SUMMARY KEYWORDS

Dysautonomia, autonomic nervous system, sympathetic nervous system, parasympathetic nervous system, heart palpitations, orthostatic intolerance, POTS, vagus nerve, interoception, exercise intolerance, cognitive symptoms, immune system, circadian rhythms, peripheral nerves, concussion symptoms.

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Dr. Ayla Wolf  00:00

And then other people can have what I call increased heartbeat awareness, where their heart feels like it's pounding in their chest, but it's not. It may not be pounding fast, so it's not necessarily that the speed is abnormal, but it's the sensation of the heart is strong.

 

Sophia Bouwens  00:18

Welcome to the life after impact podcast, where we do a deep dive into all things concussion and brain injury related. We talk about all the different symptoms that can follow brain injury, different testing methods, different types of specialists out there, and different therapies available. I'm Sophia Bowens. I'm here with Dr Ayla Wolf, and we will be your guide to living your best life after impact. I am super excited about this topic today. It's a really big one, and it's full of just a lot of confusion, and you bring so much clarity to it.

 

Dr. Ayla Wolf  00:58

Well, that's because it is confusing. And so whenever I had patients coming in, I kept finding that there was some, some type of dysautonomia very frequently, underlying a lot of their symptoms. And it had gone missed by, you know, so many different providers, because they weren't looking for it, and they weren't necessarily looking at the human physiology from that perspective, and just like with concussions being you know, every single person can have such a different set of symptoms with a concussion, if we even just look at it from an autonomic perspective and say if dysautonomia is present, we can also say that In every single individual that's gonna look very different, very

 

Sophia Bouwens 01:42

different. So this episode is called untangling dysautonomia beyond pots and bagel nerve hacks. So really important. Let's just start it with a brief overview of dysautonomia and the autonomic nervous system.

 

Dr. Ayla Wolf  01:57

Yes, so our autonomic nervous system is named as such because a lot of the functions it performs are supposed to be auto, right. Automatic, meaning that we don't necessarily have to be actively trying to to do things right. So when I go to stand up, you know, my heart rate is probably going to elevate a little bit, and my blood pressure is going to elevate a little bit. And those small adjustments account for the fact that gravity is trying to take my blood and pull it down towards my feet, right? And so to stand up, our body makes these adjustments without us having to consciously think about it. It's just automatic. It's automatic, just like when we go to bed at night, we continue to breathe because we have specific nuclei in our brain stem that are basically, that's their job is to keep us breathing while we're unconscious. And they're part

 

Sophia Bouwens  02:49

of the autonomic nervous system, exactly.

 

Dr. Ayla Wolf  02:52

And like sweating is another example, if we are nervous, we can have kind of this, like emotionally driven, you know, increased sweating response to being nervous about having to, you know, give a speech in front of a room full of people. But when we go outside and it's hot out, you know that sweating response is autonomic. You know, it's our it's our brain saying it's hot out, I need to cool my body down, and so I'm going to do that through sweating. Or if I'm a dog, I'm going to do that through panting, right?

 

Sophia Bouwens 03:20

So this complex automatic nervous system really gets broken down most simply into two different parts, sympathetic and parasympathetic, or fight or flight and rest and digest. Yes,

 

Dr. Ayla Wolf  03:33

and even those kinds of categories are maybe also a little bit overly simplified, because there's, you know, a parasympathetic arm that goes to our pupil that helps to actually constrict our pupil. That's a parasympathetic response. But we don't normally associate our pupil size with resting and digesting, you know. So that's also a bit of an oversimplification, but it does get the point across. The other thing that I like to point out is that when we talk about this idea between, you know, fight or flight as being a sympathetic response, so often the sympathetic nervous system gets demonized. You know, we're all told, like we all have too much sympathetic activity, and sympathetic activity is bad and sympathetic is evil and parasympathetic is good and and that's also not true. It's not, you know, it's not the reality. And so, you know, the way that I always like to frame it is that our autonomic nervous system is designed to make beat to beat adjustments in order for us to have an appropriate response in the moment. So when I'm exercising, I need a really strong sympathetic output, because I'm about to go put a lot of effort into, you know, running, jumping,

 

Sophia Bouwens  04:50

you need different lifting, breathing patterns, different blood pressures to adjust to that situation exactly.

 

Dr. Ayla Wolf  04:56

And so we need our sympathetic nervous system. It is so. Important. It's just we don't need it overly active at the wrong times, exactly. And

 

Sophia Bouwens  05:04

sometimes people can get stuck in this sympathetic dominance or this fight or flight mode. And then I think that brings us to an interesting talk about what the arm that counters that is, which is the parasympathetic response, or, yeah,

 

Dr. Ayla Wolf  05:18

so the parasympathetic system, basically, if we, if we get into anatomy, you know, we can ask the question of what makes a nerve a sympathetic nerve versus what makes a nerve a parasympathetic nerve. And so we have what are called pre ganglionic fibers and post ganglionic fibers. So if we look at sympathetic nerve fibers and we compare them to parasympathetic there's a wave anatomically that we're differentiating whether something is parasympathetic or sympathetic, and it's all based on the length of the nerve tracks that are either pre ganglionic or post ganglionic. So sympathetic nerve fibers have a short pre ganglionic fiber, and then a very long postganglionic fiber. And then the parasympathetic have a very long pre ganglionic tract and a very short postganglionic tract. So

 

Sophia Bouwens  06:11

anatomically, they're mirrors too. They're

 

Dr. Ayla Wolf  06:13

opposites each other, yes, and so there are these anatomical differences that define whether a nerve fiber is a sympathetic or a parasympathetic. And so again, I think that when we bring it back to just anatomy and classifications based on the length of the nerve, either pre or postganglionic, again, all of a sudden it's like, there is not this is good and that's bad. It's just this is short and that's long, right? Easy, easy,

 

Sophia Bouwens  06:41

easy. Yeah, exactly. So the vagus nerve, the longest nerve in our body, gives our brain a lot of information about what our body function is doing. One of the anatomical and functional things that fascinates me about this nerve is that its main component is to tell the brain about what is going on in the body, they go from the body to the brain. I think it's like 90% of the information in the vagus nerve goes that way, yeah.

 

Dr. Ayla Wolf  07:07

I think the 80% is Yeah. 80% is going from the body to the brain. And that is very important, because that, what that means is that we have this part of the brain called the insular cortex, which is where we have what's called interoception, right? So when I ask you, Sophia, how are you doing today? You know, it's actually you're kind of tapping into your interoception of, how am I feeling today? And a lot of that has to do with, you know, this sense of internal, internal state. So if you were super nauseous and I asked you, how are you today, that Nausea is probably going to be the first thing on your mind, right? You can probably read it on my face. Yeah, exactly. And so there's certain things, like, when I ask you, how are you today? Well, if you're, you know, overheated and you feel like you're about to pass out, that's going to be at the top of your list driving factor, for sure. Yeah, you're not going to say I feel great, unless you're just straight up lying to lying to me if

 

Sophia Bouwens  08:03

I'm in that condition, but if I'm in a different condition, I might feel great. And tell you that, and I'll be able to notice in my body I have a calm heart rate. My breathing feels good, a state of balance. Dysautonomia is marked often by high anxiety, and I think a lot of that is because the internal state feels really off. Yeah,

 

Dr. Ayla Wolf  08:22

and it can be off in kind of a vague way, so that when you ask somebody with dysautonomia, how are you, they might just have this sense of not being well, right? Maybe they feel tired, maybe they have a little bit of mild nausea. Maybe they are either too hot or too cold. Maybe they feel a little anxious in this kind of vague way where it's not necessarily related to any one thing that happened. It's just this kind of vague sense of restlessness, yeah,

 

Sophia Bouwens  08:48

like, what are some of the main symptoms of this dysautonomia? What you just listed? Are there other things that come up or get categorized? Yeah,

 

Dr. Ayla Wolf  08:55

I think that that is where, you know, we can really appreciate the complexity of dysautonomia, because if we're saying dysautonomia is a dysregulation of the autonomic nervous system, well then we have to ask the next question, which is, well, what are the functions of the autonomic nervous system?

 

Sophia Bouwens  09:16

Well, that's a great question. What are the functions of the autonomic nervous system, I think

 

Dr. Ayla Wolf  09:21

it's easiest to break it into categories of function, and then when you break it into the categories, then you can start to look at, well, what does this do? So if we look at, say, cardiovascular function, if somebody has dysautonomia and it's very much affecting their cardiovascular system, they're probably going to say that they either have a racing heart, and that can be at random times. They might just be sitting on the couch and all of a sudden their heart starts racing, or they walk up their short flight of stairs, which normally would be no big deal, but all of a sudden they walk up their stairs and they feel like their heart is racing, going out the way. Yep, yeah. And then some people have heart palpit. Where it almost just feels like it's skipping a beat. I always liken heart palpitations to, like, a submersible pump, water pump in a fish tank where, like, when the water gets too low, all of a sudden that pump starts cavitating. Yeah, and like, that's how I feel. Like, like, that's how I like to describe heart palpitations. And then other people can have what I call increased heartbeat awareness, where their heart feels like it's pounding in their chest, but it's not, it may not be pounding fast, so it's not necessarily that the speed is abnormal, but it's the sensation of the heart is strong that

 

Sophia Bouwens  10:35

awareness becomes really heightened. Yeah, and you know,

 

Dr. Ayla Wolf  10:39

like if you just started sprinting and you were running sprints uphill, when you stop, your heart's gonna be fast and it's gonna be pounding, and that's gonna be normal, and so you wouldn't necessarily feel anxious, because, you know, like I was just sprinting uphill, of course, my heart is gonna be pounding and it's gonna be fast.

 

Sophia Bouwens  10:57

But if you're sitting on the couch watching a really calm documentary, and all of a sudden your heart starts racing like that, exactly like it is racing like that. Yeah, might cause some worry, that

 

Dr. Ayla Wolf  11:06

can definitely make people feel anxious. And then, of course, you know, there's a lot of other cardiovascular symptoms, like people can actually have chest pain, they can have dizziness or a feeling of lightheadedness, because when they go to stand up, maybe again, their heart is beating really fast, or maybe their blood pressure is dropping. Or people can have all these different changes in heart rate and blood pressure that can lead to dizziness and lightheadedness and even fainting. And so there's all of these kind of symptoms that come with orthostatic intolerance and the cardiovascular system not responding appropriately to somebody changing position,

 

Sophia Bouwens  11:41

and Commonly, people will get diagnosed with pots for this reason, right? Because of this, yes,

 

Dr. Ayla Wolf  11:46

and so we'll circle back to pots, because a lot of people are kind of equating dysautonomia to pots, when really, if we look at dysautonomia as this big umbrella, POTS is just one well defined subcategory that falls underneath the dysautonomia umbrella. But it's not all forms of dysautonomia. And so I certainly have had, like, actually, more and more, because I think a lot of people on like Tiktok and YouTube are talking about pots. It's kind of become like the new popular, yeah, the new popular diagnosis. And so a lot of people are talking about it, but I've definitely had patients come to me and say, I think I have pots. And when I run them through a ton of autonomic testing, I'm like, Well, you do have something wrong with you, but it's not pots like that. You know, that's not how this is presenting

 

Sophia Bouwens  12:38

more. Let's come let's come back. Let's put a pin in that for a second, because you did mention before that there's multiple systems that this can show up in. And started with the cardiovascular system, yeah, other systems that this dysautonomia can show up in. So

 

Dr. Ayla Wolf  12:51

the next one is the respiratory system. And so that involves, obviously breathing, but also the ability of our body to regulate the balance between oxygen and carbon dioxide. And so that's really important too. And when people have poor carbon dioxide regulation, and that, you know, gets out of balance, that can cause a lot of symptoms too, in terms of breathlessness and lightheadedness. And so when we think about, you know, this whole picture of anxiety and restlessness in the body, there's just so many things that when they're off within the autonomic nervous system, then they cause you to feel anxious and restless.

 

Sophia Bouwens  13:28

I could see that leading into other diagnoses like fibromyalgia or Raynaud's or just ways that their circulation or oxygen delivery isn't getting places. And that's not to say that those diagnoses are always a dysautonomia, but some of what you're talking about makes me think about those conditions, because you see these vague but also really diffuse symptoms

 

Dr. Ayla Wolf  13:53

well, and Raynaud's really is a, you know, a dysautonomia. There's a lot of existing disorders or diseases that really do have dysautonomia as kind of, like this comorbidity or kind of coexisting with them. And so, yeah, we can get into that too. But like, for example, CRPS, Complex Regional Pain Syndrome, you know that that's kind of a form of dysautonomia. And then we look at, you know, small fiber neuropathy that's present in diabetes, and that's kind of a form of this dysautonomia coexisting with diabetes. We also have like chagrins, which is an autoimmune disorder, and so classically, people have dry mouth and dry eyes. But there's kind of a whole nother aspect of showgrens that is maybe an atypical presentation that doesn't necessarily have the dry mouth and dry eyes as the main symptom. It's actually people have more of like this fatigue and muscle pain and joint pain and difficulty breathing and so there's this

 

Sophia Bouwens  14:56

whole healing wrong cause, this autonomic nervous system. Exactly. Yeah. Yeah.

 

Dr. Ayla Wolf  15:00

So there's a lot of, I think, disorders and diseases that people are familiar with that don't but maybe they don't even recognize that the dysautonomia is really wrapped up in that component of that. It's a component of it, exactly. So

 

Sophia Bouwens  15:13

we have the cardiovascular, the respiratory, yeah.

 

Dr. Ayla Wolf  15:16

So with the respiratory symptoms, a lot of people do feel like they, you know, breathe shallowly, or they have difficulty taking a full breath. They also might report that their symptoms are worse with like changes in barometric pressure as a response to kind of perfusion in the body, sure, and then I would say that one of the huge categories is digestion. And when I I mean, I taught a dysautonomia class way back in, I think, 2017 and I presented basically three cases side by side, which were all young women who all complained of nausea as and loss of appetite as, like, their primary complaints. And then when I examined them, it turned out that all of them had pots. And so they basically all presented with dysautonomia. And because their main complaint was nausea, I think every other they doc, every other doctor they went to, were just looking at it symptomatically, as opposed to looking at the big picture to say, Well, what's driving the nausea,

 

Sophia Bouwens  16:17

functionally, what's going on? And so pots can be this orthostatic imbalance you feel, but it cannot. It shows up as many other things too, but it is a clearly defined diagnosis, which is not the case for all dysautonomias.

 

Dr. Ayla Wolf  16:30

No, it's, and that's what's confusing to people, is, you know, you can have pots, and then you can have, say, somebody gets a concussion, and maybe they don't develop pots, but maybe they develop dysautonomia that manifests in a completely different way, in terms of like migraine headaches and orthostatic intolerance, where when they go to stand up again, they feel light headed. There may be headaches get worse. They then have nausea. So you can have these other dysautonomia symptoms that come on after a concussion that don't necessarily fit into a classic pots diagnosis, and so they are almost a bit more vague that, you know, it's a more vague presentation of dysautonomia, but it's just as important, nonetheless, to identify and there's there's ways of doing that. There's

 

Sophia Bouwens  17:17

a lot of complexities in this. So the gastrointestinal symptoms you describe makes sense, because we hear about this as rest and digest. So of course, digestion. Are there other symptoms, symptoms or systems that we see were commonly with, yeah,

 

Dr. Ayla Wolf  17:31

and I mean, going back to digestion real quick, you know, I'd mentioned nausea as being a big one, but a lot of people you know will report that after they eat, they might actually feel like they have tachycardia, or their heart is beating, or we know that a lot of people with dysautonomia can actually have pooling of blood in their pelvic cavity, because when you do eat, your blood goes to your stomach to help you rest and digest, right? But then when you start to get up and move around and do other things, it's almost like your autonomic nervous system is still stuck in rest and digest, and it's not controlling blood flow properly. And so you can have this kind of pooling of blood in the abdominal cavity that feels uncomfortable and causes these other symptoms too. Because if your blood is pooling down below, that means it's not getting to your brain, and that's going to cause problems as well. So, but I mean, people can have, I mean, vomiting, and, like, really bad nausea, plus vomiting, they can have changes in bowel movements, a lot of bloating. People can have food sensitivities, and just like, general sense of abdominal pain or abdominal tension, and then some people also report that they will start choking on, like, if they have to swallow pills, they'll start choking on pills, and actually have kind of a loss of the gag reflex. Yeah. So there's a lot of other symptoms too, that, of course, each of these symptoms, by itself, doesn't necessarily mean, oh, you have dysautonomia, right? But if I hand somebody a list of, say, 100 symptoms, and they're checking every single box in my questionnaire, I start to then, you know,

 

Sophia Bouwens  19:03

right? And I think a lot of people have a form of dysautonomia, or there's some dysautonomic regulation. So it can happen on its own. It can happen as a response to trauma, some disruption, concussion, or it can happen as part of something else going on, yeah.

 

Dr. Ayla Wolf  19:21

So we can kind of break it up into either like a primary type. So for example, multiple systems atrophy is a neurodegenerative disorder that is a primary form of dysautonomia. Then we have these secondary forms of dysautonomia that are a result of, say, a concussion or, I mean, pots, for example, can actually come on as a result of a surgical trauma. I've had a patient that that was the case for her. And then we can also now have, you know, pots, I think, has become more popular because it has become a side effect of COVID. And so you can have post viral dysautonomias. You can have. Post surgical dysautonomia. You can have dysautonomia as a result of a brain injury. So those would all be secondary types. And then there's, you know, the idiopathic dysautonomias, where they just are not quite sure what's driving the process. And then those kind of coexisting ones that we already talked about, right?

 

Sophia Bouwens  20:18

So this is an interesting thing, because I think a lot of times, people will break it down and say, well, dysautonomia means that your sympathetic nervous system is in overdrive, so we need to stimulate your parasympathetic or your vagus nerve to get you into better balance, right? So there's all these vagal hacks to help with these dysautonomias. Why might that not be the full picture?

 

Dr. Ayla Wolf  20:41

Because in some cases, people aren't having a proper sympathetic response. It's not that their sympathetic nervous system is stuck in overdrive. For some people, it's the exact opposite. Their sympathetic is not responding appropriately. It's actually they don't have enough sympathetic output. And then in so in some cases, the parasympathetic nervous system is not necessarily the problem. It's not the thing that isn't working. And so to try to simplify dysautonomia, to say that it's always too much sympathetic activity and not enough parasympathetic that's just simply not true. And so we can't say that that is the case for everybody, and we can't jump to that conclusion for anybody. And so just simply doing vagal nerve stimulation is not the solution. It's not the appropriate it's it's not the appropriate response. Because if you haven't had all the proper tests done to see, do I have the right sympathetic output? You know, what is my parasympathetic nervous system. Doing you know those tests are important to be able to understand what category each individual person falls into, to then know what is the appropriate treatment, and

 

Sophia Bouwens  21:50

so some of these conditions, like pots, have clearly defined testing and parameters. What might be some other types of testing that we would do to gage the autonomic nervous system functioning or not functioning. Well, we

 

Dr. Ayla Wolf  22:04

can look at the pupils, and we can look at how the pupils respond to light in terms of what is the rate of constriction of the pupil when you flash a light in the eye, and then also, how long does it take for the pupil to dilate again? So we call that the 75% recovery time of what was the original pupil size, what did it constrict down to? And then how long did it take to then get back to 75% of the original size? And so we have these like very well established parameters to say we know you know how the pupil constriction is mediated as a parasympathetic response, and we know that dilation is a sympathetic response. And so we can look at the pupil to just say, what does the orchestration of the autonomic nervous system look like with this one reflex, which is so powerful,

 

Sophia Bouwens  22:57

and how are these partners dancing and who might be misstepping And where exactly, yeah, gives us insight into a pupil violation and constriction. So

 

Dr. Ayla Wolf  23:05

that's one of them. And then you can also look at a valsalva maneuver. So if somebody is, you know, holding their breath and bearing down, like, right when you sneeze, that internal pressure, right? So when we do a valsalva maneuver, there's a there's also this kind of response by the heart rate and the blood pressure in response to that increased pressure. And so Valsalva is another way of looking at, you know, is the system responding appropriately, so

 

Sophia Bouwens  23:33

checking all these measures that the nervous that part of the nervous system governs, right? So, blood pressure, pupil violation,

 

Dr. Ayla Wolf  23:40

I would say that the other kind of bedside test that's really valuable for understanding, if there's enough sympathetic, you know, output is looking at this five minute, sustained hand grip test, where you find somebody's Max grip strength, you take 30% of that, and then they have to hold that for five minutes. And love that

 

Sophia Bouwens  23:59

test you do. I think there was a paper that you got really excited about when you first brought that to my attention, how they had correlated it really strongly with dysautonomia.

 

Dr. Ayla Wolf  24:11

So this has been around for a long time, but I almost feel like it didn't get popular enough. And part of the problem is, again, like our modern medical system really relies on lab work and imaging, right? And so they don't often throw in a lot of these, you know, bedside tests that take five minutes where you're having to look at blood pressure and heart rate over and over again and make somebody grip this thing, right?

 

Sophia Bouwens  24:36

And also, if you have 15 minute increment with someone, and you're gonna have them sit there for five minutes. It's like a third of your time with them, and you have so much to get through,

 

Dr. Ayla Wolf  24:45

right? Yeah, and so that's where, you know, I think if, if medicine got better at doing more screenings to, like, there's the compass 31 questionnaire, for example, one of my teachers, he basically just said. Know, I have all my patients fill out the compass 31 and if they don't score very high on this, then I know that I don't necessarily need to spend an hour assessing their autonomic nervous system. If they can actually go through this questionnaire. And they don't, they don't have very many of these symptoms, right? Sure. And so, you know, for me, that's why I also love my symptom checklist, which is, maybe, you know a lot more than the compass, but i very i love to gather information. So so yeah, it's that same concept of, like, if we just did more screenings, you know, this would probably get caught more and be

 

Sophia Bouwens  25:33

better treated, because we can maybe see how and where the complexities are happening, right? Yes,

 

Dr. Ayla Wolf  25:39

and because it is so complex, and there can be a lot of different drivers for, you know, like, what is causing the dysautonomia treatment is definitely not straightforward, and it's not easy, and it's not simple, it's really complex stuff, which is why I think a lot of people just kind of, like, they're like, I don't have time, like, I don't know. Let's

 

Sophia Bouwens  26:00

just see how this goes. So we have the cardiovascular system, the respiratory system, we have the digestive system. Are there other systems that you would name or involve? Yeah,

 

Dr. Ayla Wolf  26:13

one of the things that is also, I think, important to differentiate is that, you know, I mentioned, the autonomic nervous system is in charge of these beat to beat adjustments, but it also has, like, long term control over our immune system and also our circadian rhythms. And so a lot of times when people have dysautonomia, they also have immune system imbalances. There's a lot of kind of CO existing autoimmunity that can happen with dysautonomia, and even just beyond that, people can have, you know, frequent colds and flus, or they might even have mild fevers. They can have, you know, chronic fatigue, or even, like, unexplained vertigo that might actually be associated with some kind of autoimmune imbalance because of the dysautonomia. So it can get pretty complex in that regard. And then because of the fact that it is involved in the circadian rhythms, a lot of people also have very poor sleep because the circadian rhythms are affected. And then we mentioned sweating too. And so again, the sympathetic nervous system is responsible for sweating. So some people might say they sweat way too much. Other people might say they can't sweat at all. A lot of people say that they have heat intolerance, right? If you can't sweat, if you can't vent your heat, then you're going to have a lot of heat. And heat, yes, yeah. And so that's where, you know, a lot of people are talking about, you know, the use of saunas being so helpful as well. And you know, usually I pay attention. And even, like, 20 years ago, when I was first learning Chinese medicine, you know, they would teach you, it's like you're feeling your patients pulses. But how do their hands feel? Are their hands super clammy and wet? Are they? Are they super hot? Are they super cold? Yeah. I mean, just like the temperature of somebody's hands and the moisture content can tell you a lot.

 

Sophia Bouwens  28:02

And I think that Chinese medicine tunes into the autonomic nervous system way more than we realize.

 

Dr. Ayla Wolf  28:07

Yeah, I mean, the language of Chinese medicine, it really is a language of function and balance. I mean, that's really what it is. It's a language of what are the different functions. And, you know, like the original word for sympathetic. The reason why they called it the sympathetic nervous system is that that word actually came from people back in, I don't know, the 1800s saying, you know, we think there's this nervous system that is sympathetic to the other organs, like these organs are sympathetic to each other, pay attention, yeah, the organs are like, paying attention to what is happening with the other organs, and so we have this nervous system that's like communicating between the internal organs and sympathizing with them. That's where that came from. And

 

Sophia Bouwens  28:49

the dysautonomia is the difficulty in the sympathizing and adjusting. It's a

 

Dr. Ayla Wolf  28:53

difficulty with the sympathizing. Yes, the hardest like not sympathizing appropriately with what's happening with the kidneys and the blood pressure and what else needs

 

Sophia Bouwens  29:02

to happen? Yeah. Okay, so there's so many different symptoms. Are there more even that you would know?

 

Dr. Ayla Wolf  29:08

Yeah. So a lot of the you know peripheral nerves are involved, because obviously our peripheral nerves are bundles of sensory, motor and autonomic fibers, and

 

Sophia Bouwens  29:18

peripheral being one's far away from the center of our body,

 

Dr. Ayla Wolf  29:21

the nerves that don't directly go into the brain or the central nervous system from

 

Sophia Bouwens  29:25

outside of the central nervous system, yeah, on the outside. And so because

 

Dr. Ayla Wolf  29:29

of that, a lot of people can have numbness and tingling. And the key there is a lot of times it moves around. So like, if you've got carpal tunnel, your numbness and tingling is really in one place, it stays in the same place. A lot of people with dysautonomia can actually have numbness and tingling that moves around and doesn't necessarily follow a clear pattern, but people can complain about generalized weakness, about kind of random muscle soreness or joint pain that doesn't seem to really make sense. A. Lot of people will say that they feel shaky, or they had this sense that they're like, internally, they're kind of shaking or shaking. And sometimes I can feel that, sometimes I can't, you know, somebody says that they feel like they're shaky, and sometimes, you know, they hold out their hand, and you can literally see their hand shaking. Sometimes you can't see the shaking, but when you you know, put your hands on their feet, for example, the all of a sudden you can just feel the whole body is vibrating, so the shakiness is real. So that's a common thing. And then a lot of times, you know, especially with concussions, exercise intolerance is a form of orthostatic intolerance, because usually you're upright, right? But obviously there's a lot of exercise that can be done on your back or in other different positions, upside down, whatever. But exercise intolerance is again, the inability to have the right autonomic response to the fact that you are now using your muscles and you're trying to exert energy in a way where you need to shunt blood to your muscles, and so if your body is failing to do that appropriately, people are going to have things like, you know, nausea, headaches, lightheadedness, dizziness, fatigue, maybe tachycardia. And so the exercise intolerance, one I would say, in the world of kind of sports concussions, is huge. Because if you're an athlete and you can't do your sport, that's a problem. Yeah. And so exercise intolerance is kind of a big, you know, I would say it's well described as far as a form of dysautonomia, we also have the buffalo treadmill test, which is a very, you know, now, well established means of, kind of categorizing that. So that's another important one

 

Sophia Bouwens  31:42

too. Sure. Are there others? I mean, this, the list goes on, doesn't it? There's so many. Well,

 

Dr. Ayla Wolf  31:47

I mean, I think those that you can definitely have urinary functions so different changes in bladder control. A lot of people that I work with with dysautonomia, they say that they have to go the bathroom like all the time, frequent urination, right? And then some people might say they actually have difficulty, like initiating urination too. So changes in bladder function, changes in bowel function, and then there are cognitive and emotional symptoms too. Like we mentioned, a lot of times, people feel a sense of agitation, restlessness, anxiousness. You know, I know for me, I had maybe some mild dysautonomia with all of my different concussions, but one of the things I really felt was that if I ever had to wait in line, I would start to get very anxious and restless. And I think for me, that was a bit of this, like orthostatic intolerance, where I had to stand upright in a line not moving, and so I would constantly be like shifting my feet, and I'd feel agitated the longer I had to stand there. And so I think, you know, for me, there was a long period of time where I didn't understand why I was so restless and agitated and anxious and uncomfortable in my own body, and it was probably because I had dysautonomia, and I just didn't know it at the time. It was just

 

Sophia Bouwens  33:05

coming out as this, like restlessness or irritability. So it could be, yeah, yeah. Scene is different. And

 

Dr. Ayla Wolf  33:11

obviously, you know, the the autonomic nervous system is supposed to send blood to the area that needs it the most, and that's true for the brain as well. So if we're trying to perform cognitive activities that require us to shunt blood to our frontal lobe and our autonomic nervous system is failing to do that, well then we're going to have brain fog and difficulty focusing and concentrating. People can even have blurry vision as a result of dysautonomia because of blood flow issues, yes. So there's tons of you know, like cognitive and emotional things that are associated with it as a result of the autonomic nervous system failing to shunt blood to where it's needed in the moment. So this

 

Sophia Bouwens  33:52

is one of the reasons I was so excited to dive into this conversation. I think we just scratched the surface too. It's such a big one, and it's really misunderstood, because it is very complex, and it gets oversimplified incredibly into this rest and digest imbalance, fight or flight, and then over put into like we just need to stimulate your vagus nerve and you're going to be okay. I wonder. We'll maybe do some more episodes on different caveats of this. But are there main takeaways that you want our audience members to know from this initial conversation?

 

Dr. Ayla Wolf  34:23

Yeah, I would say the main takeaways are kind of what you described. Is that dysautonomia is actually very complex, and it does not automatically mean that the parasympathetic system needs to be stimulated or like that. Vagal nerve stimulation is the answer to everything, because it's not so that's a huge takeaway, is that people really need to get properly assessed and evaluated to understand exactly how the dysautonomia is manifesting for that individual person, and they need to be able to work with a provider who understands how to also then how. Triangulate other issues that might be driving the dysautonomia. So you know the ocular motor system, if there's imbalances there that can drive dysautonomia. If there are vestibular imbalances, the vestibular system fires so heavily into the brain stem. If that system is sending you error messages, it's the equivalent of living in a house with a fire alarm going off all the time. And so we have to recognize that when there are problems with the functioning of the vestibular system, the cerebellum, the, you know, the frontal lobes, the ocular motor system, the immune system, all of these things can drive dysautonomia. And so we have to look at it, you know, from a very individualized perspective, to say, what is going on with this one particular person, and what are what's the best path forward in terms of, you know, addressing some of the drivers for that individual and and then what do we need to do to not only manage their symptoms, but then also treat the

 

Sophia Bouwens  35:58

the problem Driving cause? Yeah, right. Yeah. Bigger picture. So

 

Dr. Ayla Wolf  36:02

that's, that's kind of like, the big takeaway is that this is way more complex than Tiktok would make you think, right, absolutely, and that vagal nerve stimulation is not the answer to everything. And then I would say, like, next time we can actually do a deeper dive into pots, because there's some, a lot of fascinating data on pots

 

Sophia Bouwens  36:23

has really predictable measures, we know, yeah.

 

Dr. Ayla Wolf  36:26

I mean, the one good thing about like, awareness around it growing is the fact that, up until now, a lot of people that suffer from pots often have to go for many, many months to years before they get the right diagnosis. And so I'm hoping that now that just everybody is kind of more aware of it, that maybe the actual screenings will happen better or more frequently, and that people won't have to wait three or four years before somebody figures out that that's what they're dealing with.

 

Sophia Bouwens  36:54

Well, let's dive into that the next episode we do just on exactly what those screenings are and some of these complexities with pots to understand even more this dysregulation of this autonomic nervous system. Perfect. Yeah, let's do it all right, stay tuned.

 

Dr. Ayla Wolf  37:13

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