Veteran Lindsay Gutierrez is Reaching New Heights with Traumatic Brain Injury

Episode Transcript

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

Dr. Peters:
I am Dr. Katy Peters. And this is the Brain & Life Podcast.

Dr. Correa:
Welcome back to the Brain & Life Podcast. So we are deep into the fall. We're seeing the colors. And Katy, what's your experience with hiking the outdoors? Do you forest bathe?

Dr. Peters:
I guess I do, yes. I love trees. I love hiking. You may even find me spelunking, which is the exploration of caves. We are so lucky to have so many wonderful natural areas in North Carolina. So I just want to send my thoughts and prayers and all my good wishes to everyone affected by Hurricane Helene in Western North Carolina and Eastern Tennessee. Appalachia is just such a beautiful, beautiful place and what a great place to forest bathe. Just wishing their quick recovery so we can all go back and enjoy it safely with them.

Dr. Correa:
Yeah, I hope for safety and health for all of our families throughout the southeast and throughout the country and dealing with natural disasters at this time or more recently in this last season. I think so many of us have been affected and I'm hopeful that some of my family down in that area are safe at this time. And how about the idea of climbing and hiking? One of the world's tallest peaks? Imagine even doing that while you're living with chronic headaches and recovering from a prior head injury.

Dr. Peters:
So wow, that's just so impressive and brave. I'm very cautious of heights. I actually avoid ladders in general. I don't even want to think about it. So that just sounds amazing.

Dr. Correa:
Well, I was amazed and enjoyed my discussion and today in our interview we'll be joined by Air Force veteran Lindsay Gutierrez. She shares her own story of Air Force Service, a TBI on deployment and her path through rehab, and in that, the discovery of her own personal mental health and physical benefits of movement and getting outdoors. And make sure to stay tuned throughout the episode and catch our discussion with our medical expert. We welcome back Dr. Michael Jaffee and we talk about TBI recovery, but we also touch on some of the topics and brain injury and traumatic brain injury that have been coming up in various settings, including our recent episode with Cam Heyward and in the NFL recently. So I know it's at the front of our minds for many people to make sure to catch that discussion.
Welcome back to the Brain & Life Podcast. Today I'm joined by Air Force veteran Lindsay Gutierrez. She sustained a traumatic brain injury while deployed in Africa, and as with some TBIs, the injury can be invisible to others since she later developed chronic headaches, depression and memory problems. And then six years later, she returned to Africa to climb Mount Kilimanjaro. So today we want to continue the discussion that she had with our writing team for the Brain & Life Magazine in spring 2024 and hear more about her own history and path. Lindsay, thank you so much for joining me.

Lindsay Gutierrez:
Well, thank you for having me.

Dr. Correa:
So I don't want to define you as having a TBI or even those of us who've worn the uniform don't always necessarily want to be defined by the camouflage we wear. So who is Lindsay?

Lindsay Gutierrez:
I am a potbelly pig mom, a dog mom, a military spouse, veteran, social worker, active volunteer in my community. I think those are the areas that best sum up what I do and who I am and the ones that I'm really proud of.

Dr. Correa:
So who came first, the potbelly pig or the dog?

Lindsay Gutierrez:
And so we actually had our dogs Violet whenever we were in England. My husband Anthony and I were stationed there. So dogs came first, but the pigs came quickly after.

Dr. Correa:
Sounds like they are probably great stories there, but we're going to move on a little bit to other things. So why did you get into the Air Force? You've traveled the world some with that time and training, but what was your path to picking to do Air Force and military service?

Lindsay Gutierrez:
It didn't come naturally, I'll tell you that. After I graduated college, my undergrad's in theater, so I am originally from Oklahoma, so I wanted to do something in special effects makeup. But being where I lived, I didn't really have that opportunity in Oklahoma. So I knew eventually I was going to be moving out to California at some point just to really get out there and start initiating something, whatever that looked like. That was my goal. So I did, and it was about the summer of 2009 and I think as we all kind of encountered challenges erupted and I didn't know really how to face those. I mean, I was trying to pay my bills while getting my experience in special effects makeup, but then you have to also take on jobs that don't pay, but those bills don't pay themselves either. So it was just a catch 22 everywhere I turned.
And so growing up, my grandfather had served in the Air Force and so he had planted this little seed in all of the grandkids' mind about pursuing military at some point. And then that came up many years later. My grandpa always said either do the Air Force or Navy. And so I took his advice there and thankfully I was able to get with a recruiter in the Air Force who got me the information I needed. I pursued the path that I really wanted to go down, which was security forces because I want to do something completely out of my realm of comfortability. And oh gosh, I think it was a week before I was due for basic training is whenever I got the call.
At the time, there was no age waivers in 2010 whenever I joined. And so I had gone in May to see the recruiter all the way up to September, nothing had come up. And then about four or five days before I was due to basic training, that's when I got the call saying, "Hey, there's a space that's opened up for you. Do you want it?" So I made a decision right then and there and that following Tuesday is when I went to basic training in Lackland, Texas. Yeah, San Antonio.

Dr. Correa:
That really actually just totally choosing to put yourself in new situations and challenge what's normal. We're coming to this discussion today because of an injury and recovery path that you've been on, but aside from the injury, what were some of the positive experiences and reflection that you've gotten from your service time?

Lindsay Gutierrez:
Oh my gosh. I would think the camaraderie. The camaraderie is just, it's second to none. You just have a really great connection with the people that you serve with. And you're in that all together, whatever that may be for somebody in their career field. You're there sharing that experience with other people so you have that connection with them. And of course, the travel was amazing. I was very fortunate to be stationed in England and have the different opportunities to deploy and go to temporary locations.
And then I met my husband, so that was another perk as well. And we started our first family in England. So it was just an all-around incredible experience and I really encourage people to try it because out of it I got some amazing education benefits connected with other veterans, helping support veteran organizations now for others who may be experiencing something similar with the TBI experience I went through, just helping them wherever they're at. So it's really paid off and come full circle.

Dr. Correa:
For the readers and listeners who didn't get a chance to see the article that talked about your own story and the injury that you had, can you take us back to the day of that you had your first injury that you felt like was connected to the symptoms afterwards?

Lindsay Gutierrez:
Gosh, that was a pretty incredible night and it was really just uneventful leading up to that moment. So my second deployment to Djibouti, which is located in Africa, most people have heard of it, don't really know where it's at, but it's in the Horn of Africa on the eastern coast. So we had been there for about maybe a month if that. So we were in theater supporting the army with their mission. And so what we were doing at the time was really just running a lot of exercises and making sure that we were current in the information and the details that we needed to do for the reason that we were there. And so that particular night that the accident happened was in August of 2014 and I worked a night shift. So during this particular night it was about 4 AM. As we were leaving base, I had some kind of premonition, I don't know what it was, because it's never happened to me before, but I had this feeling like something's about to happen.
And so I didn't predict it or anything, but I just had this feeling that I needed to really brace myself or something because where we were also stationed with this FOB was completely pitch dark. You don't know what's out there unless you're familiar with the roads. And by that point we had become somewhat familiar, but in the language that we used, it was called a wadi, which is like a river. And so it was like this small little bridge that kind of goes over this river and that is what we were crossing at the moment that the accident happened. We fishtailed in some loose gravel and we weren't going very fast, but it was enough for the speed to counteract with the loose gravel. That caused the vehicle to start fishtailing and spinning. And then all of a sudden, next thing I know we're rolling down this ... We go over the bridge. It's not a huge bridge by anything, but I call it a little bridge because it's just a little crossing.
But we go down this bridge and we flip two, three times or so that I was able to count and I could tell because of what I had seen in daylight time that there's these huge rock boulders. And so I was just praying that we weren't going to land on top of the boulders, that something wasn't going to crash through and hit us anywhere at the same time. We had all of our loose gear, the loose tire iron, the spare tire, all of the gear that we had with this was loose in the bag because if anybody knows from deployment vehicles, not everything is really safe. And so I just knew I had to protect myself. And so my initial instinct was to brace myself for the impact. So I folded over like you're trained to do for a vehicle rollover accident.
I prayed that the vehicle would finally stop rolling and it did and we landed right side up in between two boulders. I wasn't able to open up my car door, so I had to climb out of my leads door. And at this point, the adrenaline and everything is just running through us and I'm trying to think straight but can't think straight. He's not sure where he's going. Everything's dark. We're trying to adjust our eyesight to figure out what's going on. And eventually we walk up to the top of the bridge. It took us a couple minutes to get there, but I grabbed the phone out of his hand because he wasn't able to make the emergency call to our flight chief to let them know what had happened.
And so I made the call and I told our flight chief what happened and he thought for a second that everything was just a joke. And I was like, "This is not a joke. This is a real world situation. We have crashed, send emergency personnel out." And then at that point, within moments, everybody who was on the FOB came out and that's really what started the procedure with getting the medical care.

Dr. Correa:
Wow. So it's such a unique situation, one for it to be occurring out of country on a deployment in a different setting with different resources, but it's also your experience highlights and helps us highlight how traumatic brain injury or TBI in the military in many instances still occurs in similar situations to what happens here domestically in the United States or in many other countries. It's not all the combat scenarios or blasts leading to traumatic brain injuries. There are many other situations. United States, the most common cause of a TBI is a fall or other types of accidents.
And the same things happen, nothing changes when we go abroad. And in deployments like yours, there's things that can happen in training just like people do when they're working in a factory or in a restaurant or just in day-to-day activities. But there's aspects for you and sometimes in military settings that just make it another level of a challenge in getting the care you need.

Lindsay Gutierrez:
Absolutely, absolutely. I think a lot of people don't realize either that most of the military is probably not going to see a combat environment. That's just not the way that the military is structured. There's more support roles than there are actual combat roles or support combat roles in that sense. And so this TBI led to another TBI and again, in training. And so I think it's really important for people to understand that you are going to see more TBIs in common situations than you are in frequent ones. Just seeing how many I experience is a testament to that.

Dr. Correa:
So many people listening have either been in a situation or recall seeing someone, whether they were playing sports or someone collides with something as an accident on the street or at the house. And there's a moment where people look, "Oh, are they okay?" Maybe they saw them hit their head so that people are paying a little bit of extra attention to how they're doing. But as you talked about happily, and luckily in many of the mild TBI situations, there might not be a lot of outward appearances that show an injury. And even taking some of the pictures with a CAT scan or even some MRIs, it may not show anything but there are symptoms that seems to tell something is different in that situation.
And so for you, what were some of the symptoms that pointed out to you that these situations in your combatives training or after this car accident, even though it wasn't just a regular car, that these situations and experiences were different from maybe other times where you've bumped your head and felt fine?

Lindsay Gutierrez:
I think once that shock wore off and the protector that my body was using to fight off some of these symptoms, that's whenever I started to recognize I have a major concussion because I woke up and I had the most excruciating headache I've ever had in my life to the point where I couldn't even walk outside. And of course now we're in a deployed location, so the sun is bright and it's beaming off of sand, which is blinding as it is. So I was struggling to find a way to take myself to our medical clinic on base to get that care, but I had to because I was the only one that was available to walk myself over there. So I had that headache. I had significant pain just in general, not headache type pain. I had that, but just other kind of pains in my head.
And then I had the point where I was just extremely exhausted. And those were the first few types of symptoms that I had and then came some of the residual effects afterwards of now I'm having trouble remembering just some simple things. Even now I have trouble remembering zip codes. That's the one thing that always stands out to me whenever it comes to doing anything is trying to remember zip codes or certain patterns of numbers. That's hard for me. And so it's not maybe a huge thing, but I know that that's not something that I had trouble with before. So something has definitely shifted in the way that my brain chemistry has developed and healed itself since the injury. And then of course, the concussion and just the pain that I felt with some of the baton and then the ... Oh gosh, what did I just call it?
Our training with ... Yeah, see there I go again. So just trying to remember certain things with our crowd control training, just things like that. And see, I think it's important to also show that these things happen and you can't expect them to happen either, some of these memory things. So it affects me. And so I also let people know in advance, "Hey, if I forget something, it's not that I'm trying to be rude or forgetful. Here's what I've experienced. And I'm very open about that because I want you to understand that this is what TBIs do." And so those are some of the symptoms and the things that I have noticed immediately after and in the years past.

Dr. Correa:
Now specifically, you talked about early on these really incapacitating headaches. How was your experience, and each person's going to be different in different situations, but how was your experience while you were in service and then after returning home, managing these headaches in support with either your colleagues, superiors, other people in the community?

Lindsay Gutierrez:
Gosh, that was a challenge because deployed you really have very limited resources. It's like you're there for a job and there's only so many people there. So if you're out of commission, then who else is going to fill that position? Because they sent a certain amount of people in this deployment and these roles have to be filled. So unfortunately, it was almost like a suck it up and just battle through it kind of situation, which was hard because I was in a lot of pain, but I couldn't take a whole lot of time off. Thankfully. I had some great flight chiefs and people in leadership positions who understood that this was a really major accident. And so they gave me some days off and provided me in a space to work where I didn't have to do some really intense duties until I started feeling better and I had healed from it.
So I was able to be in that kind of environment for about a week, but then I ended up going back to work, but I still had the trauma from the accident, so I saw the car once they pulled it from the wreckage. And so that triggered some additional feelings too. And then trying to talk to my now husband at the time because deployed as well, trying to explain to him the seriousness of the situation. Whenever it just comes off sounding like kind of a car accident, I'm like, "No, this is what happened." So people not taking you seriously or really understanding the severity of the situation and then coming back stateside and knowing that there's some differences that have happened and some personality shifts as well. And where do you start to explain that these things are probably contributed to a TBI? Because you can't really show that.
There's no outward thing to show other than here's my reactions, but my brain is doing something different and I know it is, and where do you begin to articulate something like that? So it was hard. It took several years honestly before I was even diagnosed with the TBI. Like I felt like I had it, but it wasn't until the VA acknowledged it a few years after my discharge that I finally got that validation of thank goodness somebody is finally listening to me. That was my big, big problem was having somebody listen to me.

Dr. Correa:
And then once you were back stateside, how did you approach some of your options in terms of managing your headaches?

Lindsay Gutierrez:
Whenever I was active duty, I would let my leadership know this is what was going on, this is what I had experienced and here's what resulted from that. And a lot of the same people that were still in the leadership positions in Garrison were the same ones that deployed with us. So that was a huge benefit because they had seen it and witnessed everything that I had gone through. So I didn't have to explain a whole lot, but they still were very supportive and understanding.
Once I was out of the military, I didn't know what to do because at that point now, we were moving to a new location back stateside. And so I was basically starting over again. So I had all these life stressors that were amplifying and exacerbating what I had gone through, but I didn't have that support resource within the VA just yet or even a private provider to figure out what to do. So I think it was around 2000, I separated in '16 and I may have been diagnosed in '17 or '18, I can't remember the exact year, finally getting a VA neurologist who listened to me and understood and she finally gave me the testing that I needed and I was asking for to get this diagnosis because nobody else was listening to me.
Every time I tell them this is what's happening, they would just chalk it up to headaches. I was like, "It's more than just headaches." And I would show them where it's at and I'm like, "I understand that you're saying that maybe this is a tension headache, but I keep getting these in these different places and this is what's shifting in my mind." So what happens to one person with headaches may not happen with every single person. So we can't assume that that's exactly what it is or what it isn't.

Dr. Correa:
Now along the way, you've done a lot of different things for your rehabilitation. One of those was pursuing getting outdoors more. So what inspired you to get more into hiking and outdoor activities as a way to cope?

Lindsay Gutierrez:
I started at the time going back to school for my masters in social work. And so the more that I was going through my program, I started looking at just different therapy options and some of my research papers. And it came across different types of outdoor therapy. So I started doing my own research to see how effective it was and thought maybe this is something I could try because different therapies are great, but you just don't know if one's going to be the right fit for you or not or if just one-on-one traditional therapy is enough. So I thought, let me try it. What's the worst that's going to happen? I like it or I don't. And I ended up loving it.
And that's really how I got into hiking and doing the outdoor type therapy with different veteran groups and hiking with my husband and leading us to Mount Kilimanjaro. So we had some amazing opportunities to really put to use this therapy and it has done amazing wonders and I think there's just something about being outside in the outdoors that's naturally healing for the body.

Dr. Correa:
Now we mentioned Mount Kilimanjaro. I mean that is a significant effort and hike or even climb to do. I imagine it didn't start there. So what were some of the longer treks that you and your husband did before deciding or along the way as you were preparing to train for Mount Kilimanjaro?

Lindsay Gutierrez:
As I'm sure many people can imagine, where we live in South Georgia has zero mountains. So it really started with doing rock hikes just in our neighborhood, adding weight to our backpacks and just hiking in the neighborhood on flat terrain on the street. That was it. So that's really where the training started. And then we got connected with some different veteran groups. And so I ended up hiking in North Carolina with ... It was a co-ed group of vets, which was incredible. And then hiking in Joshua Tree, which is a group of women veterans. And that is where I really started putting to test just how I was able to hike. And then we got an opportunity to get connected with a group of organ donors. And so I'm a living organ donor, kidney and liver. And so we got connected with this group who was going to be doing a hike to Kilimanjaro. And we were going to be doing it for World Kidney Day and to bring attention to the living organ donation space.
So I thought, "Hey, being an organ donor and somebody that likes to hike and I understand how outdoor therapy helps my TBI, let me see what I can do." And we ended up doing it and my husband was actually really concerned because he is like, "We're climbing an elevation, how is that going to affect your head? How is that going to affect your kidney and what are we going to do if anything serious on the mountain happens?" And we had all contingency plans and everything. We had a great medical team and staff of people, and we were actually with doctors and some amazing people who really made sure that everybody was good to go for the hike. But it was amazing. I felt absolutely no elevation sickness. My kidney was great, my head was great. I think I was in a really great place and it did absolute wonders to my mental health and for my TBI.

Dr. Correa:
Well, I'm so glad to hear that you didn't have any major challenges, but you prepared in many ways thinking through them. And I'd love to hear what were some of the things that the two of you or you thought about that might come up? How did you plan being able to use it in a remote place or if you did that or what were some of the other situations if you've started to develop some altitude sickness? What were some of your plans that you had to think through?

Lindsay Gutierrez:
So we had already consulted with our doctors to talk to them about this is what we're doing. So we had a medical plan in place already. I had already been a few years removed at that point from my diagnosis. And so at that point I felt like I was pretty well managing, and so I was aware of a lot of the symptoms that could come up. And so I paid attention to what my body was saying to me every time we increased an elevation. So we had the proper medication as needed for the altitude sickness, which we took as directed. And that helped immensely because a lot of people did not.
And you could see just how the altitude really affected them negatively. And we worked on our breathing. So we had our breathing exercises that we were doing and making sure that we paid attention to our breath work and are we getting lightheaded? What do we need to do? We were hydrating. And we were eating well too. And so the team that we went with prepared some amazing meals that were healthy, nutritious, gave us the nutrients that we needed to sustain and the calories as well for this incredible arduous trek. So a lot of things that I feel like you could really manage day to day here, nutrition, your diet, your exercise, your water intake is exactly what we carried with this whenever we were on the mountain.

Dr. Correa:
Now the article in the Brain & Life Magazine where you're featured both your story about climbing Mount Kilimanjaro, but also your traumatic brain injury. In that we focused a little bit more on your physical recovery, but as you've mentioned, there are emotional impacts that many people with TBI as you did experience, did you seek mental health support along the way, whether it was in your time in the Air Force or through the VA? And what was your experience?

Lindsay Gutierrez:
I did. I did it so much in the Air Force and the reason being, the stereotype of being in security forces, if you go seek help, there's a weakness there. And I didn't want to expose that vulnerability because I was afraid if I'm going to go get mental health treatment, which I know that I need at this time, because I was really shifting in my personality and how I reacted to a lot of things with my husband, I didn't want to go get that treatment because I was afraid that my weapon was going to get taken away from me. And if I get my weapon taken away, I don't have a job. And if I don't have a job now, I'm going to get kicked out of the Air Force. So it's just one thing after another. And so that I think was hard because I wanted to get that help, but I just couldn't fall in that trap.
After I got out of the Air Force though, I did finally seek some mental health support from a social worker, a psychologist, a psychiatrist. So I went to a number of different people within the VA and then of course, outside of the VA. And they were amazing at setting up a plan of therapy and support for me and exactly meeting the needs that I had at the time to help walk me through this process of healing.
And I realize now just how important it is to share your story and that there's so much power and empowerment in itself in connecting with other people because you just don't know who needs to hear your story. I could have used that support system of people like me who felt like talking and having that therapy was a negative thing. And it really isn't. I think there's so much love and support and being able to realize you're not alone.

Dr. Correa:
Now, I mean an unfortunate and a sad fact that I want to highlight for both of us and in support of our community is among service members, there's about a 20 to 30 per hundred thousand rate of suicide. And then those are people who are currently serving. When we say service members and veterans are all people who've served previously in the military, so there's a lot more veterans out there. But even though in that number there's 80 to over 100 suicides per day in the veteran community. And you've shared with us your own experiences, was that a consideration or thoughts that entered your mind when you were dealing with your depression symptoms?

Lindsay Gutierrez:
It was. It was never suicide itself, but it was like, what can I do just to get rid and to alleviate what I'm feeling? And at that point, it was because I was in this dark place of this transition from moving from England to Georgia, not having a job, not finding a job no matter what, because I kept getting told, you're overqualified or we're not hiring, or whatever it was. And I was just trying everything to find this new path for my life. And everywhere I turned, I kept hitting a closed door. And so I was like, I feel worthless. I feel completely in valued, what do I do? And I could understand at that point where suicide could creep in. And the thoughts of, man, why am I even here could have darkly led down that path. And my depression and anxiety were both worsening as well.
And I'm thankful that I had the interventions that I did with my family and my support system to say it's okay to go get that help. And I am very fortunate that I did. Unfortunately, I have had, and I'm sure that you have as well, people that lost that battle. And it's something that unfortunately I see too often in my social media feed of another person that I served with who lost their battle to suicide. And that in itself shows me we have got to be more out there and verbal and expressing the need for care and normalizing these emotions.

Dr. Correa:
Yeah, it's an area of support and care that many people need. Rates are higher, and when you've experienced traumatic brain injury and certain occupations or other situations may increase some potential susceptibility. Maybe it's related to the stigma behind things. And I want to remind our listeners that there is a nationwide 24/7 hotline for help and support of any mental health need, whether or not you're thinking of suicide or if any level of depression, anxiety, whatever support that you need, just like there's the 911 number, 988 is the mental health 24/7 support line. But anyone else who needs to hear from you and your own experience, what were some of the things that you felt were essential to the support that you received in addressing your symptoms?

Lindsay Gutierrez:
The number one area that I really felt changed the game for me was having a doctor who listened, who heard me, who wasn't just really listening to the words I was saying, but hearing what my needs were because I was screaming out for help from my primary care provider to another specialist. And I just kept getting passed on to pass on to somebody else. And I was so thankful to finally reach the office of this neurologist who she was the number one person that made everything change for me in a positive way. And I got the referral that I also needed to another neurologist off base who gave me everything I needed and was like, "What do you need? What can I help you with?" And he was a no-nonsense doctor, and I absolutely loved him, and he did everything possible. He's like, "You're going to get the care you need. What is it? Because I will fight for you."
And that was so pivotal having advocates who were there. And here I am also in the social work space, realizing the needs that I had that were not being met. So where do I go with this and how do I advocate and fight for myself? And I also thought there's a lot of people out there who just don't have that energy anymore to do that. So when somebody's crying out for help or you see some changes that you know were not normal in their behavior, step in and just talk, ask them, "Hey, what can I do for you? How can I help? Where can I support you?" That's what it takes. It's just asking the question and just doing check-ins. That's what I could have used at that time, and I figured it out myself and now I know here's how I can do better for somebody else.

Dr. Correa:
Yeah, that's helpful and highlights how those of us around us, our partners, spouses, family members and friends are also great supporters and advocates in our own health and rehab or recovery from something. Well, Lindsay, thank you so much for joining us on the Brain & Life Podcast and sharing with our listeners all that you've learned about your own experience, your story, and the ways you're challenging the normal perspective.

Lindsay Gutierrez:
Thank you. I appreciate it. Thank you so much. I think one story is important, so everybody has an opportunity to share their story, and I hope that they do. You never know whose life it's going to change.

Dr. Correa:
Now, make sure to stay tuned after a brief break. We'll be back with Dr. Jaffee to talk more specifics about traumatic brain injuries, mood disorders that can come with them, TBI alternative approaches to headache and post-traumatic headache and persistent post-concussive syndrome. So continuing this discussion, make sure to stay tuned with us.
Can't get enough of the Brain & Life Podcast? Keep the conversation going on social media when you follow @NeuroDrCorrea and @BrainandLifeMag or visit Braininlife.org.
That was a great discussion with Lindsay about her own experience with her traumatic brain injury. And now I'm happy to be welcoming back Dr. Michael Jaffee. Some of you may have heard him in a previous episode with Briana Scurry where we started our discussion on brain injury and traumatic brain injury. But for those of you who don't recall him, he's a professor in the Department of Neurology at the University of Florida. He's also has special certifications in sleep and behavioral neurology and brain injury medicine, which is what covers traumatic brain injury. He completed a 21-year Air Force career, including wartime service and leadership within the Defense Veterans Brain Injury Center, and also works with many of us in the American Academy of Neurology and authored a new release of the Brain & Life Book series.
Many of you have heard us mention it, but specifically covering brain injury and traumatic brain injury where he covers how concussion is different from other forms of brain injury, what to expect and what to do if symptoms are persisting, on how to manage the symptoms to live with after traumatic brain injury. But thank you Michael for joining us here today.

Dr. Jaffee:
Daniel, it's great to be back on Brain & Life.

Dr. Correa:
So I wanted to continue our discussion about traumatic brain injury. I have my experience working in my military service time at Fort Gordon and at Walter Reed, but you've continued with this work within brain injury and traumatic brain injury for many years. Lindsay shared with us her own experience of a injury that occurred during deployment, but was really more of an occupational setting. And in something I think that many people could relate and maybe even know someone who's had a brain injury or a head injury in that kind of situation, how is occupational type injuries and falls that cause TBI different from the blast injuries or other kinds of wartime-related traumatic brain injuries?

Dr. Jaffee:
That's a great question, Daniel. And it really kind of speaks to what we call the pathophysiology or the mechanics of how some of these injuries actually occur. And when we talk about the typical injury that we think about from sports, there might be the direct impact on the head that someone might have from some form of a collision. When we talk about motor vehicle accidents, for example, there could be the impact on the head or even the rapid acceleration and deceleration, what some people would call whiplash kind of forces for the injury.
And then there's the issue of what we call penetrating types of pathophysiology. And that might be from a knife or some type of a bullet wound that's actually penetrating through the head or through the skull making the damage onto the brain. But when we're talking about blast, that's a completely different pathophysiology. It's using forces that are applying the brain and causing damage, but these are using waves, what were called blast waves. And so that's the kind of what we call the primary aspect of it, where the waves itself is the force that's causing the damage as opposed to direct impact.
One of the things that we worry the most about in these military injuries that are related to blast is not just the effects of the blast wave itself, but the context of what's happening around the blast. So for example, if you are involved with a roadside bomb, you have not just the blast force itself, but that might also cause a motor vehicle accident associated with that same incident if it sort of takes a Humvee and makes it roll over. If you're involved in a blast and you are walking, it might blow you against a wall or it might create some other debris that are flying around that would then create another penetrating injury.
So one of the concepts that we have is that we used to call as blast plus that you might have the blast plus these other mechanisms that happen quickly with that incident. But even in individuals who just have a purely blast kind of injury, the pathophysiology is a little bit different and it can penetrate a little bit more deeply because that wave aspect to it with the physics and the pathophysiology. The other thing to keep in mind with the military injuries is the context of injury. So anytime you are injured in the middle of combat or in a war field, that in and of itself is a pretty anxiety provoking situation.
So there could be some of that fear from being injured in that situation that is also contributing to some of the symptoms that one might have. And so we oftentimes have to look for the comorbidities, meaning the things happening together of the direct aspect of the head injury itself, as well as just the very act of having sustained an injury in combat, which can be a very traumatic experience for people.

Dr. Correa:
Yeah. I mean there's not the opportunity for a timeout or a quick medic assessment or physician assessment and removing someone from the field in combat. And in other situations that individuals might be a victim of trauma in other cases where there's a head injury. So how are they similar, not just in some of the pathophysiology, but then in the symptoms that we see these two types of brain injury situations?

Dr. Jaffee:
So in general, when we think about the symptoms that people can have from a brain injury or a concussion, there's different ways of thinking about them. But one way is thinking about them in symptom clusters. So in some aspects there can be what we call physical symptoms. Things like headaches, dizziness, there can be cognitive symptoms, things like having trouble with attention or focusing, having trouble with memory. There can be emotional symptoms, things like irritability, anxiety, depression. And there can be sleep symptoms, having trouble sleeping or sleeping too much or having other issues going wrong when you're trying to sleep.
And so different people have different combinations of these symptoms that are happening and that can be seen from either one of those pathophysiologies. There are some other kinds of injuries that can also occur from blast. So for example, if you are sustaining enough of a blast, that can cause a rupture to the tympanic membrane in your ear, which can contribute to some of the things like dizziness or hearing problems, and it can actually affect some of the lungs and causing some breathing or pulmonary issues if the blast pressure is strong enough in your close enough to have that impact on that.
So there can be a difference in the co-morbidities or associated other traumas that can occur from that episode.

Dr. Correa:
Wow. So in each of these situations, I think we often will say that each individual or each brain injury and trauma is unique on its own. If you've seen one, you've seen one, but there are some similarities across them. And in some ways, the symptoms that we're seeing in these occupational or warfare-related traumatic brain injuries can have similarities, but the way the injury is occurring or all the other possible traumas. Now Lindsay shared for her own type of injury something that we've seen, and as many people have talked about, both in the media and within healthcare, is that traumatic brain injuries often also come with a lot of mood disorder symptoms or mental health problems.
And Lindsay herself has shared her own challenges and to the point where at times she had suicidal thoughts. How has been your experience both in the service and then afterwards with discussing some of the mental health challenges that can come along with traumatic brain injury?

Dr. Jaffee:
Daniel, that's a great question and it is a definite consideration and concern for people who undergo these kinds of injuries. And when you look at a number of studies, it does show that there can be these comorbidities both in what we call civilian or occupational kinds of injuries as well as in the military. The military was studied early on with a lot of those things that we just talked about with the context of the battlefield injuries. But one of the ways I think it's easier to understand is that when these studies have been done, they compare someone who's had one of these injuries to someone that's had an orthopedic injury or a musculoskeletal injury.
And these comparisons have been done in both populations with both the military and with these occupational or civilian aspects. And what they have found is that the individual that had a brain injury was more likely to have some of these emotional and mood symptoms than the people that had purely the musculoskeletal injury, which has caused a lot of people to figure out why this is.
And we talked about some of the contextual issues in the military, but you don't necessarily have that when you're talking about the civilian or occupational population. So when you take a deeper look at this, it makes sense that when we're talking about a brain injury, we're talking about potential damage to different networks within the brain that are involved with regulating our mood and emotions. And it turns out that depression is thought to be due to a network of communications between cortical and subcortical structures in the brain. It's not just one location in particular.
And so when we talk about some of the aspects of brain injury, one area of the brain which tends to be most vulnerable just due to the structure of our skull, is the frontal lobes, particularly the frontal poles of the frontal lobes. And that is thought to be an important structure and network that's involved in regulation of mood. And so just because that we're talking about potential damage or dysfunction of the networks of the brain that can be controlled in regulating mood, that explains I think why we see more of that problem in people that have a brain injury compared to a musculoskeletal injury, that there's sort of an actual biological reason for it, as well as all the other biopsychosocial things that can happen.
And by that I mean if you have a brain injury and you're taking a long time to get back to doing your classes, being fully integrated with your social support network, being able to get back to work and feeling the value you do at work, that can also cause some frustration and can contribute to some of the other psychosocial contributing factors that might be perpetuating or prolonging some of these symptoms. So there's a lot of issues at play that can be contributing to mood just from both a purely biological perspective as well as kind of the psychosocial and functional aspects that can be a problem as people are recovering from their brain injury. And so the big important thing here for anyone who's going through this or anyone who's helping to try and help people navigate through this as a treating provider, is that they need to be aware that this is a common comorbidity or a common problem. And so we need to be able to really have honest conversations with patients to be able to ask them about this and be able to incorporate this into the management plan.

Dr. Correa:
Now for Lindsay, she described to us challenges that she had with post-concussive syndrome along with that also post-traumatic headache and how she ended up with integrating other alternative aspects like more exercise, which particularly led to her time outdoors and hiking and eventually a hike up Mount Kilimanjaro. But how do you help people consider some of the other additive or alternative therapies and activities that may improve some of their symptoms?

Dr. Jaffee:
So we do try to practice medicine that is primarily evidence based and so there are certainly many things that are not traditional medicines for which there is good evidence for. And so we talked about some of the therapies that are there. There's absolutely a lot of great evidence for the role of exercise. In fact, we have pathophysiological reasons that exercise can increase something called brain-derived neurotrophic factor, otherwise known as BDNF. And it turns out that that is an important substance that helps the brain heal and recover when it's had an injury.
We know that there are positive and additive effects to certain non-pharmacological substances such as magnesium or riboflavin if headaches are an issue, if we augment their treatment with that, that might be something that we incorporate into their treatment plan. And we are very aware of the importance and aspects of other forms of recovery, whether it be vestibular exercises, if we identify that there's vestibular involvement or oculomotor exercises if we identify that there's oculomotor involvement.
And so bringing together all the modalities, whether it be cognitive training and other types of cognitive aspects, and that comes back to what we talked about before, is rather than one of those therapies is going to be the answer for everyone. It's a matter of taking that assessment at the beginning and understanding what are the main symptoms that's happening so you can put together an individualized treatment plan for someone because if someone is not having vestibular symptoms, giving them all the vestibular therapy in the world is not necessarily going to help their other symptoms.
And so that's why getting back to understanding all the possible symptoms and coming up with that individualized and tailored treatment plan can be important. And that treatment plan can incorporate our traditional medications as well as all these other rehabilitation modalities and other types of modalities for which can be synergistic and integrative. And we're always looking towards function. Is this going to help the person gain more and more function and independence to get back to their baseline level?
And that's kind of the way I look at it is whether are you staying the same or are you getting better? And hopefully not getting worse. And most of the time when we see people getting better, then we're trying to see, is there a way we can get them better even more quickly? And so that's the whole object of what we do when we treat people, is trying to understand what is holding them back from getting back to their baseline and doing what we can to get them on that trajectory of recovery.

Dr. Correa:
And for our listeners to define a few terms that we threw out there, both of us I noticed. So we use the term vestibular, which is really the coordination of the structures in our inner ear to the brain stem that integrates information about sensation in our eyes for our balance. So in a way we're talking about balance and a system that could lead to dizziness and ocular motor being the coordination between the movement of our eyes and the movement of our body. Also something that often can lead towards dizziness or a sense of displacement in space.
Now let's go to some of the harder questions. We, many people listening are thinking about head injuries and brain injury or traumatic brain injury because we have family members playing sports and we have kids in our families out there playing sports. How much of what we understand about traumatic brain injury occupationally, civilian in the community and blast can help us understand about the TBI or the concussion impacts on our children?

Dr. Jaffee:
Oh, I think they all help one another. So I think you and I have both discussed in the past how the findings of military medicine can influence and help in a positive way how we treat patients in a non-military setting. And the findings and research in occupational and non-military settings can influence and improve the way we treat military people who have an injury. And so understanding the differences, but understanding the commonalities and the best kinds of treatments that we can do is really synergistic to each other.
And so when the research is funded, I think all of the investigators take great interest in trying to see how they can apply those findings into all the patients who they treat regardless of the context. So the aspect about sports-related injuries is there's actually an interesting analogy to the military decisions because in both, you're making a decision for the athlete, when is it safe to return to play? Or for the military member, when is it safe to fully return them to all of their duties? And so kind of an analogous kind of challenge there. And both have systems where we do screening acutely and then kind of do some follow-up evaluations to help determine when it's safe for them to return.
And so the ways that those evaluations have evolved over the years, I believe have influenced each other. I think sports has influenced military and military has influenced sports.

Dr. Correa:
What do you say to the community member, family member, parent that says, "Well, it's like we saw from COVID the devastating impact that it can have on our kids to be removed from activities. And it's great to hear that we are moved away from this cocooning idea that we would just restrict everyone and they don't get to participate in activities. But what if there is a fear that their child does so well when they're able to play sports and then also participate in school that removing them from play might actually have an additional impact to the child?"

Dr. Jaffee:
That is a concern. So we don't want them removed completely. So even if they are going through this protocol of returning to play, they can practice with certain kinds of drills. They can be on the sidelines. They can get the social interaction of being part of that team, which is what we want them to have. That is important parts of the recovery. It's all about safety, but I think you can still kind of go through a progressive return. It's not all or nothing, but a progressive return in a way to keep someone still a part of the team and feel connected with the team that we can try and meet all of those needs to be both safe and to maintain that need for connection.

Dr. Correa:
So we've been talking about sports and sports TBI, and it makes me think of our recent episode with Cam Heyward and he shares both his own experiences with traumatic brain injury and concussions in the NFL, his father's time in the NFL and history of concussions, and then his father's own later complications. But he mentioned also, and we've heard in the news, these new NFL Guardian Helmets. So what do we really understand about them and how they're doing in protecting NFL players from traumatic brain injury? And should we all go out and get one?

Dr. Jaffee:
So that's a great question. So for our listeners who may not be familiar with the Guardian caps or Guardian Helmets, I think most people can picture in their mind the typical football helmet. It's that hard shell. And then on the inside of that shell is soft material that kind of wraps around the brain and what the Guardian cap does, it goes on top of that outer shell is another layer of softness. So now you have soft hard shell and then soft on the inside. And the idea is that that softness on the outside kind of a foamy type of material helps dissipate the force when impact is made on the head. So there's less force felt in being transmitted onto the head injury. That's the concept and the idea behind the Guardian Helmets. And it turns out that in the NFL this year, they actually required that the Guardian Helmets be used for practices.
It's optional for players to use it during a game, but it's required to be done during practices. And so the NFL, like a lot of professional sports, is very good about collecting statistics. And so from the preseason from that 2024, they compared the number of concussions that happened while people were wearing these Guardian caps compared to the 2023 season when they were wearing the standard helmets. And it turns out from their data, they reported a decrease of 24% in the concussions that happened during preseason in the context of wearing these Guardian Helmets. So from some of that preliminary data, it would appear that that theory of dissipating force might be having a positive effect or they're kind of seeing the benefits of that. And so I think it's a great step forward.

Dr. Correa:
And are there places that are doing studies right now with the Guardian Helmet as it's being used in play?

Dr. Jaffee:
Yes, because it's relatively new. As we talked about, it was just kind of rolled out this year as the NFL. There are a number of NCAA schools that are involved in some studies, and so that data is being pulled together and will be aggregated at the end of this season, at the end of this year to look for even more data. And there was even a study that was done in the pediatric population in Wisconsin looking at the Guardian Helmet as well.

Dr. Correa:
An activity that I think many people do is to ride a bike or skateboard or a scooter. Now with a lot of the different electronic scooters and bikes out there, many more people are on either propelled electronic devices or self-propelled bikes that we've been using for years but not everybody uses helmets. How important is it to use those helmets in terms of prevention of traumatic brain injury?

Dr. Jaffee:
I'm a big proponent of helmets, so much so that here at the University of Florida, we periodically do helmet giveaways to people who are using bicycles and things along those lines. When I've talked to students who aren't using them, one of the reasons I have gotten for the reluctance to use them is that can believe it or not, they'll say, "I don't like the way it affects my hair and I need my hair to look good." And so we've actually gotten other hairstyling experts out with us to kind of help come up with some great hairstyling tips that would be helmet friendly for people if it would encourage them to use their helmet. Many people know someone that's had some kind of a head injury. And so once you see that in your own family member or friend, it becomes more of a motivating factor to kind of wear that helmet yourself.
One of the things that we never think it's going to happen to us because it's as easy as riding a bike, but sometimes things happen that are out of our control and we just want to be prepared for any eventuality. It's kind like wearing a seatbelt. Most of the time, we're not in an accident, so we haven't needed the seatbelt, but it's going to be very important if and when you do have an accident in terms of having a big impact on saving your life and reducing injury. And I think about helmets the same way. The vast majority of the time, you may not need it, but the one time you do, it's going to be very helpful. And so that's why I advocate wearing a helmet all the time.

Dr. Correa:
Well, to come back to a positive note, Mike, what are you doing to get yourself moving and healthier each day and how can we take inspiration from that?

Dr. Jaffee:
I think people have to find what gives them joy. So one of the things that I like doing is changing it up. I think the variety is what helps keeps me going and keeps from getting out of routine. And so I work with a physical trainer who very deliberately will change things up on me. Just when I think I've got the rhythm, he'll give me something different to do with a different challenge. One of the things I've been doing lately, which is very popular here in my neck of the woods is hot yoga. And so that is something where they have fit classes and so you really feel like you're working out because you have not only the cardiovascular aspect of that, but the heat as well. So it really makes you feel that way. And the other thing that happened just last night I will share with you is that I am now an empty nester and so my wife and I took up tennis lessons together and we started that last night.

Dr. Correa:
Wow. Well, congratulations on starting a new journey. Well, thank you so much, Mike, for taking the time to join us today for your service and your time and everything that you give back to your community.

Dr. Jaffee:
It's been a pleasure to be here. Thank you for having me.

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 Espanol.

Dr. Peters:
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Dr. Correa:
You could 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 are your hosts, Dr. Daniel Correa, connecting with you from New York City and online @NeuroDrCorrea.

Dr. Peters:
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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:
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Veteran Lindsay Gutierrez is Reaching New Heights with Traumatic Brain Injury

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