Please note: this transcript is not 100% accurate.
Dr. Patrick Quaid 0:00
Lot of patients come to me and they say, I’m depressed and I’m anxious, but I’m depressed and I’m anxious because I’m not functional. So it’s not primary anxiety, it’s secondary. It’s I’m depressed. I mean, you take any of us and say, Now you can’t earn a living now you’re staying at home all day long. I mean, I give you a week to two weeks to a month, and you’re like, Ah, this sucks.
Dr. Meenal Agarwal 0:22
This is Dr. Meenal, and welcome to Uncover Your Eyes, where we uncover reality. As a mom and eye doctor, I want to know it all. Many of us have suffered a concussion. Many of our patients or family members have suffered a concussion. A concussion is a mild traumatic brain injury, or mTBI. Its effects can be short term or long term, and essentially, they can affect your entire life. With concussions, we see physical changes, cognitive changes and behavioral or emotional changes. The CDC estimates 2.8 million hospital emergency visits, hospitalizations and deaths in the US each year from mTBI, the majority being concussions. Today, I have leading experts in the field of concussions, Dr. Bruce Lidkea and Dr. Patrick Quaid. Dr. Bruce Lidkea is an optometrist with a fellowship in neurorehab, and the owner of Lidkea Optometry. He is also a member of the International Sports vision Association and the College of Syntonic Optometry. Dr Patrick Quaid is also an optometrist with a fellowship in neuro-visual rehab and the owner of VUE cubed vision therapy clinics, having suffered a severe TBI at eight years old himself, he knows firsthand what a concussion can do to the academic potential of a child. Welcome Bruce and Patrick. Thank you, Bruce and Patrick, for being on this morning. Really appreciate your time.
Dr. Bruce Lidkea 2:11
Thanks for having us
Dr. Meenal Agarwal 2:13
so you know, Bruce, tell me a little bit about what is a concussion, and how do you how do you know you’ve had a concussion?
Dr. Bruce Lidkea 2:21
Well, according to the Amsterdam panel on concussion, a traumatic brain injury caused by a direct blow to the head, neck or body, resulting in an impulsive force being transmitted to the brain that occurs normally that this is involved with their sports panel, but the big thing is, symptoms and signs can be present immediately or evolve over hours to days, and now, normally it resolves, but a lot of the times it doesn’t. And
Dr. Meenal Agarwal 2:54
how is it happening? Like, can it? Can it be from, you know, just a ding to the to the head?
Dr. Bruce Lidkea 3:00
Well, not necessarily just to the head. I’ve had lots of patients that have come in that have just slipped on ice and fallen, and that jarring effect will do that, and a lot of that has to do with the difference in density between the white and gray matter, causing some axonal shearing. Or there’s that, that physiological cascade of the damage to the neurons. Wow.
Dr. Meenal Agarwal 3:24
And and Patrick, like,
How common are concussions? Are we seeing it all the time? How common would you say it
Dr. Patrick Quaid 3:30
is? Well, I mean, if you look in the literature, we see probably about half, half to two thirds of our clinic is concussion. A lot of it is more pediatric concussion as what we’re seeing cases coming in. Actually, a lot of the masquerading is learning difficulties, believe it or not. Difficulties, believe it or not. So we start to look in these cases, and they present as, you know, a kid with an IEP or a learning difficulty at school. And you look in the developmental history, and there’s no real history of prematurity or low birth weight or any anything developmental. When you talk to the parents, you know, you’ll often hear, Oh yeah, when they were five, they fell down the stairs, or they, you know, they fell playing soccer, or they they had, didn’t necessarily have a loss of consciousness, but they had what’s called an AOC, or altered consciousness. When you talk about how common these things are, it’s estimated that you get about 15% of concussions that result in post concussion syndrome. So if you get 100 people that have a concussion, the good news is the vast majority will kind of bounce back, but you get about 15% 15 out of 100 that won’t, and typically they’ll have prolonged symptoms such as neck issues, vision issues, light sensitivity and things like that. But when we go back to the definition of concussion, so shout out to Eric singman at Johns Hopkins. He’s an MD, PhD. He’s a he was a chief in your ophthalmology when we wrote the book, chapter in the book called neurosensory disorders and mild traumatic brain injury. And Carrie Balaban, I believe, is in Pittsburgh, that chapter one of that book answers exactly that question, what is a mild traumatic brain injury? And I’m just going to read this quickly, because it’s kind of interesting when you look at the NIH definition. And I’ll read this quickly and focus in on the vision. Part of this says a person with mild TBI may remain conscious or may experience a loss of consciousness. For a few seconds or minutes. Other symptoms of mild TBI include headache, confusion, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep pattern, behavior or mood changes in trouble with memory, concentration, attention or thinking. But when you look at that blurred vision and tired eyes, I mean, what does that mean? It’s extremely vague. So to answer your question in short, I mean, concussion, I don’t think is uncommon. Is it getting more common? Probably, but I think it’s also because we’re becoming more aware of it. I think we’re as clinicians, we’re paying more attention to patients who present in our clinics with be it whether it’s neuro optometry working in the optometric rehab realm, or whether you’re a physiotherapist or an OT patients coming in with these types of symptoms, I think we’re getting better at asking questions. You know, even if you haven’t had a loss of consciousness, I think the hang up in the past on loss of consciousness has been overly emphasized the vast majority, there’s some research actually showing that loss of consciousness actually results in cases that have better visual memory outcomes because the person sought care if you didn’t have a loss in consciousness, typically, care is appropriate. Care is not sought as often, because we have a hang up that a loss of consciousness has to be involved, which is complete nonsense.
Dr. Bruce Lidkea 6:12
And I think that it’s, there’s an easy definition for concussion as well, and it’s a history of trauma followed by a change in neurology. That’s really all we need. Yeah, and
Dr. Meenal Agarwal 6:25
like you said, it can be as small symptoms, like just a small headache after, or fatigue after, even just basic symptoms that we almost pass off, right, or we ignore so we don’t seek that help. So, you know, Bruce, tell me, like, what? What type of you know when, when someone suspects they may have a concussion, who are they visiting? Where? Where are they going? What should they do?
Dr. Bruce Lidkea 6:46
Well, I’m a firm believer, and I think Pat is too, is it’s a structure before function. So you want to get checked out at the ER. You want to make sure that there isn’t a skull fracture. You want to make sure that the neck is fine. You want, you want to make sure that there’s no damage or bleeding in the brain. But after that, it’s, it’s, you need to come see a neuro optometrist. And
Dr. Meenal Agarwal 7:09
who, who else would be involved in that care? So, you know, I know you mentioned the ER visit the neuro optometrist. Are there other professionals that they should be seeking care from? Oh,
Dr. Patrick Quaid 7:19
yeah. I think, you know, in terms of the team, you know, we use a six vector questionnaire, actually, in our office, because obviously the six aspects of concussion, and I’ve sent the document to you. If you want to post it, feel free. But there’s, there’s six vectors, from vestibular to vision to cervicogenic to migraine anxiety. So you have, you know, different. Every concussion is different. You know, if you’ve seen a concussion, you’ve seen a concussion, and I think it’s, it’s, it’s important to look at every case individually and work it up from that perspective. But in terms of the sequence of who you see, my opinion is, I think you know, neck has to come and again, exactly what Bruce said, You got to rule out pathology. First of all, assume that’s done once you’ve done that. My opinion is, the vast majority of cases, I’ve talked like 90% of the middle of the bell curve are going to be neck and back early vision, very soon thereafter. And vestibular once you’ve dealt with neck in the visual system. The reason being, if you do vestibular therapy, it basically involves you moving your head from side to side and looking at something. Well, if your neck is a mess and your vision’s a mess, that’s not going to be very successful. So vestibular therapy is important, but it has to come in the right place. So I’m a big fan of cervicogenic neck, first vision, very soon thereafter, and then vestibular and then an overarching where appropriate, from a psychological standpoint, making sure depending on how chronic the case is. We unfortunately, in our adult cases, our pediatric cases are quite different, but our adult cases. We’re not seeing these patients tragically till 345, years post injury, we’re almost always the last people to to the party. So when we see these, these patients, there’s usually quite an overlap of psychological things going on. So I think that has to be taken into
Dr. Meenal Agarwal 8:53
account too. And I saw a recent stat on, you know, like 20 to 30% I don’t know if that’s even right, but that’s a lot of concussion patients. 20 to 30% are experiencing depression within the first six months of their concussion. You know, Bruce, are you seeing that? You know, a lot with your patients who have had concussions?
Dr. Bruce Lidkea 9:13
Definitely, I think that the stat is it’s actually 50% of patients that have had mTBI within the first year are affected by depression. Now you bring that up to seven years post post injury, and I think it’s around two thirds, so it’s a pretty significant number. Wow.
Dr. Patrick Quaid 9:34
And I think something to also mention too, to follow up on what Bruce said, which is 100% true. I believe the Canadian Medical Journal, the Canadian Association medical journal, in 2016 published a paper, and the sample size was huge. It was like 230,000 I think was the sample size. And they looked to see, you know, out of patients that had a concussion and subsequently developed post concussion syndrome, what proportion of those patients. Who’s tragically took their own lives, and what they found was a tragic stat. It was three times the national average of what you’d expect to see. But the most tragic statistic in the paper was when you zoomed up, I think it was 667 poor souls who took their own lives. They looked in the medical records, and they had taken their life within a week of seeing a medical professional. So I thought that was a very tragic statistic. You look at it and say, you know, these, these, the notion that these patients are not seeking care, yeah, there’s a whole bunch of them that potentially aren’t. But when that happens within a week of a medical visit, it’s like, okay, there’s, we often see chronic cases where, you know these patients are, you know, I’m also a officer in the reserved armed forces, in the Canadian Armed Forces. And you know this, this stuff is pervasive, especially when you start to look at police, and you start to look at the military. Now, stuff coming out of the US is very clear on this, and I think in the general population, this study was done in the general population in Canada. So these are homegrown stats to say it’s, you know, post concussion syndrome patients are three times higher suicide rates, and over half of them that tragically follow through and do it have seen a healthcare professional within the last week of life. I think that should be a wake up call for healthcare professionals say we need to start asking more
Dr. Meenal Agarwal 11:10
questions. Wow. 100%
Dr. Bruce Lidkea 11:12
I think you know, you have to ask those patients you know, are you having suicidal thoughts or thoughts of self harm, you know. And do you have a stable and supportive network of friends and family, you know? And certainly, if there is any indication that there is the possibility of suicidal intention, then you have to get a neuropsychologist involved.
Dr. Meenal Agarwal 11:40
Do you have Bruce like a story of a patient where you feel, you know, touched your heart, that you really, you know, helped through that, that process of, you know, their mental health,
Dr. Bruce Lidkea 11:53
probably several. But I think that probably the most impactful thing I can say is that over the I’ve been practicing for about 30 years, and I’ve been doing neuro rehab for probably I started about 10 years ago. I’ve been going pretty full force for the last five I’ve had more happy cries in my chair in the last five years than the other 25 put together because when a patient comes to see me that you know, they’ve already seen their medical doctor, the regular optometrist, their physio, their chiropractor, a neurologist, and they’re coming into me either, either just in desperation or despair. And a lot of them, and some of them just think, well, this is just another box to Dick, you’re you’re not going to help me either. And then when we can actually show that a lot of the problems are visual, not sight related, but visual, then there’s this epiphany, oh, I’m not broken. It makes a huge difference.
Dr. Meenal Agarwal 12:57
And and Patrick, like, do you feel the same way? Do you feel like, you know, yeah, by helping them, you’ve helped their mental health kind of as well.
Dr. Patrick Quaid 13:06
Oh, we’ve, we’ve, we’ve seen patients leave after one visit, and it’s, it’s, yes, it’s a process. Visual rehabilitation is a process. But the validation that there is something wrong, that it’s not just them feeling gaslit, going, you know, I’m seeing all these people. They’re all telling me I’m fine. Why do I have these symptoms? I’ve stopped telling my spouse. Now my spouse doesn’t believe me to think I just don’t want to go back to work. You know, one of the stories that sticks out for me, and you know, I can say her first name because it was actually on CCTV. This actually was put on the TV, which was awesome. How it got to the reporter, I have no idea. I think it was through a family friend or something. But hanya came to our clinic, and we’d seen her before for VT, more from a amblyopia standpoint, but she subsequently had a concussion at school, and she greatly benefited from yoked tourism in her glasses, because when she was walking, the floor would look tilted to her, so she would adjust her gait to make the floor look flat, and she was drifting off to one side, and we got an instant response in just by putting the lenses in place. Now we still had to do the therapy, but it was so instant, with and without the glasses, somebody so one of the reporters got a hold of the footage. It ended up on CCTV, like her, her life has been changed because she was, I think she was like that for nine months before she saw us. And it was, you know, to see a kid that that tugs at me. I mean, probably the, probably the story I should tell is the one for myself, you know. I mean, when I mean, when I was eight, I was in a car accident, and I was knocked out of Commissioner for two years. So this is how I got into this. I mean, I did my PhD and my post doctorate in visual psychophysics, which sounds really boring, but if I tell people, it’s really I studied illusions and how the brain sees, that sounds way more cool. It’s because, you know, Bruce touched on something that’s really important, which is vision versus eyesight. Eyesight is what I see on the on the chart. Vision is how my brain puts it together and makes the world look cohesive to me. And that’s when you realize 40 to 50% of the human brain is visual machinery, and it is by far the most dominant sensory system. It doesn’t mean vestibular is not important. Servicing, cervicogenic is not important. Hearing is not.
Dr. Meenal Agarwal 20:00
Way the effect is like on you know your reading and you know the basic things that kids are doing in school. Would you say there is effect on that? And how are you helping with that?
Dr. Patrick Quaid 20:12
When we talk about kids, I think what you find with reading with children is what you’ll often hear from parents. If a kid has had a concussion and they’re not bouncing back, what you’ll often hear is, ever since the hit, it’s been, I don’t understand that my kid’s smart at everything except school. That’s the phrase I’ve consistently heard from moms, right? And it’s like, What do you mean by that? Well, you know, if I read to them, they’ll do fine, but if they read, they fall apart. They have trouble finishing their tests in time. They used to love school. They’re drifting away from school. And I think, you know, if the kid has an IEP, I you know, when you go back to that question about, what should primary care, optometry or primary care of any health care profession, to be honest, if they sit there and say, what, what simple test can I do in clinic? And my answer is, ask a couple of simple questions. Number one, if it’s a kid, is there an IEP in place? Do they have an Individualized Educational Plan at school, which is the school giving that kid extra help? That’s a red flag. Then you should be asking about, okay, were they preemie? Were they low birth weight when they were born? If the answer is no, we’ll start thinking concussion, because that’s what we find in our office. If they’re not developmental, their brain injury like there’s not a lot of in between. You also have to remember about 70% of the symptoms of Attention Deficit Disorder are identical to the symptoms of just convergence insufficiency. So if a kid can converge appropriately, so if I’m a primary care optometrist, what’s a simple test I can do? NPC, you need about 13 to 15 different areas of the brain to be working in parallel properly, to have normal convergence. So it’s a great screening test. Now mind you, if you fail the test, then good luck in trying to pinpoint where the issue is. But it’s a very good screening test. So just a simple NPC, Bruce talked about bibs, the brain injury, Vision symptom survey. It’s a good questionnaire, but I think another one I tend to ask for is light sensitivity and also tolerance of visually busy areas. That’s a big one going into grocery stores, malls, Costco type settings. We actually call it the Costco test in our office, if a patient’s like, Am I ready to go back to work? Go back to work? Back and you last in Costco for a half an hour to an hour, the answer is no. The answer is, you’re not ready to go back to work. I think the other thing is, in terms of gaging, whether somebody has had a concussion or not, or whether if they’ve had a concussion, and it’s a significance, here’s the thing I you know, I’ve got kids, right? Yeah. I mean, kids fall and hit their head all the time. So as a parent, how do I know when it’s a knock versus when it’s a concussion? And I think it’s when, when you start to see persistent abnormal function, things like reading difficulties, things like copying from the board, things like a big thing is spelling in kids. This is something actually. We just published a paper this year, 2024 in vision, development and rehabilitation, and we looked at a cohort of kids that had dysidetic reading difficulties. Let me explain that a little bit. It’s important. So if a kid has trouble reading right, it can be dysphonetic or dysidetic. So dysphonetic means I have problem with my phonics. I need to go see a speech pathologist. All. That’s fine. So you know, if you ask a kid, a kid to spell future, and they spell it with p’s and q’s. Then they have no idea of how letters and sounds go together. They need to go see a speech path. But if you get a kid who’s got spelling issues persistently at school, and they spell future, F, U, C, H, E, R, future, that is how it sounds. So English is a nutty language. I’m from Ireland originally, and trust me, English is nuts. I don’t know who invented this. Like there’s three different ways of spelling it, you know, spelling Yash, like, really, y, A, C, H, T. So English is, is, is not unique, but it’s definitely the more visually based language. Or I have to remember what the word looks like, even though it’s sounded out different to how it looks. So if you get a kid who is persistently spelling phonetically, so, station is S, T, A, S, H, u n, right future is F, U, C, H, E, R, because that’s how it sounds, right? So if that kid is overly phonetic and can’t remember what words look like, that’s called dysidetic reading issues. So dysidetic will typically not benefit very much from speech with speech speech pathology intervention. DYS phonetic cases will benefit from speech pathology intervention. So along the lines of what Bruce said earlier, it’s like diagnosis before prognosis. You have to know what you’re dealing with. So going back to the question of primary care, if you’re, if you’re an optometrist or a primary care physician, and you got a parent coming to you saying, my kid struggles in school, you say, Okay, is there an IEP in place? Oh yeah, there’s an IEP. Okay, what’s the IEP in place? For 80% of the time, it’s in place for reading. And if you say to that, to that parent, you know, does your kids struggle with spelling? And they say, Yes, and I just asked the kid to spell station of future and watch how they spell it if they spell it phonetically, it’s a visual memory problem. Concussion goes way up on your differential. So I think you have to start asking, then, okay, if your kid wasn’t premium or low birth weight, have they had any knocks or bangs, even if they weren’t deemed a concussion, have they had anything that was like, they had their bell rung, or they played hockey, or they fell, or there was something significant? I’ve actually had parents go back through their kids grades and they’ll say, Oh, now that you mentioned it, I went back to like when they were in grade three, and they had the knock. And now I. See the grades going down, specifically in English and in more the language based stuff and math didn’t drop until the kid hit the questions that involve word questions, so when they have to read them, that’s when the grades will start to drop. So it’s just knowing those things as a clinician and just knowing when to key in, because as primary care docs like, we’re busy, we got a million different tests to do. So someone’s like, screen for this screen, for this screen, for this My question is, if you were to just ask one simple question, any history of potential concussion events, and does your kid have an IEP in place at school? Two questions, and you you would cover if they have an IEP in place, we have, we have published a paper showing there’s about an 84 to 86% chance that they have a significant deficiency in either saccades, accommodation or convergence.
Dr. Bruce Lidkea 25:44
Yeah, I love the phrase, if you are a kid, or if you ever were one, you’ve probably had a concussion, that’s the thing. And the way that I kind of explain it, too, is it’s that drop a laptop. If you drop a laptop, you pick it up, you shake it. There’s no broken parts, but it doesn’t run right. Drop 10 of them. They all don’t run right, but they all don’t run right differently. So it’s a, you know, every one of them is a, you know, you you’re going to do an awful lot of testing to see what sticks to the wall.
Dr. Meenal Agarwal 26:16
You know, I love the point also that, you know, we should just be adding this to a history form, a basic intake form. You know, many healthcare professionals don’t have concussions on their intake forms. You know, we have a generic medical history, and that’s important because, you know, like you said, I have a lot of patients that I see myself, that you know, have IEPs in place, and they don’t think I’ve asked it. You know, every single one you know about concussion history or falling history, and I think that’s so important for us to be addressing that we also don’t do anything until the patient has symptoms, right? So we won’t ask for the IEP or about an IEP unless we see something like the patient’s experiencing double vision or something like that, or, you know, we won’t really ask those questions so but like you said, if we identify it, and then we, you know, even if we don’t have time as primary care physicians, optometrists, you know, whatever the profession is, at least being able to direct it and identifying it to solve the problem is huge. And I
Dr. Bruce Lidkea 27:19
think sometimes the patient doesn’t know how to answer. Like, if you ask, have you had a concussion? No, yeah, but you know that they’re a hockey player. Well, have you ever had your bell rung? Oh yeah, tons of times. Or,
Dr. Patrick Quaid 27:32
or you’ll get the you’ll get the hockey players. I mean, we, we dealt with, I won’t say the name of the team, but we, we dealt with an OHL team and a couple of NHL players, which is interesting. And what I found is a pattern is on their baseline testing. If you’ve ever heard the phrase sandbagging your baseline testing, so they will on purpose get this like the psychology behind this is astounding. They will on purpose underperform on their baseline testing because they don’t want to be taken out in case they have an injury. It’s that competitive, right? So so we changed the narrative with one of the OHL teams. I said, No, we’re going to set the norms, because if you’re an OHL player, you should at least be able to get to the age population norms. So you’re not getting on the ice unless you pass a certain level. And we’re not telling you what the level is. So now what’s going to happen is they’re all going to try to reach for their highest every single every single time. And it’s a subtle change in language. A paper that we published with the University of Toronto, think it was about four years ago, we looked at 254, varsity athletes that had had concussions and been cleared to play. The vast majority had had concussions and been cleared to play. We found about 20% of them. And you know, my hat’s off to the University of Toronto and Michael Hutchison, He’s a Professor of Kinesiology there. My hat’s off to them for publishing it, because it’s like these were people who were cleared to play. And we went in and did our testing and found that, on average, depending on the test, about one in five, about 20% of them were failing significantly on at least one important ocular motor metric. So it’s like these people were cleared, and then when you zoomed up that 20% and you gave them the biz questionnaire, the brain injury, Vision symptom survey, which is very simple questionnaire. It’s a bunch of questions. It’s a scale of a I think it’s from zero to 112 and you score over 32 is abnormal. The vast majority of that 20% that had trouble on one of the three tests had a significantly high biz score. So like, these are, and, you know, when you talk to them and said, How’s school going? Like, your third level education, how are you doing? I’m struggling. That’s what you heard from most of them. So these were people that were cleared
Dr. Meenal Agarwal 29:30
to play. Wow, yeah, I think, I mean, I think the majority of concussions is from from sports, you know, in the US, I think there’s two to 4 million, you know, sports related, or activity of sports related, whether it’s competitive or not just athletes. You know, concussions. So, so that’s huge, but interesting that you said that because I didn’t know that phrase, sandbag phrase. But I mean, like, that’s interesting, because most of us wouldn’t know that, that they’re getting tested for. Concussions, and you know, they’re underperforming, just so that if they had a concussion, then they would pass Well,
Dr. Patrick Quaid 30:08
I mean, about these folks where I wanting to go from the OHL to the NHL, so they’re they’re not going to admit it when there’s a problem. And the tragedy is, if the problem is uncovered, it can be not simply treated, but relatively easily treated, especially if you catch it early, and it’s not multiple injuries in before they finally admit that there’s a problem. I find most of these athletes when they come to us, it’s not the first injury, it’s like the third or fourth,
Dr. Bruce Lidkea 30:30
right? And when we’re doing these, you’re taking a patient that was functional and has now had an injury and is dysfunctional back to functional. But the overlap between neuro rehab and Sports Therapy is very big. So what ends up happening is you get these athletes that have had concussion, they go through therapy, and all of a sudden you’ve changed them from functional to optimal, and they can actually improve their game. And we’ve seen that a lot with with kids that all of a sudden, just kids coming in for a regular vision therapy for a CI and they’re doing that, and all of a sudden the parents come back next year. Yep, you’re right. The school, the school saying that they’re doing amazing, but he is killing it on the ice this year. And that’s, that’s what we want to see. We it’s a whole person. It’s a full functioning person.
Dr. Patrick Quaid 31:28
Well, along those lines, and it’s funny, you mentioned that a slight change in terminology. If you say rehabilitation or therapy, athletes don’t like it. If you say enhancement, they’re all over it. And you’re pretty much doing the same thing. You’re pretty much doing the same thing. As Bruce said, it’s two big overlapping Venn diagrams between rehabilitation and enhancement. And I find not that we need to do VT on everybody, but you take the average person off the street, you do a visual skills assessment on them. They’re not going to be perfect in every area, so the average person could probably be fine tuned. So you take an athlete who’s looking for a 2% to 5% an 8% improvement. I mean, for the average person, that’s not a big deal for professionally, that’s
Dr. Meenal Agarwal 32:08
huge, absolutely. And I find, you know, I like the word enhancement, because that’s, that’s huge. Like, to parents, you know, it a lot of parents are really gung ho about their children, you know, becoming competitive. Or, you know, at ages 810, years old, they, you know, they you know, they want their kids in competitive basketball or whatever the team is, hockey. And enhancing is huge. So I think that’s a word that a lot of us as healthcare professionals can use, rather than saying, you know, you need neuro rehab or you need vision therapy, which sounds like your child might have a disease, just enhancing their performance is, is such a great word to use. A lot of a lot of parents would opt into that. So, you know, I love that and, and you don’t know, maybe your child has had a mild concussion and or had a fall. You know, my four year olds had a big fall, and you guys got me second guessing this now, but you know that, you know, I don’t know what the consequences or you know what’s going to happen later on. But I don’t think I would have ever thought of that unless I talked to you guys. So, you know, I would have just thought He’s fine now, right? So parents don’t, don’t write this down or remember, so I think it’s important to, you know, keep a diary. Know what injuries your children have had, especially if they’re in competitive or, you know, these types of sports where they’re getting injured a lot,
Dr. Bruce Lidkea 33:24
if you actually enhance the intentional field, attentional field, or the visual decision making on a patient, or their multiple object tracking, you’re actually going to decrease the likelihood of them suffering another concussion. You’re you’re going to improve their safety profile.
Dr. Patrick Quaid 33:43
And I think, I think, you know what you said before about, you know, as a parent, paying attention these kind of kinds. I mean, I was lucky, because my parents really after I had my car accident, the only reason why my vision issue was spotted was because I had a speech issue as well. I developed a stammer afterwards, so my my SCMs, my neck muscles actually tightened. My head, posture went forward, and my speech was messed up for about 18 months. It was a nightmare. But on top of that, I had a CI so I saw a double and I distinctly remember having a page in front of me. I know kids are wonderful adapters, so I just turned my head slightly and used my nose to block one eye, and that’s how I read. And my dad was in the military. My mom was a nurse, and we must have gone to eight or 10 optometrists. Went to two ophthalmologists as well. And finally, my dad took me to see an optometrist who was actually involved with the military, and when he was assessing me, he just picked up a pen, said, have a look at the pen. And I just said, which one is? Like, what do you mean? I’m like, I see two. And he turns to my dad and goes, and you’re wondering why you can’t read. And I’m sitting there 18 months into my injury, thinking like, Finally I’ve got somebody who I’m now convinced that I’m not stupid. And when I go back to that, it’s, it’s, you know, and I won’t turn my head around on the podcast, but I’ve got, I’ve got a, I just got my haircut, but on the back, I’ve got a scarab about that long in the back of my head. And I think it’s, it’s realizing it was, it was not taken seriously, because there was no loss of consciousness, like they took me to the hospital, had a CT done, but. There was no loss of consciousness. And I just distinctly remember my parents saying, you know, the doctor said there was no loss of consciousness. So we wake him up every hour tonight make sure he that was the management. That was it. And we think that was back in the 80s. But, you know, you kind of think, well, things have changed now. Yeah, things are more fancy. We can do more scans. But has the management really changed that much? I think it’s getting better. I mean, if you look at 20 the year 2000 if you did a PubMed search for concussion, there was, I think there was probably about 20 pub publications in 2000 in 2017 there was 185 so like, the literature is exploding on concussion, because people are paying more attention to it. And good, but I think, I think it starts at home. It starts with the parent. Nobody knows the child better than the parent. So if you see a change in your kidney, something’s not right, and it was only because my parents pushed, because my dad was a bilateral plus eight. Didn’t get his first pair of glasses till he was 11, so you imagine his primary school was probably a nightmare. My mother was an amblyop, so she had a lazy eye. And I hate that term lazy eye. It’s like if your leg doesn’t work properly, you don’t call it a lazy leg, right? She was, she was a strabismic amblyopen. She was 20, 2040 in her good eye, 2080 in the bad eyes. Like both my parents grew up with vision, that wasn’t great. So when they started to see me struggling visually, in addition to the speech issue, it was like, for them, it was like, No, we’re not taking no for an answer. And they kept on. And a lot of parents, you know, we kind of, we talked about this earlier, but it’s, it’s the best doctors are the ones that get other doctors involved. The worst ones are the ones that think they know it all. And I’ll say that. I’ll say that very bluntly and non apologetically, like, I mean, I have a network of other healthcare professionals that I that I refer to, and I’m proud that I do. I make sure they’re competent. They know what they’re doing. Because I’m sorry, just because your license doesn’t mean you’re good. I’m going to say that too. You know you need to be, you know, people like Bruce, who are staying front of the field all the time. You know you need to be reaching out to people that you know are top of their game. And I think optometry, and it’s a great thing, optometry is really starting to branch out into, you know, special interest areas, right? You’re looking at Dry Eye, you’re looking at neuro optometry, you’re looking at specialty contact lens fitting. There’s a lot of really neat areas that are developing. And I think within optometry, yes, we need to be comfortable referring out to physio and other rehabilitation professions. But across optometry, we also need to be comfortable. We probably about half of our referrals come from primary care optometrists because they understand what we do, and because we don’t do primary care, we just do rehabilitation only. And I love those referrals, because it’s a colleague giving you the nod, going, thanks for doing that, because that’s something that we just don’t do in our practice. Yeah, and
Dr. Meenal Agarwal 37:31
there’s no shame in that. Like, I love that, you know, because there’s no shame you are. Like, we’re all in this to help a patient. We want to better their lives. So wherever direction that might mean, we’ve gotta head them that way and vice versa, right? I mean, other professionals will refer to us for other things that we might be good at, like you said, dry eye, myopia, control whatever, whatever it is. But having that network of professionals, whether, like you said, a car accident, whether it’s a Chiro involved with, you know, neck pain, a speech pathologist, you know, a psychologist and your optometrist. I mean that that’s the network that needs to communicate to help that patient, you know, from eight years of age like yourself, live their entire life successfully. And that’s, that’s huge, but it can start from a small head tilt. Like you said, many parents ignore head tilts. That’s, that’s a huge one that we get. Oh, it’s they’ve had a head tilt for a year, you know. And so, you know, head tilt mild things like you were saying a little bit double vision. Also, parents don’t ask their children, right? How come you’re not reading? What is the problem? They just they assume their child is, you know, silly or whatever the word is, like not wanting to read or doesn’t like reading. But probe your children questions. Why are you not reading? And maybe your child will respond by saying, you know, things are double or words are going blurry. That’s so important. We’re just not involved in questioning our kids to understand their symptoms better. And car accidents is a classic example. Car accidents, we just assume if everything’s fine, everybody’s fine. It’s like getting whiplash and and not feeling it till a year later, right? I mean, I had a car accident many years ago, and just this year, like, my back broke down and and everybody was probing me. What happened? I’m like, nothing. Nothing happened. Nothing happened. But little did I remember and think that car accident four or five years ago could actually impact me now, and that’s that’s similar to concussion. Sometimes people don’t feel those symptoms till a little bit later, or they don’t express those symptoms till later
Dr. Bruce Lidkea 39:31
now, yeah, another thing about the head is, you’re talking about the head tilt. But there’s also, like when you have a mild traumatic brain injury. A lot of times there’s an over activation of the sternocleidomastoids. And so you end up having the instead of this good posture, you get this. And the problem with that, of course, is that your head’s heavy and it’s no longer balanced on your spine, it’s forward, so you’ve got this activation here. But. Between compensated with your trapezius. And so you’re going to have, like, the sore, sore traps, the sore back of the head, the occipital headaches, that kind of thing. And also, we’re just a bunch of tubes, you know, our airway, our vascular system, our neurology. And there is a big difference between how my voice sounds like this and when it start talking like this, it’s constricted. And it’s not just your, your your airway, it’s it’s your, your vascular system and your neurology in there that’s getting constricted. And that’s that’s problematic,
Dr. Patrick Quaid 40:34
yeah. And actually, one of the, one of the things when I was going through rehab when I was a kid, was my speech impediment, which is a stammer. The guy had me read, and then he just pushed my head back so that the back of my head would touch the wall, and had me keep going and reading. And I was astounded at the instant difference exactly to that point. So, so when those SCMs are contracting, you get a major effect, not just on speech and muscular but also blood flow. I think that’s something that is being really has not been researched anywhere near enough, is the amount of the impact of neck muscle abnormalities on blood flow to the head. I think there’s a lot of literature now showing that, you know, concussions and brain injuries are also a precursor for things like dementia and Alzheimer’s and like blood flow to the head. Like, what’s that doing? I published a paper years ago. This is going back in my prior life, when I was at the University of Waterloo, doing a postdoc, but myself and John Flanagan looked at blood flow to the head in normal tension glaucoma patients. So these are glaucoma patients who don’t have high intraocular resorts for anyone who’s not an optometrist or an ophthalmologist. And what we found is the eye pressure wasn’t the problem, but the diastolic blood pressure was extremely low. So the perfusion pressure to the nerve was poached. It was the amount of blood getting to the nerve. So it’s like, okay, if it’s not eye pressure, what else is driving blood into the nerve, right? So it was, it was low diastolic blood pressure. And you know, in the primary care environment, we always look for high, high pressure, high blood pressure, because we’re worried about cardiovascular events. Well, if my thyroid is underactive or overactive, it’s a problem, right? If my body temperature is too high or too low, it’s a problem, right? Okay, well, why do we only worry about high blood pressure? Why not low? Like, can’t low cause a problem? So, so I think it’s, it’s, it’s looking at hypotension, not just in terms of, well, you might feel dizzy if you stand up. Well, there might be a whole bunch of other effects on the on the on the neurology of the system long term as well, right? Have either
Dr. Meenal Agarwal 42:20
of you, you know, I’ve heard a lot of buzz around like syntonics phototherapy. Do either of you, you know, use that regularly, and can you speak to that? Because I don’t know too much about it. So, you know, can you speak to what it is and how that could potentially help a concussion patient?
Dr. Bruce Lidkea 42:37
Sure, photobiomodulation, syntonics is a form of photobiomodulation, and photobiomodulation is just basically leveraging light in order to cause change. And we do it every day, like, you know, the we go outside and, you know, we utilize UVB to interact with the protein that’s 70 HC, and that actually is the precursor to vitamin D, or the active vitamin d3 you know, that’s something in medicine, they use a blue light on a regular basis with juvenile jaundice to break down bilirubin. Now, syntonics is utilizing the light in order to activate the autonomic nervous system. So blue light is something that actually calms the nervous system and supports the parasympathetic nervous system. The yellows and reds support the sympathetic nervous system. Now there, and of course, the greens are right in the middle of your spectrum. And I’ve actually had really, really good results using some of the greens for my migraine patients. And I think that’s what like companies like avalux are doing. But in optometry, I think that the certainly, the the areas of photobiomodulation that we’re seeing are in dry eye with the low light laser therapy, and then in macular degeneration, there’s some really cool things happening. I know in the states they’ve got the velita system, the Luma therapy system by velita, which is a an in office based treatment using a specific wavelength of red light for macular degeneration. In the UK, they’ve got the iPower red, which is a small, basically sunglass. And in Canada, we’ve just got the Aruna light, which is, I think, the best of the three products, because it’s a home based unit, but it’s a very robust unit. It’s a nice, big one. It’s not going to break. It’s going to last the test of time. It’s got some, some real Canadian rock star optometrists too. So it’s a, it’s, it’s a fantastic product. We’ve been using it at the office and and the whole idea behind that red light therapy is that it activates the electron transport chain. Via the cytochrome c oxidase pathway, and so it’s going to activate the mitochondria to produce ATP, and as a result, it’s also going to release nitric oxide, which is going to increase blood flow, so you’re getting added circulation and increased energy to your cells. Now it doesn’t do diddly for a perfectly healthy cell, and it doesn’t do anything for a cell that’s dead, but a weak cell, it’s going to recharge it back to the point where it may not die. And I’ve actually had patients improve a line within a couple months of using that. And the the frequency is, I think, three minutes every second day. So I
Dr. Patrick Quaid 45:41
think, I think from from my perspective, if I take a step back, because, you know, I’ve been doing VT a while, and maybe it’s the PhD in me. And I always joke that PhD stands for poor, homeless and destitute. If you ever want to make money, don’t be a grad student. But I always kind of go back, and this is why myself and Bruce get along so well, and how we kind of connected is, you know, our brains are like, I’m not just going to take somebody’s word for it. I want the data behind it, right? And I think what we found was syntonics. Initially, to me, was intriguing, but I was skeptical. So I was like, Okay, I’m doing VT. I’m doing all the traditional stuff that we used to do. So I went to a couple of conferences, and I like to think one of my best features is I might be skeptical, but I’ll dig right? I want to do it either way. And and there’s a wonderful saying in vision therapy, start where you are, start where they are, and go where they ain’t. And you can apply that to any form of therapy. If I have a rotator cuff issue in my shoulder, the physio is not going to start me up here. They’re going to start me within my range of motion and gradually get me to move my shoulder higher and higher. So you start where they are and go where they ain’t. Right. Patients come in and they’re light sensitive a lot of the time in post concussion syndrome. So you sit there, you go, Okay, I’m sensitive to light. And the patients will often say it’s not all lights. It’s like fluorescent lights drive me nuts. Okay, in particular. So then you have patients coming in trying all these different tints. Some will prefer FL 41 some will prefer a blue tint. Some will prefer a rose colored tint, like they’re all over the place, right? So part of me was, I need a measurement method to figure this out. So Bruce and I have kind of been talking, and we’ve been using something called CFF, because Bruce kind of told me he was using I was like, Oh, that’s interesting. Maybe we can use that for syntonics. So what CFF little box that he’s got there is you basically measure the threshold at which the person sees the transition from of a flickering light to a steady light, and it’s measured in hertz, right? So the normal range is about 44 to 48 hertz ish, 15 above is considered abnormal. 48 to 50 is kind of dicey. So what I started doing, very simply, was using different wavelengths of light and measuring the CFF on the patients to say, Okay, is there a particular wavelength where, where the CFF drops into the normal range. So the higher the number, the more abnormal that is. And what we started finding was a lot of these patients to exactly what Bruce said. A lot of these patients were dropping down in that blue range. There were. And when you put the filter on the patient, they weren’t all blue. But when you put a blue filter on the patient, like, oh my god, that’s so much more comfortable. And I would give some disposable filters. Say, you know, can you take it with you and and, you know, walk around Costco with the blue filters on, the patients would come back and say it was so much easier to walk around Costco with the filter on, so we knew we were on to something. So syntonics, in my mind, is a very simple way of finding the point at which they’re comfortable and then expanding the range of the wavelength. Basically,
Dr. Meenal Agarwal 48:18
okay, so is this something that you are doing on all your patients, or only every concussion patient that comes in, you take this measurement and then based on that you’re doing using the therapy, or are you doing it on every patient?
Dr. Patrick Quaid 48:31
Well, right, right now, we’ve really done a deep dive on our on our older patients. We’re now applying it to a lot of the younger patients, because younger patients actually respond much faster. We find syntonics is especially useful in those more chronic, protracted cases that are stuck, that are just not moving in therapy, I think what we find is syntonics is a tool like what I’ve determined and Bruce feel free to agree or disagree, what I’ve come to the conclusion of syntonics is just another tool. It’s just like lenses or prisms or plus and minus or vision therapy techniques, it’s, it’s should not be used in isolation, but it’s a good it’s a good way, if I use an analogy, syntonics sets the soil to be more fertile for the vision therapy to be effective, because what it does is it opens up the periphery and allows the patient to accept peripheral visual information. Because these patients just get overloaded. My PhD was basically in visual field. So think about glaucoma. Think about stroke. So I’m measuring my peripheral vision. The irony is, we measure visual fields in optometry and ophthalmology, we measure it statically, which, if you think about it, is idiotic, because we live in a dynamic world. Things move right so, so if you think about a syntonic visual field, how do we determine if the patient’s getting better or not? We have data on this in over 50 patients. Bruce and I have data that we put together on this. And basically, you have a patient, you cover one eye, you move a target in from the periphery, so they can’t look at the target, obviously, but they have to tell you, not only when they can see it, but when they can tell what color the target is. So. So it’s white, red, green and blue. And what you’ll find with a lot of these patients that have very constricted fields, it’s almost like a golden field, but it’s really constricted. And then as you start to use different wavelengths of light on the patient, what you start to find is, starting with the wavelength that’s the most comfortable, you’ll start to see that feel start to open up. And I think what that’s showing is you’re not, you’re not fixing the visual field. You’re putting the patient in a more balanced position. Remember, the term syntonics comes from the word synteny, which means imbalance. So to exactly what Bruce said, it’s taking, if you think of a seesaw, it’s taken the sympathetic and the parasympathetic and leveling them so that the patient, the patient’s not going to recover if they’re chronically stuck in a fight or flight mode, they’re just not going to recover. So syntonics helps to bring that down, helps to get the periphery open, which will then allows the vision therapy to be much more effective and actually stick. And that’s, you know, from a clinical perspective, that’s the way I look at it. There’s a couple of good books, actually, when I go back to Harry Babbitt, that’s probably the original book on syntonics, and he’s actually an MD. And then Harry Spitler is the syntonic principle. So if people want to read more about it, they can. I am really looking into why blue. I mean, both Bruce and I are convinced that blue does help in a lot of these cases. We’ve seen it with the drop in the CFF, seen it symptomatically. The patients will say, you know, I can, I can have a slight syntonic D or depressant blue filter, and it really helps. Now, the goal is not to keep them in that forever, but what we find is, I think, neurologically, and maybe, again, it’s my PhD brain, I like to have a an anatomical reason why it’s helping. And I think why it’s helping is concussion patients have problem with the periphery, right? They can’t handle peripheral motion even though the acuity is good. That’s why a lot of clinicians will get confused. They go, I don’t get it, the patient sees good acuity, but they’re complaining that their Vision’s off. And by the way, for the optometrist out there in primary care, these will be your chronic non adapt patients. These will be the ones that just you. They never seem to settle with any prescription that you give them. And I think it’s because think about the fovea, right? We have no real we have very few, if any, blue cones of the fovea, outside the fovea, the red to green to blue cones, the ratio is eight to four to one. So for every 13 receptors, we’ve only got one blue so if you put a blue filter over top, what are you doing? You’re allowing the patient to go more peripheral in a way they can handle again, it’s starting where they are and going where they ain’t. I mean, we can overcomplicate this, but it really comes down to that simple concept of, here’s a range of filters that we could use Find the one that the patient finds the most comfortable. And yes, we can confirm it with the CFF, start with that, and then slowly try to desensitize them to different wavelengths of light. And I think it’s really desensitization, because I’ve asked Eric singman from Johns Hopkins, I’ve asked, Who’s the other guy? He was at Stanford, gajal, I think is his name, but I they’re both MD PhDs, very smart individuals. And I said photophobia, light sensitivity and post concussion syndrome. Why does it happen? What’s the cause? Right? Simple question, both of them gave me an answer that was different, which tells me we don’t know what was interesting is the best definition I’ve heard. This is not my definition. I can’t remember where I heard it, but it’s a really good definition, probably, of course, from somebody way more intelligent than me. And what they basically said was, photophobia is light information that the brain can neither organize nor ignore. So I can’t organize it, but I can’t ignore it. I have to register as something light sensitivity. So what we find is photophobia. Light sensitivity markedly comes down when you use the right tint and the right approach in syntonics, and as you progress through VT, if vision is at the core, then you’ll see the light sensitivities start to come down. Now, if you have neck issues and other things involved, you have to address that as well. But we’ve, since, I’ve incorporated syntonics into my treatment, I cannot imagine doing vision therapy now without it.
Dr. Bruce Lidkea 53:52
To go back to what Pat was saying, the fact that we just in optometry typically will measure we’re sitting there static, looking 20 feet away at an object that’s static. We’ve got two visual systems. We got that 6% that that what is it? And then that 94% which is, where is it? And what am I? Where am I in space? And that’s the part that is. It works along with your vestibular system and your somatosensory system for your balance. You know, that’s a that’s but that’s, unfortunately, the system that collapses when you have a traumatic brain injury. The dorsal stream just shuts down. And so you’re almost in that tunnel vision, very similar to, you know, we’re Canadian, we have all driven in a snowstorm. You turn on the high beams, all you see is the snowflakes. You don’t see the road. That’s focal binding. And that’s, that’s a big problem with with traumatic brain injuries, that you’re so focal you that’s that whole periphery is gone, so your balance is gone, that the visual motion sensitivity, it’s the system is not playing well together.
Dr. Meenal Agarwal 54:57
That’s it. That’s a great way to put it. Okay. Thank you. Thank you guys. I mean, this was so helpful for not only healthcare professionals, but I think you know parents out there, you know who have children who’ve experienced concussions or may have these symptoms to reach out for help. So I think the burning question is, where and how can anyone find you guys? So you know, we’ll start with Bruce, if you don’t mind letting our listeners and viewers know, you know, how can they find you if they want to seek help?
Dr. Bruce Lidkea 55:29
Okay, I practice in Port Francis, Ontario. Yeah, you probably have to look that up. It’s a right in the corner of Minnesota, Manitoba, on the Ontario corner, right there. You can look me up at lidke optometry.com. I’m available at basically all the socials.
Dr. Meenal Agarwal 55:48
Excellent. And Patrick,
Dr. Patrick Quaid 55:52
thanks. Well, we’re two clinics. We got one in North York, in Toronto, and one in Guelph and Ontario. Our website’s viewtherapy sites, v, u, E, vutherapy. Dot.ca We also have something called a discovery call, which you can just jump on if you’re a parent or you’re a patient like I’m not sure what the next step is. You can book a discovery call on your schedule. And one of our team, we’ve got four, Bruce is an FC OVD as well. We got four FC OVD doctors who are fellowship trained in this area from the US, so they can jump in and kind of give you some help, and the team will just, just help you, to direct you. And there’s, there’s no cost to it, but it’s just kind of a, kind of a counseling call and say, Okay, where are you in your journey, and how can we help with the next step? And sometimes we’ll say, it’s more it’s appropriate to see in your optometrist. Sometimes we’ll say, You know what, based on what we’re hearing, you need to see this person first before you see us. So we’ll try to help you with the sequence of events, too. But events too. But the one in Toronto, in North York is on Bathurst and Lawrence and in Guelph, or on the south end of Guelph, so very easily accessible from the 401. Excellent.
Dr. Meenal Agarwal 56:51
Thank you guys so much for your time, your expertise. And I hope you know we’ve made an impact today on others. And you know, and there are people that will seek help for their concussions. So thank you guys.
Dr. Patrick Quaid 57:05
Thank you. Thank you.
Dr. Meenal Agarwal 57:05
Thank you, listeners and viewers, for tuning in. If you want to catch more episodes of Uncover Your Eyes, make sure to Follow or Subscribe on your favorite podcast platform and on YouTube. To learn more about me, follow me on Instagram @Dr.MeenalAgarwal. Until next time, keep those eyes uncovered!