Vision Rehab After TBI | How Brain Injury Changes How We See

Vision is how we move through the world. After a traumatic brain injury, that relationship can change in ways that are often invisible, misunderstood, or dismissed.

In this episode of Rupture: The World of BestGuessistan, Wendy Lurrie speaks with occupational therapist and vision rehabilitation specialist Kellianne Arnella about the complex link between brain injury and visual processing.

They explore how TBI and concussions disrupt eye movement, spatial awareness, sensory integration, and perception. Symptoms that frequently fall through the cracks of the healthcare system. The conversation also challenges the idea that recovery is linear or binary, emphasizing neuroplasticity, accommodation, and individualized care as essential parts of meaningful rehabilitation.

This episode is for anyone living in the “after” of brain injury. And for caregivers, clinicians, educators, and advocates seeking a deeper understanding of what recovery really requires.

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New episodes drop weekly, featuring conversations with experts, caregivers, and people living in the After.

Watch the full episode on YouTube: https://www.youtube.com/@BestGuessistan

Subscribe to our Substack: https://bestguessistan.substack.com/

Follow us on Instagram: https://www.instagram.com/bestguessistan/

Join the conversation on Facebook: https://www.facebook.com/bestguessistan/

Transcript

Wendy Lurrie (00:01.048)

Today I'm speaking with Kellyanne Arnella, a doctor of occupational therapy from Rusk Rehabilitation. Kellyanne is an expert on how a brain injury can break vision and how to build it back. And I have to say, just, got a personal note. I am so grateful for having met you Kellyanne when I did, because I mean, the first of the therapy worked and I can read again and I've gotten used to wearing glasses and I can manage screens, which is...

were among the things I wasn't able to do before we started to work together. But also, like you taught me so much about how a brain injury impacts vision, how to get it back, how to get past it, and beyond that, you really inspired a lot of what became best guestistan. A lot of my ideas came from you. It depends on which we'll get into another time. But also you inspired one of best guestistan's most important and most popular ministries, the Ministry of Accommodation.

Kellianne Arnella (00:30.906)

Mm-hmm.

Kellianne Arnella (00:45.265)

you

Wendy Lurrie (00:54.542)

And we can talk later about whether or not you'd be willing to lead that ministry. Obviously, the answer is yes. So let's just start with the basics and let's help us understand the problem of how does a brain injury break vision? What does that mean?

Kellianne Arnella (00:54.822)

Love it.

Kellianne Arnella (00:58.545)

.

Kellianne Arnella (01:09.691)

So, you know, vision is one of those things. is one of, you know, it's our doors to the world, right? You can have wonderful, perfect vision, see 2020, and then you have a brain injury, a concussion or a more severe brain injury, and it can, for lack of a better word, all go to crap, right? And when, you know, you still might be able to see clearly, but...

It's really the pathways from your eyes through the rest of your brain and how your brain processes the image that it sees and the images and movement, colors, everything. And that's where the messages get lost. so, you know, your brain, right, if you think of it as a highway, your eyes are here. That's what's taking the pictures.

But the center of your visual center is in the back of your brain. And so there's all of these highways that the images that your eyes capture have to travel in order to get processed appropriately. And the visual system actually gets processed in each lobe of the brain, which is a little bit different than many of our other senses. And so anywhere your brain is impacted by a concussion or a more diffuse brain injury.

there can be an issue with vision. And so it is, you know, one of the most common side effects of any type of brain injury, but also unfortunately one of the most overlooked.

Wendy Lurrie (02:45.272)

Why is it overlooked?

Kellianne Arnella (02:47.856)

That's another really good question. So with concussion especially, there's a lot of focus on the immediate aftermath and diagnosing of what is a concussion. I'm going to say this in a few different ways, and it's a little complex, but you have the group of people that get diagnosed immediately with concussion. that's a lot of our car accidents,

people who have been injured during sports, know, sporting events or a fall and they go to an emergency room or they get sideline testing, right? They look at the eyes, but they're looking at what the eyes are doing immediately after the injury, okay? And so this is the group of people that get diagnosed with a concussion. They don't really look at the eyes again unless they see someone who specializes in concussion and

complex vision or concussion and brain injury, majority of practitioners won't necessarily look at their eyes unless they're specifically trained in this area. Then you have the subset of people who never get diagnosed with a concussion or a brain injury, and they might go months without realizing that there is an issue with their vision. So there's two reasons that I'll kind of like.

narrow this down to. So you have the subset that gets assessed immediately and they get see their eyes are seeing this in this gross motor kind of way. They look at saccades, they look at tracking, but they don't look at the fine detail. They also don't look at the activity dependent like symptomology. like reading, screen use, things like that. And then the other group of people who don't get assessed right away, they

start with the activity dependent symptoms, right? And then they almost get gas lit in a way by their providers that they were never diagnosed with a concussion and they just might need new glasses or something like that. But really what it is, it's the fine details of how your brain and your eyes are communicating together to process vision and understand and tolerate what you're doing and seeing. So it's a complex answer.

Kellianne Arnella (05:11.726)

you know, immediate testing isn't sensitive enough, but also because of the way your brain heals, sometimes visual symptoms don't show up until later. And that's another reason why they're, they're missed.

Wendy Lurrie (05:23.502)

Well, I was going to ask you to talk more about that. Why, why there are such sort of different kinds of outcomes based on where and when you're seen or treated. I mean, what, there's no universal standard for assessing vision after a brain injury.

Kellianne Arnella (05:31.236)

Mm-hmm.

Kellianne Arnella (05:36.708)

So.

So there are.

I to, I hope and I believe that it's in the works. In the past 10 to 15 years, how we treat and what we know about concussion has changed immensely. So 10 years ago, 12 years ago, let's say, it was a new concept to have concussion be treated in a rehabilitative fashion, right? And so it has been this

you know, with anything, just sort of this slow pickup on the way education is, streamlined to providers. So if you were a general practitioner or you were an orthopedic, you know, specialist, 10 years ago, and you were out of school, maybe 15 years ago, you may not have had the opportunity to learn about how concussion is now diagnosed, how it's now treated.

That is something that I am very passionate about too, which is, you know, how do we make this information more common knowledge? Just recently, you know, there's more information out there about like, you know, not resting for the first seven days, which is, that's what everybody thought you should do is.

Kellianne Arnella (07:05.7)

complete cognitive rest, sit in a dark room for seven days until the symptoms go away. And we now know that that is absolutely wrong and that's actually going to bring people backwards. And I think as the research is more supported and well, you know, understood, things will start to change. There are, you know, return to play and return to learn protocols that

a lot of educational programs and sports programs follow, and that has been seen as the gold standard. But unfortunately, they are also limited in how much they've integrated more current literature and research on active rehabilitation to return to life. I think that there is, you know, it's really just a...

I can't think of the right word. I want to say like a birch. It's an emerging. There we go. It's an emerging area of practice that will only get better and more streamlined. But as of right now, it seems to sit in like the larger medical centers where there's like a big core concussion program that's been well supported. But if you are outside of one of these or if you're out in the community and don't have

Wendy Lurrie (08:12.504)

Mm-hmm.

Kellianne Arnella (08:28.941)

to a large medical center that has a concussion program that's well supported and understood, you might have a different experience.

Wendy Lurrie (08:37.304)

Well, that's super interesting. And I did read a piece probably shortly after this happened to me about how the guidance had changed, but that information wasn't necessarily trickling down everywhere it needed to. And people were still being treated with this idea of lying in a dark room, wear dark glasses, frankly, I did for the first six months, because the information just hadn't gotten to all the providers.

Okay, we're to talk more in a little bit about if you could design a perfect system, what would it look like? But I want to like just help ground our audience more in basics. so when there are vision impacts from a brain injury, like what different kinds of problems do you see? What kinds of problems?

Kellianne Arnella (09:10.095)

Yeah.

Kellianne Arnella (09:17.1)

yeah, so we, mean, I can talk, I'll talk to you in two different ways. One's gonna be the functional aspect, right? So as someone who's a non-clinician, what they might experience, right? And then I'll tell you in like the clinical sense, like what those might be tied to, okay? And they are, you I have had,

Wendy Lurrie (09:39.63)

Perfect.

Kellianne Arnella (09:44.269)

gamut of patients come into the clinic and they're like this I this sounds Ridiculous, nothing sounds ridiculous. Like it is we have heard it. We have seen it oftentimes we are the fifth sixth seventh provider they've seen trying to relay how they're feeling and what their symptoms are before someone's like, okay, no, this is like let's try to figure out what it's from and as ot is what we do is we really

we think about things from the top down and the bottom up, right? So I like to hear like, what are you having difficulty with, right? And then I know as the clinician, what clinical skills I need to look for to assess and see like, is, you know, what can we find? What can we figure out here that might be causing that? And so, you know, the first one might be tolerance for something like reading, reading.

on paper and reading on a computer, right? For some people, it might be switching between screens. So like right now I have my screen here and then I have a larger screen on the side. And depending on the nature of your work, that might be it, right? For some people, it is looking at their phone and then being able to look up at something else, right? Like, you know, while they're walking or unfortunately,

maybe when they're trying to follow driving directions and they're looking at their phone and then trying to look at the road. Another one is the visual motion when you're driving or when you're walking in nature, when you're walking in the grocery store, when you are walking on a busy street and being able to tolerate that visual motion on the side. Another common one is looking at a grocery list in the grocery store.

and then being able to scan the aisles to find the thing that you're looking for, the specific item.

Kellianne Arnella (11:49.105)

trying to think of, oh, we've had someone talking about when they're trying to do something like knitting, crocheting, beadwork, they're unable to. One of the most, recently I actually had a few people who were talking about going through a train station, an airport, and actually managing multiple things at once. And that's also something that people miss is the sort of,

It's not just vision sometimes, but it's how vision responds and how your brain is able to respond to what you're seeing when you also have to think and move at the same time.

Wendy Lurrie (12:30.06)

That's really interesting. Can you talk more about that? Because that's also where it gets into vestibular and it all sort of comes together.

Kellianne Arnella (12:31.562)

yeah.

Kellianne Arnella (12:37.171)

Right. that talk, that's like a big thing. I'm like, you know, you were saying like my perfect program. We're all like, historically, a lot of our clinical practices have been siloed. And we've been told like, okay, well, OT does this, PT does that, vestibular, you know, and it's, that's actually like, it's so limiting to the patient experience, because especially for us as OTs, you know, if you, you know,

You don't know one is only using their vision ever. Like right now I'm using my auditory system. I'm using my balances and just sitting here and knowing where my body is in space, you know, reacting, responding. Yes, my eyes are telling me part of that information, but I'm relying on my other systems. And so if, you know, if we don't treat them all or understand where the impact is in all of those systems, then when we go to treat them, if we don't reintegrate all of them.

then we're missing something, you know? So, know, Wendy, when we were doing therapy, it would be like, okay, we're gonna be doing, you know, looking at the letters back and forth. And then we started looking at things like Spot It, where, yes, it's a kids' game, but we're looking back and forth at images, right? Then we started looking at images when we were standing up. And then we were looking at images standing up while I was talking to you. And then we were walking around the clinic.

And so if we're not layering in those things, then we're missing a big piece of the puzzle. And then it's when you go out to use the skill, if we're not replicating what it looks like in real life, then there is going to be a breakdown. And that's where oftentimes people kind of come back in, you know, with needing, you know, either more therapy or they think that the therapy didn't work, but really it's, you know, having that, that.

making sure we hit every layer and we're able to apply it, you know, within the clinic so that you can be prepared outside of the clinic as well.

Wendy Lurrie (14:36.322)

Those layers are hard. was just thinking about this the other day. And you and I talked about it. I asked you, that half hour session seemed so short until we actually started doing them. it's just being able to do all of those things with all of those layers was the most exhausting thing. mean, after 30 minutes, I couldn't do anything else that day. I was done.

Kellianne Arnella (14:41.572)

Mm-hmm.

Kellianne Arnella (14:53.232)

Mm-hmm.

Yeah. And that's, yeah, I think there is a big pressure for us to have shorter sessions. But I do think, especially with the concussion vision, like concussion and vision rehab, 30 minutes really, it seems so short, you're right. But, you know, it's a lot.

Wendy Lurrie (15:16.704)

It's not. Could you just go back? everything you were describing is sort of like the patient experience of these different vision problems, like within all the layers. From a clinical point of view, what's causing those?

Kellianne Arnella (15:20.698)

Mm-hmm.

Kellianne Arnella (15:30.929)

Right, so when we think of this, right, so let's talk about something that's a little dynamic of walking in a grocery store, okay? We like to look at like what we might be, what do we use? What are we using to go to the grocery store? I think before I was a therapist, I never really thought about it. I just went to the grocery store and did what I had to do.

We like, and also like when you think of vision, a lot of people just think of how clearly you can see your acuity, right? And that's typically when you go to an optometrist, they're looking at a bunch of different things, but they're not necessarily looking at it from a functional lens. They're looking at it from like, what does your eye see? How is it seeing? And then, you know, recommending something based on that. And so we go to the grocery store, we're going to use our acuity. You know, we think up close and far away.

Okay, so you're looking at the grocery list and you know that might look okay, but then you go to transition to look in the distance. Your eyes have to do a series of back flips, right? In order to do that and we just kind of take it for granted. But acuity is only part of the picture, right? So it's seeing the list clearly transitioning to a different distance. And so your eyes have to work. I was explaining this to someone yesterday. They are the most synchronized swimmers, okay?

They don't actually, they're not one thing. They're actually two independent organs and they're working together. And when they don't work together, they can really kind of cause essentially backflips in your stomach, headaches, migraines, or they're working so hard that you fatigue out sooner. And there's a lot of visual skills involved in these things. So one of them being accommodation. And so that's how quickly you're

eye, right, responds to changes in distance and movement. And so that requires three skills, which is acuity, how your eye, or convergence, right? So hang on a second, we might have to edit that one. So when you're looking down and then you're looking up at the list.

Wendy Lurrie (17:41.71)

That's okay. can keep going. will do the edits. It'll be great. Right, Jen?

Kellianne Arnella (17:50.141)

or you're looking down at the list and then you're looking up at the aisle of ingredients and you're trying to find a specific tomato sauce, right? And you're using so many different visual skills. But the first we're going to talk about is just looking down and then up, right? And that's convergence and divergence. Yes, you need acuity. You need acuity to see up close. But then as you change distance, you start to use these other skills. Break. Yeah, yeah, yeah, yeah. So acuity, yep.

Wendy Lurrie (18:15.032)

Can you define acuity? Let's just, yeah, if you could just like help us with definitions. Yeah.

Kellianne Arnella (18:19.952)

Acuity being how clearly you can see something. Okay, we test this usually Up close so 16 did about 16 inches from your nose And then we test it at 20 feet also so and there's another test you could do it at 10 feet and then some people also Test at a middle distance my I don't I don't screen at that distance but

It's really how clearly you see at different distances. And this is what people usually understand as having poor vision, right? That's that number you hear, 20-20, right? And 20-40, all of that. My whole thing is like, that's an acuity measure. like 20-20, I've had people come in and they're like, I've had perfect vision my whole life. I have 20-20 vision. I'm like, okay, well, that's great. But.

Wendy Lurrie (19:04.664)

That's an acuity measure. That's the acuity.

Kellianne Arnella (19:15.736)

Let's see how your eyes are working together and what they're doing with the information that they see. Right? So we go back to this grocery store example. If you have acuity, let's say 2020, right? You're looking up close. This is my grocery list, by the way. You're looking up close and then you're looking far away. And so then we introduce, you know, like I said, that convergence divergence, right? And your eyes are coming down and in and then up and out. In order to do that, they have to have

two other skills intact other than acuity. Those skills are called accommodation and then motility. So your eyes being able to move in all the directions that they're supposed to. Now, when you've had a concussion, your accommodation or as you know, if you were in optometrist office, they will assess like refraction and it's how quickly your eye responds to movement, either movement in the environment, like whatever you're tracking or

different distances. And so this is one of the skills that is often overlooked. It's a little bit more sensitive than the baseline or those sideline tests check for. And what happens is people will have like a slower response. So it's a little bit what we call sluggish. It might be slower than the normal age or the age-related norm or

one eye is quicker than the other. And then you end up having this sort of argument between the two. maybe I should go this way where one eye is seen clearly here, the other eye is seen clearly there. And then they can't, you know, they're not able to communicate and be on the same page, right? And so, what?

Wendy Lurrie (21:02.03)

Does that cause double vision? Does that cause double vision?

Kellianne Arnella (21:06.041)

Yeah, so that can either there's an everybody's a little bit different. It can cause double vision. It can cause eye strain. It can cause headaches. Some people are unable to, you know, gather the visual energy, the neurological energy in order to compensate for it. But then when you do compensate for it, you tend to, fatigue a little bit quicker. Right. And so that is, you know,

It can also cause this, if not double vision, oop, there you are. If not double vision, it can cause what we call a convergence insufficiency, which again, as an OT, I'm screening for these issues. And then often I'm working alongside like a neuro optometrist or a neuro ophthalmologist for them to do the official diagnostics. But.

you know, we measure against a series of norms for these skills. And so with like a convergence insufficiency, that means that someone is unable to bring an object close enough to their nose, essentially, right? They're unable to bring it as close enough to them in order to tolerate it. Or we might see somebody kind of slip out.

or they fatigue pretty quickly. So they're able to get 10 centimeters, then the next test is 15, the next test is 20, which tells us that your eyes are working, they're trying to do it, but something is off that needs repair in order to help it be more, not sufficient, but to be more efficient, right? To tolerate these skills more. And then you go in more,

right, with this grocery, this grocery recommend, this grocery example. So your, you know, your convergence, divergence, which we just talked about has a few other skills listed in it, but then you're also scanning, right? So you're scanning the aisle, looking for the right thing. And you're using, again, a bunch of these visual skills that we need, but can be impaired.

Wendy Lurrie (23:07.628)

The example? Yeah, yeah.

Kellianne Arnella (23:28.599)

And the more inefficient they are, the more tiring it is for you. So we also look at saccades, which is alternating fixation between two targets. And that is, you know, the skill that we use not only in scanning the environment, Like a grocery aisle, but it's also what we use to read facial expressions to scan for hazards in our environment.

anything that we are not tracking or moving, we're sort of doing these jumps, right? These little psychotic jumps. Even when we read, we don't actually read in a smooth line. We're reading little jumps and spots between the words and the lines and the sentences. And so when we look at this, we look for, you know, again, an inefficiency in the skill. Are people overshooting?

and coming back to a target? Are they undershooting and having to readjust? And those can contribute to this overall fatigue and difficulty tolerating something like going to the grocery store and scanning for the right tomato sauce, amongst all those other things that I said. and it's, you know, it's very, it's complex, right? So it's hard to explain, but.

When someone comes in and they usually have these pinpointed activities that they're like, this is what has been challenging me. We can break it down into like what skills are required to do that task. And then what do we know is usually impacted by a concussion or a brain injury and we assess from there.

Wendy Lurrie (25:12.066)

So that's super helpful. If you do not have access to Rusk or this kind of training in this specialty and you've had a brain injury and something's wrong with your eyes and you go to an eye doctor, will they be testing primarily acuity?

Kellianne Arnella (25:29.273)

So it depends on the kind of eye doctor you go to. So it depends on the kind of eye doctor you go to. There are, this could be another chapter is like how many different types of eye doctors there are, right? So you have optometry and I can refer a few to you to interview, they are, so you have optometry and ophthalmology and that's typically the ones that like

Wendy Lurrie (25:30.254)

It It depends on time.

Wendy Lurrie (25:46.83)

There's an idea.

Kellianne Arnella (25:58.672)

a lot of people are aware of, right? So optometrists, and I don't love to kind of give what another profession does, right? But if we're like going to Google a, you what does an optometrist do? They're looking at how clearly you can see, right? And some of the skills of your eye in order to make the best recommendation for like a lens or if you don't need a lens, Oximologists,

are looking at the health of your eye, right? The overall health. So oftentimes ophthalmologists will look for cataracts, glaucoma, like what is, know, if there's a retinopathy, things like that, right? Then we have another subset where there's neurooptometrists and neurooptomologists, okay? And neurooptometrists are the group of people that look more at the functional

components and skills of the eye and how those functional components are impacted by a neurological condition and how they can They actually are the most closely related to us as therapists Because oftentimes neuro optometrists are able to do a therapy Then there's neuro ophthalmology that also looks at the I say it in a way to clients as like the neurological underpinnings of the eye So what is you know?

Wendy Lurrie (27:09.963)

Okay.

Kellianne Arnella (27:26.415)

what neurologically is occurring that's impacting how the eye is working or moving? And so that might be optic neuritis, or we have 12 cranial nerves, some of them in our radar eye, but one of the most common ones is like cranial nerve six, or what people understand as, if there's a cranial nerve impairment, how are we?

you know, what is the what's going on? What's causing it cranial nerve four? And then, yep, and then, you know, they're they're looking at it as, know, like, what is occurring that's causing this. And they will often follow up with patients like a six month mark, they might recommend like surgical intervention, may some of them do lenses, some of them do not.

Wendy Lurrie (27:58.146)

on floor.

Kellianne Arnella (28:22.993)

but they might recommend something like a prism lens to help with the eye movements and stuff like that. But those are the four main types and there are some other kinds.

Wendy Lurrie (28:35.79)

That's helpful. It's a lot to process when you're going through something like this and all this is made that much harder if you have vision problems and you have to sort through all of this.

Kellianne Arnella (28:38.98)

yeah.

Kellianne Arnella (28:44.497)

Of course. Yeah.

Wendy Lurrie (28:46.42)

So you talked a little bit about this with the grocery store example. That's a great one, but I sort of wanted to get into what becomes hard for people that they may not expect. So the grocery store example is great. Reading, driving, navigating, which gets you into sort of balance and your sense of safety, which gets you in any process all this emotionally. if you could just talk about.

Kellianne Arnella (29:06.348)

yeah.

Kellianne Arnella (29:10.521)

Yeah, you know, I think a good way and everybody has different types of buckets, right? We talk, you know, it's hard because it can be so different for everyone. But you know, you start your day with, you know,

Series I explain it this way to people start their day with a series of spoons, right? There's a whole spoon theory You can use whatever you want it to be but like, you know, whatever objects, right? So let's say I have 10 spoons But I had a concussion and I am having difficulty with using both of my eyes together so I wake up in the morning and I Have to check my email for work. There's a spoon gone. Then I have to get ready for the day

and get my kids ready for the day, right? And so tying laces, buttoning buttons, brushing teeth, applying toothpaste, I've used two more spoons, right? So that's three spoons gone. Then I'm going and I'm trying to drive my kids to school. And again, I'm using these visual skills that I need to work so hard to activate and utilize, right? And so I get...

I get them to school, but I've already used like two more spoons for that. Then I get myself, you know, on my way to work and I'm trying to maintain my balance. So I'm using that same skill again. While I'm navigating the noises that are occurring, people, you know, talking to me, unanticipated conversation. now it's not only visual spoons leaving, but it's, you know,

cognitive spoons, emotional spoons, right? And so by the time I get into my day, I've already used like 60 to 75 % of my spoons and I need to still get through the rest of the day. And so what we find is then people are overwhelmed. They're experiencing this sort of sensory overwhelm because one of their systems

Kellianne Arnella (31:15.757)

isn't working to the capacity that it needs to to support them appropriately throughout the day and through the entire day. And so it becomes this issue where it starts out as vision, right? Or it could be caused by vision, but then they're having sort of cognitive fatigue, they're having emotional outbursts or shutting down emotionally that is like impacting their relationships at work.

in their family, how they're able to navigate the community in a way that they feel safe and supported. And sometimes this might even look as like, like it's sort of depression, right? Or, you know, sort of like, unable being unable to sort of initiate tasks, when really, it's that your brain can't switch gears.

And the energy, like almost like one gas tank is completely empty and the other gas tanks can't fire to help support enough. And so I know it's a little complicated, right?

Wendy Lurrie (32:23.278)

No, but that's why you're here because it is complicated and I don't think everyone necessarily understands the, like how deep the impacts are that it does reach cognitively and emotionally and every other way. by the way, you know this, but in best guess, Stan, we don't use spoons, we use brain juice. And it can't be replenished, but we can slow the rate of depletion. That is our goal.

Kellianne Arnella (32:37.189)

Yeah.

Kellianne Arnella (32:42.127)

good, perfect.

Kellianne Arnella (32:46.417)

Yes, exactly. Good. Yes, you can slow. Yes, you can.

Wendy Lurrie (32:52.956)

How do you do that? How does therapy help do that actually?

Kellianne Arnella (32:55.889)

It's a great question. So let's say you have a tank of brain juice, right? The concussion has poked a hole in it. And so now it's bleeding out. And now there's another one that's poked in there. And so what we're trying to do is repair the holes in the tank, supporting the tank so it's not so inefficient, so that it's not using so much brain juice to do the things that we think are so simple.

It goes, you know, like when we're thinking about it neurologically, right? When there is sort of like inefficiency going on in your brain, it uses more energy, right? So if we can reteach your brain how to use the highways in a way that like decrease the traffic, so everyone's not trying to go to the same place at once, the hole will be repaired, the juice will stay longer.

and you'll essentially have less symptoms. The assessments we're looking at, they'll get better. And hopefully, usually, I have to say hopefully because I can't guarantee anything, but that typically translates to improved functional performance and capacity for doing the things that you want to do and need to do throughout your day.

Wendy Lurrie (34:17.964)

That's super helpful. And we are going to talk about that more, in a sec, before that, just for a second, because we, you've referenced this, but a lot of people who have these problems aren't seen by the right people, right? They don't, they don't have access. What is getting in the way? Why can't they get to the kinds of support that you, that you teach the therapies, the rehab that really make a difference.

Kellianne Arnella (34:40.857)

Yeah, I actually, this was like the whole focus of my doctoral research. And it was really, you know, I started the project because I was frustrated. I was upset that so many people were coming. So many people were getting better. But then people would still come and say, I didn't know that this existed.

I had no clue that this could help me. And like I said before, like we were like the fifth, sixth, eighth person that they had seen. And it comes down to a few things. The first one being awareness. And it's simply that people just are not aware. There is a lot that goes into it. One being that like the research is...

you know, like it's trickling down. There's also a lot of emphasis on these sort of medically centric spaces, right? So for example, like an NYU, a JFK, a Kessler, like these bigger systems that have the support and have the concussion centers, like they work, you know, almost in a funnel, but the people on the community level don't necessarily have the same

access and awareness points as the people that are sort of like connected to these larger systems, right? And that's something that I think is like, hopefully changing soon. The second part is availability, right? And so I see these larger systems, right? And you think like, you know, I don't live that far from the city. I live an hour from the city. Yes, I'm in New Jersey, but

Based like where I am, if I were to have a concussion, I would have to drive 45 minutes to an hour or take a ferry into the city or train in order to get access to a concussion center or one of these specialists that I talked about, like a neuro-optometrist or a neuro-ophthalmologist. Where I am, there's one neuro-ophthalmologist that I've really made a really good connection with.

Kellianne Arnella (37:04.431)

And then the other ones are about an hour to 45 minutes away. And I'm not in the middle of nowhere. Like I'm in a pretty populated place. So I think when you start to, that's like, okay, well I could go to a concussion center. There's one so close, but when you start to think about it, like functionally again, as a working parent, I would have to either coordinate childcare for three hours a day. I would have to take time off of work.

which not everybody has access to, right? For an hour each direction plus the half hour appointment and who knows, it's never really just like minute to minute. And that's almost like three hours out of the day. And if you need to do that two times a week or even like once a week, it's a financial strain. So like there's availability issues which wouldn't change in a perfect world that still wouldn't change. You still have to go there, but.

As clinicians, we can be better about creating systems that are more dynamic, that can meet the needs of the client. And that's where we think about more of these hybrid models of care, like using telehealth. using telehealth or even, really like, I think we did this where we had in-person sessions and then we did do a few telehealth visits so that we could upgrade or downgrade and reduce the amount of time that you're coming in.

Wendy Lurrie (38:17.038)

I was just gonna ask you, yeah.

Kellianne Arnella (38:31.793)

And then, you know, there's the overall, you know, accessibility issue of I think like the financial access of care. When you start to think about the comprehensive costs, not every insurance company covers an adequate amount of visits. Some cover no visits to someone that is, you know, like an OT.

a lot of, and that's one of the big issues with like the vision groups is that they don't see, you know, like neuro optometry has a difficult time getting reimbursed for, for some services. So they will have to pay cash. And then that makes it sort of like a, you know, a limitation on that end too. But it's, it's multifactorial, you know, people aren't aware if they don't know that concussion care is available that, you know, they, they're, if they're

An athlete they're used to this return to play model or the return to learn model, which is also very limiting It only looks at how your body is responding to physical, you know like physical stress as it's you know, healing from a concussion and you know, it's Like in the absence of actual work. How are you? You know, what are your symptoms like but without any active rehab?

and it really should be active rehab. That's what's going to help things get better. there's some catch-up that's needed in this.

Wendy Lurrie (40:02.753)

Right.

Wendy Lurrie (40:06.098)

Yeah, but I mean, just let's say so, mean, awareness, access, insurance costs. I was also thinking about your driving example. Like if you're driving from Jersey into the concussion center at NYU, your driving has probably been affected by the vision problems from your brain injury. So now you need someone else to be available for you.

Kellianne Arnella (40:11.077)

Mm hmm.

Kellianne Arnella (40:19.109)

Yep.

Kellianne Arnella (40:26.425)

Exactly, exactly. It's the it's the comfort I think in my in my research I started to call the comprehensive burden of care, right? Where it's like you're not it's not just you right? Like like I said, it's like you you either have to have someone drive you or you're taking public transportation but then that's also creating more symptoms that's making your symptoms worse and Yep Yep, and honestly if you look up Sometimes you know, I I try to do this as like I try to see what I'm like

Wendy Lurrie (40:32.856)

Hmm.

Wendy Lurrie (40:47.328)

and stress. It's adding stress.

Kellianne Arnella (40:57.681)

in the shoes of the consumer, right? If you look up concussion care, there are resources, but then it's like, here's 75 things you can do, but I'm not gonna tell you how to do them. And it's like, here's all the different providers you can go see, but the website can't tell you who to go to first. And if you just follow this one thing where you're like, okay, well, I feel anxious and I go see a psychologist, right? Then you might be missing.

a whole component that is actually being caused by like physical, the physical impact to your brain, your eyes, your systems that are causing the anxiety. So, and that's on the community side where we're so siloed out here, right? But like that's where at like an NYU, you have their systems in place where there's an outreach team that then coordinates getting you access to all different types of providers.

But when you don't have that, it's a very splintered system, which is unfortunate.

Wendy Lurrie (41:58.734)

Just the thing someone with a brain injury needs is a complex condition with a splintered system. Yeah. Okay, that was really helpful. Could you talk us through, what are the specific therapies? I I know we played Spot It and all of this stuff, but if you could like actually talk about the different things you do, the tools, the techniques, all of the stuff that happens, I think it'll be great.

Kellianne Arnella (42:02.735)

Of course. Yeah. Yep.

Kellianne Arnella (42:14.694)

Yeah.

Kellianne Arnella (42:22.093)

Yeah, so from like the like vision perspective, right, we we screen a series of visual skills. So we look at acuity, we look at accommodation in a like a very simple, simple way. We look at near point of convergence, we look at your ocular range of motion, we look at your pursuits.

which is your eye's ability to fixate and track a moving target. And then we look at your saccades, which is that alternating fixation between targets. We use a series of norms for those. We use a standard Snellen chart for neuron for acuity. We use the NSUCO, which is an acronym. And I'm going to butcher it if I try to.

think of it off the top of my head right now, it's N-S-U-C-O for both pursuits and saccades. We use the DEM, which is the developmental eye movement test to screen for, it is not a reading speed, but it looks at saccadic eye movements. Saccades, I'll spell that too, because I think a lot of people ask me that. And some people say saccades, but it's S. Yeah.

Wendy Lurrie (43:40.106)

I think, yeah.

I was gonna say sounds like cicadas, so I just wanna make sure we know what you mean.

Kellianne Arnella (43:48.598)

S-A-C-C-A-D-E-S. And so that looks at sort of how efficient and if there's any errors or emissions and how it is how quickly you scan through the numbers, but it's not reading speed. It's more like the accuracy of seeing what you're seeing. And then, there's like with brain injury and concussion.

A lot of people try to throw protocols in. I wouldn't say like a lot of people, but some people, everybody wants to know like, you know, for like a knee replacement, you might follow a specific protocol of like, you need to do this and then you need to do that because every person is different. Every brain is different. Everyone's eyes are different. It's not repeatable in that sort of sense of being able to follow a protocol, nor would you really, I don't think like.

want someone just following and being like, okay, you can't do this, you know? And so I start with, like, that's a standard evaluation of vision. Okay. I don't, I do it no matter what, I'll do all of those assessments. Even if you're reporting like one specific thing, I might prioritize different ones to do first. But I always do all of those, right?

Wendy Lurrie (44:46.912)

Right.

Kellianne Arnella (45:13.839)

I'll also do some version of a cognitive screen. we use the Mocha is a very simple paper pen cognitive assessment. It's a Montreal cognitive assessment that helps us look at memory, recall, a little bit of visual spatial awareness, and like a little bit of abstract.

you know, abstract thinking and so that one is a good one to tie in. And then there's some more in-depth ones that we might use based off of that. And then we also look at, you know, functional performance assessments that look a little bit more at like how you're utilizing your cognition along with your vision to perform a specific task. And so one of the

very popular ones is the weekly calendar planning assessment, where we look at a series of appointments that have to be made and put them onto a schedule. And we kind of can see what strategies are really utilized by the person and how we can almost use those strategies more throughout other parts of their day. And then we also might look at fine motor coordination.

and hand-eye coordination via the nine-fold PEG test and the finger-to-nose screening. And then in terms of treatment, really, again, like I said, I don't follow a protocol in a strict way, but what I'll look at is like what you reported you were having difficulty with, what the screen is telling me is impaired, right?

And then we start to work from like a basic or a fundamental sense into more complex and then adding in those layers that we talked about earlier. And so for something like saccades where we're looking left and right, like I talked about earlier with the grocery store, anything like that, we might do looking at like letter charts that are simple, single column. Then we might look at letter charts with multiple columns. Then we might transition to something like

Kellianne Arnella (47:36.284)

four square letter charts, you've had those, and then ones that are different colors. So you're adding in little bit more variety, a little bit more of a challenge. Then we might do something like the vision coach, where you can't anticipate where the next target's coming from. And so you have to do a little bit more scanning, more balance. And then we might add in more cognitive components to it.

Then we moved from letters and numbers into images. And again, more cognitive components, more balanced components as we're still building on that skill of scanning back and forth.

So, I know.

Wendy Lurrie (48:22.446)

It really points out, like sort of how central vision is. I mean, everyone knows it's foreseeing, cognition, emotion, you talk about anxiety, you mentioned depression. All of these other things come out of the vision deficits. And if we can get more focus on rehab for those deficits, could help in so many more areas. Yes. I had a protocol.

Kellianne Arnella (48:28.783)

Yeah.

Kellianne Arnella (48:36.671)

yeah.

Kellianne Arnella (48:42.159)

Of course. Yep.

Wendy Lurrie (48:46.552)

question for you, but I forgot what it was because that's what happened. Memory problems still come from brain injuries, right? I haven't figured out how to get that one back. So back from the patient point of view, when do they, there are no typical, I know there are no, there are no solid, there are no timelines. Nothing's predictable. That's why we have the, depends on because every, every answer has, every question is answered with it depends.

Kellianne Arnella (48:52.187)

Okay.

Wendy Lurrie (49:11.382)

Are there signs you see of a brain being rewired? It's new pathways, right? Is it more trying to restore the old ones or trying to create new ones?

Kellianne Arnella (49:23.545)

It's a good question. mean, it's a little bit of a combination of both. so I think that when you are, we all follow this concept of neuroplasticity too, which is like creating, and I say it in a sense of like creating new highways and rewiring the brain. It's impossible for us

to see really what's happening. We know based on fMRIs, right, functional MRIs, all this imaging that we can, we rely on it when you're doing something, when you're, even when you're thinking of something like how to move, the parts of your brain responsible for doing that are lighting up, right? And we do believe in neuroplasticity that your brain can rewire itself through a whole series of different ways.

That's a whole other conversation, I think. there is the, you know, we see it in how you're able to perform, you know, different things, both clinically and functionally, right? And so I'll do an initial evaluation with all of those assessments I talked about earlier.

Wendy Lurrie (50:25.6)

Good one.

Kellianne Arnella (50:46.723)

And then we do exercises and after a few weeks we reassess and we look back at those benchmarks and we're like, okay, so did this get better? Did this not get better? If so, like what's going on? Right. And we, then we can kind of tell, okay, maybe, maybe we need to do something different. Maybe we need to refer to another clinician, right. and kind of like what, what, you know, what the next steps are.

But then you start to see, know people really starting to be able to do more. They're they're not feeling as horrible They're not you know, their brain juice isn't running out by the end of the day and That really like that's you know the best because then you know, we get people to a certain point It's almost like you know learning how to ride a bike, you know, we take off the training wheels and then we're like, okay Look now it's up to you. You have to kind of keep going with this You know, I always say to people were never

keeping you on program until you're 100%. That's not our goal. Our goal is to get you to the point where you can manage a lot of this yourself and then keep going and start to habituate real life into your exercises until you almost forget being a patient and then you're living your life again. That's the ultimate goal. But yeah, it's...

Wendy Lurrie (52:08.526)

That's the dream.

Kellianne Arnella (52:12.643)

Yeah, I think really like there's you see this and sometimes people still feel some you know They still feel symptoms of the concussion even though their clinical numbers are improving And that is a little bit, you know, like we try to stay away from like really gauging everything by symptoms Because what can happen is there is of course a psychological component here where are they are they like psychosomatic? Are these symptoms here because you're expecting them to be and now you're looking for them, right?

And that's why sometimes the the clinical assessments are really helpful. I'll I talk to patients about them all the time and like look you've gone from here to here and I explain this is what this does and this is what it translates to and That's why you should be feeling better So, you know, I often have that conversation with people too where it's like, okay You have to believe that you're feeling better and you have to let yourself feel better, too

Wendy Lurrie (53:04.248)

That's a really good point. Actually, that's really interesting. But you raise another question. So what misconceptions do patients bring with them to rehab when they start?

Kellianne Arnella (53:13.165)

plenty. That they think, you know, they're never going to get better, that they've done, you know, they've they, like I said before, they have 20, 20 vision, they don't need it. Sometimes people think that they are making themselves weaker by wearing their glasses, which is not true. Sometimes the glasses, sometimes the glasses are here to help you do more, use less brain juice, right? And maybe you don't need them again, but also maybe you do.

Wendy Lurrie (53:31.67)

that true.

Kellianne Arnella (53:42.544)

right? I have, yeah, I mean, like, a lot of people come in and they're, okay, well, someone said I should try this, but I don't know if it's going to help. And yeah, there's, there's always, and it's like, okay, good, give us a try. And we're here, we'll, we'll, we'll help you as much as we can. But yeah, it's, it's, people come in with all different types of misconceptions. People also come in that they're like, I, they also think like, I don't need to do any work just by coming to the office, I'm going to be better and not

Wendy Lurrie (54:04.396)

I'm sure.

Kellianne Arnella (54:12.505)

Also, we have to have that conversation too, if you don't do the work outside of here, then why would you expect to experience a change? And I often say, like, you don't get, well, I say you don't get abs by going to the gym once a week, but you also don't only get abs. Right, you also don't get abs only by going to the gym. There's a lot more that you have to do. It's food. Exactly, there you go.

Wendy Lurrie (54:24.151)

right.

Wendy Lurrie (54:30.606)

I'm not doing anything.

Wendy Lurrie (54:37.678)

You have to have the red and green balls to throw in the air, which I used socks for, but it was the same idea. Yeah, no, it worked. And it is a lot of work that you have to do on your own. It's true. I I really saw when I got into the rhythm of doing the work every day, I really started to see the improvement.

Kellianne Arnella (54:44.197)

Same idea, yeah. There's a lot more that goes into it.

Kellianne Arnella (54:57.871)

Yeah, that's, know, there's a slew of things we might use for people with that too. You know, we have like accountability built, I use this accountability program and you can modify it in different ways. You know, I use a paper pen chart for people to track what they do. But sometimes it's really just having that follow up and that's where telehealth comes in too. If you can't physically make it in, but you're gonna have this

conversation with me once a week and then we can discuss what you did or didn't do and what got in the way. You know, it's not, it's not, I always tell people too, it's not like you're not in trouble if you didn't do it, but like help me help you. What got in the way that you didn't do it and how can we make that better? Like was it the wrong time of day that you practiced? Were you too tired? You know, was it too much?

Wendy Lurrie (55:39.255)

You

Wendy Lurrie (55:51.182)

That actually was a barrier for me was finding the right time of day because the later in the day, I mean, it's so exhausting that you have to find time to do it when you have the energy to do it, which is not at the end of the day, even though the end of the day is kind of appealing because then you can just kind of crash after it is. hard to figure that out. Even harder with the brain.

Kellianne Arnella (56:01.201)

Mm hmm. Right.

Kellianne Arnella (56:09.667)

Right. of course. Yeah. you know, as someone so, you know, I struggle with that myself where it's like, okay, I want to go for I want to run every day of the week, right. And it's like, if you don't schedule it ahead of time, or build yourself in these tools to kind of keep yourself accountable to yourself, and to your system and your programs that you're building, you know, you're not you're not setting yourself up for success. Yeah.

Wendy Lurrie (56:36.398)

It's creating habits. Let's talk about accommodation. So the first introduction I had to that idea was from you. And it was because my, just the acuity, we know about the convergence insufficiency in the fourth neuropalsy, but the acuity just kind of collapsed in six months. And I asked you about it because it felt that it seemed like it was some weird form of age-related...

Kellianne Arnella (56:41.318)

Mm-hmm.

Wendy Lurrie (57:02.63)

know, vision challenges, but it was happening so fast. I knew that in everyone I knew it happened over years, if not decades. And here it was happening in months. And you said, interrupting the accommodations. Can you explain?

Kellianne Arnella (57:10.395)

Mm-hmm.

Kellianne Arnella (57:15.333)

And so, yeah, so that's a really good question, because that's a good misconception by people too, where everybody's eyes change, like everybody's vision changes, right, as we get older, right? Some people hold on to different skills longer, but there's certain skills that are age-related norms, right, that change as we get older, sort of accommodation being this umbrella term.

for that how your lens like essentially bends and extends right the flexibility of the lens within your eye to see things clearly right and so yes for some people it is this slow progression down it is the reason most people over the age of 35 were some sort of reading lens okay yes I'm over 35 I have

Wendy Lurrie (58:09.07)

Over 35.

Kellianne Arnella (58:14.617)

I've talked about this, my Wednesday glasses that I only wear on Wednesdays because that was my long day on the computer, right? But I don't wear reading glasses other than that. I have 20-20 vision, right? I can see clearly, but I don't require them. But a lot of people, right, they do. it's the...

The way we screen very briefly, and this is like separate from someone who has near sightedness or far sightedness. It's a sort of complex system that we kind of look at in a screening sense and that has to be sort of said on the clinical side. what can happen with a brain injury, so like what happens is your brain can compensate.

That's sort of neuroplasticity without us even thinking about it. My eyes know that this letter in front of me is, like the letters in front of me are H-J-K-L. So even if my visual system is being challenged, either the acuity or the accommodation, my brain can kind of fill in the spots and tell me that's what it is.

you kind of make these natural compensations without even thinking about it, without trying, you have no symptoms, you you're not getting a headache, right? But then what happens is a concussion can occur, brain injury, right? And your visual system, like I said earlier, is like so throughout your entire brain that it gets juggled. And it's almost like unable to really send the messages. Your eyes can still be taking a good picture, right? But it's sort of like

the message is getting scrambled, right? Or it's slower, the processing speed is slower. And so where your accommodation, right, that number may have been not so good before. The way your brain was able to process it and compensate for it may have been better just because of you. And if you think about your work, right, you were doing a lot of computer work. You were doing

Kellianne Arnella (01:00:26.819)

a lot of writing, a lot of visual, like very visual stuff, right? And I often see this too with people who were, they were working in a lab, right? And so they might be very old, but they have this intact skill that they shouldn't have based on their age, but because they're so constantly looking at like specimens up close or jewelry makers, people who have really adapted

Wendy Lurrie (01:00:46.168)

Yeah.

Kellianne Arnella (01:00:56.069)

and have had this of like, you know, like this neurological advancement without even trying based on their, like, you know, like their lifestyle, have this like, preserved skill, right? Like I said, that they shouldn't necessarily have, but it's actually better. And so my personal thing is that I always look at them, even though people are outside of that age-related norm, right? Just to kind of see like what the, if there's a difference on the sides.

Wendy Lurrie (01:01:21.165)

Mm-hmm.

Kellianne Arnella (01:01:25.293)

right, if one is better than the other, and then also like if it is just overall better, or if it's preserved in a way. And then, you know, it really just

It can, yeah, and that, it's a skill that's usually, I don't want to say accommodated for it because you're saying accommodated for accommodation, but it it doesn't mean better, you know, by a lens, it's typically an easy fix, not an easy fix. my gosh, I shouldn't say that. It is, there are things that can help it improve, but.

Wendy Lurrie (01:01:49.038)

Meta. Very meta.

Wendy Lurrie (01:02:00.59)

Nothing.

Kellianne Arnella (01:02:06.627)

Unless you're understanding sort of like the functional use of the skill, that can get missed. And that's where sometimes on like when you go to an optometrist and they're like, okay, well, you're over the age of 54. So that's normal. Okay, you can see, okay, you can see clearly. All right. And they might miss that sort of nuance of the functional skill related to the brain injury. And, you know, not

not tell you, okay, you need to wear glasses like this, or maybe progressives aren't the best idea for you. And the exercise is to help your eyes accommodate better to the changes in movement, changes in distance.

Wendy Lurrie (01:02:50.766)

Very complex. Very complex. So you raised a thought, I have a question about it. Recovery, the whole idea of recovery. It feels like as a patient, not as a provider obviously, so I'm asking you that, that sort of the world looks at recovery as binary, right? You're either fixed or you failed. And a lot of us who are on the side of it are made to feel like we have failed because this is invisible. It's

Kellianne Arnella (01:03:00.027)

Mm-hmm.

Wendy Lurrie (01:03:18.19)

chronic, it's complex, it's difficult. But do you think the healthcare system sees it in those sort of those like kind of polarities and what are the implications of

Kellianne Arnella (01:03:29.187)

Yeah, you know, unfortunately, I think that the healthcare system sees

Kellianne Arnella (01:03:39.482)

Everything yeah, I wouldn't even say like I'm gonna say binary but they don't even see it as like like neurological they see things and like when we're filling out authorization forms, there's not even a place there for Half the things that we assess for we have to write it in because they're concerned with pain. They're concerned with things that are like, you know When you break a bone healing time is six to eight weeks

You know and that's because it's a natural like you see what happens with with the science of a bone fracture and you can see what happens and it's like But that's what the bone heals or when skin is healing when sutures are ready to come out, you know The brains aren't like that and and and that's the the the healthcare system is not built for for this

And I think like that's been something we've been struggling with because they're like, well, what's the pain? we're like, well, we don't, know, sometimes people don't even have pain, but we're trying to say like, they can't read, they can't live their life. They can't do all the things that they used to do because of this. And it's hard to hit that right note to have them understand and justify. And I've had polite arguments with.

some of the people who make decisions on insurance about, you know, why people need the therapy that they need. But I also think then we as like a population start to think of ourselves in that way too, that I'm either fixed or I'm not. And that is also a hard one because it's really difficult. People are always like, but I was like this before.

I was like this before. And I always want to validate that for people that like, okay, I understand. But also, we're people can sometimes become like hyper focused on being back to the way they were when really, it's just what you remember, you don't remember, you know, you know, I might have read for 25 minutes and gotten a headache, right? And then I have a concussion and

Kellianne Arnella (01:05:57.328)

I read for 25 minutes and I have a headache, right? But in my mind, I'm like, I just stopped reading because I didn't want to. But you're almost programmed to start to think of like, OK, it was like before this, there was this, and now never getting back to the way I was before this. When some people can actually get better than they were before. So there is this sort of dance that you have to do with each person as an individual to kind of

Wendy Lurrie (01:06:04.718)

Mm.

Kellianne Arnella (01:06:26.065)

help them understand that it's not necessarily, I don't want you to let go of who you were before, but I also need you to understand that getting back to that person can't be the goal because we just need you tomorrow as a better version of yourself today, right? Or at least like getting yourself into something different. And that is a complicated thing.

Wendy Lurrie (01:06:54.978)

I understand that though, and it's self-defeating and I know that from my lived experience of trying to stay who I was and do the kinds of work I used to do and put in the kind of hours and manners, the kind of complexity I used to do. And it took me a really long time to realize that I needed to stop comparing myself to who I was. And I'm still figuring out who I am now, but that other road of looking back and saying, I used to be able to do that, it's pointless, it's depressing, it makes everything hard.

Kellianne Arnella (01:07:22.915)

Yeah, and it's, know, and some people can do it. And but you know, I also say like you were on a track, you know, a lot of people were like on this spinning wheel, right, that they just pulled energy and mustard through things. And maybe that wasn't the best either, you know, not, you know, it's not for me to say, but also, you know, it's like, there might be benefits, and there might be positives on the other side of this.

Wendy Lurrie (01:07:48.952)

Well, I think there actually can be. mean, when you think your energy is infinite, nothing means anything because you could just always keep creating more. But when you actually have to budget your brain juice and budget your energy, it forces you to prioritize. OK, we're up to the question that I keep teasing, but I really want to hear your answer to was, here's your whiteboard. You get to like draw what the pathway from an injury or illness.

Kellianne Arnella (01:07:55.461)

Mm-hmm.

Kellianne Arnella (01:08:01.489)

100%. Yep.

Wendy Lurrie (01:08:17.76)

to treatment and to really like getting, getting back to who you were before, but getting back to a place where you feel productive and confident and you can live your life and do the things you want. Like, what would you change to get from here to here?

Kellianne Arnella (01:08:27.205)

Mm-hmm.

Kellianne Arnella (01:08:31.959)

yeah. So, I actually, so that was the second part of my doctoral project was building, you know, building my ideal program. and it is as I've dabbled a little bit in this sort of space, I've refined it a bit. I joke around, I have this, this idea for something called brains and bods.

Wendy Lurrie (01:08:34.722)

Here's the pen. Take the whiteboard.

Kellianne Arnella (01:08:59.045)

which is, know, it's the approach to neuro rehab you didn't know you needed, right? Because that big thing that I talked about earlier, that awareness, you know, like, why isn't it? Because we, why aren't people aware? You know, as an OT, right, I look at some of the stuff that we do as a profession to advocate for ourselves and we're advocating within the profession, right? People who have...

Wendy Lurrie (01:09:24.366)

Mm.

Kellianne Arnella (01:09:27.473)

you know, experience with concussions, you're in these like centers, right? And you're advocating within the groups of people that already know what the care is, you know? Yeah, and so I, you know, I actually did a presentation recently where I talked a lot about how we have historically seen community-based care as an extension of a system-centric service, right? And so people typically go, you know, ER,

Wendy Lurrie (01:09:36.654)

Right, you're preaching to the choir.

Kellianne Arnella (01:09:56.418)

or they go to like an acute care situation, inpatient rehab, then they go to outpatient, right? And then they're kind of sent into the community. And if we thought more of the population or let's say like people with concussion as the starting point and then built things backwards for them, you know, would things look a little bit different? And so

if there is a way that we could build these communities of like-minded professionals and practitioners, could we collaborate and create our own network of sort of concussion care that lives in the community and then would go back to these system-centric spaces if need be, right? Because

you know, something NYU like does outreach, you know, the shepherd center in Georgia, they do outreach. They have someone that's responsible for doing those things. They people connected with those programs. But if we could, you know, I've collaborated with local PTs, neuro ophthalmologists, and I have already met with some schools where I'm like, if you knew a little bit more about this care, then maybe you wouldn't refer to that one doctor who's just clearing people or, know, they, could actually give a little bit more.

of that comprehensive care that we know is available and beneficial and kind of work it on the way in. And then my ideal thing is to have a clinic that's not a clinic, right? So, and that's brains and bods, right? Where it's really more you're working on, I think like people see OT and they think, that's not for me. They see PT and they're like, well, I don't have an injury to my leg or my arm. Like it's not a physical thing.

Wendy Lurrie (01:11:35.416)

to

Kellianne Arnella (01:11:53.33)

Or maybe they think like, I'll just go to a PT. I see that a lot where people are like, I just go to this local clinic, but they don't get the care they need because they're ortho trained and they're just like pulling things from a hat to do some sort of like concussion management. To have something free of insurance, free of external dictators telling us what we have to do and instead us being able to do what we know they need.

Wendy Lurrie (01:12:04.76)

Mm-hmm.

Kellianne Arnella (01:12:22.019)

in order to get them back where they want to be. And that's, yeah, that's a dream, but.

Wendy Lurrie (01:12:29.646)

It's a goal. Yeah. It's having gone through this, I can absolutely see why. I love the community approach because it puts it where people are. I mean, you've talked to me about coaches not looking for these things when kids get a hit to the head. And I know what it's like to have gone through this as an adult, but I mean, when you're dealing with a still growing brain, it's that much more alarming.

Kellianne Arnella (01:12:31.918)

Mm-hmm.

Kellianne Arnella (01:12:42.779)

Yeah.

Kellianne Arnella (01:12:50.064)

Mm-hmm.

Kellianne Arnella (01:12:55.429)

course.

Mm-hmm.

Wendy Lurrie (01:12:58.7)

the access and the, it comes back to the same things. It's the access, it's the awareness, it's the understanding and remove, in your model, you just removed a bunch of the barriers to getting that.

Kellianne Arnella (01:13:07.375)

Yeah, and it's meeting the people where they are, right? And so, you one of the things they tell you to do is like, go, where your clients would be. But it's kind of hard because it's like, do you want, you never want to be like, I think about this, I'm like, do I want to go to a kid's soccer game and be like, did you get it? You know, no, I don't want to be an ambulance chaser either. But, you know, it's really just being able to speak the same language of a lot of different people.

Wendy Lurrie (01:13:27.096)

Yeah.

Kellianne Arnella (01:13:36.978)

the doctors, the clinicians, the office staff, the parents, the kids, the teachers. I've had teachers reach out to me and say, I've had a student who comes in and they're wearing a hat, sunglasses. Six months later, they were able to return to their sport, but they cannot tolerate school. And I talked with the school and they were like, yeah, the nurse has given this list of accommodations. This is the accommodations they're given.

But they never, it's like, oh, you can sit closer to the classroom, you can take breaks, and it's nothing is purposed to the person. But had they had this sort of funnel, right, or this like referral system that it's like, okay, you can go to this person, then they can determine from there, you know? But you know, I wouldn't expect people that are 45, like they're not gonna go to NYU from here, they're not gonna go to...

Wendy Lurrie (01:14:14.456)

Mm.

Kellianne Arnella (01:14:32.037)

you know, level one trauma center, they're just gonna go to their pediatrician. And if the pediatrician doesn't know or doesn't have arms to send them to, you know.

Wendy Lurrie (01:14:32.558)

That's fun.

Wendy Lurrie (01:14:41.494)

Exactly. wow. Sorry, I think I just made everything shake. That wasn't the goal. So I mean, you've been following what I've been trying to do with Best Guests of Stan and a big part of it is raising awareness specifically around the complexity of these issues and how hard it can be to be someone going through it when we live in kind of a bounce back narrative world, right? Where everyone is just aren't you better yet? And especially with something like this where it's invisible.

Kellianne Arnella (01:15:07.355)

Mm-hmm.

Wendy Lurrie (01:15:10.414)

Like the emotional cost of having an invisible disability that is chronic and that is challenging. And that also, that's the other thing, it changes, right? The symptoms don't stay the way they are.

If there really were a Ministry of Accommodation, would you run it? And then you build your system? That would be perfect. We can bring brains and bods into best guess is sound. I think we've been missing that definitely, it's, it's, it's, we'll find it a home.

Kellianne Arnella (01:15:30.409)

of course, sure. Yeah, yeah. Ministry of Accommodation, brains and bobs, I'm there. Yeah.

Yeah, no, it's, it is. It's so interesting to bring that up to like, everyone said like a bounce back, right? And especially when it's invisible, it's really hard because it's not tangible, you don't see the injury. And then you don't see the turmoil that goes on in someone's head. And I think that that part, it's, you people, you instead of bounce back, you know, you're you're you're sort of like moving forward and moving beyond.

Wendy Lurrie (01:16:12.91)

Mm.

Kellianne Arnella (01:16:14.565)

You know, I think the hard, you know, it's also a challenge for people who had a concussion, right? And either don't know they had a concussion or had a concussion in a way that, you know, yours, right? I've had a lot of people who have like, had this situation like, like you're on a trunk door, right?

on an office, like an office cabinet, people walk into a sign, you know, they don't realize that they even had a concussion. And there's an entire, there's well over 60 % of people who've had a concussion don't even get diagnosed with it, you know? And that's another big misconception is that people are like, but I didn't hit my head. And I'm like, that doesn't mean anything.

You know, that doesn't mean you didn't have a concussion. It's really like how your brain moves inside your head. It's not an injury to your skull. It's an injury inside. And I think that that part, you know, that whole, I don't think we'll ever be able to capture every single person who has had a concussion, but if you could improve the awareness of like those functional symptoms, right?

Wendy Lurrie (01:17:19.63)

Wait.

Kellianne Arnella (01:17:37.881)

and how you can move on, how you can accommodate, how you can reaccommodate to the symptoms in your life, right? Not just ignoring them, making them better so that you can be better. I think it would be really beneficial to the whole concussion population.

Wendy Lurrie (01:17:54.886)

I As a member, as a card carrying member of the concussion population, I would agree. I really wanted to thank you, Kellyanne. This has been amazing. This takes what you did for me and just amplifies it. So maybe we can reach a lot more people. But thank you so much for explaining all of this and sharing your expertise and your time. It's been amazing.

Kellianne Arnella (01:18:00.282)

Hehehe.

Kellianne Arnella (01:18:08.323)

Yeah.

Kellianne Arnella (01:18:13.657)

No, thank you. Likewise. I'm so happy to be here. And I like I said, I really do appreciate when people are able to share their stories because that's really, you know, the only way that you know, something you might have said will have clicked and been like, that was me. I didn't realize I had this, you know, I don't have to feel so, you know, maybe there's a way I can share it, I can talk about it. So it doesn't feel so invisible to me, you know, I can share this story with someone so that with my husband with my

Wendy Lurrie (01:18:38.446)

Bye.

Kellianne Arnella (01:18:43.651)

mom so that they can understand that that's how I felt inside and that you know it only it only helps people understand more so that they can get the appropriate care that they deserve.

Wendy Lurrie (01:18:51.374)

I

And that was sort of the whole point of Best Guest of Stan is to give voice to something that a lot of people go through, but might not have the language to express. And once you can talk about it, it makes it a whole lot easier. Thank you.

Kellianne Arnella (01:19:01.669)

Yeah. Yeah.

100%. I agree. Thank you.