Jimmy: Hello everyone and welcome back to the Shoulders Up Podcast where we break down complex headaches and dizziness. I'm Jimmy Pang, Doctor of Physical Therapy, specializing in vestibular and headache care, based out of San Diego, California. So I have a very special guest today. I have Dr. Lauren Young. So Dr. Lauren Young is a board-certified neuroclinical specialist and owner of Neuroelite PT based out of Lafayette, Louisiana. her practice specializes in complex neurologic. conditions such as stroke, spinal cord injury, spasticity, brain injury, and more. she also teaches continuing education courses and has served as core faculty in a hybrid accelerated doctor of physical therapy program. She's presented at national and state conferences and currently serves as the Lafayette District Chair for the Louisiana APTA. And her Instagram currently also boasts Over thirty seven thousand followers, which is amazing. Hi, Dr. Lauren, how you doing today?
Dr. Lauren Young: Hey, it is so good to be here. Thanks for that intro. I sound much busier than sometimes I feel, but some days it feels that busy. So yeah, I am so appreciative to all my Instagram followers and everyone who supports me.
Jimmy: Yeah, awesome. I hear you on the busyness thing. You know, I don't know, every day I think as business owners, especially in this PT field and neuro P T field, we're always juggling like six million different things, let alone patient care. So that feeling of constant dizziness yet feeling nothing is getting done. That is very, very I can definitely
Dr. Lauren Young: You just describe my day today.
Jimmy: relate to that. but beyond that, like so today's topic we're actually gonna be talking about A very interesting subject. And today's topic is gonna be about post-stroke dizziness. So I think we'll go ahead and just dive in with our questions. So can you explain to our listeners what regions of the brain are typically involved in post-stroke dizziness? So how does it differ from, you know, other forms of stroke?
Dr. Lauren Young: Yeah, so I I that's a great question. And and I think the the biggest thing that I try and r like tell people and I try and remember myself is like we have to screen for dizziness after a stroke. Like, even if someone is not telling us or doesn't look overtly dizzy, even just saying like, have you experienced any dizziness, any changes in balance, type questions. And screen for it because more often than not, they're gonna say, you know, I kinda have. And again, when you go in to start treating balance, you have to address the vestibular portion. so as far as regions go, like within the brainstem, you have all of your vestibular nuclei. So of course, if you have a brainstem stroke, You 100% should be looking for some type of dizziness with that stroke. With a typical like MCA stroke, you're not gonna see a lot of dizziness. That's you know, lateral cortex, looking at frontal, parietal, a little bit of occipital and temporal lobe as well. so you don't see it as much. some deeper strokes that get into that primary vestibular cortex, you might see it. But the one thing that I always like. To point out to folks is especially in a hemorrhagic stroke, there is a space occupying lesion there. If there is a space occupying lesion, even if it doesn't affect directly the area of the brain that's involved with dizziness, there is a chance that that area has been compressed, moved, affected. with a stroke. So that's like one of the reasons that I I ask those questions, especially in a hemorrhagic stroke, we know cognition can be an issue. So like you're gonna be looking for all of the signs that you typically look for with dizziness. Like, can their eyes focus? Do they when you sit them up, do they look like they're sitting if they can't communicate that with you? Of course then you have a cerebellar stroke and we know that the brainstem and the cerebellum are like tight. They are so closely linked that if you have some type of cerebellar stroke you need to be looking for forms of dizziness, vestibular dysfunction, nystagmus is is a big player there just because and I know nystagmus doesn't necessarily mean you're dizzy, but it changes that oculomotor view, which can pe some people will report as dizziness. So I think grossly vestibular is so complex as we all
Jimmy: Mm-hmm.
Dr. Lauren Young: know listening to this podcast. and so there is not one area that you can say, if this area is damaged, you definitely have to look. Of course we know brain stem is more probable, cerebellum is more probable. But when you get into strokes in the cerebral hemispheres, it's not quite as clear cut because there's, you know, primary vestibular cortices, there's the Vestibulothalamo cortical pathway that you're looking at. So it's multiple different areas to get the input that we're we're trying to to perceive from a sensory perspective. And man, I'm really nerding out right now, but we know that that vestibular input comes in from a
Jimmy: We love it. We love it. huh.
Dr. Lauren Young: sensory perspective, but then it also has outputs to give us our postural control. It helps with different reflexes that we we have as far as is maintaining our balance. So it is a sensory input problem if it's damaged, but it could also be an output problem which is is somewhat unique. Most of our sensory information then you know will travel to motor areas to then correct posture or to a volitional movement. it's just the vestibular system is very, very complex. It's it's divergent information. That information is coming in to the brainstem and going to so many different places.
Jimmy: Hmm. Lot to unpack here. you know, as I was paying attention, I started getting these flashbacks of spinothalamic tracts and all these things from neuroanatomy. god, but Yeah. Yeah. But you know, I loved
Dr. Lauren Young: Yeah. Yes, medium lateral vestibular spinal tracts, the reticulospinal, yeah, yeah, yeah, yeah.
Jimmy: everything you said. Absolutely. We see it more in those strokes kinda in the posterior regions of the brain, like a cerebrellar stroke or the brainstem where the vestibular nuclei are. I really like the part that you mentioned about the hemorrhagic stroke. How even though the blood vessel might have been in that area, it still can put extra pressure on the posterior regions of the brain. And then, you know, you kind of mentioned this as well. You can still see this in people who have maybe typical middle cerebral artery strokes. and I think that's largely because while we do understand a lot more about the brain, we don't have the entire thing mapped, right? Any and we don't have that anytime soon. So in many ways, in my opinion, the brain is still this kind of black box. So whenever you have this kind of injury, we can make predictions, but there's still very likely that something, you know, unexpected can come up. And then one thing I want to mention, at least in my experience, and maybe you can verify this too, as when I see a patient with a post stroke dizziness or especially like cerebellar infarct, where they also present with things like ataxia, they don't so much present with that typical one sided weakness as the you know the more common type of stroke like a middle cerebral artery. Would you would you agree with that? Yeah. It's ipsala it's ipsalat it's ipsilateral too. Yeah, yeah, yeah.
Dr. Lauren Young: Yeah, so if you want the neuroanatomy of that, I'll dive into it. So the cerebellar it is ipsilateral because the cerebellar tract double crosses. So it it does decassate just like our lateral corticospinal tract does, but then it decassates back. So it ends up being back where it came from. I I teach my students that, and then I started thinking about it, like you said. you don't see this one-sided ataxia. And if we talk about the cerebellum, the cerebellum has nothing to do with force production. So it's really only that coordination piece is is really what we we kind of talk about. but it modulates force production, which is like kind of a hard thing to wrap your head around. It's like it doesn't Right? Like it's not recruiting motor units like the lateral corticospinal tract is, which is the tract, you know, that does volitional activation for anyone who just needs that reminder from PT school. but it it does volitional activation mostly of our limbs for fractionated movement. So
Jimmy: Mm-hmm.
Dr. Lauren Young: the cerebellum is then saying like Well, how many motor units are we recruiting? So it's like the lateral corticospinal tract is actually activating the units. And then the the cerebellum is saying, like, okay, well, how many do we need to be able to take a bigger step over that puddle or whatever we're doing? so that's something that's like just sometimes hard for me to like wrap my head around. I'm like, okay, so this
Jimmy: Yeah.
Dr. Lauren Young: isn't generating force. so again, we don't typically see the weakness piece after a cerebellar In Farct, we see a motor control issue. So it's harder to control your limbs. Again, if it was only to one side, then we see it the ataxia ipsilaterally. The issue is, and Jimmy, you know this, there's not, it's again a space occupying lesion.
Jimmy: Mm-hmm.
Dr. Lauren Young: So if I have an infarct to one side of the cerebellum, most likely I've compressed something and I'm gonna see the ataxia bilaterally because there is just not enough room. It's it's not as I don't wanna say clear cut, but c you know, as clear cut as like a a stroke to a cerebellar, I'm sorry, a cerebral hemisphere.
Jimmy: Mm-hmm.
Dr. Lauren Young: so that's you kind of see the bilateral deficits, even though.
Jimmy: Mm-hmm.
Dr. Lauren Young: Technically it's an ipsilateral problem if it's like a stroke to the left cerebellar hemisphere.
Jimmy: Yeah, your neuroanatomy knowledge is definitely shining through. I'm just nodding here, pretending, pretending I understand. Which which for my listeners,
Dr. Lauren Young: Like yeah, yeah, I wasn't
Jimmy: my listeners, I do understand, I promise. But it's in there.
Dr. Lauren Young: Yeah. You totally do. It's it's it's in there. But this is what happens when you teach multiple years of a clinical neuroanatomy course. You just kind
Jimmy: Yeah.
Dr. Lauren Young: of it's it's all in there. But it it's it's really interesting because teaching that, you know, it's like I had this experience to draw from clinically and it's like, man, that's not what I see clinically. that is like, you know, even the vestibular stuff, it's like, yeah, this should be happening, but that is not what I see clinically. You know, it's textbook,
Jimmy: Yeah.
Dr. Lauren Young: but it goes back, Jimmy, to what you said, like We could we could map the entire brain and my brain and your brain are gonna map differently because we've had different experiences.
Jimmy: Exactly.
Dr. Lauren Young: We've had different, you know, let's say that person had before their stroke a super robust, maybe they you know, liked roller coasters or had kids and so they were on a swing. Maybe their vestibular cortex is like full tank of gas, and so when there's damage, it's really not as noticeable versus someone like me who I'm like do not. Spend me, no rotation, please. You know, I'm working from an empty tank. There my deficits might show up more because my life experience. So I think that that's and that's why we all love neuro, right? Like that's why we do this is cause no
Jimmy: Yes. Yes.
Dr. Lauren Young: one thing is gonna look exactly the same.
Jimmy: Exactly. Exactly. so you know me in my practice I work with dizziness and headaches more or less every day. but I actually have to admit that I I don't see post stroke dizziness too often in my work, but so typically I'm seeing more patients with disorders like vestibular migraine, vestibular hypofunctions, BPPV or 3 PD, right? These tr quote unquote traditional vestibular disorders. So my question is, how does post stroke dizziness differ from these other vestibular disorders?
Dr. Lauren Young: Yeah, I think complexity's not the right word. The thought is like you have more to work on. When someone comes in with a vestibular migraine, it is they have a vestibular migraine, you are working on that vestibular migraine. When someone comes in with a stroke, post-stroke dizziness, they may have dizziness. They also have transfer deficits. They also have weakness. They also need to walk. They also need to so it's not more complex. It's just you're working on a more broad area that you're trying to prioritize different things. And so depending on the severity, right? Some of it is just adding in like rotational and vestibular movements during these other tasks when you're doing walking can you you know visually scan without getting dizzy when you're doing you know if you're doing a balance task having someone do chops I love chops generally for everybody but right can I have them track a ball as they're moving so I'm getting that VOR cancellation you know can I add in some other tasks and of course as I add in vestibular task, it's gonna make the balance task a little more challenging, it's gonna make the walking task a little more challenging. So again, I think it's just you have to like be mindful that your whole session cannot be well, at least I don't approach it, that my whole session can't be working on dizziness. I have to figure out a way to work it in because there's so many other things I need to focus on as well.
Jimmy: It's a matter of prioritizing for this patient 'cause, you know, the dizziness is obviously uncomfortable, but it's probably a smaller part of what they're having problems with, right? 'Cause, you know, I know you do in home so you probably work with a lot of patients who need a lot of physical assistance, would you say? Yeah. Yeah. And
Dr. Lauren Young: Right. Yep. Yeah.
Jimmy: so you're trying to address that, get them better transfers. And then at the same time you're kind of weaving in kind of treatments on dizziness like the VR cancellation is amazing.
Dr. Lauren Young: Mm-hmm.
Jimmy: And you need that ability to turn. That's also going to take some leg strength as well
Dr. Lauren Young: Okay.
Jimmy: that they may be lacking. So getting that postural control. So kind of weaving it in there. but
Dr. Lauren Young: And like like you said, like the if you first start with somebody who does have post-stroke dizziness and they aren't very mobile, the dizziness isn't gonna affect them because they're not moving very much. So then it becomes more of a priority as they become more mobile because now their head is moving, they're turning, they're doing all of these things. And so now it's more obvious. I I've done a lot of like post TBI as well. And I will say most of mo post TBI dizziness. And I will say most of my people don't tell me about it until like the end of treatment. If I don't catch
Jimmy: Yeah.
Dr. Lauren Young: it, it's like, but it's because they're not active, like they're not doing the things that trigger the dizziness.
Jimmy: Right.
Dr. Lauren Young: So then once you get them more mobile, they're like, my gosh, the world is spinning. And I'm like, I caught it
Jimmy: Yeah.
Dr. Lauren Young: on somebody's, you know, they he was
Jimmy: Yeah.
Dr. Lauren Young: rolling and he had an astagmus. And I was like, Are you dizzy? He was like, Every day of my life. And he had fallen like,
Jimmy: Mm.
Dr. Lauren Young: I think eight foot out of a tree, landed on his head. They were trying to save his life, right? No one was worried
Jimmy: Uh-huh.
Dr. Lauren Young: about his BPP B. And we
Jimmy: Yeah.
Dr. Lauren Young: did a barbecue roll 'cause that he had canal converted. To horizontal. So we did a barbecue roll a couple
Jimmy: gnarly.
Dr. Lauren Young: times and he came back and he was like, dang, I feel great. And I'm like, I bet you do, bud. And he it had
Jimmy: Yeah.
Dr. Lauren Young: been six months since he had fallen. And I'd never asked about it. He had never said anything. And then I just happened to see his Mystagmus one day and I like, What is happening? So
Jimmy: Yeah. Yeah.
Dr. Lauren Young: that taught me to always scream for it.
Jimmy: Yes, absolutely. That's a great point you bring up. You know, I think when we think about BPPV, we're always thinking like, it must be like room spinning, it must just be like really intense or lasts a couple of different seconds. Actually it can present very, very differently in a lot of people. It's so often times, just not textbook. And then especially like you mentioned, you know, if you have these patients with reduced mobility, maybe they're not even getting into the positions where the canal is really stimulated. So and then if you know, moving on from that, if we want to do adaptation or habituation, if they don't have this basic mobility available to them. then it's gonna be very, very difficult for us to give their vestibular system the proper stimulus that they need in order to recover. So it definitely presents, you know, with stroke or post TBI, definitely presents with its own very unique challenges for sure. So a bit of a sidebar here, so you know, something that comes up often with stroke, of course, is spasticity. So I know on your social media I've seen you've been talking about this subject a lot. So can you let us know some of your insights in regards to spasticity management? So what do you think are some of common mistakes that therapists are making?
Dr. Lauren Young: Yeah, I I don't know how I like I think about this a lot. Like, how did I become the spasticity management person? But it was just like I started talking about it. The more I talked about it, the more I realized like people don't know what to do with spasticity for the vast majority. I think also we all think that there's something that we don't know about because it's really hard to manage. and so, first of all, I'll tell people there is no magic solution. I had a reel where one time I said it's called spasticity management, not spasticity. spasticity curing, like I am probably never gonna get rid of someone's spasticity completely, no matter how hard I try. I think some of the bigger misconceptions is that really that there's conservative management. There is nothing from a PT perspective that we can do to address the neural component of spasticity. We can manage you know, strengthening the antagonist. We can work on making sure contractile tissues stay pliable, not by just stretching. 24 hour positioning, putting people in splints before they need, before the contracture happens, right? Before the contracture starts. And we have literature that says the contracture starts within 72 hours of them becoming injured. So just like think about that from all of the patients that you've treated and you're like, yeah, your ankle dorsiflexion range of motion is great. And it's like, no If you pulled that all out of under a microscope, like research is telling us that it's it's contracting before we can ever see it. So like getting people in the right bracing, getting them their hands in the right position before that spasticity ever starts, I I think that's just a really big misconception. I don't think people want to hear that. and and I understand, like I spent a lot of time like in the research, what can I be doing as a PT to to get rid of rid of this problem. I will say there is transcutaneous spinal stimulation on the market, which is leading to some good outcomes, especially in spinal cord injury for spasticity, but there are people using it in stroke. That could
Jimmy: Is that is that like the V V stem or is that something else?
Dr. Lauren Young: So the the Vivastem is vagus nerve stimulator and so
Jimmy: Okay.
Dr. Lauren Young: it's going to work and I don't know if it has links to spastasy. It does improve
Jimmy: 'Cause I know it r improves function, but I don't know about
Dr. Lauren Young: Yeah, that's what I don't know either. I I think it's
Jimmy: okay.
Dr. Lauren Young: more of a functional like for the upper extremity, it's looking at motor return and it's just implantable on the vagus nerve. The transcutaneous spinal cord stimulator is two electrode pads, they're very small circles that go on the cervical spine. We you know I'm gonna talk about what's FDA approved. It goes on the cervical spine, and then you stimulate the spinal cord. versus like typical E stem where you put it on a muscle and you stimulate the muscle. This is actually stimulating the spinal cord and then you use it with activity based interventions to get the repetition, the functional repetitions that you need. I think the research said something like eighty seven percent of people with spinal cord injuries improved hand function after twenty four sessions, which is ginormous in that population.
Jimmy: Yeah.
Dr. Lauren Young: so There is some research coming out to say it's impacting spasticity, which again is a conservative treatment technique that is not medical, but the clinical device is $40,000. So there are very few clinics who have access to this device. I am fortunate
Jimmy: Mm-hmm.
Dr. Lauren Young: that I have a patient who chose to buy one, and so I've used it a lot with that patient.
Jimmy: Mm-hmm.
Dr. Lauren Young: so that being said. I think it's hard because there is not much we can do. We can use TENS, we can use NMES to try and impact the spasticity, but from a neural component, we are looking at injectables such as phenol or alcohol. We're looking at l neurotoxins such as dysport, ZMN, Botox.
Jimmy: Yeah.
Dr. Lauren Young: or anti spasmodics such as baclefin, dantrylene, tzanidine. and then kind of newer on the market is cryoneurolysis. So they actually go in, they put a needle in, they take basically like they just freeze like a little piece of ice and they numb the nerve and then it takes away pain as well as some benefits of spasticity right now. So
Jimmy: Mm.
Dr. Lauren Young: there is more stuff coming out and that's of course not it's not a toxin. I know a lot of people don't want to take baclefin 'cause it makes them feel funny. you know, and I get it. Like I understand. But I I tell people there's only a certain limit that we can get to. The other thing is dry needling. there is some more evidence coming out. I'm actually attending a course in July for neurodry needling and spasticity. So maybe we'll reconvene after I've tried it a little bit to see how the how that goes. But yeah,
Jimmy: Yeah.
Dr. Lauren Young: the spasticity piece I think compounds a lot of things. And so when we talk about post stroke dizziness, you know adds fastidity into managing that you it's just one piece of a really large umbrella and
Jimmy: Mm-hmm.
Dr. Lauren Young: insurance is saying here's twelve visits, here's fourteen visits to fix all of this stuff and so it's just
Jimmy: Yeah. Yeah. Yeah.
Dr. Lauren Young: not ideal always.
Jimmy: Yeah, I mean the insurance route, that's a whole conversation in itself. You know, said like s insurance like twelve to fourteen visits. Well, it's more like we'll give you twelve to fourteen visits and then six years later we're gonna audit you and we're gonna ask for half of that money back. Right. So, anyways, it puts everyone
Dr. Lauren Young: Yep. Yeah.
Jimmy: in a bad position. yeah, seventy-two hours. I really I learned something new today. I definitely had no idea that that process started that early. So, you know, this obviously isn't our field, but you know, what kind of implications does that have for the physician? I'm wondering. Does that mean they should be, you know, starting to think about things like Botox or Bacliffin even within that range? Obviously I know neither of us are equipped to answer that, but I it is a question that pops up for me, for sure. Yeah.
Dr. Lauren Young: Yeah, I I've talked a little bit n you know to some physicians, and I think it's hard to treat something that's not there. What I encourage for people is if we know this information earlier in acute care, in inpatient rehab, we need to be prescribing these twenty four hour positioning devices. We need to have hand splints. We need, you know, those puffy boots or the I like to call them the boots with the fur, you know, that that's those the you
Jimmy: Pray pray fell bits. Yeah.
Dr. Lauren Young: know, you've got like all sorts of of whatever. People are like, I'm wearing those. I'm like those are not meant to keep your feet in they're they're per meant to float your heels. So you don't get a s
Jimmy: Yeah.
Dr. Lauren Young: you know, a a skin a wound, and so it's like We need to be prescribing that earlier. and then and you think about like how people wear you know, even in outpatients, like, you have an AFO, that's great. But how are you most people sitting with their knees flexed. So now I don't have my gastrocs stretched. so even if they are wearing their AFO, I need them to wear it when they're sleeping so that their legs are straight. then that's a whole nother conversation, keeping the legs straight so we don't get a hamstring contracture. But I agree. I think it just I don't know that there's anything that we could do, but I think from a a just general profession perspective, we could start implementing positioning stuff earlier. And then from a medical perspective, if we could have You set up for a PM and R physician visit three months out of your stroke, that it just automatically happens, then
Jimmy: Yes.
Dr. Lauren Young: we're not waiting. Because a lot of times what I see is I start to see this fastidity develop, and then I'm reacting to this thing that wasn't there when we first started, and now it's there, and I'm like, gosh, it's gonna take us another two months because we you know you've gotta go. it's some places they want a referral and so it's like you've got to go through all these channels and then it's four or five months and we now really have a problem on our hands because the spasticity is peaking and we have nothing on board
Jimmy: Mm.
Dr. Lauren Young: to adjust it. So I you know, I don't necessarily think that they need to be medicated initially, but we need to have a better plan to get them into a physician
Jimmy: Mm-hmm.
Dr. Lauren Young: to then when it's time when the the spasticity is ramping, which is different from every for everyone, that
Jimmy: Yeah. Yeah.
Dr. Lauren Young: we have a plan.
Jimmy: Yeah. more effective and more timely standard operating procedures for our patients who are dealing with spasticity. Yes. So difficult.
Dr. Lauren Young: More proactive instead of reactive, which is hard for our healthcare system.
Jimmy: we love case studies on the show. So can you tell us a patient that you had recent success with? and let's start with in regards to post stroke dizziness. And just walk us through from eval to treatment.
Dr. Lauren Young: Yeah, so essentially like I said, you you I'm screening and when somebody says, Yes, I'm dizzy after on that eval, I'm usually not checking it immediately. I'm putting that in the back of my mind. I mean on eval day we all know we're we're checking spasticity. I'm like a huge functional outcome measure. Don't tell my students, but I don't manual muscle test. I'm like do a five time sit to stand. You know, go from supine to sit. Let's yeah, let's do a postural
Jimmy: I don't I don't either. I don't either. Yeah.
Dr. Lauren Young: assessment scale for stroke. Like that's gonna show me all that what I need. I can deduce what's a weak from watching you move. and it just takes time. You know, the more complex the history is, the longer it takes to to glean that. So a lot of times, to be really honest, I try and work and it's while I'm talking, you know, if I need to assess spasticity, The modified Ashware scale, like they're resting, they're sitting, they're it's passive movement. Like nobody's tone that pops out there. Or if it does, okay. But what does it look like when they're moving? So I'm really a proponent of like getting them up and moving if they can, doing a little bit more. and so I don't have time for a full vestibular eval, but I make a note of it. And I kind of e again prioritize. If it's something that's really bothering them, I'll come back to it the next visit. If it's something that I'm like, well You know, 'cause sometimes people are just dizzy and then we we think about why. Is it orthostatics? Is it truly a vestibular issue? you know, have they not sat upright in three weeks
Jimmy: Yeah.
Dr. Lauren Young: and so now I'm like making them sit upright in an outpatient visit for the first time?
Jimmy: Yeah, it could just be postural. It could just be postural dizziness. so just for my listeners, sorry I cut you off, but just for my listeners who aren't aware, people can be dizzy without actually any kind of damage or issues with their vestibular system. We hear this in people with neuropathy, you know, they can't feel their feet, but their inner ears and their brain, you know, more or less okay. Well, that's fine. These people experience dizziness too. And so just trying to understand that dizziness can have many sources and dizziness can totally just be postural, like we see in these post stroke situations. Yeah.
Dr. Lauren Young: Yeah, so it's like they sit up and their blood pressure tanks and then it's like, gosh, like, you know, and and is it
Jimmy: Yeah. Yeah.
Dr. Lauren Young: the fact that you were fine sitting up for ten minutes, but now I've asked you to sit to sit up for sixty minutes plus the ride here and there and and you're dizzy. So kind of delaying that. gives me a better idea. If they're still dizzy the next day and I've asked them to sit up more and I've I've increased tolerance, blood pressure looks okay, now I can say, Okay, maybe it's a little more dizziness. So then again, just like treating it. What do you see? How do I get rotation in there? how do I get the eye movements in there, right? I know the the clinical practice guideline is is talking more about head turns versus like just eye just truly eye movements for gaze
Jimmy: Mm-hmm. Sure.
Dr. Lauren Young: stability. you know, we need to be moving the head. So how do I do that? How do I on a break, right? Like I think we give our patients way too many breaks generally, in in therapy. So it's like, okay, if you truly need to rest, if you truly need to sit down, how do I make use of that time? Great. Brock strings, you grab you know, something
Jimmy: Mm.
Dr. Lauren Young: and you make look at all the the beads. You you make them turn their head. So again, you know, honestly, I'm like, you can rest when you go home. You are with me for one hour. You will be totally fine. and so I I really try
Jimmy: Yeah. No rest for the weary. Yeah. Yeah. Hell yeah. That's great. Yeah.
Dr. Lauren Young: to be you have to be. I mean that's that's just what
Jimmy: Mm-hmm.
Dr. Lauren Young: comes out of being a clinician and I don't really It's all professions in healthcare, right? Like you
Jimmy: Mm-hmm.
Dr. Lauren Young: insurance is limiting your time. It's like you've got to be creative. You've got to figure out how do you get all this done. In, you know, I was lucky that whenever I was in the clinic, I had 60 minute sessions. I now do 60 minute sessions as well. But I mean, there's places that you get 30, 45 minutes. Like,
Jimmy: Mm-hmm.
Dr. Lauren Young: that's a that's a challenge for the clinician as well as the patient. you
Jimmy: Yes.
Dr. Lauren Young: know, how efficient can you be? So then just working on that and I in my experience the dizziness has not and I'm not talking cerebellar a brainstem stroke that's a whole nother side of things and it's really difficult to get that dizziness to go away but when I have somebody with just post-stroke dizziness that's typically not you know 10 out of 10 it it's uncomfortable Adding this stuff in, I do see a pretty quick improvement in their abilities. It's like we almost just need to get them back to where they were, and then they're like, okay, I'm I feel better. and and I'm using all the same outcome measures, dizziness, handicap, inventory. I like, you know, the Berg, the FGA, all of those because the dizziness is gonna affect the balance. And so if they're able to do it. I'm doing those up, you know, upright measurements and you'll see it change because their balance is gonna be better because they're not the world isn't spinning, the floor is stable, you know, they're not feeling all of those things that they tend to feel.
Jimmy: Hm, yeah. Yeah. I actually really love that piece you said about taking too many breaks. I think pure vestibular rehab is a little bit different. We do need some more breaks, but generally speaking, I I am in agreement with you. you and I, you know, we're very pleasant people, but trust me, and I can say this I can I feel like I can say this for you too. When I'm with a client, I am I am all business. Like, you know, this is a very precious time. And you know, it's true. You can rest when you go home. This is time that we work and this is time that we make sure you feel better, which is our job to do. So really enjoy that piece.
Dr. Lauren Young: Yeah, and it's kind of hard to do that at some points. Like I I found
Jimmy: Yeah.
Dr. Lauren Young: it difficult because it's like, you know, I had this, I think she was 79 years old, and I kept her on her feet the entire evaluation and we were moving and we were grooving. She came back and she's like, I was so sore for four days. And it's like, you probably haven't done that. And so it's trying to figure out what is that line that we're not underdosing somebody, but we're also not making it miserable for them to
Jimmy: Yeah.
Dr. Lauren Young: come back. So, you know, I did back off the next day and I did
Jimmy: Mm-hmm.
Dr. Lauren Young: let her have some seated breaks. And then it I check in, hey, how did we feel after that? You know, but honestly, sometimes I'm like, I would rather push you to your edge, know your limit and then back off than never reach your ceiling.
Jimmy: Yeah.
Dr. Lauren Young: And just come back, I promise I'll fix it. Absolutely.
Jimmy: Yeah. Yeah, there's always a lot of nuance and trial and error in these things. why don't you tell us about a patient with spasticity that you've seen recently that, you know, you've had some good outcomes with.
Dr. Lauren Young: Yeah, so I'll tell you about my most probably well known on my Instagram. She has
Jimmy: Okay.
Dr. Lauren Young: a sixty-eight degree inversion contracture. So in order to get her foot flat on the ground, her tibia was parallel with the floor. I know this because we casted her, and so we had a mold of her foot and and like just to get her get it straight.
Jimmy: Are you doing the casting or?
Dr. Lauren Young: We casted for an orthotic. and that was
Jimmy: Okay.
Dr. Lauren Young: we were just gonna try and make something to pull her her foot. The the problem with a lot of braces is they only move in the sagittal plane. So flexion, extension, front, back. But
Jimmy: Yes.
Dr. Lauren Young: she was in the transverse plane,
Jimmy: Yeah.
Dr. Lauren Young: and so I needed something that would pull her medial to lateral while Very difficult to find on the market. So we were talking about like possibly creating something. so we casted her foot. I did go back and forth of do I serial cast? Do I not? She had a history of wounds on that foot. And so I really didn't feel comfortable. She lives in an assisted living facility. It was just hard. It was just hard for me to justify casting. And I really Thoughts. How long am I prolonging the inevitable? And
Jimmy: Mm.
Dr. Lauren Young: so last Monday, a week ago, today, she went and had tendon lengthening surgeries. And on her
Jimmy: Mm-hmm.
Dr. Lauren Young: right foot, which I believe was 41 degrees in a plantar flexion contracture, the surgeon called me and said that they were able to get her to a five degrees past neutral endorsi flexion
Jimmy: Wow. Wow.
Dr. Lauren Young: with an Achilles lengthening. And then they did an Achilles. Lengthening on the left, and then removed part of the posterior tibial tendon, straightened her foot out, used the tendon to maintain the alignment, and I went and saw her in her inpatient rehab, and her toes were pointing to the ceiling. And I was just like,
Jimmy: Hmm, amazing.
Dr. Lauren Young: How did this happen? So I think that you know. She had been dealing with this and she still has a long road to go. I mean, we're like non weight bearing for six weeks before we can ever like put any weight on it. Like, you know, we're not there, we're not where we want to be, but we're definitely better than when we started a week ago. and so I like to highlight that story because I didn't conservatively, there was not much I did to fix those
Jimmy: Mm.
Dr. Lauren Young: ankles, but knowing your options, knowing w all of the the tools in your toolbox side. I that's such a cliche saying, but
Jimmy: Mm-hmm.
Dr. Lauren Young: knowing what's available to you. Is it serial casting? She was getting Botox injections. Is it a baclefin pump? you know, what does that look like? And I I mean, it took me weeks to come to the conclusion and it wasn't just me. It was, you know, me talking to her family and saying, Hey, what do y'all want to do? Do you wanna put her through surgery? We can try these other options, but, you know, in my professional opinion, we're gonna end up at surgery 'cause we're only gonna be able to correct so much and then this is contracted.
Jimmy: Yes.
Dr. Lauren Young: and so, you know, I I was consulting with a well-known Dr. Monica Verdusco Gutierrez. She is a very, very well known spasticity management doctor. I was messaging her, like, hey, I've got this complex case. so yeah, I like to kind of highlight that because it wasn't really anything I did other than facilitating the necessary things to happen. But it wasn't any, you know, standing frame exercise or casting
Jimmy: Yeah.
Dr. Lauren Young: from me. but I When I saw those toes point to the ceiling, I was like, We've made it, like
Jimmy: Yeah.
Dr. Lauren Young: we can we can get up and move and and really it's just we were I looking for the ability to stand, transfer, take you know, a couple steps because she was able to stand even with her foot like that. So I'm like, Man, if we can just get them on the ground, no telling what can happen. I think we have other issues that are gonna show up, but we gotta start somewhere.
Jimmy: Yeah. That's a great story. And I think I'm really glad your pati patient is, you know, five degrees past n neutral in the dorsiflexion. yeah,
Dr. Lauren Young: So excited.
Jimmy: it's amazing. what what we're kinda highlighting in that story is that, you know, PTs we can't solve everything, right? And then having the resources in your back pocket. You know, I think that's really, really important. So, kind of going into my world, you know, I work with headache disorders, migraine disorders. When I have a patient who is so medically unstable, right, that they live in a dark cave and you know, I can't even get them to turn in half a circle without it triggering like a a migraine attack. how much can I truly do? And then you ask this patient, you talk to them and you know, they don't even have, you know, a headache neurologist on board, if a neurologist at all. And so in some cases, you know, for me, you know, what I do, it's like I can come in here and I can do the exercises with you, but I don't think we're gonna get anywhere. You know, you we need you to go have the proper team in place. And so, yeah, I just think part of successful treatment is also knowing who is a good candidate for your care. Yeah. I think that's r
Dr. Lauren Young: At the right time. Because those people will
Jimmy: at the right time.
Dr. Lauren Young: get medically managed and then you know you're you're prepped, but you're gonna be spinning your wheels. You're gonna make them feel miserable if they're
Jimmy: Yeah.
Dr. Lauren Young: you know can't do anything. You're you're no one's winning. That's what I always
Jimmy: Yeah.
Dr. Lauren Young: am like, no one is having a good time. you know, you're
Jimmy: Yeah, yeah.
Dr. Lauren Young: banging your head against the wall of why is this not working? They're
Jimmy: Yeah.
Dr. Lauren Young: you know, sick for three days because you created this problematic sis system or symptoms.
Jimmy: Yeah.
Dr. Lauren Young: You're exactly right. Like, you just kind of have to know, and part of that comes with experience, right? Like and
Jimmy: Yes.
Dr. Lauren Young: or good mentorship. because it's not always obvious, you don't always know the answers of those things when you're a new clinician. And to be really honest, even as a seasoned clinician, some people don't know it. So, Jimmy, I'm not sure if most of your listeners are patients or clinicians, but if you are a patient, understanding that like if something doesn't feel Right, and things aren't getting better, and no one's addressing that it's not getting better. It's time to call an audible, right? Like it's time to pause and say, what needs we've got to back out and see what what I need to get on board, what needs to happen because this isn't working.
Jimmy: Mm-hmm.
Dr. Lauren Young: and and I think that's where good clinicians, you know, we're
Jimmy: Yes.
Dr. Lauren Young: using outcome measures, we're doing all of these things to To check ourselves, right? Like, is
Jimmy: Mm-hmm, yeah.
Dr. Lauren Young: what I'm doing working? And
Jimmy: Yes.
Dr. Lauren Young: if it's not, you know, good clinicians are stepping back and saying, Well, why not?
Jimmy: Yeah.
Dr. Lauren Young: but if you just continue to keep on and keep on, you know, you know, I mean, Jimmy, in your world in four weeks, someone should start to feel somewhat better. and so if they're not,
Jimmy: Yes, yeah, absolutely.
Dr. Lauren Young: we figure out why.
Jimmy: Yes, yes. Exactly. I mean there's always some nuance to that, you know, discussion there, but largely speaking, yes, it's true. And then I think as clinicians we we also need to leave our egos at the door and we need to be able to have honest conversations with our patients, you know. telling them, you know, they should feel safe enough to bring up something if they feel like it's not working. And if you feel like something is not working, you should communicate that to your patient. I think that's really, really important for us to do. so wrapping up, you know, thank you so much for being on the show. You have a lot of knowledge, you know, your patients are very lucky to have you. so where can people find you?
Dr. Lauren Young: Yeah, you can find me on Instagram and it's at NeuroElitePT. that's probably the easiest place. I'm also on Facebook. I have some spasticity management webinars coming up. and then I also host a podcast. We really talk about kind of Totally different. We talk about what it's like to run a business and a side hustle on that podcast. And we have courses coming out for teaching people how to do this because I I just find like there's so many really good PTs and OTs who are just burned out from the system. They don't want to work for someone else.
Jimmy: Yes.
Dr. Lauren Young: and a lot of them can't leave their full-time job. So we kind of lay the framework of how do you stay in your full-time job but start to build something that really you're passionate about. So yeah, that's where you can find me. I'm on Apple, Podcast, Spotify, all of that. It's the rehab remix. And yeah, I am happy to answer questions or just say hello.
Jimmy: Okay. That's great. So I'll go ahead and include all that information in the show notes. So your Instagram, rehab remix and then also your website. And if you're a listener and you're listening today, if you enjoyed listening to today's episode, please consider leaving us a five star review. It really helps us get in front of the right people. So Doctor Lauren Young, thank you for being on.
Dr. Lauren Young: Thanks, Jimmy.
Dr. Lauren Young: Hey, it is so good to be here. Thanks for that intro. I sound much busier than sometimes I feel, but some days it feels that busy. So yeah, I am so appreciative to all my Instagram followers and everyone who supports me.
Jimmy: Yeah, awesome. I hear you on the busyness thing. You know, I don't know, every day I think as business owners, especially in this PT field and neuro P T field, we're always juggling like six million different things, let alone patient care. So that feeling of constant dizziness yet feeling nothing is getting done. That is very, very I can definitely
Dr. Lauren Young: You just describe my day today.
Jimmy: relate to that. but beyond that, like so today's topic we're actually gonna be talking about A very interesting subject. And today's topic is gonna be about post-stroke dizziness. So I think we'll go ahead and just dive in with our questions. So can you explain to our listeners what regions of the brain are typically involved in post-stroke dizziness? So how does it differ from, you know, other forms of stroke?
Dr. Lauren Young: Yeah, so I I that's a great question. And and I think the the biggest thing that I try and r like tell people and I try and remember myself is like we have to screen for dizziness after a stroke. Like, even if someone is not telling us or doesn't look overtly dizzy, even just saying like, have you experienced any dizziness, any changes in balance, type questions. And screen for it because more often than not, they're gonna say, you know, I kinda have. And again, when you go in to start treating balance, you have to address the vestibular portion. so as far as regions go, like within the brainstem, you have all of your vestibular nuclei. So of course, if you have a brainstem stroke, You 100% should be looking for some type of dizziness with that stroke. With a typical like MCA stroke, you're not gonna see a lot of dizziness. That's you know, lateral cortex, looking at frontal, parietal, a little bit of occipital and temporal lobe as well. so you don't see it as much. some deeper strokes that get into that primary vestibular cortex, you might see it. But the one thing that I always like. To point out to folks is especially in a hemorrhagic stroke, there is a space occupying lesion there. If there is a space occupying lesion, even if it doesn't affect directly the area of the brain that's involved with dizziness, there is a chance that that area has been compressed, moved, affected. with a stroke. So that's like one of the reasons that I I ask those questions, especially in a hemorrhagic stroke, we know cognition can be an issue. So like you're gonna be looking for all of the signs that you typically look for with dizziness. Like, can their eyes focus? Do they when you sit them up, do they look like they're sitting if they can't communicate that with you? Of course then you have a cerebellar stroke and we know that the brainstem and the cerebellum are like tight. They are so closely linked that if you have some type of cerebellar stroke you need to be looking for forms of dizziness, vestibular dysfunction, nystagmus is is a big player there just because and I know nystagmus doesn't necessarily mean you're dizzy, but it changes that oculomotor view, which can pe some people will report as dizziness. So I think grossly vestibular is so complex as we all
Jimmy: Mm-hmm.
Dr. Lauren Young: know listening to this podcast. and so there is not one area that you can say, if this area is damaged, you definitely have to look. Of course we know brain stem is more probable, cerebellum is more probable. But when you get into strokes in the cerebral hemispheres, it's not quite as clear cut because there's, you know, primary vestibular cortices, there's the Vestibulothalamo cortical pathway that you're looking at. So it's multiple different areas to get the input that we're we're trying to to perceive from a sensory perspective. And man, I'm really nerding out right now, but we know that that vestibular input comes in from a
Jimmy: We love it. We love it. huh.
Dr. Lauren Young: sensory perspective, but then it also has outputs to give us our postural control. It helps with different reflexes that we we have as far as is maintaining our balance. So it is a sensory input problem if it's damaged, but it could also be an output problem which is is somewhat unique. Most of our sensory information then you know will travel to motor areas to then correct posture or to a volitional movement. it's just the vestibular system is very, very complex. It's it's divergent information. That information is coming in to the brainstem and going to so many different places.
Jimmy: Hmm. Lot to unpack here. you know, as I was paying attention, I started getting these flashbacks of spinothalamic tracts and all these things from neuroanatomy. god, but Yeah. Yeah. But you know, I loved
Dr. Lauren Young: Yeah. Yes, medium lateral vestibular spinal tracts, the reticulospinal, yeah, yeah, yeah, yeah.
Jimmy: everything you said. Absolutely. We see it more in those strokes kinda in the posterior regions of the brain, like a cerebrellar stroke or the brainstem where the vestibular nuclei are. I really like the part that you mentioned about the hemorrhagic stroke. How even though the blood vessel might have been in that area, it still can put extra pressure on the posterior regions of the brain. And then, you know, you kind of mentioned this as well. You can still see this in people who have maybe typical middle cerebral artery strokes. and I think that's largely because while we do understand a lot more about the brain, we don't have the entire thing mapped, right? Any and we don't have that anytime soon. So in many ways, in my opinion, the brain is still this kind of black box. So whenever you have this kind of injury, we can make predictions, but there's still very likely that something, you know, unexpected can come up. And then one thing I want to mention, at least in my experience, and maybe you can verify this too, as when I see a patient with a post stroke dizziness or especially like cerebellar infarct, where they also present with things like ataxia, they don't so much present with that typical one sided weakness as the you know the more common type of stroke like a middle cerebral artery. Would you would you agree with that? Yeah. It's ipsala it's ipsalat it's ipsilateral too. Yeah, yeah, yeah.
Dr. Lauren Young: Yeah, so if you want the neuroanatomy of that, I'll dive into it. So the cerebellar it is ipsilateral because the cerebellar tract double crosses. So it it does decassate just like our lateral corticospinal tract does, but then it decassates back. So it ends up being back where it came from. I I teach my students that, and then I started thinking about it, like you said. you don't see this one-sided ataxia. And if we talk about the cerebellum, the cerebellum has nothing to do with force production. So it's really only that coordination piece is is really what we we kind of talk about. but it modulates force production, which is like kind of a hard thing to wrap your head around. It's like it doesn't Right? Like it's not recruiting motor units like the lateral corticospinal tract is, which is the tract, you know, that does volitional activation for anyone who just needs that reminder from PT school. but it it does volitional activation mostly of our limbs for fractionated movement. So
Jimmy: Mm-hmm.
Dr. Lauren Young: the cerebellum is then saying like Well, how many motor units are we recruiting? So it's like the lateral corticospinal tract is actually activating the units. And then the the cerebellum is saying, like, okay, well, how many do we need to be able to take a bigger step over that puddle or whatever we're doing? so that's something that's like just sometimes hard for me to like wrap my head around. I'm like, okay, so this
Jimmy: Yeah.
Dr. Lauren Young: isn't generating force. so again, we don't typically see the weakness piece after a cerebellar In Farct, we see a motor control issue. So it's harder to control your limbs. Again, if it was only to one side, then we see it the ataxia ipsilaterally. The issue is, and Jimmy, you know this, there's not, it's again a space occupying lesion.
Jimmy: Mm-hmm.
Dr. Lauren Young: So if I have an infarct to one side of the cerebellum, most likely I've compressed something and I'm gonna see the ataxia bilaterally because there is just not enough room. It's it's not as I don't wanna say clear cut, but c you know, as clear cut as like a a stroke to a cerebellar, I'm sorry, a cerebral hemisphere.
Jimmy: Mm-hmm.
Dr. Lauren Young: so that's you kind of see the bilateral deficits, even though.
Jimmy: Mm-hmm.
Dr. Lauren Young: Technically it's an ipsilateral problem if it's like a stroke to the left cerebellar hemisphere.
Jimmy: Yeah, your neuroanatomy knowledge is definitely shining through. I'm just nodding here, pretending, pretending I understand. Which which for my listeners,
Dr. Lauren Young: Like yeah, yeah, I wasn't
Jimmy: my listeners, I do understand, I promise. But it's in there.
Dr. Lauren Young: Yeah. You totally do. It's it's it's in there. But this is what happens when you teach multiple years of a clinical neuroanatomy course. You just kind
Jimmy: Yeah.
Dr. Lauren Young: of it's it's all in there. But it it's it's really interesting because teaching that, you know, it's like I had this experience to draw from clinically and it's like, man, that's not what I see clinically. that is like, you know, even the vestibular stuff, it's like, yeah, this should be happening, but that is not what I see clinically. You know, it's textbook,
Jimmy: Yeah.
Dr. Lauren Young: but it goes back, Jimmy, to what you said, like We could we could map the entire brain and my brain and your brain are gonna map differently because we've had different experiences.
Jimmy: Exactly.
Dr. Lauren Young: We've had different, you know, let's say that person had before their stroke a super robust, maybe they you know, liked roller coasters or had kids and so they were on a swing. Maybe their vestibular cortex is like full tank of gas, and so when there's damage, it's really not as noticeable versus someone like me who I'm like do not. Spend me, no rotation, please. You know, I'm working from an empty tank. There my deficits might show up more because my life experience. So I think that that's and that's why we all love neuro, right? Like that's why we do this is cause no
Jimmy: Yes. Yes.
Dr. Lauren Young: one thing is gonna look exactly the same.
Jimmy: Exactly. Exactly. so you know me in my practice I work with dizziness and headaches more or less every day. but I actually have to admit that I I don't see post stroke dizziness too often in my work, but so typically I'm seeing more patients with disorders like vestibular migraine, vestibular hypofunctions, BPPV or 3 PD, right? These tr quote unquote traditional vestibular disorders. So my question is, how does post stroke dizziness differ from these other vestibular disorders?
Dr. Lauren Young: Yeah, I think complexity's not the right word. The thought is like you have more to work on. When someone comes in with a vestibular migraine, it is they have a vestibular migraine, you are working on that vestibular migraine. When someone comes in with a stroke, post-stroke dizziness, they may have dizziness. They also have transfer deficits. They also have weakness. They also need to walk. They also need to so it's not more complex. It's just you're working on a more broad area that you're trying to prioritize different things. And so depending on the severity, right? Some of it is just adding in like rotational and vestibular movements during these other tasks when you're doing walking can you you know visually scan without getting dizzy when you're doing you know if you're doing a balance task having someone do chops I love chops generally for everybody but right can I have them track a ball as they're moving so I'm getting that VOR cancellation you know can I add in some other tasks and of course as I add in vestibular task, it's gonna make the balance task a little more challenging, it's gonna make the walking task a little more challenging. So again, I think it's just you have to like be mindful that your whole session cannot be well, at least I don't approach it, that my whole session can't be working on dizziness. I have to figure out a way to work it in because there's so many other things I need to focus on as well.
Jimmy: It's a matter of prioritizing for this patient 'cause, you know, the dizziness is obviously uncomfortable, but it's probably a smaller part of what they're having problems with, right? 'Cause, you know, I know you do in home so you probably work with a lot of patients who need a lot of physical assistance, would you say? Yeah. Yeah. And
Dr. Lauren Young: Right. Yep. Yeah.
Jimmy: so you're trying to address that, get them better transfers. And then at the same time you're kind of weaving in kind of treatments on dizziness like the VR cancellation is amazing.
Dr. Lauren Young: Mm-hmm.
Jimmy: And you need that ability to turn. That's also going to take some leg strength as well
Dr. Lauren Young: Okay.
Jimmy: that they may be lacking. So getting that postural control. So kind of weaving it in there. but
Dr. Lauren Young: And like like you said, like the if you first start with somebody who does have post-stroke dizziness and they aren't very mobile, the dizziness isn't gonna affect them because they're not moving very much. So then it becomes more of a priority as they become more mobile because now their head is moving, they're turning, they're doing all of these things. And so now it's more obvious. I I've done a lot of like post TBI as well. And I will say most of mo post TBI dizziness. And I will say most of my people don't tell me about it until like the end of treatment. If I don't catch
Jimmy: Yeah.
Dr. Lauren Young: it, it's like, but it's because they're not active, like they're not doing the things that trigger the dizziness.
Jimmy: Right.
Dr. Lauren Young: So then once you get them more mobile, they're like, my gosh, the world is spinning. And I'm like, I caught it
Jimmy: Yeah.
Dr. Lauren Young: on somebody's, you know, they he was
Jimmy: Yeah.
Dr. Lauren Young: rolling and he had an astagmus. And I was like, Are you dizzy? He was like, Every day of my life. And he had fallen like,
Jimmy: Mm.
Dr. Lauren Young: I think eight foot out of a tree, landed on his head. They were trying to save his life, right? No one was worried
Jimmy: Uh-huh.
Dr. Lauren Young: about his BPP B. And we
Jimmy: Yeah.
Dr. Lauren Young: did a barbecue roll 'cause that he had canal converted. To horizontal. So we did a barbecue roll a couple
Jimmy: gnarly.
Dr. Lauren Young: times and he came back and he was like, dang, I feel great. And I'm like, I bet you do, bud. And he it had
Jimmy: Yeah.
Dr. Lauren Young: been six months since he had fallen. And I'd never asked about it. He had never said anything. And then I just happened to see his Mystagmus one day and I like, What is happening? So
Jimmy: Yeah. Yeah.
Dr. Lauren Young: that taught me to always scream for it.
Jimmy: Yes, absolutely. That's a great point you bring up. You know, I think when we think about BPPV, we're always thinking like, it must be like room spinning, it must just be like really intense or lasts a couple of different seconds. Actually it can present very, very differently in a lot of people. It's so often times, just not textbook. And then especially like you mentioned, you know, if you have these patients with reduced mobility, maybe they're not even getting into the positions where the canal is really stimulated. So and then if you know, moving on from that, if we want to do adaptation or habituation, if they don't have this basic mobility available to them. then it's gonna be very, very difficult for us to give their vestibular system the proper stimulus that they need in order to recover. So it definitely presents, you know, with stroke or post TBI, definitely presents with its own very unique challenges for sure. So a bit of a sidebar here, so you know, something that comes up often with stroke, of course, is spasticity. So I know on your social media I've seen you've been talking about this subject a lot. So can you let us know some of your insights in regards to spasticity management? So what do you think are some of common mistakes that therapists are making?
Dr. Lauren Young: Yeah, I I don't know how I like I think about this a lot. Like, how did I become the spasticity management person? But it was just like I started talking about it. The more I talked about it, the more I realized like people don't know what to do with spasticity for the vast majority. I think also we all think that there's something that we don't know about because it's really hard to manage. and so, first of all, I'll tell people there is no magic solution. I had a reel where one time I said it's called spasticity management, not spasticity. spasticity curing, like I am probably never gonna get rid of someone's spasticity completely, no matter how hard I try. I think some of the bigger misconceptions is that really that there's conservative management. There is nothing from a PT perspective that we can do to address the neural component of spasticity. We can manage you know, strengthening the antagonist. We can work on making sure contractile tissues stay pliable, not by just stretching. 24 hour positioning, putting people in splints before they need, before the contracture happens, right? Before the contracture starts. And we have literature that says the contracture starts within 72 hours of them becoming injured. So just like think about that from all of the patients that you've treated and you're like, yeah, your ankle dorsiflexion range of motion is great. And it's like, no If you pulled that all out of under a microscope, like research is telling us that it's it's contracting before we can ever see it. So like getting people in the right bracing, getting them their hands in the right position before that spasticity ever starts, I I think that's just a really big misconception. I don't think people want to hear that. and and I understand, like I spent a lot of time like in the research, what can I be doing as a PT to to get rid of rid of this problem. I will say there is transcutaneous spinal stimulation on the market, which is leading to some good outcomes, especially in spinal cord injury for spasticity, but there are people using it in stroke. That could
Jimmy: Is that is that like the V V stem or is that something else?
Dr. Lauren Young: So the the Vivastem is vagus nerve stimulator and so
Jimmy: Okay.
Dr. Lauren Young: it's going to work and I don't know if it has links to spastasy. It does improve
Jimmy: 'Cause I know it r improves function, but I don't know about
Dr. Lauren Young: Yeah, that's what I don't know either. I I think it's
Jimmy: okay.
Dr. Lauren Young: more of a functional like for the upper extremity, it's looking at motor return and it's just implantable on the vagus nerve. The transcutaneous spinal cord stimulator is two electrode pads, they're very small circles that go on the cervical spine. We you know I'm gonna talk about what's FDA approved. It goes on the cervical spine, and then you stimulate the spinal cord. versus like typical E stem where you put it on a muscle and you stimulate the muscle. This is actually stimulating the spinal cord and then you use it with activity based interventions to get the repetition, the functional repetitions that you need. I think the research said something like eighty seven percent of people with spinal cord injuries improved hand function after twenty four sessions, which is ginormous in that population.
Jimmy: Yeah.
Dr. Lauren Young: so There is some research coming out to say it's impacting spasticity, which again is a conservative treatment technique that is not medical, but the clinical device is $40,000. So there are very few clinics who have access to this device. I am fortunate
Jimmy: Mm-hmm.
Dr. Lauren Young: that I have a patient who chose to buy one, and so I've used it a lot with that patient.
Jimmy: Mm-hmm.
Dr. Lauren Young: so that being said. I think it's hard because there is not much we can do. We can use TENS, we can use NMES to try and impact the spasticity, but from a neural component, we are looking at injectables such as phenol or alcohol. We're looking at l neurotoxins such as dysport, ZMN, Botox.
Jimmy: Yeah.
Dr. Lauren Young: or anti spasmodics such as baclefin, dantrylene, tzanidine. and then kind of newer on the market is cryoneurolysis. So they actually go in, they put a needle in, they take basically like they just freeze like a little piece of ice and they numb the nerve and then it takes away pain as well as some benefits of spasticity right now. So
Jimmy: Mm.
Dr. Lauren Young: there is more stuff coming out and that's of course not it's not a toxin. I know a lot of people don't want to take baclefin 'cause it makes them feel funny. you know, and I get it. Like I understand. But I I tell people there's only a certain limit that we can get to. The other thing is dry needling. there is some more evidence coming out. I'm actually attending a course in July for neurodry needling and spasticity. So maybe we'll reconvene after I've tried it a little bit to see how the how that goes. But yeah,
Jimmy: Yeah.
Dr. Lauren Young: the spasticity piece I think compounds a lot of things. And so when we talk about post stroke dizziness, you know adds fastidity into managing that you it's just one piece of a really large umbrella and
Jimmy: Mm-hmm.
Dr. Lauren Young: insurance is saying here's twelve visits, here's fourteen visits to fix all of this stuff and so it's just
Jimmy: Yeah. Yeah. Yeah.
Dr. Lauren Young: not ideal always.
Jimmy: Yeah, I mean the insurance route, that's a whole conversation in itself. You know, said like s insurance like twelve to fourteen visits. Well, it's more like we'll give you twelve to fourteen visits and then six years later we're gonna audit you and we're gonna ask for half of that money back. Right. So, anyways, it puts everyone
Dr. Lauren Young: Yep. Yeah.
Jimmy: in a bad position. yeah, seventy-two hours. I really I learned something new today. I definitely had no idea that that process started that early. So, you know, this obviously isn't our field, but you know, what kind of implications does that have for the physician? I'm wondering. Does that mean they should be, you know, starting to think about things like Botox or Bacliffin even within that range? Obviously I know neither of us are equipped to answer that, but I it is a question that pops up for me, for sure. Yeah.
Dr. Lauren Young: Yeah, I I've talked a little bit n you know to some physicians, and I think it's hard to treat something that's not there. What I encourage for people is if we know this information earlier in acute care, in inpatient rehab, we need to be prescribing these twenty four hour positioning devices. We need to have hand splints. We need, you know, those puffy boots or the I like to call them the boots with the fur, you know, that that's those the you
Jimmy: Pray pray fell bits. Yeah.
Dr. Lauren Young: know, you've got like all sorts of of whatever. People are like, I'm wearing those. I'm like those are not meant to keep your feet in they're they're per meant to float your heels. So you don't get a s
Jimmy: Yeah.
Dr. Lauren Young: you know, a a skin a wound, and so it's like We need to be prescribing that earlier. and then and you think about like how people wear you know, even in outpatients, like, you have an AFO, that's great. But how are you most people sitting with their knees flexed. So now I don't have my gastrocs stretched. so even if they are wearing their AFO, I need them to wear it when they're sleeping so that their legs are straight. then that's a whole nother conversation, keeping the legs straight so we don't get a hamstring contracture. But I agree. I think it just I don't know that there's anything that we could do, but I think from a a just general profession perspective, we could start implementing positioning stuff earlier. And then from a medical perspective, if we could have You set up for a PM and R physician visit three months out of your stroke, that it just automatically happens, then
Jimmy: Yes.
Dr. Lauren Young: we're not waiting. Because a lot of times what I see is I start to see this fastidity develop, and then I'm reacting to this thing that wasn't there when we first started, and now it's there, and I'm like, gosh, it's gonna take us another two months because we you know you've gotta go. it's some places they want a referral and so it's like you've got to go through all these channels and then it's four or five months and we now really have a problem on our hands because the spasticity is peaking and we have nothing on board
Jimmy: Mm.
Dr. Lauren Young: to adjust it. So I you know, I don't necessarily think that they need to be medicated initially, but we need to have a better plan to get them into a physician
Jimmy: Mm-hmm.
Dr. Lauren Young: to then when it's time when the the spasticity is ramping, which is different from every for everyone, that
Jimmy: Yeah. Yeah.
Dr. Lauren Young: we have a plan.
Jimmy: Yeah. more effective and more timely standard operating procedures for our patients who are dealing with spasticity. Yes. So difficult.
Dr. Lauren Young: More proactive instead of reactive, which is hard for our healthcare system.
Jimmy: we love case studies on the show. So can you tell us a patient that you had recent success with? and let's start with in regards to post stroke dizziness. And just walk us through from eval to treatment.
Dr. Lauren Young: Yeah, so essentially like I said, you you I'm screening and when somebody says, Yes, I'm dizzy after on that eval, I'm usually not checking it immediately. I'm putting that in the back of my mind. I mean on eval day we all know we're we're checking spasticity. I'm like a huge functional outcome measure. Don't tell my students, but I don't manual muscle test. I'm like do a five time sit to stand. You know, go from supine to sit. Let's yeah, let's do a postural
Jimmy: I don't I don't either. I don't either. Yeah.
Dr. Lauren Young: assessment scale for stroke. Like that's gonna show me all that what I need. I can deduce what's a weak from watching you move. and it just takes time. You know, the more complex the history is, the longer it takes to to glean that. So a lot of times, to be really honest, I try and work and it's while I'm talking, you know, if I need to assess spasticity, The modified Ashware scale, like they're resting, they're sitting, they're it's passive movement. Like nobody's tone that pops out there. Or if it does, okay. But what does it look like when they're moving? So I'm really a proponent of like getting them up and moving if they can, doing a little bit more. and so I don't have time for a full vestibular eval, but I make a note of it. And I kind of e again prioritize. If it's something that's really bothering them, I'll come back to it the next visit. If it's something that I'm like, well You know, 'cause sometimes people are just dizzy and then we we think about why. Is it orthostatics? Is it truly a vestibular issue? you know, have they not sat upright in three weeks
Jimmy: Yeah.
Dr. Lauren Young: and so now I'm like making them sit upright in an outpatient visit for the first time?
Jimmy: Yeah, it could just be postural. It could just be postural dizziness. so just for my listeners, sorry I cut you off, but just for my listeners who aren't aware, people can be dizzy without actually any kind of damage or issues with their vestibular system. We hear this in people with neuropathy, you know, they can't feel their feet, but their inner ears and their brain, you know, more or less okay. Well, that's fine. These people experience dizziness too. And so just trying to understand that dizziness can have many sources and dizziness can totally just be postural, like we see in these post stroke situations. Yeah.
Dr. Lauren Young: Yeah, so it's like they sit up and their blood pressure tanks and then it's like, gosh, like, you know, and and is it
Jimmy: Yeah. Yeah.
Dr. Lauren Young: the fact that you were fine sitting up for ten minutes, but now I've asked you to sit to sit up for sixty minutes plus the ride here and there and and you're dizzy. So kind of delaying that. gives me a better idea. If they're still dizzy the next day and I've asked them to sit up more and I've I've increased tolerance, blood pressure looks okay, now I can say, Okay, maybe it's a little more dizziness. So then again, just like treating it. What do you see? How do I get rotation in there? how do I get the eye movements in there, right? I know the the clinical practice guideline is is talking more about head turns versus like just eye just truly eye movements for gaze
Jimmy: Mm-hmm. Sure.
Dr. Lauren Young: stability. you know, we need to be moving the head. So how do I do that? How do I on a break, right? Like I think we give our patients way too many breaks generally, in in therapy. So it's like, okay, if you truly need to rest, if you truly need to sit down, how do I make use of that time? Great. Brock strings, you grab you know, something
Jimmy: Mm.
Dr. Lauren Young: and you make look at all the the beads. You you make them turn their head. So again, you know, honestly, I'm like, you can rest when you go home. You are with me for one hour. You will be totally fine. and so I I really try
Jimmy: Yeah. No rest for the weary. Yeah. Yeah. Hell yeah. That's great. Yeah.
Dr. Lauren Young: to be you have to be. I mean that's that's just what
Jimmy: Mm-hmm.
Dr. Lauren Young: comes out of being a clinician and I don't really It's all professions in healthcare, right? Like you
Jimmy: Mm-hmm.
Dr. Lauren Young: insurance is limiting your time. It's like you've got to be creative. You've got to figure out how do you get all this done. In, you know, I was lucky that whenever I was in the clinic, I had 60 minute sessions. I now do 60 minute sessions as well. But I mean, there's places that you get 30, 45 minutes. Like,
Jimmy: Mm-hmm.
Dr. Lauren Young: that's a that's a challenge for the clinician as well as the patient. you
Jimmy: Yes.
Dr. Lauren Young: know, how efficient can you be? So then just working on that and I in my experience the dizziness has not and I'm not talking cerebellar a brainstem stroke that's a whole nother side of things and it's really difficult to get that dizziness to go away but when I have somebody with just post-stroke dizziness that's typically not you know 10 out of 10 it it's uncomfortable Adding this stuff in, I do see a pretty quick improvement in their abilities. It's like we almost just need to get them back to where they were, and then they're like, okay, I'm I feel better. and and I'm using all the same outcome measures, dizziness, handicap, inventory. I like, you know, the Berg, the FGA, all of those because the dizziness is gonna affect the balance. And so if they're able to do it. I'm doing those up, you know, upright measurements and you'll see it change because their balance is gonna be better because they're not the world isn't spinning, the floor is stable, you know, they're not feeling all of those things that they tend to feel.
Jimmy: Hm, yeah. Yeah. I actually really love that piece you said about taking too many breaks. I think pure vestibular rehab is a little bit different. We do need some more breaks, but generally speaking, I I am in agreement with you. you and I, you know, we're very pleasant people, but trust me, and I can say this I can I feel like I can say this for you too. When I'm with a client, I am I am all business. Like, you know, this is a very precious time. And you know, it's true. You can rest when you go home. This is time that we work and this is time that we make sure you feel better, which is our job to do. So really enjoy that piece.
Dr. Lauren Young: Yeah, and it's kind of hard to do that at some points. Like I I found
Jimmy: Yeah.
Dr. Lauren Young: it difficult because it's like, you know, I had this, I think she was 79 years old, and I kept her on her feet the entire evaluation and we were moving and we were grooving. She came back and she's like, I was so sore for four days. And it's like, you probably haven't done that. And so it's trying to figure out what is that line that we're not underdosing somebody, but we're also not making it miserable for them to
Jimmy: Yeah.
Dr. Lauren Young: come back. So, you know, I did back off the next day and I did
Jimmy: Mm-hmm.
Dr. Lauren Young: let her have some seated breaks. And then it I check in, hey, how did we feel after that? You know, but honestly, sometimes I'm like, I would rather push you to your edge, know your limit and then back off than never reach your ceiling.
Jimmy: Yeah.
Dr. Lauren Young: And just come back, I promise I'll fix it. Absolutely.
Jimmy: Yeah. Yeah, there's always a lot of nuance and trial and error in these things. why don't you tell us about a patient with spasticity that you've seen recently that, you know, you've had some good outcomes with.
Dr. Lauren Young: Yeah, so I'll tell you about my most probably well known on my Instagram. She has
Jimmy: Okay.
Dr. Lauren Young: a sixty-eight degree inversion contracture. So in order to get her foot flat on the ground, her tibia was parallel with the floor. I know this because we casted her, and so we had a mold of her foot and and like just to get her get it straight.
Jimmy: Are you doing the casting or?
Dr. Lauren Young: We casted for an orthotic. and that was
Jimmy: Okay.
Dr. Lauren Young: we were just gonna try and make something to pull her her foot. The the problem with a lot of braces is they only move in the sagittal plane. So flexion, extension, front, back. But
Jimmy: Yes.
Dr. Lauren Young: she was in the transverse plane,
Jimmy: Yeah.
Dr. Lauren Young: and so I needed something that would pull her medial to lateral while Very difficult to find on the market. So we were talking about like possibly creating something. so we casted her foot. I did go back and forth of do I serial cast? Do I not? She had a history of wounds on that foot. And so I really didn't feel comfortable. She lives in an assisted living facility. It was just hard. It was just hard for me to justify casting. And I really Thoughts. How long am I prolonging the inevitable? And
Jimmy: Mm.
Dr. Lauren Young: so last Monday, a week ago, today, she went and had tendon lengthening surgeries. And on her
Jimmy: Mm-hmm.
Dr. Lauren Young: right foot, which I believe was 41 degrees in a plantar flexion contracture, the surgeon called me and said that they were able to get her to a five degrees past neutral endorsi flexion
Jimmy: Wow. Wow.
Dr. Lauren Young: with an Achilles lengthening. And then they did an Achilles. Lengthening on the left, and then removed part of the posterior tibial tendon, straightened her foot out, used the tendon to maintain the alignment, and I went and saw her in her inpatient rehab, and her toes were pointing to the ceiling. And I was just like,
Jimmy: Hmm, amazing.
Dr. Lauren Young: How did this happen? So I think that you know. She had been dealing with this and she still has a long road to go. I mean, we're like non weight bearing for six weeks before we can ever like put any weight on it. Like, you know, we're not there, we're not where we want to be, but we're definitely better than when we started a week ago. and so I like to highlight that story because I didn't conservatively, there was not much I did to fix those
Jimmy: Mm.
Dr. Lauren Young: ankles, but knowing your options, knowing w all of the the tools in your toolbox side. I that's such a cliche saying, but
Jimmy: Mm-hmm.
Dr. Lauren Young: knowing what's available to you. Is it serial casting? She was getting Botox injections. Is it a baclefin pump? you know, what does that look like? And I I mean, it took me weeks to come to the conclusion and it wasn't just me. It was, you know, me talking to her family and saying, Hey, what do y'all want to do? Do you wanna put her through surgery? We can try these other options, but, you know, in my professional opinion, we're gonna end up at surgery 'cause we're only gonna be able to correct so much and then this is contracted.
Jimmy: Yes.
Dr. Lauren Young: and so, you know, I I was consulting with a well-known Dr. Monica Verdusco Gutierrez. She is a very, very well known spasticity management doctor. I was messaging her, like, hey, I've got this complex case. so yeah, I like to kind of highlight that because it wasn't really anything I did other than facilitating the necessary things to happen. But it wasn't any, you know, standing frame exercise or casting
Jimmy: Yeah.
Dr. Lauren Young: from me. but I When I saw those toes point to the ceiling, I was like, We've made it, like
Jimmy: Yeah.
Dr. Lauren Young: we can we can get up and move and and really it's just we were I looking for the ability to stand, transfer, take you know, a couple steps because she was able to stand even with her foot like that. So I'm like, Man, if we can just get them on the ground, no telling what can happen. I think we have other issues that are gonna show up, but we gotta start somewhere.
Jimmy: Yeah. That's a great story. And I think I'm really glad your pati patient is, you know, five degrees past n neutral in the dorsiflexion. yeah,
Dr. Lauren Young: So excited.
Jimmy: it's amazing. what what we're kinda highlighting in that story is that, you know, PTs we can't solve everything, right? And then having the resources in your back pocket. You know, I think that's really, really important. So, kind of going into my world, you know, I work with headache disorders, migraine disorders. When I have a patient who is so medically unstable, right, that they live in a dark cave and you know, I can't even get them to turn in half a circle without it triggering like a a migraine attack. how much can I truly do? And then you ask this patient, you talk to them and you know, they don't even have, you know, a headache neurologist on board, if a neurologist at all. And so in some cases, you know, for me, you know, what I do, it's like I can come in here and I can do the exercises with you, but I don't think we're gonna get anywhere. You know, you we need you to go have the proper team in place. And so, yeah, I just think part of successful treatment is also knowing who is a good candidate for your care. Yeah. I think that's r
Dr. Lauren Young: At the right time. Because those people will
Jimmy: at the right time.
Dr. Lauren Young: get medically managed and then you know you're you're prepped, but you're gonna be spinning your wheels. You're gonna make them feel miserable if they're
Jimmy: Yeah.
Dr. Lauren Young: you know can't do anything. You're you're no one's winning. That's what I always
Jimmy: Yeah.
Dr. Lauren Young: am like, no one is having a good time. you know, you're
Jimmy: Yeah, yeah.
Dr. Lauren Young: banging your head against the wall of why is this not working? They're
Jimmy: Yeah.
Dr. Lauren Young: you know, sick for three days because you created this problematic sis system or symptoms.
Jimmy: Yeah.
Dr. Lauren Young: You're exactly right. Like, you just kind of have to know, and part of that comes with experience, right? Like and
Jimmy: Yes.
Dr. Lauren Young: or good mentorship. because it's not always obvious, you don't always know the answers of those things when you're a new clinician. And to be really honest, even as a seasoned clinician, some people don't know it. So, Jimmy, I'm not sure if most of your listeners are patients or clinicians, but if you are a patient, understanding that like if something doesn't feel Right, and things aren't getting better, and no one's addressing that it's not getting better. It's time to call an audible, right? Like it's time to pause and say, what needs we've got to back out and see what what I need to get on board, what needs to happen because this isn't working.
Jimmy: Mm-hmm.
Dr. Lauren Young: and and I think that's where good clinicians, you know, we're
Jimmy: Yes.
Dr. Lauren Young: using outcome measures, we're doing all of these things to To check ourselves, right? Like, is
Jimmy: Mm-hmm, yeah.
Dr. Lauren Young: what I'm doing working? And
Jimmy: Yes.
Dr. Lauren Young: if it's not, you know, good clinicians are stepping back and saying, Well, why not?
Jimmy: Yeah.
Dr. Lauren Young: but if you just continue to keep on and keep on, you know, you know, I mean, Jimmy, in your world in four weeks, someone should start to feel somewhat better. and so if they're not,
Jimmy: Yes, yeah, absolutely.
Dr. Lauren Young: we figure out why.
Jimmy: Yes, yes. Exactly. I mean there's always some nuance to that, you know, discussion there, but largely speaking, yes, it's true. And then I think as clinicians we we also need to leave our egos at the door and we need to be able to have honest conversations with our patients, you know. telling them, you know, they should feel safe enough to bring up something if they feel like it's not working. And if you feel like something is not working, you should communicate that to your patient. I think that's really, really important for us to do. so wrapping up, you know, thank you so much for being on the show. You have a lot of knowledge, you know, your patients are very lucky to have you. so where can people find you?
Dr. Lauren Young: Yeah, you can find me on Instagram and it's at NeuroElitePT. that's probably the easiest place. I'm also on Facebook. I have some spasticity management webinars coming up. and then I also host a podcast. We really talk about kind of Totally different. We talk about what it's like to run a business and a side hustle on that podcast. And we have courses coming out for teaching people how to do this because I I just find like there's so many really good PTs and OTs who are just burned out from the system. They don't want to work for someone else.
Jimmy: Yes.
Dr. Lauren Young: and a lot of them can't leave their full-time job. So we kind of lay the framework of how do you stay in your full-time job but start to build something that really you're passionate about. So yeah, that's where you can find me. I'm on Apple, Podcast, Spotify, all of that. It's the rehab remix. And yeah, I am happy to answer questions or just say hello.
Jimmy: Okay. That's great. So I'll go ahead and include all that information in the show notes. So your Instagram, rehab remix and then also your website. And if you're a listener and you're listening today, if you enjoyed listening to today's episode, please consider leaving us a five star review. It really helps us get in front of the right people. So Doctor Lauren Young, thank you for being on.
Dr. Lauren Young: Thanks, Jimmy.
