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Daniel Yazbek

Understanding Dysautonomia and the Autonomic Nervous System with Daniel Yazbek

Daniel Yazbek

Understanding Dysautonomia and the Autonomic Nervous System

Today we’re chatting with Chiropractor Dr Daniel Yazbek about Dysautonomia.

Dysautonomia refers to the abnormal regulation of both the sympathetic and parasympathetic branches of the autonomic nervous system. Many conditions fit under the Dysautonomia umbrella, including post orthostatic, orthostatic tachycardia syndrome, and orthostatic hypertension. Today we discuss the assessment and management of these conditions.

About Daniel Yazbek

Dr Yazbek is a chiropractic clinician in private practice for the past 5 years. His clinical application in everyday practice concerns the diagnosis, treatment and management of neuromusculoskeletal and spinal-related disorders. He ensures that every treatment decision surrounding a patient’s health encompasses sound clinical reasoning and an ethical, all-around evidence-informed approach.

He completed an undergraduate degree in Exercise & Sport Science in 2012 and a Masters in Chiropractic Science at Macquarie University in 2015. His unique special interests are within functional immunology, clinical and functional neuroscience, motor control & learning, sports and exercise medicine, as well as general, integrative & lifestyle medicine.

He is currently in the final stage of completing his Diplomat of Chiropractic Neurology with The Carrick Institute as well as Practitioner Certification with the Institute for  Functional Medicine, which will complete the circle of knowledge necessary to address his patients’ needs from all angles.

After successfully establishing and developing The Chiro Hub over the past 4 years, he has now entered a phase of expansion as his practice transitions to become Insight Health and Medical, with the enormous task set to amalgamate medicine with his niched allied health perspective.

Connect with Dr Yazbek:

Website: www.chirohub.com.au 

Instagram: www.instagram.com/thechirohub

Facebook: www.facebook.com/YazbekChiropractic

References:

Nerve Express: www.nervexpress.net

Transcript

Introduction

Andrew: This is Wellness by Designs, and I’m your host, Andrew Whitfield-Cook. Today we’re speaking with Dr Daniel Yazbeck, who’s an expert on dysautonomia. So, obviously, we’re gonna be speaking about this. Welcome to Wellness by Designs. Daniel, how are you?

Dr Yazbek: Well, thank you glad to be here. I’m excited to talk about dysautonomia, and ways we can potentially assess and manage it from a, more so from a non-pharmacological perspective.

Andrew: Now this is great stuff because we’re going to be talking about some quite technical aspects, but we’re going to explain it in a way where practitioners can take it and use it in their clinic tomorrow, so that’s fantastic. But we first got to start off with the definition, dysautonomia. Now, I’ve got a definition in my head. But can you clarify that for us, please?

Dr Yazbek: Yeah, generally speaking, dysautonomia is essentially the abnormal regulation of both the sympathetic and parasympathetic branches of the autonomic nervous system. So, I mean, we’ve heard of things like, you know, post orthostatic, orthostatic tachycardia syndrome, and orthostatic hypertension, they both fit under the umbrella of dysautonomia. So, essentially, it’s just a dysregulation imbalance between parasympathetic, sympathetic systems at rest, or during, or the onset of exercise and the imbalance throughout exercise.

Andrew: Okay, just as a sort of side thing of that, you know, we have periods of the day, for instance, where we are in, or supposed to be, in more, let’s say parasympathetic dominance, like eating, like sleeping, showering. And then, of course, there’s the sympathetic dominant aspect of our lives. There’s the exercise, there are the work stressors, which is something that we have to handle, but we manage it. So, I guess what we’re talking about here is when that management just goes awry, we don’t come back into a balanced state. Is that correct?

Dr Yazbek: That’s correct. That’s correct. So, essentially, yeah.

Andrew: You keep going with this.

Dr Yazbek: So, yeah, we do have, like, you know, a diurnal variation of our autonomic response. Generally speaking, when you wake up, our sympathetic nervous system is slightly more elevated than our parasympathetic. But as we tend to head towards the end of our day, our parasympathetic nervous system generally is supposed to kick in to set us for that rest and digest mechanism prior to the end of the day before sleep. And so that can… So, gonna go on so.

Andrew: So, you know, this is something that’s always interested me is like, for instance, let’s say the reticular activating system, the RAS, we’re supposed to wake up when light hits our eyes, sunlight hits our eyes. And we’re supposed to just have this lovely little yawn, and bang, we are awake, and we get on with the day with a smile on our face. That ain’t happening to many others. So, yeah, take it from here, like lead us through what’s going wrong with this for a start?

Dr Yazbek: Yeah. Yeah, well, there are many mechanisms involved in maintaining or regulating the autonomic nervous system. Let me start from the top down. So, you know, generally, we have, you know, our midbrain reticular activating system, which is very much governed by our higher cortical function. So, generally, the three main areas within our central nervous system that regulate the autonomic nervous system is the cerebellum, the mid-portion, the brainstem being the pons.

And these two areas have a very intimate relationship in increasing parasympathetic tone and downregulating sympathetic tone. And that’s very much governed by the medial frontal, the prefrontal cortex of our brain, which has an ultimate result in descending inhibition of the sympathetic system. So, any dysregulation to those areas, whether it be from concussion whiplash, or head trauma, or even a quote chronic low-grade infection.

With the release of your interleukin one, two, and your other inflammatory cytokines can certainly cause some dysregulation to these areas and can set you up for a cascade of autonomic dysregulation, especially throughout the day. So, the times in which you’re supposed to be waking up feeling fresh, you’re fatigued and the time that you’re supposed to be feeling cool, calm and collected before bed, it’s reversed. So, you can tend to have a reversal in your sympathetic and parasympathetic systems throughout the day.

So, pretty much we have, yeah, so that top-down effect and also you have to take into effect the pharmacological aspects of our sympathetic parasympathetic nervous system, our running angiotensin, aldosterone system, and many things like that. Neuroendocrine function, hormonal level, stress levels, things like that. So, they all play a part in the mix, in determining the final output of obviously, etheric and parasympathetic branch of the nervous system.

Andrew: Yeah, I think this is something that we tend to oversimplify very, very commonly. And we just go, “Yeah,” like, it’s the nerve sort of thing. But there’s, as you say, as hormonal overlays, there’s pharmacological, there’s light, there’s behaviour, there are all sorts of overlays. Can I just go back to something you said before, the cerebellum? Now, normally, I would have associated that with fine motor coordination and things like that. Obviously, I’ve missed something here. Tell me what’s going on here.

Dr Yazbek: Yeah, there’s been some research into how the cerebellum coordinates behaviour from a notorious movement perspective which, you know, the fine-tuning, the coordination, ensuring that endpoint movement is, the output is in sync with what we originally intend for our limbs or for our bodies to do. So, when our cerebellum goes haywire when we have, you know, for example, autoimmune aspects, autoimmune degeneration to the cerebellum, or any other aspect, the cerebellum also can fine-tune the autonomic nervous system response.

So, if it’s involved in the stopping and starting and movement, and the coordination and movement, then it also has an effect on the coordination of our blood chanting response, the autonomic response, but also cognition as well. So, it’s very much involved in the cognitive aspects. It’s very much involved in stopping and starting and the appropriate intensity in the coordination of the sympathetic and parasympathetic branch of the nervous system too.

So that’s very, very important to know. A lot of times, our treatments are very much looking at vagal tone, improving the efforts from the gut back into the central nervous system hierarchy. But we have to also look at the top-down perspective in how the cerebellum integrates with our midbrain, same level as well.

Andrew: You know what, it’s raising a historical issue with me, and that is that we’re talking at least a century ago, possibly two people didn’t sleep lying flat. They used to sleep propped up very much on pillows. And looking back on, I’m gonna say, my young and silly days, where I might have drunk too much alcohol or something like that, and you couldn’t sleep, you’re lying down. I have a couple of episodes in my head, and you cannot feel rested. You search for lying flat. And I’m wondering, is that hooked into this cerebellum thing with fine motor coordination, with breathing, with the prefrontal cortex, is that all tied in together?

Dr Yazbek: Definitely, definitely, 100%. One of the things you can do to look at the integration of the cerebellum and supine to standing is, you know, for example, if you wanna know if the brain cerebellum, the high cortical aspects involved in dysautonomia, you can get the patient or the clients to perform arithmetic. So, for example, you know, calculating numbers. So, for example, if I mentioned repeat after me backwards, 6, 14, 20. They mention 20, 14, 6, and then they go to stand up and you ask them to repeat three numbers backwards, it will take them a much longer time to be able to repeat those numbers.

So, you know, things like that are a really good way to have a look at the top-down approach from supine to standing if the latency or delay is much greater than repeating those numbers backwards, it suggests some type of cognitive aspects to the dysautonomia as well. And so that’s really important to look at.

Andrew: Yeah, just as a differential, though, would you have to be very comprehensive in your assessment, so that you don’t confuse things like dementia, vascular dementia, things like that?

Dr Yazbek: Yes. Yeah, very important. So, a thorough examination and a pool of questions to tease out you know, Lewy Body disease, alpha synchronalopathies. These things like that are very, very important because even in those populations have been shown to have some dysregulation of the autonomic nervous system. And so yeah, that’s where very strong diagnostic skills, thorough questioning, examination and history is really, really important to really rule out, in fact, pulled out many other causes to dysautonomia.

Andrew: Let’s go further into the symptoms of dysautonomia. You’ve mentioned a couple there, which is more of an assessment but one of the major presenting symptoms of dysautonomia apart from what I would have thought is feeling stressed or not being able to get to sleep.

Dr Yazbek: Yeah, sure. So, it really depends on if someone’s sympathetically or parasympathetically dominant. With those who are sympathetically dominant, it’s quite not uncommon to find people with SIBO. Or, for example, malabsorption syndromes, or they feel is that their heart’s pounding out of their chest when they go from supine to standing, this is an indication of very much involved in hyper regulated sympathetic nervous system. Also, they might have, you know, a history of urinary tract infections.

So, the parasympathetic system is involved in the micturition reflex around the ability to void. So, history of UTIs, SIBO, chronically elevated heart rate, blood pressure, or even, for example, high blood sugar, which is another example of people who are sympathetically driven. Because the sympathetic tone, baseline sympathetic tone to the pancreas is such that it helps reduce the insulin response, whereas the parasympathetic function is to increase the insulin response.

So, people who are the opposite, highly parasympathetic dominant, will tend to have more low blood pressure and low blood sugar, blood glucose levels as a result, that’s a very generalized statement. That’s if everything else is held equally. But as a general rule of thumb, that’s something we tend to look for as well.

Andrew: Got you. You had to get me thinking there when you said insulin response, rather than insulin. It’s the response of insulin put there.

Dr Yazbek: Yes, yes. And also to, you know, just by observing the discolouration of the hands that have cold hands, cold feet, is it cold and sweaty or is it cold or is it warm and sweaty? So, some of the really high key sympathetic response will tend to have more, more of a warm and sweaty hand or a high sympathetic response can also be a cold and sweaty hand. But when the sympathetic system goes down, you’ll find that they will have more cold and dry hands. So, that’s a really good differential diagnostic that clinicians can use in the clinic. It just requires a pair of hands and palpate and feel for, you know, the sweating response and temperature as well.

Andrew: Got you. Part of this sort of thing obviously is adaptation, and resilience of somebodys… No, resilience, just keep it at resilience. So, I’ve covered this sort of ages ago, and that is, as somebody’s reserves dry up, their adaptation to a stressful stimulus becomes less, they just can’t react to things. And so, instead of going from this, you know, huge, let’s say a startle reflex over time they just simply can’t give that startle reflex response. So, it just becomes this lackadaisical response. And that is at odds with somebody who is hyper-vigilant. How do you govern where they’re at along that line of hyper response, normal response, hyper response, and then they’re just they’re knackered, they’ve got nothing left in the pot?

Dr Yazbek: Yeah, it’s really interesting. I think, to address that we, I mean, we really need to look at objective markers, I believe. So, looking at someone’s cortisol awakening response is one method of looking at that or gauging that, because looking at the general trend of cortisol throughout the day will give us some insight as to how well they’re churning through that sympathetic reserve. And it can take months or years for our sympathetic nervous system to, you know, to crash and thereby leaving us with not much sympathetic reserve as well.

And then, we also have to consider parasympathetic reserve. Because, you know, people always talk about being overly sympathetically dominant, but being overly parasympathetic dominant is also a concern for us, and a parasympathetic person may, you know, may not always be more adaptively healthier people. So, that’s one thing, you know, one thing to look at.

So, I’d say that the cortisol awakening response, and being able to quantify the nervous system is important. And just really gauging those responses and measures and ensuring that the person does maintain some state-level within those systems.

Andrew: How do you check the parasympathetic reserve? Do you frighten them? Do you give them a sympathetic stimulus?

Dr Yazbek: Yeah, so basically, what you can do, really the only way you can really test for it is by certain technologies that can actually look at the actual parasympathetic response. And there are technologies out there and software that, you know, type technologies out there, the one I tend to…the one I like, that I have in my clinic is called Nerve-Express. And, basically, it just quantifies the RR interval between SA node intervals and the blood group, the heart rate, blood pressure response, and it has an inbuilt algorithm that actually tells you the parasympathetic and sympathetic response.

But other than that, it’s pretty hard to actually just be the pair of hands or a stethoscope to see how well someone’s doing from a parasympathetic standpoint. Generally, if they’re standing up and their parasympathetic reserve is very low they will tend to not be able to, you know, shunt, you know, blood to the core. And so, the majority that could, due to gravity fall down to the extremities, and therefore have an increased sympathetic response to pump more blood up to the brain. So, these aspects are very important. But you need certain technologies to actually quantify those branch nodes because it can get very tricky. There’s so many variables involved that can be really, really tricky.

Andrew: Yeah, I was imagining, for instance, you know, one of the ways to trick yourself into decreasing heart rate transiently is to get to do a Valsalva maneuver. Is that important in this?

Dr Yazbek: Yes. So, basically, when someone has… Yeah, so basically, when you perform a Valsalva you increase intrathoracic pressure. And as a result, you increase the expulsion of blood from the carotid baroreceptors. And so basically, what happens is, you actually can use this bedside. You can apply a stethoscope to the S1 area of the chest wall, and then occlude their carotid arteries on the right side of their neck. And what are you supposed to hear for is a gradual decrement, or decrease in their baseline heart rate.

Now, if you don’t hear a decrement or decrease in the baseline heart rate after or during carotid compression, then that generally shows that they’ve lost some parasympathetic tone. Because the glossopharyngeal nerve that innovates the carotid baroreceptors send information to the medulla, lower brainstem and then that fires down to then reduce the heart rate as a result from increased pressure from the occlusion.

So, by not having a blood, their heart rate drop after it or during the occlusion, that suggests that some type of decrement or decline in parasympathetic function. Conversely, if you, if you hear for the heart rate to drop, but there’s no increase at all, especially when they expire after the Valsalva that shows that the sympathetic reserve is somewhat declined as well. So, this is a really good baseline test that you could do to kind of tease out which system may or may not be working so well.

Andrew: I would imagine that that technique, though, would have to be taught to you by an expert because that could be quite dangerous, overstimulating, over massaging the baroreceptors in the neck, yeah?

Dr Yazbek: Yeah. Very much so. So, that’s why it’s really important just to you know, just to gauge their, you know, take a really good history, observe their, you know, take a really good history and ensure that you know, there’s a potential risk of doing, you know, some type of syncope involved. But, generally speaking, a slight amount of pressure can be justifiable and you can do…it you can elicit an actual response. It doesn’t have to be that hard. But if you find that you could potentially do it on the supine position rather than a standing position, if you’re concerned, things like that.

Andrew: I was actually wondering if there might be some merit in looking at the difference between standing and supine Valsalvas. Does that give you any information?

Dr Yazbek: Okay, yes, it can help you. Yeah. So basically, yeah. So, essentially, you’re gonna have in supine position. So, if you were to occlude the carotid body and perform a, listen to their heart rate as a result if you don’t feel, if you don’t sense a decline in their heart rate, then you can say that their sympathetic is overexcited, or their parasympathetic system is not kicking in, and then they get into stand up and perform the same test. When they have that gravity component to it, then it’s gonna affect things as well. So, I haven’t really tried that, you know. I haven’t tried it yet but it’s certainly something that you can do.

Andrew: Got you.

Dr Yazbek: And there’s actually another way, and a really, really cool way you can observe the amount of blood shunting to one extremity is by performing a dynamometer strength test. And so, what you can do is someone, for example, who’s a right-handed dominant person, you get them to squeeze a dynamometer as hard as they can and whatever level of Newton meters it is you multiply by 0.3, or take 30% of that value. And then, you ask them to squeeze at that value, say if it’s 100-newton max, newton meters max, you get them to squeeze it for 30-newton meters.

And then you get them to hold it for five minutes while you measure their blood pressure and pulse oximetry on the other arm. Now, by measuring the blood pressure… By measuring the response and pulse oximeter on the other arm, you could determine effect if the other arm has an increase in blood pressure, then you know that there’s some type of dysautonomia because you should be having blood shunt in the arm, which you’re actually squeezing.

So, if I’m squeezing my right hand, my left motor cortex sends cortical spinal activity to the opposite right hand, but it’s actually what it does, it increases the inhibition of the sympathetic tone to the hand that you’re not using. So, most likely shunting to the opposite side. And so we should see no change in the blood pressure on the arm that’s not being used, if not maybe a decrement.

So, if you see an increase in blood pressure on that arm, then you could postulate that you’re, you know, you’re not shunting blood very well to the opposite extremity. And you find these with a lot of, you know, patients with whiplash, head injury, concussion, and things like that. So, really good bedside tests they can do. You just require a dynamometer, a stopwatch. And, yeah, very, very useful.

Andrew: You know, we never really think about shunting of blood in humans on a functional basis. We think about, you know, for instance, heart left to right, heart shunting. If you’ve got a perforated foramen ovale, a PFO. Or we might think about something with a trauma to it or something like that. But we don’t think about it in a functional sense. Forgive me, but where I’m going with this is, you know, cetaceans, whales, sharks even, so, fish. When they get an injury, they can shunt blood away from a wound. What you’re talking about is actually this sort of effect, but it’s more of a functional thing rather than in response to trauma.

Dr Yazbek: Exactly, exactly. Right. Exactly right. So, yeah, you really look and what modulate…

Andrew: That’s so cool…

Dr Yazbek: Yeah, really cool, really cool. And what modulation ability to shunt blood to the extremity that’s being utilized for work output is pretty much controlled and governed by your body maps. And your body maps are very much governed by an area in your midbrain called the superior colliculus, which is also responsive to visually reflexive eye movements. And the parietal lobe that has a body map more so on your left hemispace, but generally both.

And so if you have an abnormality in body map seen in those and say, for example, Complex Regional Pain Syndrome, or chronic pain condition, if you’re not aware of your left hemispace or you have an inability to map out the way the target location should be with regards to movement, then you’re gonna have an inability to map out how much blood and the location in which where the blood should be shunted towards.

So, the proprioceptive effects from movement can also be a causation for autonomic dysregulation due to not being able to shunt blood to the areas where it needs to be. So, that’s really important. So, what I do is I look at their normal autonomic function, but I also look at their cranial testing, their brain stem function, things like that, which is really, really important. Really important. So, that’s a whole another discussion to talk about.

Andrew: Podcast three. Daniel, can we go into a few of the therapies that you use or the techniques that you use to help people balance this? You know, like I’ve heard of, well, we’re all very well, very well aware of meditation and, you know, stress management and mindfulness and things like that. But what about physical things that we might be able to do? Like I’ve heard of, you know, left arm to right knee, right arm to left knee, that sort of rebalancing. Does that help or do you use other things that are more useful for you?

Dr Yazbek: Yeah, no, that’s stuff is great. And, you know, like, I think anything really good, it just has to really go in tandem with the examination findings. So, I mean, guess what I’m saying is very much crossed hemispheric type of movements. So, for example, complex arm movements on your right side will have more of a right circular effect, which can potentially down-regulate the sympathetic response. Because the cerebellum pons sign aspect in the right, so I can inhibit SA node firing to prevent the heart rate from undergoing a technicality response.

So, really, I think the best way to do this is to apply the stethoscope and really check to see if there’s a bradycardia, a tachycardia response with certain movements really. And I think that’s really the best way you can, at least attempt to quantify that. Because I’ve seen in the clinic where I have someone turn their head rapidly to their right side. And that heart rate just drops. And you’re stimulating that right cerebellum pon sign access, which can then increase the threshold for SA node polarization and therefore decrease heart rate.

So, I think the best way to do this is, you know, looking at movements because a movement if you administer movement, you can either have a really positive response or a really negative response.

Andrew: No, really?

Dr Yazbek: And so this is could be…

Andrew: Okay, so when you’re doing that, when this patient is turning their head to their side, how are you assessing heart rate? Have you got an ECG attached? Do you do it just by a radial pulse?

Dr Yazbek: Yeah, no, we’ve got a… I got an onyx pulse oximeter on their finger. And I also can use this. Yeah, or I can also use a stethoscope on the S1 region, and pretty much looking for just the change in the heart rate and the dynamics of that.

Andrew: Okay, I got another question. When you’re talking about blood shunting when somebody is doing the pressure, forgive me, what do you call it? The chronometer?

Dr. Yazbek: Dynamometer, yeah, dynamometer.

Andrew: Dynamometer, thank you. So, you’re holding, you’re crushing with your hand that dynamometer to 30% of max. If you had, like pulse oximetry on, say, both hands, both fingers, be a little bit tricky, because you’ve got blood, you know, physical closure of one. But I’m what I’m thinking about, could you actually affect or see effects in blood gases from one side to the other? Blood saturation?

Dr Yazbek: Yeah. 100% 100%. So, yeah, great. Great thinking. I love your thinking so. Yeah, I mean, you could certainly apply the pulse oximitry to both, you know, both fingers and look to see which area is being, you know, shunted more blood, not just blood, but blood oxygenation, as well, hugely important. Hugely important. So, definitely, definitely worth giving it a go. And it can also reduce the variability having, you know, two sides tested as well. And then also I have to say that…

Andrew: Okay, so we need to…oh, forgive me. You go.

Dr Yazbek: With people with who are parasympathetic dominant things in those types of patients is, you know, you hear a lot about wellness and you hear a lot about, you know, bringing restoration in the system, and calmness, meditation, which is all very great stuff, especially for someone who’s sympathetic dominant, but we have to ask the question, is it useful for those who have parasympathetic dominant?

What I found with people when I use the Nerve-Express technologies, those who are very parasympathetically dominant, because acetylcholine is heavily utilized in the parasympathetic nervous system, acetylcholine is very much used in liver and renal detoxification. So, I find those with the very high parasympathetic tone, very high parasympathetic tone, actually calling undergoing some hepatic detoxification, phase two liver detox, things like that.

So, they’re the ones that get mistakenly being healthy. They’re the real calm, relaxed, you know, type of people. But that’s one thing, you have to be careful, you can’t just treat like the five art program and remove replace, we inoculate, repair rebalance that also has to be involved with the autonomic nervous system. So, you have to address the cause whether it be inflammation, you know, things like that. Gut immunology, trauma, and things like that. And lastly should be restoring parasympathetic sympathetic tone.

So, if we intend to bring balance to the person with the nervous system, you have to understand, like an OST test, for example, there’s no wrong or right result. We have to understand that it is what it is from what we see. But maybe the person attorney so high because acetylcholine’s being chewed up to increase the liver detox pathways.

And so you’re getting that increased parasympathetic tone. So, once you understand the neurotransmitters and different, the same different receptors for the same neurotransmitter, it gets so deep and complex, you can start to see how complex the system gets, and you know, that you have [inaudible 00:31:12] from there.

Andrew: Okay, so talking more about treatments do you use any other supplements? Like for instance, we’ve spoken about acetylcholine and choline. What other neurotransmitter nutrients do you use? Magnesium is the poster child of all nerve issues. Where do you find it sits?

Dr Yazbek: I think magnesium is pretty important in GABA as well. I mean, you don’t want to be suffering in GABA long term, but you could… You can, you know, you can really use that to see whether someone is deficient in the GABAergic response by doing a GABA challenge and see how it makes them feel relaxed and calm after. But, I mean, magnesium is great for those who are specifically sympathetically dominant.

We have to be careful, those who are sympathetically dominant that we don’t increase their calcium levels too much. So, that’s really important thing to kind of be aware of. But, I think anything to bring restoration and calmness to the sympathetic system, you know, potassium, as you said, magnesium, you know, your adaptogenic herbs might have some good value. So, yeah, I haven’t really teased into walking and treating, you know, disorder from a nutritional perspective as yet, but it’s something where I’m probably more focused on in the future given the complexity of it all.

Andrew: You mentioned adaptogenic herbs. Is there anything in particular that you use and do you use any nervines as well? Maybe, you know, skullcap, kava, any of those other nervine herbs?

Dr Yazbek: Yes. Yes. I love skullcap. I use skullcap with any complex, skullcap, Withania and Rehmannia is especially those who have an overlay of some autoimmune complexity as well. So, I really love those three especially. I tend to just use those three. And there’s some of that I [inaudible 00:33:18] as well.

Andrew: Yeah. And you said, you know, you need to do some more work on nutrients. But when you’re talking about, for instance, concern about a calcium influx. Magnesium, as I said, is the poster child of blocking that or helping to reduce that, but what about things like, if you’re a long term risk of a sympathetic tone causing calcium influx into cells and maybe you’d be cautious about calcium deposition. Do you think about things like vitamin K2, for instance?

Dr Yazbek: Yeah, yeah. 100%? Yeah, very, very important to be considered vitamin K2 as a result. So, yeah, it gets tricky. But that’s definitely one thing that we have to consider, is vitamin K2. Yeah, it’s just… I’m still trying to find where to start when it comes to dysautonomia. You know, generally, you wanna treat the parasympathetic nervous system first and then the sympathetic nervous system.

But from a general rule of thumb, I personally refer out to a nutritionist naturopath, who understands those aspects far more to a greater degree than I do. But that’s certainly warranted and very important. So, what they tend to do is run a nodes test and look at, you know, cofactors, vitamin, mineral aspects, which is very, very important. Very, very important.

Andrew: Got you. And I did just want to cover off on a few red flags. Now, we’ve covered off that baroreceptor issue. When are you very cautious? What would you say like never to do or to be extremely cautious of? I guess, particularly with the baroreceptors, but other things as well dealing with the neck, for instance.

Dr Yazbek: Yeah, I mean, anyone you know, for example, that previous surgery or stent, for example, targets then, or anyone who, you know, has explained with any history that they have a very, very like, for example, the base for his dizziness or syncope, or lightheadedness, or visual type of scintillations, or changes, especially when they go to…like if they’re getting out of bed where they’re forced to use some abdominal contraction as a part of a partial Valsalva mechanism, or just any significant postural-related change.

So, if that if that’s deemed relevant in the history, then I tend to not go there when it comes to performing the Valsalva. I just tend to go more towards sorry, as supine to standing tests in a Valsalva, but without the actual carotid compression. So, yeah, there are certain contraindications that you have to be quite aware of especially.

Andrew: Sure. Yeah. I mean, you as a chiropractor are very well trained in this, but I guess we just wanna be very safe that somebody doesn’t attempt some of the things when they don’t have that specific training. Daniel, you’ve obviously looked into this a lot. Have you written any courses or any resources that people can learn from?

Dr Yazbek: You know, that’s a great question. I haven’t but it’s, it’s certainly something I’m actually looking into. And really, having a real deep dive into dysautonomia, how to assess it better from a bedside perspective for the average clinician, and then how to treat and co-management I think it’s very, very important for us to… You know, especially during you know, long haul COVID. We’re going to be experiencing a lot of patients with dysautonomia. And I think it’s an aspect where we have to really get good at observing, assessing, analyzing, and treating, and really tying in the functional neurological aspect to the functional medicine aspect.

I think you just have to have both and I’m certainly very much interested in, you know, writing up a course on dysautonomia, and how to assess it from both functional medicine and functional logical perspective.

Andrew: Dr Daniel Yazbeck, there’s so much more obviously to cover in this. You’re obviously an expert, but I do make that caution for those people who aren’t thoroughly trained in this and don’t have appropriate I guess, even litigation that I’d leave this to somebody of your expertise. But it’s so interesting in what you’ve found out, how you treat, how you monitor, and how you help and care for your patients with dysautonomia. Thanks for covering this in Wellness by Designs today.

Dr Yazbek: Thank you, Andrew, very much. I truly enjoyed it and I hope to be back soon to discuss far more in-depth this topic that I’m very much passionate about.

Andrew: And thank you for joining us today. Remember you can catch up on all the show notes that we will post up for you. There’s a lot but also you can catch up on the other podcasts on the Designs for the Health website. I’m Andrew Whitfield-Cook. This is Wellness by Designs.