Episode 52 – Functional Neurology with Dr. Lovich Functional-Neurology.mp3

00:01 Announcer: Welcome to the Standing Up to POTS podcast, otherwise known as the POTScast. This podcast is dedicated to educating and empowering the community about postural orthostatic tachycardia syndrome, commonly referred to as POTS. This invisible illness impacts millions and we are committed to explaining the basics, raising awareness, exploring the research, and empowering patients to not only survive, but thrive. This is the Standing Up to POTS podcast.

00:29 Jill (Host): Hello fellow POTS patients and stellar people who care about POTS patients. I'm Jill Brook, your highly horizontal host, and today we have an episode of the POTS practitioners. Today's guest was someone that I reached out to because one of you, dear listeners, wrote to me and said the following, and incidentally, she gave me permission to read it here. She says: “Hello there. I just started listening to the podcast recently and it has helped to communicate things that I couldn't have said myself. I think this is such a great tool in getting the conversation started. I was diagnosed with POTS in 2017 and after having symptoms since about 2000-2001, I didn't really understand what was happening. And after one of my mother's cardiologists was convicted of sexual misconduct, I was terrified to get checked out. I started passing out a lot - a couple dozen times a day – but I thought I was just falling because as soon as my knees hit the ground, I'd be awake again. Ouch. It was very strange, but eventually I got in with the right doctor and once I pursued diagnosis, I was diagnosed within nine months. So, extremely lucky. I was going to school for athletic training before diagnosis and knew that my health would not allow it. I eventually got my personal training certification and I'm now running my own business. But, in 2020 I got hit very hard with my POTS for whatever reason. I had a syncope episode at my work, where they did not know about my diagnosis, and I was in this fog state for about 15 hours after. The doctors literally asked me if I had overdosed on fentanyl because they had no idea what POTS was. After so little help from all doctors I currently had, I decided to take an “abnormal” treatment route, and went to see a functional neurologist. This doctor changed my life, and I am referring his name over to you guys to maybe feature him in an episode. I couldn't shower, had to take baths or sponge baths. I couldn't stand long enough or sit long enough to cook. I passed out on the stairs and fell down them multiple times. I saw Dr. Mike for about 1.5 hours once a week for five weeks, maybe six, and my life improved so dramatically. We worked on eye tracking, the inner ear fluid, muscular work to help relax structures impacting my head or arteries, balance communication, and the ability to draw words. I think that this style of medicine could change the POTS community.” OK, this next part gives me chills, listeners: “Because I stabilized so much, I enrolled back in school to be a part of this fight. I am pursuing my degree in neuroscience and a minor in psychology, with intent to pursue a doctorate in neurology. I know what it's like to be a victim of this disease and I was given a chance at a normal life because of Dr. Mike, and I do think this will be a way to pay back our community.” OK, I just have to cut away from this letter for a second just to say that this is giving me chills and it's kind of making me tear up. I'm so happy for this listener to be back in school and pursuing her dreams again, and it is so beautiful that she's going to pursue a career that involves helping other POTS patients. That's so lovely. It's making me emotional. OK, back to the letter. “Dr. Mike owns Delta S Performance, a functional neurology clinic that helps with concussions, dysautonomia, anxiety, and depression, and more. He has no idea that I'm reaching out, but I'm sure he would answer any questions you guys have. All the best, Samantha” OK, so first of all, thank you Samantha! You rock! And best wishes with your schooling. So, Michael Lovich is a board-certified chiropractic functional neurologist and board-certified chiropractic sports physician. He holds an MS in sports medicine with additional training in brain-based functional medicine and functional movement-based rehabilitation. He has served as medical director and on the medical staff for various organizations and events in professional, amateur, collegiate, and high school athletics. He specializes in integrating the physical aspects of sports medicine and chiropractic care with the brain's neurological and physiological systems that are often overlooked. He is the owner of Delta S Performance Functional Neurology and Sports Medicine with clinics in the Denver, Boston, Seacoast and Providence Metro areas. Dr. Lovich, thank you so much for being here today.

05:33 Dr. Lovich (Guest): For having me.

05:35 Jill (Host): Most doctors don't know very much about POTS, if they have even heard of it at all. Can we just ask how you became familiar with POTS?

05:45 Dr. Lovich (Guest): Before we start on that, like usually when I'm on podcast trying to give information, I don't get tear jerking moments to begin with. It's gonna roll a little differently than usual for sure.

05:53 Jill (Host): [Laughs] Well, oh man, I mean we don't hear that many success stories right? People fight hard to have their successes and that's why we had to get you on here. Like, wow, this guy gave her a life back. So, so yes.

06:09 Dr. Lovich (Guest): I have to give her a shout out too because people who know about the POTS community, people who can support the POTS patients - we need to give them all support we can to make sure that these patients get the care and don't start going down a rabbit hole like the cardiologist did.

06:27 Jill (Host): Wow, and it would be so exciting if we could also almost have like an inter patient network to help more people get careers in things that will help POTS patients.

06:36 Dr. Lovich (Guest): So back to your question, I first became familiar with POTS when I was doing my internship under Dr. Glen Zielinski in Portland, Oregon. There was a specific case that I remember vividly. This patient was carried into the office by - I believe it was his wife and daughter after collapsing in a hot shower. And I'm sitting there thinking, wait - he took a shower and then he collapsed to the ground, and I didn't really, like I knew of autonomics, I was learning all the functional neurology didactic material at the time, so I knew of dysautonomia. I had an idea of how functional effects could affect the autonomic system and what it can look like, but until you actually see it, it doesn't do it justice. So I saw this person who was - every step he was like shaking. Getting in, I was like, what happened to this guy? Is this like a movement disorder which we see a bunch of? Like, what is this? And he’s like, “POTS.” And I'm like, “What?” So, it was really eye opening that there can be something as simple as a shower trigger. And the thing that was even more eye opening was watching Dr. Zielinski work with this patient. Just to walk you through it, there is a tilt table - like a table you can lie on that can rise and lower, and most listeners I'm sure would be familiar with a Tilt Table test, which is when you do blood pressure every couple of degrees to figure out like at what degree do your POTS symptoms kick in. But lie them down and started doing neurological rehab exercises using what we're going to be talking about today, which is visual system, inner ear systems, proprioceptive systems, remapping that stuff lying down, and then I just watched him gradually raise up more, raise up more, raise up more, and by the time they got him to a point where he was almost vertical, still doing rehab exercises with appropriate rest in between, he was able to walk, get up off the table, and get back to normal life until the next trigger happened, which to see that over the course of what must have been, I would guess approximately an hour, an hour and a half, of care with rest in between where he’s just kind of like chilling on the table, closed eyes, like, let your brain recharge before we do more, but to see like such a big change, to bring somebody who is - if you brought into an ER or something, you're just gonna lay there until he feels better, to feeling better from an acute episode within an hour and a half, that's what really cemented in that I couldn't not learn functional neurology. I couldn't just do like a musculoskeletal sports medicine practice because if I missed this stuff, or if I didn't know this stuff, I'm sitting and wasting a patient's time when they can get better in an hour, where I might be saying, “Well, this might take four to six weeks to get better.” Like, why do that when I can get someone better in two weeks? So, and it's not even saying like I can get somebody better, it's the patients doing the home exercises. It's a teamwork approach because the patient and I have to work together or figure out what's going on with them, and so it's really important to have that team approach. But on top of that, it is still watching the body - and this was the thing that was so fascinating was it wasn't like there was a POTS diagnosis and then here are 15 exercises that help with POTS - it was figuring out based off the patient presentation, not what the patient was saying, 'cause the patient - what the patient was saying was barely audible because he couldn't speak. But looking at the way the eyes move, looking at the errors within the eye movements, not just can you move your eyes back and forth? Oh no, that didn't work. More like when the eyes are moving here, at this point they fell behind or they jumped ahead. Looking at the way the eyes like different reflexes interact when you turn the head. Looking at just overall body color, like being more pale, but you can see it more on one side of the body than the other or seeing the facial expression changing more on one side than the other. And you can see these imbalances, you can see these changes and you can apply therapies directly to these imbalances and changes instead of saying, “Here's a blindly applied therapy for a dysautonomia instead of individualizing directly to the patient. And the most important thing is every therapy was directly applied to the patient's individual needs. And this was just one of many examples I saw in that office showing a next level of rehabilitative care. So that was the craziest thing about seeing a population for the first time. I didn't even know this existed. And now we've worked with many POTS patients over the years since we've opened up.

11:23 Jill (Host): So that's interesting that you say that 'cause every doctor that seems to have a good track record with treating POTS does say the same thing about there is no one size fits all, you have to really take all that extra time to pay attention to the individual. And I'm sure that's very annoying from a business standpoint, 'cause a one size fits all is so much more efficient.

11:47 Dr. Lovich (Guest): The way we set up our business was to take that into account, and this is why one of the reasons that we're not able to take insurance at this time. Running the business is kind of like a balancing act because we want to help the patients as much as we can, but also, we need to be able to keep the doors open. When you use an insurance model, you have to go based off of the amount of time that you spend with the person, because they're only going to pay a certain amount and you need to be able to cover your overhead. What ends up happening is in order to see enough people to cover overhead, you need to shorten the amount of time spent with the patient. And I think with - what is the national average for the amount of time that you spend face to face with your actual medical doctor?

12:23 Jill (Host): Oh, it's ridiculous.

12:24 Dr. Lovich (Guest): Yeah, I believe it's 7 minutes, but if you count the minutes you actually spend with your doctor doing the exam, it can't be more than 20 minutes. And so, well, that's why we're out of network, 'cause we got to spend that time. We created the entire business around the framework of you get time. It allows us to spend the time figuring out the patient, trying some therapies. If the therapies don't work, we'll be able to see changes - functional changes - immediately. And then we can say let's try something else. Or is there a fatigue system where this exercise would work, but the brain can't handle at this point, so we need to slowly exercise the brain just to be able to handle doing rehab. It gets complicated. [Laughs]

13:07 Jill (Host): Yeah, that's really interesting. OK. So can you tell us what are most of your POTS patients like? Or, like, what tends to be their complaints? Are they mostly concussion related, or what do you see in your POTS patients typically?

13:20 Dr. Lovich (Guest): Most of the POTS patients that we see are varying levels of dysautonomia. Most of the patients that we see are secondary to concussion or infections, like we've worked with other - with integrative clinics that work with chronic Lyme disease in New England. We've actually found some patients that were misdiagnosed with chronic Lyme when they were in fact POTS patients, and those patients started getting better really quick as soon as we started working with them because, I mean, there's only so long that you can try and go after the gut or you can try to go after an underlying infection when, hey if the if the gut’s not working, sure, it needs to be fixed. But if the brainstem isn't working and it's not self-regulating then no matter what you feed them, it's not going to make those neurons connect. It's not going to make those reflexes work on their own. I heard a great quote by Dr. Datis Kharrazian, if you've heard of him or followed any of his work.

14:13 Jill (Host): Oh my gosh, I love him. I think he's a God. [Laughs]

14:16 Dr. Lovich (Guest): He had a great quote that was in the first module of functional neurology seminars, that was: “You can't give somebody a supplement that targets and creates muscle growth in their bicep and only their bicep, you can't fuel their systems. You can if there's a mitochondrial issue, you can work with that you can look at all these energy systems, but improving energy systems...” and we're leaving the quote now, improving the energy systems only goes so far. It's like having a broken engine in the car and you step on the gas, 'cause you realize that there was no gas in the tank and the engine is still broken. You still need to go into the engine and fix it. So, that's what we do is we get in there and we try to make the pathways in the brain that are supposed to be working in a certain way and with a certain amount of accuracy we try to make those more accurate. So, most of the patients that end up in our office, they - sometimes we'll get we'll get people coming in who just have a weird vague neurological symptoms that don’t know that they have POTS. And we'll refer them out for POTS testing because it needs to be taken care of. But it's good that we can notice these things. If we were to describe what people have for people who may be listening to this but aren't really familiar with POTS, complaints vary. They can look like pulses skyrocketing when sitting on the couch or asleep. They can cause headaches, migraines, dizziness. I once worked with a hockey athlete. The thought was that because she was a high-level athlete, she was getting POTS because of just the size of her muscles. But it turns out, like, there's so much variability in how you have to work with these cases that there's never just one reason why this happens. It's usually a collection of things that we have to look at multiple moving targets at the same time. So, most of the main complaints that we have are like headaches, migraines, dizziness. Those are the people that are driving in or we get these chronic brain fog people who are just feeling off. And usually if you have a chronic brain fog issue, the first thing that I'm looking for during my exam is, or one of the first things is: how is there vagal tone? So you heard the vagus nerve? I want to figure out not is the vagus nerve working, but are the things that fire into the vagus nerve working? Because if you have tone on one neuron firing, you can't just say, well if that's not firing the problems in the nerve, you have to say well, what causes that to fire and what are the different things there? Because you'll find one or one or more of those things that are just dysfunctional. And if you improve those things upstream, then downstream will then work. So some have come back after work with me saying that their mood has become more stable as well, which is - it's a nice side effect that when you take a treatment, the mood gets better, not worse.

17:00 Jill (Host): Right. [Laughs]

17:02 Dr. Lovich (Guest): And some patients have said they no longer needed medication, less or resolution of intrusive thoughts. From my clinical experience, this isn't because stress of having a condition is less - so stress and anxiety is less - it's because anxiety and depression are the conscious experience of dysfunctional circuits along the pathway, connecting like the cerebellum, the brainstem, and the frontal lobes together. In other words, we didn't remove or change anything in their life, nor did we provide any coping strategies for these patients, we just made the brain's ability to cope with life better. Does that make sense?

17:40 Jill (Host): That's so interesting and I really like reframing anxiety and depression as that because I'm sure a lot of us have felt like, OK, I feel this way. I don't have a reason to feel this way, what's wrong with me? And it's real quick before you just start blaming yourself and feeling pathetic. And it's really nice to feel like it's what you said, like a manifestation of something in the brain, just not working quite right.

18:08 Dr. Lovich (Guest): One of the first discussions that we had with most patients is trying to reframe the idea that the mind is just an output of your brain function. And if you keep chasing the mind, you're chasing the output. And if you look upstream, if you look at the things that create that experience and you make sure the health of that works better, whether it's nutritionally or physically or physiologically, which it would be like cellular interactions, you end up getting pretty quick results and you put the power back with the patient, 'cause they're like, you know what? If I start feeling a certain way and I do some exercises that I know my brain needs to balance itself out, then it gets better. Or I know that if I eat certain foods that are going to create an inflammatory response in my brain and if I avoid those foods, then it gets better. It puts the onus, but also puts the power back with the patient, so that way they can be in charge of their life.

19:00 Jill (Host): That sounds great. You know it's funny because as we were getting ready for this podcast I was thinking to myself, OK, functional neurology, what does that sound like to me? What does that mean to me? And I almost had to laugh because I was like, functional neurology! That sounds like what everybody wants in life. I would like my neurology to be functional, you know, as someone who has a couple different kinds of neuropathy and such. But I realize that I think we've been like gnawing around the edges and giving examples, but could you just make sure that we know - like what is functional neurology? What is the definition? Can you kind of like just give us like the foundation for those of us that don't really have experience with it? Like, what is it? What’s the approach?

19:46 Dr. Lovich (Guest): Sure. As a profession, functional neurology is multidisciplinary, which means that you don't have to have a certain license behind your name, except you have to have something that's diagnostic, like you have to have some physician level license where you can do a good enough exam to create diagnosis because the exam is the hallmark of how we figure things out. That's why I refer to myself as a chiropractic functional neurologist because I don't want people thinking that I'm claiming to be a medical doctor or an osteopath or any other type of physician. I just want people - I like to manage people’s expectations and make sure that things are accurate. But let's talk about functional neurology itself. When we're talking about neurology, we're talking about the study of abnormal neurology, pathological neurology, or towards the more severe ends of pathophysiological neurology, when things aren't normal. So that, ideally, you would apply treatments to make them more normal or at least tolerable. Functional neurology means that, after those things are checked to make sure that they're taken care of appropriately, we're looking within normal. We're saying, for what is considered normal in the world or within normal limits is a term that you'll see in chart notes, where are they? Are they directly in the middle? Are they trending too high? Are they trending too low? So, within what is still normal, if you add up all the normals, does it create something this abnormal even though if you test it individually it's still normal? Does that make sense? I'm sure that was confusing for a couple people.

21:30 Jill (Host): If I'm hearing it right, it's about getting things truly optimal, not just OK, and I come from the world of nutrition where I see all the time that there's a huge difference between optimal and just OK. People who are just OK can actually be doing pretty lousy, but still qualify as just fine. Is that an apt metaphor?

21:50 Dr. Lovich (Guest): That is very accurate. And so, when we take this approach and we try to apply it to a patient, which that's the whole goal is to get patients better, think of functionality as a method of evaluating a patient that balances that traditional neurological and physical evaluation that you get with an approach that looks at everything within normal limits. And the main question that we’re asking is, although it's normal, is it normal for you? And if you think the brain is a simple input/output system that I was talking about before, the way that we explained functional neurology to patients is really this sort of story, if you don't mind. It's a simple input/output system whose goal is really only to answer 2 questions: Where am I in the world around me, and where is the world in relation to me? And your brain needs to have accurate answers to these two questions in order to appropriately navigate the world, and also respond to challenges and threats that you may receive in that world. Your brain maps you out in the world using your senses, and that includes your sixth sense, which is your inner ear which is how you are in relation to gravity. It uses your eyes to visually map out the world, so you know where things are. It uses that sixth sense - your vestibular systems - so you know which way is up, and you can map yourself moving through a gravitational field. And it uses your muscles and joints to figure out where you are in space. And through a series of complex circuits, all this information is taken and interpreted by your brain, your brainstem, and your cerebellum, and it allows you to make a decision on how to go about navigating the world. So, this is why a brain-centered approach like we use in our office can demystify the constellation of symptoms many patients get. Something that can look like a number of independent systems may now fit nicely into a pattern which which ends up with two responses from the patient: some patients end up being super happy, they’re like, “Holy crap, it finally makes sense,” and others be like, “Why haven’t my other doctors figured this out?” I'm like, “They're trained to look at the individual system by itself, not how it works together. So they're doing appropriate treatments based off of their approach, but we're going to do appropriate treatments based off our approach, which is now putting it all together.” So as an example, just to give people an idea of how this functional approach can create a physical manifestation, let's say that your inner ear is having trouble mapping out gravity. Maybe there's an imbalance between the paired systems on the left and right sides causing a subconscious perception that you're falling forward and to the left. Since your brain really only cares about staying upright so it can do its job and so it could feed itself, it will clamp down on all the balancing muscles on the right side of your back pull you backwards. Over time, this will look like a chronic muscle tightness. Does that make sense?

24:50 Jill (Host): Interesting, OK. Yep. Mmm hmm.

24:52 Dr. Lovich (Guest): So that was just an opinion based off of how if you have an issue with a vestibular - with a certain part of the vestibular system - how your muscle and joints may be able to get a physical reaction from that.

25:05 Jill (Host): Fascinating! So you had mentioned that your exam is a really big deal when you assess a new patient. Can you tell us more about your exam? Like, what are you looking for?

25:17 Dr. Lovich (Guest): So first and foremost, we do a full neurological exam 'cause we want to make sure that if something is progressing - that maybe they saw a neurologist 3 months ago and now they're seeing us - we want to make sure that just in case it was normal back then that it that it's still normal now. So we do a full neurological exam. But then we go into that functional world where we measure the inputs and the output of the brain. We use balance testing. We use eye movement testing, and we not only test these systems individually, but how they work together in reflexes, because you can get your eyes working fine, but if your eyes and your inner ear aren't working together well, then what's the point? We're measuring how well your eyes move, how will they move together in unison, how well they move together with your inner ear and with your your neck and your body. And it's because these reflexes are super important, and they are the things that your body is supposed to do automatically. If when you walk, people - when they walk - they bob up and down, their heads bob up and down. Now think about it like this - if you didn't have a reflex that made your eyes move equal and opposite, every time your head moved you would get nauseous and dizzy so quick, right?

26:27 Jill (Host): Yeah, I never thought about that. Yeah.

26:29 Dr. Lovich (Guest): So, this is a reflex called the vestibulocochlear reflex. When your brain feels your head moving up in gravity, it's going to move the eyes down, keeping you focused on a single point. Otherwise, if you didn't have this reflex or this reflex wasn't working or dysfunctional, you'll feel just by going for a walk that you're riding the high seas. It's not the most pleasant experience. So, when they don't work, then your frontal lobe has to come in and control it. I like to use this example recently: Like, if you've got like a parent and a bunch of kids that are running all over the place instead of doing what they're supposed to do, at some point the frontal lobe – the parents - are just going to be like, “Fine. I'll just do it myself. You just sit and be quiet.” And then the parent gets stressed out. And so this is your frontal lobe. Now, your frontal lobe is getting stressed out. It’s doing more work than it should be doing and now you have symptoms from that. So, you're expending dedicated energy to do things that should have been done on their own. And to put it simply, POTS is an issue with the brainstem not responding appropriately to the inputs to it. And our exam’s goal is to measure first all the sensory inputs to that brain stem to make sure that they're working properly, and then measure the interpretation of the brain through its outputs. And the brain's outputs is motor - so movement and mind, thought. So that's why brainstem dysregulation can create changes in mood, changes in emotionality, changes in thought processes. It can create a situation where, let's say it's firing too high at some point and you're in a situation as a patient with POTS. If you're in a situation and you respond inappropriately to it during the moment you're going to feel like, Yes, this is the correct answer for how to respond to this challenge. And then maybe a couple hours later, you're going to be thinking about it being like, why did I respond like that? There was no reason to respond in that way, but the thing is, you're only able to respond to the world as your brain interprets it. And this is a huge thing. This is one thing that I really try to coach my patients with is when you have something going on with your brain, give yourself some slack. The thing that you use to figure out the world and figure out how you're doing is not doing that well. It's not as functional as it needs to be. It's not as optimal. So that means your interpretation of the world and your interpretation of yourself is not going to be optimal. So you need to give yourself some slack and be like, OK, maybe I didn't respond appropriately or maybe the world did seem like it was an issue but maybe it was because I need to be able to catch up to it. Let's figure out how to rehab that brain so you can speed up and be able to keep up with the world.

29:19 Jill (Host): That's so fascinating! OK sorry, keep going.

29:22 Dr. Lovich (Guest): No, no, that's - it really is. And it's a tough thing to swallow, like I went through when I had my own concussion. It's tough to feel like the world that you're in isn't accurate. We have to be OK with the idea that we can improve. And we have to be OK with the idea that as long as we keep taking like one step forward, we're going to get better. But the patients need to give themselves some slack and say, like, “Hey, I'm making progress. That's all I can ask of myself.” But that also means that if we base our clinical judgment solely on what the patient feels and describes, and they're using that organ that allows them to take stock in themselves to describe it, if that isn't working well, we need to have more physical ways to determine functionality of the brain.

30:05 Jill (Host): That is so interesting and you're the first person I've ever heard tie the emotional part into it as well, 'cause it all makes sense that the inputs and the outputs and things can get fouled up in the middle. But you're the first person who's ever connected those dots for me that probably a lot of our listeners are thinking this right now, but I'm going through my memory of there are certain situations where I become not myself. And I get emotionally all off and riding in the car is one of them. And now I'm starting to wonder if that's one of those situations where my brain is just not able to handle what's going on, and that's why 20 minutes in a car turns me into emotionally a totally different person. And based on what you're saying, I am starting to see how maybe just some simple brain disconnects or malfunctions could lead to that. I spent 17 years trying to get diagnosed and I was pretty much blaming myself the whole time and so I think I'm very quick to blame myself when I'm not in my brain [inaudible]. I really appreciate what you're saying about not just the motor stuff and the cognitive stuff, but also the emotional stuff being at the whip end of whatever is going on with these systems, if I'm hearing that right.

31:24 Dr. Lovich (Guest): Yeah. And this is the thing that blows a lot of people's minds. Now, this is super stressful for people to go through. And anything brain is super stressful for people to go through. So, it's not diminishing your experience, it's not saying that it's not valid, it's just saying there's a huge window we can use to improve it. But - remember I keep talking about it's the interpretation through your brain, your brain stem, and your cerebellum? For people who have not heard of what these parts are, your brain or your cerebrum is like the big lobes of the brain. Your brain stem is where it all interprets and it ties everything together. There's a lot of little nuclei in there that control everything that happens downstream from your body. And then there's your cerebellum, which is traditionally known as movement, coordination, and balance, but it's also coordination and balance of thought. Think of thoughts as motor outputs from a brain perspective that instead of going out to your body to make you move, they go to your frontal lobe to make you think.

32:28 Jill (Host): Oh my God, my head just exploded! That's a cool way to think about that.

32:21 Dr. Lovich (Guest): So, when you're going through this stuff, you can use a functioning cerebellum to control things forward, or if there's a cerebellar issue you can improve that and then thoughts just get better. And it's the first thing that patients notice is like all of a sudden, they're like, “You know what? I'm having more good days than bad days now.” And if that's as simple as it needs to be to start, that might be enough for people just to feel like the world is not falling on top of them.

32:58 Jill (Host): Wow, yeah! Which is a big deal. That’s a big deal. So do you mind talking a little bit more about - so once you have done someone exam and you have maybe identified some things to work on, can you talk about what happens next and maybe throw in some examples of POTS patients?

33:21 Dr. Lovich (Guest): No, they're proprietary secrets. Sorry. No, I'm just kidding.

33:25 Jill (Host): [Laughs]

33:27 Dr. Lovich (Guest): So the idea is if you have, um - so we already talked about the visual system, the inner ear, and the physical systems and we talked about how it creates changes in cognition. But what did therapies look like? They look like exactly that - vestibular rehab, ocular rehab, like eye movement exercises, physical exercises when appropriate, and cognitive exercises. Now, we also include stuff called receptor-based therapies. So what receptors are - they are things that take a signal and then create activation somewhere in your brain and body. So we can target certain areas to create localized activation in a certain location. For example, if I wanted to create activation in the lower left brainstem, I can do vibrational or electrical stimulus to the lower left part of your face, which is going to receive information from part of your trigeminal nerve – V3 – which is going to take that sensor information and it's just going to create activation in the neuronal pools upstream. And so, there are certain patterns that you can use, and I'm not saying like it's like a traditional pattern, it’s sort of like, you know, that, OK, if this stimulates that side, this stimulates the other side, and there are areas in the lower brainstem that help modulate autonomic control in the lower brain stem, if we stimulate this and we find things that inhibit or control top of the brainstem, which also fires more sympathetic output into your brainstem or to your body, we can use these exercises to fire it. So, when I train other doctors to do this, I view exercises as either activation exercises or modulating exercises. Think of modulating as training or controlling exercise. Think about it like this: if you go to the gym and you workout and you create a ton of activation, but you don't do any activation that's in a functional pattern or functional movement pattern, like if all you do is just chest press but you never have a reason in life to use a pushing movement, then once you get to a point where you have to push and all you've trained is on your back in a bar, you don't have the same inputs and outputs to your brain, like gravity on your system, to be able to create that amount of push and leverage. Does that make sense?

35:57 Jill (Host): Yeah, absolutely, and I think they even call that functional fitness, right, when you do the thing you actually would do in real life.

36:04 Dr. Lovich (Guest): Everything is functional now, right? That's like the hottest term. So when we're working with the brain, we want to activate these areas, like using fiber torque or electrical stimulus, or even just making someone move a certain way. And then we want to use other exercise to control those systems and it gets relatively complicated relatively quick, but you can use eye movement exercises is because of something called a homologous column. It means that every time your eyes move, everything in this column, including your tongue, movement, and sensory and it's called your vestibular spinal tract, which are the fastest firing neurons from your inner ear down to your body. It allows you to balance or in react to things, so every time you turn your head and don't fall down. But it means that you can use eye movements to improve body awareness and balance. You can also use body awareness and balance to improve eye movements. Or you can use the tongue to create activation in that same system and then use exercises, like maybe looking at a target and slowly bring your head side to side in order to create activation and teach your brain to use a control with activation. Does that make sense?

37:16 Jill (Host): Because it's all connected.

37:17 Dr. Lovich (Guest): It's all connected. So, if some people are asking like, “What does activation mean?” Activation is exactly what it sounds like. It's an exercise or something like a stimulus that creates more cellular activity in specific areas of the brain. And those controller modulation exercise are there to train the brain to control the activity of the brain. Does makes sense? It’s training the brain to control other things that happen.

37:43 Jill (Host): OK, mm hmm.

37:44 Dr. Lovich (Guest): And the whole point of doing this is to make the brain, work more efficiently and every patient gets exercises dependent on their presentation. It means that, sure, that we have some basic ones that most people get at least to start. But we're going to progress them where we're going to change them depending on what we see the patient needs. Because an exercise that is performed correctly should never make the patient feel worse as we're moving along well. There's a few reasons why that may happen, but most of the time a patient should feel better with every therapy provided. And if it doesn't feel right, then that exercise may need to be changed. It may need to be tweaked to be more accurate to the patient's individual physiology.

38:29 Jill (Host): So, if we were going to go back to the example of Samantha, your patient who wrote in to us, she said that she saw you for about 90 minutes a week for five or six weeks. Now, in addition to that, was she also doing things at home? And then my other question is, does she have to keep doing things forever to keep those parts of her brain functioning and trained?

38:55 Dr. Lovich (Guest): Let's talk about her case a little bit and we have permission to talk about our case, which is really, really lucky because it's hard to explain these things without like having a person there. So, she came to the clinic looking for like a 10% improvement. That was her hope. She was like “That would be significant. If we get 10%, we are good.” She was having issues with her pulse spiking throughout the day, in the morning, when she was sleeping. Like the letter said, she's a personal trainer, so sure, job is relatively physical. And she needs to be able to think on her feet. She needs to do a breakout exercise in case somebody like can't do a certain thing. It's like the stability issue. She's got to be able to say like, “OK. What do I do to fix that now?” Cognitively, she was not able to do the job at the level required. Now, she was able to do the job. Were her clients able to get a benefit from seeing her? 100%. But could she do it better? Of course. And so, on her intake paperwork, she was talking about inconsistent tachycardia, syncope, inconsistent eyes adjusting to light, sleep issues, and then memory and concentration issues. So we've already kind of mapped out a lot of these systems with our current discussion, loosely. We found some vestibular issues, like something called a right beating nystagmus, which is an issue where there is an imbalance in either the vestibular input or the cerebellar input, side to side. And so for her the eyes were drifting to the left and then snapping back to the right. So her subconscious perception is that the patient is constantly slowly spinning. And then she gets information from her muscles and joints from the brains like, OK, when the frontal lobe has too come in and be like, OK, well am I spending or am I not spinning? My body says I'm not spinning, my eyes say I'm not spinning, but my inner ear is saying I'm spinning. So, brain has to react to that world as if the world is rotating to the left. So, think about it like this, a nystagmus - a spontaneous nystagmus - that you can only see if you are able to see the eyes without the eyes being able to see the world, 'cause if I said OK, open your eyes, look at me, they're going to look at something because you're gonna stay on the target. But what we use infrared goggles, we just put them on and it allows us to see the eyes when the eyes see pure blackness. So what happens is when we see the eyes drifting to the left and then snapping back to the right, a right beat nystagmus. It means that the brain thinks the body is slowly turning to the right with that slow phase, and then the snap back is the kind of like, Oh, I'm moving. Or my eyes - I thought they were here, now they're here. So if you're slowly turning to the right 'cause we're breaking this down right now, we're slowly turning to the right, which way would the world will slowly be turned? To the left. So if he were to walk in a straight line with her eyes closed, and her brain is saying that she's turning right in the world is turning left, is her ability to react appropriately to the world good right now? Not necessarily. Now, is the problem that that she has a spontaneous nystagmus? No, that's not the problem. The problem is why she has it. What reflexes are involved, and they all go through the brainstem. So there's multiple reflexes that are involved that could cause a spontaneous nystagmus. So what we do is we go around and we start working on the brainstem reflexes and then that starts to sort of straighten itself out. So, there were more things than just the right beating nystagmus that we found, but I thought this was an interesting thing to talk about, something that we look for and that we can improve. So, most of the issues we found were in the brain stem and the regulatory system for autonomic function is in the brain stem. And the brain stem controls responses as well. So, by improving brain stem systems, the patient’s symptoms improve. We get best results with patients who take an active role in their care and are diligent with the exercises that we recommend, and also try during the rehab sessions, like someone who's like OK, I'm going to do my best. This may not be the most horrible thing to do. It may like suck while I'm going through it, in terms of like relearning how to do something that seems super simple and maybe frustrating to just be able to like, why can't I keep my eyes on the dot? That seems like the most simple thing in the world, but apparently I can't. So, most patients that come to us feel some sort of change, and whether it's clinically meaningful to us is different than whether it's meaningful to the patient, and that's part of the conversation that I have to - that we have to have - is what would be meaningful for them? How can we measure changes in their life beyond do they feel better or do they not? You can feel the same level of suckiness as you're getting better, but if you're not tracking it with something else, I mean like, hey, my pulse in a spike overnight. Hey, I did a hard workout and I didn't have any symptoms. Hey, this - I haven't had a headache in weeks. Looking back, tracking things, actually writing things down, because like we said, our ability to take stock of ourselves might be skewed, give yourself some slack. Write things down and check it out. So for this patient she came for a 10% improvement. She got what she describes as a 50% improvement. But on the surveys that I provide, because I want to find more quantitative ways to ask questions to say are we actually getting better - she did an 84% improvement in under three weeks.

44:15 Jill (Host): Wow.

44:16 Dr. Lovich (Guest): Which, again, shows the complexity of the mind versus the body.

44:22 Jill (Host): Right.

44:23 Dr. Lovich (Guest): And so, there are a few factors that make this stuff more difficult, though, and I'm just going to be frank here. I see the across the board that there’s slower improvement in patients that refer to themselves as, for example, with a brain injured person versus a person overcoming a brain injury.

44:41 Jill (Host): Oh, you mean just the language of it makes a difference?

44:44 Dr. Lovich (Guest): Just the language of it. If you view yourself as the disease, as the condition, it is a lot slower to improve. If you view yourself as a person who can get better, who will get better, and the person who is finding ways to show themselves that they're getting better, that will move, and it's not necessarily a placebo effect, it's when you remove a symptom from somebody who currently feels like the symptom is their new normal, then they are going to try to fill it with something. We'll have patients who - their symptoms will improve, but their symptoms are missing now, and they don't feel like the absence of symptom is better. They feel like that symptom was filling a space for them and now they need to fill that space with something else. Ideally, we need to fill that with something else that's productive and helpful, but a lot of times patients will fill that with something else, or they'll just bring their symptom right back because they'll find a symptom that's now reduced but magnify it personally and say no, it's still there. I can still feel it.

45:49 Jill (Host): What you just said a minute ago about the language matters, and patients who think of themselves in this one way are way more successful than patients who think of themselves in this slightly other different way. Can you say that again, to make sure that we all got that?

46:04 Dr. Lovich (Guest): I'm going to throw a little bit of a different spin on it for people who might need a little differently. So you know when you're when you have an issue that you have been told is your new normal, and you've been going and working with people who have been teaching all these different ways to cope with the new you, it cements in the idea that you and POTS are synonymous - that you are one. Don't think like that. Think POTS is a dysfunctional thing you've got, like a sprained ankle, and if you slowly rehabilitate it, there is a chance for it to improve and potentially get you to a pre-POTS level or an absence of POTS symptoms. But what this means is when you're trying to remove the POTS from you, you may feel like there's something missing now. Sometimes working with us, the symptoms will get better, but the patient still feel like their symptoms are there because the symptom did get better, but because it's still there, or because they don't have something else to replace it with, they magnify it. My goal is to remove my symptom, the goal should be I remove my symptom and replace it with something healthy, with something else that will occupy my time.

47:22 Jill (Host): Yeah, that makes a ton of sense, and I think, boy, I feel like I could talk to you for hours and hours and I know you need to get back to your clinic. But it it gets back to this whole idea that it is so tough on your identity to have – first of all have POTS come up and now you've got something that you've got to like manage all the time. What we don't focus on is when maybe you get your functionality back, that it’s an additional sort of stress to your identity, and so that's super fascinating that even as you are kind of getting your life back, there's that danger that you have a hard time.

48:00 Dr. Lovich (Guest): That's why I keep saying we don't want to view it just based off of how do I feel today? We want to view improvement based off of physical changes. One of the things I'll try to do with the patient is like, all right, like with Sam, she was like, “OK, I'm feeling better,” and then right away I'm like, “OK, we gotta replace this with something like when was the last time you climbed a fourteener?” Imagine climbing a fourteener with POTS going to high altitude low oxygen, and we need to create a goal. Something that she can do that can show that herself that she got over some symptoms and that she's functional and that she made progress. And POTS is honestly great compared to some of the other conditions I work with. It's great 'cause it's physical. You can track these physical issues and it just makes it so much easier. We can create physical changes in a person and people can track and say I'm able to do this now, I'm able to do that now, instead of just saying, “Well, rate your POTS symptoms from zero to 10, or rate how you feel.

48:59 Jill (Host): Right.

49:00 Dr. Lovich (Guest): We want to make sure that there is tangible changes because we're tangible beings. Other complicating factors - severity of the injury that caused it. Sometimes if it's TBI related, that just makes it tough. If there is a chronic infection going on at the same time, that can also trigger it. Anything that's like a traumatic or an acquired brain injury together with it, that can be part of it. Genetic factors can also make it tough, and you know, we like to think that there's epigenetics, which is it's not nature versus nurture, it's kind of the two together and you're the way things are developed. Some patients only can get so far. So, you were saying before, do patients have to do these exercises the rest of their life? First and foremost, if the exercises make them feel better with literally zero side effects, it's not the worst thing in the world have to do like 5 minutes of exercises, couple times a week. However, there are some changes certain medications can have ototoxicity. So what does ototoxicity mean? It means that the medication can create like some sort of degeneration in the inner ear. And there is a study that shows that asymmetry in inner ear output creates inflammation in the brain.

50:11 Jill (Host): Oh, interesting.

50:13 Dr. Lovich (Guest): These physical things create so many other effects that once you start following it, you're like wow, yeah, of course you would have these symptoms. So, when we're talking about the inner ear, there's decompensated and there's degenerated inner ear. A degenerated inner ear is going to be something where a patient will have to do their exercises for the remainder of their life. A decompensated inner ear means that there's a possibility that they will be able to do their exercises, then stop and be good. And then if things start to slowly come back, they can just do their exercises on their own, and then they'll be fine. Now either direction means that they won't need constant ongoing care from my office, which is the goal. We want people to be able to be in control of their own lives. I want you guys to be on your own living your life. [Laughs] But the brain does change. And sometimes the exercise that you need do change. So we'll do like a check in if somebody has a symptom and we'll say, like, “OK, do we need to change any of the home exercises?” And if we do, then we change it and we say alright, call us again when you need us. But that's why we say everything starts with the exam, because after seeing real time response or rehabilitation, we have an accurate picture of what we're dealing with. And we can do the same thing with follow up care, but we may have to do like another mini exam to be like OK, what changed? What part of the brain needs the input now? And when it's a straightforward case, we can see changes within like a week. It's pretty nice.

51:44 Jill (Host): Wow, yeah. That's just amazing. And I think when we were talking before, I had asked if this can be done at the same time as sort of a conventional POTS treatment, or how do things work in terms of coordinating with that?

52:03 Dr. Lovich (Guest): I view functional neurology as adjunctive medicine. In other words, work with your neurologist. If you could find a dysautonomia specialist, those are the people that you want to work with. You want to work with somebody who's educated on POTS because just because they have a good idea doesn't mean they have good arguments to base their ideas off of if they have never really worked with these cases. It's very different. But when these things are managed, making sure that things are - that you now have autonomic stability, we can still work with the reflexes at the same time, and then what usually happens is after patients following their medical approach and keeping that sense of stability, we rehabilitate the dysfunctional systems underneath and then when symptoms get better, we - like the patient and I and the prescribing doctor - can work to wean the patient safely off medication if the doctor feels it's appropriate and do it in a safe way. I recommend seeing us or any functional neurologists at the same time. If a patient’s looking for a functional neurologist near them, on my website I put a map up of people that I personally would go to if I had an issue.

53:17 Jill (Host): Oh nice, can you tell us where can people find you online? And I think you had mentioned a YouTube channel?

53:25 Dr. Lovich (Guest): My business is Delta S Performance. You can check out our website. If anybody is interested in - if you're like a prospective new patient, or you just have questions - just go to our website and click the “Get started” button. That makes sure you get in the queue and we can make sure we get to everybody. [Transcriber’s note: you can find the Delta S Performance website here: https://deltasperformance.com/] On our page, if you click on the “Resources” tab, you can go to the functional neurology map. Those are the people that I currently recommend based off of people that I would personally see if I had an issue, and also people that I have seen practice in their office and know they provide a certain level quality of care. And there's other people out there that may do great work or better work than me and other people on there, but I haven't seen them personally, so I'm not going to make a recommendation to something on a whim.

54:11 Jill (Host): Excellent. Well, Dr. Lovich, I know you need to get back to your clinic and we're so grateful for all this time you took to explain these fascinating things to us. Like I said, I feel like I could talk to you for hours about some of this stuff 'cause it's it's so, so intriguing and in in combination with here and how it helped Samantha and others. But thanks for sharing your approach. Thank you for all the work that you do to help POTS patients. We really appreciate your time and knowledge. And, hey listeners, remember that as always, this is not medical advice. Consult your healthcare team about what's right for you, but thank you for listening. Please consider subscribing because it helps us get found by more people like you, and remember that you're not alone. And please join us again soon.

55:00 Announcer: You can find us wherever you get your podcasts or on our website, www.standinguptopots.org/podcast And I would add, if you have any ideas or topics you'd like to suggest, send them in. You can also engage with us on social media at the handle @standinguptopots. Thanks for listening and we hope you join us. This show is a production of Standing Up to POTS. © 2022 Standing Up to POTS. All rights reserved. [Transcriber’s note: If you would like a copy of this transcript or the transcript for any other episode of the POTScast, please send an email to volunteer@standinguptopots.org]