Episode Transcript
Welcome to Not Another TV Lawyer. I'm Chris Shakib. I'm Jessica Hall. And this is a podcast sponsored by the law firm, Terrell Hogan, that's been in Jacksonville for greater than 50 years. And we are very passionate about helping people and personalizing our service. to help them get the service they deserve.
Once again, I'm Chris Shakib, and this is Jessica Hall, and we're here on another episode of the podcast, Not Another TV Lawyer. And with us is Dr. Mike Sandborn. And, uh, we appreciate you coming. Dr. Sandborn is a medical doctor in Jacksonville or the Northeast Florida area. And can you tell us what is the name of your practice?
Sure. And thank you for having me, by the way. It's a Spine, Brain and Joint Institute. Okay. And what are the Spine, brain and joint. Obviously the, you concentrate on spine, brain and joint. But what, uh, what does your practice concentrate on? Um, honestly, so myself and my partner, Dr. Lupi, we're both, uh, trained in physiatry, physical medicine rehabilitation with a focus on pain management and specifically interventional pain management.
So part of our practice, is focused on the pain management side. And that's the spine and the brain, I'm sorry, the spine and the joint side. So we do, um, we see a lot of, uh, people that have sustained injuries to their, to their neck, to their mid to low back. Um, we see a lot of joint injuries, shoulders, hips, knees, that, uh, while we, we do, um, we kind of think of ourselves as the, the captain of the, of the team.
And we, and then we utilize, we kind of develop a treatment program. for these patients. And that treatment may include therapy. Sometimes the patients come to us from, uh, the therapist, physical therapy, chiropractor. That may include medication, which often we'll prescribe. Um, and we try and stay away from opiates and things like that.
Um, and then certainly the interventional side of, uh, of what we do is, is a predominant, that's the, the major part of our practice. And that involves doing procedures to help relieve pain, uh, so they can, Hopefully get back to a, uh, you know, uh, semblance of their, of their life prior to the pain. Where does the brain part come in?
So the brain is the other side and I guess you could include that as, as, as part of pain. Some people would include that. Um, But, uh, so myself and my partner, um, also we, we actually both trained at Emory University, um, in physical medicine rehabilitation. A large part of our, residency program was focused on traumatic brain injury.
And so he and I both spent several months at the Shepherd Center, which is one of the preeminent, , hospitals treating, , injuries for the central nervous system, which include both spinal cord and brain injuries. And we also did, , spent several months at the Center for Rehabilitation Medicine, which is part of Emory University.
just focusing on, traumatic brain injury. At that time, we were, doing mostly, it was mostly severe head trauma. Um,, so we had a lot of experience with that. The clinical part of my practice since, Since finishing residency, which has now been 25 years, it goes by fast, doesn't it? It goes by very fast.
Um, I've, I've seen, brain injury from all, uh, I've seen, uh, as an inpatient, uh, rehab physician. I've taken care of, uh, patients with severe brain injury. head trauma after the acute stage. Um, I'm also an internist, um, and I worked as an internist in the hospital, working in, , primarily, um, I mean, it's all acute inpatient medicine that would involve some critical care as well.
And so I, uh, was involved in the medicine part of these, uh, traumatic brain injuries, severe traumatic brain injuries. Um, and then since I've been here in Florida. which has been since 2011. I have seen the majority of my practice, which is what we're getting to, has been focused on mild traumatic brain injury, which is a large, we see a number of patients with these mild TBIs, another name for concussion, So concussions are a big thing that people talk about now.
I know when I was a kid playing tackle football, we didn't really, we didn't do much. I absolutely, I would wear a helmet that was called a water helmet. That it was cushioned, but it was like a sponge with water in it. So it was extra heavy. Wow. And there's no way they would, that would be legal nowadays, but I liked it because I would put it in the, in the refrigerator before practice and it would keep my head cooled in practice.
But it was. You know, it was so heavy that had to have been dangerous to have been that heavy, right? But, you know, we're folks are paying attention to these things now. In fact, we're seeing, uh, football players in the NFL wearing those special caps now that protect them and they're right. They have new helmets.
Um, uh, it. And that is, that's thanks to the CDC and there's been a lot of attention on concussion, especially, um, you know, with this chronic traumatic encephalopathy, CTE, and which was brought out from football players, the Junior Seau and others, and then they had a movie, , which was focused on somebody with CTE.
So that brought it into the mainstream, which is very good Absolutely. I mean football, um, if you compare what flag, I've read this a while back, but comparing flag football to tackle football for, for kids, their, um, uh, traumatic impacts to the head 23 times greater for tackle football.
Um, and that's, that's current. So it's a, it's pretty significant. Um, and, and certainly the more attention that is, uh, that's paid to it, the better we are at, at prevention. You mentioned the CDC, so when we get auto cases in, I have a checklist that's from the CDC that says if you have headaches, if you have light sensitivity, if you, and I go through those, I go through this checklist with our clients, and if they answer, if I'm getting more yes's than I'm getting no's, I'm like, hey, you know what?
Right. I think you might need to get seen for this. Like, um, it's a good way of doing it. Yeah. Because the, you know, do you have light sensitivity? Do you have frequent headaches, noise, and you know, things like that. I go through the list and I'm steadily checking off what they're telling me on the list and then when you get done.
The whole list is almost checked off and I'm like, well, we got to get this person somewhere. So that's smart because, um, honestly, a lot of these mild TBIs concussions are missed. Um, a lot of times patients that have sustained these just kind of, uh, explain away symptoms. They just, I've got a headache. I'm a little busy.
I'm not thinking it's anything. Maybe, maybe a little more irritable. They don't even notice it, but it's their, their partner that notices it. it's the, you, you have to, so when we see patients, we see, you know, patients, uh, after accidents or they're referred to us and we go through a checklist as well. We ask them those questions to try and identify patients that have had a TBI that may not, they may not even be aware of it.
Right. And it, and, and the key there is it's, it's essential to identify them so you can begin. The proper treatment plan. Yeah, early treatment. So, we, we know that this is something that people are paying attention to now and taking more seriously. I, I, I definitely, you know, I've been handling injury cases exclusively since 1996.
And even in 1996, I don't, we didn't really. It wasn't something we looked for as much, and we, we called it closed head injury, and it was, uh, I don't know, it was a little different. Now, now it's something that we look for, and you hear about it being talked about. But what I don't always hear talked about is, what are the, what do you, how do you treat someone with a traumatic brain injury, particularly, you know, a mild traumatic brain injury?
Sure. Yeah. And funny thing in 1991, 1997, I gave a grand rounds. So this is goodness. Uh, 20, 27 years ago, um, on traumatic brain injury on mild traumatic brain injury. And so there's a lot more that we can do now. compared to 1997. Although there was a lot of literature back then, even on, but it wasn't in the forefront.
And, and, you know, people are like, why are you doing a grand rounds on, you know, and it was, I was, it was geared more towards, sports related, concussions. Um, but it was a great grand rounds and, and, uh, but they're, they've come a long way. So with, again, with, uh, with, so these concussions with mild TBI, um, There's a, uh, everyone's experiences is kind of unique, right?
But there's some basic elements that we tend to see. Headaches, often a part of it. And those headaches could be more migraines type headaches, post traumatic migraines. Dizziness can be part of it. I would say more than half my patients that have had a mild TBI have some component of dizziness. There may be some mood changes, some irritability, some depression.
Um, certainly cognitive complaints. And that can be things just from mental fatigue. They're tired. They're not motivated. They're just, uh, feeling like they need to lay down and sleep. Um, it could be, uh, problems focusing attention, uh, problem solving. Um, it can be short term memory. Um, things that you don't even You use all those things every single day and common complaints that I get from just to from my my patients um, just day to day things not even just the multitasking that we do at work and problem solving that we do at work, but somebody just doing some shopping going to a grocery store and now They don't they have to go and they have to actually have a list with them or they're planning meals um, like we we we use our memory You Uh, which is our short term memory, like it's a, it's a working memory where you are storing things and kind of using, um, uh, things that you see or things that you think about, and you're kind of problem solving in your head, right?
And you're coming up with a solution. So you store things briefly to, to, to work that out. That part of it is often affected with these mild TBIs. So people have a difficult time if they have the cognitive part of it, uh, uh, uh, uh, um, they have a hard time with problem solving. So the first thing we do when we see patients with mild brain injuries is we identify the problems that they're having, right?
And so the And I have to say the first part of the best treatment is prevention So if we're talking about car accidents, the number one thing you do is you got to wear a seat belt, right? You don't want to drink and drive drinking no seat belt and speed going fast Are the number one things for automobile tbis and deaths so you avoid those things you've at least given yourself , you know a a chance Airbags certainly, uh, are important and have reduced the, uh, the number of, uh, brain injuries.
But when we, so when we see these, the first thing we can do is just implement some lifestyle changes. So, you know, back in 1997, it was rest. I mean, significant rest. Um, now it is, it's, we kind of think of it as relative rest. So, meaning you want to relax, rest the brain, rest the body. That could be for a day, that could be for two days.
It all is, again, each person's, you know. experience is unique, their injuries are unique, and I base it on what they're, what they're feeling. , in today's age, we have, computers, phones, tablets, big TVs, all of these things. There's a lot of sensory overload. We've got to shut that down for a period of time.
And, Let the brain relax because with a brain injury, the problem is that with these mild TB eyes, there's a biochemical process that's happening. That's the injury part of it. The brain is in an energy. deficient mode. And so the more you use in your brain, the more energy you require.
So we have to rest it. , so that's the first thing we do with the lifestyle changes. I imagine with younger patients, that's hard to get. Absolutely. So we bring in their peers. Their parents. And we talk about how important that is because it 100%. Um, that is the truth I have, uh, especially games.
So gaming, um, you know, I've seen a lot of teenagers that have sustained, uh, you know, mild TBIs and, um, especially, uh, you know, uh, young 15 year old that in their, their, their gaming every day, they're on their, that is, that's a pretty significant sensory stimulation that as they're recovering, um, now as you go on in a, in a TBI, it actually could be form of therapy, but in the initial period, we want them to kind of, uh, you know, take a break from that.
Right. Well, I'm a gamer myself. And so I, I can understand that because I, I play them to, you know, Wine down so that because I don't have to think and it's just mindless and I can do that So I I could understand from your perspective and from like a patient's perspective especially When their brains are not fully developed at that time anyway, right.
And now the brain is like, we must do all the things we've got to do all the things. And there's a lot of, uh, you're, you're a hundred percent. And in those, those games, like things like call of duty. And I mean, it's, it's significant. I mean, there's. visual and audio and then you're problem solving and and so it's uh, it's I'm not a gamer But um, I I know uh my son my son is my son was and so I've watched it and I know that the brain is involved in a lot of that so much of that.
Absolutely Yeah, so we'd like him to just take a break and I certainly would would uh, I talk to the parents as well When we're doing that, what about music? So again, um, I think that um, some sort of uh You certain, certain music. Um, there's, there's a lot of genres. Uh, yeah. Right. Um, uh, initially I would say again, if we're seeing them right after everyone is unique, but if they're like, you know, uh, I need to listen to some soft, you know, relatively calming music.
Um, yeah, whatever it is, new age, uh, meditative, uh, type music. That's okay. Right. But you know, Hardcore, you know, rap, metal, whatever. I think, uh, anything that's going to, again, stimulate those excitatory pathways in the brain that we want to kind of relax because that is going on. I mean, they've, they've, they've measured all that and they know that there's a lot of, there's already a lot of excitation in the brain and that we need to kind of quiet down in them talking about the very initial period.
Okay. So, we got a patient who's had a mild traumatic brain injury, they're in the first level of care, which is resting, resting the brain. Uh, what, what's the next step? Sure. And so part of resting the brain is also if they're, say they're avid fitness, I take, they take a break out of the gym as well. Now that would be the hard part for me.
Yeah. Because I think I do, I do stuff. just about every day. Yep. So I feel like I haven't brushed my teeth if I don't. Yeah. So initially, I mean, we just kind of, I mean, again, everyone's unique, so it may not be that you need to, you know, just limit yourself to household mobility and walks. If you feel like you can do more, you do more.
And then we do it. We basic, basically would do a symptom limited activity, but if your symptoms worsen, then you need to take a break. So you kind of get to know yourself. Um, I would say that, um, you know, the, uh, so the initial period outside of that, we're also making, uh, recommendations to avoid. And so again, good defense is good offense for a football analogy, right?
So, um, to move forward and progress and get better, we have to avoid certain things. So toxins, alcohol, you know, we want to avoid that when we're right after a, uh, a mild TBI concussion, avoid drinking. Some, uh, you know, marijuana is a big one right now. Some people are in favor of it after a concussion. I truly think that, you know, it's, it's probably not a good thing as you're recovering from a, from a brain injury.
certain medications, even if there, um, would be things to avoid. And that, that even comes into play with us. We're treating pain at the same time. We want to avoid medicines that could impair and get in the way of the brain, uh, healing. We may actually add some supplements that could facilitate healing, uh, things like Omega 3, fish oil, um, choline is another one that can be, uh, that beneficial.
Creatine even is a fuel that the brain can use. Um, and there's, these are all anecdotal things. No, you know, double blind placebo controlled. studies, but things that, uh, case studies, um, and I think they've been shown to be beneficial. I do make recommendations for some of those supplements. And those, this is all, again, this is the initial, initial period.
Once they are, um, and then, I don't let them go out and, uh, you know, uh, okay, I'll see you in six weeks. These are patients that I'm going to bring back frequently. I may even see them the following week just to see how they're doing, especially if they're not in school, they're taking a break from school.
They're taking a break from work. I want to see them. So I get them back into their life. Cause we also know that, you know, getting somebody back into life is good for mental health and actually good for recovery as well. So we, we, again, I've said this a few times, each person's unique. I like to see them frequently to make those adjustments and make sure they're on the right treatment plans.
Yeah. Yeah. And then, and then we start getting into, you know, uh, headaches, right? So, if somebody has a headache, it's a common one that requires treatment. And, um, seeing somebody who understands headaches., I think is important because that could be a post traumatic migraine, post concussive headache, that we would treat much like a migraine where we're using migraine type medications both, for prevention as well as something we call preventive therapy as well as abortive therapy.
Um, it could even be, there could be a cervicogenic component, meaning that the, they've had an injury to their, to their neck and that's contributing to the headache. So we. in the initial periods, we're, we're figuring that out. And then we're going to possibly start medication, possibly, uh, therapy, possible injections for those things.
Dizziness is another common complaint, right? Would require further evaluation and that evaluation would then lead to treatment. Um, mood disorders, depression. Don't let them, you know, we don't want somebody to be depressed for eight weeks, 12 weeks before we start treatment. You know, we're going to start treatment that can involve medication that can involve therapy, counseling, cognitive behavioral therapy.
There's a lot that can be done for these, uh, for these conditions, right? But the worst thing you can do is nothing or go back to life the way it was. Absolutely. What about driving? So driving is one of those things again, um, independent, probably initially, uh, you know, you're going to take, take a break from, from driving.
There's a lot that goes in to driving that we just take for granted. A lot of multitasking, a lot of problem solving, a lot of visual spatial, uh, depth, all of that. Um, and, and that can be affected. with, with these mild TBIs, right? So it can affect, again, the brain it's an organ just like the heart, the kidney, the lung, but it just happens to be probably the most important, organ.
And it makes you who you are and me who I am. And, it's very complex and it allows us to move, to think, it allows us to interact. With our environment, perceive our environment, and respond to it in an intelligent way. And so, when we have a brain injury, it affects those things. Driving is our ability to take a several ton, you know, vehicle into and around other people and their cars and pedestrians that require us to have all the sensory feedback, process it quickly, and react to it.
I've had some cases with mild TBIs where they haven't driven for, you know, four weeks. Part of that could be the visual spatial, it could be, um, part of it could be anxiety, some post traumatic stress. We see that. And I've had, Where we kind of gradually get somebody back into it when there's an issue Um, not to the point of where they need to go and get driver's training But something where they're not putting themselves out on i 10 or 95.
They're driving through the neighborhood Maybe they have their their husband or their parent with them Um just to test it out And uh, and then I certainly make sure that you know, somebody that is, uh, somebody that's unsteady when they're, when they're walking or they have, you know, ongoing dizziness probably shouldn't be behind the wheel.
Right. Right. So there are things that we can assess and then make those determinations case by case. How do you, if a condition seems to linger and you know, is not improving and it may suggests there's, there's, it's more serious than a mild traumatic brain injury. What, what's the next level of care? What are the things you look for?
Well, you know, so this is a thing. So mild traumatic brain injury has, there's a specific definition for it, right? It's a, it's somebody that, so just one thing with getting back. So with the, with the definition, you know, they're like, what's 4 million. traumatic brain injuries in the U. S. alone. 80 percent of them are considered mild.
About 10 percent have loss of consciousness. That means that 90 percent do not. Right? So that's one thing that um, we know that somebody can have a brain injury without loss of consciousness. For a mild traumatic brain injury, you have this um, traumatic event, whether it's a car accident, a fall, a concussion related to sports that results in a fairly early, immediate, you know, neurological change.
There's some brain dysfunction. The definition of a mild TBI is that you have loss of consciousness less than 30 minutes. You have post traumatic amnesia, less than 24 hours, and that's your ability to recall and remember things after the event, um, and that your Glasgow coma scale, which is a very bad scale for mild TBI, but it is the scale, um, is 13 to 15.
And so that is a definition of mild TBI. Now we call it mild because it's not fatal and it's not initially catastrophic, but The problem with a mild tbi is that it's not necessarily mild. So what you're getting You're making the point. It is still a mild tbi. It could be based on a definition, but it's affecting their life severe Yeah, yeah, it has it has a personal impact if somebody's suffering from a headache Um and dizziness and they and I see it all the time, at least weekly, where I have patients like this.
It's affecting their quality life. It's affecting their, their interactions and their relationships at home. It's affecting their, can be affecting their job, which then has a societal impact when we're talking, you know, the, the financial impact of loss of work. There's so many things, um, how, how this can affect, um, Our society.
So mild. Um, if I'm hearing you right, when you say mild traumatic brain injury, that's not synonymous with saying temporary. No. So a mild traumatic brain injury can can be a chronic condition. It can. Yeah, absolutely. Most of them, most patients that have sustained mild TBI, most of them will recover quickly.
I mean, sometimes same day, some within a few days, some within a few weeks, some months, some years, some they have chronic ongoing problems. We do have, um, you know, through studies, we do know that there are certain conditions that will, they're kind of risk factors, uh, for having this prolonged recovery.
And when they have a prolonged recovery, I'm getting into looking at, I'm evaluating it in more depth that could involve imaging. Um, something, uh, like an MRI, but a specific type of MRI. Uh, so there's different things, but one, the, the one that I was getting is a diffusion tensor imaging. Oh, okay. DTI. Yeah.
DTI. Yeah. And, and the, and what that is, um, so DTI compared to traditional MRI, right? So mild TBIs in general. aren't thought to result in structural changes. It's a functional type injury. However, there are changes that are occurring at that, at the microscopic level. A traditional MRI is essentially the same as if we could just look through your skull and see your brain.
Somebody has a stroke, you could probably see it, you know, if you were looking at their brain. Somebody has a tumor, you could probably see it. Avascular malformation, you could probably see it. Somebody with a, um, mild TBI, you couldn't see it. What the DTI does is it looks deeper, and it does that by looking at the flow of water.
It looks at the diffusion of water, so that's where the diffusion part of it comes in. Water normally diffuses in one direction, so it's linear. When it, when there's an injury, and what the When you have this force that is imparted to the, to the brain, it causes the brain to move and it causes a stretching type injury to the neurons, um, to the, to the, to the axons.
which can then disrupt the messages. And they see that on a DTI with the flow of water, the flow of water no longer is linear. It will flow out perpendicular. And that's what a DTI will show you the amount that it's the ratio of how much water is flowing in a linear versus how much water is kind of leaking out from the sides.
And if you see that, what's, what's the next step? Yep. So we, I mean, we see that quite a bit, right? And we can see that. Um, so in, in all, um, I guess, stages of, uh, of a mild TBI, I have found in my practice that the more severe the findings are, With, uh, on your DTI, I often see that with more significant symptomatology in my patients, but we are going to, we're going to bring up.
Um, you know, now we're getting, we're going to, uh, be aggressive with, with therapy. That could be physical therapy, vestibular therapy, psychotherapy, cognitive therapy, um, that can, uh, involve medication. Again, I mentioned medication for headaches. We have medication that we can use for attention, focus. We have medication that, um, we can use even to facilitate memory.
Um, We will be very aggressive in treating somebody's mood disorder, uh, again, not just therapy, but medication. Um, we know that the earlier we get on that and we, the earlier we do that, the better off they are. You've mentioned vestibular therapy. What is vestibular therapy? So vestibular therapy is, is, so I have a patient, so if we have somebody that, that complaints of dizziness, right?
