In this episode, hosts Dr. Daniel Correa and Dr. Katy Peters answer your questions. They discuss the advancements in stroke recovery with AI and robot-assisted therapy, how lower oxygen impacts brain function, and their thoughts on Botox for head tremors. They also touch on supplements, anti-depressants, and fatigue when it comes to brain health. Thank you to the Brain & Life Podcast listeners who submitted questions. Happy Holidays!

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Additional Resources


Botox and Head Tremors
Low Oxygen
Stroke Recovery
Anti-depressants, Fatigue, and Supplements
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Episode Transcript

Dr. Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Peters:
And I am Dr. Katy Peters, and this is The Brain & Life Podcast.
Hello, Brain & Life listeners and happy holidays. I want to welcome all of our listeners, and of course, my cohost, Daniel Correa.

Dr. Correa:
[foreign language 00:00:29] coming up soon for everybody.

Dr. Peters:
Today, I'm very excited because we really wanted to hear from our listeners about questions, what they like about the podcast. Our listeners ended up submitting information to either our email or to our voicemail, and we have some great questions today.

Dr. Correa:
I'm really looking forward to these excellent questions. There's also a great section at the beginning of every one of the Brain & Life magazines, where both listeners and magazine readers submit comments and questions. You can get this quarterly discussion and responses to questions also through the magazine.

Dr. Peters:
So, Daniel, I think we're going to start out with our first question. I think it's from Linda G.

Dr. Correa:
Linda G said, "Would love to hear what you have to say about head tremors. I was diagnosed over 30 years ago. As I have gotten older, it has become more of a problem. For one, it's painful. I've had Botox injections that really don't make a difference and I look forward to hearing your thoughts."

Dr. Peters:
Well, Linda, thank you for your comment and your question and wanting to learn more about head tremor. So, living with head tremor is definitely a unique experience that's filled with various aspects that require very careful exploration. You need to really understand that journey with your neurologist, also, with your family. We need to know a detailed medical history, social life history and family background because it can help pinpoint exactly what the diagnosis and the cause is.
For the diagnosis of tremor, we look for whether it's the shaking of the hands or other body parts for at least over three years. And it's crucial to note that the absence of specific tremors in your head or voice or variation based on different tasks and positions. So, when you go to see a neurologist, they're going to ask you to do different things to see what makes the tremor worse or will make the tremor actually go away. So, sometimes it can be tricky to figure out what is the etiology of the tremor. But again, going to a specialized neurologist or even a general neurologist can help pick up those really important parts of your history and your physical.

Dr. Correa:
Yeah, and it's important to note that sometimes it could be just a tremor or there can also be an abnormal muscle movement or activity. When it comes to addressing what we describe as an essential tremor, that's a certain type of tremor, we typically will start with non-invasive treatments and medications, especially if the symptoms are more mild. It sounds like you've had some experience in that already. As the tremor impacts more of your activities or more discomfort or pain, then often this is where things like injections like botulinum toxin, or the Botox as you describe, may be used. And in that, it might not just be that whether or not it works, it may be figuring out which muscles need to be injected, and the dosing that needs to be used that may help over time with the tremor.
In more severe cases, there are also some surgical interventions that may help with tremors or certain types of abnormal muscle movements, or what we call dystonias. It's important to recognize that essential tremor is not just about the tremor itself. We completely understand it affects lots of different aspects of your life. Managing it could help not only you a lot, but also in terms of just getting through your daily activities and your family. And it really requires a team effort with your neurologist. So, we hope that working along with your current healthcare professionals or maybe even seeking additional opinions from movement disorder and muscle disorder specialists may help with that.
Choosing the right treatment in collaboration with those care providers that balances how severe your symptoms are, the types of symptoms and the type of movement problems or dysfunction that they identify really can help maybe improve both your daily life and the quality of life for anyone living with a tremor or an abnormal muscle movement. And hopefully, it contributes to improvements in social interactions and your own other activities.

Dr. Peters:
I want to share something I learned particularly about head tremor. I looked at a paper, it was 14 patients, and they looked at where do they think the head tremor is coming from? Is it a condition similar to Parkinson's disease or is it a different type of disease called a dystonia? And what they found is they used a special test called a somatosensory temporal discrimination threshold, and all that means is what is the time that you can detect two sensory stimuli? And they also did specialized pictures of the brain that looked for dopamine, and they found that the dopamine was fine in the brain of the patients with the head tremor, but that somatosensory temporal discrimination threshold was different. So, this is not a phenomenon like Parkinson's. And I think we have some podcasts that are on dystonia, isn't that correct, Daniel?

Dr. Correa:
That's right. We've talked about both the use of Botox in dystonia. The most common dystonia is a cervical dystonia, or another term sometimes is used as torticollis. We had a podcast episode with our former co-host, Dr. Audrey Nath, where she interviews Rogers Hartmann about her experience and journey with dystonia and receiving treatment with it. We have a medical expert that goes into further discussion about living with dystonia in that episode. And we have an upcoming episode we haven't even mentioned before, and we're still working on, with a runner who has runner's dystonia. So, we'll tell you much more about that episode and stay tuned and make sure you subscribe, so you don't miss that episode.

Dr. Peters:
Well, I'm staying tuned. And also, guess who's staying tuned? And that is Mary W. She has a great question for us and she was curious about the lack of oxygen. So, her question says, "I'm curious about your thoughts on how lower oxygen affects the way the brain functions. I'm a medical professional, a registered respiratory therapist. Thanks for your time." So, thank you Mary W.

Dr. Correa:
Thank you so much, Mary, for listening, and we really appreciate you bringing up this important aspect. A lack of oxygen, or the term what we would describe as hypoxia, can contribute significantly to new injuries, especially in acute traumatic brain injury. Oxygen's essential and crucial to the function of all of our body and cells, and a disruption can lead to harmful effects. Now, it's less clear how the fluctuations of your oxygen levels day-to-day or during activities may affect someone who's in recovery from something like as a stroke or as a traumatic brain injury who's had an injury in the past. And a lot of times when we talk about hypoxia, we're really talking about big drops in those levels.

Dr. Peters:
Yeah, and what's really fascinating is that lack of oxygen alone, because I know that's your specific question, Mary W, and you know about oxygen probably more than anybody because you're a respiratory therapist, is that once you have that lack of oxygen, it's sort of a cascade, where the energy function in the system of the cell begins to break down and the cell becomes damaged. And without that oxygen, our brain cells, also called neurons, just can't perform their normal functions that are crucial for energy production.
And once that hypoxia begins to occur, it leads to many different cascades of damage, where the neurotransmitters that are really important for our neurons to talk get dumped out in excess. And then, actually that overstimulation can cause more damage to those important brain cells, also called neurons. Moreover, there's just a lot of inflammation that occurs. And so a lot of research in this area, and I've actually done some research about acute injury to the brain, is how to prevent these toxins from coming out that are innate in your body, this inflammation that really just become toxic. Do you have any thoughts about it, Daniel?

Dr. Correa:
As you mentioned, there are key processes that our cells, especially the neurons, the ones we think about and talk about, the nerves in the brain have to perform to produce energy production, as we describe it scientifically as oxidative phosphorylation. And so, without oxygen, you can't necessarily go through that process and those cells start to get starved in a way and switch into a different type of metabolism. And essentially, when that persists long enough, some cells can go forward into cell death or apoptosis. The key thing with any emergency that every doctor learns is focusing on assessing how someone is breathing and how they're getting oxygen in. And that is often the first step that we assess for any emergency medically, whether it's neurologic or otherwise.

Dr. Peters:
And I guess this is my time to really give a plug for people learning BLS and ACLS because brain is time, and the more that we can get our heart a pumping and the oxygen to our brain, the better outcomes we can have.

Dr. Correa:
Basic life support, activities like CPR. And so, maybe if you aren't familiar or haven't done a class, especially in the last few years, there have been updates where really the first thing that we focus on now is doing that chest pumping. But it's important to go participate and watch videos about how to do this correctly, so that you're not stressed in the moment and you can help someone recover and get to the hospital as soon as possible.

Dr. Peters:
So, Daniel, I mentioned that time is brain, and I think our next question is on stroke. Is that correct?

Dr. Correa:
Yes. So, Marianne L asks about the advancements that have occurred within the recovery from stroke. Thank you, Marianne, for that question. I think this bring up lots of exciting areas of improvement, a lot of them are active ongoing research. And one of the things is looking at how those cells reorganize and recover in the brain, or the term that often gets talked about is neuroplasticity. Now, that gets thrown around in lots of different ways, but in this way we're talking about reconnections of those networks and cells that are injured.
One of the active areas of research right now is using stimulation of those areas of the brain where there's injury to have recovery. One of the ways is with something called transcranial magnetic stimulation. It's been used in depression and anxiety disorders and in headache and other conditions, and now it's also being studied in stroke. And it's been shown in some studies with very good results to stimulate over the area of the brain where they had a stroke that there can be substantial improvements in the time for recovery for strength in the opposite arm because wires cross in many parts of the brain.

Dr. Peters:
Everybody's talking about artificial intelligence and AI, and they're using the same thing for stroke patients, whether it's virtual reality, or augmented reality, to create an immersive engaging environment for them to go through the physical and occupational therapy that they would traditionally go through. So, I think it's pretty exciting that they're using both virtual reality, augmented reality and artificial intelligence across those. And I think, again, even pushing the envelope more, now let's add on maybe telemedicine and remote monitoring. So, how much can we do with the computer? How much can we do with these advanced technologies? And I need to learn more about this because it just seems to be the direction we're going.

Dr. Correa:
Yeah, and it acknowledges the reality that not everyone after a recent stroke or going through stroke recovery are going to have as much of access directly to all the different therapists and therapies that are out there. So, how much can we help connect in someone's home so that they continue to get the care and therapy that they need and have the best chance for continued recovery and return to many of their activities? One other exciting area is instead of thinking of implantations or other technologies, how devices can help someone with recovery. And robot-assisted therapy devices have been started to use within rehabilitation centers and have been shown with help with training of stroke survivors, with ambulation or walking.
And so, these are devices that can be put onto the outsides of your legs and there are now also robot-assisted devices for the upper extremities or your arms to help through the movements and activities that you're unable to do at that time because of a change in coordination or strength, but then can improve with time with that robot-assisted therapy. Now, it's definitely one of those things, like we were talking about with everything else, that it's being ramped up in its use around the country and world, and it's probably not as accessible as it should be in many places.

Dr. Peters:
Well, I think that that is really exciting. And you can imagine those robots and what they could do to help all those individuals with stroke and how they recover. What I think is really a positive development is the community reintegration programs. And what this really focuses on is it isn't just about the patient, it's about their family, their community, their work community. Also, the community of just rehabbing... Some of these patients are elderly individuals who live in a facility, maybe they live in a nursing home, or they can even live in a community for older individuals. So, I love the idea of these holistic programs that address all parts of the equation, social, vocational, emotional for all parts of the recovery because that will, in fact, really improve quality of life.
And we do know from one of our other talks about social isolation is that when patients are isolated, they don't recover from stroke as well, and there could be morbidity and mortality associated with that. So, I think you need to bring that community in. That's also the spirit of the holidays too, getting together.

Dr. Correa:
I completely agree. And those are just some of the many things that are being studied and have had new advancements. Of course, there is a long list of potential medications and therapies, including stem cell therapy, that many of them are in different stages of research. They're probably not at the stage where we can say what the effects and responses will be, but we're excited that that research continues. In general, it's important, of course, to talk with your healthcare professionals and neurologists about the current advancements that are available within your area and community, ways that you could participate and even think about and talk to them if there are research protocols and studies that you could participate in any stage of your recovery or after a stroke. Because it's important that your voice and your perspective gets included in research, so that all of this can advance much better and faster.

Dr. Peters:
I have a question on Parkinson's disease from Mishwa M. They say, "I listened to the podcast this evening with Richard, who was a comedian with Parkinson's disease, and Dr. Friedman. The podcast was very insightful and thorough. I do have Parkinson's. I am in the current magazine in the October-November issue on exercise and dance. But hearing the doctor talk about some of the nonphysical symptoms of Parkinson's was really fascinating. And I just wanted to compliment you, Dr. Correa, on the questions you asked in your format." The question said that she's using a voice command, so she hoped the sentences are coming out correctly. I think they came out perfectly. And kudos to you, Dr. Correa, in our great podcast with Richard Lewis and Dr. Friedman.

Dr. Correa:
Oh, yeah, I mean, I really appreciate all of you reaching out, letting us know that you're enjoying the episodes. Thank you so much for, really, your comment and your kudos and your response to the episodes. It's touching to us to hear that they're helpful and that you're connecting with these stories, and finding, also, the expert information. Very helpful. Now, you noted the use of the assistive devices, vocal or speech-assisted devices to manage all the different technology and computers that we use gives us a great idea for a future episode, so that we can share and help the community understand about the variety of the options that there are, and maybe some of the challenges of navigating that. So, we'd love to hear more from all of you in the community about that and gives us an idea to work on.
Now, we also heard from Judy M, asking us a question about antidepressants. Judy M said, "I was taking antidepressants for years. They may have helped at one time, but I got to a point where I felt they weren't effective and weaned myself off of them. I continued to try to find ways to handle my chronic pain and migraines without meds. Luckily, new migraine meds allow me to function. However, the fatigue from chronic pain and the difficulty sleeping from that have led me to look for more and other solutions. To that end, I started trying to use supplements and activities to help regulate serotonin, norepinephrine, and dopamine. I like Andrew Huberman's podcast because it makes sense to me. My request is, can you address the use of supplements as a way to achieve some of the benefits derived from pharmaceuticals and the regulation of brain chemicals? I realize you are not providing medical advice, and I wouldn't ask you for that. I'm curious as to whether this is a question worth investigating and where I can find more in-depth information on it."
Judy, thank you so much for your question. I think there are a lot of people who are enjoying lots of different podcasts to get various information, and you've obviously spent some time learning about the different brain chemicals, as you mentioned, serotonin, norepinephrine, and dopamine. It's a challenge to balance what we know about pharmaceutical medications because they have more study, and the limited study and understanding of different supplements that are out there.

Dr. Peters:
And Judy, I don't think you're alone. This is one of the number one questions I get from the patients of what supplements or what dietary changes should they do. And in regards to the use of supplements, what we need as a medical and scientific community to help our patients is more controlled randomized studies with a strong design, with really good power to look at the statistics and well-defined outcomes before we can really claim the beneficial effects on brain functioning.

Dr. Correa:
It's difficult to know and make big recommendations for our community at large because of the limitations of those studies. The challenges also is that many of the supplements don't have the same regulations. They can vary a lot on the dosing, even though what they say on the package is one thing, medicines, when they're regulated by the FDA, are only allowed to vary in the actual dose by tiny, tiny margins. Things that are supplements can vary a lot accidentally from one pill to the next or from one bottle to the next that's produced by that company. They're verified and tested a lot less often. There are some organizations out there that help verify and test supplements, but it really limits how well we can recommend the use of them.

Dr. Peters:
And when I was reading your question, Judy, one of the things that really popped out was your question's about fatigue. It wasn't just about supplements. It sounds like you want to be very proactive, and what can I do? But fatigue as a symptom is just so challenging because there's never just one cause or one solution. It's truly multifactorial and it needs to be evaluated in so many ways. And I, as a neurologist that sees patients with brain tumors, fatigue is a very common problem. And I always try to look at all the potential causes. Could it be a medicine side effect? Could it be due to depression or mood changes?
Is it a problem with their physical function? Because there is a phenomenon of your peripherally fatigued to where your muscles are just tired, versus a central fatigue, which is really, your brain just doesn't have that get-up-and-go that it should have. Could it be due to low blood counts? Could also your hormone levels be out of whack, so we need to test the thyroid or testosterone. And Daniel, I wonder, how do you combat or look at fatigue in your patient population?

Dr. Correa:
Yeah, I mean, I think the first part is to make sure and test for some of the laboratory findings that may suggest certain hormonal or other causes, and make sure we address those first. Then, particularly, also looking for interactions of other medications or the possible contribution of medicines to a person's fatigue, along with things related to mental health conditions. And then, trying to increase and bring in different types of activity levels and/or their sleep patterns, to work at those.
With a lot of symptoms, whether it's fatigue or other symptoms, having a sense of how often it affects you then gives you a better sense of how long you have to try something new to really have an understanding whether or not it's making an effect. So, a lot of times we will say the cycle of symptoms. You need sort of three or four cycles of something to know whether or not there was a change. So, if you have a symptom every day, it's easier to try something and see if there's a change within three or four days. But if you have a symptom once a month or every two months, it takes a lot longer to really find out if a change made a clear effect for you.

Dr. Peters:
I completely agree.

Dr. Correa:
Well, it was really exciting to get all of these questions, get some time to think about them and look up some of the updates in science and the resources that are available. We'll include some links to articles from Brain & Life Magazine and other resources that may be helpful for some of these questions in our show notes. And we're looking forward to all of your suggestions, future messages and voicemails, so that we can respond to some of those questions and help incorporate that into our planning for future episodes. Happy holidays, everybody.

Dr. Peters:
Happy holidays, Daniel. And happy holidays to our amazing Brain & Life Podcast listeners. Thank you so much.

Dr. Correa:
Thank you again for joining us today on the Brain & Life Podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life Magazine for free at brainandlife.org. Don't forget about Brain & Life en Español.

Dr. Peters:
Also, for each episode, you can find out how to connect with our team and our guests along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in an email to blpodcast@brainandlife.org. And leave us a message at (612) 928-6206.

Dr. Correa:
You can also find that information in our show notes, and you can follow Katy and me and the Brain & Life Magazine on many of your preferred social media channels. We're your hosts, Dr. Daniel Correa, connecting with you from New York City and online @NeuroDrCorrea.

Dr. Peters:
And Dr. Katy Peters joining you from Durham, North Carolina, and online @KatyPetersMDPhD.

Dr. Correa:
Most importantly, thank you and all of our community members that trust us with their health and everyone living with neurologic conditions.

Dr. Peters:
We hope together we can take steps to better brain health and each thrive with our own abilities every day.

Dr. Correa:
Before you start the next episode, we would appreciate if you could give us five stars and leave a review. This helps others find the Brain & Life podcast. See you next week.

 

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