Ologies with Alie Ward - Neuropathology (CONCUSSIONS) with Mary Alexis Iaccarino

Episode Date: January 5, 2022

Hi, last week I fell down a flight of stairs. Then I went to the hospital. Then I emailed Dr. Mary Alexis Iaccarino, a Harvard Medical School professor and specialist in rehabilitation from traumatic brain injuries. I asked her all about what happens during a concussion, when to be worried, how long it takes to heal, when a person should get their ass to a hospital, what a brain scan can tell us about a head injury, what it CAN’T tell us about a head injury, if you can fall asleep after a head injury, and the differences between mTBI, TBI, SRC, CTE and even ATGATT. Plus, bike helmets, Natasha Richardson, fruit fly role models and some truly infuriating statistics on who gets mTBI treatment and who doesn’t. And stay tuned later this week for a bonus episode on what happens when bighorn sheep bash their skulls together. Follow Dr. Mary Alexis Iaccarino on TwitterA donation was made to HomeBase.orgMore episode info and linksSponsors of OlogiesTranscripts & bleeped episodesBecome a patron of Ologies for as little as a buck a monthOlogiesMerch.com has hats, shirts, totes, masks… Follow @ologies on Twitter and InstagramFollow @alieward on Twitter and InstagramSound editing by Jarrett Sleeper of MindJam Media & Steven Ray MorrisTheme song by Nick ThorburnTranscripts by Emily White of The WordaryWebsite by Kelly R. Dwyer   

Oh, hey, hi, it's your brother-in-law who waves his coffee beans, but in a cool way. Allie Ward, I'm back with a foggy and groggy and super timely episode that I never knew so many of us needed. So we're knocking Noggins this week, Neuropathology, yes, I did phone up an expert on concussions. But this is a podcast, it's not an appointment with your doctor. So of course, nothing here is intended to diagnose or treat my or your head injury. So I'm just putting that up top because as a person with a very recent head trauma, I know that things can get a little soupy.

But as I learned this week, over half of folks have sustained at least one concussion in their lives. So chances are your brains are curious about this or someone you know or love has goose egg their way into concussion town. So thank you by the way to everyone who has been concerned and sent really sweet messages and looked at my pictures of me and ambulance and the ER. Thank you also of course to patrons for sending in great questions on short notice for this episode.

You too can join for as little as a buck a month, it's at patreon.com slash allergies. But for free, you can also help out the show just by telling friends and tweeting and gramming. You can leave a review, which I have read all of them, including this fresh one from an angel named angry undies who wrote that allergies is like a warm hug for your brain timely. We love you angry undies bunch. So speaking of brain embraces, neuro pathology, we're going to get into it. So it's the study of diseases of the nervous system and neuro or neuron are those long

stringy cells that relay our brain messages via chemicals and zip zaps of energy. That word neuron comes from the Greek for sinew, cord or penis. What? Yes. According to ancient Greek scholars, your brain is just a tangled clod of electric disco dicks and pathology derives from the Greek for passion. Passion gets its root from suffering. So I'm going to go into detail about my recent head trauma and why I asked for recommendations

for experts on this later in the episode, but we were really lucky that she made room in her schedule to record this two days ago, even though I was five minutes late. This all just went to medical school at Georgetown. She did her residency in physical medicine and rehabilitation at Harvard medical school and at Spalding rehabilitation hospital where she was chief resident. She also works with nonprofits to assist veterans who are suffering from mild traumatic brain injuries, is the attending physician in the Massachusetts general hospital for their children's youth concussion program.

She's on boards to help identify risks in contact sports and is an instructor in the department of physical medicine and rehabilitation at Harvard medical school. What a feast for brains. But wait, there's more. I also talked to Dr. Headbutt and in a bonus mini episode out this week, we're going to take a brief look at concussions in the animal world. So that is coming out later this week, but right now a fix your head protection and gear up for a chat about everything from brain bruises to after school rugby, falling off

horses, headaches, ADHD, sea and stars, comorbidities, video games, solitary confinement, convulsions, the best time to tumble down some stairs, post concussive syndrome, old rom-coms and more with head trauma specialist, minor traumatic brain injury researcher and concussion coach and neuropathologist Dr. Mary Alexis Icarino. My name is Mary Alexis Icarino and I go by Alexis, she, her. Didn't plan on this episode at all, at all, at all, but you fall down some stairs and then before you know it, you're like, who knows something about concussions? That's usually how people get in touch with me.

Nobody likes coming to my office. I bet. I bet. Yeah. So I'm sorry to hear that. I did, I did think, well, I'll give her an extra 10 minutes since she's recovering from a concussion. I know, you know, I haven't had my phone on me much as a clock the last like week because

I have been ordered off screens essentially, but here's the deal. Like what happened was, I'll make this quick, but I bounded down the stairs to surprise my sister-in-law. We flew in early and I was like, I'm here and absolutely ate shit on a flight of stairs, but I hit the back of my head pretty hard and I was like, oh no, I just really killed the vibe. And then I was like, I'm fine. I'm fine.

And I got up and then I passed out and apparently I started convulsing. They picked me up. I passed out again. And then at that point, all of the, yay, you're here turned into like the ambulance is on its way. Such a buzzkill. So I have never to my knowledge had a concussion before, but what is happening when you get bonked on the noggin like that?

Wow. Well, that sounds like you had a pretty significant injury, but, you know, concussions even within themselves can vary, right? So there can be these very, very mild hits to the head and then people, you know, might have a convulsion or a loss of consciousness or even, you know, amnesia for some time. But essentially a concussion is the brain shaking within the skull from some force or impact, right? And so that can be a direct blow.

Like I fell and I whacked my head or I got hit with something, but it can also be a shaking motion, like if you're in a car accident, you get whiplash and the head shakes back and forth, but it never actually hits another object. And then the other time we can see it is if somebody's around like an explosion, right? Because remember, the brain sits in fluid, right? Since it has this jello like consistency and it sits in fluid and there's space there for it to move within the skull, which is really good because if, you know, there's a little swelling or something like that, there's some room for the brain to expand a little.

But that also means that it can shake around and hit the sides of the skull. So essentially, when you talk about concussion, you're talking about some force making the brain shake inside the skull and it usually doesn't produce your classic bruising or bleeding. It actually is this more microscopic kind of injury or change. And sometimes you can get changes in some of the electrical activity in the brain, which is why you can get a shaking spell right afterwards. Oh, and so that, you know, is something that can happen. They'll tell you it's pretty rare, pretty rare, but possible.

OK, so if you're shopping for a minor traumatic brain injury, there are three flavors of concussions. It's exciting. Grade one, there's mild with symptoms like headache or dizziness or blurred vision that last less than 15 minutes. There's no passing out. Grade two, moderate. Those symptoms I mentioned lasting longer than 15 minutes, still no passing out. Then there's grade three, which is severe in which the person loses consciousness sometimes

for just a few seconds. So kind of an overachiever. And I went for grade three, but I don't fully remember it. So I fell down the stairs and I got up a minute later and then I walked to the kitchen and the next day I knew I was on the floor again apologizing. And I actually heard my sister-in-law on the phone with 911 saying that I passed out twice. And I was like, no, I didn't. But honestly, I was the worst eyewitness in the room because I was not conscious twice.

But I'm told that my limbs seized up and started shaking and my speech was slurred and my eyes rolled back. So it was scary for everyone. Was this a seizure, though? Depends on who you ask. But TBI researchers didn't want this post-concussion brain activity to be confused with seizures caused by epilepsy. So the rather musical term, concussive convulsions arose to describe those benign impact

seizures. And as the medic in the ambulance explained, it's kind of like your brain shutting down and then rebooting. Also, in the bonus episode about headbutting, we're going to go into exactly what it takes to assess impact damage to neurons. So what they're really looking for when you go to the ER is the big stuff, like visibly bleeding traumas in your head rather than the micro damage, which is probably what I got. Yeah. So it's not something we can really see if we were to take like a conventional CAT scan of your brain, right?

Where we get a picture or an MRI of your brain, where we get a picture. We usually wouldn't see anything because it's something happening closer to a cellular level. But nonetheless, it can be quite impairing and can give people a lot of symptoms. It's a tough injury that way because you want to be able to see it, right? If you break a bone, you want to look at the X, right? And see where it's broken. Yeah. But with concussion, we don't really have that nice, neat picture to show people where

injury happened. Yeah, I keep wondering, like, is there a spot on the back of my brain where I hit that is like a bruised peach? If I could look into my brain, would there be kind of some redness there? Or would it really, really be microscopic where you're like, I can't tell that there's a bunch of like busted oozing cells. Like I'm trying to get a mental picture so that I take better care of myself. So yeah, it is a hard one.

It is a hard thing to visualize. And it's hard for a lot of people, too, because it's not like we put a bandaid on your head or put your head in a cast, right? So here you are walking around and you look just fine to most people, but you don't feel fine. And so that also can make it kind of a tough injury in that way for a lot of people. And from what I understand, a concussion is something that's a clinical diagnosis, right? They can't look at a scan necessarily, but they can say, based on what you told me, sounds

like it's like you did have a concussion. Yes, you are exactly right. So it is a clinical diagnosis, meaning we hear about the injury, right? And you have some force that was substantial enough to cause trauma. And then we ask people how they looked and felt right afterwards. We can do some examination testing, like balance testing or cognitive testing, where we test things like reaction time or memory or attention. And that can show us sometimes that people are not doing well in some areas, but there

is no single diagnostic test, like a blood test or a scan that we can do to clearly diagnose concussion or to actually say that it's over. So people also want to know, when am I better? Yes. And could you get me a scan or a blood test that says this is gone? And we actually don't have that either. It's a very gray space. In every way.

In every way. Gray matter space. But let's wedge some terminology into our squishy gray matter space. Can you explain the difference between a concussion and an MTBI and a TBI? I am happy to try to explain that. But I will tell you that even among scientists, there is some debate still between the terms concussion and MTBI. Okay.

So for most of us and me included, a concussion and an MTBI, the M standing for mild, so a concussion and a mild TBI are the same thing. Not everybody out there would agree with me, but most, I think, people in this area of medicine and this space would agree. Okay. So as you can imagine, there's all kinds of terminology and things change really quickly. And looking it up, I felt like your mom in 2015 Googling BDE on Urban Dictionary.

But I have also learned that there's a ton of debate with concussions and traumatic brain injuries, like so much. There's a ton of shit we did not know. There's also a lot of money at stake, either via industries that involve occupational hazards or through making money on the recovery from them. And some doctors have moved to call athletics head injuries, SRCs, sports related concussions, instead of using the term minor traumatic brain injury. Others consider a concussion a subset of MTBI's, which are in and of themselves a

subset of more serious conditions that may include skull fractures, penetrated penetrative injuries. I'm not going to say that word right, but it means getting poked real bad with something and hematomas, which would be considered TBIs. So all of those things under the umbrella of TBIs, it's confusing, even if you haven't recently blacked out on a kitchen floor and then passed out being carried to a couch. It's been a wild week, folks.

I'm not going to say penetrative, right? Now, TBI is a broader term, right? Traumatic brain injury encompasses everything from concussion through people who have severe trauma to the brain and are in coma or have paralysis, right? So it encompasses all trauma to the brain from very mild through very severe. And so within this category of traumatic brain injury, MTBI or concussion is the most mild. And when should a person get checked out?

I feel like since the death of Natasha Richardson for what seemed like a relatively minor skiing accident. Richardson suffered a head injury Monday while taking a ski lesson in Canada. She was pronounced dead Wednesday at a hospital in New York. She died two days later. I feel like there's something really innately scary about, as my dad would say, thumping your pumpkin really hard. When is it time to go to urgent care and make sure you don't have like a giant hematoma?

And when is it just like, if you're not passing out, you're probably fine. I think it's good for most people to get checked out. Not everybody will. And there are certainly some symptoms that people get that should make them get checked out more than others. For example, if you have a shaking spell or a seizure, you absolutely need to get checked out. If you've been unconscious for any period of time, right, you definitely should

get checked out. If you have other trauma, right? Like if you got hit hard enough or you've big enough accident that you broke other stuff, you probably should get checked out. If you're somebody who's prone to bleeding, right? People, sometimes older folks who are on blood thinners, those people definitely need to get checked out. And then if you're somebody who's thinking about going back to do something where

you're going to whack your head again, you definitely should get checked out. But really, anybody who thinks they've experienced any head trauma, whether, you know, you can't say with certainty, it's just a concussion or it's something else, like in the case of Natasha Richardson. So it's very reasonable to go get checked out. Most people should feel comfortable doing that. It's not an overreaction to go and get checked out and make sure that this is really just a concussion versus something like an epidural hematoma or a skull

fracture or something else that, you know, is going to require more monitoring or potentially a surgical intervention. Okay. So now we understand that within TBIs, there are MTBIs and within MTBIs, there are concussions and then within concussions, there are SRCs or sports related concussions and I promised myself when we started this, that this episode would be easy, but researching it was actually, it felt like carving a set of Russian nesting dolls out of my own skull bones and then painting it with other people's

flame wars about concussion severities and subsets. But let's take a more objective approach. There is the industry standard medical quiz. It's called the Glasgow Coma Scale and it goes from a 15 down to a three. 15 is doing just fine, walking away from it unscathed and three is literally dead. So I guess there's two, which must be just a frustrated ghost and maybe one is a poltergeist that hides your keys and shakes its junk at you. I'm not sure, but yeah, 15 to three Glasgow Coma Scale or GCS for TBI.

Now, one term you may also hear is CTE, which is chronic traumatic encephalopathy, which arises from repeated trauma to the head. And according to last year's Second National Institute on Neurological Disorders and Stroke and the National Institute of Biomedical Imaging and Bioengineering Consensus Meeting to Define Neuropathological Criteria for the Diagnosis of Chronic Traumatic Encephalopathy. Leading researchers there associate CTE with symptoms, including aggression and depression, suicidal ideation, tendency towards substance abuse, dementia,

some motor challenges, even Parkinson's disease, cognitive challenges and financial impulsivity and more. But before any armchair quarterbacks start becoming armchair neuropathologists, it is imperative to know that CTE can only be diagnosed with an autopsy or from three to one on the Glasgow Coma Scale. So yes, you must be dead to be diagnosed, at least for now. And the film Concussion with Will Smith is a biopic of Dr. Bennett Omelou, who is a forensic pathologist who's made strides in CTE

recognition, but not all researchers agree with all of his work. Again, lots of debate in this field. And there's Boston University's Dr. Ann McKee. She's also a leading researcher in this. And her website has scans of the tau proteins, is what they're called, that appear in individuals with CTE. And she writes that CTE has been found in athletes, military veterans, victims of domestic violence and others who experienced multiple falls or injuries.

And CTE has been known to affect boxers since the 1920s. It was initially termed Punch Drunk Syndrome, she writes. But more recently, it's been found in players of American football and ice hockey, rugby, soccer, MMA, pro wrestling and other contact sports. And we'll have more on the diagnosis post-mortem in the bonus episode on head bedding coming out this week. What a treat. But back to concussions and getting those diagnosed when you are just a regular,

old, alive person. I wonder if, depending on the health care system your country has, if more people get checked out for concussions somewhere with universal health care versus, you know, like I bonked my head, but if I call an ambulance, that's like two grand. I wonder if there's a reluctance in certain like cultures or systems to get checked out for things as soon as my sister-in-law called 911. I was like, good idea. I am having a little bit of convulsions and a seizure, but also like,

it's going to be so expensive. Yeah. I mean, that's something that, you know, a lot of people have to grapple with. Right. Am I really going to go get checked out about something that's seemingly, you know, mild? And I think, you know, certainly for some of the things we just discussed, those things are potentially signs that you've had something worse than a

concussion and you probably need a scan, right? Or something bad could get missed for folks who don't have any really concerning features at all. They might do okay. Just going to the urgent care by car as opposed to. The ambulance ride and that that might be a little bit more economical. But yeah, it's certainly, you know, the ability to access healthcare for a lot of people, it can make, you know, my recommendations about getting checked

out more difficult for sure. PS, 100% the right thing to do. I was knocked off my rocker so hardcore and I had this weird combo of like foggy reasoning plus a big helping of, I wonder what my yearly deductible is for a ride in the wii wii wii mobile. But given the TBIs account for, I now know 30% of the accident deaths in the U.S. every year, fully no contest warranted and worth it to be in an act brace and get a brain scan.

But I'm probably not alone here. So instead of making this easy, I decided to dig up a bunch of research and I found a 2019 Centers for Disease Control, Morbidity and Mortality Weekly report called traumatic brain injury related deaths by race, ethnicity, sex, intent and mechanism of injury. United States 2000 to 2017 plus a more recent CDC article on brain injury trends that said over the last two decades, TBI contributed to the death of over a million people and in that period over 400,000 U.S.

service members were diagnosed with TBI and other research suggests that 46% of people in correctional facilities have a history of TBI. Folks who experience homelessness are up to four times more likely to have had a TBI and up to 10 times more likely to have had a moderate or severe one like I had and survivors of intimate partner violence who sustained traumatic brain injuries also have worse prognoses and anyone with lower incomes or without health insurance, at least in the U.S. has far less access to TBI care. Country folks also, if you live in a rural area, the chance of a fatal TBI is

higher as specialized medical care can be farther away, harder to get too quickly. And the CDC report continued on that indigenous folks have higher rates of TBI hospitalization and death than other groups. People of color, less likely to receive follow up care and rehabilitation following a TBI compared to their white emergency room neighbors. So who is granted quality and sufficient care is huge as our increased risk factors and resources to cover the bill. And what kind of bill are we talking in the U.S.

According to the 2019 study in hospital costs after severe traumatic brain injury, a systematic review and quality assessment in hospital costs per patients were generally pretty high and range from $2,000 to $400,000, which is so many dollars. So I have health insurance and luckily like six jobs right now. And after passing out twice with convulsions before the horror stricken faces of my loved ones this week, the thing I thought about the most lying on a gurney in the hallway of a crowded ER in isolation a day before

Christmas on the East Coast during an Omicron surge thing on my mind the most the expense and I have it the easiest. So what about Dr. Igarino has she ever been on the other side of the gurney? Have you ever had a concussion? Yes, I have had a concussion at the time I was a kid and I don't think anybody really recognized it for what it was. But now that I live, breathe and work in this space all the time, I can

absolutely say that I I fell off a horse. I hit my head and I was helmeted, luckily, but I, you know, was nauseous. I threw up afterwards. I don't really remember, you know, the next couple of hours so well. So I feel like I can say with certainty that I've had a concussion myself. Yeah, you're like, I can clinically diagnose myself from the future. Did you have any lasting effects from it? I don't think so.

No. And again, I was a kid and at that time we weren't looking so closely like we do now about concussions in sports. So I don't think that I had any lasting effects. No. How do you trace your path to becoming a doctor at Harvard who is working on this? Yeah, absolutely. So my specialty of medicine is called physiatry. Come again. I don't know if that's something you've ever heard of.

A lot of people haven't. My own family sometimes thinks I'm a podiatrist. I'm like, nope, not feet, brains. So a physiatrist is someone who specializes in recovery from injury. So that could be like a knee injury or it could be something like a brain injury or a stroke or a spine injury. So it really runs the gamut. I was super interested in neuro rehabilitation or rehabbing the brain

and spinal cord after injury, and I'm a huge sports person. So I struggled between going into sports medicine and going into neuro rehabilitation. And this is where I kind of found my happy place, if that's even possible, to have a happy place in concussion. But I work with a lot of young people. I work with a lot of athletes. I work with a lot of young military service members. So, you know, a high functioning group of people who've had this neurological disturbance

and now are trying to recover. And Dr. Icarino was herself a patient of rehab. She also suffered a spine injury as a teenager and was steered toward this work, helping others recover, which is amazing. And now if you're listening to all this and you're like, you know what? I'm going to sell my roller blades to my cousin. I'm going to keep up my holiday lights until next year. I'm staying off the roof.

Let's talk about how do people wind up with a minor TBI. So studies show that 50% of us have had a traumatic brain injury in our lifetimes. Dudes, bad news. You're twice as likely to be hospitalized, three times more likely to die. So overall, 30 to 50 million of us out in the world will knock our Noggins pretty hard this year. So hello, welcome to my club. Enjoy the sweatpants. Now, according to the National Center for Injury Prevention and Control,

the most common causes are falls. That's the most popular one. Been there, done that, don't recommend. Then motor vehicle accidents, getting struck by objects, including sporty things. And then there's violence, assault, and intentional self-harm, which has the highest mortality rate. But yes, for most of us, it's just not paying full attention to safety or physics being an asshole. Lots of people have concussions. They fall down the stairs.

They get in a car accident. They have an injury at work. So it's pretty common in a lot of people. And many people have probably had a concussion and, you know, they didn't have a seizure or they didn't feel so bad. And they never saw a doctor, right? And within a few days, they were kind of back to their usual self. So the reporting on concussion is probably lower than the number of concussions that actually happen. I think one of the reasons there's a big focus on people in sports and the military, because these are areas where people are at high risk of getting concussions

and potentially more concussions, right? So they're doing things that put them at risk of a head injury on a pretty regular basis. And so that's probably why there's a lot of focus on those groups. What does recovery entail? If you are in physiatry, which is a word I now know, when you are treating someone who has had a concussion or multiple, first line of defense, is it like get off your iPad? You don't need to be scrolling social media now, or is it cognitive puzzles? I was told to stay off screens and literally not to think too much, like not to play Scrabble or anything.

And I'm I'm not sure how long people have to be wary of that. What's your your plan for people? Yeah, so it's really interesting because the field of neuro recovery and concussion recovery has really changed in the last 10, 15 years. So we used to tell people to rest and not just like hang out on the couch, but go in a dark room and pretty much sensory deprivation. Don't look at anything bright. Don't turn on the lights. Please just leave me alone. Don't listen to anything loud.

And what we found is actually people didn't get all that much better doing that. And we didn't really have any good science to say why people should do that. Just seemed like kind of the thing to do. And and and now we've really moved much more to a more sort of moderate approach, which is that we don't think people need to be sensory deprived or put in dark rooms. We actually think that we make it harder for them to maybe get better. Oh, just because you're completely removing yourself from all your usual validating life activities, right? Putting people in solitary confinement makes them depressed, right? And anxious, right?

You have nothing else to do but sit there and think about how bad you feel. So that doesn't actually do a lot of people so much good. But what we like to see now is that people do what I like to call relative rest. So hang out, don't over exert yourself, like go for a big workout or certainly don't put yourself in harm's way of getting another head injury. So if you're an athlete, don't get back out on the field before you're better. But it's OK for people to watch a little TV, be on their phone or their computer a little bit. You might find that being on screens or being in a really loud place or a crowded place makes you not feel so well. And if that happens, then you kind of back off from doing those things.

But there's not really great evidence to support people staying off screens, staying in dark rooms, just for the sake of it. So we really like to go with how people feel and how they are responding as an individual to various stimuli. Because this is a very individualized injury. I'm sure you've talked to other people have had concussions and maybe they haven't experienced the same things you have. And that's because it really boils down to the person and maybe what their sensitivities are and some of their other medical conditions or background. Everybody's going to be a little bit different. So we want people to have a few days of relative rest, like bumming around the house. And then actually, after about day three, we're OK with people getting back to a little bit of work, a little bit of school and just seeing how they do and kind of using their symptoms as a guide.

But everybody will be different. And so there's no reason to give everybody the same exact prescription on how to get better. OK, that's actually great to know. Because I had posted something where I'm like, little concussion, fine, you know, CAT scan came back fine. And I got a lot of comments on Instagraming like, watch the fuck out because don't look at screens. Someone else, you know, would say, I got a concussion. I got post concussion syndrome. Be really, really careful.

And so I was kind of left not sure, is this going to make something worse? Is it not? I hadn't heard of the term post concussion syndrome before this. Is that something that is a scientific clinical term or is that like a catch all? So a post concussion syndrome is a term that refers to people who have symptoms for longer than expected. And it's actually being phased out. So it used to be a clinical diagnosis that was made. And we've actually phased the term out because of what I just kind of talked about, that everybody's kind of individualized. And sometimes, you know, people will have symptoms that last a little longer, but they might be related to another condition they have.

Like somebody who already has maybe migraines or somebody who already maybe has light sensitivity or noise sensitivity. So it's a term that's getting phased out. And I kind of prefer to think of it as persistent symptoms or prolonged recovery because I'm also really mindful that when you give somebody diagnosis as a doctor, right? You have the post concussion syndrome, but I don't have any treatments or really great cures for that. It can actually make people feel a little worse, right? If you tell them that they've got some prolonged syndrome, we can actually maybe kind of change the narrative in a bad way. So the term has fallen out of favor for a lot of reasons. But it still kind of means the same thing, right?

That some people experience symptoms longer than other people. OK, so I'm very lucky to have an in with Dr. Jane McGonagall from the Lettology episode on video games, who has done a ton of research and even a TED talk on her own M.T.B.I. Sustained from accidentally slamming her cabesa into a cabinet at home, which I do not envy. So two days after my own fall, down a flight of stairs, I emailed her asking for advice and she was amazing. She echoed to take it easy, to get some rest and fresh air, maybe some walking, watching some familiar or comforting movies, perhaps pressuring a loved one to give me a foot massage, which I did. And she said if something felt like it was off or too much to back off and don't push through it. And this part really struck me, did not intend that pun, but it mirrors what she said in her Lettology episode. So with her permission, I'm going to repeat it here.

I'm going to read part of the sweet email that she sent to me last week. She said, the other thing that really helped me was learning that some people experience depression as a neurological side effect of a concussion. So during healing, the brain is trying to put the brakes on your normal activity and it wants to avoid another impact. So to preserve your precious energy, literally the glycogen your brain needs to heal, it depresses you. So your brain wants you to stay in bed and feel like nothing is worth doing until it heals. And for me, she writes, learning that this depression was a natural and helpful physiological response to concussion and not a fact of my life or a psychological weakness or just an emotional response. Helped me write it out and see it as a healing response without suffering as much. Many people don't experience depression after a concussion, she writes.

So this may not come into play for you at all, but it is common enough that I always try to tell people that if it happens, know that it's just your brain trying to keep you restful and it's not a feeling that continues after you recover. When a concussion is healed, those feelings go away. And she concludes, I hope you are one of the many people who recover quickly and relatively comfortably. And if like me, you take a little longer to surf it out, don't fight the waves, go with them, give yourself grace, rest, because there's no benefit to fighting your own brain. Ugh, Dr. Jane McGonagall, a frickin' saint. So her website and her talks are linked to my website, which is linked to the show notes. You don't have to remember anything or write anything down. Also, side note, serious huge thank you to my sister-in-law and wedding dress designer, Samantha Sleeper, who has continued to house Jared and I for a long, languid, two week vacation of fireplace hangouts with Chris and Mason while I neuroplasticize my noggin.

What is that word? Neuroplastic? Okay, so I looked up studies and in the 2016 book, Translational Research in Traumatic Brain Injury, it explained that neuronal circuits can adapt structurally and functionally to injury neuroplasticity. So they recruit new cells to replace the damaged ones, and then your brain uses molecular modifications to reroute and get the job done. So if you're feeling a little weird or down or funky after a concussion, just consider it kind of like a renovation. So pardon your own dust during the remodel. You're figuring it out. And what about right afterward?

I know we talked about you don't have to go into solitary confinement necessarily. And I did notice, you know, I was fine to do some things. I'm luckily I'm in a relative's house and I've just been beaching myself by the fireplace. But as soon as I started playing Super Smash Brothers with my nephew, I was like, all right, this is too much flashing lights and screaming gorillas. Yeah. So I often tell people to try to do all the good things for their body, you know, so stay hydrated, try to, you know, eat a relatively balanced diet. There are no specific diets that have been shown to make concussion go away faster, nor have there really been shown to be any supplements that'll do it. There's lots out there and people can definitely try them, but nothing.

That's a slam dunk, you know, and then have the ability in your day to take it easy if you need to, right? If you find that you kind of overdid it playing video games, have the ability to say, you know, I think I'm just going to step away for a little bit. Or I'm going to, you know, work part time for a couple of days and take some breaks during the day. We actually used to recommend that people not do any exercise until they were all better. And now there are some studies that show in their mostly studies in athletes, because that's where this tends to be a common issue, that some light aerobic exercise that does not make your symptoms worse might actually help people feel a little better. So this would be like, you know, taking a brisk walk or getting on an exercise bike or something like that. So it's been interesting that we went from people not doing anything, right? To actually, oh, well, maybe, you know, getting moving a little bit, you know, in a controlled way that doesn't make you feel worse might be helpful.

So if your idea of a workout is maybe some light cage fighting, perhaps hold off, just for a bit. Your usual triple shot cortado. What about that? Yes or no? I've heard people say, you know, I cut out all my caffeine, right? Well, how many cups of coffee did you used to drink? Well, two in the morning. And now I have a raging headache and I'm tired.

I'm like, okay, just go back to your usual coffee intake, because I think we've actually, by eliminating coffee, you have actually made yourself feel worse, right? So yeah, so we want people to be like on their normal routine. We don't want them to turn themselves inside out and take away all their sort of usual behaviors and activities completely, or they can actually make themselves feel a little bit worse. I think some of the things that we want to stay away from right after concussion are things like alcohol and stuff that can make you feel hungover and be kind of mind altering, right? Because that usually doesn't make people feel better. What about glycogen? I read somewhere that your brain needs a lot of glycogen to heal. Your brain needs a lot of glucose, right, which is sugar.

Actually, that's the only thing your brain survives on. So, you know, fasting is probably not a great idea when you have a concussion or being extremely restricted in what you eat. But otherwise, there's not a lot of dietary stuff that might really make a big impact for most people. And so we don't tend to really recommend it. Okay. Okay. So that being said, side note, there is emerging research on very low carbohydrate or ketogenic diets and brain function after injury. And the Journal of Frontiers and Neuroscience published a 2019 study from the University of Connecticut that showed a high fat diet reduced aggression in males, they say, after concussions.

And the scientists explained some evidence that concussions might cause some brain cells to die off by overexciting them during a trauma. And then that causes the cells to use up all their glucose all at once, all too fast to die. Now, brain cells usually run on glucose, right, stored mostly in the form of glycogen in non-neuronal glial cells. They're called astrocytes, doesn't really matter, good to know. But the brain can also use ketone bodies or fat metabolites in a pinch if you have no more glycogen left. So many past neurological studies point to ketogenic diets as a way to keep brain cells kind of out of that excitotoxicity zone, which can prevent things like seizures. So it's possible that this 2019 research into ketogenic fuel and concussions could help prevent MTBI damage in folks who are prone to concussions like pro athletes, which could be huge in this field. Shoot, I forgot to mention.

All the research was done with fruit flies. So animals who don't have to work on spreadsheets or navigate society and whose brains are the size of a poppy seed. But listen, before you scoff at fruit fly research, let's remember with our big meat brains that their fly brains do have 100,000 neurons and tens of millions of connections. So yes, they are a small model, but they're a mighty model nonetheless. But we do have a long ass way to go. So ask your own doctor because opinions on brain trauma recovery and prevention are, like your own brain, pretty split down the middle. I myself have been eating lots and lots of holiday cookies. And right now I'm pondering how much of my sluggishness is fully the result of a brain injury versus just some good old fashioned pancreatic overwhelm in January.

So just be kind to your construction zones is all I'm saying. Now, what about just firing up your bomb or buying some Goop certified white lady cannabis? So I asked another neuroscientist, pal, who said that CBD is definitely being researched and used in TBI recovery. So I found a study called review of the neurological benefits of phyto cannabinoids, neuroprotective, anti-inflammatory and immunomodulatory benefits. And I was like, okay, but then all the way at the bottom in the conflicts of intersection, there was a disclosure that the leading researcher was a shareholder in a CBD gummy startup. But maybe he just really believes in it, which is totally fine too. Once again, a lot of research is emerging. A lot of it has merit, but I'm not your doctor.

I'm just a lady with a brain injury Googling her way out of confusion and then back into deeper confusion. As I record this at 2 p.m., the same day that it's getting released and I'm still wearing pajamas I put on 36 hours ago, a question remains. You know, important question. How long can I milk this? I fell down some stairs like, when do I have to start returning emails? Yeah, I mean, everybody is different. You don't have to be a hundred percent better to start reengaging in a little bit of school or work, right? You want to go by your symptoms, but it's also very reasonable to not just jump back in to everything right away and work a 18 hour day with dinner and drinks at the end of the day, three hours of sleep and then do it again the next day and the next day, right?

So the people who do best are somewhere in the middle, right? They don't just rest for days and days and days and they don't go full tilt on their daily schedule, right? They're doing this sort of middle of the road, working my way back in a controlled fashion. So easing back into it is probably good and, you know, that's hard for a lot of people. If you're a busy person, like I imagine you are, it's very challenging, but that's usually how people get better fastest. Average times for recovery. Again, this is really quite broad, so I hesitate to even throw numbers out there. But anything from a week to honestly, like 10 to 12 weeks is considered normal, like it's considered kind of within normal range for feeling all the way better.

OK. Oh, that's good to know. Those like one week people are, you know, kind of at one end of the spectrum and the people taking a couple of months, maybe a little bit at the other end of the spectrum. And then unfortunately, there is a group of people who take longer. There is kind of mixed reporting on this kind of data, like who has prolonged symptoms. And again, prolonged symptoms is how most doctors refer to it. But it was once commonly called post-concussive syndrome. And I'll be honest, as soon as I heard the term post-concussive syndrome, I personally kind of freaked out. So I understand from my own perspective how it's helpful to frame it as something less scary and less permanent.

That being said, that prolonged recovery does happen. But how many folks who actually get seen by doctors? Estimated anywhere from 5% to some studies, like closer to like 25, 30% of people that, you know, have at least a symptom longer than that. Now, again, I think it depends on what population you study, right? If you're studying a group of people who are really interested in concussion and have prolonged symptoms, you're going to get a higher number. Where if you study those people who don't even go to the doctor, right, those people probably get better pretty fast. So I think it depends on the population you study. But there are this group of unfortunate folks who do have symptoms even longer than that.

If you get a concussion, should you go enroll yourself in a study? Because I imagine it's really hard to study because you're like, who out there has concussions? You can't bonk someone and then do experiments on them. That's not ethical. Yeah, no, not ethical at all. And the human brain is really different than other brains. So even a lot of the data that we have that comes from like animal models, you know, you still at the end of the day are like, well, OK, but it's not the human brain, right? Which is an extremely complex organ.

I think if you're somebody who gets a concussion and you are willing to help science better understand that injury, then you are an awesome person. So if you're concussed, maybe you can give your time. I looked into studies I could participate in as long as I had a messed up brain. But most of them were either looking for former NFL players between the ages of 45 and 74, or they only needed my brain between a one to three on the Glasgow Coma Scale, if you know what I mean. So there are folks doing really great research under the 30 million dollar care consortium, which is the world's largest investigation into traumatic brain injuries. And it's funded by the NCAA, the National Collegiate Athletic Association, a.k.a. College football and the U.S. Department of Defense.

Have I mentioned you should follow the money with this stuff? You should. In this case, let's aim our own money hoses towards some causes of theologist's choosing. So this week, Dr. Icarino asked that it go to Home Base, which is a Red Sox Foundation and Massachusetts General Hospital program. And it's dedicated to healing the invisible wounds for veterans of all eras, service members, military families and families of the fallen through world-class clinical care and wellness, education and research. And Home Base operates the first and largest private sector clinic in the nation, devoted to providing life-saving clinical care and support for the treatment

of the invisible wounds to include post-traumatic stress, traumatic brain injury, anxiety, depression, co-occurring substance use disorder, family relationship challenges and other issues associated with military service. So you can learn more about the great work they're doing at homebase.org. And that donation was made possible by some sponsors of the show. So a lot of you had repeated questions. So let's hit it. It's about getting hit repeated times or multiple concussions. I'm looking at your noggin's patrons, Scott Duncan, Leah Lodovico, Marisa Holtzman, Alan Lee Palmgren,

Alia Meyers, Timothy Wong, Chelsea Ravel, Ross Balu, Heather Moore, Cumulus Cloud Tower, Allie Vessels, Pei Fei Dong, Lulu Hall, Karen Seidler, Claudia Dana, Beverly Sobelman, Jessica Beckwith, Spex L and Julia Splittorf, whose life highlights include running face first into a brick wall to meet Harry Potter. Then getting kicked in the head by a mule and getting whacked in the head by a baseball bat by someone trying to break open a pinata at their birthday party, which landed them in their helicopter to the hospital for a few weeks. Julia's question, how am I alive and functioning? Let's ask a doctor. Olivia Schaefer says, how many is too many?

A lot of people are like, I play hockey, I was in roller derby, I played football. The repeated concussions. What's the deal with that? What is the deal with that? Yes. This is a hard question, but one that I field a couple of days a week. OK. So the answer is that there is no number.

There's no specific number where we say, OK, hang up your roller skates, turn in your, you know, your varsity letter jacket, it's over. Yeah. And this really goes back to that every person is different, right? Every person is different. How they respond to the injury is different, how long it takes them to get better is different. And what they're going back to in their life is different. If you're a person who's had three concussions because you were in car accidents,

we're not going to tell you to never get in the car again. That makes no sense, right? But where we get a little bit concerned about folks is if they're in a recreational activity like sports or job where they are pretty much guaranteed to get repeated head injuries, right? Those are people that we want to start talking and thinking about how much do you want to expose yourself to a head strike or how much risk do you want to take? Right? So when we talk about repeated injuries,

those are the groups that we start to get a little bit worried about because we know that they've signed up for more events where they could take another hit. And we do think that many hits over time could in some people, not everybody, but in some people could lead to either symptoms that never go away, right? So you don't actually get all the way better or that as you get older, you start to maybe experience cognitive difficulties, meaning like thinking and remembering things and paying attention or other symptoms and that those may be related to all those hits to the head.

We do worry in some groups about how many, but there's not a specific number. And then the other thing we worry about is also how frequent. So like a boxer takes 20 blows in a fight, whereas a gymnast, and I'm not saying all gymnasts, let's just say a different sport where it you can hit your head and you probably do from time to time, but that's not the goal, right? The goal was not to hit someone in the head, right? Those are different things.

And so we worry about how many and then we worry about how frequent they are, how close together, did the brain get time to recover sufficiently? Or do you think you took more hits when the brain wasn't fully recovered? Those are factors we care about. So number matters and then frequency and time to recover also probably really matter. But I would say if a person is concerned that they've had a lot of concussions and they are worried that they've signed themselves up for more, right? Like I'm going to continue to do my sport.

I'm going to continue in this field of work. It is very reasonable to try to see somebody who's a physiatrist like me or a neurologist or someone who has experience in concussion to sort of talk about what might be the threshold for stopping that activity. But I think it's reasonable for people who have had a lot of injuries or work in fields where they know they're going to have a lot of head injuries to have these sort of discussions and know what their options are. If you see someone riding a bike without a helmet,

do you ever scream out your window like, I've got a helmet on. So I scream with my windows up and then occasionally if it's like kids in my neighborhood, yes. But but I try I try to keep it on the inside. But, you know, concussions can be tough injuries for some people. And as we said, there are some people who take a long time to get better. But let me assure you that it is still the mildest form of a head injury. And if you are unhelmeted, you are much more likely to get a skull fracture

or a brain bleed or something way, way, way worse than a concussion. So helmet up. Yeah, helmet up because when I see bikers who are helmeted and come to me with concussion, you know, they're obviously upset. They have a concussion. But what is missing from the discussion is, well, thank goodness, you had a helmet on or else you might not be walking into my office to talk about your concussion, I might be seeing you over in the neurological ICU because you

had a huge brain bleed. So everybody helmet up. And I'll just say I'm up here in, you know, Boston, skiers, sledders. I know you might not feel cool if you go sledding with your helmet on. But, you know, sledding is job security for me because people hit their head sledding. Snowmobiling activities on wheels where a helmet will save your life.

And then you can just come to a concussion clinic to talk about that. So, yes, I am a huge, huge helmet person. So big applause to helmeted oligites out there. Kelly Eulig, Rob Lara, Tony Vessels, Cycling Tiger and motorcyclist Doug Stewart, who said, don't worry, Dadward, I at GATT. I had to Google it all the gear, all the time. And for anyone who has had multiple concussions, remember that neuroplasticity that reroutes and compensates for injured areas?

Well, do that many, many, many, many times. And that's more of a rerouting burden on the brain. And some scientists call this suboptimal signaling pathways in your brain. So protect that coconut. You only get one and it's resilient. Don't push your luck. Wear a helmet. Also, when it comes to safety gear,

definitely consider it a wise investment and do your research to get the best and the safest you can for your budget. And if you can buy in person, it's best to get fitted for a helmet so that you're not seeing phosphines, aka experiencing photosia, aka seeing stars, which side note is your brain playing tricks on you from sudden changes in oxygenation and pressure, especially from a bonk that affects the vision system in your occipital lobe in the back. Which brings me to the next question.

Is your skull like real estate? Many of you, such as Anthony, Steffi, John Worcester, Karen Burnham, Jess Wan, and Jessica Morgan, one of whom asked about hitting someone with a rock to incite a concussion and will remain anonymous, Steffi, but wants to know, essentially, is it location, location, location? Some folks wanted to know, is it worse to bonk different areas of your head? Like I hit the back of my head. Is that not as bad as hitting the front?

No, I would say that's probably a bit of a myth. OK, because remember in the beginning, I said to you, you actually don't have to directly strike your head. Yeah, you just get shaken. Shaking or like an explosion with a blast wave or some things. So no, not necessarily. Last listener question. Michael Sedenboga, Dylan Mantle, Rosaria Neyra, Sarah Crowder, Megan Ramirez,

Greg Wallach, Rachel Selby, Nathan Ogden, first-time question asker, Kyle Pollock, Heather Dykes, all of these people wanted to know about drowsiness and sleepiness with a concussion. And can you not go to sleep after a concussion? Will you die in your sleep if you go to sleep after a concussion? So the concept that somebody would be awake and then die in their sleep, actually more closely ties back to injuries that are not concussion, but something more severe, right?

So like Natasha Richardson, right, who hit her head, was kind of walkie talkie. And then went to, you know, she didn't go to sleep. She probably collapsed, but you could imagine if it was evening, you'd go to sleep and never wake up, right? Yeah. And that wasn't necessarily due to concussion. She had a hemorrhage. But if you go get checked out and you just have a concussion, you can go to sleep.

So where people get more concerned about not letting people fall asleep is if people are so drowsy, they can't stay awake, right? So I'm sitting next to you. You've just say, hit your head and it's broad daylight and you literally can't keep your eyes open, right? Well, then I'm worried about you because your brain is not able to maintain consciousness, right? And that's actually a reason to go get checked out and maybe get a scan

because we're worried about something maybe more severe than just concussion. But if you have a concussion, not as some more severe brain injury, you should be safe to go to sleep. If somebody is so concerned about somebody being sleepy right after a head injury, that person should go get seen at a hospital. OK, that's good to know. I was yawning a lot afterward and I was like, why is this happening? But I think that there's this myth that you have to stay awake for 24 hours,

like a telethon, in order to prevent dying in your sleep. I don't know what movie it came from, but I feel like we all saw a movie in the 90s where that happened or something. I'm sure I'm sure we did. And it's very common to be tired after concussion or want to sleep more. That's actually a common thing. And that is OK to do as long as you actually have a concussion and not a more severe brain trauma.

OK, I looked for at least an hour, maybe two hours. I have no idea what movie made us all believe that you can't sleep after concussion. But if you have been checked out and had a scan and you don't have a brain bleed or severe trauma, the doc will give you the OK to snooze. And if you know what movie is lodged in our heads, please tweet at me because it is just frying my ganglia. I cannot figure it out. I'm so tired.

Any responses in general to concussions in the media or the movie concussion or just in general, anything in pop culture that that gets it right or gets it really wrong? I don't know that I'm going to go on the record. Yeah, yeah, that's fine. Just like any other medical condition, there are tremendous myths about concussion that get that probably get perpetuated through the media. And and of course, you know,

various non-scientific entities and some aspects of social media. I do think it's a it's a serious condition that if you experience it again, you should go get checked out. But for an overwhelming majority of people, they're going to get better and feel just fine and probably forget that it happened to them. So again, not true for everybody and the things you're going to read on the internet are probably those folks who are struggling for sure and trying to caution others, but there's many, many people out there who've had a concussion and are

doing just fine. That's that's such good news. And that's very hopeful because I think I I got a little bit more scared. The more I read about it and I did find myself kind of tiptoeing and it's been really great to rest and I've definitely noticed like, OK, my eyes feel a little bit tired, I'm done for today. But but this tiptoeing that you'll make it worse if you resume normal activities was kind of freaked me out a little bit, to be honest, you know?

Yeah, no. And I talk to people every day who are just so actually the worry and the anxiety about what can I do this? Shouldn't I do that? Did I did I injure myself more? It can become its own beast. There are good resources. The CDC is a great resource. The Brain Injury Association of America is a great resource.

And there are, you know, a number of good resources out there. But also if you're somebody who is, you know, not getting better, you know, it's been a few weeks, I'm not getting better. You know, and you're able to and in a position to it's it's always very reasonable to reach out to a person like me to get some more focused guidance. What about the most troubling thing or the hardest thing about your job? Hmm. The hardest thing about my job.

Well, I think one of the hardest things about my job is talking to those folks where we think that their brain has had enough and, you know, it might be time to to think about no longer engaging in combat or collision sport or thinking about, you know, a career change. Those are hard discussions. And I don't have them that often, you know, overwhelmingly. I think people being active and in sports has so many benefits to their mood, to their health, you know, we want to keep people doing what they love.

But there are times when a person is just not recovering, showing too many symptoms or has had too many injuries or is, you know, plays a sport a certain way or works in a certain way that they are just very, very high risk. And so those are those are hard discussions. I, you know, road horses for many, many years, I can't imagine if somebody told me like, look, you've hit your head too many times, you have to hang it up. You know, I would be beside myself.

You know, it's such a passion and many people are passionate about their careers and their sports. So I think those are those are the hard ones. What about the best days of your job or research or clinical work? What do you love about this? Getting people better. What do you love about head trauma? Yeah, what do we love about head trauma?

People get better. Yeah, the brain is an amazingly resilient organ. We think of it as very fragile. And in some respects, it can be. But overwhelmingly is quite resilient. Many, many people can have head injuries some more severe than concussion and they get better, it can take time, you know, and they need the right rehabilitation. But but they really do get better and people go back to doing what they love.

And that is those are the best best days. Well, thank you so much for doing this on such short notice. Definitely did not have this on the schedule for this week. But I appreciate you fitting me in to let my brain ask your brain questions about my brain. Absolutely. Absolutely. So ask smart brain people all of your simple brain questions or your complicated ones. If you are lucky enough to just have one that you could ring up or have a podcast because that's one way to do it.

You can find Dr. Mary Alexis Icarino on Twitter at Icarino MD. She is wonderful. Also, stay tuned for a bonus episode coming out this week on headbutting in animals. I recorded it. I was going to put it in this one. Decided to make it a bonus episode that's coming out in a few days. Cross your fingers.

You can find us at oligies on Instagram and on Twitter. I'm at Ali Ward with one L on both. You will find a link in the show notes to this episode page where there are tons more links and research, all kinds of good stuff. Also, a link to homebase.org, which is where we send a donation. Links to sponsors are also linked in the show notes. Thank you to Aaron Talbert, who admins the wonderful Facebook group full of oligies listeners. Hello out there.

Hello to the subreddit. Hi. Thank you to Shannon and Bonnie, who help with merch. Thank you to Susan Hale and Noel Dilworth, who do so much oligies business behind the scenes. Thank you to Kelly Dwyer, who makes our website. She can make yours as well. Her link is in the show notes. Thank you to Emily White of the Wardery, who makes professional transcripts

available. Those are for free on our website to anyone who needs them for any reason at aliward.com slash oligies-extras. We also have bleeped episodes. Thank you, Caleb Patton, for bleeping those. If you have seen Smology's episodes in the feed, heads up. Those are short, small episodes for Smologites. They are classroom safe. They're everybody safe, a little bit less saucy, but they get right to the point.

Thank you, Zeke Rodriguez-Thomas, for working on those with some help from Steve and Ray Morris. Thank you also to Nick Thorvern, who wrote and performed the theme music, and thank you to Lead Editor, primary husband and person who carried me to the couch while I passed out, Jared Sleeper, who has been taking excellent care of me, including some foot massages and literally like waiting on me as I am just beached on the couch in front of a fireplace. Thanks, Jared. I love you.

If you listen through the very, very end of the episode, you know, I tell you a secret. One secret is that when they loaded me with a gurney, they have like a picture on the side of the ambulance that shows like how the gurney is to be lifted. And I swear, it looks just like a cricket or a grasshopper. And they were loading me into it. And I was like, doesn't that look like a cricket or a grasshopper? And I think they probably thought like, oh, but I remember thinking at the time like, shoot, that probably sounded weird.

But I would have said that on any normal given day, just because crickets are cool. My other my other secret is that I was trying to make new calendar sheets for my little planner binder, and I was in bed trying to use my nephew's Swiss army knife to poke holes in the pages for the binder. And then I fell asleep doing it and I woke up in the morning to just like open a Swiss army knife in the bed, dangerously close to my baby Gommie, which is a dog. But I closed it really quick and Jared was like, is that a knife?

Did you just close a Swiss army knife? Was that in the bed? Did you sleep with that open in the bed after you were punching holes? And I was like, I was maybe. So it's been great to blame a lot of this on a concussion. But I think a lot of this probably would have happened anyway. Sorry, sir. We survived.

We survived. OK. Protect your noggins. Thanks for listening to this very long episode with a lot of his sides. There was so much more research than I thought. I hope it helps someone out there. All right. Bye bye. I love you back, dear, by the way, I just realized I left you hanging with that. I have a brain injury.