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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

What constitutes a traumatic brain injury in a child?

How is it diagnosed and how is it treated?

We have the traumatic brain Injury Program lead here tonight, and she is from the El Paso Children's Hospital and Texas Tech Health El Paso.

And we're going to discuss all of these things and even more.

Thank you for coming back on.

This program is underwritten by El Paso Children's Hospital.

And we also want to thank the El Paso County Medical Society for having this program since 1997.

I'm Kathrin Berg, and this is the El Paso Physician.

Neither the El Paso County Medical Society, its members nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Good evening.

This evening we have with this Amanda Chiao who is the assistant professor at Texas Tech El Paso and also the pediatric audiologist at El Paso Children's Hospital.

And we're going to be talking about pediatric trauma, brain injuries in the borderland.

So it's a difficult subject to talk about.

There are so many different aspects to this and ancillary strings that we're going to talk about.

So I thank you so much for being with us.

I remember that you were here, several years back.

Yeah.

But I understand that you have 20 weeks worth of a baby in your belly.

I do, I do teach right from my OB appointment.

So thank you for being here.

Because mommys know you're climbing a mountain every single day.

Yes.

That feels like it.

Yes.

So if you know someone who's pregnant, give them a break, just saying.

Thank you so much for being here.

We're going to be talking about, again, treating pediatric traumatic brain injuries in the borderland.

And it's it's like, well, it's not a brain injury.

It's not brain surgery.

But a lot of times it is.

So, I would like for you in this area and the subject, if you can kind of explain what it is that you do all day, every day in this realm to kind of help the audience get to know you a little bit better.

Yeah.

So I'm just one piece to a really big, you know, team.

And to do, in my opinion, management of pediatric TBI, you really have to have a multi integrated team.

So I'm a pediatric audiologist.

What I focus on is really addressing a really big component of pediatric TBI, which is the signs and symptoms of dizziness and visual disturbances.

And so as an audiologist I diagnose I also can provide some rehabilitative support.

Just because of my training and my experience, I used to work for the University of Nebraska, Lincoln, where I really trained with student athletes at the D1 level for 5 or 6 years.

Oh, so I really learned what recovery looks like in that children with, traumatic brain injury can recover and they should be able to go back to their activities or sport through life.

And, if you do it right, that that can happen.

So for me, that's kind of my role, but I'm just one piece.

So our teams at children's but really any major pediatric TBI team consists of pediatric, you know, sports medicine or, pediatric neurosurgery, pediatric neurology, behavioral health, to support more of the mental health aspects that come with pediatric TBI.

And then, of course, we would be, nowhere far in recovery for traumatic, TBI if we didn't have our occupational and physical therapists and sometimes speech therapist.

So and with these kind of injuries and you were talking earlier that you do a lot with the rehab and that's where the magic happens.

And that's where you see things coming back.

And so I'm very happy that we're going to concentrate a lot on that today.

One of the big questions is when you say traumatic brain injury, that's like traumatic, right?

Yeah.

What constitutes a traumatic brain injury from a brain injury from like and I don't know, that's kind of the defining when you see it you see it.

Right.

But we don't know because we're laymen.

We don't understand how that works.

How would you all define that?

You know, there's a lot of different, terminology that's used in the research and different guidelines.

So it kind of depends on who you talk to and kind of what field you come from.

But in our children's hospital, we focus very much on the neurological side of things.

And so to us a traumatic brain injury is a TBI that is a result of a jolt, a bump or a blunt trauma to the brain.

Okay.

And it can impact the skull and actually called a skull fracture.

In addition to trauma to the brain.

And then it's really graded off the severity.

So the one that we're most commonly think of as a concussion, right?

A concussion, more notorious is linked with a mild TBI.

Okay.

That's a level of severity that really corresponds to that.

There was no bleeding in the brain.

There was no, skull fracture to, you know, where the injury was.

And then it really goes off of the, child's symptoms and their signs.

And then from there you have moderate and then severe TBI, which, I'm much more critical.

And then really does changes the, you know, the landscape on how we go about identifying and recovery for that patient.

Okay.

And then going through that, I'd like to, because you've already worked you said you were working for several years in the athletic area.

So you've seen.

Yeah, children come in pediatric.

I would love for you to give me a case study or two.

Just give me an example like, well, this person who was three years old came in.

This is how they got the injury.

Yeah.

This is how we walk through it.

Just anyone that kind of sticks out in your head.

We all have those 2 or 3 cases that are like, oh man, I remember that case.

Yeah.

So I think where I'm probably most my experience, they're kind of big kids, right?

They were like 18 and 19 years old.

But that didn't change sort of the the seriousness of it.

So in the kind of athlete world sports concussions are oftentimes considered a little bit more on the mild, mild TBI realm.

And so with those patients, I distinctly remember, again, having an 18 year old kid and we think he's an adult, but I still had to pick up the phone and talk to mom on the phone.

Right.

And, and discuss, you know, he's already had multiple concussions.

When do we stop telling them he can play football?

That's really crushing for a D1 level athlete who has aspirations to go to the NFL draft.

And so what I remember a lot about that experience is how, young brains, how narrow plastic they are and that children or young adults or even adults can recover.

It's about feeding the brain with that neuroplasticity and giving it stimulation in a graded progression.

And so I got to work with him and actually did his, his vestibular rehabilitation.

What that means is that we actually I remember was talking about that last time and that is now I love that word vestibular nerve.

Yeah.

So we actually rehabilitate that system and and the eye movements to recalibrate, if you will, how the head and the brain adapt for quick movements.

And so I got to work with him and I got to do some really fun stuff in his rehab that when we think about physical therapy, we think, you know, maybe in a therapy room with maybe a yoga ball or something, but you could actually adapt to and you should adapt it for the patient.

So for a sport, kiddo in sports, and like him, he was a running back.

And so we did more running back, like, type of drills.

And I'm not an athlete at all.

So for me, I just leaned on his athletic trainer and I kind of, you know, provided more of the science behind it.

And it was really cool to see him really recover and so even though he was 18 and considered an adult, he's still a big kid, right?

And and he's someone's kid.

So, that was really fun to see him actually recover and recover correctly.

A lot of our research has shown in that realm that, children with concussion, especially sustained at the, elementary and middle school level, they're really not managed for concussions well, and they can continue on to high school and maybe even college level and have persisting visual and vestibular deficits.

Yeah.

And they kind of just live with it.

And I saw that a lot.

And what we don't realize is that we can actually rehabilitate that through PT and OT and even speech therapy when it's more cognitive.

So it's really fun to almost like undo a lot of bad stuff that had happened.

So you can you can do it from years before, years before.

So that's I'm sitting here thinking, give me some specific examples of what you do in rehab.

You know, you're saying that when you're stimulating and what exactly are you doing during the rehab process.

So in concussion rehab it can be in multiple ways.

You can look at more dynamic gait and balance.

You can look at more visual ocular motor okay.

This is really what I look at.

And so the most common findings after concussion is a big problem is called convergence efficiency.

So what that is is, you know, our ability to pick up our cell phone and look at in text while we're walking in the hallway and look up, you know, at the teacher or look up at someone talking to us, we don't realize, but that's actually ocular motor, which means ocular and then muscle movement.

Right.

That's often disrupted after or after a TBI.

And that's what leads to blurred vision.

That's what leads to headaches.

That's what leads to dizziness.

And so you can do very simple.

We call like pencil push ups, which are just like kind of bringing in a pencil and kind of pushing your eye muscles in and out.

And then we can make it more fun based on the kid.

So I've actually, you know, with, athletes done even just like, you know, a tennis player, for example, and I'll hit a ton of, you know, a tennis ball and I'll change the distance so that they have to adapt their eyes for close distance of the ball versus far.

So that's where it's fun for me, because we can take the therapeutic approach and really tailor it to the patient, the kiddo.

And then they get into it and then the athletes get competitive and say, well, I have to beat this.

This is easy.

You know, this is easy.

I should be want to do this.

So I really love working with pediatric TBI, and I really love working with sport injuries because those are often the kids that, you know, are they what are they doing in the game.

Yeah.

And they're really motivated to get back to where they were.

And when you talk about recovery, it's not just, oh, I feel better, but am I as dynamic or as I, you know, had the same agility, the same sport performance that I did before?

So that's kind of my experiences since coming to children's and starting our program with our, you know, our medical team.

It's been a shift because now out of hospital and hospital, we focus a lot more on complex TBI injuries.

So beyond just the sport injury you're talking about children with skull fractures, children with you know, subdural hematomas that have, you know, bleeds in the brain, children with facial trauma, children with seizures.

And so it's been really interesting to be able to now look at a patient from a more complex medical angle.

And I always joke, I wish Dr.

Cuzshe was here today.

I know he'll watch this.

And last because on our clinical team, she is very much a neurosurgeon and very much like protect the brain.

You should stop playing.

By the way, he's in surgery and that's why he's busy.

So we tell the world because sometimes things don't just stop.

Yeah, I just, like you gotta go.

See, he's quite pragmatic about things and will tell a kiddo who really probably thinks they're going to go to the NFL draft, like, you should just pick another sport to play.

And then I have to go in there and say, well, he really meant what you know.

And so we I tell Mom and dad to yeah, that's a whole nother thing.

So we always joke about how we have a really good balance of a medical team that looks at this very seriously.

You know, that this is this is repeated impacts to the brain and what that can do over time.

And then you have us on the rehab side that say, okay, well let's work with what we have.

And let's try to also retain functionality at two days of living.

But also, you know, satisfaction and functionality.

And so I think that's one of the greatest parts about our team is that we have all the different players and we all kind of speak up and say, well, what about this?

And again, we joke about it because, you know, he's a surgeon.

He sees the worst.

And then I see the best, right?

Yes.

So it's been a good dynamic.

So here's a question that probably every parent is asking and maybe you can't answer it.

And I completely understand that.

And maybe you can say why.

But how long is it going to take them to get back to normal?

You know, that's probably the question you get a lot.

How do you answer that?

And I know that there really isn't an answer because you won't know until you go forward, but because you're faced with that question a lot.

Yeah.

How do you deal with it?

So one thing that we always tell parents too is, you know, normal is relative.

So normal a normal brain, we could none of us walk around and know what our normal brain looks like, you know, in concussion and in TBI, unless it's pretty severe, we have indications to do imaging, CTR, MRI.

We're not only taking pictures of the brain, we're really going off of signs and symptoms.

But what's important when we talk about normal is or how long will this take till they're normal is to do a really good assessment of what was pre morbid.

So what we do a lot at children's in our clinic as well as in the Ed as well.

We're trying to standardize to which we're asking the same questions to every single trauma patient, head injury patient where we're asking, you know, questionnaires that are been validated that look at symptom inventories, which are important, some inventories.

So it's perfect sense when you say it out.

So we're not just kind of willy nilly asking some questions, but we're actually addressing all the symptoms that can happen after a TBI.

And then we have to ask is this different for your child?

A lot of our adolescents at this stage have pre morbid mental health conditions.

They have ADHD, ADHD and they might even have substance use.

You know, misuse or disorders.

And if you just look at that in itself sometimes those symptoms can almost mimic a concussion.

If there was a bump to the head.

And sometimes the more often it exacerbates it or it changes their trajectory of how they recover.

So us having a really good assessment of what is normal for your kid, and now we have a bump, jolt or blunt trauma to the head.

And now something's changed, right?

That's what I look for.

So doing assessments like that as a baseline and then assessing are we getting back to that baseline.

That's the right way to do it as far as timing goes.

You're right I don't typically say it'll take this this this next we go off a lot of the CDC, guidelines and heads up programs.

So providers interested in getting more information, that's what we go to.

And so when we look at that research, it's been shown that for a mild TBI, in those instances 80% of children are going to recover within 1 to 3 months.

Oh my goodness.

That's quick start that I give parents.

And I think the end, it's really important for health care providers that we are sharing that narrative.

There's a huge misconception.

And back in, you know, probably maybe 12 years ago before different guidelines came out, that after a head injury, children need to be in a dark room, not be on their iPads, not be, you know, do anything.

And that's really not the guideline anymore.

We are seeing that there's actually better neural connections being rebuilt.

When we actually provide low levels of stimulation and then progress it in a graded way, and we just really rely on the kid out to give us the the green light.

Okay.

Now we can go a little bit longer.

Now we can do this a little bit more, but we don't want to avoid we don't want to avoid physical activity.

We don't want to avoid screens.

We don't want to avoid noise, because we don't live in a quiet and still world.

So we have to kind of provide a little bit of that stimulation.

And that is what I have found.

Parents are shy away from.

They want their kids to rest, and I have to undo a lot of that fear and say, look, yeah, in one, two, three months, your child should be fully recovered with this is we do X, Y, and Z. And if we control for the pre market conditions of x, y and z. So I'd like to have a question.

And I almost feel like I'm asking you to repeat what you said.

I don't but now let's take it to we're not sure somebody bonked his head.

Say there's a 13 year old who bonked his head really hard, but nobody really noticed.

You know, he's at home right now.

He's feeling what?

And I'm saying that because sometimes somebody starts feeling bad and doesn't realize, oh, this guy maybe have has a concussion or something happen.

What can parents and or the people that have it be looking for like what are the symptoms before, you know.

Yeah, he probably has a concussion.

Yeah, it's a good question because there's a misconception to that.

You are supposed to see symptoms right away after an adult bump or, you know, trauma to the head.

And that isn't always true.

Sometimes it takes a few hours, even a day or two, to present itself.

Okay.

Yeah.

So I would say the probably the ones that I, you know, clinically as well as the research indicates is different.

So you have kind of your red flag signs and you have kind of more of your subtle signs.

I would say the subtleness is has a lot to do with the vestibular system.

Is there reporting dizziness, headache, clumsiness?

Dis coordination.

That in itself will tell you.

And they're not typically like that.

That in itself will tell you the disruption to the vestibular system.

And in kids, that's not common.

Right.

There's always a reason for it.

Right.

And so that would be an indication.

So any clumsiness, any falls, any report of headache, and dizziness.

So years ago and I'm going to interrupt only because it stuck in my mind years ago.

It was talking about if a child appears like he's drunk and obviously he's not, as you know, but if that's the appearance, and I'm just trying to visualize this or have people who are listening be able to visualize that, that that's kind of to some extent.

Yeah.

I think it can look in different severity.

But what you might notice too, is a lot of positional dizziness.

So kiddos who are getting up from bed and they're like, oh gosh, I'm dizzy, right?

The older you get, that kind of happens.

The just, you know, as you get older.

Hey, yeah.

You know, you need more time to get up.

But then kids, they don't do that.

And so, yeah, positional dizziness will give you a good indication.

Bending over to tie your shoe and then taking a minute to kind of come back up that could indicate vestibular could also be more autonomic, which can happen after concussion.

You know, this kind of dysregulation with blood pressure and that kind of thing.

But of course the the red flags, this is a oh my gosh, we need to go to the Ed right now.

Is any indications of them really difficult to be aroused.

So, you know, okay, sometimes these kids crave sleep.

And again, the myth was don't let them sleep.

But if they if they're sleep you a little bit more, you want to watch them.

But if you can't arouse them and can't wake them up, we've got to get to, you know, immediate attention, medical attention.

Okay.

If they have a seizure, an immediate medical attention, complete disorientation.

Describe what seizures can present as.

Because some seizures, people think, oh, yeah, but a seizure could be very quiet and still as well.

So maybe I love that you said the word seizure at that moment.

Describe what seizures can look like, because there's a whole variety of ways in a seizure.

And and I wish that we had our doctor, Ellis, Ali Melendez studied here because she really is the expert in seizure and kind of what it presents like.

So I don't want to misspeak and say what it could.

I think you're right, though.

A lot of times this seizure can look very, you know, classic of how we see seizures with kind of that movement and sometimes are kind of quiet and silent, and maybe it's just a change in their overall their days.

And I was slumped over and a blank stare.

Yeah.

So any time I would say this, any time that your kiddo is not acting themselves in terms of physical or even kind of like cognitive engagement, we can't rule out something more neurological.

And that's when we go to the emergency room.

Okay.

Seeking your PCP can get in that day.

So we're talking about now, I'm 59 year old, years old, and I and I say that often because I think about what I remember when I was a kid in high school.

Concussions were probably happening all the time.

So now we are hyper aware of that, which is fabulous.

But I'm thinking in my day, when I was in high school and nobody treated concussions because nobody really knew it was a thing, you bonked your head, go sit down for a while.

What do you see the difference of not being treated versus now that you are treated?

So if someone just misses it and it's been missed for months and months and months.

Yeah.

What is the the outcome.

And again let's go to 13 years old because I feel like that's a kid but it's not a kid.

It's like somebody in the middle, right.

It's like everything's still growing, but they're probably not going to say anything because they're embarrassed or whatever.

What are the big differences in outcome versus treatment and non treatment?

Well, maybe I'm biased, but I can distinctly tell the difference.

So in a, in a child who, maybe has a misdiagnosed concussion and now we have spent more than those three months.

Right.

So now we're past the acute phase where passing in the subacute and now we're kind of hitting these chronic TBI like symptoms.

Sometimes physicians will classify that as post concussive syndrome.

And whatever you want to call it, essentially what those children look like are, what I would consider to have more severe.

But more, kind of either mental health, a lot more vestibular issues.

Because what happens is that in some instances, if the injury was significant enough and the kiddo is not an athlete, for example, they might have adapted, they might adapt now their every day to avoid, feeling a certain way.

So if it's that now in their new normal.

Yeah.

And I see a lot more an effect on their mental health, on their overall social, you know, desire to be social, there is some research to show that, you know, repeated concussions that are untreated, especially in boys at a certain age with past history of ADHD, that that to lead to early indications of one of engagement with substance misuse.

You know, so there is is there is this tide here.

And that's where I think rehab is so important in early rehab, when I see children who we can get in quickly, we can ID the concussion or the TBI quickly.

We can get in with intervention quickly once we're cleared to do so.

Those are the children where their brain takes over that neuroplasticity, and then they can get back to doing what they enjoy doing.

Going to school is incredibly important.

Children who will stay home from school are homebound for, you know, mild TBI is that is, really a detriment, to their ability to recover from the concussion but also reintegrate, into every day.

And we see that often where kids will have been at home, you know, for 12 months, have missed their whole sophomore year of high school.

Yeah.

And now we're not so much dealing with a concussion or a TBI anymore.

Yeah, the brain has likely done its healing.

But now we have a lot of, psychosomatic.

We have a lot more functional learning differences that, and behaviors I should say, that have developed because us.

Right.

So we see a huge difference.

And that's why our clinic and our hospital has a big push on identifying children earlier.

Managing them quicker, and integrating all of the disciplines.

So we're all looking at it with our own lens.

Right.

Managing TBI for a pediatrician is a lot of work.

It's a lot.

And so that's really where us specialists come in and we can say, you know, let's help you out and let's give some recommendations.

And that's really the premise of our concussion clinic at children's, too.

So I, I want to keep going back to this because I know we see vestibular a lot.

And we've been talking about it.

So we know what that means.

But explain vestibular to the audience.

You know, it's like the the central nervous balance.

We talked about this.

I show two because you educated the heck out of me on this on the last program we did.

So maybe if you were teaching a class right now, professor, as you are assistant professor.

But, professor, how would you describe the stimulus system, so to speak?

So I'll first say vestibular does not equal balance.

Balance is a multimodal system that encompasses your eyes your inner ear, vestibular system and then your sense of, touch your proper sense of symptom.

And after concussion, balance can be disrupted.

So all we have to do is unpack is a vision.

Is it?

You know, it's not a sensory or is it inner ear or a combination of them.

Vestibular is actually more related to how the inner ear picks up signals and then sends the signals up through the brainstem to your eye muscles.

So the vestibular ocular reflex is traditionally what is affected from any vestibular injury, but often after concussion.

And what that is, is that it's a reflex.

It's very fast.

It's like eight milliseconds.

None of us in this room will ever think about our VR because it's just working for us in the background.

So an example is if I hit my head around quickly, my eyes don't dum dum dum jumble.

They actually stay fixed on you.

And if they jumbled, then I would feel vertigo.

Just like you would feel if you were dizzy.

You know something happened to you and you were sick.

That sensation.

And so this is a pathway.

It starts off with the inner ear that senses movement from your head and tells your brainstem, oh, we're making a left turn or a right head turn.

And the eye muscles counteract that, that reflex is fast.

It's efficient.

And it's with it's to protect us.

But after a concussion, it's the integration between how quickly that signal is taken to the eye muscles.

Sometimes the eye muscles are just sort of weak in terms of how they receive that information.

And that's how we rehab it.

So nothing structurally wrong oftentimes.

And it can happen where you can have damage done to the inner ear from a blunt trauma that was really significant more often than not in a mild TBI, it's just a processing issue, a calibration issue, if you will.

I like that.

So with rehab, I'm really training the VR.

So I'll have my patients move their head around while they focus on a sticker, or I'll have them touch it.

Now, as you're saying that I'm like like how where are my eyes going?

They'll catch a ball, you know, that I throw up in the air and they have to look for it.

So, we can recalibrate that VR pathway.

But oftentimes when I work with, especially my athletes and I'll say, okay, I want you to move your eye muscles and I want you to do this, you know, ten reps.

They look at me like, are you serious, lady?

I do has this much or, you know, this is my older app.

It's important, I promise that these eye muscles are incredibly important and it a little goes a long way.

So the vestibular system is really that connection between the inner ear up to the extra ocular eye muscles.

And that goes through the brainstem and the cerebellum.

Okay.

It's so beautifully explained when you say that.

And I'm just trying to think to let's go away from concussions for a while and talk about some other brain injuries that can occur and how they may occur, that aren't concussive, so to speak, and how you treat those as well.

So you mentioned seizures earlier.

And that could be maybe not at all related to a concussion or a sport injury, but, take that opposite route.

So more just conditional kind of brain injury, other things that can cause dizziness or dizziness or can cause whatever it is that would land them to come spun.

Got it.

Yeah.

To have you help them.

Yeah.

Not normal.

That's a terrible word.

You can get to where they can start functioning and better.

I would say that my clinic from a vestibular standpoint is 90% migraine headache.

Oh wow.

And now becoming a lot more in concussion.

Really.

So yeah.

So what we would not have thought that.

And I say, you know, that kids are not often the ones that report dizziness in the sense of the inner ear.

So when we think about you might hear this, you know, oh, I'm dizzy.

And your doctor said to me, inner ear problems, 90% of the time that's actually not true in a child.

Unless children have a reason to have an actual insult to the peripheral inner ear organs, whether they have hearing loss or there's something congenital, it's wrong or there's a tumor.

It's it's about 10%.

Maybe less than that.

The majority of my patients are coming in because they had a concussion.

Now they're dizzy or they have the start of the stimulant migraine, or a type of migraine that makes them incredibly motion intolerant.

They are triggered by visual motion, which uses or extra ocular eye muscles that VOR, vesticular ocular reflex And so I'm assessing their, you know, vestibular system to make sure that it looks good.

The signal can go all the way through there.

Probably some stuff there.

When you say that make sure looks good.

Because I'm thinking to myself when I get headaches would be a day honestly.

Like today.

And no offense to the lights in this room, but these three lights really affect me.

And then tonight, within an hour or so, I'm going to get that funky and I call my light headache.

You know, it's from lights.

So when you're what was the question?

I was just asking.

I forgot what I was just asking.

Goodness gracious.

So yeah, when you're when you're looking at lights and it's a headache that comes from that of my vestibular headaches that can be brought on by lights.

Is that how do you know that when someone's very young, like, how can.

Yeah, you how do you know what's causing the vestibular migraine in childhood is a relatively new, newer diagnosis.

And it actually my experience now has seen that it looks different in the neurology world versus otolaryngology world.

And that's the world that I come from.

So in the otolaryngology world, pediatric vestibular migraine, is actually well adopted and well accepted as a likelihood to explain dizziness in a child who has completely normal peripheral inner ear function, and who has a history, a form that has a indications of possible migraine.

So in a young child, we called the vestibular march.

Okay.

The vestibular march is at a young infant by about 24 months.

That VOR that vestibular reflex is fully match rated.

But it's not fully, you know, reliable until about age four.

So this is the kiddo that you put in the car and they throw up in the car.

The the motion.

Sick kid.

Right.

And when you're in a car, your inner ears are telling you're moving forward, but then you've got everything going backward and you have a visual conflict.

Interesting people who have migrated traditionally more vestibular migraine, that's their problem is that they have a really high reliance on their visual system.

And if that isn't stable, it can trigger dizziness, nausea, motion sensitivity issues.

And so the vestibular march starts what starts with them.

And then those kids might develop kind of like abdominal migraines or abdominal like issues stomach aches vomiting.

And then once they hit puberty and it's more prevalent in girls, particularly as they start to get into the years of kind of menstrual cycle and all of that.

We see a peak now in actual associated, photophobia, which is sensitivity to that light phoner phobia, sensitivity to sounds.

They could have tinnitus, which is ringing in the ear.

They could have perceptions of hearing loss.

And they could plus or minus have head pain.

That's usually like unilateral kind of one, you know, behind the eye or kind of one area.

And there's all different ways to diagnose migraine.

And I'm not the expert in that by any means.

But in our field of audiology and otolaryngology, when we see a patient present for dizziness, they usually go to the ENT and the ents, like this is an ear.

Then they come to me and we go through a series of vestibular tests to make sure that all of the ear works fine.

And then we look at how well they're able to track lights or follow lights.

And it's like, okay.

And I can usually see within kind of that area that they're really sensitive and they they can do it, but they don't do it well or it makes them it triggers a headache.

Right.

And that in itself already tells me that that is it, that they're triggered by visual motion.

We go off of the International Headache Classification diagnostic list for vestibular migraine in childhood.

Relatively new.

I'm still learning a lot about how different, you know, fields accept that or not.

Yeah.

But if you ask me in my clinic when I get a referral for dizziness, you're going to check 50% of the time.

I always ask, do you have headaches or migraines?

does your mom or dad have headaches or migraines and you get sick in the car?

You know, we're asking a lot of those questions that may lead us to think of that vestibular march.

So, you know, that infancy kind of fundamental issues in the early childhood.

Now it's migraine like that usually goes along with hormones.

So here's another, question.

I'm just thinking my motherhood when I have younger kids.

And if they don't know the difference because they've always had vestibular migraines, maybe they've always had these headaches, but they're so used to them they're not going to complain about them.

How how do parents come to you with smaller ones that may not be able to, you know, describe what's happening?

How do you find those?

Or what are some case studies of parents saying, I don't know, I'm just trying to figure out how would I know that my child is having issues.

So a lot of times in younger, because you're right, they're not usually going to be able to verbalize that.

Yeah, yeah.

But in young kids it's usually like a delay in their gross motor skills walking, standing.

It's also a apprehension.

Those are the kind of the fearful kids that don't want to go down the slide.

They're the kids that throw up a lot in the car.

They're the kids that maybe are more clumsy and fall down a lot.

Usually that's kind of what we'll make a referral initially.

And a lot of times those referrals go to neurology.

And they and they should a lot of times you want to be sure that we're making sure it's not something more severe.

And so they'll do imaging and kind of rule that out.

And that's how that patient gets to me.

But you have some kids that are a little bit older that will verbalize in their own kind of, you know, way that, oh my gosh, they're I'm dizzy, their room is spinning and they might vomit a lot.

So I get a lot of referrals from otolaryngology that come that way.

Because right now it's still kind of common practice to associate vertigo and dizziness with ear inner ear.

Okay.

So that's kind of how I would get them.

But you're right, it is hard for kids to report that, but in the migraine kids that they actually it's it can be very debilitating depending on the kiddo and depending on kind of what happens.

So, you know, it's a newer field within what I do, but it's really, really prevalent.

Okay.

I'm going to ask you to step out of your comfort zone and if you don't want to just say, let's step back somewhere.

Okay.

So, we had a neurology surgeon that was going to be on the show, but he's in surgery.

Yes.

So if he were here, what would be some questions that you would ask of him or I should have asked of him that you might be able to answer even if and I will.

Full disclosure.

Yeah, I know this is not your area of expertise, but you said earlier, and I love it that we're a team.

Like we talk to each other.

This is how this happened.

This is how this happened.

So what might be some of those questions that you think could can be, you know, shining a light on that.

Yeah.

So for doctor that my she is our pediatric neurosurgeon.

And I would say he as well as even our pediatric neurologist, Doctor Ali Melendez, I think they, get a lot of our patients, like, want to see them.

I could be like, you know, on the sideline or whether they don't care about me, but they really want to see those two, or at least one of them, because I think it gives parents a sensation of feeling like comfort.

Imaging MRI's and CT can be very comforting to parents, even though for certain instances in traumatic brain injury it's not indicated to scan a child.

I still find that parents really want to know that it's if.

Yeah.

And I think I see a lot of times where parents will ask more of the our medical team of, should when should they stop playing a sports.

Are they ever going to kind of go back to normal.

Did what tests can you make to tell me when to stop playing, when to stop playing, or, you know, what is their brain to look like?

And I think I would be safe to say again, I don't honestly, to my cuzshe, but I think I'd be safe to say that imaging, MRI and CT are indicated when we suspect that there is a brain bleed or even a skull fracture, and we have signs and symptoms clinically that make us think, oh, we need to put this child through, you know, the CTA head CT yours, you know, MRI, a cervical MRI.

But I would feel that a lot of parents kind of would want that as a check mark.

Yeah.

And what we have to remember is that with MRI, particularly when we look at the brain, we really can't diagnose a concussion by looking at an MRI, right.

There is a lot of research in fMRI, functional MRI, which is being used in research and even DTI, you know, difuse tensor imaging that is to describe what those are.

So in a sense, those are looking more at the kind of connectivity pathways of the brain.

Okay.

So when we do an MRI we're really looking for tissues and fluid and things like that to make sure that there's no swelling and bleeds and things like that.

But in the fMRI and DTI eyes, that kind of still on the forefront of research of could we diagnose a concussion if that connectivity or that activity in this part of the brain lit up differently than the other?

So it's exciting.

But as they say, there is no pregnancy tests for concussion, right?

There is no pregnancy test for traumatic brain injury.

It really is a constellation of signs and symptoms in when indicated imaging.

But I think a lot of us get asked that question of I really want to.

I had a patient just, you know, today that was like, I really want an MRI and it wasn't indicated.

And the neurologist said the same thing.

It's not really indicated.

So we have to tread a fine line, I think, of wanting to I think the question a lot that still needs to be answered is when is enough enough?

What is repeated head impacts do over time?

I think that would be an interesting question to kind of get some the sense of, of more of the medical side.

There are physiological changes, microvascular changes that do happen to the brain, but on a first scan of a half of a MRI in the Ed, no one's looking at it at that level.

We are ruling out the severe things, because that changes the pathway.

So I would say that's a really common question that those guys get asked.

And, those parents are really you're really, really wanting to kind of get like that picture, right?

I just came from my own equipment.

I want to ultrasound.

I want to see the baby.

So I get it.

I actually really, really get it.

But we have to, have a really fine line of what is standard practice.

What is evidence based.

Right.

And, and not just what's going to make you feel comfortable in any given time.

Exactly.

I, I know we have some prevention strategies here, and I know sometimes you just can't foresee that.

And we've been talking a lot about concussions.

Let's talk about, if it's in your purview and if not, let me know.

But let's talk about a car crash.

You know, now we're talking concussion, but this is like a major injury.

There's blood and skull issues, you know, etc.. Throw anything out that you may have worked with before that might help pertain to what we're talking about now.

Yeah.

So I've talked a lot about sports, but motor vehicle accidents and those ATV accidents are a big one.

And I think I've seen that a lot here in El Paso as well.

We have a lot of kids who want to go in the ATV's and go on the desert.

And that has oftentimes leads to produce significant trauma, that can lead to a skull fracture that can lead to hematoma, subdural hematoma.

That can also lead to a lot of cervical, fractures or changes.

So we actually had a patient in our clinic that was in a C color and, you know, in a brace and a spine brace just from an accident similar, and it does it changes, the seriousness of, the conversations that we have, but it also changes the therapeutic approach.

Yeah.

Right.

So a kiddo who does have a skull fracture, who does have a hematoma, who is in a cervical spine as his spine for a reason, for a structural reason.

And we as the therapy side, we don't we can't go as fast as we want to, you know, or we would.

We have to really think about intracranial pressure.

We got to think about, you know, mobility.

We can't just have the kiddo move their head up around like I want them to and catch a ball.

So those instances change our therapeutic approach.

And while the recovery might go a little bit slower, it is safer.

It is safer.

Tell me why that's counterintuitive in my head.

Yeah.

If this if the brain injury is more than a mild TBI and there was a skull fracture, there was a, you know, a brain bleed, we don't want to increase the heart rate so much.

Like go have them do lifting things and then have them, you know, have an increase intracranial pressure.

If we if our neurosurgeon has them in particular brace of some kind and our spine surgeon or something and work as rehab therapists, we want them to be moving around.

We could damage the they just, you know, we could put them at risk for something, nerve injury, things like that.

So it changes their recovery.

But it's a safer approach for them.

Okay.

And and if you're looking at El Paso Children's.

Right.

So there is, there is coming from all over the region in the borderland etc.. What are the most common and recent ATV?

I feel like a couple of years ago, when the razor scooters were first a thing, that there was a bunch of those, what was it?

Just recently we were just talking about ATVs, car crashes, not so much bikes anymore.

But but in general, what are the most that you see?

And I'm seeing this also in the world of prevention, like ATVs, where, where a helmet, where you think you're, you're the buggy looking thing.

Why would you wear a helmet?

But yeah.

Scooters.

Those motorized scooters actually are really common without helmet use.

This might be really funny, but even, like, you know, like dogs, dogs coming at you.

I like those pit bulls.

No kidding.

Especially a little kids, you know, and little kids.

The the thickness of the bone is different.

Their brain is still very much developing.

And so they're more susceptible to more severe injuries with smaller impacts.

And so falls kiddos that just fall from the back of the couch.

Or.

Yeah, they're crawling and they're near the their bigger dog that comes at them.

And it's no one's fault.

It's just collision.

We kind of see it all.

And sometimes you're like, how did that happen?

All right.

I would say from a prevention standpoint, we actually see still quite a bit of scooter bike accidents.

Without helmets.

Okay.

That seems to be a really when it's not sport related.

That seems to be one of the bigger ones.

Okay.

So now I'm going to ask you as a going to be mom, you actually are a mom already, by the way.

So I started looking at things very differently.

When I was pregnant, for example, I was learning how to ride a motorbike.

Like I want to be a motorcycle girl.

And I got pregnant.

I stopped that completely because it just freaked me out.

And I want to talk about motorcycles for a minute because Doctor Tyroch who's here again, he always brings up traumatic brain injury with motor crashes.

He says they're not accidents, Katherine.

They're crashes.

So when you see a helmet, somebody was wearing a helmet.

Yes, but there's still a traumatic brain injury.

And this may be, you know, people can drive motorbikes from the age of 12 on.

What have you seen in that type of a traumatic brain injury?

And when it is life or death situation for a while, too, once they're past the the danger of not being alive anymore, once they're past that, how long does that process take or what?

Maybe, maybe the question would be, what are some of the very first steps in rehab when you have like a major crash and things are just, thank God you're alive, right now?

Where do we go from here?

Yeah, I think a lot of those individuals would likely be more on the, you know, moderate to severe TBI around those are the kiddos that are probably admitted straight from our Ed to the picture to the intensive care unit.

I pick you and you're right, it's about stabilizing them.

They, you know, we want to prevent, more bleed.

We want to prevent, a lot of issues that might come up when it's probably more significant like that.

That really relates to the level, the impact, the level of acceleration, level, the impacts to the brain, the skull, all of that together.

And then the cervical spine.

You know, I guess that's kind of what I'm trying to ask, but it's a hard question to ask.

When is the damage done?

I think that's really hard to say.

Okay.

I think it's really hard to say.

It's really based on the patient.

It's based on how many prior injuries they might have had.

If it's something related to rehab, though, in that instance, would start very, very slow.

And so we wouldn't be too focused on doing a ton of, you know, upper mobility issues.

It actually might be a bigger focus on the cognitive side.

This can they swallow.

So our speech therapy, you know, kind of group, cognition, we use different grading scales as well to assess cognitive status and alert and mental status after a brain injury.

And that gives us a better indication, of kind of where they're at and what that recovery will look like.

So a lot of times when it comes to a severe TBI, vestibular people are not in the room, right?

Where we're not too focused on that.

It really is to make sure that patient is stable and probably working a lot more on their cognitive and mental alertness.

To be able to, to kind of get them starting with that.

Those are the patients have a very, very long recovery.

Sometimes those patients require more inpatient rehab therapy, or they recover or they, you know, kind of a different therapy that's more like neuro, intensive.

So they get therapy multiple hours all day, you know?

Right.

Sometimes a week.

So, that type of brain injury, really necessitates longer recovery and probably much more intensive neuro rehab.

Okay.

So I like how you said that to intensive neuro rehab.

And I'm thinking to myself, the brain has this beautiful way of healing itself with your help.

And maybe if you're able to explain why that is because I think neurology.

Right.

Like, nerves are so, like, crazy cool.

And they can regenerate and they can reproduce here.

And how does that work in tandem with what you're talking about?

So it's not rewiring, but it's kind of like rewiring kind of is it's rewiring.

It's neuroplasticity.

It's trying to use what it, had before to remember, whether it's muscle movements, it's reflexive movements.

I'm guessing it's like things like swallow.

It's things like, you know, handwriting, motor movements of the hands.

Muscle memory is really important.

And, like, nerves are like muscles in the body.

And so if we don't exercise them and utilize and provide that stimulation to them, you have a higher risk for, you know, reduced neural integrity and health.

And so that's the reason why we might do more intensive rehab is to provide more consistent, and more long term rehab upfront when we discharge a patient and maybe don't give the correct instructions of what to do when you get home, you have a higher chance of those patients becoming pretty sedentary and not using those, not exercising those neural connections that are important.

And so we lose time.

Yeah.

In, in a, in a younger child, it's even better because we want to really maximize that young, healthy brain and older adults and, and traumatic brain injury that it's different.

And so for young kids, which is reason why I only work with children is I love how they recover.

We have, you kind of had that added benefit as long as we give it to them, they can recover in a fast, sometimes a lot more of a faster way.

And it's all based of, you know, neuroplasticity and brain racing wants to grow at that point.

We're kind of nearing around ten minutes.

So what I want to do is like, stop asking questions, because this is my favorite part of every show, is what you do in the field.

You're out there all the time.

You're you're you're getting education.

You're going to conferences.

What do you see coming up in the future, in maybe the next 5 or 10 years, that you're excited about?

Like you talked a little bit about some stuff earlier?

But that's always fascinating to us because doing this exact same show in five years might look very different because of what's on the forefront that we don't see just yet.

Yeah, I think for sure, in the in the realm of concussion or traumatic brain injury, man, we really, really want to have some like more definitive biomarkers, right.

Objective measures that tell us again that pregnancy tests for concussion, what we have found here in the borderlands.

And I think a big push as to why, you know, we're talking about this topic and why El Paso Children's and why Texas Tech physicians, like we're all trying to become the Mecca, the center of of trauma and pediatric TBI is because in these areas, there's a lot of misnomer.

There's not a lot of that cool research that we see on the East Coast here.

And so you don't know what you don't know.

And if you've been a physician for 70 years, you know, and you've been practicing in a certain way, it's really hard then to kind of what's new on the forefront with this.

And so our job at children's and our job at Texas Tech Physicians is to be able to deliver that education to the community, to doctors, to, therapists, all that stuff.

And the more that we know, the better that we will all be, creating equity and how we're diagnosing traumatic brain injury, how we're managing traffic by injury.

So while the research and the kind of exciting stuff and, TBI, at least in my world, is biomarkers that pregnancy test, can we take a picture with the mirror and say that is a concussion versus that's not yes.

That is something very, very people want.

But right now that isn't realistic, do you think?

I think it's realistic.

But I think we're far from it.

Still.

Okay.

Because when you talk about biomarkers, you talk about, you know, blood levels and things like that, there's a whole lot of variation and a lot of, of stuff that comes with it.

It would necessitate huge, huge clinical trials, which I'm sure they're doing.

But it's also feasibility.

Yeah.

Those tests are expensive.

Does every hospital have access to them?

Do we know how to interpret them?

And that's what I mean by equity, is that that may happen at some of these larger centers.

But we have to think about our community here and what are we doing to make sure that we're not overpromising and under-delivering.

And I think as a as a first step, what I already know will be short term for our field and the world of concussion and TBI is this whole idea that we are no longer recommending sedentary activity after concussion, right?

That is something that you said that several times this evening.

It's about quick progression or it's about, you know, quickly getting back into school, getting back to activity for the sake of, earlier recovery, integrated progression.

And if all of us can keep that mentality when we first diagnose concussions or worker patient questions, we are doing such a better service to our patient than a biomarker.

Right?

Right.

And it's cheap.

It's free.

And that's what I tell patients all the time.

This is something free that you can do here, right now, and I already will tell you, has already been shown in the research to benefit.

Right.

So and you're saying this to some thinking about use an audiologist and and again it's, it's I remember when I first met you I thought well what in the world is that.

So there is a team of audiologists around the country if not around the world.

And how often you meet, what do you share?

Because like you said, it depends on, you know, how much money do we have in our region?

Or maybe, you know, in some areas of Europe, there's a ton of money in the researching this.

Like, how do you guys keep tabs on all this and who's doing what and who's bringing what to where.

So I that actually that's exciting.

Yeah.

Actually audiology I always joke when like what is an audiologist doing a concussion team.

And that's fair because when I do it it's all about the student.

Yeah.

But I think I'm a little bit of anomaly just because of my experience and my really interest in concussion and my own personal research and search and, and kind of clinical work within it.

Most audiologists don't work this deep into concussion or traumatic brain injury teams.

So I see it as a luxury.

And I still are learning from you.

Maybe.

But more so than that, I think it's also showing that, what we can contribute to the team, especially in our community, where maybe we don't have access to, you know, 20 more types of vestibular specialists.

How what we have can, you know, can step up to the plate and serve that role.

But I think in the field of audiology, how we're kind of all connecting.

You definitely have your folks who are much more vestibular in nature, and we're the ones right now utilizing, you know, eye tracking, utilizing certain types of objective measures to show that we're not just diagnosing concussions or TBI after the symptoms, but we can show that something has changed along the ocular motor pathway, and that is likely correlated to head trauma.

So that's what we're contributing to the field right now.

And that's really why a lot of physicians will refer to me in that context.

And I'm just listening to you throughout this hour, you know, as you're describing certain things, I'm like, I've had that feeling.

I've had that feeling.

They're fleeting.

But then you kind of wonder to people that have this all day, every day, and especially what I think we could do an entire program on migraines because of all the different descriptions you were giving.

Yeah.

On how people get migraines feel, migraines, how they present, how they manifest, etc.. So in that field, in and of itself, because you hear it's almost like a catchword.

Oh, I have a migraine.

Yeah.

And all of us actually have migraines.

No, I have knock on my door when I do, I have like I call it a you know, a light headache.

Yeah.

Meaning from light.

Yeah.

But it goes away in a couple hours.

But I know it's from this because I can feel it coming in right now.

Driving at night.

That happens to me too.

So what do you see in that in the world of migraines?

And I know it's not really per the show, but I feel like everyone in the world knows what a migraine is, is kind of felt like what?

A migraine.

How how do you see that world in the next ten years?

Because you're talking about Botox can help some of it.

Maybe.

Maybe not, I don't know.

And again, there's a whole like slew of people who are just migraine specialists like neurologists.

I just do migraine.

So I would, you know, they probably have a lot more to say on that.

I think in this part, I think something similar I do believe probably believe migraines, probably Overdiagnosed.

I think just so I hear it, like I say, I have a bike.

And my husband was like, no, you don't like, you know, different things.

Yeah.

You know, it's a but what I want to express like, no, it's severe to me.

It's it impacts me.

It's significant to me.

So I probably think that migraines are probably overdiagnosed, but similar to concussion and head trauma, there is no pregnancy test for migraines, right?

I mean, there's certain things you can look at.

But it's in my opinion, at least when I look at a child who may have vestibular migraine, I have really going off of their signs and symptoms and their history, not off a Cat scan MRI.

Yeah, really.

You know, in my opinion, and so there's a lot of things that I think we as, as providers and practitioners, we have to go off of patient report.

And that can be hard, especially the little kid.

And especially when you have worried parents, like you said, you see their kid and it's like, I just want them to be feel 100% better, right.

No pain.

Right.

And so sometimes, you know, you can spend a whole hour, I can spend an hour just on a case history on like there's vestibular symptoms.

So there's a lot there.

But you're right, it's incredibly prevalent.

And I think it's exciting to be able to sort of now be able to deliver those types of even services out here in our community, because a lot of these kids were suffering being sent out.

Right.

So, you know, we're getting started.

Well, before this program started, we were talking to Daniel for helps put a lot of this together, and it was like you were the person that kind of brought all of this to the borderland.

So thank you so much for being here, truly.

And again, the program, that we have, because there's a couple of different ways that you can watch this program.

If you missed a lot of this this evening, sometimes you tune in late, etc., So if you tune in to the show a little bit later, if you want to watch it again, there's three different places that you can access it.

The streaming one is PBS El paso.org.

Also the El Paso County Medical Society website which is epcms.com and then youtube.com and all of those sites.

You can just type in the El Paso Physician This particular program is called treating pediatric traumatic brain injuries in the borderland.

If you just throw in pediatric brain injuries, that also pop up.

But those are always, nice to be able to go back and look at it and don't watch yourself because that's always it's I never do good.

We've had with this doctor, Amanda Chiao, who is the assistant professor at Texas Tech, El Paso and pediatric audiologist over at El Paso Children's.

Thank you so much for being here.

You've explained so many different things.

I'm Kathrin Berg and this has been the El Paso physician.