FUNCTIONAL NEUROLOGY ANATOMY AND CENTRAL … · I’ve been doing functional neurology for, I...

MODULE ONE TRANSCRIPT – LANgUAgE PAThwAyS | COPyRIghT © 2016 FUNCTIONAL NEUROLOgy SEMINARS LP | PAgE 1

FUNCTIONAL NEUROLOGY ANATOMY AND CENTRAL NEUROLOGICAL PATHWAYS (MODULE ONE)

Transcript – Language Pathways

Presentation by Dr. Brandon Brock

Okay, language time. So look. We have looked at – just to review – can you find where you’re at in this wonderful thing called the brain? Dr. Kharrazian had this wonderful little analogy of orbitofrontal types of, you know, epileptiform activity, or seizure activity.

I’ve got to tell a real quick story just to kind of get going here. I have this really sort of bad luck with some things on occasions. I was trying to get here yesterday from Durham, North Carolina. There’s really not a direct flight. So United decided to just cut my flight off. Like they said, “Eh, we’re just not even going to have it.” So I had to jump to American.

And so I’m flying to Chicago, then I’ve got to fly from Chicago to here. And so flying to Chicago, somebody has a dog on the plane. And the dog takes, like, a number two in the aisle, okay? Yeah. So I’m watching this, and it’s not a service dog, it’s just a dog, okay? And so you see the dog go into the hunch maneuver, you know, and you’re like, “Oh no. No no no no no..” So the dog does it, takes like six steps, does it again, and apparently if any living creature defecates on an airplane other than in the latrine, you’ve got to land the plane. So we had to land in another city, and then take off. So I mean, I’m just sitting there going, like, “Will I ever make it to San Diego?”

Now, a guy lost it and his orbitofrontal system completely evaporated. He was going to, you know, text the FAA, he was going to do all these things, and it just really reminded me of my journey down here.

But in the middle of this, this guy, he got so angry that his language changed, His emotions changed. His posture changed. He was having, like, problems with fluency. He was having paraphasic errors. He was, like, substituting one word for another. And I was just like, “This guy is…” I wished… I was, like, trying to find my phone because, “I’ve got to record this, man, because I’ve got to show this tomorrow.” So it didn’t work out, I didn’t get that, but I did get a good adventure, and we made it here, and you know what? It all works out.

So far we have learned that cells go through a process where they either grow or they don’t. Meaning they grow in their capacity to connect to one another. And that is plasticity. And I know… we are intentionally being more repetitive in what we are teaching, because if we are not, we’ve found that people just don’t


learn, okay? So it’s really nice, especially when you’re just kind of getting into this, and a lot of people have been doing it forever, and they’re like, “Oh God, we don’t want to hear this again.” Well, sorry. You probably need to hear it again, okay?

But you see people who have, like, epileptiform activity. They have seizure activity. And then you look at people that have unstable cellular groups. And one of the things that we really decided that we were going to do is, we’re going to say, “Hey, we need to teach the people in this program safety.” Not every single person is this patient that you just put in this functional neurology world, and just assume it’s going to fix everything. There are people with tumors. There are people with strokes. There are people with infectious diseases. There are people with pathological problems where it either needs to be co-managed, okay? Even if you co-manage, it doesn’t mean you’re like a zero. You’re probably a greater hero by saying, “Hey look, I just need you to help me with this, and we need to work together.” Is that fair enough?

And I made it a… just kind of a, you know… again, about the time period the dog decided to do his thing, I was sitting there thinking about some things I wanted to say. And one of the things I wanted to say was, “Find practitioners that you trust, of different types.” You know what? There’s all kinds of different types of practitioners in here. And really, what I would encourage you to do: Go to socials, talk to each other, let this become a community, and work with each other on knowledge. Because all of us have a little bit of a different knowledge bank. And I will tell you one thing right now, with seizure patients – and the reason why I bring this up is because they scare me.

Now, I’ll give you a couple of examples. Number one: If somebody comes into your office and you’re the world’s greatest functional neurologist, don’t tell them to stop taking their seizure medication, please. I’m just being honest with you. Because if that patient has a seizure and drives off the road and bowling-pins nine other people on a playground, it’s your fault. Work with somebody that knows how to titrate if they’re getting better. You’ll know when they’re getting better and they don’t need the medication, because they’ll be sedated all day. They’ll be like this: [mimics falling asleep]. And you’re like, “Wow. That medication’s really working. Like they don’t need it that much.”

Okay, so work with people to help you on those things, and learn to co-manage cases, and learn this: We immediately said, “Hey, we want people to learn that this is a metabolic case, or if it’s a pure functional neurological case.” And I don’t really know that there’s really one without the other any more, to be honest with you.

And then we wanted people to understand, hey look: This is a physiological, unstable environment versus a pathology that is not about just cells not having the capacity to function.

Now I do want to say something. If you have a tumor, or you’ve had a stroke, you will have pathology. But it doesn’t mean that somewhere down the road you can’t have a secondary functional issue after that. So you will have – and Dr. K… I’ve got to say, Dr. Kharrazian did a very good job last section of starting… do you see how he started the layer things? Like, “Hey, what about neurotransmitters? What about catecholamines? What about dopamine?”

And it goes back to the layers, and that’s why I told you about those layers and those cell types, because it’s getting you familiar with there’s different cell types and different layers and different neurotransmitters


that do different things in different parts of the brain. What if it is a blood sugar problem and a thyroid problem? How many people come in with more than one metabolic condition? And then you start reading things about certain medications downregulating cellular function and mitochondrial activity. I mean, lots and lots and lots of things out there to learn.

The one good thing about this program is, it’s not just a flowchart and you memorize it and you’re done. You will now be a lifelong learner. I’ve been doing functional neurology for, I don’t know, almost twenty years now, but for the last three years, every day, all day, continuously. And I’ve learned that I wasn’t as great as I thought I was. I’ve learned that I had to practice and practice and practice, and I ate a lot of humble pie. But I learned a lot from my colleagues, and I really want you to know that the practice of functional neurology is going to be given to you in this.

So what’s real? What do you see every day? And that’s what I like about what we’ve given you so far is, guys, sometimes there’s pathology and sometimes there is stroke and there is flare sequence imaging, and there is part of a battery of an MRI that can show those things if they’re there. Diffusion tensor imaging is going to become more common. There is ambulatory EEG, where you can start to see different types of seizure activity. But so many people are deemed “pseudo-seizure.” I love those patients, because we’re like, “Those are right in our wheelhouse.”

So you’re already so far ahead, because you’re starting to see the differences and the nuances. There’s groups of people that just believe in pathology, and nothing else exists. And there’s a group of people that just believe in these functional lesions, and pathology doesn’t exist. And I’m like, “Man, I sure hope real pathology doesn’t walk into your office.” And I do hate the word “lesion,” because when you say “lesion,” everybody gets scared, they start jumping out of windows, they start, you know, “God, oh my God, I’m going to kill m…” And its one of those things where you’re like, you know, I just usually use terms like, you know, “This area’s not optimized in it’s function. Let’s just maybe optimize it a little bit,” and then give some examples. And that kind of keeps them a little bit less, you know, antsy.

Now, if there’s real pathology there, and it’s something to get worked up about, I would also make another suggestion: Send them to somebody else to make the diagnosis if you don’t feel comfortable. I’ve made a couple of diagnoses of cancer. One of them was a kid that had bone cancer, according to the MRI, clearly. I said, “Wow, this looks like a neoplasm, it looks like, you know, bone cancer.” They went, and it turned out it was nothing. And so the parents were like, “I hate you.” And I’m like, “I hate me too. I’m sorry. Blame it on the radiologists.” So, at that point in time.

So we’ve got to this point now where we’ve looked at the cell. First of all, let me go back. We’ve looked at a thought process, and we’ve given you a paradigm, which has never been done before. I want you to understand that first diagram was a conversation of about five months. No, actually, I take that back. It’s been an ongoing conversation for a decade. It was a slide that was a six-month thought process. Because it takes it and it says, “Where do you enter? What do you think about? When do you do this? When do you do that? When is it ablative? When is it not ablative? When is it functional? If it is functional, how many areas are involved? Where is the problem?”

Now, I want you guys to understand: We’ve given you one layer of where the problems can be, and that’s the cortex. What we haven’t given you is, what if the cortex is not functioning the right way because the


basal ganglia is not allowing it to? So there’ll be another layer put on it. Or, what if the cortex is discharging aberrantly because the cerebellum is discharging aberrantly? We will give it to you.

So for those of you that are, like, “It’s not the whole story,” you’re right. It’s not the whole story on purpose. And it’s because the human brain that is just learning neuroscience, can only hold so much information. So I’m just warning you: We are layering it in a way to when you walk out of here, you actually feel like going out tonight and having some fun, and you’re not sitting there in your hotel room, and you know, and you’re like this: [mimics being dazed]. A little drool coming out….

Well, we’ve done these lectures before, and I’m like, “I’ve got to get through all this stuff,” and we just decided that, man, we’re not going to crunch it. I’m just going to take it nice and slow and just let it build. And do it different. Okay?

Now, language. The worst thing I’ve ever seen is people not have the ability to communicate any more. I really think it’s devastating. There’s a couple of things that I always strive for. I always strive to get people to ambulate, because I think it’s the number one way to keep the brain from just slipping off the deep end and going away. Okay? And you saw that with that girl. I mean… by the way, she just finished college. So, I mean, okay, look. Great. It’s cool, but – thank you – but I want you to understand that that’s what this is about, man.

That’s why it’s, like, you keep coming back day in and day… take a whipping. We take a whipping every day, because we’re like, “I think I know what this is.” We still say that. So if you say it, don’t feel bad, okay? But you get better, and you learn more. And you integrate more. And then you read more. We gave you a lot of journal papers. Here’s how you read a journal paper: Look at the title. Do you like it? Go look at the end. Do you like the conclusion? Read the abstract. If it… I always look for the coolest diagrams, and then I go read the paper.

But we started putting stuff in there to challenge you. You read and challenge the system of teaching. It’s a flipped classroom. That’s what it’s going to be from now on. We are going to try to get the stuff to you as early as we can, and the next module will review this a little bit, but you will have to have reviewed this information, pass the online quiz, you come back, and now you’re ready to take on the next section, and it’s going to flow like a soap opera. And it probably will be a soap opera. Who knows what will crap on the plane next? Probably me. Probably me. I’m just saying…

Okay. So I had this guy with ALS – it’s the same guy I told you about – and he comes to me. I’m the only doctor he trusts, because he goes to the VA – which, just for the record, I love the VA – but the VA satisfac-tion is so low right now, because there’s so many vets with so many complications that are going in with so few practitioners and so little resources that they are not getting the diagnostics and the treatment that they need, and so they’re getting frustrated, okay? That’s just the deal. Non-politic – I don’t even want to get into any of that. I’m just telling you the reality. Okay?

And so, he came to me, and he’s like, “[wheezing]” and he’s like really struggling, and I’m like, “It’s time for you to get a trach, because you need a trach. Because you’re fixing to get to where you can’t breathe.” Now, what is the problem with being trached? You can’t talk any more. That’s it. So what I just said is, “Stop talking.” Now, what do you think happens when you stop talking, to your brain? It degenerates faster.


Let me ask you a question. What happens if every number that I’m supposed to memorize, like when I was a kid, if you don’t do it any more? Or all the directional stuff like the GPS, you no longer do any more? Does anybody really think about that stuff? Like, what is happening to our younger generation? They are developing certain parts of their brain. Their brains look radically different than ours. I can still remember my best friend’s phone number from, like, fifth grade: 353-5022, if he still lives there. I didn’t give you the area code.

But we live in a world where brains are changing. Brains are plastic. That’s how we treat people. This guy needed a trach. I had to make a decision to do something to save his life, knowing he was going to lose brain function. Okay?

I had another guy I’m going to show you in a minute. I had to make a decision to give him a G tube, or a button. Now, let me ask you a question: What’s that going to do? The vital centers that swallow and talk run the risk of transneurally changing. So we did activation on those, with a needle electrode, where we just put them in certain places, and tk tk tk tk tk, stimulate them while he stimulates swallowing.

Now, I promised myself I wouldn’t talk about treatment this weekend, but there’s lots of cool things that you can… that we are going to teach you. Some of them unconventional, and when they’re not supported by literature, I will tell you. How about that. Is that fair enough? That way you don’t go off and say, “Hey, this isn’t in the literature.” Somewhere I’ll be like, “No, no, not really.” That’s one of the things about functional neurology. That’s why it’s important for us to give you as much literature as we can, and you need to do as much research as you can, and everybody in here is capable of doing some of it. If I can do some research, anybody can do some research, okay?

Now, so I’ve been babbling, confabulating, cooing, and everything else right now, which you’re fixing to learn these terms. There’s a lot of terminology. Now, I’m not trying to make you a speech pathologist right now. And I’m not trying to make you a language pathologist right now. But what I need to do is give you enough information so that when somebody comes in, and they have one of these regions that’s damaged, you can look at them and say, “The back of your brain is damaged,” or “The front of your brain is damaged.” “The connecting fibers that run superior are damaged,” or “…that run inferior are damaged.” “Your left brain is damaged” or “Your right brain is damaged.”

You see, language is not just something that we use to communicate with each other. It’s a great window to see what’s wrong with somebody. It is. It’s beautiful. And what you’ll start finding is, when people get tired they’ll replace words. Or they can’t find words. Or they will just become repetitive. Or they’ll tell you a story over and over. In other words, it’s not straight-up receptive, expressive, conductive aphasia, it’s just this: “Wow, did you see what just happened with that little bit of language?”

That fatigability thing that Dr. Kharrazian just talked about. I love this topic. I didn’t love this topic too much until I started getting a lot of people that came in with language problems, and I’m like, “You know what? I know they have a language problem, but I’m not really sure if this is receptive or expressive.”

I gave you some simple breakdown diagrams, where if you literally can’t make the diagnosis then you can’t read a diagram. Well, that’s a different lesion. That’s parietal. We just talked about that earlier, okay?


So remember the lobes lecture? We’ve got to know some terms, and I call this the swirling language formation. It’s all right here. Auditory processing, back all the way through to output, back all the way to immu… I’m going to show you how this whole thing swirls around on the left side, and on the right side it says this: “Make the pitch go up and down. Put some intonation into it. Put some prosody into it. Don’t be aprosodic.” Meaning like flat-affect-but-I-can-still-talk-just-perfect.” When you see people like that, you’re like, talk to them on their left side, and see if you get the same responses as when you talk to them on their right side. Because when you’re over here and they’re right-brained, it doesn’t work so good. They’re like, “Hey-I-barely-see-you-I-have-a-hemi neglect.” And then you come over here, and they’re like, “Oh hey! What’s up?” You know, and it’s like, “Whoa!”

Now, some of these people can learn to rhyme, sing, and cuss, and speak a lot better. Some of them can have a normal conversation with just regular linear talking though. So it’s the strangest thing you’ve ever seen. Let’s talk about it.

The cerebellum has a lot to do with this. Now remember, the muscles of vocalization – it’s a motor pathway. Quite, quite, quite detailed. Which motor mechanism do you think has the most mathematical calculations to actually be accurate? Eye movement. And there’s about point three percent of humans on this planet that their conscious capacity to do math is wired into their frontal eye fields. So they can do a mathematical calculation immediately. Because you have to determine trajectory, and it is millions of math calculations every time you move. Start-stop. Start-stop. Boom, boom, boom. Focus in. Focus out. Okay,

But the cerebellum is going to be responsible for… the person may be “with it.” They’re fluent, they’re repetitive, they have no problem with expression, but when they talk, it’s just like a tremor in their voice. Like a dysarthria. “Ah-ah-ah-ah,” okay? They’re all there. When you start seeing that, you’re like, “It’s down, it’s not up.” If they don’t have that, you say, “It’s up, it’s not down.” And if it’s pure language problems, you say “It’s left, it’s not right,” in the fast majority of people.

And then I just have to teach you a few things. Fluency, repetitiveness, naming. So I have just a flow… you just go through it. And by the time you learn how to do it a few times – and by the way, Dr. Kharrazian was talking about putting up cases; I’m going to put up fifteen language cases. If you run through them, you will never have another problem with language again. And now here’s the thing: I’ve been on the Angoff Committee for the neurology board, I’ve worked with neurology diplomates forever, and very few of them know this stuff. They just know expressive and receptive aphasia. It is not that simple. Deal?

So I love this section. When I made it, I was like, “I’ve got forty-five minutes to go through. Now less. So the whole brain relates to language. It’ really does. Now, where do you learn language if you’re just a baby? Back here. Wernicke’s. If you learn it as an adult, you learn it in Broca’s.

So now, people who have frontal lobe lesions that are on the left side, we can start teaching them different languages and they change. If it’s on the other side, dun-da-dun-dun-dip, they learn to play the guitar. I’ve got all kinds of goals if I ever, like, calm down a little bit. Yeah. If I ever quit school or whatever else it is that I’m doing. I’ve got an addiction to school for some reason. I think Dr. Kharrazian’s worse than I am.

Okay, so look. Typically it’s left brain. If you don’t have it, it’s aphasia. If you lose the tone, it’s aprosodia. Does everybody get the terms? Again, I want us all speaking the same language. I don’t care if you’re a


speech pathologist. If you are, cool. I can meet you later on. I wish we had more in this class. Anybody a speech pathologist in here? Okay, well, then I can mess up. Alright.

Dr. Kharrazian said ninety-seven percent, some of the literature says ninety-nine percent. It’s – look – it’s a high number, okay? Especially right-handed people and even a lot of left-handed people are still left-brain dominant for language. It doesn’t always switch.

Now, the one thing I would say is, don’t switch a kid’s handedness unless they really don’t have a hand. The last kid I had that came in with mutism, their TSH was over two hundred. It was a child. They did not – the mother did not run a PKU because she thought it was some sort of evil, like they were going to send it off to the government or something. The kid had no thyroid. Had missed every, every developmental milestone, and I was just looking at him going, “Could they test more than just PKU in that?” They test for about ten other things. Run the test! Okay? The kid started taking thyroid hormones and went through multiple stages of development very rapidly, and language was extreme. I couldn’t believe how fast the kid learned. Because they had all that stored, they just didn’t have the developed brain capacity to actually start to express things. I was floored when I saw it. I mean, I was like, “Wow. This is a case I may never see again.”

So, if language is acquired secondarily after adolescence, it’s different. Primary Wernicke’s, Broca’s, frontal lobe. So, anybody that is… and Americans are really rough about this. We don’t speak enough languages. We really don’t. We rely on English. But you go to different parts of the world, and they speak multiple languages, and I really think that helps their frontal lobe survive.

Now, I will also say this: that there’s various layers in the cortex that degenerate in the language-speaking centers if you don’t use a language over time. Now, there’s another thing that’s interesting, and that is, if you grew up listening to those phonemes and those certain sounds, the ability to learn that language later is great, as long as you preserve the posterior aspect of your brain, so you’ll learn it faster, because you will recall your Wernicke’s area to project to your Broca’s area, and you will learn it faster.

So here’s what I told bilingual parents. “One of you talk in English, one of you talk in Spanish,” or whatever. And when you do that, the kid’s like a frontal lobe superstar. Okay? And we already know what frontal lobes get you, right? All the girls, all the cars.

This is a simple picture, but I like it. So think about it. How to say… So anyway, information comes in to the temporal lobe. What you hear, what you think, all this stuff. So you have this silent speech right here. Like, “You know what? That dog just crapped on the floor. Should I say something or should I not? I think I’ll just text it with emoticons.” Well, Wernicke’s is going to say this: “Ah, no-no-no-no-no. We’re going to Broca’s.” And when Broca’s is activated, it’s all coming out. So it goes whssht, right over here, and then you reflect a little bit. And you’re like, “Okay. That’s what my internal silent speech is saying. Now this is what I feel,” because all of these – there’s other projections in here you don’t see – but all of your limbic system stuff is coming up to here and coming up to here. So your reflection map can get distorted, and your Wernicke map can get distorted, and your temporal maps can get distorted by these deep limbic areas.

The limbic area wants to always pick a fight. It always wants to get kissed. It always wants to do these crazy things. And your higher cortical areas are like, “Just chill, man. Just relax.” And you can always tell when people get fatigued and lose it, okay? So you get up here to this reflection map, and then finally it goes


down to the orbitofrontal system and the cingulate system, go over to Broca’s, then it says, “Let’s say it,” and it goes down to the vocal cords. This is that circular type of thing. Internal reflection: “Do I need to say it?” “Go say it.” “Make sure it’s the right thing to say.” “Limbic system, you can come into it, but you probably need to shut up.” “Boom – expression. Go down to the vocal cords.” Vocal cords are like, they’re nothing but this: pathways coming down, corticobulbar – bulbar meaning cranial nerve – corticobulbar pathways that make you talk.

Okay, so you do this, and then you’ve got to remember these guys. Uh-oh, remember these guys? Well, I like this because this shows left brain. And it shows you the same thing. Now, we have memories; that goes into speech. We have emotion; that goes into speech. And it all comes over and it gives you this: phonemes, and the sounds of language, and the recognition of word sounds. And it comes over here, and those that can’t spell worth a crap, look at their left brain right here.

By the way, they’ll also be bad at names. So I always like to say, “How are you at spelling?” and you give them some words, you know, that are not so easy, like whippoorwill or something like that. That’s not very fair. But anyway, and they go, “I can’s spell worth anything.” And then you say, “Well, how about names? Are you good at names?” “I’m terrible with names.” And you’re like, you start building this picture of this left brain that’s not so great.

So this stuff comes over here, and then you’ve got information that might come in from what they see – has a little bit of what they’re going to say. Like, “Man, what I see is a fresh pile of dog stuff lying right there.” That information’s got to be processed into speech, okay?

So right in this area is the spatial arrangement of language. This is where you’re getting ready to say this: “I’m going to formulate a sentence, and I’m going to tell big Broca how to do it.” So this information right here now gets projected over to this area, and really, the orbitofrontal area is… it helps you what not to say. But when it’s not there, you don’t know what not to say. You just say whatever you want to say.

And then you come up here, and it creates new patterns or ideas and language. This is the writer, the philosopher, and the thing that really makes it nice. And then you get linear sequencing up here.

So what I want you to understand is, if you watch somebody write, you can literally break down their whole cortex. If they don’t know how to put certain words in order, if they can’t make their ideas flow. To become a good writer is difficult, because we don’t write that much any more; we talk. We’re pretty good at texting, for the most part, okay? My kids are amazing. I needed to get something off my computer – or, my phone – earlier, and I almost called my sixteen-year-old. I was like, “Look…” She’s already certified in Microsoft, and got accepted at college. I’m like, “You are superior to me.” I had to say it.

So as we go through this, that’s the deal. Now if we go to the right side, this is, you know, music and visual stuff and being cool and, you know, my feelings and fears and humor. Now, a lot of people with exotic right brains, they love horror movies. They have bad fears. They have weird phobias. They’re maybe agoraphobic. There’s a lot of strange things that happen in the right brain, okay?

But this really just gives us a little bit of stuff about more the environment on the other side. Like what’s going on. And it has a map for both sides, and it tells us a whole lot of things about motor control. But it


will still help us create new patterns of behavior, and it will make your… You see, my thing is much more right-brain than left-brain. So all of my current writings are not in the passive voice. I want to put adjectives, and flowery words. And research, researchers that are very left-brain, they want to kill you when you do that. They’re like, “None of that! No! None!” It’s, “This worked,” not “This was great.”

So for me, it was extremely difficult. Thank God my wife is an English teacher. Ta-da! But she’s very right-brain too.

So what happens is, there’s sound waves. They come into the ear. Now, I want to tell you something. If you have sensory neural hearing loss, your acoustic nuclei, you know, the nuclei that are in your brainstem, they’re going to inch closer to threshold, and you can get tinnitus [tin-`eye-tus] because you don’t – or tinnitus [`tin-i-tus], you know, look, tomayto-tomahto, succahd-succayd; get over it, okay? I don’t want to see any Facebook posts like, “This guy mispronounced the word.” I’m from Texas. I can mispronounce any word I want. That’s just the rule, okay? Just complain all you want. It’s just going to come to me and Datis and we’re going to laugh at you, okay? So that’s pretty much it. That’s great, dude! All the complaints come to us! Alright!

So, but you’ve got to understand something. When a cell type is not activated, it gets closer to threshold. So when people start getting, like, ossicular chain problems, and they get, you know, like otosclerosis, or they get conductive hearing loss, it’s easy for them to get tinnitus because the cells inside the brainstem that project up to the cortex, they’re now, like, not getting activated. So they shift closer to threshold, and then that changes the auditory cortex, and now the auditory cortex changes its threshold.

So when you’re doing this, you really need to run audiometric studies to say, “Hey, where is the problem? Is this conductive or sensory neural hearing loss?” We’re going to show you… we’re going to do a lot of practicums as we go through this. And a lot of videos. And just a three-minute video and to show you: how do you find conductive versus sensory neural hearing loss? And then how do you localize along the sensory neural pathway where it is, okay?

So anyway. I’ve been using the… I use the laser pointer for everybody online. Did you see that? I just tried to look into the camera. For everybody online, so… I’ll learn it eventually.

So we have sound waves. And then we have neural encodings. So what does the sound wave mean? It’s encoded. Phoneme sequences, like putting together parts of words or not. Sometimes people will delete like a syllable, and put a different syllable in there, and the word is just confusing. And then you put those words in a sequence, and then you give them meaning, and then you initiate a sentence, and then you have internal understanding, and then you have expression of the word. Any of these can be messed up. It’s not just expressive or receptive aphasia. You got it?

Alright. Not easy to understand. So, Aphemia. The word is pure anarthria, which means no speech output at all. They’re like this [makes motionless face]. You see it a lot with bilateral frontal lobe lesions. Or vocal paralysis. But those people will still, like, “Can you understand me? Blink if you can.” They’ll be like [nods and blinks]. But aphemics don’t do those things. They’re just out, okay? So the corticobulbar pathways are damaged, and the written language and verbal comprehension is intact. It’s almost a locked-in deal, but they can move.


Pure word deafness, that’s auditory verbal agnosia, is caused by… the temporal lobe becomes damaged, so now it’s difficulty to understand the spoken word. You heard Dr. Kharrazian talk about that. They can’t understand the background noises and stuff like that. So they’ll start saying things like, “Huh? What’d you say?” but they pass a hearing test, okay? And a lot of people that are… it’s just about the time you get readers, you start getting that. And you’re like, “I’ve got to have readers, and what’d you say?” So I’m going to fight the readers thing as long as I can. I can still see okay, but I’m sure it’s just a matter of time. Dog crap and readers, that’s pretty much what it’s going to boil down to. Okay.

So now, don’t confuse aphasia with dysarthria, right? Aphasia is difficulty with actually generating words; dysarthria is: you can generate these, but just… they’re screwed up. Like, they’re tremored. Or you can’t… you know… Here’s the thing. Is your cerebellum degenerated? Well, go get hammered, turn that bad boy off, and then see what your voice does. And you’re like, “Ah, man, ahhhh…” and you’re like, “Wow, you’ve got an alcohol-induced dysarthria. Your cerebellum’s probably not so good.” And they’re like, “I hate you!” And I’m like, “I hate you too!”

Alright, so anyway, this is all left stuff, but it’s the superior temporal pathways. They get damaged, and this gives you, you know, some diff… I’m going to go through this a little bit more.

So, take a look at this guy. This is when he first came in. This is “wormhead,” for those of you that were… By the way, that case study was too hard. I apologize. Everybody was like, “This is not good.”

Okay. What’s one thing you notice? So in order to get him to swallow, I have to get food in his mouth, and manipulate his head in nine different directions to get the food to go down. On barium. He was swallowing one out of eight bites. Now let’s go back to what Dr. Kharrazian has been talking about, fuel for delivery. Is that possible? Guys, you can’t do that and live. There’s no fuel. There’s no sugar. There’s no protein. He was becoming cachexic. He was emaciated. And you want me to do brain rehab on this guy? That’s the other problem. He had no epiglottal function. Aspiration. Aspiration turns to pneumonia. Infectious disease on a guy with a bad brain is a bad idea. It’s called death. A guy like this can easily die from pseudomonas or strep pneumonia or something else, and you start pumping with antibiotics, and you have no idea how their body’s going to tolerate that, depending on their microbiota, depending on a lot of things. Man, you are treading into dangerous territory.

So, this is him after the button and one day of treatment.

Can you say hello? “[unintelligible mumbling]”

Where are you from? “[unintelligible mumbling]” Alaska.

He’s non-vocal, when he came in. We’re teaching him to talk with mirror neurons. So he’ll watch himself. As he watches us, he records it on his iPad, and then he looks down and he watches himself and he says the words over and over. So we’re re-training him to do repetition, and it’s just a different part of his cortex that will allow him to express. It’s not coming from different areas.

Now, let me ask you this: Is his lesion down here or up here? It’s down here. He had – this is why it’s called wormhead. He had cavernous malformations. Five. That’s where there’s no capillary bed. So now the artery


is connected to the vein, and as soon as your pressure goes up, it expands, so you get, you know, obstructive lesions. And he had them around his brainstem. So they went in through here, they went right around the pons, and they went up to the mesencephalon, and they compressed it just a little too long, and now he has a mesencephalic tremor, he has a velocity storage abnormality, so you see his eyes going one way, his head compensating the other way, and he’s got all of these mesencephalic types of tremors that are really non-wingbeating, and earmuffs.

So there’s a lot of things that are going on with this guy. A lot. And they only took out two of them. They did another one up here. He has three left. And I was like, “You do those, and he’s toast.” And he was completely normal before the surgery, but he was a ticking time bomb.

Now, three weeks before he came, he could stand up. Now if you look at him in the first picture, he has a belt on, holding him to the wheelchair. In the second one he doesn’t. Three weeks before he came in, he was sitting upright and he was doing just fine. So he’s going downhill quick.

We did MRIs, sequential MRIs, and he was starting to transneurally degenerate all the way through the brainstem. We cut it off and got him food right before it hit his respiratory centers. Now what would have happened if it would have done that? Trach. Trach. Then there’s no possibility of language. Do you see how important your work can be? This guy’s borderline vegetated. So you have to watch these things. Just an example.

So really, these are a bunch of terms. Ankyloglossia, this is where, you know, you’ve got to clip the tongue underneath; they’ll get tongue-tied.

Apraxia is really a disorder of articulation characterized by impaired capacity to program the speech. This is just: they can’t do it. They’re apraxic. Motor apraxic. Speech apraxic. You can have any kind of apraxia. It’s all over the place. Like, I had a girl that came in, was completely apraxic. I’m like, “Hi!” And just nothing. Completely absent.

Auditory processing – we just talked about that – and auditory processing disorders. Really bad in a lot of children with developmental disorders. They have auditory processing problems which leads to attention problems, and attention problems lead to what? Bad behavior and bad grades. Depending on what types of lesions they have, they’re not all just right-frontal or left-frontal. Some of them are actually a little bit more posterior as well, and a little bit more one-hemispheristic than the other in regard to language capacity or processing.

So as we go on, we’ve got a few more things. You know, babbling, and stuff like that. These are all just words that really explain, you know, stuff you can read.

Dysdiadochokinetic rate. You’ve seen us talk about that. You have this in speech. Puh-tuh-kuh. You’ll actually have dysdiadochokinesia in your verbiage. Okay?

You can have dysarthria. Some really good famous actors that had dysarthrias and cerebellar-based problems. You’ve seen Katherine Hepburn, and stuff like that. They didn’t do so well.


Dysfluency. The type of speech is marked with repetitions, prolongations, and hesitations. An interruption in the flow of speech sounds. I’m going to break all that down.

Echolalia. Lots of kids have this.

Fluency is a big one. Fluency and repetition are big. If somebody doesn’t have fluency, that’s where you start. Fluency, so they’re hesitating. They’re pausing. As you look at it, it’s the smoothness of sound, syllables, words, and phrases are joined together. Does it hesitate or not? Okay?

So we go through and there’s some more things here. I’m not really worried about jaw-grading and stuff like that. Some people have a lisp. There are some people that just have this: oral articulation problems because of tongue, or their larynx, or they have a cleft palate, or whenever they talk they whistle, because they have, you know, some sort of, you know, laryngeal issue. You see it a lot in kids. It’s not going to kill them; they’ll usually grow through it sometimes.

Perseveration. The tendency to continue an activity.

And a phoneme is the shortest unit of a sound, and a lot of times people will substitute. So I’ll show you what that is in a second.

So here is, you know, the phonological process, and this right here is what we want to talk about.

So pitch is brain, all the way down to prosody, which is right,

Don’t worry about semantics, that’s just the study of language.

Syntax is the way in which words are put together in a sentence to convey meaning. A lot of people with left-brain lesions, especially with Broca’s lesions, they have syntax errors, okay? They’re completely aware, but they lose fluency.

This is what I care about. This is what I care about. Fluency, naming, comprehension, repetition, and paraphasic errors.

So I’m going to fly through to this. There’s four types that we’re going to go through. And this is where just the meat and potatoes of what we’re going to be doing. Do you have Broca’s, transcortical, Wernicke’s, transcortical sensory. And what I want to do is kind of summarize all of them, but I’m going to give them to you in a quick flowchart.

Now, I took the flowchart and I broke it down into explanations. So when I jump through the next few slides, don’t freak out. It’s just words explaining the charts, okay?

There’s Broca’s, there’s transcortical, there’s Wernicke’s. Now as we go through this, here’s what I want you to understand: These guys right here are going to be put into a nice chart., okay? So why read it to you when we can go through this?


So rule number one? Are you fluent? Do the words come out nice and smooth, not choppy, and it’s just precise? I’m not talking about meaning; I’m talking about fluency. Because I could go, “Ninety-ninety-ninety. Ninety-ninety-nine. Ninety-ninety-ninety-ninety-ninety-ninety-ninety-nine.” You’re like, “Wow, that was fluent! But what does ninety-nine mean?” Okay?

Well, if somebody is not fluent, you then have to say, “Are they even comprehending what we’re saying?” If they’re not fluent, and they don’t comprehend and they can’t repeat what you’re saying, like, “Say ninety-nine.” And they’re like, “[silence],” then those people have global aphasia. Look: red and blue. Back and back. Both sides. That’s an entire middle cerebral artery infarct, down here at the main branch. Probably at the internal carotid. Those people usually die. Okay?

Now, if you don’t have fluency, and you don’t comprehend, but you can repeat, then it’s kind of a mixed transcortical. So it’s a little bit of both. In other words, it didn’t quite make it to global. It could be watershed. It could be that some cells are still hanging on, okay?

If you’re not fluent, but you definitely comprehend, but you don’t repeat, that is Broca’s. Now listen: I’m going to give you a case over every one of these, to the point where you are literally blue in the face. You are going to know this chart. This was the best one I could find.

If we go all the way over here, and you’re fluent, and you comprehend, and you have repeats, that’s just an anomia. But if you come over here and you’re fluent and you comprehend but you cannot repeat, that’s a conductive aphasia.

The biggest thing is, well, what if I… just give me Wernicke’s and Broca’s. Okay. So here’s Broca’s. What is the difference? So first of all, Broca’s is non-fluent, Wernicke’s is. That’s the person that’s like, “Ninety-ninety-ninety-ninety-ninety-ninety-ninety.” It’s perfectly fluent. However, with Wernicke’s, they don’t comprehend, and they don’t repeat. So you’re like, “Say seventy-seventy-seventy.” They’re like, “Ninety-ninety-ninety-ninety?” And you’re like, “Whoa.” Perfectly fluent, don’t repeat. I’m not sure if they comprehend, because everything’s “ninety.” That’s a Wernicke’s.

If you come over here to Broca’s, it’s not fluent. So they’ll say, “hu-ss-hs spank me,” between breaks. Okay, so look. So if you come over here and it’s Broca’s, it’s like, look: Fluency versus no fluency. Comprehension. They’re all pretty much… if you see this it’s yes, no, yes, no, yes, no. Yes-no-yes-no-yes-no-yes-no, all the way across the bottom.

So Broca’s is non-fluent. Wernicke’s is fluent. Broca comprehends. Wernicke doesn’t. Why would Wernicke not comprehend? Because that is where everything integrates into meaning. Broca is simply this: the expres-sion. So when the expression is damaged, there’s fluency problems. When Wernicke is damaged, there is, you know… the true capacity to comprehend is gone, but they’ll be completely fluent. Because here’s the deal: Broca’s is just still going perfectly – blblblblbbl – but it has no meaning. Did you guys catch that?

So again: back here – and I’m going to summarize with this slide, okay? – back here is where everything integrates for meaning. Up here is where everything’s executed for vocalization. Well, Broca will go, but it doesn’t mean anything. So when you look at this, Broca will not be fluent if it’s damaged, because it’s like saying this: that the pathway that makes motor… by the way, what lives in the frontal system? Motor


output or sensory input? Motor output. So if it’s broken, what’s going to be broken? Motor output. So when Broca’s damaged, motor output’s damaged, so you’re not fluent. And you’re like, “Are you understanding?” and they’re like, “[silence].” They can’t say it.

With Wernicke, Broca’s perfect. It’s like, “Blblblblblblbl.” But they have no idea what they’re saying. Okay? The only things in between now is a transcortical sensory and a transcortical motor. Sensory and motor. So what is the difference? It’s transcortical.

Quickly: transcortical sensory, guys, is just Wernicke’s buddy. Because it’s a sensory pathway going to Broca’s. Okay? Transcortical motor is Broca’s buddy because it’s motor. So what is the difference? Transcortical sensory – the difference between Wernicke and transcortical sensory is this: Transcortical sensory people can repeat. So if I go, “Say ninety-ninety,” they go,… or if I go, “Say seventy-seventy,” they go, “Ninety-ninety.” That’s Wernicke’s. If I say, “No wait. Seventy-seventy-seventy,” they go, “Seventy-seventy-seventy.” The repeats are different. That is the difference between a transcortical sensory aphasia and a Wernicke’s aphasia.

Now, what is the difference between Broca’s and transcortical motor aphasia? Repeats. So when you have transcortical motor aphasia, Broca is not fluent but they have the ability to repeat. With true Broca’s they don’t.

So look right here: Know this compared to this. And that is ninety percent of your language problems. If language is intact, but they’re just aprosodic, just go look at the right brain. Fair enough? It all belongs to this. I told you: is it anterior or posterior brain? And if it’s a sensory system, there’s going to be repetition changes. If it’s an anterior system, it’s a motor system. There’s going to be fluency issues. Fluency just means this: Is the motor system repetitive, and can it do its think fluidly? Does that help you some?

Now, difficult topic, I understand. The case studies will parse it out, and then I’ll make a little separate video that just goes through each one in five minutes.

Now, I’ve got one more slide for you to read on your own. This is easy. Right here. But the coolest thing right here is this slide, and it gives you the hallmarks, the vasculature, the naming, everything. It even gives you the hemisphere. If you can read this – and don’t memorize; learn! Why is it this way? What part of the brain is involved, and what does that part of the brain do? And go back to that circle and say, “Oh yeah, that’s auditory processing. Oh yeah, that’s projecting to Broca’s area. Oh yeah, that’s going down and Broca’s area is now having some internal meaning and expression and motor capacity to the vocal cords.” Think about it, and when somebody walks in, and you’ll say, “They can’t repeat, they’re not fluent, they can’t comprehend, then it’s this.”

Okay? So, that leads me to this: your summary of evaluation. Is there disturbance in articulation? No. Is there mutism, like they can’t speak at all? Are they fluent? Can they name things? Do they comprehend? Can they repeat? Is there paraphasic errors? Do they perseverate? Do they have emotional intonation – right brain – and is there a visual field defect along with the learning, and that will tell you if it’s posterior brain or anterior brain.

That is in your clinical concepts right there. If you can do that, you’re set.


Now, I will review this again tomorrow, and I will review it again tonight, because I know for a fact this is a hard topic. You’re going to get plenty of information, and we’re even going to post links up to each one of them. Deal?

So, hopefully I can be fluent enough when I say: Thank you for letting me teach you a little bit about language. We will continue to go over it, and everybody have a left… and awesome left experience. And here comes a right-brain experience.

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