Okay, I think it is 2 p.m. on this marvelous first day of May, and I am so honored and grateful to be here. I am Jonathan Ruchick. I am both a neurologist and an occupational medicine physician. I am in the San Francisco Bay Area for 20 years or so. I trained in neurology in New York City and then did, as a neurology fellow, occupational medicine and MPH and some EMG, and for about now 21 years I have a practice in San Francisco where I treat patients, mainly worker injuries, and do consulting on various issues of mental solvents, head trauma, et cetera, for both industry, defense, and plaintiff attorneys. I lecture at UCSF to nurses and physicians and lecturing to an ACOM and neurology groups. I do not have any conflicts. Today we are going to dig deep, but if anyone's heard me speak before, I kind of like to go soup to nuts, which leads me to be pressed for time, but I'm talking about a lot of different topics, so I'm kind of going to go, will be some basic things, but mostly those for the experienced folks, too, and certainly I'm available for questions at the end. We're going to talk about the simple diagnosis of concussion, seizures versus syncope, post-concussion seizures, traumatic encephalopathy syndrome, which is the clinical syndrome of CTE, movement disorders and neurotoxicology or neurotoxicity, functional neurology, which is a very big topic, COVID-19, and lifestyle medicine. I'm putting this all together with the idea that treatment for all these neurological conditions really goes back to the idea of preventive medicine, and away we go. We have a 60-year-old commercial driver. I use the term commercial driver because we're going to talk about some of that, who basically has a head injury. She's also an administrative office person, and I'll tell you, I see at least once to three times a week a person who bends over under her desk and hits their head. Anybody want to raise their hand how often they see these people? A lot. And the symptoms can get better very quickly or not, and I suspect you're in this room because a lot of people see people who do not get better so quickly. So the idea of a concussion, you've got to remember it does not need to have a trauma. Mildest form of traumatic brain injury, transient constellation of symptoms, witness or explainable acceleration or deceleration, comorbidities contribute to resolution, very, very major point of information. Recovery unique to the individual, another very important point. It's not that everybody's going to get better in two days. Anterior retrograde amnesia is kind of important for that diagnosis of concussion. Is there any kind of amnesia? Of course, we're looking at the Glasgow Coma Scale. Clinical diagnosis in the military and sports settings, there are a lot of algorithms and writings about how to take care of these people, but outside of that, there really aren't, which means that we don't all agree on what to do, or we don't all do the same thing when we're not seeing them in sport or military. So there's five million people a year who present to ERs, and it's likely underdiagnosed, so that's a lot, and falls and MVA are most common. So again, we're going to be kind of simple. How do you test for concussion? You really can't, but there are a couple of FDA-approved gadgets. CAT assessments, they're not really used clinically that much, GFAP and UCHLI, and if they are negative, are you really not going to get a CAT scan? Well, that's the goal of this pharmacological intervention. There are a lot of papers here that I reference. So as I said, we're not going to go into all the soup to nuts of mild head injury, but basically we see these people every day. Are we going to get them to go back to work right away? They're drivers, they're this, they're that. So if they don't have a seizure, you're certainly maybe thinking, is it now? Is it later? Is someone referring them to me to be cleared? Well, so the FMCSA says one year, but the 2009 expert panel says if no loss of consciousness, maybe one month or three months if there is. So again, Dr. Hartenbaum, I don't think she's in the room, might say, you're the doctor, you're the provider, you make the decision. So this is kind of the outline of what to do. You got to consider the individual situation. For police, I've recently written something about that, but it's very vague in the early stages for mild people. For firefighters, there's an NF national fire protection material that is also part of the LEO of ACOM. Anyway, returning to exercise, the way I like to think about it is, are you really doing all the things you did before the head injury? Are you exercising, not having any symptoms? Do you have any risks of any kind of issues that may very well lead to a problem? So the case continues, and the patient now at three months has a lot of symptoms, headache, anxiety, depression, et cetera. There's really nothing on exam except tenderness. Maybe there's tinnitus. We know that mild TBI is a more severe form of concussion. You're describing, rather than a diagnosis of PCS, you don't really want to say you have post-concussion syndrome. You have symptoms. So let's talk about them. Let's treat them. The more symptoms you have, it may be that the longer duration of post-concussion syndrome exists. It certainly is associated with litigation, extracranial injury, amnesia, loss of consciousness, and being female. The predictors also include things like prior history of migraine, prior history of childhood migraine, prior concussion addiction. So for athletes, we find there's a shorter duration of return to work and play, as I mentioned earlier. Maybe military as well. We have a lot of comorbidities. Maybe I'll go like this. Can they hear me now? Yes. So depression and anxiety, if they had these issues before. If they had prior disability, vertigo, tinnitus, sexual disturbance, bladder incontinence, stuttering, these kinds of things can be premorbid. Maybe they also had, we'll find out later in this talk, that there's always an increase of functional neurological problems, I see head nodding, when there are, wait for it, I had a problem, a medical problem, but the doctor couldn't figure it out. Well, interestingly enough, there's literature about that now, and it says that unexplained medical problems increase the risk for functional medical conditions. We all knew this, but it wasn't in the literature. So we talk about headache, and this could go on for hours, but we're not. The idea of migraines versus a tension. So I'm always looking, is it hurt when I touch you in the neck? Does it hurt you in the jaw, in the temple? No. Is it pulsatile? Is it exertional? So exertional, pulsatile, maybe migraines. Is it tension related? Then you're thinking, oh, ice, icy hot, Motrin Tylenol. The idea of migraine for me, for years, we never really thought that trauma could give you migraine. It seems that the epidemiology shows that migraine characteristics are very common in post-traumatic headache, but does that mean you're going to use Emgality? No. Not necessarily. It's a $30 pill. You do what you gestalt, know what to do when you get a headache. You calm down. You drink water. You make sure you're focused on sleep, mood, ice, heat, icy hot, Tylenol, Motrin, before you go to Diclofenac, et cetera. And then you think whether you need a preventive strategy. Excessive caffeine I'm thinking about. You're asking the history. Bruxism in TUMJ is very much an underdiagnosed thing from trauma. Look for it. Does it, even with a mask on, does it hurt here when you open and close? Does it hurt here when you open and close? Yes. Is that where the headache is? Yes. Oh, okay. Well, then maybe chiropractic care and massage is going to help a lot. Maybe then you also need a sleep study. But sure, there are things like glaucoma, trigeminal neuralgia, and so there are medication situations that you need to consider. Sleep issues. Huge. Obstructive sleep apnea. Did they have problems sleeping before? Do they have a thick neck? Do they have trouble with snoring? Does their relative say so? Their partner. Well, then that's important to get testing. Will it be authorized in the workers' comp? Don't know. But if not, use any kind of means you can to be creative to help them get it. Because it's treatable and it could get rid of all their headaches, even though the headache started after the trauma. Doctor, well, it's related to my injury, isn't it? Okay. Well, these are the things we're trying to look into because they are low-hanging fruit that are treatable. We don't need to know why. Your injury is already accepted. Let's try to treat you. So periodic limb movements and REM behavior disorder is also huge in the neurology literature now, and it's difficult to diagnose the questionnaires, but that may contribute. So is there a reason for ropinarol or gabapentin? Maybe. Post-concussion dizziness, huge, okay? But we think it's all in a category that we can easily identify. Is it BPPV or is it chronic this or that? These kind of events can recur and be chronic, and they also can be functional. So it's a wastebasket. If there's no nystagmus and maybe you do send them or you don't send them for an ENT consult for a BAER, then this can be a wastebasket, and we're going to talk way later about treatment for all these things. So BPPV, you're looking for nystagmus. Exertional dizziness, well, that could be blood pressure. It could be neck-related. It could be stamina-related. So you think about how to treat in those regards. Vestibular migraine, you're talking about stress and exercise and diet, all these things we're going to talk about more. BPPV, though, canalithiasis. Vertigo begins from motion. Well, they may also not get nystagmus, and it may be from neck pain or a head injury and we're not sure. But attacks can be less than one minute and recur in over two weeks. Again, at the bottom you see it's recurrent. So that can make you really confused. Hearing loss is absent, because if it's present, it might be many ears disease, okay, but in a certain population. So we move on a little bit into this patient who now has some sort of seizure event. I see a lot of people who don't get better from a head injury after six months to a year, and then they call you and your nurse practitioner and they say, I don't know, I may have lost consciousness. I kind of had some events. I don't know. What do you do? Is it a seizure? They're home. They haven't worked for two years. Whatever. They don't even know their history. But here's one important thing. Get them to take a video of it with their phone. That's big in the neurology lectures and literature right now, too, because you can video what happens. Can you video it? And then you can see it and you can look at them. So that's one idea. Is it functional? Is it fainting? Is it a seizure? When? So first of all, we're talking about seizure versus syncope. Fainting versus a seizure. The take-home message here is that seizure on the left, I can't hold two things. Yes, I can. Wait. Five minutes or so of post-tickle confusion and sedation. I'm tired, but I knew where I was. That's not really enough. Post-tickle confusion and sedation. I'm tired, but I knew where I was. That's not really enough. Post-tickle confusion and sedation. I'm tired, but I knew where I was. That's not really enough. Post-tickle confusion and sedation. I'm tired, but I knew where I was. That's not really enough. Post-tickle confusion and sedation. 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So there was a great paper in 2021 by some of our ACOM colleagues regarding the idea of all these factors and statistics to try to assess whether they can be going back to work and the issues of comorbidity and can they do their specific job is huge. Risk to harm to themselves or others. With regards to post-concussion seizures, most common in moderate to severe injuries. They're not so common in mild head injuries, but there is a risk of 0.5 to 10% overall. Those that recur in seconds, now I've really come across this recently because it's always confusing. And I wonder what LAO people think about this at some point. No risk of epilepsy if you have a seizure within the first few moments. Some Australian literature about this, concussion in boxers, didn't really, really know this until I read this recently. Early post-trauma does have an increased risk of epilepsy, but again, you're always thinking about non-epileptiform seizures in a mild head trauma setting. If it's within the first year, if it's after that, then you're confused because, gee, seizures get less of a risk from the mild traumatic injury. They get less as the years go by. Medications amazingly enough recommend it, but there's really no evidence that it's going to reduce the risk of epilepsy. The idea of maybe it reduces the risk of the first seizure, but then still it doesn't reduce that risk of maybe that second seizure, meaning the second seizure means that they now have epilepsy. Seizure type. I also often have these patients who have maybe like an absence type seizure in their year one, year two, and it's clearly anxiety. They haven't worked. They might have lost their home, their family. So it's pretty sensitive. Usually I'm thinking functional, but is absence seizure at all related at all to post-traumatic seizure? Not a lot of literature on this because it's mostly focal, focal to GTC, temporal lobe, but there's a literature that says temporal lobe 25%. I couldn't dig that whether that was an EEG or whether they thought that there was some behavior when they made that statement. EEGs can be significantly abnormal, mostly slowing. I'm not getting any use of this though. PT, post-traumatic seizures more common in young males, prior history of head injuries, obviously prior history of seizures, but 20% of epilepsy is probably related to a mild TBI. 20% of epilepsy. When does the seizure happen? Well, mostly it's the highest incidence is early and it wanes, but there is a risk over 10 years. So those who are thinking about whether return to work people who have a head injury, there is an increased risk of probably two times a person without a head injury up to 10 years. It's probably up to eight times in the first six months from this literature, Mahler and Frye. 30% of unprovoked seizures had a head injury six months ago, 60% had them within the last two years. So if you had a seizure, 60% of those people who had seizures had a mild traumatic injury to within the last two years. At 10 years, the risk is doubled for mild TBI, eight times for severe, as I said. Latency is 9.6 year, average severe TBI 1.6 years. These are the factors that increase risk, obviously alcohol, SDH, ICD, ICH, intracerebral hemorrhage. So gee, doc, will my head injury give me dementia? You only get this question every day. So we understand this nosology of mild concussion, mild severe concussion, single head injury versus multiple or complicated head injury plus prolonged concussive symptoms, probable CTE, then a subclinical or chronic. And where do we go with all this? Well, it's been very confusing, but last year there was a consensus report that describes the idea of traumatic encephalopathy syndrome, not CTE, but what do you do when the person has the syndrome that looks like CTE? What is that? Well, interestingly enough, it can overlap with the real dementia or it can overlap with functional things. So there's usually involvement of high exposure contact, military service, multiple head injuries, but there is cognitive impairment plus progression, preferably substantiated by a standard measure. That's what they say, but they made neuropsych tests obviously, hopefully with validity testing, not fully accounted by other disorders, and a level of functional dependence is the way they grade it. It's a clinical syndrome, not intended as a diagnosis of CTE, but there's lack of pathological data other than for football and boxing people. So other than that, we don't really know if CTE exists that well in non-boxing football players yet, and preponderance research suggests that single moderate to severe TBI is what demonstrates the chronic or progressive impairment, nothing else. But yes, we know there's pathology of the one hit situation and young people who've gotten in hockey or football who then died, who then had pathology. The idea of pathology is unclear, there's a disagreement of what the pathology is, and biomarkers lack anything but post-mortem stuff. So don't make the pre-morbid diagnosis of CTE, it's only going to lead to problems, and in fact, there's literature showing that some of these people lose their focus, they can't get treatment, and they often hurt themselves. So it's very bad, your goal is to treat them. We switch gears a little bit, because we're going to keep on this fun with neurology theme. Our patient has a funky tremor. Huh, what? And slow, not fast, muy despacio, nice and slow, pay attention, pay attention, nice and slow, pay attention. Arms out straight, and arm like this, slowly, can you go slower? What's entrainment, by the way, anybody know what the word entrainment is? Muy despacio. Look at the left arm, there you go, what happened to the right arm? I want to see what you just did there, go ahead, good, keep doing the hand, go ahead, circular, circular, I want a circle, look at the right hand, now go like this with the right hand, 1, 2, 3, 4, look at the slow change in the right hand, muy despacio, left hand changes, 1, 2, 3, 4, 1, 2, 3, 4, look at the way the right hand changes, it changes from being circular to round, this is a very debilitated woman, very sad, about 3 years after the event, she has these total body shakes, and I really thought it was functional from the beginning, and she's seen some movement disorder colleagues, and slow, it's pretty functional, but so what is essential tremor, though, gee, let's start from the basics, essential tremor, which is much more common, upper limbs, but it may include head, voice, lower limbs, could that lady have an essential tremor, it's worth discussing, the laterality is bilateral, the duration has to be 3 years, absence of other neurological signs like dystonia, ataxia, Parkinson's, but an isolated focal tremor, head and voice task specific tremor, it should be absent that, it needs to have more than that. This is simply the Netter picture, which shows the drawing, you know, when you have micrography, it's Parkinson's disease, but, you know, tremorless circular drawing is usually an essential tremor. Parkinson's disease is a bradykinesia, plus tremor, plus rigidity, and unilateral. And there's also very interesting literature now about REM behavior, sleep disorder, and olfactory loss as prodrome, as well as constipation and anxiety. So, but there is always a clear benefit to dopaminergic medication. But there's no real cerebellar signs or autonomic stuff. There's some, or severe autonomic stuff that is, because there's all kinds of Parkinson's plus syndromes, but you have to start with this. This just shows a slide of a severe debilitating gait disorder that would be Parkinson's. But there's a functional tremor, which is complex, present in all postures, and variable, and the idea of entrainment, meaning if I show you to do this, it may either distract the other limb, or change that limb, or the other limb. Alteration. So, this is an interesting skill that we all should learn as providers to kind of assess an unusual finding that we have. Functional Parkinson's, you know, maybe it's a Parkinson's, it's a gait problem, but it's really slow. It might really be exaggerated. But, oddly enough, it's, there's a high incidence of co-occurrence with Parkinson's disease. So, well, that throws that out the window. Functional gait disorders can be bizarre. The patient's balance is demonstrated to be better than claimed. What's this? Back. Hello. There you go. What are you doing there? Okay, you stand back up now. Look at me. Look at me. Look at me. Open and close your hand. Open and close your hand. No, just look at me and do what I'm doing. Open and close your hand. Hand stop. Just the right hand. Open and close as fast as you can. Come on, focus on the hand. Count to five. One, two, three, four. Now, change to the left hand. One, two. Now, let's see. March in place. You can do it. March in place. Good. Come on. Very variable. I mean, come on. Anyway, the biggest problem that we have as providers is judging these people because it's a mess. She's not trying to do this. It's extremely sad. You know, you're thinking, well, she's trying so hard to show me the tremor that when she's trying to open and close the arm, so she's got to be, you know, intending for this. It's much more complicated than that. We have to have some, we have to have care and help these people. What about functional dizziness? Really? I mean, we just, I just thought that these people have chronic forever dizziness from head injury and they don't get better for various reasons. But, well, there's something called persistent partial perceptual dizziness. One or more of the symptoms of dizziness for three months or more, persistent without provocation, exacerbated by upright posture, active or passive motion, exposure to moving stimuli. Well, it kind of sounds like our head injury post-COVID people, right? So you're seeing where my lecture is going because all my stuff is talking kind of similarly. Post-concussion, functional neurology. We'll talk about COVID and stuff later. Significant stress in this situation. What's a functional cognitive disorder? What? Well, there's now literature about people who take on the role, get so anxious about their cognitive impairment, if it exists at all, that they then do much better on neuropsych testing or they hold full conversations with you and they may not have any progressive symptoms except for the anxiety and depression that bring them down. Well, there's a disorder that this is being really elucidated and focused on a lot by neurologists and neuropsychologists in the, you know, in the dementia sections of our university hospitals. Psychogenic and non-epileptic form seizures. Emotional experiences have three times the risk. There's a great provider of physicians, psychologists, actually a psychiatrist neurologist at Brown who recently lectured at Academy Neurology, which I thought was great. Risks of youth include unexplained symptoms, ding-ding-ding, psychopathology, family dysfunction, learning and social difficulties. So it's not, but the thing about functional neurology disorders, we don't need to identify in a history that they had one of these. Well, because as providers are not spending that much time, used to be you have to identify that stressor. Now, the criterion has lost that, but we often do find that and in fact, it's a predictor. Adult risk include personality and psychiatric or psychological disorders, medically unexplained symptoms in the past. Functional disorders may mimic almost any neurological symptom, inconsistency and incongruence. They should not fall into the gap between neurology and psychology or psychiatry. This is what often happens. Just like neurologists send it to the psychiatrist. Psychiatrist says, I don't do that. Psychiatrist sends a neurologist. Neurologist says, I don't do that. Who's gonna do it? It's pretty, it's a pretty sad situation. So no clear objective findings. The terminology is important because you have these conversions, somatoform, psychogenic, dissociative, non-organic. 14%, I think this is very under diagnosed, of the new neurological evaluations were deemed functional. But I think it's like 30 to 50% of all new patient visits of any and all university clinics. What's a Hoover sign? We all love this one, right? Oh, should I go back? Let's see. You know what a Hoover sign is, right? It's if I'm gonna ask the patient to push down with the right leg and they and I want to assess what they're giving full effort. I use the left leg to see whether they're actually trying. Cue the video tape. I want you to pick this leg entirely off the bed. All the way up high as you can. To the ceiling. To the ceiling. To the ceiling. To the ceiling. To the ceiling. To the ceiling. To the ceiling. Come on. To the ceiling. Look at the left leg. No real effort. Again, intentional or just not sure? So that's a positive Hoover sign. Push me up. Push me up here. Okay. Okay. Relax. Let's try this again. This leg. This leg. The left leg. I want you to push up against my hand as strong as you can. Strong as you can. Come on. Come on. Strong as you can. Strong as you can. Strong as you can. So we're not getting anywhere with that. Everybody understand that? So, high prevalence for movement disorder clinics, general medicine, unexplained symptoms, 33% of primary care clinics, disability and occupational impairments equal to defined diseases but higher rates of psychological comorbidity. No western or modern invention. Worldwide similar frequency. Neuroscience is there in that there are functional medicine, MRI and more PET scans and fMRI kinds of abnormalities in supplemental motor cortex and prefrontal areas. What kind of strategies can we develop and there will be to help these people with their genetic susceptibility. So how do you handle them? You focus on the symptoms, what brings them on. You communicate that. You don't tell them and mislead them. Or if you do, you tell them when I distracted you, you did this. You try to really be front forward. You focus on what triggers they have. And this idea of fear avoidance treatment is really huge. But it requires a really hard working psychologist or neuropsychologist. You talk about what it is and what it's not. And you don't really tell them what they don't have after you said, well, you say what they don't have. And I know it's not this. I know it's not that. So I think it's a software problem, not a hardware problem. And you tell them distractions improve their condition. Like we saw in the two different females. It's not MS. It's not epilepsy. But these people often may have PTSD. What is the diagnosis of that? What's that? It's greater than a month. Functional impairment. There is a traumatic event. There's avoidance. There's intrusive thoughts. Numbing or negative alterations. Alteration of arousal or reactivity. Of course, there's risk of substance abuse. Military personnel, very high prevalence. Associated with heart disease. And treatment is all kinds of things. Mindfulness is huge. We'll talk more about it. Okay. We're going to talk a little bit about neurotoxicity. Neurotoxicology. And we're pretty much going to focus on movement disorders and what kinds of things can cause movement disorders in the workplace or the environment for the next few slides. So we start with a carbon monoxide exposure in that we have a person presents with a tremor after being in enclosed space. And he has a HBCO of 19. Kevin and Bimbo. And how old are you, sir? 53 years old. Do you have any family members who have ever had a tremor or Parkinson's or Alzheimer's? No. Any brothers and sisters with Alzheimer's or tremor or Parkinson's? No. Your wife has multiple sclerosis. Is that correct? That's correct. Okay. How long have you had it? 20 years. Put your left hand also on your lap too and uncross your legs if you could. Tell me what happened to you and when this happened. How many months ago did this begin? Three months ago I was exposed to carbon monoxide poisoning while saw cutting concrete inside a confined space. Had you ever used a respirator before? No. Was the respirator specifically for carbon monoxide? I was told that it was, but it was not. Okay. And so this was in a confined space or what exactly was the room like? Did any windows in the room? There was just a door and no windows. Okay. And who else was with you? I don't need to hear his name, but just what was your one colleague in the room with you? Yeah, one fellow worker. Okay. And then your other colleague outside the room? Yes. And how long do you expose do you think? 30 minutes. Okay. And what was your first experience that was negative? Getting lightheaded and dizziness. Okay. Did you get nauseous? Later on I was feeling nauseous. Okay. Did you lose consciousness? No. Did you hit your head? No. Okay. Had you ever hit your head or had a psychiatric illness before? No. Taken psychiatric medications? No. And you never had an exposure and got sick before it worked, did you? No. Okay. You also noticed a tremor. When did you first notice a tremor? At the time of the exposure. How many months ago is that now? Three months. Okay. So how has the tremor changed since you first noticed it? It was a slight tremor at the beginning and it increased over a couple weeks period. Okay. When do you not notice the tremor? It lessens just prior to going to sleep. Okay. Any other medical history that you have at all? Other than I had Bell's palsy approximately 30 years ago. Okay. Put your hands both up in the air. Okay. And tap your right knee over like this. Open and close, open and close. First finger. Okay. And tap your left knee. There you go. Open and close, open and close. First finger. Okay. Show me your teeth. Okay. Could we cross your arms and stand up from a chair? Okay. Stand over here and face the wall. Put your arms down. I'm going to pull you back. I want you to keep your balance. Try again here. Okay. Have a seat over here again. Okay. Actually, I want you to stand up. Stand up for me. Put your arms straight up in front of you. Okay. Take your left hand. Touch my finger. Touch your nose back and forth fast. Your right hand. Okay. Turn your head slightly to the right. Okay. And keep doing that. Open and close your left hand. Okay. Put your hands both out, outstretched arm. Okay. Kevin. So we noticed that the tremor did not really change, even though I could have done a little bit better job as a one-handed videographer. But the tremor didn't change when we asked him to do other activities, interestingly enough. So the idea of carbon monoxide and carboxyhemoglobin, it doesn't always assess the severity. But there is literature on the idea of vigilance, headaches, and what kind of HBCOs may lead to a disability. Increased morbidity with greater than one hour of exposure. I mean, certainly for him, we wonder if the tremor did exist in the beginning. Probably not. I saw him like month four, I think. We know that carboxyhemoglobin or carbon monoxide can lead to a fatal arrhythmia. We know it's an odorless and colorless gas. So you assess these things. You identify whether there's a smoker. You identify what HBCO is, what's oxygenation. You try to treat these people. The idea of oxygen versus nasal ganglia versus hyperbaric oxygen. The idea of whether an asphyxiation can occur from a mixture. And what other things they were doing. Of course, the literature on hyperbaric oxygen, you can read about it. Whether there's a change in mental status, whether they're pregnant. And then there's all kinds of vagaries as to whether it's beneficial and at what point it may reduce the half-life of the carbon monoxide in the blood. So hyperbaric oxygen may very well help people with the late sequela, but the literature is still vague on that. One can actually calculate the PPM from the HBCO if you know the duration of the exposure and vice versa. It's important to do this and compare to the literature to see what may very well come. There's neuroimaging that's important from MRI. There's even now PET stuff and metabolic testing that one can do and assess. These are mainly sensitive but not really specific kinds of tests, however. Neuropsych testing is important, and there are parameters for how to do neuropsych testing and what tests to do. Always validation, validity tests are important in neuropsych, and usually tests and retests are important. 10% to 30% may develop delayed neuropsych symptoms as well. There's some literature for peripheral neuropathy, although small. When we're thinking about any kind of exposure, we're always thinking about what was the preexisting history? What's going on now? What's happened since the exposure? Parkinson is usually unresponsive to medication. It's an atypical Parkinsonism, not Parkinson's disease, and there's always PTSD issues that we need to think about. Assessing a consistency of an exposure and the condition is important for any occupational mental health evaluation. We know about carbon dioxide, the parameters, and the idea is color is odorless, and there's 50,000 or so deaths in a 10-year period, often from faulty gases. I remember growing up, we had a family friend who's lost their son who went to a cabin and didn't open the flue in the cabin, and this is unfortunately still going on, not uncommonly. So, gee, do we need... Maybe someone knows of a good app that tests for carbon dioxide in our phone when we go to hotels and go to places, but that certainly would be useful. There are all kinds of regulations and recommended levels. Important to know what those are, comparing them to your patient. Movement disorders are rare, usually onset two to eight weeks, like any other neurological issue, and there's usually a good prognosis, but there are patients who have a monophasic presentation and then maybe they have a tremor after having mutism, incontinence, and gait disturbances. So I recently published a paper about a patient like that. Again, looking at any evaluation of a patient with an exposure-related problem, is the chronology consistent with the exposure and the syndrome that they have, the symptoms and the exposure? Is there objective evidence, exam findings, diagnostic tests to support subjective complaints? Is their exposure significant to cause this condition? Is there a simple explanation or confounder in the history? Does the literature, animal or human, support any specific condition that you're describing? What is the disability, and is that disability related to prior problems, the exposure, other traumas, or other things that happen between then and now? All important stuff. What's the motivation of the injured? What's the motivation of providers? Our health care is a challenge for people to receive good care, good motivated providers. If you have an injury and you don't have insurance, or even if you do, where are you going to find the provider to listen to you and to consider all options? Even if they didn't work on the first time, therapy can be different from different provider. Meditation therapy, we'll talk about this as we get closer towards the end. But Parkinson's disease can also come from solvents. There's a lot of literature that describes case studies of people having solvent-related Parkinson's disease. There's this basis of Parkinson's disease coming from drug abusers and the neurotoxicity of MPTP, which is a mitochondrial metabolite, and also leading to these Parkinsonian features from presynaptic dopamine cells in the substantia nigra, which, if I can show you, is the midbrain substantia nigra right around here. There you go. Solvents such as trichloroethylene has been identified where there's a metabolite that can also have neurotoxic properties in the midbrain. There's actually some basic science that has been developed to support these ideas that patients who have solvent exposures retrospectively, in fact, there's an explanation for this neurotoxicity. There's animal literature, and there's individuals, and there's groups, and then there's now basic science for trichloroethylene particularly. One of my colleagues at UCSF, Dr. Goldman, has published a twin study and described how there's exposure to trichloroethylene, significantly the odds ratio of greater than six for increasing the risks of Parkinson's disease. Then there's a twins veteran study comparing the exposures to the subject and the twin, reducing confounding, and, in fact, showed other increases as well as other papers describing solvents or toluene, so there's a greater risk for PD but tended towards typical significance. Obviously, we're interested in the small details of these kinds of epidemiologic studies. Other papers described younger onset of age in a standard type of Parkinson's. In other words, the Parkinson's that we described earlier where they do respond to medication, maybe unilateral, rigidity, tremor, what have you, but usually the age of onset for general Parkinsonism, standard Parkinsonism, is in the young 60s, but in these cases, they were five, two more years younger, which is statistically significant, and that's a theme for solvents as well as for welders and people exposed to manganese. I saw about 300 people years ago now and found that most had no evidence of neurologic illness, but basically there were 15% with a mean onset of 50 years old to develop Parkinson's disease at an earlier age. What is manganism? Manganism is the idea that it can be atypical with significant high-level exposures, usually short-term high-level exposures, and there are probably abnormalities in the MRI, but there's also early onset regular Parkinson's, standard Parkinson's, that Parkinson's disease that does respond to medications, but it comes at younger ages of onset. And there's also neuropsychological abnormalities. And they have all kinds of other kinds of symptoms that are neuropsych, erectile dysfunction, sleep, and that literature has been developed more in the last 15 years. The idea that genetic influences matter, neuropathology relating to alphas nucleon, and that these types of abnormalities are also in other neurodegenerative diseases. And then the idea that welders were found to have abnormalities in alpha-synuclein. So there's basic science also developing with the idea that manganese can lead to Parkinson's disease from through basic science affecting the cell. The same kind of pathology that we know Parkinson's disease has in vitro. We know also that pesticides such as Maneb and Rotenone and Paraquat have been implicated, more than implicated with increased risks of Parkinson's disease. Patients in the Central Valley who lived near 500 meters from a home where they was found to use Maneb and Paraquat were found to have increased incidence of Parkinson's disease. Rotenone is used to kill fish and other animals. Paraquat's usually, I missed that. Paraquat is used for potatoes, beans, and tomatoes, interestingly enough, in the home. So strongly associated with increased risk of PD and the pathological mechanisms were well-founded. Again, early onset of PD. There's heritable genetic factors relating to this early onset of Parkinson's disease. So this is obviously a susceptible population. It's not that everyone would get that from these exposures, but that some are susceptible than others, more susceptible than others. The idea that neurotoxicity exists, it's the idea that chronology precedes the onset of symptoms, the exposure. The agent is associated with a neurological diagnosis. Condition is not easily explained by a neurologic or psychiatric entity. Neuropsych testing is important. The idea of test and retest methods. The idea that some domains may improve, other may remain abnormal. Progression is rare after removal, unless these are issues of anxiety and PTSD, and that's quite common, so they can be confusing to the evaluator. Imaging and literature is very important to assess these and predict abnormal domains of testing. PTSD, depression, somatoform injury can be difficult to separate, and one needs to really have an understanding of the neuropsychiatric results in these three types of patients. Very difficult to find. Not to mention the statistical significance of an abnormal neuropsych test. So you're using the history, the exam, and the testing. Imaging, examination, neuropsych testing, test, retest, and these are complicated assessments. We pause. Any questions for the moment? Too many. So obviously, we've been dealing with this for more than two years, you know, COVID, and, you know, what's COVID's gonna cause? What's the vaccine gonna cause? What's a long hauler? What's a long-term care plan? What's a long-term care plan? What's the vaccine gonna cause? What's a long hauler? What are either the COVID infection or the vaccine lead to? What are the risks? And so, obviously, still quite a black box, but this patient, hypertension, moderate obesity, develops COVID in the workplace. The discussion as to whether COVID is industrial is a whole other world. I had recently a deposition for the first one that asked about industrial causation. I'm like, I've seen gazillions of COVID patients, but no one's ever asked me to be deposed about the causation. The patient is a nurse, but apparently, before she had COVID, she was quarantining because her son had COVID. I'm like, okay. Anyhow, three months later, the patient, in this case, complains of brain fog, hair loss, headaches, postal tinnitus, right? Well, sort of similar to a head injury or a person who falls out of a tree or a person in a car accident, right? Kind of is. Sort of, except there's no shortness of breath. These kinds of people, they may have shortness of breath, although you certainly may see stamina issues and difficulty with exercise tolerance in head injury. So the MRI, in this case, though, did show some increased intracerebral pressure. I was fascinated, but before I could give her medicine, she said she was feeling better, did not need to do anything more, and she did improve, which is good news. But there has been some literature on, I think I have to say this later, on increased ICP in some small population of maybe young women. This other person, obesity, allergies, two weeks after recovery, admitted with anaphylaxis, course of steroids, painful sensory neuropathy, hands and feet. So is this from the anaphylaxis, from the COVID? What's this all about? Some small fiber neuropathy. So all this stuff is kind of, we don't really know, but we do know that a lot of literature about all these different symptoms that patients have, headaches, dizziness, brain fog, and now PPE headaches, long-term symptoms more common in young female, anxiety history, in the history of depression, as many as 80% are those with long-term COVID. Some of the papers retrospectively found 80% of the people that had a history of depression. 80% of the people that had a history of depression. Headaches can be associated with ICP. They say that migraine medicine doesn't work as much. Not sure who wrote that, but it's true, and it's even a lot of neurology literature, and UCSF Neurology Conference and the Academy Neurology Conference all say that. So I'm sure the migraine pharmaceutical companies aren't that happy about it, but that's true. So using Tylenol Motrin, things that you know, maybe gabapentin. A vaccine not associated with a headache or not specific to the COVID vaccine, but there is a vaccine-associated headache that they write about. Certainly a few reported Guillain-Barre. The idea of stroke, hold on a moment, I'll show you another slide. No specific treatment, but basically stress management, hydration, exercise, apps, journaling. We'll talk about this. So this whole list of the whole, you know, Megillah, so to speak, of post-COVID symptoms are wide and varied. Fast-beating heart, dizziness, cough, menstrual period, tiredness, brain fog, joint muscle pain, diarrhea, and there are groups of people like this. We all know them. What do we do with them? Aha! In fact, there was a study of 86,000 people in Sweden. There was an increased risk of COVID-19. I didn't give you the whole study here, but basically there is now evidence of increased risk of MI and stroke from COVID, so get your vaccines. That's what the bottom line of this paper was from Lancet. There's a lot of neuropsych literature about how to help these people, but they found anxiety, depression, fatigue, sleep disorder, very common in these people. Some cognitive impairment found, but they felt it was unrelated to the disease severity. Methodology was criticized. Emerging factors, perceived stigma of infection, infection of a family member, social isolation, prior psychiatric history, all issues of importance where there'll be more things for you to read about it in JAMA and in every other journal that you get. I get way too many. So, we put all this together. We think about head injury, functional neurology, functional tremor, functional seizure, functional cognitive issues, COVID, and we think, boy, we kind of have to look at these people very similarly. What about peripheral neuropathy, sensory neuropathy, these people who have the wastebasket of a peripheral neuropathy? We're not sure what to do with it. Lifestyle medicine is huge now, and it's more important not only for these people, but for everyone in this room. So, the next bunch of slides are gonna be talking about things that we can do for ourselves and we can teach our patients because of what we've done for ourselves and how it's worked, and we can motivate them to focus on all these different areas. Prevention and secondary treatment. This is what our life's about. This is what taking care of people is about. But when you talk about headaches, sure, there's Tylenol. You try to keep it to a low amount a month because this medication overuse headaches. Creams and lotions, sure, there's people with medications. Medication overuse headache is huge for all these people because people are giving out medicines far too much. What's the diagnosis? Yeah, 10 to 15 times a month. That means you have a medication that's giving you a rebound headache. What do you do about it? Get them off it, make behavioral change, get them to do a headache journal, get them to use creams, ice, lotions, and maybe put them on a preventive medicine, and that's what the literature shows helps them. What about dizziness? Well, we know about the Barony Maneuver and this maneuver. Take a picture, do it yourself, be able to do it yourself. Demonstrate for your patients in the room. Know how to do it. It may not help everybody, but it will help some, and it'll help a lot of people, actually. What about other things? Well, ENT talk about pencil push-ups. I'm looking at my finger and I'm basically going up and down and looking at the tip of my fingernail. I'm going left to right, I'm going up and down, left to right, near and far. Left side of my body, my visual field, right side of my visual field. How many times a day do you do it? I don't know, five minutes a day, three times a day. The other idea I have, which is a good one, I think, as well, get a balloon or a ball and throw it from your left arm to your right arm. Focus on your visual praxia, your ability to move your eyes and develop stamina, maybe with a balloon initially, because it moves slowly. You look at the balloon, you bounce it to the left arm, you look at it again, you bounce to the right arm, you bounce it off the wall. It moves slowly, you don't get a symptom. It's a sub-threshold exercise. And then you increase it with a tennis ball or another ball. So it's sub-threshold exercise and stamina for your vision. Yes, visual vestibular therapy by a physical therapist. It matters to how good the clinician is. Maybe you need an ENT to do testing. If you find nystagmus, BAERs, and maybe you need prism glasses for people who have converging disorders. That's kind of the threshold and algorithm I kind of like to use. Boy, what about sleep hygiene? Are we all doing this? I certainly should. Regular bedtime, cool, dark room. Do we all know that if you're in a cool room, you sleep better? Uh-huh. There's literature on this. Look it up. Limit device in blue light. Yeah, two or three hours before you go to bed, don't put it in your bedroom. Avoid caffeine in the afternoon. Eat lighter dinner. Mindfulness or sleep meditation. Everybody, nightly wind-down routine. Sure, there's medicines, and I'm going to teach you something you might not have known. Sleep hygiene, CBD, behavioral therapy. Sure, magnesium, zinc, melatonin. I like a very low dose of melatonin. It's usually given far too high. There's literature that three milligrams of melatonin might be preventive for headaches. So you could try it. I think it's grade C evidence for preventive neurological medications for headache, migraine, post-traumatic headache. Three milligrams for a month reduces headaches in quantity and quality. Maybe sleep too, acupuncture, et cetera. But, dun-da-dun, I don't think anybody knew this. Trazodone is not on my bad list. Trazodone, older folks who've used Trazodone have found an increase in slow-wave sleep, and unfortunately there's a piece of this lecture that's missing. But the reduction of cognitive impairment, yes. Reduction of cognitive impairment or a prolongation of the deterioration of cognitive impairment for older folks who use Trazodone. Crazy. So there's no cognitive impairment from using it long-term, and it in fact reduces the risk of having cognitive decline. So that's some new information. But traumatic brain injury, as all these things, can affect autonomic systems. So they have all these symptoms, which may really be an autonomic neuropathy. Hypersensitivity neuropathy relates to stamina, but maybe there is a regulatory problem, an inability to regulate their blood pressure and their heart rate when they are exerting themselves or standing up. So you have to kind of use these sub-threshold exercise situations. I have them, of course. Keep a journal. Oh, I can go stand and cook for 15 minutes. Oh, great, great. Document the time. How long do you do it? What's your heart rate? Then you can go out and go walking and mimic that heart rate for that time. Then you can increase the duration of the walking, increase the intensity of the walking by checking your heart rate. And you can develop stamina, which will, without doubt, lead to improved stamina in your neuro-visual systems, your respiratory systems and your cognitive systems. Huge. Exercise below the threshold of your symptom and then increase the duration and frequency. So this is right out of Academy Neurology, you know, return to work, dealing with sleep, sleep hygiene, cognitive behavioral therapy. This is the...this great slide is about sub-threshold exercise and increasing it, going back to prior stages if you don't, but taking more time at each one. All this is all certainly very applicable to functional neurological difficulties. The idea of fear avoidance, because PTSD can develop from the tread trauma, from the COVID, from a problem that leads to a functional neurological problem. Fear avoidance behavioral therapy. Not easy to find a good counsellor, a good cognitive therapist, but that's what we need to try to do. We need to interview them all. Yes, there's all kinds of other things like hypnosis. I think that could be huge in all these conditions. Meditation, medication, multidisciplinary groups are number one. Big hit. Following up with and reassessing. A lot of people, a lot of workers, physicians are encouraged to say, quote, ready? I have nothing more for you. I have no more treatment I can offer you. Well, unfortunately, someday it could be us. And we have an undiagnosed or difficult-to-treat problem. We need a provider to stick around to help and go through the whole process again if necessary. Sure, get them back to work, try to close their claim, all these pressures from the insurance company, but we need to do both. We need to act in all those realms. Cryptogenic neuropathy. You know, you have people with chronic feet pain. What are you going to do with them? I have nothing else to do for you. Well, no. Let's talk about all the things we mentioned. Sleep, meditation, exercise, and diet because metabolic syndrome is huge in our population. Of course, I'm throwing this wrench in the whole idea is that, oh, we think that peripheral neuropathy is either large fiber or small fiber. Large fiber meaning we can identify with an EMG. Small fiber, people have pain, but we can't identify. Oh, so then we put it in the wastebasket of a metabolic problem. But unfortunately, there is now literature that describes a patchy upper limb predominant, really, small fiber neuropathy, which looks just like, well, conversion neuropathy or psychogenic neuropathy. I've seen plenty of patients like that. So again, we have to always be mindful of psychogenic, functional, and things that are supported by evidence, science-based evidence about abnormalities that are objective. But still, metabolic parameters are huge. 43% of adults greater than 60 have a metabolic syndrome. I think it might be higher than that. All these other things, triglycerides, independent risk factors, prediabetes, higher triglycerides. This is kind of a great slide that helps with integrating all these lifestyle and diets into the treatment for neuropathy, for muscle and nerve. Reducing weight, importing lifestyle. Exercise, gee, there's actually literature describing that sleep quality improves memory, improves mood, reduces the risk of cancer, obviously reduces weight gain and heart disease. All these things we know. Gut motility, there's literature on that. Okay, you ready for this one? Get ready to be uncomfortable. Only 8% of the people asked are able to agree yes to all these. I am within five pounds of my ideal body weight. I exercise 30 or more minutes a day, most days of the week. I eat plant-based whole food diet with fruit or vegetables most days. I don't use tobacco. I have two or fewer alcoholic drinks per day. Bing, bing, I get seven to eight hours of sleep per night, most nights. Okay, I'm not going to ask the room to take a poll, but I think it's a challenge for us all to do this. Now, of course, this is also, we're not going to talk about the challenges of all the populations in our country or in the world, access to be able to do this, whether it's financial or access to food or access to care, because that's a monstrosity, huge issue. Stressed, attention pulled in multiple directions, what? Skipping meals, inadequate sleep, neglected interpersonal relationships, overusing technology and substances. Sure, these are all of our people who have functional neurological problems, head injuries, COVID, and everything else, but it's also us sitting here in this room, all of us. Prevention, movement daily and resistance training reduces the risk of stroke, cancer, and dementia. That's all I have to do. Seven, eight hours of sleep reduce risk of metabolic syndrome, cancer, CV, dementia, depression. So, there we go back to that trazodone thing. Maybe we should be thinking about that. If we have a problem for a short term, there's nothing really wrong with that apparently, so far from what the literature is saying. Getting great sleep can lead to tremendous benefits for us. Doing all the other things can do it without pharmacology though. Identifying a stressor, ask for help in sharing the load, creating boundaries, talking to professionals, breath work, mindfulness, physical activity, all these things can help all our patients and us. Diet, good paper. Limit dairy and animal products, really. What's the movie from Game Changers from Christmas two years ago? I saw it, you guys should all see it. Netflix, simple organic foods, vegetables, whole grains, legumes, avoid processed foods. Stop before fullness. My grandmother didn't tell me that. Cessation of unhealthy habits, cigarettes, alcohol, illicit drugs, prescription, caffeine, overuse. Yes, this is all related to head trauma, functional neurology, seizures, and what have you, it is. Dementia prevention is secondary treatment for MTI, COVID toxicity, peripheral neuropathy, and functional neurological nutrition. Mediterranean diet, reduce risks of cognitive decline, minimal alcohol, modest dairy and meat, et cetera. Cognitive decline, however, the purists might say, gee, there really is limited correlation with diet and Alzheimer's disease. Mediterranean DASH diet, pescatarian diet, there's a neurologist named Dale Bredesen who's talking about the 12 mindful, 12 activities, 12 factors that can literally reduce the risks of neurodegenerative diseases, and there's really a lot of literature about that more and more. Intermittent fasting is a topic to be discussed, and eating less, three hours or so prior to bedtime and helping with the big cognitive decline. These are fact things that they describe. Environmental factors are very important. They help with gut, help with diet, exercise, and I think all very, very important to help our patients and help us. And with that, I think that's my last slide. I couldn't believe I thought I'd be over time. I did pretty well. Thank you very much. I really thought I'd be close. I would not be able to make an hour and a half, so I can't believe it. Anybody have any questions? Yes, I see one hand in the back. I don't see it. I guess I'll repeat the question for the virtual people. Yeah, I really can't. It's a clinical diagnosis, and as I mentioned the first couple slides, there is some FDA-approved gadgets which can be assessed, but their use is only to be really in the emergency room to determine whether they need a CAT scan or not. It's really only correlated with a subdural or intracerebral hemorrhage, so that doesn't have anything to do with a concussion. You know, what you have to do is look the person in the eye, interview the other employees, interview them, listen for inconsistencies, and is there an opportunity for the applicant or the claimant to be pulling your leg? Sure, and that's difficult. And it's difficult to say that they're deceiving you. Professor Israel, may I ask you, you may have the stage. Yes, you're not Dr. Israel, although I thought you were. I mentioned in a slide that that is something that you can do at the end of your assessment of a person with dizziness. I mean, look, if you see nystagmus, and you see a convergence disorder by putting your finger and looking at them and watching them follow close to you, and you see they have some intortion, you know, they may have a pre-existing weakness in a muscle, which can give them a double vision, and plism glasses may help. But first of all, how many neuro-ophthalmologists or neuro-optometrists in workers' comp do you know? Not many are going to accept your claim. So that's what I'm recommending these kinds of things to do, which are, you know, doing pencil push-ups and treating them or getting them vestibular therapy. But you may not find that the therapist knows what much what to do. Most therapists know a bit about, I went back, I think, most, no, they're farther, most therapists know about helping people with dizziness so they can get them started. But then it may recur, and then all these other things that we talk about are very important because people, you know, they don't sleep well, they don't eat well, they don't exercise, and so all these other things are a really important thing for them to to focus on as well. You just can't look at someone with small glasses. You've got to be broad, and all these kinds of people. Yes, in the upper left corner. Yes, the trazodone has improved their sleep, and they have less sleep symptoms from the literature that I read, and those lacking in sleep symptoms help with focus and concentration, and in fact, don't remember how long these people were followed, but they had less cognitive decline compared to the people who did not take trazodone. I mean, really interesting papers. That's kind of new, my thoughts, the last few years. Yes. Yes, well, I think we can all read about what literature is, but you know, if you look up the New York Times articles on these things, it talks about two to three hours, you know, before bed. There's literature. What is the real reason? What's the real, really causing the difficulty with sleep? Is it the blue light? Is it stress? I think the most recent thing I read was that it's not the blue light, and it's the stress and the hyper stimulation, so I'm a big fan of, well, how is it easy to get stopped two hours before bed? Not as easy as you think, but I'm big in putting it in a different room and stopping two hours. If you can do it in three, excellent. If you can eat three hours before bed, phenomenal. If you can make certain you take a warm shower, and then you're in a cool place, and you cool your bedroom down, I sleep better, I know that. Sure enough, there's literature on this. So, two to three hours. Other room. Tell my wife. Just kidding. Yes. Maybe I should repeat these for the virtual people. The question is, what's the correlation between my seeing problems with their initial treatment, people with traumatic brain injury or concussion? Is it that they were sent back to work too early? Did they get the wrong treatment? What have you? I think all those factors are true. You have people who complain. We know that prior history of psychiatric conditions with multiple symptoms after their injury, the more symptoms, the more likelihood that's going to be a delayed recovery. But yes, when you have a provider that doesn't listen, when the provider says you go back to work, that develops anger, which triggers all kinds of other emotional reactions. And because we're now looking at these situations broadly, not just the left forehead, we realize that the sleep, the mood, the anxiety, all these things matter. The diet, the exercise, all these things matter. If you don't feel well, you're not going to exercise, which means you're going to get worse or you're not going to get as better as soon as you could. So all your points are well taken. Yes, if you're sent back to work too early, if you're given a narcotic, that could lead you to have a longer return to work. Of course. Not good. So just spend some time. Make use of, you know, make-believe. Try to pay attention and see what kind of advice you can give them to help them. And yes, we understand that there are all these conflicts like, is it really a head injury? Was there really a work injury? Are they pulling my leg? Did it really happen that way? You can't really decide. And I know we're all in the role of both the investigator and the treater. We're kind of a treater, but we're also supposed to be the advocate. Plus, we're supposed to determine if it's work-related. So these are all in conflict with each other. We've got to balance that wire. You know, we've got to walk on that high wire and make sure we're, you know, ethically correct as best as we can. That's all we're doing. Whereas other doctors don't have that ethical challenge, right? Any other questions? Yes. Good question. I think anything you do as a headache journal, the question is, is headache journal therapeutic? Yes, because it gives you insight as to what might cause your headache, when you get a headache, what the symptoms of the headache are, how sleep relates to the headache, what the diet relates to the headache, what other stresses relate to the headache, and much more commonly, when I see post-traumatic headache, I'm thinking neck, jaw, sleep, or stress, not some sort of shushugamushi fever. So all that stuff is relevant to a headache. And the person, most of these people who are not getting better, are not very body-conscious. They're not very aware, because they might be running around like a chicken with their head cut off, too stressed. So maybe sitting down two or three times a day, especially if they're not working. The other thing I find very helpful is helping them, encouraging them to make a schedule for themselves. If they're not working, they feel miserable. Okay, you're getting some workers' comp benefits, hopefully. You can't do your job of a climber, a tree climber. You have a head injury. Let's try to focus on all the things you can do, but let's make a list of all the things you like about life. And let's say you like Mary, who lives a half hour away, but you can drive. Go see Mary on Thursday afternoon. You want to use the like the doors on Wednesday morning. You're gonna listen to some doors on YouTube, which is free. You're gonna do finger painting. You're gonna go out and look at your lemon tree. You're gonna go out and take a walk around the park. You're putting these things in your schedule, so you know what your schedule is for the next two weeks, regardless of your doctor visits and feeling like crap. And you're gonna also learn how to meditate, which you can, as a provider, teach them, which is a whole other hour-long lecture. But a psychologist, hopefully, will encourage them. Talk about free apps. Talk about apps that cost money. I like guided meditation. You may not. What's meditation all about? Have you ever meditated? I'm more and more surprised that people are doing things like yoga and meditation on their own, and they don't pay for it, and breathing techniques every day, which is great. So you find people who are active, and then you find under, you know, undereducated people with, who are immigrants, whose English is not their first language, who the community is not really, they don't have a warm community, they don't really know what to do. So this is your opportunity. And yeah, just because you're stupid XYZ is denied, you can spend your time giving them behavioral modification exercises. I listed a dozen just there. So that can be what our time is spent, and it might even be more useful to the patient. And maybe the carrier will benefit from it, too, because it'll actually help the person in the long run. Let's say they go back to work, and now they know how to meditate. They're not going to have as much of a risk of a long-term post-traumatic concussion syndrome, because they now meditate. This is an opportunity for them to teach, and then teach their children, teach their family, teach their community. I think it's a good thing. It's a major thing. Long answer. Any other questions? Yes. Yeah, I mean, it's ordered like crazy. You may find that if you have an accident and you have a lean, you might find chiropractors doing it all the time. Have I seen a bear that's really useful? You know, a bear is going to find a brainstem injury that's objective, that reveals something in the eighth cranial nerve, brainstem, or cerebrum. So, it's difficult to read. The waveforms are difficult to evaluate. I used to try to do them. You're looking at chicken scratch, and you're trying to put multiple waveforms on top of each other to see if there's any statistical significance, which means you picking a couple of waves that look alike for a peak. So, they're going to be abnormal if they're done well in a university setting, if there's an abnormality, and it's either peripheral or central. The goal is to identify whether it's a peripheral or central abnormality, but in a lot of these mild cases, we're not going to find an objective abnormality. If you find a stagmus, go for it. If you find hearing in a stagmus, go for it. If you think you need an ENT exam, they probably will order one because let's hope that they do one. But in private practice, they may not do one, and they may ask to do it, and no one does it. So, they may not get ordered. In a university setting, you know, the ENT or neurologist would order it. Yes. Look at the literature. That's what the side effects are just basically grogginess and sleepiness and maybe, I don't think nausea. I think nausea and constipation maybe could be on that list. But it's just the effectiveness is really at physiologic levels in our body, which is kind of in the below three to five milligrams. You know, we just flood ourselves. It's not going to do much. It's going to make you feel crappy. So, you're going to negate any effect you'd have. The question is about melatonin for the virtual people who are not here. So, why do I suggest one to three milligrams? Yeah, there's literature about three milligrams as preventive for migraine and preventive in post-concussion headaches and 0.5 to 1 may be helpful for sleep. So, everybody's different, but that's what's physiologic. Yes, in the back. Thank you. COVID to what? Concussion to COVID. Thank you. Yes, I gave the slides to the people. I think I'm hearing here that, oh, I have some questions here, too. I think I've heard that it was just uploaded. So, check now, maybe. Okay, let me ask some questions on the discussion. Although, I think I read before, let me go up higher if I can go. I don't know if I can do that. Can anyone check to see if it's on the swap card? I think I saw that it was. Yes, to the question. Yes. That's a good question for the LEO people in the 1, 2, 3, 4, 5th, 6th row. Raise your hands or hand more than one. Yeah, I mean, that's a good question. I haven't looked at the NF stuff in the last few months, but maybe there is. I mean, do you have a specific question about a certain type of seizure? I mean, the vagaries are really related probably to the person who had a seizure and is on medicine and has no new seizures. There is, you know, they're tending towards letting these people go back to being a firefighters after they have, you know, no new events and they have a consistent lifestyle for five to ten years, whereas commercial is ten years. There's exemptions in commercial and firefighter is now that kind of thing. If they're consistency with medications, they're letting people go back to being firefighters. So you got to be the provider though and make those decisions. Any questions I can answer? I'll ask you some of these live questions. The most, well, I can't go back to the beginning here. Let's see. We've seen significant numbers of employees who suffer from sleeping difficulties post COVID. There have been properly investigated. No positive findings. How do I look at this? Can you recommend comment on disruption of circadian rhythms post COVID-19? Yeah, I mean physiologically, I don't know the physiology right now going on. There's new and new literature. But I think all the things I've discussed are important. Step one, focus on sleep hygiene. There are really great lists of things that they should be doing and then thinking about pharmacology. But we've also described how Trazodone can be helpful for a lot of patients. That may be a good option after you try simple things like melatonin and Benadryl if you need a pharmacology. Let's see, I'm having trouble. No one taught me how to do this. How do I go up? Nope. Maybe, okay. There's some literature regarding, I just lost it, difference between idiopathic and manganese. Is there any difference between these, come on now. What is the deal? I can't read this, scroll to bottom. Difference between, okay. Is there a difference between these two and the PD induced herbicides, triclothrin? Well, I think it's difficult to say. We're talking about the early onset of PD in people with solvents and manganese and also pesticides. Or you have idiopathic Parkinson's disease at a younger age or atypical. So you have the idea of atypical Parkinson's disease or Parkinson's that's idiopathic, that's responsive medication that comes out that begins earlier. And so these are case-by-case basis as we just don't know enough I think at this point. It does say the slide deck is not on swap card. Don't ask me why. I'm not sure that was it. I don't know what time that is. But it certainly was, I think she said that it was. We keep reading this. Say again. Yeah, oh they are, okay good, fabulous, beautiful. Well, that's good to know. I know I got more questions here, but I can't. Okay, okay, any other questions in the back? I see a hand to the right, yes. I'm not sure how I'm going to be able to hear you. But speaking about COVID and post-COVID, is there any relationship between tinnitus and post-COVID? Any relationship between tinnitus or tinnitus and post-COVID? Yeah, it's definitely listed as one of the things a lot of people are complaining. What's the physiology? Is there an atrial nerve abnormality? Not necessarily on imaging. But there might be some functional imaging coming down the pike that we may find so. You know, usually this is olfactory area anatomy of the brain. And so, but as far as tinnitus, it's a symptom that people get from head trauma, from COVID, from toxicity. We don't really know where the physiology is for that specifically, but I'm sure we're gonna learn more about it. Any other questions in the room? Yes. Uh-huh. Good question. A lot of times I lecture about the idea of when you examine a patient and do a lot of testing, you'll find things that aren't necessarily related. What is and what isn't? An asymmetric pupil is a big thing that I like to talk about. But so bilateral hearing stuff, I mean, is that a noise-induced hearing loss? So you have to really know what that noise-induced hearing loss looks like. So those Achmed people in the room who passed their boards know about the notch. Or if it's not, if it's diffuse hearing, it could be age-related or it could be congenital. So you've got to make a determination. If there's no skull fracture, then the hearing loss situation is suspect in my opinion. It's sort of like, you know, you have a head injury and they have some neck pain and then you find carpal tunnel on an EMG, the carpal tunnel is probably from a cumulative trauma. That might be from cumulative trauma or it might be from congenital issue. So that's a great question. You know, when you're doing exams, you definitely find that patients have all kinds of abnormalities that you find that may be unrelated. Copy the slides. Copy the slides. Any other questions? I see a head scratch on the back. Not a question. Let's see. We talked about Parkinson's disease and trichloroethylene, COVID-19, swap card. Very informative presentation. Slides are visible. Okay, slides are visible, but the hard copy handout is not. I don't know what that means. Okay. Okay. Well, I know who to call, but I'm not sure what to do other than that. Any other questions? My information is on the first slide and I'm always available. I'm in the San Francisco Bay Area, and I really appreciate you guys all attending. And feel free to email me with any questions at any time. And happy spring. I'm around. Thank you. You

neurology

occupational health

concussion diagnosis

seizures

syncope

post-concussion seizures

traumatic encephalopathy syndrome

movement disorders

neurotoxicity

functional neurology

COVID-19

lifestyle medicine