Rethinking Neurological Rehab: Advances In Technology

Key Takeaways:

• Vestibular rehab isn’t just for dizziness. It can benefit people with migraines, POTS, chronic fatigue, neck pain, and even back pain—because your brain’s perception of balance affects your entire nervous system and body.
• “It’s not just ear crystals.” Many clinicians oversimplify vestibular issues as BPPV, but central (brain-based) vestibular dysfunctions are often the real culprit—and they require advanced evaluation.
• Traditional therapy often fails. Protocol-driven rehab may worsen symptoms in 10–20% of patients. Precision matters. Rehab must be personalized, not “one-size-fits-all.”
• Cutting-edge tech is revolutionizing diagnostics. Tools like video oculography (eye tracking), computerized balance posturography, and rotating chair assessments are enabling more accurate, faster, and safer neurological care.
• AI will change everything. Artificial intelligence is already being used to enhance clinical decision-making, track progress, and personalize care—offering faster answers and better outcomes than ever before.

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Transcript

Dr. Garcia, thank you for being here. I'm excited to talk about the advances in neurological rehab technology and also vestibular rehab. Thanks for having me on, Dr. Zimmerman. I appreciate it. Yeah. First, I just want to go into vestibular rehab like who should think you know who benefits from vestibular rehab is it just the dizzy patient you know because they're normally the ones who are being sent from their providers Like, is it just them or are there others who should be considering it based upon conditions? And then we can also go into some of the symptoms that people may have that would warrant a vestibular rehab evaluation. All right, so who should be getting vestibular rehab or thinking about vestibular rehab? I mean, the obvious answer is those dizziness patients, right? And that's where people start thinking about this type of thing. But here's where patients, right, those listening to this podcast need to step back for a second and realize this about their physiology or their neurophysiology. It is such in your body that everything stacks on top of your perception of where you are in this world. Meaning, let's put it this way. There's patients out there listening to this and they have something called a dysautonomia, right? Which means that your autonomic nervous system, your ability to send blood to different parts of your body is messed up. And maybe when they sit up from a chair or they move around, they get dizzy, they feel woozy, things like that. your vestibular system can be contributing to that. So somewhere there's a patient who needs vestibular rehab that has a dysautonomia that isn't making that connection because they don't have dizziness. They just have, maybe their hands turn purple a couple of times a week because they have a condition like Raynaud's. Or maybe there's a patient who has migraines for example same thing they could actually have vestibular caused migraines and that person needs vestibular rehab but they're like oh I just had headache and migraines my entire life I've gone to ten doctors nobody can figure it out I've tried four different medications So you have to realize that your vestibular system and all your other function stacks on top of it. It's like fundamental to everything. So in my world and the way I look at it, and even by the way, even when it comes to pain, even when it comes to back pain, knee pain, shoulder pain, I'm assessing their vestibular system. I want to know what's going on there. So to me, everybody should be thinking about pain. should my doctor be prescribing or recommending vestibular rehab and if it's necessary you do something to it and if it's not you look elsewhere but it's a in my from my perspective it's something that many many clinicians miss and a lot of patients are missing out because of it because it could give them such a big win with a pretty safe way to make huge changes in patient care Yeah, and I'm going to ask this, and I know you're going to enjoy this, but humor me. But Dr. Garcia, I thought the vestibular system was just about ear crystals. Oh, yeah. So, wow. Now we're going to go down the rabbit hole. You ready? Dr. Zimmerman, you're getting me going. Let's not go super deep, but let's start busting some of these myths because... that's typically what it's getting reduced to a lot of the time is, oh, you've got inner ear crystals or no, you don't. And that's like, I'll be all of the vestibular system. So, so let's, I'm gonna let you briefly go after that because a lot of people, I'll tell you why it happens. I'll tell you, because that would be easy. Most clinicians want it to be some crystals in your ear. That would be easy. Wow. I mean, there's a, there's a, there's a pretty good, protocol to find out if that's the case. And there's a pretty good protocol for treating it. And I wish that every time there's a patient in front of me, or if I was consulting with a group of clinicians that I could tell them that that's going to be ninety percent of the time. But it's just not the case. That is like the low hanging fruit of conditions. And I'm telling you, most clinicians will want it to be that way, but it is not. First, let's do this. We're talking about the vestibular system. I want to talk about peripheral vestibular system and central vestibular centrally maintained vestibulopathies or vestibular issues and I'm going to keep it simple for everybody listening at home but check this out when we're talking about crystals in your ear we're talking about the literal hardware yeah you have these little little and it's very small right like literally could fit on a pencil these little canals that perceives angular rotation and then you have otoliths which perceive linear acceleration And you can have crystals in these little things and it mechanically stimulates it. causes electrical impulses and tells your brain that you're moving and visually you're not moving. So you feel kind of weird, but that's peripheral. Then there's central. What do I mean by central? Well, I told you there's hardware, right? And you can mechanically stimulate this hardware. And also when I move my head around, there's fluid around, that fluid kicks off those little sensors and tells my brain where I am, that I'm moving around. That's how I could, you could spin me in a chair, I could close my eyes and I could tell you which way you're spinning me, right? Because I have this. Now let's talk about centrally maintained vestibulopathy or issues. That means the information gets in there from this hardware and the computer, that is your brain, which is the software, interprets all that information, but the output is incorrect. So when you bring up the issue of crystals, that is a peripheral issue and patients undoubtedly have them. And I know you know what to do if that's the problem. And I know that clinicians want peripheral issues to always be the problem. They're actually less complex. But when it's a central issue, a software issue, it requires a special clinician to understand that, recognize that and step back and go, all right, I need to change my exam process and find out what's going on in the rest of their brain and find out how to tune the software to have a better Output. And the output would be, hey, I know where I am in space, which can then affect things down the stream, like my autonomic nervous system, my ability to not have migraines anymore, my ability not to feel woozy, dizzy, have headaches, things like that. So it's not always about crystals. That's a hardware issue. Sometimes it is, sometimes it isn't. But sometimes there's a central issue. And that's software really requires a trained clinician to recognize that and know something, know what to do on it. But I understand why clinicians would always want it to be peripheral or the crystals. Yeah. And I think even when we look at the research, I think central mediated vestibular issues are massively underdiagnosed. You know, they're like, Oh, it's just like this tiny little bit. I'm like, that's interesting. Cause like I'm finding it in most people I'm evaluating with dizziness, chronic neck pain, headaches, um, brain fog, chronic fatigue, prior concussions, dysautonomia, POTS, long COVID, stroke, people having dementia, neurodevelopmental disorders, all of them. And I think it's important that people understand is it's not, when we say central vestibular-based issues, it's not like we're talking about a tumor impacting the brainstem. It's not like we're talking about a stroke. It's, you know, if you view it like a muscle, right? You can have issues with your muscle without tearing it. You can have impaired firing and recruiting patterns within your muscle that impacts your ability to run if you're trying, if it's with your legs, right? It doesn't activate in the way it should. And it's kind of the same thing when we look at the vestibular system. It's, hey, yeah, you've got your peripheral that feeds in. but then it still has to that's really kind of a relay station almost it's like well we've got here we're going up and we'll talk about where it goes up to with the eyes but then we also know it feeds down into the cervical spine we also know there's vestibular sympathetic responses as well which you were talking about dysautonomia so there's there really is a lot to this and reason why we're doing this podcast is because so many people are just dealing with vestibular based issues and now I do want to clarify this is not necessarily the only thing they've got and vestibular system as we talk about this it's way more than just balance which we will talk about balance um but before we go into some of the nuances and the weeds Right. We want to kind of go through what people have been through. So they've got headaches, right? They, maybe they had a concussion and they're being sent to vestibular therapy. What does traditional vestibular therapy look like for people? And then from there, we'll go into why we see so many people who don't actually get better from traditional vestibular therapy. And then we even have a subset for me, it's about ten to twenty percent who actually get worse from vestibular therapy. There were like three different questions. Give me the first one in there. Give me the first part. First one is what does traditional vestibular therapy look like? So their ENT or their sports medicine docs like, hey, you had a concussion. Send you there. All right. So it really depends where you're going. Right. If you're going to the managed care scenario, sometimes you can find yourself in a practice and you can actually let's say you had a concussion. Your GP says you need vestibular rehab. They send you to a managed care practice could be a physical therapy. For example, you may find yourself with three or four other people that are doing a protocol. Everybody could be sitting in a chair and they could be standing there looking. I'll do it. Looking at the camera, looking ahead, looking at their thumb and doing doing this for sixty seconds. And the therapist may be saying, hey, I need you to do this as fast as you can, keeping your finger in focus for sixty seconds. Right. And what they do is they're moving through these, you know, very traditional and important. And again, very can be very powerful vestibular rehab exercises. Right. The problem is, is that historically, and this is less, more in the past and less in the future as clinicians become more educated, they're doing these protocols giving people, hey, these are the things that you should be able to do with your vestibular system. They have you do them all. Let me tell you what's happening now. clinicians are becoming smarter, more specific. So now, instead of having a patient sitting there and saying, look at your thumb and go like this for sixty seconds as fast as you can, you may have a patient, you may go to them and say, oh, I know exactly what's going on in their physiology. I'm going to have them quickly go to the right, slow to the left. quickly to the right, slow to the left. So you may bias your rehab specific to that condition. That's a big change that I've seen, and it really comes from the clinicians recognizing that they need a certain level of individuality to their care plans to deliver the outcomes that they're looking for. I'm sure, Dr. Zimmerman, the type of patients you see are the ones that have done the protocols and come off the end of it sometimes feeling worse, aren't they? Yeah. So, I mean, like I said, probably ten and twenty percent are definitely worse than everyone else. You know, they really didn't get good results. And it's you know, I even have some of those people. We have to break it up because you've got to remember. Right. So if you're watching the video, awesome. But if you're listening to this, imagine you've got your thumb out in front of you and you're staring at and you're just moving your head left and right. Some people, they get dizzy just from moving their head left and right, going up and down and they cannot handle a combined movement because it's not just vestibular activity when you do that. You've got vestibular system, you've got visual system, you've got cervical spine. It's all of them. It's all three. And so I often have people who, when they're that, If they're really bad, we have to do it laying down, but we don't do that. I have them do, I just call it pivoting for easy sake, makes sense to the patients. I'm like, no, you're only going to move your eyes to the target. Then we're going to move your head to the target. So we're going to break up the movement into something that requires less activity neurologically because you can't handle it yet. And as we get those systems stronger, we can then combine it and do more of a dynamic movement. And so not everyone can handle a full dynamic movement from the beginning. And so we've got to- Can you give an example of that, Dr. Z? Let me give you an example of that. So there's mechanisms in your vestibular system that make your eyes come together and go apart. So for example, if I put you in a roller coaster and push you forward and you're focusing on something, as you get closer to that, your eyes come in. That's called convergence. If you go backwards, that's divergence, right? And that's what your otoliths, you translating forward like in a roller coaster and translating backwards. Now you could also do convergence divergence just by looking at something. So your body's not moving and now you're looking at a target going in and going out. So they're similar, but not the same. So in some cases, your vestibular rehab, you're not even moving your body. You're just, you know, for lack of a better word, strengthening, exercising the same components that the vestibular system integrates with. So again, I'm not translating forward on the roller coaster, but I'm maybe working on my convergence and divergence by looking at maybe I have an Emory board here for whatever reasons. You can see my wife or daughter have been around. Maybe I'm following that in and out. Again, I'm not translating, but it looks similar, but it's not the same. The clinician needs to make the decision about what is the safest way to get the largest positive outcome in the patient as quickly as possible. So that's why I don't really like protocols per se, because protocols often, especially the ones that come out worse, they took one step forward and one point five or two steps backwards. And it's either one. Most often it's because the clinician wasn't trained well enough to understand that that patient needed more individuality. So that's the example I would give for sometimes doing things similar but not the same. They're not even moving. But it requires a well-trained clinician to recognize those things. Yeah, and part of it, a lot of my patients will tell me, it's like, you know, you did some stuff that was similar to what I did in the past, but you made me pay way more attention to how I felt instead of pushing through it. And there's a big difference in execution because I'll often tell people doing the right thing the wrong way or doing the right thing too much is actually very damaging when we look at the brain and and I think this is where we see vestibular rehab go wrong for so many people it's they're trying to do it through a physical therapy musculoskeletal based model which does not work when we look at neurological based issues because there's there's limits of how well your brain produces and uses energy and the way you can pay for that that you may not pay for when you like yeah your muscle you push too much you're not going to tear it right you may be a little bit extra sore but that's going to stay local but if you do it too much neurologically you don't just impact that one little part of your brain you can tank a lot of it and that's why a lot of people you know that I know you've worked with in the past they get flares they're like yep I did too much now I'm in a flare Well, I know your educational background and the level of clinician that you are. You are well-trained to observe somebody to find out when they're fatiguing before the patient even perceives that they're fatiguing. I mean, that's why your outcomes are different, and I know they're better. Your level of observation is much higher than a normal clinician because you're not doing the canned protocol. And then you're stopping them before they get to the point of experiencing a flare-up because I know what you're looking at. You're looking at their pupil sizes. You're looking at the color of their skin. Do they suddenly start sweating? Before the patient even perceives it, you're stopping them, which is very wise of you. Is that not what you do? Yep. Yeah, I mean, we'll stop and like, oh. Yeah, how'd you know I was starting to have some issues? It's like, well, you know, you could see it. Remember, some of those other practices, they go, all right, cool. Here you go. Do this for a minute. The clinician, the therapist or doctor, they walk away because they're working with four or five patients at a time and then they come back. So they're not even watching the rehab be done. In the model that we operate under, we are right there. Somebody's most of the time there with the patient to make sure everything's, one, being done properly, so you're hitting the target, and two, that their metabolic system can handle the energy consumption that you're having this brain do. Your brain is very metabolic. It has to be. This thing is computing things all the time. Not only is it computing the things that you're conscious about, but it's also ignoring lots of stuff. For example, everybody at home, can you feel your socks? Right, well, now that I mentioned your socks, you can feel your socks if you could, you know? So your brain ignores stuff all the time. In fact, it spends tons of energy to ignore things, right? Until you bring your forefront of your energy. So everybody thinks about brain, power and utilization of the the energy that you use as like the things you're focusing on but it's also the tons of stuff that you're ignoring right and then you have somebody who can't ignore things and they and they get a certain set of symptomatology so it's very fascinating and this is why I love neurology I mean it's you really got to know what you're doing when it comes to it but it's a it's like a giant puzzle in regards to how to help patients Yep. It really is a giant puzzle, you know, and there's, and there's a lot of advances coming out, you know, that are helping us to better do it because in the past, you know, and I've always been more on the equipment side with technology, but there's a lot of people who are like, oh, well, you know, I followed my provider's finger, their thumb, and they told me my eyes were skipping, or they had me stand on one leg and then they had me stand with feet together right and they're just doing all of these I'm gonna call these subjective objective tests um because there's a lot of opinions in them that you know they're not documenting but they exactly saw they didn't no one no one documents it to the specificity of what was truly observed and So what's already available? Because a lot of these things that are available that I know I've used for a decade, most people have still never seen. And then I want to talk about, and we won't go into it quite yet. We'll talk about it later in the show. So make sure you keep listening. But we're going to go into what is the future of this whole arena? Because just like everything else in the world right now, everything is amped up. and it's going way faster than it was, twenty years ago, ten years ago, even five years ago. We're no longer taking the boat across the ocean. We're using jets. So what technology do we have that maybe patients should be getting evaluated with? Let's just start with balance. Let's start there. But you made a comment. I want to bring that comment out that you made because I think it's very interesting. You know, there is bedside examination of a patient, which means that the doctor's using their eyes and their hands, right? And maybe some light equipment. That is important. What I've realized, this is bedside examination, is really to look for gross abnormalities, right? It should really tell the doctor to dig deeper. As I keep studying, because I'm a perpetual learner, what I've realized is the biggest weakness is, In healthcare is the clinician. Let me tell you what I mean by this. You said something about following fingers, right? So there's a test, for example, where I wish I had a, I have nothing but my daughter's artwork around here. So let me see here. of all the times that I wish my daughter would leave a doll in here or something, right? So you're holding somebody's head, right? And you have them hold their head and you have them stare at your nose and you very quickly would rotate their head and I'm looking for the ability to look at my nose, okay? So I've recently looked at some research And it says that even the best trained clinicians cannot do that test well. And you go, hold on one second. These are the best trained. How can forty percent of them have done it wrong? That's a large number, right? And these are the people that already thought they were good at a head thrust test. How are they doing it poorly, getting bad data? Right. And the problem is that one, they don't know they're getting bad data. Well, what could be what could be wrong? Right. One, we're counting on the clinician, the doctor's nervous system to perceive that. Did they keep their eyes on your nose or keep their eyes on the target? Then you're saying, all right, the clinician, they're left handed or they're right handed. So when they rotate your head one way or the other, the pulling hand usually has more pull. So if they're not doing that symmetrically, you're going to change direction. the outcome as well. So one, our brain isn't good enough to perceive the things that it needs to perceive. Two, we're not symmetrical and perfect either. So again, just a small point to kind of illustrate that what I'm realizing is that the biggest weakness in the exam is the clinician, but you don't have to worry. Now we can leverage technology to get data, which is essentially as close to perfect as it can possibly be. So for example, on a head thrust test, there's a test out there called a CR hit, computerized head impulse test, which literally does it perfectly for you. I mean, just the things that go out there being invented and being created to basically help doctors become perfect data acquisition machines is technology because the technology is perfect. Now, I'm not saying you're going to have a robot or an Android doing these tests on you, maybe in maybe in fifty years, but maybe in ten. But it's been very interesting to me because I came from the world of thinking that, well, you know what? I should be able to do this with with nothing, just my eyes and my hands. And the more I learn about the flaws in just your eyes and hands, I realized that we have to move forward. We have to get off the boat, get onto the jet and leverage this technology to get better patient outcomes, get better diagnostics and better treatment. So I have to beat that drum because we as clinicians have to concede that we may be the biggest flaw and the biggest thing holding back our patient care. And that's why I love seeing so many clinicians embrace technology to become perfect data acquisition machines and they can make better decisions. That to me is very, very exciting. What do you think Dr. Zimmerman? Yeah. And it's how, it's how we even map progress and everything else. Cause I was saying when people track, right, someone's finger, no one's documenting that appropriately. It's like, well, okay. You know, what's a better way to show a patient a result, right? Oh, well, you know, I, I saw your eyes skipping, you know, and a lot of people get told they have nystagmus, which don't at all. Um, but it's commonly a used term and it's, it's usually never the issue. But whenever you can show a video recording, that is much more precise to say, look, this is where you're at. This is where you're at now. It's just like if you break a bone, your orthopedist doesn't say, hey, I think you broke a bone because you told me your arm hurts. Let's cast it. They say, no, let's get an x-ray. We're going to cast it. But not only are we going to x-ray it initially, but They x-ray it along the way to make sure it is actually going through the appropriate healing process. And if not, they're able to spot it. And you don't necessarily feel great until it fully heals, and that's when they take it off. And that's the same thing, the computerized testing, when we look at video oculography or video nystagmography for eye movements, computerized balance postulography for balance, it's really letting providers do it as well. unfortunately most providers do not have the technology um in their clinic so people are you know they're they're kind of having to trust the provider a bit more which I also really like having the technology because look I I can't fake your eyes skipping like what am I going to sell you like oh your eyes are skipping and I show you a video of your eyes being perfectly still or tracking perfectly like No, it's, it's what you did. Um, and so that's, you know, and that stuff that's been out, but once again, it is being advanced. And so you really should be looking for people who are utilizing that testing because it is game changing. And since we, you know, brought up video oculography, let's, let's talk about that a little bit. Like, but. You know, Dr. Garcia, I went to my optometrist and my eyes are good. Why should I get video oculography done? Right. All right. So there's definitely a difference. Be going to a traditional optometrist and measuring your acuity, how clear things are. Right. Maybe you need readers. Maybe you're near or far sighted. Right. That's acuity. But then there's another way of looking at your eyes. And you said the right words, video nystagmography, video oculography or eye tracking. They're all a little different, but similar. Right. That is for looking at eye movements to find out how your brain is doing. So it's like giving you a brain report card. You go, well, why the heck do I want to look at my brain? Well, here's what you got to realize. Your brain is a governing system of your body. So I do not care if you have knee pain, back pain, dizziness, headaches, migraines, nausea, I'm gonna look at your brain. Guess what? All those things I just named, your brain controls and affects and integrates those things. And I need to know if your brain is the problem. Could it be an end organ problem? For example, I said knee pain. Could something be orthopedically wrong with the knee? Yes. Could something be orthopedically, biomechanically wrong with your hamstring or quad? Yes. Can those things cause knee pain? Yes. Can something be wrong with your cerebellum which causes a biomechanical problem in your knee. Your cerebellum is a little part, like the brain behind the brain. Can there be a problem there? Yes. Can that cause biomechanical problems in your knee? Yes. Can there be a problem with your cortex, the big brain up here that causes poor biomechanics in your brain? Yes. I need to know, is it end organ? Is there a problem with the nerve? Is there a problem with my spinal cord? Is there a problem with my cerebellum? Is there a problem with my brainstem? Is there a problem with my cortex? I need to know what the problem is so then I can then, again, the game is, can I make the biggest positive change with the least amount of risk and the least amount of effort for the benefit of the patient? That's why we're looking at eye movements to find out what's going on in the brain. Different than just acuity. So if you have a clinician or patients, so the patients out there, if you go to a clinician and they're suddenly looking at all your eye movements and even want to put... hopefully some goggles on you and look at your eye movements that way. They're doing that not to be an eye doctor or look at your acuity. They're getting a window of your brain health and how your brain can be contributing to the condition that you walk into that office with. That is a very forward-thinking and innovative clinician. You should feel good about going to that type of clinician. That, to me, would be exciting. That, to me, is the standard of care. You're going to hear me say it. I think that is going to be the standard of care in the very, very near future. Because more literature is coming out about us being the weak part of the exam. Technology is going to become part of health care. It's already there and it's accelerating. Yep. And we do know based upon research, we've seen research where if someone's had ACL surgery, the part of their brain responsible for controlling it shrinks. We know if people have had concussions, the risk of any musculoskeletal injury goes up for the next two years. And people are like, oh, but I haven't had a concussion. That's okay. You don't have to have a concussion to have abnormalities with your eye movements. But as you said, right, we're measuring how well your brain controls your eyes and your eyes. Ultimately that last part, it's the muscles of the eyes. And so if it can't coordinate those muscles, then it's probably not going to do the best coordinating other muscles. And it's why a lot of people who we treat their neck pain, their back pain gets better, or they finally start holding adjustments, right? So if you're trying to say like, Ooh, do I need this testing? those who do not hold adjustments they do not hold what physical therapy is trying to do massages acupuncture like I do it I mean I feel great for maybe a couple hours or a day and then it's as if nothing ever happened and it's because you're trying to treat it as if it's a muscle issue when it's not a muscle issue it's actually a neurological issue but the paradigms in those schooling it's not yet where it should be it's kind of an outdated thought process still and saying, oh, well, it's actually neurological, especially when we start looking at more of these chronic things, almost kind of the more chronic something becomes. It's like, you know, the greater likelihood that your pain is neurological, the greater the likelihood that your muscle tightness is neurological. It just keeps going up. because that's not, you know, if it was truly the muscle, you should see something there, that there should be other findings. And that's why people, they're just not keeping the results in the way they should. Let me give you an example. I love talking about pain. Pain is something I'm very passionate about. But one of the first things I do when I look at a patient who's in pain and got to ten other doctors is I look at their brain function and I say, how good is their brain at inhibiting pain? There's ways to figure that out. The end organ, the joint, the muscle, the tendon, the ligament can be healed. That injury happened ten years ago, and they're still in chronic pain now. I'm looking at brain. Can it inhibit that response? Why does the brain think it's appropriate to feel pain when there's no more nociception? Right? The best way I can illustrate that is somebody somewhere has pain on a limb that's not even there. You know, a veteran that maybe doesn't have a limb there and they still feel pain there, but the limb's not there. So obviously your brain's involved in the perception of pain. So that right there illustrates you that we have to look at the brain, even in what people think are biomechanical things such as pain. The brain always matters. Yeah. And I, you know, something I want to bring up really quick is You're probably realizing right now we're talking about stuff that's probably very foreign to you and it's new. And we're talking about dealing with the brain, but also body-based issues through a brain-based approach. Most of you have even started doing natural medicine, functional medicine, supplements, and you're used to trying to fix neurological issues by... hoping the brain improves as other parts of the body improve, which works for some things, but then others, it just does not do so well on. And you're just trying to figure out what you're missing. And that's why we're doing this to really talk about these other things. And so, you know, Dr. Z, let's give them another example. you mentioned posturography or computerized dynamic posturography a few minutes ago you asked me then I took us on a detour so my apologies for that but hopefully it was still still fruitful for those listening um and let's make that mechanical right so let's say you have somebody severe back pain it's ten years they've gone to ten doctors those are usually the people I end up working with or consult with the doctors who treat those patients my job is to make clinicians better why would that person why does that person belong on a balanced platform well first of all what is that it's a machine right and you stand on it and what it does is it measures how good are your balance so again not some people who feel dizziness they belong in this platform in my world people who are in pain also belong on this platform and in fact if your patient has a brain I believe they belong in this platform only takes a few minutes to test it it'll tell you if there's a problem but let's go bring it back to pain let's make this really real Let's say you're on this platform and the doctor looks at the report and it says, hey, this person has a interior center of pressure. So why would they be leaning forward? OK, well, maybe the patient's brain and their visual and vestibular system perceives that they're falling backwards. If you think you're falling backwards, what do you do, Dr. Z? You lean forward, right? Right. Exactly. Exactly. Perfect. I love that analogy. So there you go. All right. Now, I could do things to this person's body. I could poke their muscles. I could do pin and stretch. I could do adjustments, manual therapies, soft tissue techniques, all these things to try to get this different tone in their biomechanics because they're leaning forward. So if I'm leaning forward because I think I'm falling backwards, that means that my anterior muscles are going to be shortened. My posterior muscles are going to be lengthened. Okay, you guys following that at home? Now, I could do things to the soma, the body, and try to make some changes. But the problem is that it could be coming from your brain. It could be coming from the hardware of your vestibular system or the software of your brain, which is causing this anterior center of pressure. If I don't fix this, what's going on here, I may never, and I probably won't get the outcome that I have for the severe back pain for ten years. That's why even something like computerized dynamic posturography or balance platform is so important. In my world, because I see the patients that are seeing people after they've seen so many other doctors, I got to tell you, it's a little bit of advantage because I know and I ask the patients, what have they done with those doctors? And have they looked at them through these models that I'm going to look at them through? Are they going to look at them with the technology that I'm going to look at them with? Does that make sense? And that's why it's so crucial. But you want to have that objective data. You don't want it to be subjective. Now, I could look at a patient and look at their posture and give myself some objective data and say, oh, I see a forward head posture. They're leaning forward. But then the question becomes is why do they have that? So then I want to start looking at other elements of my exam and say, hey, they're leaning forward. Is it biomechanical end organ cause or is it brain based? So that's why a good clinician can look at all these components of an exam and start mapping as to what could be causing things. And then the clinician makes the decision, again, about getting the biggest positive change with the least amount of risk and the least amount of time. And sometimes we're going to be doing brain exercises to get you to realize that you're not falling forward. So you don't have to lean forward. I was not falling backwards. Sorry. So you don't have to lean forward. So suddenly. start picking your posture up like this and suddenly your tone changes in your body and that back pain suddenly starts going away and you've been to ten other doctors and nobody could figure it out because they forgot about this super important organ up here which controls everything and that's so that's why I include balance platforms and and consult a lot of clinicians on how to leverage that type of technology so important also I gotta tell you that to me the balance platform ability to be upright in space is one of the most it's like the best overall grade so I could put somebody on a balanced platform and very quickly find that get an overall general scorecard of how good their nervous system is doing so right off the bat it's just so many pluses for why postureography would be is to me is paramount and dr z do you do it you do it right yep I bring everyone through neurological testing um know because they've already done everything else you know and I don't know if I would bring everyone through the same depth if I was the first provider for everything but I there's there's needs to be a better cut off on things right like I'm not opposed if you want to try chiropractic or pt but I'm also anti the six months to a year guy right like like no offense If you're not fixing something at that point in time, you need to stop. You're completely missing the boat, right? Like maybe you've got back pain. They work on your psoas and you start getting progressive results over a month and you feel great. Cool. No issues there. But when you go back and they're like, man, it just keeps getting tight again. I need you to understand that you're in the wrong place. It doesn't mean maybe that can't be a good addition. It just means on its own, you're never going to get to where you want. And one of the reasons we have this podcast is to bring awareness to other things out there because my average patient, a lot of them, they've been burned by chiropractors and physical therapists who should have told them a long time ago, we're not getting the results. You need to be somewhere else. Once again, I'm not opposed to a few weeks or a month, but there's just this overkill where it's just like, look, man, they're never going to get better with that approach as a standalone. stop doing it. Right. You, you've got to understand this and, and they don't. Um, and then, you know, I've got some of these pet peeves, so I do need to get some of these out. You are going to know, I want to hear it. You are hearing more about these people who are like, Oh, where we are neurologically focused chiropractors. Most of them couldn't tell you to one thing about the nervous system. You're just like, Oh, where the cranial nerves at? I'm like, I don't know. What they mean is they believe if they adjust certain parts of the spine, you are going to get your life back, and they're considering that nervous system-based. Or they're saying, oh, we're using a sensor that we put along your spine. No, that is not neurologically focused. That's a marketing term. That's all it is. Same thing with the upper cervical people. Drive me nuts. It doesn't mean they don't help people. But it does mean when most of the population has some sort of findings on their cervical spine x-ray, there is zero correlation. And there's a time where you say it's worth treating. And there's a time where you need to say, look, honestly, you should have been getting better by now. You should have been getting improvements and building. I don't need to have you do a year-long treatment plan because your x-ray says this. We've got to move beyond that because it's hurting. a lot of different things, but it's hurting the profession. And honestly, the profession doesn't do itself any help, which I don't even care about that anymore, but it's hurting patients. Cause the longer you keep patients that aren't getting better, the less likely they try something that could actually help. Agreed. Agreed. So we talked about, we talked about posturography about the NG. We talked about the need for, um, the need for technology in healthcare. Can I tell you some other things that I think are really important? And I think you're gonna be coming very, very much more mainstream. Can I share a few more? Yeah, so what's coming out? What are other things there? The two things that I think are gonna be becoming very, very mainstream in the near future are going to be rotating chair and then the inclusion of AI. So let's talk about rotating chair stuff first. So you may have seen some patients or things on the internet where the people get, and it looks like a carnival ride or some sort of like NASA training module, where they get in there and they get moved around and spun around. You go, well, why the heck would I want to do that? Well, we start off this podcast talking about the vestibular system, right? And for me, for anybody to measure the vestibular system, at some point, you need to move this person. And the problem is that I shouldn't have to pick up a human body and move it around or I shouldn't have to grab a head and move it around because I am not perfect. Right. So I could have a computer do it and I could have a chair that somebody could sit in. They get strapped in and I could move them around very specifically. So I do consulting for a company called Spryson. Spryson has been making custom made chairs, rotating chairs for the last thirty years. for research, the government. I mean, they make BNG goggles that are up on the space station right now. So they're making the best of the best of the best. I'm doing a lot of consulting with them and they're making some very exciting things. So for example, their motor has an incredible amount of data points in one revolution. So I can spin somebody, move somebody very, very specifically. And then I could look at how their nervous system responds. Because there's one thing is if I'm looking at the vestibular system, I could look at components of it, but eventually to get the biggest window into the vestibular system, guess what I need to do? I need to move them. Now, the way Sprycen does it, for example, is they would do, remember we're talking about VNG and looking at eye movements before? They have a VNG that fits in the chair. So to me, spinning somebody around in a chair or moving them around in a chair, but not measuring or looking at their eye movements at the same time What are we doing? This is not rookie time anymore. You have to capture that data. And I'll tell you, here, we're talking about pet peeves, Dr. Z. To do virtual reality rehab, but not be assessing eye movements at a high Hertz rate to me is also crazy. Like we have to be looking at this information all the time. So when I do rotation chair work, I have a VNG on the patients and I'm looking at what's going on very, very precisely. That's the way it should be done. So rotating chair technology is going to be incredible because not only can I put a VNG on somebody, a video nystagmography unit on somebody, move them around in different ways and find out how their nervous system is responding, that's on the assessment side of things. Then I could do things rehabilitatively. So I could put somebody in a, for example, Spryson's chair, it's called the Neuroautologic Testing Center. They have a model called the ProPlus. I could put somebody in A reclined position, put the goggles on them and spin them for precisely the left anterior canal and measure all their eye movements. Nobody else in the world is doing exactly that. Nobody, just period, full stop. This is the level of precision that technology is now getting to. And I'm just, I feel very blessed because I had to consult with these companies and help them build and create these incredibly powerful diagnostic and treatment tools. So I could put somebody in the chair, pre-position them, put the goggles on them, stimulate their left anterior canal, find out the reflexes that are happening in their eyes, find out if it's all working well. And if there's something going on there that's not working well, guess what I can do? right there on the spot I could rehab that canal and measure the eye movements as I'm rehabbing it so I can go from assessment to treatment in the chair to reassessment and that can be done in about seven minutes and then give them objective data in regards to how well we just did for that patient that six years ago sounds like you know twenty fifty look it sounds so you so much in the future and we're here right now that's what's happening That should be incredibly exciting to any patients listening out there because now you know that doctors who have access to this technology and the training to know how to leverage it can really figure out exactly where your problem is in your brain, in your vestibular system, in your visual system. and very precisely do therapies, whether they do them in goggles or they do them in a rotating chair or together. Because imagine this, and this is what Sprycen is doing, which is very exciting to me. They're able to change the visual input so they control what you're seeing. They could change what the patient's seeing relative to the movement, which then means that I could change the software in addition to the hardware. Now, I know if you're a patient listening to this, that's a little bit of a leap because you have to really understand the intricacies of your neurophysiology. But if there happens to be a clinician listening to this, they're probably stopping right now in their car going, oh, my goodness, this is possible? Because, again, I've got to tell you, ten years ago, This would have sounded like the future, like, oh, man, maybe in a hundred years. That's happening right now. This is very, very cool, very, very powerful. And there's research happening with this technology making powerful changes in people right now. So rotating chair technology, I think, is going to become super, super mainstream. The prices are all coming down. The integration of other technologies like BNGs and eye tracking happening in rotating chair makes it makes it a scenario. It's not one plus one equals two. It makes this scenario. It's one plus one suddenly equals a thousand for these patients because it's on top of it. Remember, it's a perfect data acquisition machine. I mean, what am I going to do before? And this was me. Fifteen years ago, you know what I was doing, Doc? I'm sitting somebody in a chair and I'm spinning them around and I'm looking with my eyes trying to see what I could glean from it. That's how I started. We don't have to do that anymore. I mean, how many things did I miss years ago because I'm counting on my eyes and my nervous system perceive something that my nervous system isn't even sensitive enough to pick up? Isn't that wild? Yeah. Yeah, but, you know, and we're also not saying that some of this stuff doesn't work because it did work, right? Like putting people in even office chairs and spinning them definitely helps when you do it right. It may help. Correct. Right. When you do it right. It's not just, oh, spin them for the sake of spinning them. Exactly. But in our arena, it's always about how do we do something better? How do we help a case that we couldn't help? Or how do we help someone faster, right? Maybe someone in the past would have taken us longer. And now because of the advances in technology, we're helping them faster. And as a result, you know, cost of care ends up coming down. You know, there's a lot of things on that side. And then as we're talking about these, I did want to bring up the fact that, look, if you bring this stuff up to your provider, they're not going to have a clue. of what you're talking about in general. I don't care, like your neurologist is really going to be clueless. I know you'd like to think they know when we talk about concussions and POTS dysautonomia, they're really going to be clueless on most of this. ENTs will have a little bit on some of this, audiologists are gonna have a little bit, primary care, is going to be pretty clueless. And so don't think because you bring up something to them that because they don't know, doesn't mean it doesn't exist and actually can't work. It means it's new. Like we both been treating concussions before they said you could treat concussions. They're like, Oh, you guys are nuts. What are you trying to do? Um, so these are things of the future that, to get to a better spot because like you said it is still currently being researched right it's being researched and and we know if you wait for things to be universally accepted if it ever is you know you probably got a twenty year wait right like twenty year wait from the time the research gets published And, and it's history already is essentially what you're saying. It's history. But if you need help now, you need the, you need the cutting edge clinician. So the cutting edge clinician, all the things that I've, we've been talking about, they're like, they're either like, Oh yeah, I'm getting. that soon or I have that in my practice now. That's how I look at my patients. This is a technology that I leverage to help my patients. Because if you wait for it to become mainstream, that is historical already. And that probably means you're already many years behind. And somewhere there's a clinician who's even still more cutting edge. That makes that modern clinician, because everything's now accepted, look old too. So this is why it's exciting to me to always, I'm very blessed. I get to hang out with very brilliant people like yourself, Dr. Z, who are just cutting edge, doing the latest and greatest to really help patients. And that's, I love that because I get surrounded by what are traditionally very good people because they care about patient care, right? That's why anybody becomes a doctor. Anybody who's studied thousands of hours of education as you have, you want to help people. And that's why you stay on top of all this technology too. Yep. Yeah. I mean, and really just thinking about it, the delays are only going to get worse because things are progressing faster than they ever were. So what would have taken twenty years for technology may only be a five year gap because of how much AI is doing. And if you're waiting for insurance, which is historically always way behind to make changes. Right. If everything keeps moving at the same speed and technology advances at the speed it's currently advancing. It's going to be like, you know, by the time it's like, oh, it's approved. It's like, yeah, man, we're a third generation now. That was Gen One. Like, we are so far beyond that. And I mean, you know, with this being new, you know, because most people, they've never heard about these rotational chairs. Maybe they've seen something with some sort of rotational chair. I mean, how many of these are actually out there? I know a couple of different companies making a couple of different ones and with more coming from different vendors. I consult for a company called Sprycin and I'm contributing to what I feel is going to be the best platform of this type in the world, just period. And they are so far ahead in regards to their VNG technology and the rotation technology and the integration of those that is the be-all, end-all. They recently, they have a you know, and you mentioned AI, I want to talk about AI too, because I think this can be very important for patients to understand. And also clinicians, if we have clinicians listening, but they have this neuro AI platform that involves the goggles, the BNG and, uh, You know, it's funny how many they sold of these just in a few months because the forward thinking clinician, the clinician wants to be the best of the best, looks at this and says, that's what I'm going to do. They recognize immediately how far in front of everybody else this is. But that's neither here nor there. Can I talk about AI, Dr. Z? You mentioned it and you literally, an idea went off in my head. You know, let's talk about AI really quick, because I mean, we know it's speeding up research, you know, so much data on that. But yeah, I mean, how is AI going to change patient care? All right. So let's it's come from two sides. I recently had an experience where on the patient side of things, I wasn't my patient. Right. Because it's actually ended up cancer. Right. From the patient side of things, the family was able to figure out this tough diagnosis before the doctors did by them feeding the AI all the information. They fed it the reports, the imaging. They were able to find out. And they were able to guide the doctors to the right diagnosis. Not only that, but when it came to, hey, what is my next three months going to look like when I'm doing this diagnosis? treatment, the AI even told them that. So the reason I share this with you is I want you to understand that patients are gonna be able to leverage AI to not only help themselves a little bit more, and I don't want this to become a WebMD thing where you suddenly have So let's see, that was the problem with the WebMD, right? It was dumb system. It was you trying to find out what you had and you're speculating. Well, AI does a little less speculation, but it's not perfect. So you have to realize it is not perfect. You still need a good clinician to confirm things, but it is very, very helpful. So clinicians, so patients are gonna be able to help themselves, find out what's going on, find out what the experience is gonna be like, and be responsible for part of their own healthcare, be their own advocate by leveraging artificial intelligence. It also goes on the other side, Doc. Clinicians are also going to be able to leverage AI. So let me tell you one of the projects I'm contributing to with Sprycen. We are creating and we're doing two versions of this right now. We're creating clinical decision making support. So when you have somebody and you're looking at their VNG data, you're looking at the rotation share data, you're looking at their VNG and rotation share integrated data. It'll literally tell you what you need to look at next and give you, we'll call them bumpers, in regards to what you should be looking at next and what areas you should pay attention to. And we call that clinical decision-making support. This platform, all this data is going into the cloud. And once we have enough data there, they're going to turn on the AI. And then they're going to be able to look at you and say, all right, here's Dr. Z. He's had a concussion. He's this age. This is your symptoms. This is her subjective, perfect condition. acquisition data and the system using AI, we would say comparing you to thousands and thousands of data points, be able to say, this is the probable diagnosis. This is the probable correct approach for rehab, for this care, even to the point of saying, this is how long it should take. and so on. So AI is going to be able to help patients help themselves and become their own advocates. And doctors are going to be able to leverage AI. And Sprycen, again, is doing a masterful job of creating these systems and platforms to help doctors so that AI will even guide them and say, hey, you just did this test. What does it mean? What do I need to look at next? The system will tell you. Hey, I did this rehab. Am I doing the right thing? The system will tell you. We'd be foolish not to leverage this technology. It is accelerating so quickly. And it's wild to me because what I thought ten years was going to take a hundred years, fifty years, I'll never see it in my lifetime. Now I'm kind of thinking, I'm going to see this in three years. I'm going to see this in two years. This is happening now. I feel very blessed that I can contribute to the creation of such systems that I think they're going to change the lives of millions and millions of people. We're in conversations with countries that want to bring this technology in to help their citizens. How countries realize that this is the direction they need to move in. Do you know what I'm saying? They want to take care of their own population, right? You have an aging population. You don't think you want to be really, really good at Alzheimer's, mild cognitive decline, Parkinson's, all that stuff. Fall prevention, a hundred percent doc, a hundred percent. This is, I mean, so check this out. You could have a world where a patient comes in, they, they get a, they put on the DX, two hundred goggles from Sprycen, right? They get their brain scanned. They stand on a balanced platform for two, three minutes. Then they, then they get in the chair, put on other goggles, they get moved around and they look at their eyes and boom, I could tell you more about your brain and your body without you even having to tell me just with that data. And I could probably tell you the three or four areas that I would focus on to get you maximal changes in your body. That's what's coming. Not only that, it's getting to the point where that platform, and again, I don't want to let the cat out of the bag, but we're doing it now. Diagnosing. objectively diagnosing things with the data that the systems are giving us. This is all being researched out and being vetted and proven. It's going to be incredible. Doctors with the right technology are going to be able to be perfect data acquisition machines. Healthcare is going to change for patients. It's going to be incredible. It's going to be beautiful. It should be exciting because what took this long to get a diagnosis, the care is going to become this long. It's going to be great. I'm grateful because I get to one, contribute to it and to see it in my lifetime. AI. It's incredible. Yep. I mean, just the amount of data that's being crunched. I mean, the things that we find out in research papers, it's, you know, and it's important whenever you're talking about that, you know, the patient who's able to, the family that was able to figure out stuff, AI is only as good as the data it is given. That is super important. So if, if the, wrong technology is being used, the wrong information is being gathered, then AI, it's pretty worthless. Um, you know, and that's where people may be worried like, oh, but you know, the clinician, it's like, look, it's, it's always going to be both. Um, a AI is only going to make a great clinician even better. Now that's what it's going to do. Um, It's going to elevate the game and the outcomes for those that know how to fully leverage it. It's exciting times, my man. It's exciting times. I know we've covered a lot, all things vestibular. We've talked about vestibular rehab, talked about where it began, evolution, technology, what people are doing now, and then technology in the future. Is there anything else that... People should know that's coming down the pipe or what they should be looking for. You know, I think, and I'll keep this to the patients because I spend most of my time with clinicians because that's who I work with the most. My passion is making clinicians better, right? I want to serve as many patients as possible by creating amazing clinicians. But to the patient out there, If you've been searching for a solution and you're not getting the outcomes you want, I want you to pause for a second and the clinician you're going to and go, you know, do they have a real, truly modern model for looking at my problem? Are they leveraging truly modern solutions for getting data about me? And if, because if they're not doing that, then maybe that's why you still have this problem. And maybe you need a little stop, pause, and look for that cutting edge clinician who has this technology to get you the outcome you're looking for. That should give you hope. And it is a hopeful statement because I know incredible clinicians out there getting incredible results. You just need to search them out, you know? there's help out there. Okay. All right, Dr. Garcia, thank you for being on the show. Now, if people want to learn more about, you know, work you're doing at Sprycin, where should they go? If you, yeah, if you want to, Uh, well, spryson.com is, uh, who I'm doing consulting for. I'm doing, I'm director of clinical success. So it's a, it's a great, it's great where I get to contribute to the technology and I get to contribute to the clinicians while everyone uses this technology. It's what I've been made for. Cause I've been for the last, um, Close to twenty years of my life, I've been in the clinical neuroscience education space. That's what I've been into. So if you want to learn more about Sprycin and the technology I'm contributing to there, go to sprycin.com. That's S-P-R-Y-S-O-N dot com. Again, I'm director of clinical success there. But if you want to follow me on social media, I'm on all the normal channels on Instagram and Facebook and even X or Twitter dot com. You can find me at Freddy's XG. That's my first name. F-R-E-D-D-Y-S-X-G. is my handle and I'm glad to connect with everybody whether you're a patient or clinician feel free to say hi and if there's any way I could help you ask a question if I can help you I certainly will okay thank you thank you