Okay, thank you everybody for joining today's member community session. Before we get started, I just want to review a few housekeeping notes. As a reminder, this session is being recorded and will be available along with the ability to claim your CME through the Academy's online learning portal. For the best attendee experience, please mute your microphone when you're not speaking. You are invited and encouraged to keep your camera on and to select the hide non-video participants. This will ensure that speakers are prominent on screen. To ask a question, please use the raise your hand feature and unmute yourself if you're called upon. Alternatively, you can use the chat feature to type your question. Please note that time may not permit the panel to field every question, but we'll do our best. Just a quick note about the Zoom platform. The microphone and video controls are located in the bottom left of your taskbar and controlled by the caret to the right of the icon. Red lines through the icons indicate these functions are off. Click them to turn them back on. Participants and the chat function are found in the middle of the bottom taskbar. You can bring those both up by clicking on each of those icons. To raise your hand function is located in the reaction section on the right of the bottom taskbar. To hide the non-video participants, you click on the three dots at the top and then click on hide non-video participants. Thank you so much. I'm going to turn this over to your community director, Dr. Tewari. Thank you. And here we go. Thank you, Lily. Can everyone hear me okay? Okay, awesome. Yeah, you can give me a thumbs up or whatever that works. Okay, so I'm Anita Tewari. I'm a physiatrist over at the Toronto Rehabilitation Institute, which is a part of the University of Toronto's health network over up in Canada. So I'm a little far north compared to I think where everyone else is. But it is my pleasure to introduce Nirali Chauhan today, who's going to be presenting today's session. So Nirali is a second year medical student at the University of Illinois at Chicago and is also a certified meditation teacher. She is passionate about empowering others to meaningfully change their external worlds by first and continually nurturing their internal ones. Before medical school, Nirali earned her BA in public health studies from John Hopkins University and her master's in public health from Dartmouth College, where she graduated at the top of her class. She also wrote and published her thesis on adapting yoga for survivors of traumatic brain injury. Nirali sits on the advisory board for the Love Your Brain Foundation, is a board member for Keen Chicago, which is a nonprofit that offers free adaptive recreational programming for youth with disabilities. She's a peer reviewer for the International Journal of Yoga Therapy and has been invited internationally to speak on adapting yoga as therapy. So without further ado, I'm going to pass it over to Nirali and we can get started. Thank you, Dr. Chauhan. My name is Nirali. Just like a thumbs up if you can hear me. OK, awesome. Thanks so much, Kristen. So, yes, so today will be kind of interactive. The idea is to just talk about the evidence based therapeutic benefits of yoga, meditation, mindfulness. So mind body practices among people with TBI, especially those with chronic mild traumatic brain injury will be doing some of the practices today as well. So feel free to come in and out of that container of experience, however you'd like to. I know it's lunchtime. Maybe you have other things you need to do, like nourishing yourself. We'll try to nourish your brains as well. And that way we can also get to a point where we can share resources with one another. I think there's a lot of regional resources that are really rich, but one to share with patients especially. So if you'd like to, I like to open up with a meditation. It is really short. Feel free to come in and out as you'd like. But basically, before we begin, I like to say let's arrive into this time together. So what that means is just taking the next few moments to transition from whatever you're just doing in your life. Maybe it's been a really busy morning already. Maybe you're coming off a long weekend like some others and just coming into this time together. And so as you begin to arrive to yourself, you might naturally let out a sigh that kind of signals to your body that you have come into this moment. And you might begin by sitting in a way that brings steadiness to your body. So that might mean placing both feet on the floor. If you're seated in a chair, lengthening your spine. Maybe this is the one time during the day where you allow your lungs that full expansion, that space. If it feels good, you can rest your hands on your legs. And feel free to close your eyes or find a soft gaze, whatever feels good for you. And this is called the calm meditation. So it's an acronym. Calm will stand for chest, arms, legs, and mind. And it can be a good one to share with anybody that you work with, or even for yourself. But beginning with the chest, we'll just begin by taking a full breath in. And releasing it out. As a tool to just gather our attention. And coming back to a pace that feels just right for you, just begin to notice your body breathing. Notice your chest, gently expanding and softening and synchrony with your breath. If you practice diaphragmatic breathing, that expansion and softening may be a little bit lower. And beginning to feel the pulse of your breath, gently moving in and out. Next we'll begin to notice our arms, they might be heavy and at ease by your sides. You might begin to notice any sensations you feel in your shoulders, your elbows, your palms. And as best as you can just try to relax your arms just 5% more, whereas there's some tension that you can let go of. Moving to your legs, feeling that steady connection of your legs resting on whatever surface is beneath you. So perhaps that's your seat on a chair, or on a cushion like myself. Maybe it's your feet on the floor, whatever place you can find a little bit of grounding. Trying to notice how your legs feel from the inside out, really going deep. And moving to the M of calm, mind, with kind attention just notice the state of your mind. Does it feel focused and at ease? Maybe you're a little bit distracted and tired. Perhaps there's anticipation of what this talk is about because we're meditating. Just welcome whatever is most present for you. We're just acknowledging where we're starting from today taking inventory. Can choose to take a slow breath in and a slow breath out. Sometimes easing out of a seated guided meditation, something that can be helpful is slowly introducing a little bit of movement. So you might choose to cross your hands over your elbows as if you're giving yourself a hug, kind of just giving your arms a gentle massage. You can feel free to slide your hands to rest one on top of another over your heart. This for any person, especially a patient, can be a really great way to feel into a caring place and to physically welcome whatever that place might be holding for them right now or you. This can be an opportunity to show yourself gratitude, somebody else in your life, gratitude, something. Taking slow breaths in and out. Whenever you're ready, you can release your hands. If you did think something that you're grateful for that type of gratitude practice to be really good before coming back into the space, it's a good opportunity. You might even notice some sort of sensation creep over you. And if you haven't already, you can feel free to open your eyes. If you'd like to in the chat just so that we know where people are coming from. Feel free to write down your institution or what city you're in so that we kind of just know where people are geographically. I personally am calling in from Chicago. Toronto. Thanks. Krista, I noticed you unmuted yourself. Were you going to chime in? Oh, I thought, are we putting it in the chat or saying it? You can say it too. This is such a fun, intimate group. So feel free to just hop in. So anyway, my name is Krista McKenna. I am a physiatrist. I'm in New Jersey at the moment. I work for Rehabilitation Specialists in New Jersey, and I'll be live in Baltimore next week for anybody who's going to be going down there. Oh, awesome. Cool. Fantastic, fantastic. Welcome. And then Lily, who's on the call, who's part of the AAPMR staff is not too far from me. She lives in the city in Chicago and is calling from the nearby suburb. Cool. So maybe we should get started. So why are we here? Well, these statistics are not new to any of you, but I will run through them just really briefly. So over 2.8 million Americans sustain a TBI each year. According to the Brain Injury Institute of America, a person in the US sustains a brain injury every nine seconds which can add up to 3.5 million injuries that can include brain injuries as well. All of these are likely underestimates as well. They further report that more than 5.3 million individuals in the US are living with a permanent brain injury related disability. So that's one in every 60 people. And 75% of these are MTBI. So mild traumatic brain injuries which are often labeled as concussions and they tend to resolve spontaneously but they can become chronic when they last more than three months, especially with repeated injury. Over 2 million emergency department visits are due to MTBI. And it's estimated that $17 billion are lost including in indirect costs like lost productivity or direct medical costs due to mild traumatic brain injury. So it's considered one of the most expensive public health problems in the world. I'm doing something new with the, there we go. So TBI affects the whole body. You all know this, just diving a little bit further into chronic traumatic or mild traumatic brain injury. It's estimated that at least up to 43% of folks can develop chronic symptoms, but just quite a few. Most everyone in this room has probably heard like TBIs be compared to snowflakes. So each brain is different. Each injury is different. There's like really complicated sequelae leading to variable cognitive, physical, emotional, and behavioral symptoms. They affect the physical body, emotional body, cognition, function, super difficult to treat because they often overlap with post-traumatic stress. And the symptom clusters also don't exist in silos, right? They're interrelated. They can exacerbate one another through feedback loops that have social implications that makes that even more difficult to treat. Stress, anxiety, depression can further exacerbate chronic symptoms and even maintain them. And so for example, headache can lead to disturbed sleep, can lead to impaired job, academic athletic performance, can lead to emotional distress over and over and over. And that can be a really difficult cycle for patients to kind of find ways to get help in. And it can be really difficult for psychiatrists to treat as well. And so we're here basically because a lot of people are affected. They're affected in a big way, as we can see. And the constellation of circumstances can be really expensive too. So as a public health issue, what can we do in community at a large scale that is sustainable and hopefully self-directed that can address this? So is there a therapeutic gap to fill? Kind of. So we've moved away from that passive rest as the primary way to treat mild traumatic brain injury. And we embrace like more proactive treatments like aerobic exercise and like cognitive activity, but they don't necessarily directly treat the emotional and the psychological symptoms that are present for folks with brain injury. Cognitive behavioral therapy, so CBT is often used for TBI, but it might not necessarily be the most feasible for all populations, especially post pandemic. Like psychotherapists are really thinly spread at the moment. There's other issues due to access and cost. And so as a result, mind-body practices. So yoga, meditation, mindfulness might be the way, and I'll try to convince you throughout the next hour. So a really good way to kind of target the emotional and psychological components and remain a little bit more feasible than CBT. Not to replace this by any means, but in addition to treatment plans. Okay. So because we're talking about a whole body injury, a whole body condition, I think it makes sense that we would also consider whole body interventions. And because each TBI presents uniquely, because each brain, each injury is different, we can see that what is similar across people's post-injury experiences is just the profound way that their bodies, minds are impacted spiritually, occupations, their social lives. And so yoga, meditation, mindfulness have been shown to improve outcomes and quality of life for people with TBI. We'll go through each practice, not doing any physical yoga postures today. We'll do like little bite-sized samples of each. And I think mostly because I feel like I can tell you about these things all day long, but I think what's most effective is if you experience like a tiny shift in your day by doing something small and sharing that with somebody else. As you get more curious, you might already be very familiar with these topics, but you might see these same therapies called mind-body therapies, complementary and alternative medicine, holistic interventions. All of these are kind of talking about the same things. And yeah, so they can just be really powerful additions to treatment. They're adaptable, super low impact, affordable, accessible, especially if we're talking about doing things at home and I'll share a lot of free at-home resources that you can share with patients. But I guess because we're not going to be doing any yoga or asana, if you'd like to, you can feel free to just stretch for a moment if you haven't already today. Just like unclench your jaw and roll back your shoulders. I have to do this repeatedly. I'm a hunchback. So I guess I'll offer this to the group. There are no wrong answers, but in your opinion or in your understanding, what do you think yoga, meditation, mindfulness all have in common? There are actually a lot of right ways to answer this. But I'm just curious what comes up. I'll just say that they don't cost very much, something you can take with you wherever you go. Yeah, exactly. And on that similar note, thanks Dr. Short, on a similar note, the breath. So the breath is one of those things that you can take everywhere you go. It's always with you, not usually thinking about it. And it's the foundation of any mindfulness, yoga or meditation practice. The breath, especially even in the context of a TBI experience is really important to consider because a lot of patients can experience changes in their breathing patterns without even noticing it. That can lead to dizziness, lightheadedness, incomplete breath or lack of oxygen can of course have super important implications for healing in the brain and even shallow breathing. So kind of the breathing that gets your shoulders moving more than the diaphragm can really lead to muscle tension in the neck area that can exacerbate headache, other symptoms caused by the neck, especially the cervical neck. So breath is important for all these practices, but it's also important in the context of TBI. And the reason it's so powerful, like Dr. Samari said, it's a tool that we always have with us. It's successful at any time for calm and balance and presence of mind. Breath work in general has become pretty increasingly popular, I'd say, as a mode of natural healing for anxiety, depression, PTSD, other trauma, chronic pain, especially that diaphragmatic breathing or that belly breath to get that really nice deep breath. And so prana, and we'll talk about like, there's a lot of Sanskrit words that are used in yoga and used in other modalities as well. So prana means like life force. And the reason we connect breath to that is that's like the physical manifestation. That's like the one physical tool that we have of life force. And so in yogic tradition, the breath is not only guiding the five senses, but the entire body. And you might notice that your breath changes when your emotional state changes or there are physical changes happening within the body. It can be more challenging for people with TBI to kind of tap into that interception. So connecting with the breath can be a really good way to kind of get some of that mind-body connected again. But some breathing exercises that can be really good is just that easy one-to-one breathing. So there's this little visual on the side, but like breathing in for four counts and we can do it together. So breathing in two, three, four, holding two, three, four, exhaling two, three, four, and holding two, three, four. And that can be a really powerful, like small way to ground in the moment, especially if you see like, I do this one a lot when we were doing emergency vaccinations during the pandemic and folks had a lot of anxiety with needles. This was like a really easy one. It can feel like we don't have time, but it's only like 16 seconds. It can be a really good way to get your patient back in their body just so that they can center and tell you what's going on. And yeah, it's really good one before during the blood pressure cuff especially as well. But this extended breathing, this two-to-four, basically it's inhaling for two and exhaling for four. And the reason this one's especially powerful is because naturally during inhalation, and you all know this, but I'll go through it really quickly anyway, is during inhalation, your heart gets that like little stimulation to beat a little bit faster. During exhalation, your heart gets a tiny message to slow down. And so the overall effect is very little in heart rate from minute to minute. But if you make one of the breath, one part of the breath cycle shorter or longer, you get the accumulated effect to the heart. So by increasing the time spent in exhalation, just by one or two counts longer than the inhale, and if you practice this for a few minutes, your heart rate will slow down and then it'll send a feedback message to your brain saying things are more peaceful and calm than they were a few minutes ago. So that one can be really powerful. Another few breaths, if you have attended like a yoga class or anything, you might know the Ujjayi breath. That's the victory breath or the ocean breath. It's like a constriction of the throat, creates some heat. That's said to maybe improve concentration. It can release tension, regulate heating and cooling because it physically warms your core from the inside. The lion's breath is one that's really powerful at like releasing tension quickly. And so I'll demonstrate it for you. You can do it. You can do it too. It's a little goofy looking, but I do this all the time when I'm feeling like a little overwhelmed, I just like you get something out. So what you do is you like, take a deep breath in with your eyes closed. You think of that thing that you're trying to release. And then what we're going to do on the exhale is you literally physically stick out your tongue and open your eyes really, really big. And the reason is just like, let it out. So you go inhale, exhale. And it's goofy. Might not want to do it in public, but it's powerful. And I do it. Another one is horse's breath. It physically releases your muscles in your face. So you breathe in and then you kind of go. And also a silly one, but really good for just, yeah, releasing tension based. And then a sigh out. Sighing gets a bad rap, but scientifically adding a sigh to your normal pattern of breathing can stretch your alveoli and your lungs and give you a sense of relief. So sighing is actually a good thing. And I hope you will spread the news, but yeah. So a pilot study found that breath focused yoga showed significant changes in several measures of observed respiratory functioning. And that I believe was, it was breath holding, breath counting, which they operationalized, I believe, as inhaling and exhaling and then holding a tone. And they also saw a reduction in heart rate in this group and self-reported physical and psychological wellbeing over 40 weeks was also significantly positively changed among those with severe TBI too. So the findings are not just among folks with mild traumatic brain injury. This is for all folks, but yeah. So encouraging patients with TBI to tap in their breath and just be a small but powerful way to ground in the moment, but also build respiratory strength and also improve emotional wellbeing and self-regulation. And that's just like a tiny tool. So what is yoga? Yoga is, it's a lot of things. It's a 5,000 year old spiritual path. It typically involves three core elements. So physical postures, which is what a lot of us associate with yoga. Those are called asanas. Breathing techniques, that's the pranayama. So that prefix prana comes back life force and meditation or mental relaxation practices. And there are eight limbs of yoga that you can see here in this infographic from the Art of Living. But the idea of yoga is to achieve this connectedness of the mind, the body, the soul. It's a holistic, dynamic way of life that promotes strength, coordination, stress reduction, self-regulation. Might be different than what a lot of people might be familiar with in North America. In our side of the world, it tends to be more like capitalistic process where studios and companies benefit from ancient practices. There's a lot of really cool work around decolonizing yoga and its teachings. That's really interesting if that's of interest to you. So this is what we're talking about when we think of yoga. And how does yoga influence the whole? So we can think of it through two different models. You're probably familiar with the biopsychosocial and then later on evolved into the biopsychosocial spiritual model. But the panchakosha model is part of the yoga framework. So basically taking the eight limbs of yoga and applying them to holistic models like this, we can see how it influences the entire person. So each kosha in the panchakosha model is basically sheep. It's like a layer moving more and more towards the core of who somebody is. And they get a little bit more nuanced coming in, but moving from the outside in, there's the physical body, the energy body. So again, that prana, that breath, and then coming into the mental emotional body. So basically how we interpret input presented through our physical senses. Then there's the wisdom body. So that's a little bit more than processing or thinking or the reactive mind. It's referring more to that like higher wisdom that guides us through life. It can represent like the reflective aspects of our consciousness. And then finally the innermost, the core is the bliss body. And it's referring to this unbounded experience of reality or like the deepest level of someone's being. So it's one of like pure joy, love and peace. And this is part of how yoga is conceptualized. This one's a little bit dense, but basically how does yoga influence the brain and body? So there are a lot of different studies here. They're all referenced later. And if you're interested in any one of these, I encourage you to dig a little bit deeper, but it improves attention skills. So by increasing the thickness of the prefrontal cortex. So that plays a, of course, a central role in cognitive control functions modulated by dopamine. So influences attention, impulse inhibition, prospective memory and cognitive flexibility. By enhancing, yoga can enhance the working memory as well. And that's through augmenting brain structures like the hippocampus. One of my favorite facts is, I don't think this exists anymore because of Google maps, but back in the day to become a cab driver in London, you had to like memorize, I think it's like close to 25, 30,000 streets and landmarks. And they took scans of these cab drivers' brains and their hippocampus were like massive. I love thinking about that. But yeah, yoga can reduce mental fatigue as well by supporting better information processing, can reduce stress by shrinking brain structures like the amygdala. So modulating that fear response and the anxiety response centers by down-regulating the hypothermic pituitary adrenal axis. So yeah, and by decreasing cortisol as well, playing these like key roles in homeostasis and the body's response to stress. Can improve strength, balance, endurance and flexibility. A study found that it could help repair axonal damage. So by showing to increase BDNF, which has neuroprotective effects. So basically in playing an important role of like neuronal survival and plasticity through the gut, through the CNS, through other tissues, it can be protective as well. Can augment self-esteem, community integration, overall quality of life, especially when practiced in communities. So there'll be some, there's this program that I'd love to share with you later on that can really play into the community integration aspect. But lastly, yoga can also reduce acetylcholine, which can increase vagal tone. So yeah, fundamental to the parasympathetic nervous system. So many effects of the vagal activity, like heart rate reduction, dilation, constriction of vessels, glandular activity, inflammation, like so many things. So yoga really hits a lot of it. And that's what a lot of these studies show. So yoga therapy. So given all these amazing benefits of yoga, especially for TBI, I think it's worth mentioning the definition of yoga therapy, of how it's been conceptualized by the NIH. And I'll just give folks a moment. I, yeah, I'll give folks a moment to kind of just read this for yourselves. I won't read it to you. And that's kind of just summarizing what we've already chatted about. But I think what's really important to highlight is yoga is really not about forcing the body past its comfortable limits. And I think when we think about it, or at least sometimes when I even think about it, it can be this, you can do healthy challenges, but considering it as an exercise can kind of put us into this gray area of wanting to push the body past its limits. And yoga as therapy really is kind of working with the body and not necessarily stretching it. And because it's a longitudinal practice, over time you see these effects, but it's really not supposed to be like a true intense challenge. That's really important. And what I have included on the slide below is some books that have been written and they're really fantastic for yoga therapy for a number of different conditions. So Parkinson's, MS, stroke, adaptive yoga as a whole for a variety of bodies and conditions. What we see is that yoga is still actually not widely accessible for TBI. And while there isn't necessarily a book on adaptations, there are some best practices. And so this was my master's thesis. It's so funny citing yourself, but basically what we found is there's this network of teachers through a nonprofit and talk more about them later. Dr. Tewari mentioned them in my bio as well, but called the Love Your Brain Foundation. You might be familiar with them. Among the 175 yoga teachers that worked with people with TBI through Love Your Brain, a number of themes had emerged for eliciting best practices for adapting yoga. These included very specific adaptations to prevent dizziness, headaches, to improve balance and address spasticity and neck pain. It was really important to patients that each time similar movements and sequences were practiced, you would think that it might be counterintuitive. At least it was for me at the beginning to think, oh, well, maybe we should switch it up. And that's certainly true for different in-community practices. But for folks with TBI, it's really good to repeat just for learning and memory. Ensuring soft lighting, music, no sense to mitigate those hypersensitivities that are very common among this population. Incorporating strategies to focus attention and facilitating group discussion as well, especially with empowering themes to build community resilience. And that's where that in-community piece can be really powerful. So we'll talk about what is meditation? Meditation is operationally defined as a self-defined method using a specific technique to relax the body and focus the mind. Here, I wanted to just show the spectrum of meditation that can exist. There's a lot of different types. They kind of range from active meditations, which are usually something simple and repetitive. It's something that you can do while you're actively moving. Because that movement, you can kind of lose yourself in that and find your stillness inside. Something, a reference that I like here is, I don't know if you've watched that Pixar movie, Soul, but basically the main character, he's like in the zone when he plays the piano. And that's kind of how I think of an active meditation as well. And you all probably have an activity already in your life where you kind of lose yourself into it, and that is an active meditation. And yeah, so basically the idea with active meditation is the more senses that are involved, like so the more intense the breathing, they're just sensory anchors to help you anchor into the present. And then there's passive meditations as well. And so the benefits of yoga plus meditation, because meditation is a core part of yoga, meditation itself can also change the brain as well. So what we see is a lot of the same things. There'll be a lot of repetition, but hopefully that means we're also developing deep grooves about this as well. But stress and anxiety reduction, improved attention and self-awareness, improved interoception. So again, that perception of sensations from inside the body. So perceptions of physical sensations related to organ function, like your heartbeat and breathing and other autonomic nervous system activity related to emotions. An example could be if someone's heart is racing and they feel butterflies in their stomach, it's their interoception that lets them know that that body physical sensation means that they're nervous. And then that can help them identify their bodily needs. And interoception can be compromised post-TBI and improved through meditation. And since meditation involves attentional regulation, the brain physically changes as well, especially in areas associated with that. So the dorsal lateral prefrontal cortex, interior cingulate cortex. And the more you practice, the greater the change. So meditation is truly just best started with repetition, not perfection. Just like any other muscle, you're just trying to get your reps in. It's like creating a habit. And over time it becomes progressively more automatic with more and more repetition that long-term potentiation kicks in. And then the more the structure of your brain becomes efficient at it. So there's like that like Hebb's law at practice, like neurons that fire together, wire together. And examples of that are like in musicians, for example, we see like big changes in the cerebellum in mathematicians, like gray matter related to computation and calculation. And the longer they've been a mathematician, the bigger the change in the size. So that's really fun to see. So I have a practice. If you'd like to, there's two. I wanted to kind of demonstrate what an active meditation could be and a passive meditation. So the active one is, is if you have a pen or paper, something to draw with and something to draw on basically, the practice is looking at yourself, especially if you're on camera, or you can look at somebody else if you are comfortable remaining on camera and somebody else drawing you. But the idea is to only look up, not down at your paper at your hand and in a continuous line, draw yourself and see. And then you can see at the end what that looks like. But the idea is to be really focused on the observation of what you see and not what you have conceptualized. So yeah, I'll give like a minute or two to do that. I'm gonna, I also did not grab these things before sitting down. So I'm going to get my pen and paper. Thank you. It's hard. I can see some of us like really fighting the urge to look down, especially if folks in medicine, we tend to want it to be perfect too, so just focusing on, yeah, even the sensation of what it's like to not look down. And then if you're done with yourself, you can try somebody else on the screen too, and we'll do it for like one or two more minutes. Cool. And as you kind of wrap up that one, we'll have an opportunity to share as well, but kind of moving into more of like a passive meditation. This one's the five senses meditation. You might be familiar with it, but it's such a simple way to ground and like a really simple one to share with patients as well. Basically, the idea is that we're all on a spectrum of things we've experienced, of course. So it's just like creating space to ground without getting too deep. And so a way to incorporate like a movement element, we were talking about like that, how sensory anchors can help come into stillness. If your patient is somebody that needs like movement and stuff, something that can be really good is this butterfly hook. Kind of incorporate some bilateral stimulation. Basically, you're crossing your thumbs and do alternate tapping. It can happen on your chest. This can be good, can feel good to folks, arms, thighs. That said, moving through like a mental process, like we'll go through the senses and movement together can also be challenging. So just like whatever feels good for you or for somebody else, but offering options like that. Basically, how we do this is we just orient ourself in space. So we'll begin by just gazing around the room that we're in, just looking around to see where you are and acknowledging that you have senses, that you'll be accessing them and taking inventory. And beginning by looking around and trying to just locate without necessarily making a story about them, locating five things that are the color blue. And if you're somewhere that doesn't necessarily have a lot of blue, you can choose another color, but you'd be surprised at how many like shadows or reflections might have that. Just noticing. So that was sight. And then moving into touch, touching four things just around you and just looking, feeling what texture they are. If you're doing the bilateral simulation, maybe it's this shirt that you're currently tapping on or your pants or whatever you're wearing. We touch so many things all day long without thinking about the texture. And so this can be really just good for folks. And then going into sound, three things that you can hear. And it can be helpful to move from furthest to closest. So something in the distance, something closer. If you're somewhere very silent, it might even be your breath. And then moving your attention to your nose, take a whiff. Maybe there's two things that you can smell, maybe just one. Maybe you have a stuffy nose like me. The seasons are changing. And then finally moving your attention to your lips and mouth and trying to identify if there's a taste still lingering in there that you can bring your attention to. And then finally, trying as best as you can to bring awareness to that full spectrum of sensation of yourself within this environment. So where did you, what did you see when we were looking around? What textures were you feeling? What were you listening to? What did you smell? What could you taste? And how many of those can we incorporate into a larger picture? And that one can be really challenging because our brains are quite literally wired to not take in all of the stimulation and be kind of overwhelming as well. But it's a really good, it can be a powerful way to come into the moment. And if you still have like a bilateral hook going you can release that as well. But yeah, so those are just like two different, like way different exercises that are both considered meditation. And they feel so different and we'll actually share a little bit about if you did it and you don't have to share of course, but basically quick note on sharing. So the only reason I have this slide in here is because I feel like mindfulness and meditation are really considered solo activities, but a lot of that community reintegration and the community like resilience building that we see in TBI especially comes from sharing. And so that can come from like the peer support, normalizing conversations for folks sharing can help process one's own experience and develop compassion towards others. So that's just like a little note. So not only encouraging patients to like employ these tools but then also following up and asking them, how did it go? How's it been going? And that can also deepen their practice as well. Okay, so yeah, quick reflection. What were the experiences like for you? What came up? What was challenging? What was natural? You can show us your drawings. But basically the blind contour drawing is just this tool to bring focus to observation skills rather than memory, especially if there's like an emotional component attached to someone's memory or a loss thereof. So if somebody comes to you and it's like their memory is something really challenging, their cognitive functioning has been impaired, this can be like a really powerful meditation to help someone feel really empowered by their observation skills and develop some hand-eye coordination as well. And then the five senses meditation is, yeah, just a way to ground into the moment and enhance experiences, especially if someone feels like a little bit more detached from their body as well. And so, yeah. Is there anything you all wanted to share? I can show you. This was me, Dr. Tiwari, Kristen, looking good. Yeah. Oh, nice. Whoa, you did that without looking down? I tried. That's incredible. So that's Lily. It looks like a spitting image of her. Yep. Nice. Beautiful, Kristen. Yeah. Cool. Very cool. So let's see. I think we might have a little break coming up. Yeah, so we'll take a little break. If you'd like to participate in a mindful eating exercise, like when we come back. So it's 12.50, let's say right now for me is central time. So we're at 50. We'll come back in like six minutes at 55. But yeah, if you want to grab like a tiny snack, I know it's also lunchtime. If you want to go like deep into your lunch, that's totally fine too. But we'll take a break and then come back and do like a mindful eating exercise and then talk about some resources and then yeah, connect. We'll open up the space as well, a little break. Well, if you're still aware, just coming back, that's totally fine. You can just listen to me in the background. But moving along, because I've been talking for 55 minutes, I want to make sure we get to resources and that you all get a chance to share your resources as well. Real quick, so how is mindfulness different from meditation? So we're at the third discipline that we were going to, that we wanted to hit today. We've talked about yoga, we've talked about meditation. Now we're talking about mindfulness. How is it different? So it is a form of meditation, and it's different or unique in its way because it's a technique, more to direct your focus on the current moment. So it's more of a witnessing versus a focusing, whereas meditation's a focused event. And mindfulness is a witnessing and lots of overlap as well. So what is mindfulness? Mindfulness means to pay attention to our present experience, our thoughts, emotions, sensations, environment, with this openness and curiosity. It is this tool to be with or work with the nature of life, with the idea that when something happens, rather than being so reactionary, there's a little bit of space created to respond in a way that feels more like aligned with who we really are. And so it's not necessarily about a destination or a goal. We're not really trying to get anywhere. It's just this exercise, again, in witnessing and about focusing your mind on the present moment without worrying about the past or future. And that's really the key to it. So there's truly no right or wrong, but the idea is to not have any judgment involved. And mindfulness-based interventions cultivate that. They cultivate that self-regulation of attention to the present moment with non-judgmental acceptance, which can be really important when you have traumatic brain injury and your life has changed in a big way, especially from the acceptance point of view. And so that can be a really good way, a really good tool. Something to note, though, and something to share with patients is that while it helps us achieve peace, it is not necessarily always peaceful or relaxing in the moment. That said, mindfulness helps us work through challenging emotions without being attached to them so that you might even find a little bit of comfort in them, too. So just by, actually, really good. So the waves are here. A really good way to conceptualize this is like all experiences, so physical sensations, emotions, thoughts, they have a beginning, a middle, and an end, just like a wave. And so mindfulness means noticing our experiences, both the positive and the negative, as they arise and as they pass, just like a wave. We do this without being attached, without running away from the experience, because we always know if we have this core belief that like a wave, everything passes, it arises and it passes, it can help us with challenging experiences as well. Another water-themed analogy is a waterfall. If any of you have been underneath a waterfall, they're incredibly beautiful, but being underneath one is a harrowing experience. It's a lot of force. And so the feelings and emotions that you experience in your everyday life can be like the water of a waterfall, and you can choose to be right under it, or you can take a step back and view it without being flooded on your head and your shoulders by these emotions and these feelings. So the waterfall can be a good way to conceptualize as well. I think with mindfulness, it's interesting to notice how like when things change inside of you, things tend to change around you as well. So how does mindfulness affect the brain? Let's see. Again, increased gray matter over time, especially in the hippocampus, structures related to self-awareness, compassion, introspection. We see a thickening in the cerebral cortex with again, attention and emotional integration, decreased density in the amygdala. And yeah, the longer-term practices may also produce changes in the insula, which is like a harder one to get to, which can be associated with self-awareness. So a larger mindfulness-based intervention for mild traumatic brain injury had highlighted that the brain regions that are typically affected by MTBI, so frontal parietal white matter tracts, were the same ones that were also bolstered by mindfulness-based stress reduction and MBC, Tusa Mindfulness-Based Cognitive Therapy. And yeah, let me see if there's anything else I want to say about this. I think we've covered it. Let's see. So again, just kind of showing these, the frontal parietal, reminding ourselves what all the wild things that these brain structures do. So zooming out, mindfulness can help with a lot. So the self-acceptance piece is huge. That cultivates our ability to be with what is, again, to be more aware of and enjoy the positive experiences, and then being able to cope with challenges as well. Awareness and self-regulation, so reestablishing that healthy relationship with our emotions, our thoughts, and our beliefs, so that we can keep them in perspective as messengers of telling us when we're on or off our course. The mental health aspect, so it can reduce anxiety and stress, creates just more space to be with greater kindness with ourselves, which can be really important, especially if somebody's at a longer recovery and rehabilitation path, instead of just like, it can be really, I mean, there's this fascinating statistic that for every negative thought, we need six positive ones to overcome it. And that's purely just because negative thoughts used to help us survive when there were lions and tigers and stuff, and we don't need them anymore, but our brains are still catching up to that, that we don't need to anchor in to the negative cognition behavior. So it can be a practical strategy to slow down, gather attention, consolidate memory, behave more skillfully, and the empathy and compassion piece as well. So mindfulness is this ability that all humans have, and it's just a muscle that we have to practice, and part of the practice is mind-wandering and it's just riding those waves of thoughts and emotions rather than trying to stop them. So mindfulness as therapy. It's pretty new. It entered modern medicine in the 1970s. This is a smaller infographic, but mostly to show that there are steps that have been taken as mindfulness as therapy, but it is relatively new. Two methodologies that are particularly popular are MBSR, which I've mentioned, and MBCT. So MBCT tends to target specific conditions, whereas MBSR is more of this generic application that's applied to stress in a variety of life events. And MBCT, mindfulness-based cognitive therapy, has shown a lot of decreases in depressive symptoms, especially when compared to psychoeducation, so it's quite effective. And that can include body scan, yoga, walking, seated meditations, sitting, mindfulness, stretching, a whole host of different therapies. Okay, so let's practice. If you picked up a snack like I did, I got a blueberry, we are going to do something called mindful eating, and this can be especially powerful for people whose appetites have been influenced in any way. Maybe it's nausea, maybe it's through nerves, maybe there is some GI considerations that can be really powerful here, but it's a good one for anybody because we all tend to eat something throughout the day and it's a good way to slow down, it's an opportunity to slow down. So if you have a snack, actually let me know what the snack is so I know how to cue. Oh, we have chocolate, that's such a good one, that is a very good one. And then Kristen, do you have a snack? You can also practice without one. Is that a little candy as well? Yeah, it's a little Jolly Rancher. So it's a hard candy. Okay, awesome. So interesting. So we'll have like slightly different experiences, but now that I know you have like wrappers and stuff involved that helps. And I have a blueberry. And so what we will do for this mindful eating exercise is we'll place our snack in our hand and we will take time to really see it. So gaze at your candy and you might even choose to unwrap it at this time. Gaze at it with full care and attention as if you are this being that landed from Mars and you've never seen this thing before. Really let your eyes explore every part of it. And that might include the wrapper as well if you want that to be a part of it. You can examine where the light shines on it, if there are any darker hollows, if there are any folds or ridges, any asymmetries, unique features perhaps. Just taking a moment to really look at it. And now touching, and this might be more challenging if you have something that can melt in your hand, but just turning this snack over between your fingers or in your palm, whatever feels good, but just exploring the textures. And you could even close your eyes for a moment to see if that enhances the experience of touch. But as you're here, you might even choose to think about what it took to bring this object into your hands. Did it require soil at some time? Was there, was the sun involved, the labor of humans? Maybe you think about the transportation to where you purchased it or came into contact with it. Maybe it was a loved one that brought it for you. Perhaps you brought it for yourself to nourish yourself. And as you touch it, you can even choose to show gratitude for the many factors and people that made this tiny little snack possible. And once you feel like you've really got a sense of what it feels like, the textures, the texture might even be changing in real time, holding the snack underneath your nose and drinking in whatever smell that might arise. And as you smell it, however fragrant or not fragrant it is, you might even notice that you're, that something interesting might be happening in your mouth or in your stomach in anticipation. And you can choose to slowly bring it up to your lips. And even in this moment, like noticing how your hand and your arm know exactly where to position this, and you can gently place it in your mouth, but we are not going to chew. And you're going to notice how it gets into your mouth in the first place, and then spend a few moments just exploring the sensations of it just in your mouth. You can move it around your tongue if you'd like. And like really resisting that urge to really engage with the chewing process. But when you're ready, you can either prepare to chew or if it's a hard candy, like just have it in your mouth, but just noticing where and how it needs to be placed in order for you to engage with it further. Just being very conscious of either the biting or the movement, noticing the experience and the taste that emanates as you engage with it. And you might have swallowed already, but if you haven't, just noticing those bare sensations of taste and texture, how they might change over time, moment by moment, any changes in the object itself. If you want, you can close your eyes again for a moment to see if that enhances the experience at all, enhances the taste. And on your next swallow, when you feel ready, you can see if you can first detect the intention to swallow as it comes up. So even that intention is experienced consciously. And then following it down, see if you can follow what's left of it or left of the saliva that's helping it move down as it goes down into your stomach. And then sensing how the body feels as a whole after completing this mindful eating exercise. So yeah, that is mindful eating. And curious if any of you have done this before, what it was like for you, or even if you don't want to talk about this, if throughout this conversation, something has popped up in your brain and you're like, oh, I'm actually mindful about something in my life already and what that thing might be, if you want to share. I think my body just wants more chocolate. Like your body might just be like, I'm hungry. It is. This was great. Give me more. Awesome. Yeah, so there's like that satisfaction level and also that like, I'd like more. Cool. Yeah, so this is just a quick one. I tend to do this during breakfast. I don't do this with every bite, but that would be highly inefficient for Wednesday, but it can be a good one to incorporate. So this is just basically evident from today's talk, meditation, yoga, mindfulness, all of these things have significant overlap. This is how I contextualize them. So within yoga, we have meditation. Within meditation, we have mindfulness and the breath is the basis of all of this. The big picture for us here is basically to know that through meta-analyses and, yeah, collating studies that we know that mind-body practices have a moderate effect on depression, anxiety, stress. They can improve cognitive function, pain management. This particular one, you might've seen it referenced throughout today's deck, but it was a recent meta-analysis among adults with mild traumatic brain injury that pooled 20 studies and found that there were significant improvements in overall symptoms, but especially those related to mental health. Physical outcomes, I think, are really important, especially pain and pain intensity, quality of life and self-related processing, especially locus of control. And the greatest improvements were in fatigue and depression. And that's probably because a lot of the therapies that have been developed are mostly rooted in targeting this, especially mindfulness-based cognitive therapy. So, yeah, and this particular meta-analysis had identified a few research gaps to fill. I bring these up because maybe if you're interested and you want to fill these gaps, this is a place of opportunity. There was only one study with folks with repeated injury, and it's really important to look at this group further because we know that repeated injury is associated with greater symptom severity and duration, greater neurological damage, neurodegenerative diseases. There were no studies with youth and adolescents, even though this is a really major health concern among youth and adolescents. A second gap was in measurement techniques. So they relied too heavily on self-reports. There weren't really any studies that took on neuroimaging, likely due to cost or accessibility, didn't look at changes in cerebral blood flow, among those with traumatic brain injury. There are a lot of other studies that look at these things and other settings, but not among TBI. There was a gap in sleep studies as well, especially, which feels like a big one because there's a lot of research highlighting that sleep is very important for brain health and TBI can cause impairments in sleep-wake cycles. It can increase the risk of comorid disease. So this is important to look at. Follow-up especially is important to look at to see if these are sustainable practices, if the effects are seen over time. More population details can be definitely very helpful. So do folks have prior meditation experience? Is there a medical history before injury that puts them at higher risk for mental health concerns? And just to see how that might affect how these interventions work. And then mechanistic analysis would be so great to know. Like what from a biological perspective of mechanism analysis, how do we know what part is being affected by yoga, meditation, mindfulness? There's one study that has suggested that yoga and meditation modulate IL-6. So kind of like suggesting that there's like an inflammatory pathway that is affected and that's why pain and depression are relieved through these practices, following a mild traumatic brain injury. So that's really cool. But more in that line can be really effective and have downstream effects, especially for coverage through insurance too. Like the more research, the more folks can get paid and greater accessibility for these. So Love Your Brain has this... Love Your Brain is this organization that partners with studios and yoga teachers and meditation teachers across North America and internationally as well. But through their analysis of folks with traumatic brain injury, they saw that through a six week program that they offer free of cost. There were significant improvements in quality of life, resilience, cognition, positive affect. A lot of these participants had reported improvements in strength, balance, flexibility, attention control, that community integration perspective, group rehabilitation can really just increase a sense of belonging and connection and a self-empowered ability to move forward after injury, which can be really challenging for a lot of folks. So that community aspect is really great. And they actually just published a crossover pilot study investigating if this six week program and community program would be effective, accessible feasibility or accessible or feasible for adults with MS. So it's cool to see this branching out for more than TBI. And there were really positive results from that. So a little bit more about Love Your Brain. So I do serve on the advisory board for this organization. They're a nonprofit that was established after a man named Kevin Pierce had a severe TBI. He was training for the Olympics. He was like Sean White's number one nemesis and fortunately took a really big tumble on practicing for the Olympics in 2010. And basically I think what this family saw was that brain injury can be incredibly isolating and disempowering. And so group programs like Love Your Brain have the ability to rebuild community and sense of resilience for healing. And so there are a number of programs that they offer free of charge that are research backed. There's the yoga program. So the Asana physical postures, they're in person and I believe they've offered them virtual as well. They have a clinical affiliate program that's really interesting. So if you want to have them at your rehabilitation center, at your hospital, they train folks to offer that. There's an online caregiver retreat. We see that caregivers are really burnt out, also feeling incredibly isolated and deserving of empowerment as well. So that can be a really great place for caregivers and community retreats that are in person. So this is a four day retreat free of cost in Maine and Colorado where people with TBI, many of them are meeting like somebody else with a traumatic brain injury for the first time. And so it's like a really powerful place for people to just feel seen and supported. And then there's online programs as well. So there's the online yoga, online group discussion, which is meditation with like facilitated discussion or on your own for people that really need to pace. And like the computer just doesn't feel like an accessible way to connect with other people. Maybe they have to do it at their own pace. And so, yeah, that's Love Your Brain, really a great organization. And they also have a film that the brothers, that family made, Adam and Kevin Pierce called The Crash Reel, which can be a great way for people with TBI to also feel seen without necessarily connecting because it shows the story of this family. And yeah, it's just good. And so an example class is basically 90 minutes. Much like today, there's breathing exercises. We didn't do the physical postures, the yoga, but there's gentle guided meditation, relaxation, and some facilitated discussion with psychoeducation where that community aspect is really forged. Some other resources. These are like really now very commonplace ones, but in case you wanna point your patients to some apps, there's Headspace. I believe it's free for 30 days. Might be through the Starbucks app still. There's like a portion of it that's available on Netflix. So there's a lot of different things, a lot of footholds that Headspace has. Insight Timer is a good one. This one with the four panels is Yoga Glow. I really like their interface because it almost makes it feel like you're in a studio, but you can practice from home. And there's also free trial for that. And then the Calm app, especially for somebody that requires a little bit of guided meditation into sleep, like if they're having challenges with sleep. Progressive muscle relaxation can be really good for that too, but a guided meditation can help. And Calm has some really good ones. Some books that I love. The Body Keeps the Score. That's written by Dr. Vandercook. Eckhart Tolle's books are really good. James Clear's book, Atomic Habits, is like incredibly popular. And the reason I put this in with like meditation stuff is because again, it's just like creating a habit and that can be really great. And then there's this one. I've just chosen one of Thich Nhat Hanh's books, but he's a global spiritual leader, poet, peace activist, who recently passed. And there's a lot of like little how-to books. There's like how to love, how to fight. And those are really, they're actually fantastic. So I have these in here as well. Other free yoga and meditation resources for TBI. So we've got Love Your Brain. Dr. Kristen Neff's self-compassion exercises. There's online mindfulness-based stress reduction as well. And Yoga International has a free 30-day trial as well. So these are all resources. And I'll pause here just for a second if you want to jot anything down. And I believe the recording is going to be available as well and I believe the slides too. So those are some. Finally, we have gotten to the point where you, if you have a resource or something that you'd like to share with the group, this is a great place to share or even question. I have one resource, but it's kind of geographically specific. So if you're in New Jersey, there's a traumatic brain injury fund and patients like we just fill out a very brief form and it lets patients use it for by insurance. So I have had some patients have things paid for, like not exactly this kind of mindfulness, but I would imagine this would also be paid for. So there might be a resource if you find yourself in New Jersey. Oh, that's great. Thank you so much, Kristen. Cool. So, yeah, as we kind of wrap up, I think from like a personal perspective, physicians and folks in health care and people that are like really at high risk of burnout, unfortunately, just like little cues for yourself to like showing yourself all the kindness that you show your patients can be incredibly important. So just like those posturing, your breath, your thoughts. But yeah, so here we have our references, feel free to dig through them. And then this is my contact information, Dr. Tiwari's contact information, if you have any questions or want to, if you have like, even if you don't know where to point somebody, I'm happy to like dig into my network of like what resources might be available. But yeah, definitely feel free to reach out. Yeah, that's it. Wonderful. Thank you so much. I have one question. So, you know, a lot, all us working in brain injury in general, so this might be outside the scope, but do you have a sense that these things might, in general, have any like studies that support using it in patients with stroke or tumor resection, which are more of my patients, although I do have traumatic brain injury patients. And then if that's outside the scope, I totally understand. But people do tend to ask me about stuff like that, who've had strokes and other types of brain injuries. I, well, I'll let Dr. Tiwari speak to this too, if she has anything to add, but stroke, especially, yes. Like so many of these studies are among patients with stroke, the love your brain. Honestly, a lot of the people that I see through love your brain. So through my advisory position, I also serve as a meditation teacher for them as well. And a lot of the folks have acquired brain injury too. And these are incredibly helpful for folks with stroke. Of course, it can feel like when you put people together that have such different like symptom constellations, it can kind of feel like less relatable, of course. But just for stroke patients, yes. And there's so many studies. I can try to dig some up for you too, for some like specific meditations that are good for stroke. But yeah, there's- It's okay. I don't want to put you to the extra work. It's just nice for me to have that as, you know, to offer when patients, a lot of my patients are post, they're either, they're well after their initial injury. And we're sort of working towards secondary stroke prevention and like, what else can we do when therapy has ended? And that's the part that I try to work with people like this is the, you know, the stroke results are here with us forever, but we can still push things in a positive direction rather than them just feeling abandoned because their formal therapy ended. Exactly. And so I think, yeah, there's so many, there's so much there, but like the community piece, super applicable still there. The acceptance piece, maybe even more so. And so, yes. And you can absolutely like for Love Your Brain specifically, you can share that resource with folks with stroke. But all of this is like, this talk could be for any patient population, human, et cetera. And they're just, I just happened to bring the studies that are specific to TBI, but really every single person can benefit. It's just about how to adapt, especially for reaching physical postures and breathing exercises, because quickening or slowing breath can be really uncomfortable for different patient populations. So I think those are like the safety considerations. Absolutely. I think, you know, when we have certain patient populations who feel like they don't have control over what's happening to them, giving them something that gives them back some sense of control, whether it's home exercises or meditation, things that they can kind of take with them and do actively engage in. I think that definitely helps the healing process. There was that one book for yoga specifically, but I know there is, there it is. Yeah, Yoga Therapy for Stroke is a really good book. Cool. Lily, did you mention that there was something at the end that you wanted to share? No, no, we're all good. Cool. So Lily, is it correct that this is available later? Because there was a lecture yesterday I really wanted to go to about like, you know, women physiatrists finding balance, but I had another obligation. And then when I went, I clicked, it said this was live streamed, it's over. So how would we access that if we couldn't get to it at the time? Yeah, the recordings are going to be posted back into the meeting platform for a few months. And then I believe it's in February, they're going to, the platform is going to go down, but all of the content is going to be posted into AA Rewind. So probably this was like only at five o'clock yesterday. So there's just like, wait a little while and it'll go up. Okay, thank you so much. Yeah, no problem. That's both me and Dr. Tewari again. And yeah, that's all we have today. I just want to thank everybody for spending your afternoon with me a little bit of it. Thanks so much, Dr. Tewari for sharing space. I really appreciate it. No, absolutely. We're happy to have had you.

yoga

meditation

mindfulness

therapeutic benefits

traumatic brain injury

TBI

breathing exercises

brain and body

stress reduction

self-awareness

community integration

Love Your Brain organization