Specialists

An acupuncturist is educated in the theories behind acupuncture and its practice developed over 5000 years. Some acupuncturists practice strict traditional Chinese acupuncture and will also prescribe herbs and use glass balls, heated on the inside and applied to the skin to create suction. From personal experience, the glass balls make your back look like a creature has sucked on your back, but breathing is so much easier, you don’t care.

Others practice modern acupuncture. A few specialize in brain injury.

In Canada, acupuncturists are regulated and must meet certain standards of education and practice to belong to the regulatory colleges and have the designation of, for example, Regulated Acupuncturist.

Acupuncturists who practice safe acupuncture will use disposable needles; not touch the end of the needles that go into the skin or muscles; will angle the needles in so that if the patient accidentally moves onto the needle, the needle will slide underneath the skin instead of going into the body as would happen if the needle was inserted vertically.

The first appointment begins with a detailed history. Prior to each treatment, the acupuncturist will examine your pulses and tongue. The tongue tells a lot about your state of health. Physicians used to be practiced in how to read tongues and fingernails to quickly determine one’s health status.

Some have very good technique in inserting the needles, others not so much. But the effectiveness of their treatments is found in their decisions of where to place the needles. Not whether their needling is painful or not.

Learn more at https://ctcmpanl.ca/learn-about-traditional-chinese-medicine/what-is-an-acupuncturist/ and https://ctcmpanl.ca/learn-about-traditional-chinese-medicine/what-is-acupuncture/

People with brain injury are missing a lot of cognitive skills like organization, problem solving, focus, memory, reading, and so on. They need patient assistance by a skilled person to help them achieve their goals and normal kinds of activities. Behavioural assistants provide a secure foundation that boosts confidence and motivates functioning. Brain supporting brain allows a person with brain injury to achieve successes, small or large, short term or long term.

For brain injury, because learning is slow, memory fails, the injury isn’t usually healed or only partially — because brain injury isn’t static and untreated brain injury can lead to worsening cognitions with age — lifelong behavioural therapy is necessary to attaining and retaining functionality. Computers and voice-activated AI can do only so much. People with brain injury need a human resource to accomplish tasks and projects, which in turn leads to restoring self-esteem and a sense of competence.

The human resource in the form of a behavioural therapist spots early signs of deterioration, either from untreated injury or from environmental or social stressors, and adjusts the therapy plan to get the person back on keel. Or to get additional help. They should also be familiar with and able to teach their clients how to use smart technologies to replace their lost ability to initiate action because most won’t have a human resource to do that.

For me, that’s the clearest definition that fits the term. Other institutions and health care units define case manager differently. I find the differing definitions confusing.

The case manager coordinates all the health care professionals involved in care. They’ll meet with the GP* and specialists. They’ll meet with the client regularly to ensure their overall treatment plan is being carried out. They may fulfill the recommendations of an occupational therapist’s report.

Insurance companies are supposed to hire a case manager, but I don’t think I’m alone in having an insurance company who failed to do that. As a result, many aspects of my rehabilitation were missed. A case manager means that the person with brain injury doesn’t have to coordinate their care. Hopefully. Yes, it is bonkers to require a person with very poor focus, no memory, and constant exhaustion to marry multiple reports and specialist visits into a coherent treatment plan. That’s why a case manager is essential and needs to remain part of the person’s rehabilitation team until they no longer need to attend medical appointments for their brain injury. Yes, that could be lifelong.

*GP stands for General Practitioner. Other names are Family Physician or Primary Care Physician.

A dietitian collaborates with researchers, works with physicians and surgeons in hospitals, creates menus for a population, works one-on-one with clients to advise them on how to get the nutrients they require. Because the brain is healing, its nutritional requirements and fuel consumption will differ from the norm. Glucose is the brain’s fuel, and I found my brain required much more, especially after cognitive work. A dietitian will provide the client with printed, individualized materials to help them carry out their professional advice.

Your GP or specialist may refer you to a dietitian. Hopefully, your referring physician will collaborate with you and the dietitian to ensure everyone understands the dietary plan and helps you carry it out. Changing food habits is not easy. Taking supplements is a pain, particularly when you have memory and swallowing problems. Scientific support through the dietitian and psychological and emotional through the health care team, increases success.

See also https://www.pdep.ca/accreditation/accredited-program-list.aspx and https://www.dietitians.ca/About/Learn-About-Dietitians

The only way the GP can become the big-picture person is to change the system to a collaborative model. That starts with understanding collaboration and how it works. Then restructuring the current health care system into a collaborative one, keeping in mind that the key to any health care success is the relationship between doctor and patient.

You can’t have any old GP or specialist substituting for each other. They cannot build up a big picture and historical understanding of you. That comes only from person-to-person relationships. Nor can any person in a limited amount of time possibly come up to speed on a person with brain injury so as to advise them appropriately within a 15-minute appointment or even a one-hour appointment. Nor can a GP keep on top of rapid changes that come from neurostimulation therapies if they see the person only monthly or less.

Seeing a GP weekly is exhausting yet necessary for good health care of brain injury in the early phase of injury and treatment. Virtual care is ideal for allowing the GP to keep up with treatment progress and responding to issues while not exhausting the Resilient through forcing them to travel and to wait in one more waiting room for one more doctor or therapist.

The other aspect to keep in mind is that most GPs know little about brain injury. Not much physiology is taught in medical school, even less neurophysiology. And regulatory colleges do not push for doctors to educate themselves on brain injury, as far as I know. It’s left up to individual GPs to recognize that a substantial proportion of their patients have this hidden injury; that’s why they need to improve their education on brain injury in order to provide their patients with optimal care. The solution is to make brain-injury education and annual upgrading of that education mandatory for all GPs because the area of neuroplasticity and neurostimulation therapies is rapidly advancing. Until that time, individuals have to somehow educate their GPs. I hope this website will help do that.

“To become certified as an adult neurologist it requires 5 years of approved
residency training. This period must include:

?‍⚕️ 1 year of basic clinical training;
?‍⚕️ a minimum of 1 year of Royal College-approved residency training in internal medicine (2 years are preferable);
?‍⚕️ and a minimum of 3 years of Royal College-approved residency training in neurology.”

CMA (Pediatric neurologists have extra training.)

When conducting a neurological exam, a neurologist should be aware that brain injury impairs nerve conduction beyond the central nervous system and that MRI and CT cannot detect diffuse axonal injury and concussion. For example, a neurologist should test all the reflexes, including the ones usually not done in a regular exam, especially in a cold country like Canada. In my experience, these have been omitted.

A neurologist will conduct muscle function and nerve conduction tests, as well.

Since they study cell structures, how neurons work, the cellular makeup of the brain and spinal cord, and the cranial nerves, they ought to have a scientific understanding that injury can affect everything and anything. Thus they should attend to cognitive, mood, and internal changes as a result of brain injury, but like other medical specialists, or moreso, they ignore that aspect. I personally will not see another neurologist again until they learn to do complete exams, tests appropriate to brain injury, acknowledge injury affects every aspect of function including cognition and emotion, and stop being so arrogantly dismissive of people’s and GP’s concerns.

“A neuropsychological evaluation is used to characterize a person’s neurocognitive, emotional, and behavioural profile. This information, along with information provided by other medical/healthcare providers, is used to identify and diagnose neurobehavioural disorders and implement intervention strategies.”

York University

Insurance companies like to use them for the hours and hours of testing that they do, which cover the gamut of personality and intelligence tests to mood disorder tests. These tests are problematic in their inherent racial and cultural biases, which much has been written about. I have personally experienced a test for memory based on the idea that North Americans would have no knowledge of British cultural references. In a diverse country like Canada, that cannot be assumed. I had extensive pre-brain injury knowledge, so my memory tested as good. From the insurer perspective, the tests are used to deny legitimate claims. (See Concussion Is Brain Injury: Treating the Neurons and Me.)

A neuropsychologist, like many clinical psychologists, ought to include in their knowledgebase how to conduct and read qEEG and evoke potentials tests since these are more related to their field, which is based in the science of the brain.

See also https://link.springer.com/article/10.1007/s40167-017-0050-2 and https://scholar.google.ca/scholar?q=neuropsychological+tests+biased&hl=en&as_sdt=0&as_vis=1&oi=scholart

There are two branches of philosophy underlying the practice of neuropsychiatry. One branch sees a neuropsychiatrist as solely a consultant. The other branch considers them both as a consultant and a regular long- or short-term therapist who uses a number of modalities from psychodynamic therapy to brain biofeedback concomitant with counselling.

My issue with the former is what I’ve learnt from my father: research or consults in the absence of direct experience with long-term outcomes keeps the specialist in the theoretical rather than actual reality. Furthermore, the key to good health outcomes is relationship.

Brain injury unfolds over months and years when it goes untreated or undertreated; thus one consult cannot fully grasp how this complex injury affects each individual. At best, they can observe and perhaps test for the gross presentation — the overall big picture with typical symptoms — but not understand and create a dynamic working treatment plan that takes into account changing brain, environment, financial stressors, and social support and life.

A neuropsychiatrist grounded in understanding of neuroplasticity and neurostimulation therapies, who understands that medications can worsen brain injury while masking symptoms, who works with the patient’s other specialists, who sees patients regularly over the long term, and who recognizes concurrent complex continuing PTSD, is the best bet for guiding and treating a person through the long haul of recovery.

Nutrition is a field of study in universities that’s separate from dietetics. You can have a B.Sc. (Bachelor of Science) in nutrition that doesn’t include dietetics. Nutritional science is a rigorous field of study. Although you can learn much about nutrition and food through experience only, nutrition studies teach the science down to the cellular level in a way that experience alone does not. I would advocate finding a nutritionist who has a B.Sc. in nutrition or, at the very least, nutrition as part of their university degree.

See more at https://www.dietitians.ca/About/Learn-About-Dietitians/The-difference-between-a-dietitian-and-nutritionis

The occupational therapist meets with the client regularly to enact the treatment plan and adjust it to their progress. In a multidisciplinary clinic or institution, they’ll meet regularly with other therapists and specialists to discuss the client and collaborate on ongoing treatments and progress. In community care, they’ll meet the person with brain injury in their home and help with applications, form filling, finding help for such mundane things as getting their home cleaned, and so on. They allow a person to live independently. However, unrealistic standards by agencies can hamper both their effectiveness and prevent a person with brain injury from receiving the lifelong help that they need.

“Occupational therapy is a type of health care that helps to solve the problems that interfere with a person’s ability to do the things that are important to them – everyday things like:
? Self-care – getting dressed, eating, moving around the house,
? Being productive – going to work or school, participating in the community, and
⛳ Leisure activities – sports, gardening, social activities.”

Canadian Association of Occupational Therapists

People usually call their occupational therapist their OT. The OT works within institutions as well as in the home or workplace. In the home or workplace, they will measure the client and the environment, including counters, sinks, tables, desks, chairs. They will also observe the client’s function and behaviour within their environment. They will use this information to design ergonomic spaces, provide tools designed to compensate for physical limitations, develop plans to limit physical and cognitive stressors, and so on. The case manager may carry out the environmental changes while the OT works to help the client adjust.

The best OTs make you feel better every time you see them as they work in practical ways to solve your difficulties. They are not paternalistic nor condescending nor should they treat you and your home as if they’re festering with germs (even if you do have cockroaches). They should also be familiar with and able to teach their clients how to use smart technologies to replace their lost ability to initiate action because most won’t have a human resource to do that.

Provincial health plans ought to cover preventative eye care for adults since blindness or even vision impairment is a devastating loss, difficult to adapt to, expensive for the government, and is very disabling for something that is highly preventable. Unfortunately, Ontario delisted it for adults 20 to under 65 years old and is trying to cut it back even more.

Having a relationship with your ophthalmologist means that they will recognize the changes before and after your brain injury. One hopes. You may require a referral to a subspecialist and/or surgeon in order to receive the care you need. This will probably entail a long wait because there aren’t many versed in vision changes after brain injury. Also, the vision changes may not be in the eyeball but in the brain or both, and that requires a specialist who understands the visual cortex as much as they understand the eyeballs, optic nerves, and supporting musculature, innervation, and blood flow.

“Neuro-ophthalmologists take care of visual problems that are related to the nervous system; that is, visual problems that do not come from the eyes themselves. We use almost half of the brain for vision-related activities, including sight and moving the eyes. Neuro-ophthalmology, a subspecialty of both neurology and ophthalmology, requires specialized training and expertise in problems of the eye, brain, nerves and muscles. Neuro-ophthalmologists complete at least 5 years of clinical training after medical school.”

North American Neuro-ophthalmology Society

*I swear they have the hardest to spell specialty name!

When you have brain injury, you’re referred to many, many different kinds of physicians. And sometimes your GP or, in my case, my brain biofeedback Clinic Director won’t say, “I’m referring you to a chronic pain specialist.” Instead, they’ll say, “I think [insert name of physician] will help you with regaining mobility and reducing pain.” So you’ll trot off to the clinic without knowing what kind of specialist you’re about to see — such was the case for me.

You’ll experience the power of not only having your pain, strength, and mobility observed by a pain specialist and subjectively measured by you on some sort of scale, but also of being provided effective treatment that stuns your physiotherapist at the rapid, dramatic improvement in your ability to move your neck, shoulders, back, hips. For me, pain reduction was a bonus.

Two big problems with seeing such a specialist.

Avoid these problems by — the moment you’re injured — seeing a pain specialist who provides effective treatments like low-intensity laser therapy in concert with physiotherapy and acupuncture (and massage therapy once your injuries have healed enough) along with specialists who provide neurostimulation therapies to heal the brain. In that way, pain, inflammation, and stiffness hopefully will not set in and you will avoid the daily, expensive chore of managing pain, inflammation, and spasms for the rest of your life.

“Physiatrists are physicians who specialize in physical medicine and rehabilitation, a medical specialty that deals with the evaluation and treatment of patients whose functional abilities have been impaired. The disabilities and impairments may result from injuries or diseases such as stroke, neuromuscular disorders, musculoskeletal disorders, cardiopulmonary diseases, arthritis, peripheral vascular disease, cerebral palsy and others. The physiatrist can help to improve a person’s functional capabilities by medical treatment and organizing and integrating a program of rehabilitation therapy such as physical, occupational, speech therapies, psychological, social nursing, prosthetic, orthotic, engineering and vocational services.”

Canadian Association of Physical Medicine & Rehabilitation

“The heart of the physiotherapy profession . . . is understanding how and why movement and function take place. Physiotherapists are highly skilled and autonomous health professionals who provide safe, quality client-centred physiotherapy through a commitment to service availability, accessibility and excellence.”

Canadian Physiotherapy Association

A physiotherapist may work independently, in teams, in clinics, and/or in hospitals. GPs will refer patients to a physiotherapist after car crashes, falls, strokes, and similar injuries. Your physiotherapist is the heart of hands-on rehabilitation of your muscle injuries, and you need to have faith and trust in them because of the hands-on nature of their work around and on areas that are in extreme pain. If you don’t, find another one.

See https://opa.on.ca/about-physiotherapy/discover-physiotherapy/ for more

Brain injury when not treated early becomes a lifelong debilitating injury. I’ve found psychologists understand the needs and desires of people with brain injury better than psychiatrists and so provide more effective treatments, using several modalities as appropriate. But most medicare plans don’t cover psychologists — a big problem — nor the neurostimulation treatments they provide — bigger problem — and people must seek out psychiatrists instead. This is why psychiatry must return to its roots of relationships that aim to restore, not simply monitor for medication levels or provide consults only. Even more important and given the mental health pandemic about to hit from COVID-19, instead of relying on psychiatrists or consulting GPs, medicare needs to start covering psychologists, social workers, and psychotherapists. And they need to fund the high needs of people with brain injury who, especially if they have concurrent PTSD, require multiple visits per week. Nothing heals better than a trusted relationship with a supportive human meeting multiple times per week.

“A psychologist studies how we think, feel and behave from a scientific viewpoint and applies this knowledge to help people understand, explain and change their behaviour.”

Canadian Psychological Association

“In Canada, the professionals who most commonly treat people with mental health problems are psychologists and psychiatrists. A psychologist holds a master’s and/or doctoral degree in psychology that involves from 6 to 10 years of university study of how people think, feel and behave. Psychologists who hold doctoral degrees, can use the title ‘Dr.’. Psychologists who practice (and hence those who are licensed) typically will have completed their graduate university training in clinical psychology, counseling psychology, clinical neuropsychology or educational/school psychology.

Although psychologists are licensed generally and not in specific specialty areas, they are required to declare their areas of competency to the regulatory body and required to practice within the bounds of their competence. It is important that, for example, a psychologist practicing neuropsychology (assessing and treating problems in thinking or brain function that might occur after an accident or stroke for example) has been trained in the area of neuropsychology. . . .

Psychiatrists are medical doctors who go on to specialize in mental health and mental disorders. Psychiatrists often use medication to help their clients manage their mental disorders [and some] do psychotherapy much like psychologists do. For more information on the study and practice of psychiatry, please visit the website of the Canadian Psychiatric Association at http://www.cpa-apc.org.

Sometimes a client might consult his or her family physician about medication while seeing a psychologist for psychotherapy. Some family physicians have an interest and training in treating psychological problems.”

Canadian Psychiatric Association

How a psychiatrist practices varies — some see patients infrequently for regular medication checks, while others see patients weekly or biweekly for talk therapies as well. Some will also use or refer patients to neurostimulation therapies. Medication is known to worsen brain injury; medication checks alone are completely inappropriate for brain injury care.

Psychiatrists are the only mental health professional covered by provincial medicare plans outside of hospitals or medicare-covered clinics or institutions. This will have to change because there aren’t enough psychiatrists to cover the current need of the brain-injury population never mind all the other brain issues. COVID-19 injuring neurological function and causing sharp upticks in anxiety and trauma is also increasing demand and will require the kind of healing only frequent regular appointments plus neurostimulation therapies provide. Because of the pandemic, medicare now covers virtual visits in the form of phone calls and secure, private videoconferencing. Some provinces cover email as do some private insurance plans. Access to secure texting depends on the plan and psychiatrist.

Psychiatrists, more than psychologists, have resisted learning about and using neurostimulation within their practices. A psychiatrist may refer patients to clinics that use them but may not collaborate with them, leaving their patient to figure out how to combine their psychiatric care with the neurostimulation therapy. Problems thus arise because the psychiatrist may not recognize the rapid changes from neurostimulation and thus treat it badly, deteriorating their patient or at best not supporting their patient through the chaos of a rapidly healing brain.

Psychiatry as a profession is familiar with and comfortable with medications; they need to expand their comfort level to neurostimulation therapies. Without this change, people will continue to languish into worsening health and forms of dementia and not be restored to life.

A good psychiatrist develops relationships with their patients. Recovery rests on the strength of the therapeutic alliance.

“The CPA defines psychiatrists as physicians who “enhance the person’s quality of life by providing psychiatric assessment, treatment and rehabilitation care to people with psychiatric disorders in order to prevent, reduce and eliminate the symptoms and subsequent disabilities resulting from mental illness or disorder”. The UK College of Psychiatrists states, “Psychiatrists are informed and uniquely skilled in the integration of medicine, psychiatry, neuroscience and the psychosocial sciences”.

The psychiatrist is trained primarily as a clinician to diagnose, treat and provide ongoing care for mental disorders to patients of all ages. Psychiatrists are primary, secondary and tertiary care physicians. Psychiatrists not only provide direct care to patients but often act as consultants to other health professionals such as family doctors.”

Canadian Psychiatric Association

“Psychotherapy is primarily a talk-based therapy and is intended to help people improve and maintain their mental health and well-being. Registered Psychotherapists work with individuals, couples and families in individual and group settings. Psychotherapy occurs when the Registered Psychotherapist (RP) and client enter into a psychotherapeutic relationship where both work together to bring about positive change in the client’s thinking, feeling, behaviour and social functioning. Individuals usually seek psychotherapy when they have thoughts, feelings, moods and behaviours that are adversely affecting their day-to-day lives, relationships and the ability to enjoy life.”

College of Registered Psychotherapists of Ontario

Registered psychotherapists are licenced by their college, much as clinical psychologists or psychiatrists are by their respective professional colleges. Psychotherapists cannot use the initials “RP” or call themselves registered without being licenced by their college. It’s a good idea to search for a prospective psychotherapist’s name in the college online directory to ensure they really can use the RP designation.

Ontario’s Registered Health Professions Act defines licenced psychotherapy as

“Treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning.”

https://www.ccpa-accp.ca/wp-content/uploads/2017/12/Understanding-when-Psychotherapy-is-a-Controlled-Act.pdf

Psychotherapists “can offer art, music, drama therapy or more one-on-one sessions with an individual. She adds creative types of therapies may be helpful for people who may have a hard time speaking about their traumas.” Read more on the differences between psychiatrists, psychologists, and registered psychotherapists in this 2017 Global News article. https://globalnews.ca/news/3825025/psychotherapist-psychologist-psychiatrist-difference/

Social work is a practical hands-on profession. Like an occupational therapist, a social worker can help with form filling. You have no idea how difficult form filling can be until you have a brain injury; a brain injury specialist coming to your home, offering to help you with a form is like a miracle manifested at your kitchen table. Like a behavioural therapist, a social worker can help resolve social relationship issues (assuming all sides want to). They also work on a person’s role in the community.

“Social work is an academic discipline and practice-based profession that concerns itself with individuals, families, groups, and communities in an effort to enhance social functioning and overall well-being by aiding them in finding their own solutions that leads to self-reliance.[1][2] Social functioning defines as the ability of an individual to perform their social roles within their own self, their immediate social environment, and the society at large.”

Wikipedia

“From individuals and families to organizations and communities, social workers collaborate with their clients to address challenges through a process of assessment, diagnosis, treatment and evaluation.

Registered social workers have specialized university education and must participate in continued professional learning and skills development to fulfil the requirements of their professional regulatory body, the Ontario College of Social Workers and Social Service Workers.”

Ontario College of Social Workers and Social Service Workers

See also https://www.casw-acts.ca/en

The speech-language pathologist will work with other rehabilitation professionals or independently.

“When most people think about speech-language pathologists (S-LPs) they probably think of someone who helps people who stutter or have a lisp. While it’s true that they do help with those issues, their scope of practice is a whole lot broader.

Speech-language pathologists are highly-educated professionals who have a minimum of a master’s degree in their field. As in any health-care related profession, S-LPs are required to study anatomy and physiology, but they also study neuroanatomy, genetics, human and language development, linguistics, psychology, acoustics and more, which is why they are qualified to evaluate, diagnose (restricted in some provinces/territories) and treat a broad range of delays and disorders. . . .

? Speech delays and disorders including articulation, phonology and motor speech disorders.
? Language delays and disorders, including expression and comprehension in oral and non-verbal contexts
? Fluency disorders, including stuttering.
? Voice and resonance disorders.
? Swallowing and feeding disorders in adults, children and infants.
? Cognitive-communicative disorders including social communication skills, reasoning, problem solving and executive functions.
? Pre-literacy and literacy skills including phonological awareness, decoding, reading comprehension and writing.
? Communication and swallowing disorders related to other issues. For example, hearing impairments, traumatic brain injury, dementia, developmental, intellectual or genetic disorders and neurological impairments.”

Speech-Language & Audiology Canada