thank you so much for having me. It's really a pleasure to be with you.

 

Dr. Ayla Wolf  01:29

Well, I have been a big fan of all of the content that you put out through vestibular first, which is a company that you are the founder, the creator of, and the you have created, these infrared goggles, which many people are maybe familiar with them, but I think you really brought a particular design to market that was affordable for many clinicians that had small clinics. So thank you for doing that.

 

Dr. Helena Esmonde  01:57

Oh, well, it's, it's, it's funny, because it's not only is it my joy to do so, but I have to say that it was really initially a very personal thing, because I had worked at a clinic that had inferred video goggles, and before that, I worked at a hospital that didn't. So I was like, All right, I know the difference from my own experience, in addition to what's in the literature, I'm not going back. And then I needed to change jobs for family reasons, and so I found a clinic that was a great fit. But of course, they had never had a therapist, of course, didn't have goggles. And I said, Well, this is a must have. And they're like, Well, how much are they? And so I, you know, priced out different choices, and they're like, none of these can we afford, which is fair, because I was going to be part time, especially, and and I understand that. So luckily, my husband is a tinkerer. He's been taking apart VCR since he was three with his dad and such. So he's like, I think I can make you a pair. I'm like, go for it, like I'm in and luckily, he was able to repurpose a VR goggle for our first kind of prototype version. And we had no intent to have a medical device company, but then I had other clinician friends of mine saying, What are you using? Can you make us a pair? And I'm like, well, not going to make a bunch of kind of not that ours were unsafe, but just, you know that initial prototype was not anything officially FDA cleared or anything like that. So, you know, my husband, I sat down, we said, All right, are we going to do this? Like, gonna be a thing? Like, can this work like, you know, like many of us over the years that maybe have gone on, on a limb right in various times of life for personal or professional reasons. And so this is my limb, but so far, it's holding steady. So great gratitude for that and to help so many people is always been my life goal. So it's a pleasure,

 

Dr. Ayla Wolf  03:49

amazing. Well, the goggles I've I've had with the kind of the initial prototype that I then had to, like, send back in once the other prototype came in. So I've been with you from the beginning. And I also, you know, I was so excited to have you on the show, because you are an absolute expert when it comes to Vestibular Disorders, which is, I think, one of the most complicated aspects with people who have concussions, but also people who don't too I can't tell you how many people come into my clinic and they say, I've got dizziness or vertigo, and they've been to numerous doctors, and they don't have a clear diagnosis. They don't know if it's coming from the peripheral vestibular apparatus or if it's a central issue. They don't know the difference. And so there's still so much confusion in this field, and I think you're really shedding light on how to do proper diagnostic workup. And so I wanted to talk to you. You know, in for our listeners who are dealing with concussions, who maybe also are dealing with dizziness, vertigo, rocking, swaying, bobbing, all these symptoms and disequilibrium, maybe we can kind of talk through some of the. Work that you're doing to try to help people figure this out, so that they're having clear diagnosis, diagnosis which leads to obviously clearer treatment strategies.

 

Dr. Helena Esmonde  05:09

Absolutely, absolutely no. I'm totally empathetic. That's the right word when I haven't had a concussion, but I certainly have had many patients, unfortunately, who have dealt with this, and there's no question that, because concussion involves the brain, which I think everybody's on board with that, it becomes extremely challenging, because there is a lot of individuality to our brains. So I have you know patients certainly that will say to me, Oh, well, I feel this set of symptoms that must mean this, or does that mean this? And I'm like, I care about your symptoms because I care about how you're feeling. But very few symptoms give us a very clear directive of what is the root cause of that symptom is that the brain talking, which is how I kind of characterize like sensations that really come from the brain, perhaps struggling to process sensory information, things like that, or, like you said, is it the peripheral inner ear, vestibular system, you know, also having an issue that could be related or unrelated to the initial trauma of the concussion, and then other secondary issues that can come up post concussion, such as post concussion migraine, which is a pretty challenging situation for most patients if they have no history of migraine, in particular, because then they're really this is new territory, and the really challenging fact that there are types of migraine, essentially, that do not necessarily involve much in the way of headache. And this, I find that my patients get really confused by because historically, I think migraine and headache have pretty much been used synonymously. But in fact, it's not so clear cut, although certainly some people with migraine do primarily have headache, but because I like to call migraine the cranky brain, it's just sensory processing challenges and hypersensitivity to sensory stimulation, and because people with migraine, again may not have the same triggers or things that kind of tend to kind of make the brain more cranky. It can be confusing, because, like, well, you know, I read that you can't drink red wine, but I can drink it, and I don't feel any different. Well, that's just not it's not it for you, but it's both the cool thing about the brain, but also the challenging thing from like a treatment perspective, even more so than blood pressure, which I understand from physicians. Also, sometimes you have two patients with high blood pressure, and one medication works well, and another patient doesn't respond to that. So I think looking at our our individuality, of being human again, is super cool, but also from a medical standpoint, super challenging, absolutely.

 

Dr. Ayla Wolf  07:59

And you know, I just got an email in my inbox from from you the other day that was talking about a typical Benign Paroxysmal Positional Vertigo. And it, you know, I just really struck me of how neurology is really the field where it's it's almost like, when someone comes in and they fit a textbook description, you're kind of like, Oh, thank you. Because so often people come in and they don't fit these textbook descriptions of what you learn and what you would expect to see, and then you've got to figure your way through that. And so neurology, somebody once said, like biology is messy. I feel like neurology is even messier.

 

Dr. Helena Esmonde  08:39

Yes, yes, yes, yes. And so again, I'm so empathetic to the patients, because on their end, you know, understandably, they're like, Oh, the advanced science we should, you know, have all these answers. And I think that is becoming more true than it ever has before. But yet, because of the complexity individuality of the brains. We're definitely not all the way there. You know, whether that's a given treatment, is this going to help? And there has to be, unfortunately, sometimes some trial and error. And so, you know, I always try to establish, like, a really kind of open communication with my patients. I set certain parameters, like symptom level. I tried very hard, if we're going to try some different ways to stimulate the system, to try to work as a better team between the eyes and the vestibular system in the brain, or what have you, that I don't want the symptoms to increase by more than two units from baseline. So it comes visited a two out of 10 dizziness. I don't want their business to exceed a four out of 10 as we're trying to train the brain to process movement better. And, you know, I'm always trying to look at the big picture. You know, if we're not making progress, what maybe hasn't been assessed that needs it, and it might not be something that's my specialty, and that's okay. I really believe concussion in particular, and I'm sure you've had many guests on that are of different discipline. And for that reason, you know whether they need neuroautometry, you know, maybe specialized glasses, prism lenses, things like that, might be great for one patient, not needed for another. So you know is one person really more neck issues than anything else. I've definitely had patients that I have provided neck care, but also gladly handed patients off to me, folks with the chiropractic world, to provide, you know, more specialized manual care than maybe would be appropriate for me to do, you know. So I think that if we all kind of are comfortable in our disciplines and our training and always trying to learn, we can continue to help these patients with the I like to say layers to the onion that are often present, you know, because once we just get stuck where we just can't make progress, because something really needs to be addressed, and that could be emotional support is needed, because there's the brain also processes emotions. I try to remind patients of that, because sometimes they're like, Why do I feel so irritable? Or, why do I feel so, you know, frustrated I normally am so like, you know, can kind of handle, you know, like, what's going on in my life, even if it's really chaotic, and now it's just like, the littlest thing sets me up. I'm like, you have to recognize, like, yes, we have some management of our emotions and whatnot, and some control over them. But ultimately, I remember hearing a talk a while ago, and it really stuck with me about a patient who had had a concussion, and, you know, was significantly felt like they are, and the family felt that way more irritable. And you know that, you know it was literally years, like 1015, years before they got adequate care for the emotional piece. And once that happened, it was like a turning point for, like, all their other symptoms, which doesn't mean that that's always the answer, but again, like, I think it's good to try to look at like, what piece or pieces maybe need to be addressed? Is it sleep? That's a big one, right? So, you know, when I think about dizziness, you know, I like to say the crystals putting them back. It's like the easy part. Like, I just gonna play the game with the plastic ball and the plastic maze and move you around. And, you know, use your eye movements and tell me where the crystals are out, and I'll put them back. And, like, really, if you're well trained in that, like, that is straightforward, because it's a physical issue. It's a mechanical problem. I just got to put the crystals back. But when it comes to these other layers, the brain layer, you know, and how long we've had symptoms, that means the brain has kind of learned that when I turn my head right, that means dizziness. And so how we kind of have to retrain that, for example. And so, you know, I'm just very passionate about, like, I attribute it to being at grad school at Marquette University, and their motto is cura personalis, which in Latin, it means care for the whole person. And I know that those in the Chiron and functional neurology world also are that way. So one reason I think that what you guys do is also super cool, because you're willing to look at things like nutrition and, you know, whoever else might be kind of playing in to, you know, what's going on with the symptoms, and how can we help?

 

Dr. Ayla Wolf  13:12

Yeah, and now I imagine, in your practice, you are obviously looking at people's eyes all day long with these infrared goggles on. And so people who aren't familiar what we're talking about are these Gog almost they look like scuba. Got scuba goggles, but when the patient puts them on, they can't see anything. They're in the dark. But the little infrared cameras allow us to look at a computer screen and see the eyes. And so talk a little bit about this idea that when somebody has their eyes open and they can fixate on a target, that can inhibit a lot of pathology, it can shut down a lot of pathology as soon as you put the goggles on and somebody cannot fixate on anything, we kind of get to see what this connection is between the eyes and the vestibular system, and sometimes you can see some pretty immediate pathology. And so talk to me a little bit about what you do often see, or what it is that you're you're either looking for or observing when you put pop these goggles on and are looking at somebody's eyes for kind of the first time as part of your evaluation.

 

Dr. Helena Esmonde  14:21

Absolutely, yes, yes. I like to joke that it's all the eyes looking, but not all the romance. You know, again, it's really cool that there's something called the vestibulo ocular reflex, which is this great, fastest reflex in our body, connection between our inner ear vestibular system and our eyes, and that is mediated at a brainstem level as well. So we do have the brain in the game. So we've got all three there, and this is really a helpful reflex from a vestibular assessment standpoint and ocular motor assessment standpoint, because when there's different pathology. Is present, whether it's inner ear pathology, brain pathology, we can get certain eye movements that some are spontaneous just sitting at rest. I can see something. Sometimes I can provoke it with something like I want you to look with your eyes to the right or left, so that's kind of a gaze evoked type test. Then I can do vibration induced nystagmus test, where I put a vibration tool on the mastoid behind the ear and stimulate the peripheral system this way. And there's a few different things I look for, and depending on what you might be going on at that level, we might see a different direction of eye movement. So we're just looking at what type of movement. Is it persistent, or is it kind of brief? We're looking at the direction that the eyes are going, and we're looking at everything. So it's not one test by itself that gives me all the answers. I really have to do a full exam to get the full picture, which I know some patients find frustrating, because they often comment online on our posts on social media. Well, you know, I feel dizzy when I turn to the right. Does that mean that I have a problem in my right ear? And unfortunately, I don't know, because until you get that full exam from someone who's trained, you know, turning your head to the right and feeling dizzy could be due to a neck issue, vascular issue in the neck. Blood flow not going right, something going on in the right inner ear, something going on in the left inner ear, but it just happens turning right. Kind of got things moving on the left, something going on with the brain processing, movement going that direction. So the symptoms, again, although I want to hear about them, because sometimes they give me a clue by themselves, they're not particularly diagnostic, and yet that's what the patient's feeling all the time. So they're pretty aware of the symptoms, which is understandable, but also, again, not as helpful as I'd like. So we're going to do different positional tests, things like that, to stimulate the vestibular system in the brain in different ways and see how the eye movements respond. So there's normal responses, and then there's abnormal responses. And the types of abnormal response could say, yep, everything's saying that the brain's not processing well. Or I see one eye as soon as you're in the dark, it deviated laterally. That means their eyes are having trouble working as a team. So, you know, again, there's some treatment I might apply for that. Then there's some referral I might do for certain cases, because it might need more intervention than I have available as a physical therapist. So, you know, it's, how do I summarize years of training. But that's what we're doing. We're we are doing a science. It's certainly not exact, because, again, individual variation. So the good news is there are usually patterns. So if I skip to see kind of a patient who has a bunch of eye movements that are fitting a certain pattern of crystal, being at a crystals, being at a place in the inner ear, which we all have, these crystals, they go in the wrong part of the inner ear, versus, you know, this pattern is really fitting someone who has a mixed presentation, where they have clear, you know, issues with coordinating their eye movements and things like that, which is more of a brain level issue, but then also they have signs of damage to a vestibular nerve on one side. So sometimes, unfortunately, someone has multiple issues, which might have happened at the same time, or might be, you know, happen one thing happened because you had an ear infection as a kid, and that's just going to affect maybe your progress, and what kinds of Rehab we need to apply to help get everything back on track?

 

Dr. Ayla Wolf  18:29

Yeah, yeah. So the kind of take home message is, you know, for for people listening, is that your your symptoms are not necessarily always the clear path towards the diagnosis, you really need to go through all the testing, both with your eyes, kind of, without fixing, fixating, and then also, obviously with fixation and looking for differences and looking for normal versus abnormal responses to things, to really just allow the clinician to go through that differential diagnosis of it isn't this, it's not that. It's not this, but this, it is this,

 

Dr. Helena Esmonde  19:04

right, and to understand things can change. So I've certainly had a patient post concussion who had no signs of crystals being in a place, definite signs of, you know, some difficulty with eyes working as a team, and things like that. We were applying rehab for those things. Patient was making good progress. We're all happy. And then we're about four weeks in, and she comes in, she's like, feel different. I feel off, yes, very, very vague language in this case, but that happens, and that's not to judge that, and that's what's her physical experience of what's going on. So I think to myself, Okay, I'm going to do some screening and compare to the first day anything different or the same. So I didn't do my full, full exam from the first day, but I picked out some key elements that I thought could be involved. Okay, nope, that looks the same. Okay. Goggles on, you know, your brain, again, wants to suppress some of these abnormal eye movements to try to make you feel less symptom, which is very nice at the brain, good job. But. As a clinician, I need to see these eye movements. I'm gonna put you in the dark so I can see them better, so they don't get suppressed. And actually, the patient did end up having a certain type of BPPV in the horizontal Canal where it can get stuck. So it's kind of a stubborn type, notorious for being more difficult to clear. So you know, some BPD will actually clear itself, which is nice for the patient. They don't necessarily always. Necessarily always need a maneuver. But in this case, that was unlikely. So we were able to apply, you know, proper treatment for that, and have her rest and then retest after the treatment. And that eye movement that I was seeing that was telling me that otoconia, we're stuck, that went away, and so that's an indication that we've cleared that. So it's a really nice kind of before and after testing that we can do in a case like that. But to speak also to some patients feel like, oh, you know, I feel these symptoms. I must have crystals out, unfortunately, again, symptoms not always being a good report or a good helper here, you know, there are many patients who are doing maneuvers, or even having clinicians do maneuvers on them, and because the crystals aren't out of place, it's not harming them, but it's not going to help the symptom. We have to, again, always be trying to look back to one or more root causes of why we're feeling this way, and kind of work on those. And some of them take a lot of time, unfortunately, especially brain changes, can can take time. If you ever tried to learn Spanish or any foreign language, you'll know that. You know, the brain is a wonderful learning machine, but it can take time to make changes. So

 

Speaker 1  21:32

yeah, when you break up a good point, there are lots there's lots of information now online about how to do different at home maneuvers, if people have a Benign Paroxysmal Positional Vertigo, and I know you guys also have some great handouts that you give to people, it seems like there's like a new maneuver coming out constantly. So what's up with that?

 

Dr. Helena Esmonde  21:54

Yeah, no, that's a great question. So, you know, it's interesting, because although I totally understand why patients or people with symptoms of various types. Might look at our material from vestibular first or follow us or make comments. You know, the reality is, I do build what we create primarily with clinicians in mind. And as far as the number of maneuvers, having tried to move crystals back where they belong for 20 years, I have learned that many respond to a couple of my kind of key, kind of well studied maneuvers, certainly a modified, aptly, very popular, and we know that from multiple studies, it's between 91 to 93% effective for a certain type of BBB, which is the posterior canal, where It's floating canal with ISIS. So I use that maneuver. But there are patients where that's not going to work. First of all, because I said 91 to 93 not 100 so even if it is floating and everything fits, as far as like it should work, I think this is a maneuver for this issue. It's just not, you know, because the particular person's anatomy, shape, or whatever it is, it's not hitting it. So this is where many clinicians and researchers, I would say, usually they're both, if they're doing research on PvP, many of them are also clinicians, but they're researchers. And so they'll say, Oh, what if we try this variation? Or what if we tried, you know, a totally different approach, you know, in case that the canal is shaped this way or angled this way, and the anatomy is a little bit different, which there's multiple studies on that showing that there are, there is some variation between individuals. So this is part of why we need different maneuvers to address those. And then on top of all of that, we have, again, individual patient bodies. So some patients lying on their back and rolling a certain way, it really hurts their shoulder to lay on that side. So I can always go through my mental catalog of maneuvers, which I don't have all the memorized, but I'm getting there, and I'll say, Oh, I could try, you know, the universal maneuver, because then we don't have to be on that shoulder for more than a minute. Or, you know, something where I think it's going to work for that individual person's, you know, body type, or if they're pregnant, or whatever it is that might change. What I choose to consider that, and not least of is a cervical range of motion. So you have people in hospitals, they're in collars, and then we even have patients who just have very limited range of motion in their neck, fusion, from surgery, whatever it is, right? So I might have to kind of change up how we're going to move to try to get these crystals clear. Because I don't have the interesting and cool but very, very much large machine where you can put someone in a chair and bring them all directions, which I think could clear crystals really well. But, you know, some patients might also not tolerate that motion as well. So it's always pros and cons to every choice. And I try to give a lot of maneuvers so that clinicians can, as they grow more and more experienced, say, oh, like, oh my gosh, I have this tough patient I would normally try. A, B or C maneuvers, but none of those can work. What else is out there? So I like to provide backups and as much information as I can about efficacy, because some maneuvers are known. You know, over time, as we get more research to be kind of more effective. So as I stay bang for my buck, I want to and really for my patients buck, I want them to, you know, get the best outcome possible if we can. So I'm trying to choose those maneuvers that you know are upping our odds of getting clearance with not having to do 10 maneuvers, because that's not fun for anyone. So, you know, we're trying to be efficient as well. So there's a lot of variables in this one area of just clearing crystals that I like to take into account. So I know, in the end, hopefully more and more research, there's probably a couple maneuvers that'll kind of just fall into like they really aren't useful enough, and they don't really fit any cases. You know, these other five or six or 10 work so, you know, but for right now, it's still, there's only a few maneuvers where we have multiple studies. So the rest, we're still trying to sort out what's going to end up being the best for certain cases, or even just in general, the best efficacy and things. So I'm open minded,

 

Dr. Ayla Wolf  26:10

yeah, yeah. And I know in your clinic, too, you use a lot of really fun and creative kind of therapies to help people in terms of rehabbing their balance and their their trust in their own ability to just move through the world. I think one of the ones I loved was you had different colored felt on the floor, and then you toss little silks at people. They have to, like, catch the yellow silk and then touch the yellow felt on the floor. Yes, I love that. And I went out, I bought, I had to buy, like, the silks, and they're not that expensive. It's pretty good, yeah. But I was like, Oh my gosh, I love that. What a fun thing to, you know, just have somebody in, like, a safe environment be able to practice, you know, some hand eye coordination and then having to move their foot according to the color. So I just, I love your creativity that you bring to your clinic. And I'm sure your patients probably end up having fun, as far as

 

Dr. Helena Esmonde  27:03

they like, is this like some of them, you know, my older gentleman in particular, they'll be like, I'm not a kid. But then they're like, laughing as they're playing. I'm like, I know. But what's really fascinating is that both enjoyment and just having a dual task, meaning something else to think about, time and again, has been shown to improve balance better than just like I'll call a more straightforward balance activity by itself, as well as to reduce dizziness, which I'm super big on. For many of my patients that have some learned or other brain type of dizziness, will say crystals or crystals. We got to move those. But you know, for a lot of the other dizziness out there, or from inner ear vestibular nerve damage, even, you know, we do want to be moving our head. We want to kind of getting some stimulation. And again, used to still following my two unit rule. But you know, I have found that if I give a patient a simple Okay, I want you to just kind of turn left and turn right and grab, you know, just a cone, and it's kind of boring. You know, all my dizziness is up. But if I'm, like, engaging with them, and we're like, All right, now you got to put the ring on that cone. Oh, nope. That's a yes. That's a no, go, no go. We're like, Oh no, no. You can't put it on that cone. And, like, all of a sudden, it's like, 15 minutes later, and they're like, Oh yeah, I'm not maybe when they stop, they're like, I feel a little more dizzy, but like and so it's both in the research and in my personal experience that the more I can get creative make it salient, which is like, how is this can be similar to some issue you're having, whether it's, you know, a task at home, like moving laundry into the dryer from the washer, or it's something you enjoy, like, oh, I want to be able to bend down and, you know, pick up that fish hook I dropped when I'm going fishing or whatever. So just trying to kind of figure out how to relate that to also their goals. I always tell my patients that your goals are my goals. So I really want you, you know, to meet those. And so that's also kind of part of when I think of activities, when I'm trying to get out of it. So there's really a lot of pieces to, you know, sometimes it's just something fun, but really, honestly, there's usually several reasons I've chosen to try that with somebody. And, you know, not everything's 100% win. Like, sometimes I'm like, Yeah, okay, we're done with this one. Let's Great job. Let's move on. And that's okay, you know, because you're you are trying to, again, individualize it, which means you're not always going to hit the mark right out gate, but just pick something else and move on. And

 

Speaker 1  29:27

that's good, yeah. And you know, you mentioned, like, the laundry thing. I have so many patients that say, Oh, I get really dizzy when I have to unload the dishwasher, or I have to move the laundry, or I have to bend over and put water in my dog's bowl. It's like, it's those daily activities that are those triggers. And so the more you can kind of recreate similar types of things in the clinic. And then also, like you said, bring in a cognitive component where they're also having to focus on something else cognitively while they're moving through these types of things. Yes, yeah, it's so important for people to start to have that trust that they can now move through life without feeling dizzy and anxious about it,

 

Dr. Helena Esmonde  30:10

right? And and then I like to have my bridges. So a really big bridge that works really well for anyone who has visual ability is to fix their gaze as they move. So a lot of patients at first need that bridge. So if we're going to bend down and come up, instead of just bending down and coming up and hoping that if we keep repeating that, it'll feel better, sometimes it helps to both slow it down and then also to say, Okay, I want you to look at that fire extinguisher and then the doorknob and then that black spot on the carpet that we probably need to clean. And you know, as you come back up, same deal. So you're really allowing the vision to be a bit substitutive, but in a helpful way, to help the brain. Because otherwise the brain, if the vested system, is having trouble, whether it's on a brain level or an inner ear level, it always says, Wait, where are we? And the wait, where are we feeling is probably going to feel like dizziness or off feeling. And so if we can kind of give that vision to be a little bit helpful, and say you're here, you're here, you're here, the brain's like, oh, up and down. I think I know where we're at. And what I find is often, then the brain is able to kind of re wear it. So so eventually we don't need that bridge, you know, we'll do less spots, or we can move more quickly with just one or two, you know, kind of points to look at. And, you know, ice skaters do this, and if you guys know when they're spinning, they kind of fix their gaze. So it's, I think one of my jobs as a clinician is definitely to try to figure out what bridge do you need. So it's not just, oh, just do the movement, and hopefully it'll feel better, like it's really like grounding is another big one. Like, feel where your body is, plant your feet really using our appropriate section or somatosensory as much as we have it. Hopefully, you know, to again, give information the brain say, Ah, this is where we are. And there's really cool research that comes out all the time about the brain and how a lot of folks who have brain issues and even inner ear issues that are creating dizziness is it's craving good sensory information, because the vestibular system is trying to heal, but it's just not there yet. You know, we want to do some sensory re weighting, which is really kind of using our vision and like, most importantly, our body and our body information. But I allow both, because in the beginning, we just got to use what we got, and then we can start to maybe decrease visual dependence, you know, with some activity, maybe eventually eyes closed. But I mean, not right away. Like there's a lot of ways to bridge to eyes closed sunglasses. I mean, there's so many choices. I'm always putting up stuff about that stuff, so hopefully people pick up all my tips. But yeah,

 

Dr. Ayla Wolf  32:39

yeah, I'm always amazed at sometimes, how powerful it can be just to, like, reach out and just kind of hold on to somebody's ankles for a moment, and then all of a sudden they're like, oh, okay, yes, I do have feet. I am grounded. And that takes away, or, like, takes their symptoms way down by just reminding them, like, you've got feet, you've got ankles. Like, yes,

 

Dr. Helena Esmonde  33:01

don't forget Absolutely, yeah. So we can, we can use our hands to help guide, and I've also in some patients, that actually decreases 13 this not everybody to put a little bit of we have, like, cuff weights, which is weight that you don't need to hold, but you can loop around a wrist or an ankle, and sometimes just a two pound cuff weight on each wrist or each ankle. I found I have one lady who is a pretty involved vestibular migraine situation, and she can't walk her dog, really, without the cuff weights on her wrist. But as long as she wears those two pound cuff weights, she still has some symptoms, but they really seem to kind of give her body a little extra somatosensory input that the brain's like, Oh yes, I got this. You know, maybe she won't need them forever, and that would be great. But for right now, it's a wonderful way so that she can at least get outside. We know that being outdoors really good for the brain, you know, they call it like the forest bath or whatever. But like, you know, just kind of getting that green nature, oxygen, sunshine, vitamin D, all that stuff. You know, we try not to have people kind of be stuck in a cave in their house, because, you know, the stimulation, and if she's light sensitive that day, she's got, you know, her special lenses now that really help her to, like, have that not be a big stimulant for her brain. So it's kind of finding these ways to kind of hopefully bridge, you know, yes, we'd love to have no symptoms and have nothing bother us, but, you know, we might get there, but we might take some time with that, or maybe we always need a little bit of help, and I think that's okay.

 

Dr. Ayla Wolf   34:29

Maybe give some advice to people if they're looking for somebody to help them with their symptoms. A lot of times, you know, patients are kind of at the mercy of whatever insurance company they have, or who's in their network, and all those things, but maybe you can just give people some ideas of like, what questions to ask when they do call and look for somebody who might be a good fit when they're dealing with these kinds of vestibular issues.

 

Dr. Helena Esmonde  34:54

Absolutely. So I'll start by saying there's a couple great resources for the US and. There are some for other countries that if people need that, I can reach out and we can let them know what's there for some countries, not every country, unfortunately, but in the US, it's the easiest, because I definitely have those memorized. So one that's just about to be released is owned by myself and my husband. It's called the Z Care Network, and essentially, we have a questionnaire that was created by Mayo Clinic, and it's pretty detailed, but it allows folks to know kind of what they should do next. So like, for example, the patient fills it out, and part of their symptom profile is a lot of hearing symptoms. It's probably going to recommend pretty early on, you should have a hearing test if you haven't already, so it's going to help kind of suggest some kind of next steps. And sometimes that's like, oh, you need to be matched with someone who really knows how to check if you have crystals out of place or not, because your symptoms sound like it might be that. Now, if it's not that, at least the person can screen that right? So that's the idea. And so we're about to do a Local Launch here in the Philly area, first, make sure it works well, and then it'll be launched naturally nationally. So if anyone wants to learn more that's Dizzy dot care vestibular.org which is the Vestibular Disorders Association, also has a find a provider, so folks can go on there, put in where they live, and it'll suggest clinicians Now, unfortunately, sometimes it's like the next closest clinician that's on our network is, you know, 50 miles away. So that's not ideal. There are sometimes telehealth options, which is also good, particularly for certain issues where the guidance the person could benefit from the most doesn't need to be as physical. So that's why it's still worth looking to see on these networks whether they have anyone who's doing how the health that's licensed in the state that you're in, and a lot of PTS now, at least, can have like, called compact, which means, like, multiple states recognize the license of the other state, which is cool. So those are definitely two options off the top of my head, on finding a trained clinician. And then the questions you can ask are really to me if you have had symptoms for a while and have seen several practitioners, which unfortunately is the case for several patients I've seen post concussion in particular. I think if you know you're you're not the easy one, you're not the one that, like, kind of got better on their own or with just, you know, the first practitioner you saw on some time, and a little bit of, you know, rehab, you got all the way better. That's awesome. For those who are not in that bucket, we're not that lucky. I think you want to look for someone who has quite a bit of experience. So I'm going to say experience isn't really age, but it's definitely years of practice. So you know someone who has 20 years of practice, chances are they at least have seen more patterns. And so that's like a piece of the puzzle to me, for a complex patient, you know, I don't know what that line is, 10 years, 15 years, 20 years, you know, just see what you can find for sure. And then the second thing is, if the clinician says, Oh, I absolutely can fix you, no question, you probably should step away, which sounds like odd. Yes, that's exactly what I want to hear. But unfortunately, that's usually an indication of possible, kind of over promising.

 

Dr. Ayla Wolf  38:34

But I would agree with you, like, if somebody, if a clinician, hasn't even evaluated the patient, and then they're acting super confident they can fix them. I would also say that's probably a red flag. It's one thing to go through a comprehensive exam, yes, their understanding of what you're seeing, and then say, Okay, I'm pretty sure I can help you. But when you're telling when you're making those promises, before you've even seen the person that, I would say that's a bit of a red flag,

 

Dr. Helena Esmonde  38:59

yes, yes. And so a person who's saying, look, let's take a look. Here's what I know. You know, this is what I'll rule in or out. You know, based on what I see, I think it's this or if I was you, I would go see this clinician next and, you know, like, that kind of language is much more reassuring to me, because it means, you know, I kind of can hear them problem solving, like, what are they seeing? What are they thinking? You know, this is what we'll try, you know. And so you really have, like, a good sense of, like, Why, the what and the why, you know, yeah, well,

 

Dr. Ayla Wolf  39:33

and you know, you, you brought up acupuncture too. And what I always say to people like you, you need to choose the right tool for the job. So when someone's coming in with BPPV, acupuncture is not the right tool, like you need a maneuver to correct that. But if somebody's dizziness is maybe coming from their neck, well then yes, maybe acupuncture will help with that dizziness. If you're working on their neck and improving their joint position, sense, or

 

Dr. Helena Esmonde  39:57

is it stress? Because you have, you know. A stress related dizziness that might be a piece of a migraine condition. And so your major trigger is stress, and you find things that you know really relieve your stress. And you know, as much as I think meditation is great, some people either struggle with it or this just not doesn't seem to really kind of fit the bill for them, like it's good to kind of look at what are really my options that are safe and reasonable, and in my budget and so forth, you know, kind of fitting those variables, hopefully, you know, and that's kind of where I think the problem solving comes in. And the other thing I'd say is that having a clinician with certain tools I do think is important. So, you know, I know that I own a company that makes infant video goggles, but it's not because I sell them, it's because the research is there to say that there's eye movements you would miss in room light. So if you want a full vestibular exam and the clinician does not have goggles for whatever reason, maybe they couldn't have that. You know, even though I've tried to make them more affordable, maybe it's still not in their budget or what have you. I'm not saying don't go to them, but just understand that their information set is going to be more limited. And so again, especially if you're a more complex patient, maybe that's not the right fit for you. So it's just kind of looking at those kinds of variables and saying, like, okay, like, what is right for me?

 

Dr. Ayla Wolf  41:15

Yeah, absolutely. I mean, I just had somebody come in this week who's had vertigo episodes for, I think, four years, and she had seen a PT, and she had seen a nurse practitioner, and neither of them had infrared goggles, and so they kind of did their exams and were like, well, you don't have BPPV, and then kind of left it at that. And then as soon as she came in and I popped the goggles on, she had a continuous ripe eating nystagmus. And, you know, when she when her eyes are in the dark and she can't fix it on anything. And so right away, I was like, Okay, well, you absolutely, they have, there's a reason why you're having vertigo. Like, it's pretty clear, yeah,

 

Dr. Helena Esmonde  41:55

yeah. And it's really validating for the patient. I actually will show them their videos sometimes, because they're like, oh, you know, because it's hard having a symptom that's not obvious, I guess, like, Oh, if I have a broken arm and I have an x ray that shows, look, there's my fracture, and I have a cast, like, everyone's like, okay, broken arm, we get it. But when we're talking about dizziness and imbalance and off feeling and headaches and things that are kind of hard to pinpoint, you know, because they seem like more vague symptoms. Oh, I've had dizziness. Well, maybe you're just dehydrated, like, unfortunately, there's, like, you know, lots of reasons to be dizzy. And so it's definitely a little bit more challenging to, you know, have someone who hasn't experienced it that particular type of dizziness will say, to understand. And so a lot of patients, and they want me to show their their spouse or whatnot, like, Look, honey, I'm not crazy. Like, Alaina found this, and this is what we're going to do about it. And you know, that's really can be very helpful. And even if we don't find abnormal eye movements, which does happen sometimes, but their history is pretty much sounding like they had a vestibular issue that probably resolved itself. So for example, the crystals maybe were out of place and they dissolved or found their way back, which we know can happen. Sometimes the brain will then, unfortunately, learn to be dizzy because of when the crystals were there, and they'll still kind of think they're there. And so we have to reteach the brain, and so, you know, you have to fit certain criteria to have what I'm describing, which is called persistent postural, perceptual dizziness. And having crystals out of place and then having to go back is just one possible cause of that issue, but it is basically a learned dizziness in the brain, and they've been able to find it's a very expensive machines called functional MRIs that, you know, there are real changes to the brain and those folks that experience that condition. So for me, since I did not have this really expensive machines, and you're not going to probably be able to get a doctor to run you through that test just to confirm that, per se. So we do have criteria, there's there's clinical practice guidelines and criteria that, you know, the experts in the field that our researchers have set forth to help us clinicians say, Okay, have I? Have I done all the things that allows me to say, Wow, it really seems like you're fitting this criteria. And we've done a good job of ruling out other competing causes and not just jumping to this condition right away. Yeah.

 

Dr. Ayla Wolf  44:18

And you know, that's kind of interesting. You talk about that people had BPPV, and then it went away, but they're like their brain is still kind of almost remembering that I had this one episode where I had gotten off an airplane, I walked into the air, you know, the airport bathroom, and I walked into the stall, and I immediately had a moment of just vertigo that kind of came out of nowhere, and then it passed. But then ever since that, every time I walk into airport bathrooms, it happens, yeah, totally, it's ridiculous. I'm like, okay, brain like it happened one time. You don't need let's move on. Let's get over this. And it just speaks volumes. Totally

 

Dr. Helena Esmonde  44:59

legitimate. I. Like to say the brain is a beautiful learning machine, and that's good and that we can retrain the brain so it if we wanted to really work on that, there would be strategies, you know, to get the brain to reset itself from that bad learned pattern, or not a useful pattern, to a more useful pattern. But, you know, I think again, like retraining the brain, not only can it take time, but it can take doing your homework. So some patients, understandably, they're busy, they're tired. You know, I totally get it busy. You know, life, there's a lot going on. It's hard to do the homework, but that's why I kind of keep the homework tight, like we're talking like, three exercises Max in my book, and then we might change it, like, okay, we're not going to do that one anymore. You don't really need it. Let's, you know, upgrade to this one or whatnot. So that's another good sign of a good clinician, is that not every condition needs homework, but many, I'd say, in the vestibular world, benefit from some, some kind of homework.

 

Dr. Ayla Wolf   46:01

So, yeah, yeah. And, you know, I've always been kind of amazed at how many people will come into my clinic, and basically, kind of, they've reached a point where they're like, Yeah, I have all these symptoms, and I just kind of live with them, and it's like, well, like, have you done this? Have you, have you looked into that? Have you tried this? Have you, have you gotten this diagnosis? And it's kind of like No, no, no, no, no. And so I do think that there's a lot of people out there that are probably suffering from symptoms, but they're not even aware that there are treatment options, or that there are these like ways of, kind of diagnosing it and looking into it deeper. And so I almost feel like this world of vestibular PT is still kind of unknown to a lot of people.

 

Dr. Helena Esmonde  46:43

Absolutely, and I think one of my favorite stories about a patient after concussion, just because I think it's really instructive to clinicians, but also to patients, perhaps, is I had a woman who was a nurse, and she was downtown Philly, she was walking across the street, and she tripped on the curb or something, because, you know, the curbs are a mess, and this is the real thing. And unfortunately, she didn't really catch her balance, so she ended up hitting her head. And she's a nurse, so she's like, Oh, I'm pretty sure I had a concussion. So she already kind of knew her diagnosis out the gate, so she saw the right clinicians, a physician at the concussion clinic, they suggested vestibular rehab, or, you know, physical therapy. And so, you know, she happened to see me, and so do my full screening. I found bBV right away. I'm like, Okay, well, let's clear that. To get that cleared early, because, you know, the longer it's there, the more confused the brain can get. So we want to get that square. But she still had some dizziness, which could be kind of a brain level dizziness. She definitely had some ocular motor and kind of sensory processing issues a little bit. And she had a history of migraine, which we know can just make it harder to recover, because the brain is already a bit sensitive. So it's like, now, what? Fair enough brain Fair enough. So she was doing really well, and she was towards the end, I felt like of a rehab where she almost had, like, gonna go back to baseline during, you know, kind of before the concussion, which is what we all want, and she had this little residual dizziness, but it wasn't really provoked by movement. It was kind of there all the time. And I'm like, Hmm, what else could it be? So we went back through her medication list, and I'm like, oh, like, remember, they added this headache medication. She already had one on board from her migraines, but they'd added a bonus headache medication after the concussion, because her headaches had been elevated at that time now they were really resolved, or at least back to whenever she got the occasional migraine before, which was again, back to baseline. I'm like, you wanna check with your doc and see if you can come off this med. And so they did wean her off over like a week or two, as they should for that particular medicine, and that residual dizziness went away. So in her case, that was basically a side effect of that medication. So I think it's tempting on the clinician side to say, I can fix all dizziness, right? Oh, we just didn't do the right vestibular exercise. Maybe I just need more scarves like, No, this patient didn't need more scarves, although we had a nice time with, you know, tossing the ball and stuff when we needed it. But like, that had kind of done what it needed to do, and I just needed to sit back and say, okay, like, what is this? What else could it be? And it's being willing to always kind of come back to the table re examine, what am I kind of seeing? What I you know, what have I not looked at yet or not re looked at? You know, again, I always check on other big ones, hydration, nutrition, sleep, you know, look at all these things that like come into the symptom onion layers. They encourage patients to kind of think that way too. Like, you know, I mean, it may you feel like you've tried everything and you've seen everyone, and I totally get that, because some patients really have gone above and beyond. And I totally, my heart goes out to y'all that you know are just like, I feel like I've done everything and seen every specialist possible and flown to Dubai or something, but like, you know, maybe it needs a fresh pair of eyes. Maybe. You know, it is worth I have had a few patients. Sadly, I feel drive from like, you know, two hours away just for me to, like, take another look, you know, because a fresh set of eyes. And sometimes that's helpful, and sometimes I'm like, Well, I rolled out this like, at least I can listen and maybe suggest, like, some other piece that might not have been looked at, so you are absolutely worth the two hour drive. Oh, thank you. Well, I try. I like to joke. Oh, no pressure. Helena like this. You know, what have I got to offer here? But you know, I'm always going to be honest as to what I find and what I don't, you know, not going to well.

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Dr. Ayla Wolf   50:35

And I think that medication piece is also an interesting one, because I often have to remind people who maybe they've been on medications before their concussion, and then they get their concussion, they get all these symptoms, and then we, you know, we're getting people better, but then there's still, like you said, these lingering things. Well, people can respond differently to medications after a brain injury, and just like alcohol, right? So many people say, Well, I could have a glass of wine with dinner before my concussion, and now, after my concussion, I take two sips of wine and I feel like I'm drunk. And so it's the same thing. It's like your brain is different. After a concussion, you can't process alcohol the same way you used to, and you might also be having trouble with some of the medications that you used to be totally fine with. So we have to take that into consideration. If at the end of the day, people are still symptomatic, and you're trying to like, like, gosh, all these exams look fine, and this looks fine, and that looks good, and it's like, what else is going on? I think that that medication review is always an important one that that can get missed, because they will say, Well, I've been on this for 10 years.

 

Dr. Helena Esmonde  51:43

Like, yeah, no, 100% yes, I agree. And I think to even something as simple as, like, the type of exercise you do, you know, like you might need to kind of transition that or adjust that, you know, it's, it's difficult because, you know, sometimes you just feel like you're like, scatter shot, but like, I think the goal, even though it's slower, is to be a bit methodical and say, Okay, I'm just going to change this one thing. And let's see over, like, a few weeks, two to four weeks, maybe, depending on the change, how, because we might see like if that has an impact positive or negative?

 

Dr. Ayla Wolf  52:24

Yeah, absolutely. Well, thank you so much for your time tonight. Why don't you let people know where they can find you and all of your great information.

 

Dr. Helena Esmonde  52:33

And absolutely no happy to help so you can always find us at vestibular first.com that's our website, and then we are on several social medias at vestibular first, nice and simple. And I have no problem with people email me, emailing me directly. So that's my first name, Helena, H, E, L, E, N, A at vestibular first.com, so just let me know what you guys need. You know, clinicians, patients, I like to think of a wealth of resources. I try to point people directions and be a connector as much as I can, because I feel as much as I haven't had a lot of vestibular issues so far in my life, I really have a huge amount of compassion, both for the patients who are really, you know, often struggling and frustrated and have fluctuant symptoms, and that's a lot going on, and I know that's tough. And then on the clinician side, you want to do your best job, and sometimes it's unclear, like, what's the next right step for this patient? And so you know, whether that's a bit of information you need, maybe another referral source that's near you to kind of have them take a look at the eyes or something, or course, that you might need to help you with something like atypical BBB, which can be very, very tricky in my experience. And if I knew now, if I knew back when I started vestibular, what I knew now, man, there's so many more patients that would have not that they weren't helped, but they would have been helped even faster and even more. But that's, that's the wealth of experience, right? So, you know, I try to accelerate everybody else's experience, so that doesn't take them as long as I feel like it's taken me to get where we are today. So, you know, we're always trying to learn, always trying to improve, and just, you know, keep trying to do your next right thing. Be kind to yourself. Be patient.

 

Dr. Ayla Wolf  54:23

Yeah, yeah. Well, thank you so much. You're doing so much for just clinicians in general, with all of your information and your expertise that you are sharing so that hopefully we can all help get patients feeling better and feeling more like themselves as fast as possible. So thank you again, and I look forward to consuming all your future content.

 

Dr. Helena Esmonde  54:45

Sounds good, and I yours. Thank you for all your important work as well.

 

Dr. Ayla Wolf  54:49

Thank you all right. Have a great night. You too. Bye.

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