205. Beyond Rest and Recovery: What Actually Heals the Brain After Concussion | Marissa McCarthy, MD

Welcome to Medicine Redefined. I'm Dr. Ultima Sharaja. And I'm Dr. Darsha. Let's put the hell back in healthcare. Hey everyone, on today's episode, we're joined by Dr. Marissa McCarthy. She is a board certified physical medicine and rehabilitation physician, brain injury specialist, and one of the leading voices in concussion and neurorehabilitation. She serves as a residency program director for the University of South Florida Physical Medicine and Rehab Residency. She practices at the USF Concussion Center and is part of the Performance Lab in Tampa, where she works with everyone from athletes and military veterans to patients recovering from traumatic brain injury. In this episode, we go far beyond the basics of concussion care. We discuss why complete rest is no longer the standard after a concussion, how sleep, exercise, nutrition, and inflammation influence recovery, and what the current evidence says about supplements like creatine, magnesium, and omega-3s. We also explore post-concussion syndrome, hydrobaric oxygen therapy, cognitive reserve, and what it really takes to build a brain that's resilient, not just after injury, but throughout life. So whether you're a healthcare professional, an athlete, or someone recovering from a concussion, or simply interested in just optimizing your brain health and longevity, this conversation is packed with practical and evidence-based insights. If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, I'm now seeing patients through my telemedicine practice who are finding health and performance. I'm opening a limited number of founding member spots at refininghealthrx.com. All right, let's jump in. Dr. Marissa McCarthy, I'm going to put you on the spot here to start off with. So we're all PM&R trained physicians. And to this day, my colleagues have no idea what I do. Best kept secret, kept out of the bag now. A lot of people are applying. And so I'm hoping that more and more people try to understand what rehab is. You said that's probably the brain injury. And I don't think a lot of people understand that that's even a fellowship that you could do. If you were at a dinner party and somebody asked you, hey, Dr. McCarthy, what is it that you do? How do you explain that? It's a loaded question. Really depends on your audience. How many people are there and how long they're willing to listen? I think, I don't know if you guys learned it during your training, but where our specialty came from. I don't know if you guys are familiar at all. We kind of had that as one of our lectures to kind of learn, like, where was the birth of PM&R, right? And a lot of people think there's an N in between the M and the R. And I'm always like, what does the N stand for? That one really wasn't, by the way. Right? I still get it, even from like medical personnel. But physical medicine and rehabilitation, obviously born out of the Second World War, they were seeing a lot of people come back from war with different types of injuries, specifically amputations. In Warm Springs, Georgia, they had a lot of different providers, if you will, providing what we now look at as rehab, whether they're shaping a residual limb, they're getting somebody up and walking, looking at that functional element of what we do. I think the biggest way to understand it is what a lot of people tend to write also in their personal statements is like, how can I become as functionally independent as possible compared to what I used to be? So I think in a layman's terms and the easiest way for people to understand is that we help people regain as possible after any type of injury or catastrophic injury or sports injury. or a mere slip and fall. So I think that's the easiest way to describe it. I think when I was in medical school, it was the plenty of money and relaxation. And I'm sure you guys can agree that's not necessarily the case now. Far from it. And then there's also the word physiatry, which many people confuse with psychiatry. So then that often becomes a topic of conversation. That being said, there are some elements of psychiatry that bleed over into physiatry, specifically in the brain health world, brain injury world. A lot of neuropsychiatrists work with us hand in hand, helping to deal with some of the issues that can come up after brain injury, including agitation, mood disorders, erratic behavior, insomnia. Even though it's not the same thing, we do work well together. I love that. What drew you to it? Great question. My fourth year of medical school, I didn't know what I wanted to do. And I came home to Tampa, where I am now. A good friend of mine who I had grown up with was actually part of the Tampa-based rehab group, Rehabilitation Electrodiagnostics. He's since retired. He was mainly their electrodiagnostician. And I knew I didn't want to do that. But he's like, oh, well, there's these other people in my group. They do general rehab. So why don't you shadow them? So I actually did an away elective as a fourth year. I worked at Tampa General Rehab. The first day I fell in love with it. I think being part of a team, there was a team meeting that day. So you had everybody in there, all the different disciplines from nursing to social work to the different therapy staff. And then they bring the patient in and then the family in. So I think I just really like that team approach. To be honest with you, if I hadn't done a residency, I probably would have done something else, either in pharma or in business as it relates to medicine. So I really wasn't drawn to anything in particular until I found and I was in medical school at the University of Miami. And at the time, we didn't have a PM&R residency training program. So once I came home, stayed with my parents, which is a big mistake when you're like 23 and you've already left home and then you come back and they're asking you where you are at night. I was like, okay, this is what I want to do. Then I went back to Miami and I had to seek it out. So I found a neurologist that did neuro rehab at Reiter Trauma Center. I found a spinal cord injury doctor that was doing a lot of research in spinal cord injury. So that way I was able to get more of an exposure before I went off to residency. So with brain injury, most people, I presume, think about military bomb blasts, concussions, motor vehicle accidents, loss of consciousness. Right. Those are some of the buzzwords that come to mind. But we're now entering a territory where brain health is becoming a big topic, too, and treating some organ that thinks about itself in a way. but also is really new on the frontier aspect of things. What is the thread that you're holding onto? You've had a lot of experience, right? You've been at the VA, you're at USF, you're now at the performance lab. So you've definitely been in a lot of different settings. What is this common thread that you've been hanging onto and what is really pulling you forward? I would say neurogenesis and neuroplasticity. The fact that the brain has the ability to rewire and reroute if we treat it correctly. there is that opportunity for healing, recovery, prevention of early cognitive decline. Because just beyond brain injury itself, a lot of people will come to me and say, am I going to get Alzheimer's? Am I going to get some type of frontal lobe dementia because I hit my head one time? I think that is almost like a fear factor for a lot of people. And if I can give a shout out to Dale Bresden from the UCLA Buck Institute. He wrote The End of Alzheimer's. And I read that book probably 15 years ago or so. And to be honest with you, I feel like that has been my Bible in terms of brain injury recovery, prevention, again, of that early cognitive decline or early onset dementia. I did have two grandparents who suffered from dementia, and it is an awful way to go. not just for them, but for their family members, not being able to recognize my mom and her sister. I think that really takes a toll on people. Again, not just the person suffering from it, but really the family surrounding them. So that was something that I kind of took to heart and how can we really tackle that and still provide them with a great quality of life. And if you read that book, you'll understand why. What's the name of that book again? It's called the end of Alzheimer's. End of Alzheimer's. And it's not just about Alzheimer's. It's about a lot of that you can do to help your your mind and your brain be a lot more in tune and age well. I think a lot of the things that we are all focused on at this point is how long can we stay looking young, acting young, feeling young? And the same thing goes for your brain. And honestly, that's where it all comes from in the first place. I mean, your muscles aren't going to function as well if your brain isn't functioning well. A lot of it, again, is also lifestyle related. The biggest factor, and I'll tell you this from my perspective, and people make fun of me because I always say I have a love affair with sleep. They don't understand how I have four kids, I work four jobs, and I still sleep nine hours a night. Yeah. You're going to have to give me some secrets before this ends, or maybe we can do it off camera here. So much comes to mind when you're talking about that. It's interesting because this term longevity is being thrown around more and more. And I think the aspect of people trying to promote their aesthetics has been around and come in waves back and forth. And when you look at a person and they appear fit, I'll put that in quotes, on the outside, you might think that that person is healthy. That's a little bit easier too, because I think this, us human beings, we like to pay attention to what we can see, right? And what we can't see is you can't see somebody's brain. You can't see what's inside the cranium. That's more of you got to test it out. And when there are these subtle changes, sometimes it can take a long, long time to be able to pick that up. Certainly, you might pick it up in yourself sooner than you might pick it up in a loved one or somebody close to you, especially if they're somebody who had a ton of cognitive reserve to begin with. I'll put high performers, I'll put physicians, you know, intellectuals, attorneys that we were talking about offline, those folks in that category. However, it's really difficult when you don't have your cognitive capacities. It doesn't matter that physically that you might not be in pain, because if you're not that person, not only is it painful for you, as you pointed out, but it's so painful for those who love you. This term ambiguous loss, I came to learn this about a year or two ago is where if you have somebody who's dealing with a neurodegenerative condition like Alzheimer's or brain injury, that person is physically there, but cognitively they're not. And the world who doesn't know that person might not recognize that because they have limited interactions, but you, maybe it's your mom and you've seen a certain version and now it's completely different. And like people who've had frontal lobe tumors come to mind or have had some type of injury where their executive function is completely derailed and it's nothing like it used to be. That's something that strikes me. That's hit me because some loved ones in my family have experienced that. And it's a form of grief almost, but it's not fully processed. And when you listen to people talk about that, they're like, it's a bittersweet moment when somebody with Alzheimer's passes because now you can formally grieve as opposed to before. You can't really grieve because the person is there. You know, you're following me. You're 100% accurate on that. I don't want to make. Sorry, go ahead. I said, no, you're 100% accurate on that. So anyways, I share all that to talk about how critical this is. And I think all the more reason for us to do everything we possibly can to make sure that we're less likely to have that. No matter what you do, just with anything else, with time, there is going to be some quote unquote, taking some steps back. There is going to be some degradation in performance and cognitive function. But what can we do to get that glider as high as possible? So just like bone health, just like muscle, as it declines, you are starting up at a higher point. And I guess maybe the lens that we can look at this is maybe we can start with injury and we can go from the acute injury and then chronically talk about it that given that you work with a lot of people with brain injury. And this is not something that we've talked about. I'd love to look at it from if a person comes who's had an injury, a brain injury. And we'll call it maybe just they've had trauma and they're presenting the acute setting to the emergency department, maybe the urgent care. And they've gotten the CT done. And the CT is quote unquote normal. There's no obvious bleeding or anything like that. And they say, hey, listen, you've had a concussion because you have a headache. You're going to get better. Go home. I'll say this because you and I know what the right answer is. But maybe we'll say, go home, sit in a dark room and you'll get better in like seven days. Just rest. Don't get light. They come see you maybe 10 days later. What went wrong then there? Maybe a lot of things, but take that off. And don't forget, a lot of the individuals that I see are also children. There is a protocol in which they don't like to administer radiation to those under 18. So many of them don't get CAT scans necessarily, which again is OK. So, yeah, I mean, typical signs of concussion. You kind of hit the nail on the head there. The number one presenting symptom is usually headache. They can complain of blurry or double vision, maybe ringing in the ears, difficulty concentrating, trouble finding words. You go to the ER, yes, you get a CAT scan. You make sure there's no bleeding in your brain, but now what? So I will tell you what I recommend when they see me, whether it's immediately or 10 days later, we are dealing with inflammation. that we can't see. We're not gonna see that on the CAT scan, but at the molecular level, there's being release of a lot of different neurochemicals, neurotransmitters, things that can be very inflammatory. I put every single one of my patients on the Mediterranean diet. So I tell them no red meat and no sugar, and nobody wants to do that because we know that red meat and sugar are very inflammatory. Everyone gets fish oil high in DHA, food for your brain. Again, inflammation reducer. And then to manage the headaches and potentially the insomnia and the anxiety surrounding it, we do magnesium glycinate. So I usually tell them to take that about half an hour before bed, 300 to 400 milligrams. And I'm going to tell you, I've done this for myself when I had a concussion. I've done it for my kids when they've had a concussion. I would say for me, it was like literally day seven. I felt completely back to normal. For my daughter, it was probably day four, but she's 13. I really believe that if you can get the inflammation under control, the symptoms of concussion will improve much more rapidly. Now, the go home, wait, go in a dark room definitely has gone by the wayside. You still want to be active, do things that you do, don't sit in a dark room. If you want to go on your phone, fine, but if it causes a headache or it causes eye strain or you to feel very different, then stop. Don't do that. If you want to get a workout in and you want to do a heavy lift, If it gives you a headache, stop. But that doesn't mean do nothing. It doesn't mean lay in bed in a dark room and just lay there until you feel better. Moving around is great. Increases blood flow to the brain. Gets rid of the bad cells. Brings in new healthy cells. Getting out in the sunlight. Natural vitamin D. 10 or 15 minutes a day. If the sun is bothering you, throw on a hat. So you definitely, from a lifestyle perspective, want to do things that you are doing. As far as alcohol goes, ideally during that period of recovery, you don't want to be drinking, especially because you're trying to figure out cognitively where you're at. If you throw alcohol or any type of drug on top of that, it's going to muddy the picture. Staying well hydrated, electrolytes are great too. So basic things that you would think to be a healthy individual is really what you should do after a concussion is fine. As far as return to play, that's a different story. If it's a sport-related concussion, then there is a protocol that we do go through. And you cannot start that protocol until you're completely symptom-free. And then it's about five days back to play or practice. It really just depends. And what I like to tell everybody is every brain injury is different. Everyone's brain is different. Everyone heals differently. So you have to keep that in mind. People with underlying autoimmune disease, they tend to not get better as quickly as those without it. Their body's always at war with itself. So now you throw an injury or trauma on top of it, they're going to take a lot longer to recover than somebody without that type of disease process. So much to follow up on here. Maybe I'll start with getting tactical first. The certain supplements, your stack, if you will, to calm down that inflammation, does it change your protocol whether you're seeing them three days post-injury versus 25 days? Does that matter for you? It doesn't matter for me and it could be 25 months. If they're symptomatic, you're doing this. You're doing it. And then you said DHA, what type of dosage do you like for DHA? Do you like DHA exclusively or a combination EPA DHA? So what I like is, if you read the side of the bottle, I want the ratio of DHA to EPA to be two to one. Most of your fish oils are gonna be higher in EPA because they're more for the cardiovascular component, but specifically when you want to focus on the brain and getting crossing that blood brain barrier, you want higher DHA. I'm sure you guys follow because I know you like functional medicine. Creatine has come into the brain health space, if you will, for 20 grams a day. So obviously the first five to 10 grams are really only gonna go to your muscles. If you've really wanted to get to your brain, you gotta get to the 20, which can be difficult for some people I usually say divide it up, do 10 and 10 in whatever beverage you're having it in. But I definitely noticed a difference, not only personally, but also in my patients for those people that are on creatinine. Yeah. Well, actually, I'll come back to that question, but I do want to ask about magnesium. So you mentioned magnesium glycinate. There's been a lot of discussion about magnesium L3N8 actually crossing the blood-brain barrier, whereas glycinate does not. I'd love to hear your thoughts on that. Again, there are many forms of magnesium. Those two are some of my favorites. I like magnesium glycinate specifically if they're also dealing with insomnia, if they're dealing with muscle fatigue or anxiety. The L3 and 8 is really great for attention, concentration, focus. And if anyone that I'm treating has a history of ADHD, I'm more likely to recommend magnesium 3 and 8. Makes sense. The other thing, yeah, I want to just talk a little bit about DHA again. I actually remember doing one of my journal clubs and fellowship was about how DHA, not only from a recovery standpoint, but can actually even have a protective effect. So I remember, and I'll try to find this study and link in the show notes for, I think this was NFL athletes, Division I athletes, football players in particular. who preseason DHA supplementation turned out that subsequently had far less incidence of concussion. And so that was one study that we had talked about with and without DHA supplementation. So to control group and DHA supplement to intervention group. And then also boxers, that's another group. And so the other study was looking at boxers who continuously supplemented with DHA. I think it was DHA alone, but I don't know if it was an isolated DHA product or again, that ratio that you had talked about, which shows that that's far more productive than EPA. So kind of like you pointed out. Are there certain products, not that we're affiliated or we're getting paid by anybody, are there certain DHA products that you like on the market? Because there's some nuances that I'd love for you to talk about fish oil and oxidation and stuff too. I think that's really important to discuss as well. Yeah. So going back to what you said, remember you said earlier, people with a higher cognitive reserve, physicians, lawyers, even athletes that are taking supplements that can be neuroprotective are going to have a higher reserve compared to someone who's not. As far as brands go, I'm going to tell you personally, I like Nordic Naturals. Pro DHA, it's tiny, it's strawberry flavored, and you don't burp. Like I have no affiliation. I'm just telling you, like I took that when I was pregnant and I put the liquid DHA in my kids' bottles for brain development. I think it's the oxidation problem. That's a real concern with any type of fish oil, right? DHA, I imagine has the same thing. No, I mean, you know, obviously every brand of supplement has their own, I guess it's a quality control mechanism in which they use. I will say I know they source their products from the Pacific Northwest. Yeah. Yeah. Wild Alaskan, I think. Fish. I haven't heard of that being an issue with their product. So I think, and Darsh, jump in here if I'm misquoting some of this. So I think my understanding was any type of fish oil, a lot of times then when they do third party testing that because fish oil, EPA and DHA will oxidize, it's essentially rancid and toxic to the system by the time people even get to it. So when some of the best practices rather are when you have fish oil, whether it's EPA, DHA, is that light exposure is a really big one that you want to try to minimize it. So if you'll notice the liquid ones, capsules tends to be less, but the liquid ones are always in a darker bottle. Nordic Nationals is one of them. I forget Carlson's another one that I like. And then when you're putting in a refrigerator, you kind of want to put it in a dark area and then you want to keep it cold too. You certainly don't want to keep it in a warm area. So you want to keep it in cold or cool. So I actually recently moved mine. I was listening to Ron or Patrick talk about this and actually had it in my pantry and I even moved it to the refrigerator just because that's something that you, have you heard anything about that? Yeah, no, mine are in the fridge as well. Even the Nordic Natural, some of the bottles that are white are that hard white plastic that you can't see through. And when the fridge door is closed, there's no light on. So I think you're really protected in that realm. I mean, and to be honest, even in the cabinet, when the door is closed, there's no light hitting it. If you open it up and you close it very quickly afterwards, I think you should be fine. You could do, you know, they have the omega blood testing you can do to see where you're at with 369. You could do that pre and post just to kind of see if anything changes with regards to the supplementation that you're taking. Is that something that you've considered? You just gave me an idea. It's somebody who's had a brain injury. Is that something you've done? Like when you start? No, I have not. That would be a study idea that I'm just having right now. We're trying to think of ways to measure it or see what it actually does within the system. That's something you could do. And they do, they make a finger prick one that you can do that you can mail to people rather than having to go to the lab and get your blood drawn. But I'm going to tell you, like, you know, regardless of metrics and measures and data, which is all great, what we look for in medicine, most patients will come back to me and they'll tell me how good they feel. And a lot of them will ask me, can I stay on this even though I feel better? The biggest thing with fish oil is at very, very high doses, it can be a blood thinner. So something always warned to them if they're going to have any type of procedure, make sure you let that provider know. Most anesthesiologists will request that you go off of your fish oil or any type of supplement prior to any surgery. Yeah, there's a tiny signal. I think the strength and reduce it, the two trials, the big ones over the last couple of years, it's a tiny signal with AFib incidence, but it was marginal. I forget which one it was. Darsh, you had something. Yeah. So speaking of Omega Quant, right, I think that's the test of Amazon again, not affiliated, but that's how I started getting on Omega-3. And I do the algae, Omega-3, I'm plant-based. But speaking about blood markers, is there any blood markers that are validated to check for concussion or to see that inflammation in the brain? There is to determine whether or not you need a CAT scan. Okay. Is that GFAP or... Yeah. So that if that's positive, that's an indication that you should scan the brain, that there is likely blood product there. Now, are providers routinely doing this or is this still something that. It's not providers. It would be ERs, right? Oh, yeah. OK. Yeah. So where they're first presenting, if the ER is suspicious and if they have that test, could not every single ER has it. Gotcha. Okay. Yep. I want to see if we can dig a little bit into the pathophysiology. So you talked about inflammation is a critical component that you're trying to address. I know that there were certain types of imaging that we could get that might be able to pick that up. Like for instance, I don't think it'd be functional MRI. And I'm wondering if PET scans or something like that, is it experimental? Is there any clinical utility to any of these advanced imaging modalities to see whether from a diagnostic purpose And I'm really more interested in that concussion because I think most concussions, if I remember correctly, 21 days or something is three weeks. They get better. 90 percent of the concussions will get better within two to three weeks, depending on how old you are. Am I remembering that correctly from Michael Gorilla? Yeah. The biggest issue when someone has a concussion is you want to make sure that they don't have a second one within that 10 day window for that risk of like an impact syndrome. again, which has to do more with that return to play and why we wait until they're completely symptom-free and then start that return to play protocol. Yes, the majority of concussions will heal within a two to three week timeframe, maybe even sooner, especially if you implement some of the things that we spoke about earlier. There is not a good, even research-based neuroimaging there right now that can detect the inflammatory cascade that is potentially happening in each individual when they have a concussion. Even with PET or functional MRI, you're not going to see that because that cell's leaking. So if you were able to extract the cells and then look at them under the microscope and see what's happening, then between a molecular biologist and a cell physiologist, we might be able to capture at that point. But most likely that's going to be in animals and humans. Makes sense. I want to shift a little bit more to slightly more challenging patient population. So post-concussive syndrome, what is it and why is it challenging? Is that who people call the miserable minority? Talk a little bit about that. Post-concussive syndrome by definition is when you have symptoms of concussion lasting longer than three months. Because we just said the majority of the population will recover within a two to three week time period. Now you've got these other individuals that still have problems with their vision. They say it could be anything from headaches to nausea to dizziness to issues with their emotions. All of a sudden they're laughing and then they're crying. So... I think that you have to kind of dissect what it is that they're hyper focused on, because usually it is maybe one particular symptom, but then everything else follows behind it. And a lot of times it snowballs, right? So they have a headache. They're dizzy. They're not sleeping. How do you feel the next day if you haven't slept, you have a headache and when you get up out of bed, you're dizzy? Now try having that for six months every day. So they're miserable. They are truly miserable. Now, were there things that went undiagnosed, such as a vestibular dysfunction? And when I say vestibular, I mean a balance issue. So there's a reflex between the eye and the back of your brain. And that is kind of what can be, let's say, jarred during any type of injury, even a slip and fall, even a rotational force. Or maybe the alignment of your eyes are just so slightly off that you're not able to converge on an object or you're not able to truly track an object. So in most ERs or even a primary care office, they're not testing your visual pursuit or your convergence. Maybe even your balance. When was the last time your primary care doctor had you stand on one leg? Takes too long. It's not enough on them. It's not part of a general physical examination for a help check visit. When I first see a post concussive patient, I go back to the history. I go back to what was done for evaluation and then what was done for treatment and if there was any imaging in that timeframe. And then kind of looking at each symptom individually and seeing how we can address those as well. And also bringing in that inflammation treatment modality, which most of them didn't do either, because it's not going to hurt you to be on a Mediterranean diet. It's not going to hurt you to take fish oil or magnesium, stop smoking, stop drinking, get enough sleep. I mean, these are all very basic things that most of us should be doing. So none of that is going to negatively impact their recovery. handset. That being said, going back to the history piece, remember I said earlier, autoimmune disease, autonomic dysfunction, history of POTS, chronic pain patients, they kind of get also lumped into the category of the miserable minority, right? Because they're already living that life and now you throw a head injury on top of it. So now it's one more thing to add to their took off list. It's kind of like the patient that comes in with 25 allergies, right? Are we really allergic to 25 things or is this just another thing to add on there to make that medical history so long and bust? And there certainly are a subset of individuals that malinger or have a secondary gain, whether it be be involved in financial litigation, perhaps something social within their home structure. I mean, that does exist too. That's also when we kind of bring in our expert neuropsychologists when we're really having a difficult time, like what is going on here? You know, they are able to really, them to focus for eight hours of testing, figure out if there's more of a mental health component, if there's an effort component. component, if it's truly a cognitive dysfunction, or are we really looking at more of an emotional issue? And you know what the emotional issue could be from the brain injury? It's not just cognitive, it's not just physical. There could be emotional ramifications of a traumatic brain injury or mild concussion. I never count anyone out. You do your full assessment. You're seeing them for the first time, regardless of where they've come from, what treatments they've had. And then obviously the whole goal is to make them feel better. Getting back to what we do as physical medicine and rehab doctors, like how can we make them as functional as possible, enjoying their life? For those that truly do have post-concussion syndrome three months after, is there a pattern that you're seeing as to why they might have lingering symptoms over their other colleagues who might get better in those two to three weeks? Are we seeing more like childhood trauma or pain perception? I guess the reason I'm asking too is, is there... Similar to how we use meditation to like increase pain tolerance, right? And go to a pain psychologist. We talk about neuropsychology to get a little bit more nuanced in terms of other type of symptoms. Like you said, attention, memory, cognition, whatever it might be. Is there something that you then think about for these people that truly have these persisting symptoms that are not malinkering? So yeah, I mean, obviously getting that history is really key. And then it's part and parcel to how the treatment goes forward. The literature will tell you that it's typically more related to those people that have ongoing litigation issues. But I'm going to take it back to sleep. The majority of Americans don't sleep. American Academy Sleep Medicine recommends seven to nine hours a night. Find me in a group of 10 people how many actually get them. Is this a chicken or the egg thing? Like the concussion is not allowing them to sleep? Or do you think they just have poor sleep patterns and sleep behavior that is then not allowing them to heal? Most people have poor sleep patterns even before they've had the concussion, which then doesn't allow them to heal. I couldn't agree with you more. And I'm thinking about a patient or two that I've taken care of where I think most people do want to sleep. Most people feel better when they sleep. There are a few genetic rare mutants out there who can get away with four to five hours sleep and truly don't need. I'm not talking about the person who's taking two 20-ounce cold brews and is saying they're doing just fine on six. Maybe they're doing just fine, but they're not thriving. And we're all about thriving on this podcast, right? However, sometimes your circumstances don't allow you to do that. So I'm thinking about a patient who had a brain injury. Young person has five kids. I know you got four kids and you got nine hours of sleep. The person has five kids. And the biggest thing is like she feels like her life's been taken away. Like we talked about sleep, right? We talked about, okay, like what does it look like? One was bedtime previously for you. Okay, bedtime was always around 11 p.m., 11.30 p.m. You know, can we have some type of consistency? And can we get seven hours of uninterrupted sleep? Like, can we try to figure that out? There was like a yes and no, because now there's like, well, okay, well, what's gonna happen with my five children? All of them are under the age of eight. That's a lot on the partner. Well, the partner's also taking care of this person. Or maybe they have other things where they also have to continue to work or accept this one, like all these other things. So I guess the question all around this is understanding how critical it is for brain recovery and just brain health. And maybe, like you said, it's the most critical piece. How do we play with that when you have these external things that are outside your control, or maybe you don't, quote unquote, have the luxury of getting the nine hours that you would absolutely need? Is this when we think about using pharmacological aid to help enhance the healing process? How do you work through that process? So before pharmacological aid, why can't the entire family be on a sleep hygiene protocol? Why can't kids also do the same sleep routine that mom or dad is going to do? I have one four-year-old and this is a conversation I have with her every single day and it's not working out well. So this is where, tell me how old your kids are. 18, 14, 12, and 6. I want to know when they were young, under the age of five, were you still getting nine hours of sleep? Yes. Yes. Okay, then you definitely have to share the secrets. Maybe that's what we should talk about for the rest of the podcast here. So sleep training is real. Okay, I started it with all of them at six months old. Yes, I got up at night to nurse when they were newborns. And I slept in two or three hour increments for the first three to six months of their lives and my life. But at six months, this is what a good friend of mine, she's a pulmonary critical care sleep medicine specialist. And I was at her house and my son was really tired and it was six o'clock and I was like, I'm not putting him in bed at six o'clock. And she's like, why not? I was like, what do you mean why not? She's like, put him to bed at my house, transfer him to the car. And when you get home, put him in his crib. I was like, it's never gonna work. She's like, no, it is. It's called sleep training. And I was like, all right, get up on this one. So I did that, put him to bed at her house. I left her house nine o'clock, came home, put her to bed at 10 and he still slept till six. So he slept 12 hours that night uninterrupted, which meant I got to go to bed at 10 o'clock and get up at six in the morning. And that was pretty early on. And honestly, I did do those routines with all of my kids from that early age. And I did do the cry it out thing as painful as it was. And honestly, it lasted less than a week for all of them. And now there's always a routine. We dinner at this time. We do our homework. We take a shower, read a book. We go to bed. I've never co-slept. The kids do not come in the bedroom. They each have their own bed. The lights are out. The room is cold. They get if they want to listen to music, that's fine. Yeah. But it's regimented in a way where it works for everyone. And they will tell you that they don't feel good when they don't sleep enough. Just like we don't feel good when we don't sleep enough. If somehow the family can incorporate that, same thing with pets. They really don't do you justice having them in the bed with you. Yeah, that's why I don't have any kids. I couldn't agree with you more. And I think probably all of us can agree. It's easier to work with the person who already had good foundational habits. And I don't want to pass judgment on everybody, but everybody has different circumstances. For some people, you know, if you go to sleep, that's fine. But let's just say for this, hypothetically speaking, if we agree that, hey, sleep training, you've done that in that window of six to 10 months or whenever you did it, and it worked. It's probably harder to do if you've been co-sleeping and now they're five, six years old. And now the person has had the brain injury in front of you and you have multiple of those kids. But now you also have a brain injury. Maybe you had a moderate brain injury. That's a much harder conversation to have with that patient. Yes, it is. That's the scenario that I'm really interested in learning about. It's like she can't go back in time and do that, right? How do we work with what we got, right? Has the ship already sailed or are there things we can do? No. So let's call it an addiction, right? If co-sleeping is your addiction, it takes 21 days to break an addiction. So you start out by putting the kid in their room and they come into your room in the middle of the night. And then you walk them back to their room, you rub their back and they go to sleep and then you leave and then you do it again. And again, until, I mean, it eventually wears off. They eventually enjoy sleeping by themselves in their bedroom. One of my kids was a little more defiant. She would come out of her room often. And I don't know if this is gonna bode well for the audience, but I would lock her in her room. I reversed the lock on the door. She would try and come out. Sometimes she would fall asleep on the floor in front of the door, but inside her room where she was totally safe versus opening the door, coming out, walking around the kitchen, turning on the stove in the middle of the night. We broke that behavior. And that was probably, she must have been four or five at that time. You truly can. You have to be consistent. If there's two parents, they both have to be aligned. You can't have one softy and one hammer. You have to really implement what you say you're going to do. And it really can work. Looking at like twins, right, that do share a room or share a crib. They do a lot of sleep training with them in particular because one might wake the other. on up. But creating the right environment for sleep is something that a lot of us don't really think about. What we have to do here in Florida to have our rooms at 67 to 69 degrees, you're going to have a massive electric bill. But that's really the temperature in which your body's, hey, let's go to sleep. Why do bears hibernate in the winter? It's cold. It's time to go to bed. Same thing with exercise. I always tell people if you have trouble going to sleep, don't exercise two or three hours out because now your core body temperature's up. It's not gonna get the signal that it's time to go to bed. So think about your kids too. If they play sports or if they're out at practice till night or 10 o'clock at night, they're gonna have trouble going to sleep right when they get back. Exhaustion eventually sets in, but like being on that routine and creating that consistency is really the best way to get everybody on the same pattern. Yeah, exercise is an interesting one. I think that Jade Wu was here a while back and we talked about this. I think certainly if you're going to do high intensity exercise where your heart rate is sky high or you're doing resistance training, it's going to be different. If you're going to do end of zone one, zone two, which can get you into more of a parasympathetic state, that might actually be beneficial. That's fair. Yeah. Now, speaking of, right, so I think we all agree that sleep is critical and environment's important. You've got to get your partner to get on board. Now, exercise is an interesting one. You brought this up earlier. It's a double-edged sword with somebody with a brain injury because we know that exercise, BDNF from a neuroplasticity, they were talking about. blood flow is beneficial. In fact, I think it's Dr. Bruce Letty from up in Buffalo, who's done all this work on sub-symptom threshold exercise for concussion return to play, stuff that we try to implement as much as possible. However, in this post-concussive syndrome, PCS person, where we want to be able to get them moving, get them exercising, it's going to be good for their brain, but it can also incite a lot of their symptoms. And so how do you play with that? How do you prescribe that? What are some guardrails that you gave them? Are there certain types of exercise that you like over others? Walk us through that. I would say walking, number one. Most of my patients are walking. Let's say they are in a wheelchair or something like that. Movement. Anything that gets your heart rate above baseline at this point is exercise, okay? It doesn't have to be a CrossFit workout or a heavy lift in the gym. I just want the heart above where it rests for at least 30 minutes a day. Ideally, if you can do it outside and get that natural light, that will also then help with that circadian rhythm and getting into a better sleep cycle pattern. So... If you can't do anything and you can sit in a chair and fidget and that gets your heart rate up, I'll take it. So we step, baby steps. What are you willing to do? Do you want to dip your toe in the water? Make some circular motions with your foot? I mean, if it's chair yoga or whatever the case may be, I mean, it's just movement. Perfect. Let's dive into another subtopic, hyperbaric oxygen therapy. Now, primarily through training, we've always learned about this with wounds, but I guess maybe there's new evidence, maybe there's not. I know it's debatable whether it can help with brain injury. Tell us a little bit about your thoughts on it, maybe what the data shows or doesn't show and your experience with it. So when I first started 18 years ago, that was when the first study that we did looking at hyperbaric oxygen, there was a study out of LSU, Dr. Paul Harsh. I believe it was in Rath looking at mild traumatic brain injury and using hyperbaric oxygen as a treatment modality in terms of recovery. It was, I think, two atmospheres at either 60 to 90 minutes. And then they found that, again, rodent study to be beneficial for brain injury recovery. Being in the situation that I was in, which was a very large polytrauma hospital in South Florida that was treating severely injured soldiers, the families were very high on, let's get them hyperbaric oxygen. This is gonna make them better. And we're talking about people with disorders of consciousness. in a vegetative or minimally conscious state. So here we're grasping at straws. We did that, we did the 40 session dives, two atmospheres, 60 minutes. And what we actually had to do with all of them because they weren't able to communicate well is they all got ear tubes put in. Because in order to go in a hyperbaric chamber, you have to be able to clear a pressure because it is like diving, right? So that happened. One of the things, and I don't wanna say it's a con, was high levels of oxygen created what we call CNS toxicity. So it increased their risk for seizures, especially in ones that had already been shown to have seizures. And as we know, moderate and severely head injured individuals are at an increased risk, especially within the first two years post head injury. So there's a caveat to doing something like that. You know, we always are taught to do no harm. So keeping that in mind and knowing what the risks may be, we notice an uptick in seizures. specifically with the severely head injured. So we kind of took a step back from putting them in the hyperbaric chamber. Fast forward now, honestly, to 2025, 2026. University of South Florida and the VA have partnered, and they are currently doing a study in active duty and veterans looking at how hyperbaric oxygen therapy can help heal mild traumatic brain injury. injury. So they have a whole protocol. It was funded by the state. I think some of the things you talked about are like system change, right? TBI is not currently FDA approved hyperbaric oxygen use as a treatment option. Now, this study, depending on what the results show, could change the way in which hyperbaric oxygen is utilized, either post-concussive or for treatment of maltraumatic brain injury or concussion. So it's... It was a very large multimillion dollar study. A lot of interest in participants, obviously, because there's a lot of individuals who have come back from war now 20 years later, having had blast exposure, multiple concussions, were they necessarily, severe had injuries? Probably not, but they were probably more like the athletes who had repetitive, what we call sub-concussive blows. They didn't necessarily lose consciousness. Maybe they were near a blast. You know, maybe they were around a lot of artillery and the brain's kind of been shaken inside the skull. They didn't necessarily lose consciousness any particular time. But now they're looking at themselves 15, 20 years later. And so they just say, I don't feel right. And again, you're looking at a population that doesn't necessarily sleep well. They definitely love to drink. Poor lifestyle habits. They do love to work out. But sometimes it's at odd hours of the night. Again, you have to put the whole picture together. But I think once we have information, especially from that population and that study, we'll have a little bit more to go off of in terms of hyperbaric oxygen as a treatment option for those with head injury. And again, as I mentioned before, I'm okay with it as long as it's not going to harm anybody. The true benefits of it, I think, are still yet to be determined. Speaking of the harm, how does it create CNS toxicity? Very similar to like, you know, when babies have like jaundice and they have too much oxygen, then same thing can happen. Overloading essentially a damaged brain and it becomes, I'm going to say like excitotoxic. So then that's what epilepsy looks like, right? There's a focus that's now been stimulated and it's going to cascade into what looks like a seizure. understanding that there is, the jury's still out for this, are you using it? And if so, what percentage of your population are you using at HBOT from a clinical perspective? I work in a couple of different locations. And one of the locations, it is a treatment option. We have a hyperbaric medicine physician who leads that area. He typically does an evaluation, determines how many sessions, how long the dive is going to be. We've seen people with post-concussive syndrome. We've seen people without concussion at all that want to kind of have that neuroprotective benefit. They may or may not be athletes that really want to make sure that their brain is very healthy before going into game weekend, things like that. But again, ideally, like you're having some type of a metric that you're looking at pre and post, which I think, again, we'll be able to see better with this larger study versus just the clinical realm. What I will say is you have to be careful. A lot of places will propose, oh, we have hyperbaric oxygen. But really, it's normobaric oxygen and you're just wearing an oxygen cannula. Or you're in one of those like zipper things and it's really getting you to 1.3 atmospheres, which would be like diving in your pool. As far as like potential patients or clients, make sure it's medical grade, that there's a medical director and that there is a hyperbaric technician that is with you the entire time that you're in there. At this point, is it a patient request when it comes to you thinking about referring to that person? Or are there certain clinical things that you're like, I think you would benefit from this and therefore should go talk to my partner? It's usually a patient request. That being said, in the traumatic brain injury world... We haven't spoken about it, but there are other types of brain injuries such as anoxic or hypoxic brain injury, right? So that's where we've had either decreased blood flow and or oxygen to the brain. And there's anoxic where it's been completely cut off. Let's say a cardiac arrest patient, carbon monoxide poisoning, you're drowning. I believe, haven't studied it, that's a population that would really benefit from hyperbaric oxygen. What's the youngest age somebody could do this treatment that we know it's safe at this point? As long as they can clear their ears and they have that cognitive capacity to let you know, I know that there are children that do hyperbaric oxygen. I love to ask my wife. She's a pediatric neurologist. And I know that she deals with a lot of people or a lot of children with an oxybrain injury and sees them or sequelae down the road. I mean, sometimes we'll see spasticity because of that. They've had some type of that. And so I'm curious if this is something that is pediatricians will use from time to time. Understanding that there is a lot to think about when you are referring to the right place, because you talked about whether you've been getting what is being advertised. Anything else to cover on this topic? Because this is one of those things that I think people will hear about on social media. It sounds very sexy and people will wonder, I should be doing this, right? There's this whole social comparison idea when a lot of people talk about it, like, I need to be doing this for my brain health. I guess I also want to know, have you tried it personally? I have not tried it. The reason I have not is because I actually have an issue clearing my ears from chronic air infections as a child and I am not allowed to dive. Oh, okay. There's some mystery on me. I was gonna add on Dr. McCarthy, on talking about tech and social media, I mean, you go to some of these conferences where you see a lot of these vendors, and again, using the word sexy, it's like brain waves, eye stimulation, light. Is there anything that you're actually excited about that you think has potential? I mean, there's obviously a lot of gimmicks out there and that could be a whole other podcast probably, but let's talk about actually maybe what does work or what you're excited about. Yeah, I'm going to say technology for brain injury, like the best thing that we have is computerized tests to actually assess what's going on. As far as treatment goes, I do think it's better in the hands of a live person skilled therapist. So if you're doing vision rehab with an individual versus doing something on your own on a computer or an eye gaze device or a balance board for vestibular, there are times that you can actually do things where it will go in the opposite direction of what is anticipated. So maybe I'm just old school, but I really think that working one on one with a therapist is the best way to go in terms of treatment and recovery and therapy for individuals with TBI. Couldn't agree more. Yeah, to come back to your point earlier about being multidisciplinary as a specialty, and maybe you actually didn't use that word, but I think there's a distinction between multidisciplinary and interdisciplinary. And there are a lot of, I think, specialties out there that will say they're multidisciplinary, but I think PM&R is one of the first ones and probably one of the few that are truly interdisciplinary. And there's a distinction to be made for sure, because I think the latter is preferable when we're thinking about enhancing patient outcomes. Now, I am curious. I think you mentioned people with autoimmune disorders where they're just fighting their own body. Certain things like pre-morbid anxiety and ADHD, where that could make it more challenging for that recovery process. want to learn from you is why is it that certain people can take a lot of those sub-concussive blows where they keep getting their quote-unquote bell rung, somebody like me where we just play a plate, and they don't have a symptomatic concussion where it's debilitating. Whereas the next person who might have the same type of hit sub-concussive blow or an actual concussive blow, and they go down the PCS pathway, the miserable minority, is there anything unique about profiles, pre-morbid conditions, et cetera, that make people more susceptible to something like this? I would counter the question with two people smoke, you know, two packs of cigarettes a day for 20 years, lung cancer, and one doesn't. I mean, that's kind of the, you know, I say we don't know. I do agree with you. Like what you said earlier, you have a higher cognitive reserve than somebody who maybe didn't have as much of an education, grew up in a low socioeconomic status. If you look at the TBI model systems, they'll say that. They'll say highly educated, the NUN study that looked at like the Alzheimer gene, who was more likely to get early cognitive decline with the gene mutation. That's another thing we haven't even talked about. What about epigenetics? What if those same two people have the same type of injury, but this one's gene got turned on and this one stayed exactly as is. So now you've got this one going down this other pathway where they're rapidly declining and another one who's totally fine. Sorry, I'm not... Are we talking about the ApoE4 or are you talking about something different? No, I am. So I was talking about two different things at the same time. So why do some people get Alzheimer's, right, with the ApoE4 and then some don't? That was the NUNS study. And that was the one that showed that those with higher cognitive reserve were less likely to have as much of a cognitive impact. But then same thing goes, let's say for concussion, you've got a higher cognitive reserve, you've had the same injury. Now, did one of your genes get turned on and the other person's didn't? Now I'm not saying for a mutation, I'm just saying in general, let's say like you brought up the autoimmune case, like oftentimes autoimmune disease is brought on by trauma or virus or some inciting event. Whereas if it hadn't happened, would that gene have been expressed? I'm just kind of throwing things out there in terms of things that we don't know, areas of opportunity to look at, like, why does one person recover and one person doesn't? To your point, why does this person get lung cancer and this one doesn't? So Dr. McCarthy, you also work at the Performance Lab. And for those of our listeners that are from Tampa, they probably heard of it or seen it on Instagram, right? State of the art facility. Altamont, whenever you come down here, we'll take you on a tour. It's truly impressive what you guys have done there, right? We truly talk about interdisciplinary. You got pain medicine. You got brain health with you, spheric oxygen therapy. Then you got the whole sport and athletes that with the entire gym, then physical therapy, occupational therapy, patient therapy. You got it all. And then you have imaging right on top of it. So you guys can do MRI as well. Yes, MRI, x-ray, ultrasound. X-ray and ultrasound. Is this the dream set for you when it comes to brain health? Is there anything that people can learn from when it comes to performance lab in terms of setting the most optimal practicing facility? Yes. The hardest thing for a patient with a brain injury is to keep track of their appointments, especially if they're going to multiple different locations. And I'm sure you guys recognize either if you ever worked at a VA hospital or during residency or something like that, the way that they have case management that's like the center of making sure that the individual and the family knows exactly where they're going and when, and then kind of bringing that team together as an interdisciplinary approach. So now we've got patient centric care. You've got all different kinds of specialists within your realm, all in one place. It's not a phone call to an orthopedic surgeon or a nurse surgeon, because we do also have that as well. So we have ortho and neuro, so that we kind of cover all the bases of which, we would be referred or we would be referring to. so that we can marry, hey, did you see this person? And we can have a conversation, especially in the outpatient setting. Obviously, inpatient, you have a controlled environment. They're getting their three meals a day, delivered by nursing. They're getting their vitals taken. They're going to PT, OT, speech. They're meeting with social work. They're having a family meeting. They're meeting with nursing. And then we come together every week and we talk about them. And then they go out into the wild of outpatient and you never hear back from anyone about anything. And they come to see you in an office visit. Did you go to PT? I think so. Was it this place? And you're like, I don't know. So obviously you're going to have better care. It's going to be more coordinated. It's going to be easier for the patient. It's going to be easier for the provider. It's a win-win. Honestly, no negative aspect to having it that way. And in the private sector, I've never seen anything like this. Yeah, it's truly a blessing for me being an inpatient provider. And again, I think in Tampa, PM&R is in the outpatient setting. It's somewhat lacking, especially with the resources. So to refer my patients to you guys, whether it's spinal cord or brain injury or a lot by stroke patient or even just general therapy, it's good to have what you guys have there. So yeah, really cool to see you guys expanding. Yeah. It's so critical. I think that I was actually just having a conversation today with a couple of my trainees and a patient because this patient I found was a young person coming for low back pain. People come in, they say they have hip pain and is it SI joint? Is it buttock? What's causing this? But the reason I want to bring this up is because this person was seeing one, two, three, four, five. four different musculoskeletal physicians, right? So a family medicine sports doc, myself, Pimentar Sports, an interventional spine doctor at a different system and an orthopedic surgeon within the same system. Now, luckily I could see three of the notes because they were within the same system, but the other one across the bridge in Philadelphia, I couldn't really see. And so, you know, sometimes it's like you ask patients, hey, like, what did they do in injection? They're like, they did in my back. And it's like, well, what does that mean? Is that a facet? Is it an epidural? Is it a side joint? What's the specificity of it? And the reason I bring that up is because it's frustrating for us to be mad at the patient or like it's easy for us to do that. It's frustrating because we want to say, hey, like, don't jump around and see that. But reality is patients are suffering and they're often just grasping a stroke, particularly that miserable minority that we talked about. They just want to get out of pain. They want their life back. And this like chronic pain and chronic headaches, like it's a really difficult type of disability because externally, people cannot see the suffering you're going to. going through, right? As opposed to spasticity or like when you have weakness after a stroke or a spinal cord injury when you're in a wheelchair, people can see that you have a disability. But when you're in chronic pain or you're dealing with horrible migraines or brain injury, like the world can't see and you still expect it to quote unquote be normal. And so they're just reaching for straws. The problem is though, when the practitioners are not great at communicating, it's going through multiple systems and they might end up getting procedures or treatments that are actually conflicting with each other. And then they end up paying the price for it. And so that's a conversation I found myself having at least three times in the last month with patients like, hey, you just want to be careful because you're the one who's going to pay for this. But what you've described here, what you guys have done, I was actually just browsing the website again, really seems phenomenal and is the word that Darsh uses, Dream. Yeah, I love that. And the next question is kind of, we talked a little bit about optimizing and being healthy versus injury and getting back to normal. Where's that line for you, like treating the brain injury and optimizing a healthy brain? And how do you find out, it's like how hard you want to push for the person who wants to optimize and keep themselves healthy and keep themselves primed, quote unquote, as you stay on top of the literature, as you think about these exciting technology and devices and all that kind of stuff. How do you figure that out? It's really important to treat each person individually because no brain injury is the same. There are people that are renegade and they want to try everything, even if you don't recommend it. And that's a whole different conversation than with someone who's kind of happy where they're at. I think, again, going back to the lifestyle piece, there's so much you can do with that, that you don't need to take any medication to allow the brain to heal and to recover. If you really do the things that we talked about, you know, with the diet and the exercise and the sleep, you can really optimize your brain health. And again, optimize the prevention of early cognitive decline. One of the things that we didn't really talk about is talked about in that book I told you about the end of Alzheimer's. Are you guys familiar with the glymphatic system? He really touches on how important that is to get rid of toxins and build up in the brain that we know can either lead to, let's say, Alzheimer's or chronic traumatic encephalopathy. So if you can have a 16 hour fast every night and create what we call autophagy, where the bad cells kind of kill themselves off and get. excreted, then you are going to have a healthier brain. Then supplement that with good quality supplements, good diet, good exercise, good sleep. Think about, I don't know about you guys, but I think about my great grandparents came over in the late 1800s and they all lived well into their 90s. None of them drove. They walked everywhere and they ate one ingredient food like eggs or chicken or broccoli. And then I saw my parents, parents' generation, my regular grandparents all dying in their 60s. And their parents lived into their 90s. So it's not what's happening, right? That is when cigarettes... margarine, baby formula, like all of that stuff started coming out, how it became easier access to processed foods. Now you've got, you know, the invention of motor vehicles and, you know, nobody's walking anymore. If you go to the blue region where you have all the centurions, they farm and they fish. They don't eat anything in a package. They don't eat anything that has a paragraph of ingredients that you can't pronounce. They are mobile all day long. They're out in the sun and they have a very low stress life. Can we emulate that? I mean, not exactly, but we can try our best. And it all starts with your upbringing. And, you know, what did your parents show you? And then what are you showing your children? There has to be a shift again, systematically in how we're raising our children. And I think there's been some getting rid of the artificial food dyes from our food. But why does it, why do the Skittles, why do we have Skittles? But why do they have to be made from artificial dye, right? What's wrong with raspberries and oranges and eating bananas and fruits and things that come from the earth versus the manmade? They're toxic to your body. Yeah. As you were talking about that, it reminds me, I think I heard Michael Smoke talk about this recently, where we have to manufacture adversity in our lives. Right. All the things that you're saying is we've adapted to comfort. We're wired for comfort. If I'm going a mile, I'm getting in the car and it's not going to be a walkover just because it's faster. I can do more Uber Eats, Instacart, DoorDash, you name it. The way we manufacture adversity, at least I do, is I go to the gym, whereas your great grandpars didn't have to do that because they were out there farming. That's the only way we do that. And by the same token, you have to manufacture cognitive adversity. Now, we know this is directionally right that most people, a lot of people, in fact, when they stop working, when they retire. Darsha, I think you wrote about this. We talked about this is they have a pretty rapid decline afterwards. And one of the reasons, sure, there's purpose as part of it. But another reason is they're not being cognitively challenged. They don't have cognitive adversity for most people. Their job, their career was a source of cognitive adversity. And so I think finding your ways to introduce adversity, if you're not going to get it naturally, which if you've been blessed to be most people, I think if you're born in the United States and the Western Hemisphere, like, or at least in the US, you're better off than a lot of places in the world. So you're going to have to figure it out because the alternative is not so good as Comfort Crisis, a book that I haven't read yet. I think as we wind up here, I want to ask about just kind of your thought process on training the next generation of physiatrists. You work with residents, PNR Residency, the USF, excuse me, is my understanding. I do too. I think one of the important lessons that I'll share is that I've learned from you, but also previously from other mentors is concussion and PCS is a clinical diagnosis. Kind of as you talked about, I thought about the one example that you gave is like if a person can't stand on one leg, well, there's nuance to that as well. For instance, if somebody has no athletic background, And they don't do anything. And they have terrible balance to begin with. If they fail that single leg test and I'll do the whole scat when I'm doing my thing. You're probably familiar with that. People who aren't, that's a sport concussion assessment tool. I'll always ask that person. I'm like, how's your balance on baseline before the concussion? They're like, yeah, I'm horrible. Like, that's not a reliable test for me. But if it's a gymnast, you better be able to stand 30 seconds on one leg, right? With your eyes closed, et cetera, and so on. So there's nuance to that. And really, that's why there's no one specific test, no one specific imaging that's going to help. It's really the whole picture, which is the phrase you use multiple times. But as you train the colleagues, the physiatrists who are listening, what are you making sure that they're doing differently than how maybe some of the antiquated philosophy, whether maybe I won't say antiquated for you or you're too much older, you look really, really young, but some of the older philosophy that people have training, like cocoon therapy and that kind of stuff, how are you training them differently? You always have to have an open mind. And what might be recommended today is not necessarily what's going to be recommended tomorrow, 5, 10, 15 years from now. And you have to stay up to date with what's happening, maybe from a research perspective, but also from a clinical perspective, like what we're doing. What scout are we on now? Six? Making sure that you stay relevant along with your trainees and that they continue that. Something that interests you and being able to be part of that as you progress in your career. When I was a resident, I didn't want to do pain. I was like, there's no way. I can't stand that population. No offense to any chronic pain patients out there. And when I chose brain injury, I was like, why do you want to do brain injury? Yeah. And I was like, you want to know why I do brain injury? Because they make me laugh. They're like the funniest group of patients that you could ever ask for. And I love to laugh. And let's talk about that. Laughter is an amazing medicine. And that's why I chose it. I also think that we know very little about the brain. And there's so much more that will be uncovered over the next 100 years. I think... making sure that you really find something that you're passionate about, but still being able to speak to the things, obviously, that you're trained in. I wouldn't say that there's anything archaic from my training. I had a very well-rounded training, and I'm very appreciative of that. And I think that's what I actually brought to the USF program here, is I wanted to make sure that there was no sewn unturned. If there was a weakness in the program of either exposure, education, or rotation, that we created one for them. because I wanted to make sure that they felt very comfortable after graduating, that they could go practice anywhere or go to fellowship anywhere and not feel like, oh, I wish I had exposure to something that they didn't. Because there are some programs out there that are community based out in the middle of nowhere, and they've never seen a spinal cord patient. Never, not once. And they've only read about it. And coming from large trauma hospitals, to me, it's like, how's that possible? How have you never seen one? You've only read about it. So obviously the breadth of your training makes you that type of clinician and allows you to cross over into different... Specialties to be able to have those intelligent conversations with other specialists from surgical background, from medicine background. And again, pulling your minds together to help the individual that you're working on. I'm definitely like the mom of the group. They can all be my children at this point. And they are that to me. So, you know, I appreciate the opportunity to be part of that growth, the discovery, the education of the minds of the upcoming physiatrists for the United States to be able to present to the world. So I'm very honored to be part of that. And we have a very open communication and dialogue. So if they have issues, whether it's personal or professional, I'm 24-7 and that's just kind of how it's always been. And, you know, we're family. I think that's awesome. And both of you, I think both of you guys do such a good job with leadership and what is needed in PM&R training. And that's being open, being that type of coach, that mom or father or whatever you want to call yourself, but also having that diversified experience. I mean, Dutch McCarthy, you've gone on to the news or media training in a sense, right? Like seeing that, I think, allows inspiration to really grow as a resident. So I think it's really cool that both of you guys are really showing that in our field. Anything else, Altafosh, that you had? Otherwise, Doug McCarthy, if you're okay with it, we can do some rapid fire. Maybe we'll go viral like Clay. Who knows? Okay. All right. So first question is most underrated recovery tool for traumatic brain injury that no one talks about? Sleep. Fair enough. We talked about that again about today. So there we'll get you nine hours, eight to nine hours. Okay. Biggest concussion myth you want dead? Don't lay in a dark room and do nothing. One thing every primary care doctor should do differently for concussion patients starting tomorrow. ask them what happened, see if they remember it, find out if they lost consciousness, find out if they went anywhere for any type of imaging. And then if they're having a symptom, follow it. Or if it doesn't get better, refer to the right provider so that they can get the treatment that I need. That's a history of taking. That's like PTSD from oral boards that I just took. All right, last one here. I'll change it up a little bit. If you could only recommend one supplement for your patients to take, what would that be? For brain injury? Yeah, let's see brain injury and then one just in general. Maybe that you like or that you take. I really am high on the creatine right now. Okay. Yeah. We just had Darren Kando on recently talking about creatine and brain injury. So we'll definitely link that too for people that want a little bit of that topic. Very cool. I know you're a magnesium glycinate fan as well. Is that from a brain injury perspective too? That's one that you recommend? Absolutely. So again, yeah, because it works on sleep, anxiety, muscle recovery, and headaches, it's a good one to target four different things with one supplement. Awesome. Dr. McCarthy, I just want to thank you so much for your time. This again was a topic that we haven't really touched on, especially concussion and brain injury. So thank you so much for taking us on a deep dive through that. For our listeners, if they want to get in touch with you or follow your work, is there a website or social media that they should go to? for the performance lab. It's TPL Tampa doc. I also work at USF concussion clinic. I am the residency program director for the University of South Florida physical medicine and rehab residency. You're not difficult to find if you just Google your name. So is that awesome. And then the last question we like to ask everybody is, how do you put the health back in health care? Why did it leave to begin with? Oh, yeah. Nobody has something. We're going to have to ask that question of our ancestors. That's fantastic. I love it. Thank you, Dr. McCarthy. I appreciate it. Thank you for having me. Thanks for listening to another episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter, and TikTok at medredefined. We also want to thank our team for the production of this podcast, specifically Ethan Ju on video, Harita Yaporian on social media, Zanab Lugmani on research, and Saira Khan for newsletter. Oh, and if you want to get similar bite-sized information delivered to your inbox every Sunday, please be sure to sign up for our newsletter. Also, if you enjoy this show, please be sure to subscribe, review, and share with anyone who you think will gain value from this as well. Now, time for the ever so important disclaimer. This podcast is intended for general public use and is for educational purposes only. It does not constitute the practice of medicine, nor should be construed as medical advice. No physician-patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.