Studying brain injury; pancreatic cancer surgery; strengthening the pelvic floor: Upstate Medical University's HealthLink on Air for Sunday, Jan. 28, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a neurologist tells about a new study designed to improve outcomes for people with traumatic brain injuries.

Devin Burke, MD: ... This is the perfect kind of disease to try to do more research to provide better care for our patients. ...

Host Amber Smith: A surgeon explains a complicated operation with the potential to cure some pancreatic cancers.

Mashaal Dhir, MD: ... Even before going to the operating room, we know that the likelihood of success would be more than 80% to 90%. ...

Host Amber Smith: And a physical therapist discusses the benefits of mind-body exercise.

Rebecca Carey, DPT: ... There's also benefits to our memory and cognitive function, and it goes without saying that there's also improvements that have been demonstrated in some research studies on our physical health. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn how a complex surgery can cure some early-stage cancers of the pancreas. Then, a physical therapist tells of the benefits of mind-body exercises.

But first, a neurologist explains a new study that will involve patients with traumatic brain injury.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Upstate was chosen to participate in a national $32 million multi-institutional clinical trial to improve patient outcomes after severe traumatic brain injury. Here to explain how the study will work is Dr. Devin Burke. He's an assistant professor of neurology at Upstate.

Welcome to "HealthLink on Air," Dr. Burke.

Devin Burke, MD: Thank you, Amber. It's great to be here. I'm very excited to talk more about the trial.

Host Amber Smith: Now, this trial, this study, is paid for by the National Institutes of Health. In addition to Upstate, how many other institutions are participating?

Devin Burke, MD: So it's a multi-center trial. There's about 50 sites around the country. These sites are all Level 1 trauma centers like Upstate Medical University, and sites that see a large volume of severe traumatic brain injury, just like Upstate.

Host Amber Smith: What does Level 1 trauma center mean? Can you explain why that's an important designation for patients with TBI?

Devin Burke, MD: A Level 1 trauma center is a health care system that specializes in the management and resuscitation of very sick trauma patients. In order to be a Level 1 trauma center, you need availability of multiple specialists on call and also have some capabilities such as urgent surgical intervention, burn intervention and things like that.

Host Amber Smith: So when does this study start, and how long does it last?

Devin Burke, MD: We're in the process of submitting our IRB, which is an Institutional Review Board document, and once that's approved by the study site or the countrywide study, then we're hoping to start enrolling patients as soon as possible.

Part of our approval for the IRB is making sure we do enough due diligence to spread word about that we're doing this trial that is soon coming to the Syracuse community.

Host Amber Smith: Well, let's talk about the scope of the problem of traumatic brain injuries. About how many people come to Upstate with traumatic brain injuries every year?

Devin Burke, MD: Traumatic brain injury is a very common disorder and even more common in certain age groups, age groups that are mobile, driving vehicles; elderly population that is susceptible to falls; and those that are in high-risk activities, such as cycling, motorcycling, contact sports, and things like that. Of those that get a traumatic brain injury, a severe traumatic brain injury, which is the patient population that we're looking in, in this trial, is a little more rare.

I would say Upstate as a whole sees about 100 people per year with a severe traumatic brain injury, so that is the patient population that we are going to be focusing on for this trial.

Host Amber Smith: How do you define severe traumatic brain injury, as opposed to regular traumatic brain injury?

Devin Burke, MD: Severe traumatic brain injury, or the categories of brain injury, are usually defined by the examination on arrival, so people who have a severe traumatic brain injury are usually comatose, not following commands and likely requiring mechanical ventilation to provide their body with enough oxygen.

So these are very sick, comatose patients who have a traumatic brain injury.

Host Amber Smith: And I know it's individual, based on the patient, but in general, what is the prognosis for someone who has a severe traumatic brain injury?

Devin Burke, MD: It is certainly the most morbid type of brain injury.

I would say about 30% to 40% of people with severe traumatic brain injuries, those in a coma, those who are not waking up, will die in about six months. Of those patients that survive, which can be about 60%, a lot of them suffer lifelong disability, about 80% suffer lifelong disability.

Your outcome depends upon age, medical conditions prior to the traumatic brain injury and also, what we hope, is what we do here in the ICU and operating rooms, and things like that. So it's a large problem, a very common disease that is very serious and morbid.

In our minds, this is the perfect kind of disease to try to do more research to provide better care for our patients.

Host Amber Smith: I wanted to ask you what sorts of procedures might be required for these patients during their hospitalization?

Devin Burke, MD: The trial itself involves a couple of procedures.

One of the procedures that's done after you have a traumatic brain injury, one of the predictors of how you will do, is basically how high the pressure is in your brain after you hit your head, and it can swell just like any bruises or any injury. The brain is a little different because there's no room for your injury to swell, so you can have increased pressure inside your brain.

One procedure that we'll do in an injury this severe is to place a monitor intracranially (within the skull) to continuously measure the pressure inside the brain. We have certain parameters that we like to keep it below and keeping it below those certain parameters has shown to improve outcome in prior studies.

With this trial, there's another monitor that we can place inside the brain that measures the oxygen present inside the brain, and that is a thing that we've actually done here at Upstate for a number of years. But there has never been any high-quality, randomized controlled data to support this practice.

That is really the crux of the research that we're doing, is to look at outcome with the brain pressure monitor versus the brain pressure monitor and the oxygen monitor. These are the two groups that we're going to look at and see if one group does better or worse.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with neurologist Dr. Devin Burke about a new study designed to improve patient outcomes after severe traumatic brain injury.

So the patients who are part of the study, how will they be able to give consent to be in the study if they're comatose with a traumatic brain injury?

Devin Burke, MD: That is an excellent question, and that is one of the things that makes our trial unique.

So when you have a disease such as this, that really the patients with severe traumatic brain injury are unconscious and unwilling or unable to give their consent, the government passed a law in the '90s to try to remedy this conflict. You have these diseases, such as traumatic brain injury or other emergent diseases, that require high-quality research, but you have the problem that the patients that would be enrolled are too sick to be awake or to give consent.

To remedy this conflict, the FDA (Food and Drug Administration) passed a law (technically, it created an exception) called the Exemption from Informed Consent Act. This is designed to try to improve the quality of research done in patients with emergent illness. It comes with a lot of specifiers and a lot of requirements because what we're asking for is to enroll a patient into a trial without their consent, so that's a pretty serious venture. So the things that it requires you to do is to, one, consult the community as a whole. Let them know that this trial is being performed, and to solicit their input and their thoughts and opinions, and really to reach all sorts of demographics within the community.

The youth -- we went up to Syracuse University, we talked to the Neuroscience Club up there and got their opinions, because the youth, that is a population that is at high risk of traumatic brain injury.

We've also talked to elderly populations and received their opinions on the ethics of this trial. We're required to do six of these events, and we've completed all these, which is great.

The second thing that we're required to do is public disclosure events, to disclose that this is a trial we will be performing, and give people advance notice. Some things we've done are certain press releases, and really, this podcast helps as well. "The Informed Patient" plays an essential role in disseminating this important information. We thank you for that.

Host Amber Smith: Well, you said, or you described, that you'll be comparing this test for the intracranial pressure, with the intracranial pressure test and the brain tissue oxygenation test. You as a practitioner, do you have kind of a gut feeling of which one you think is going to be a better way to determine which patients are going to do well?

Devin Burke, MD: Here at Upstate University, in the department of neurocritical care, we have been placing the intracranial oxygen catheters for a while. That's on some lower-level evidence, some retrospective studies, some correlatory studies, some animal studies that showed that increasing the oxygen or monitoring the amount of oxygen in the brain can possibly lead to a better outcome, so we hope that that is the case.

It also gives us another tool to try to optimize this disorder that has such high morbidity and mortality (sickness and death). However, in order for a trial to be done, there needs to be a panel that decides that one is not better than the other. We call this principle "equipoise." In order to perform a trial, it has to be truly unclear what treatment is better, because in this trial, we are going to be treating patients with intracranial pressure monitoring alone, so it has to be clear in the evidence that there is a gap and there is not a certain answer, but obviously, we're hoping that we can have some more tools to treat these patients.

Host Amber Smith: Well, please walk us through how this is going to happen practically. When the trial begins, and a patient arrives in the emergency department with a traumatic brain injury, what happens then?

Do they call you?

Devin Burke, MD: I want to emphasize it takes a village. This is a multidisciplinary venture. So, the first people other than the EMTs (emergency medical technicians) that the patient will see is the, emergency physician and emergency team. So the emergency team will usually alert trauma surgeons that there is a trauma coming in, and if the trauma potentially involves the brain, and there's a threat of a severe traumatic brain injury, neurosurgery will be alerted as well. And our trauma and emergency team will both assess the patient for any life-threatening injuries that require resuscitation, and then we will start to consider the patient for the trial.

So there'll be some criteria. The criteria will be mainly around what does the examination look like? Is the patient comatose, and if so, then we would hope that our emergency and trauma colleagues alert our research team. We'll come down to evaluate the patient for enrollment in the trial.

It's the easier end because truly what we're doing in the trial is very similar to what we do on a daily basis. It's not really changing much. It's just incorporating these patients in a more systematic way to evaluate if the treatments that we do, if they help or not.

Host Amber Smith: Some of these patients will have more than just a traumatic brain injury. They'll have other injuries as well. Are they still able to be in the trial if they're having their other injuries taken care of before?

Devin Burke, MD: Yeah, most of them will. We are always in close consultation with our trauma team to evaluate the safety of enrolling in the trial.

If the other injuries are not too life-threatening, then yeah, sure, they can be enrolled in the trial. However, If there are urgent surgical emergencies that need to be taken care of prior to treatment or monitoring of the severe traumatic brain injury, then those will be taken care of at that time, and the patient will probably likely, not be enrolled in the trial. So always, the life-threatening issues take precedence.

Host Amber Smith: How do you decide which arm of the trial the patient will be in? Either the one where they're just getting the intracranial pressure, or ...

Devin Burke, MD: Yeah, so it's a randomized trial, so once the patient has met criteria for inclusion, the information will be sent to our central hub, and the computer will randomize to one treatment strategy versus the other. So the clinican, and nursing at bedside, won't really know at the time what group the patient gets assigned to.

Host Amber Smith: And they'll stay in the same arm the whole time they're in the hospital, right? That's kind of the whole point.

Devin Burke, MD: That's exactly right. Yeah.

Host Amber Smith: Well, I appreciate you making time to tell us about this, Dr. Burke.

Devin Burke, MD: Of course. I'm happy to talk about it. Traumatic brain injury is a passion of mine, and we truly need better options out there. And there's such a need for research, and we're happy to be on the cutting edge here at Upstate in the neuro ICU. And I just want to shout out to all the nurses in the Neurocritical Care Unit that work hard every day to provide good care to our patients. And thank you so much.

Host Amber Smith: My guest has been assistant professor of neurology Dr. Devin Burke. I'm Amber Smith for Upstate's "HealthLink on Air."

The Whipple procedure is one of the most challenging surgeries -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Some patients with early-stage pancreatic cancers may undergo an operation that can remove the cancer. It's a challenging surgery, and here to tell us about it is Dr. Mashaal Dhir. He's an associate professor of surgery at Upstate and section chief of hepatobiliary and pancreatic surgery.

Welcome back to "HealthLink on Air," Dr. Dhir.

Mashaal Dhir, MD: Thank you for having me.

Host Amber Smith: I understand that you now have robotic assistance for a major surgical procedure nicknamed the Whipple procedure. What is this procedure for?

Mashaal Dhir, MD: This procedure is named after the surgeon Allen Oldfather Whipple. It's basically removing the head of the pancreas and first part of the intestine called duodenum, and bile duct. It's mainly for cancers arising within the head of the pancreas, the lower part of the bile duct, or first part of the intestine called duodenum.

Host Amber Smith: So, of course, the trick is knowing that there's a cancer there, right? It's difficult to find these cancers when they're small.

Mashaal Dhir, MD: Yes.

Host Amber Smith: But once you do identify it, this Whipple procedure, tell me a little about how it's done because you've named, I think, three organs or structures, but sometimes it involves even more, right?

Mashaal Dhir, MD: Yeah, traditionally these organs, but sometimes we have to do some work around the blood vessels, reconstruct the blood vessels, which go in this territory. And gallbladder, if present, is also a part of this procedure.

A lot of patients, when they develop a tumor in this area, present with what we say jaundice. You know, they turn yellow because the tumors often block the liver duct, the bile duct. And that's how they come to attention. Some patients cane develop obstruction of their GI (gastrointestinal, or digestive) tract if the tumor starts obstructing the duodenum. Others may have vague symptoms, for example, unexplained weight loss, some abdominal pain. But jaundice and bowel obstruction are two most common modes of presentation.

Host Amber Smith: So, for the traditional open surgery, the open Whipple procedure, how long does that typically take?

Mashaal Dhir, MD: For the traditional open, it can take from 6 to 8 hours in general, but can vary based on certain factors, how difficult it is to remove the tumor, if you have to do additional work on the blood vessels, and other factors.

Host Amber Smith: And are there risks during the surgery and after the surgery?

Mashaal Dhir, MD: Yes. It is one of the most challenging procedures that we do because pancreas is in general wrapped around two major blood vessels, SMA (superior mesenteric artery) and SMV, (superior mesenteric vein.) That's why we encourage patients to have surgery in high volume centers, and Upstate is one of the high volume centers. That means we do this a lot. We do it well. And we monitor our outcomes.

The risk in general, as with any major abdominal surgery, a risk of infection, a risk of bleeding. But two particular risks which we talk to patients about are the risks of pancreas leak, where you connect the pancreas to the bowel, and "sleepy stomach." That means the stomach just doesn't pump very well, which is in general a temporary problem and goes away in four to six weeks.

Host Amber Smith: But if all things go well, you can cure an early pancreatic cancer, right?

Mashaal Dhir, MD: Yes, that is the potential of this procedure.

We use the term "potentially curative." That means that is the intent, but it remains to be determined, and that's why we have to do the surveillance, keep an eye on our patients. We check scans every three months for the first three years, and every six months from years three to five.

Host Amber Smith: Is recovery, did you say, six to eight weeks? I'm curious about the recovery for the patient. How long does that take?

Mashaal Dhir, MD: Yes, in general, I would say patients, everyone is variable based on their strength, how strong they are, but in general, patients spend a week in the hospital. Full recovery takes six to eight weeks, but sometimes up to 12 weeks. Depends on if there are any setbacks along the way, how quickly the patients bounce back from the surgery.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith.

I'm talking with surgeon Mashaal Dhir, who's the section chief of hepatobiliary and pancreatic surgery at Upstate, and we're talking about the Whipple procedure, which is used to treat cancers of the pancreas.

What is the overall success rate for being able to remove the cancer?

Mashaal Dhir, MD: The technical success rate is pretty high nowadays with the good quality CT (computerized tomography imaging) scans. Even before going to the operating room, we know that the likelihood of success would be more than 80 to 90%. In general, in 10 to 20 percent of the cases, we might find unexpected findings. For example, spread of the disease to outside the pancreas or liver, small lesions or masses may not show up on the imaging. Other times, some unexpected findings may be seen at the time of the surgery, but we try our best to avoid a noncurative operation, but sometimes that is inherent to what we do.

Host Amber Smith: Well, let me ask you, if you would please, to compare the open Whipple procedure with what's being done now using a robot. How does that work?

Mashaal Dhir, MD: With the open surgery, we work through a large midline incision. But for the robot, we usually make four or five small quarter-sized incisions on the belly and one near the belly button. And once we are done with removing this head of the pancreas and first part of intestine, we put it in a bag and then just slightly enlarge the incision near the belly button, maybe a few, maybe a couple of inches to get the specimen out, and then put the pancreas, bile duct and stomach back together.

Host Amber Smith: How long does this take, compared with open, (which) I think you said could be six to eight hours, right?

Mashaal Dhir, MD: Yes, and through small incisions, it could even be longer. Because we have to work under magnification. It's more methodical in a way that we have to make finer movements because we are in a limited space. We have to blow up the belly with the gas, create the space, and work around the blood vessels. So, in general, it takes in our practice about eight to 12 hours, depending on how extensive the disease is and how easy it is to dissect the tissues.

Host Amber Smith: So this is a procedure that's one of the most challenging to begin with, but it sounds like it may even be more challenging doing it robotically. Why would you want to do it robotically? What are the benefits?

Mashaal Dhir, MD: I think it is worth it for the patients. Patients value quicker recovery. If they have smaller incisions, they experience less pain. And I would say patients bounce back quickly. However everybody is different, and the studies haven't shown significant advantage in terms of the survival, but a lot of studies do show that patients start treatments for chemotherapy faster. They do recover faster. So I think there is value to it, not having a big incision and quicker recovery.

Host Amber Smith: Which patients would be candidates for the robotic procedure?

Mashaal Dhir, MD: The patients have to have smaller tumors, away from the blood vessels because when we are working on the blood vessels, it's good to be there with your hands in terms of controlling the blood supply as there's potential for bleeding. So smaller tumors around the junction of the bile duct and the pancreatic duct are good for the robotic procedures, tumors which are away from blood vessels. So that's where we are offering robotic surgery in our practice.

Host Amber Smith: Do patients make the decision if they want open or robotic, or is that something that you tell them what will work?

Mashaal Dhir, MD: I think it's a collaborative decision, ultimately. We discuss both with the patients, if they are candidates, and I think it is unusual for patients to choose open over robotic. But yeah, most of the times we offer this open based on the challenges posed by the tumor itself. But for patients who are candidates, they are readily agreeable to getting this done robotically.

Host Amber Smith: Dr. Dhir, thank you so much for making time to tell us about the robotic Whipple procedure.

Mashaal Dhir, MD: My pleasure. Thank you so much for having me.

Host Amber Smith: My guest has been Dr. Mashaal Dhir, an associate professor of surgery at Upstate and section chief of hepatobiliary and pancreatic surgery. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," the value of mind-body exercise.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Today, we'll explore the benefit of mind-body exercises -- which are relatively low intensity and slow in pace -- with a physical therapist who has a lot of experience with mind-body exercise. Rebecca Carey is a doctor of physical therapy at Upstate and the lead physical therapist for the oncology program, and she has an interest in integrative medicine and pelvic health.

Welcome to "HealthLink on Air," Dr. Carey.

Rebecca Carey, DPT: Thank you so much for having me, Amber.

Host Amber Smith: I know that yoga is considered a mind-body exercise, but there are others. Can you tell us how mind-body exercise is defined, and then what are some of the other exercises besides yoga?

Rebecca Carey, DPT: Yeah, so mind-body exercises are typically movement sequences that involve breathing, control, attention regulation on the breath, which is a little bit different than typical physical exercises. Tai chi, meditation, mindfulness, even Pilates and qigong are all considered types of mind-body exercises.

Host Amber Smith: When you think about yoga, there's all of these different styles of yoga. Do they all count as mind-body?

Rebecca Carey, DPT: Yes. So, whether it's chair yoga that someone's practicing, or a high intensity, sometimes referred to as a power vinyasa class, the focus is always going to be on breath regulation through different movements. So there's lots of layers of benefits here.

Host Amber Smith: OK, so exercises like running and swimming, those are meant to keep your heart and lungs healthy. Strength training with weights is meant to keep your muscles and bones healthy. What is the benefit of yoga or tai chi or meditation? What is that working on?

Rebecca Carey, DPT: Yeah, so really the entire body.

So there's a lot of research showing us that it can help improve mental health, so particularly stress, anxiety, depression. There's also benefits to our memory and cognitive function, and it goes without saying that there's also improvements that have been demonstrated in some research studies on our physical health.

So things like balance, flexibility, strength. And I think flexibility is probably the No. 1 that I often hear from both patients and students that I want to improve my flexibility. I'm going to start practicing yoga or start practicing some type of Pilates or tai chi. But I think that really the experience of practicing something like this is that we are able to shift our attention from our physical status to our breathing. And so by doing that, it's like working a muscle where you, you're strengthening your attention, your ability to concentrate on something other than a physical sensation.

Host Amber Smith: You mentioned the mental health benefits. How quickly would someone, maybe, notice an effect?

Rebecca Carey, DPT: The research for this, it really depends on the study. I've seen it vary anywhere between four weeks to 12 weeks. So it just depends on the individual and what's going on. But the good news is that for most of the studies, looking through all of the literature for any population is that as little as once a week can be beneficial.

Host Amber Smith: And you said balance, flexibility, strength, I mean, those are sort of the physical benefits of this. Is that something that people would notice right away, that they, their balance is, they're getting better with that or they're more flexible, they can reach further or bend deeper?

Rebecca Carey, DPT: Yes. I mean, I do think that after about four weeks, folks can start to notice some changes in that. Now, we know from a physical and physiological standpoint that muscle tissue does not actually change until about six weeks of strength training. So you won't actually see changes if they looked at someone's muscle under a microscope. However, you will physically feel some differences. And that's because what the brain is telling the body to do. So the brain is sending a signal to those muscles that it needs to use them in a stronger way, to meet the resistance and to meet the demands that the practice is calling for.

Host Amber Smith: Well, I know a lot of these mind-body movements are sort of lower intensity, slower movement types of things. Can they also, can they give you a workout? Do you ever see people doing yoga who are sweating, for instance?

Rebecca Carey, DPT: Absolutely. So, it really depends on the type of practice that you're looking for.

There are some practices in yoga where it's entirely movement and very fast-paced movement. So those would be types of yoga like Iyengar or Ashtanga, for anyone who's listening and is familiar with that. There's also a very common term at most studios, Vinyasa, which is also known to be a very fast-paced practice.

Now, for anyone listening who is thinking they might want to try a practice like this, something like tai chi is very slow paced. And even the YMCA, I believe, has tai chi classes. The Syracuse Parks Department has chair yoga, for seniors especially. There's lots of different options, and the practice doesn't always have to be slow. That's where some of the cardiovascular benefit can also play a role.

So it's not only in just our ability to regulate our blood pressure and heart rate, which are also demonstrated benefits of practicing any type of mind-body exercise, but there's also a benefit in actually physically challenging our system so that we can have that improved reduction in long-term high blood pressure and those different types of things that we typically would see as a benefit from any type of e exercise.

Host Amber Smith: Now, what age do you recommend people begin with mind-body exercise? Is this more for seniors?

Rebecca Carey, DPT: Anyone can begin at any time. It's very commonly practiced in Central New York in schools right now. And the benefits are huge to kids learning stress management tools that can be used at school or at the home, in their home environments. The Syracuse Parks department, as I mentioned, they do have chair yoga and regular yoga classes for all ages. And there's lots of other studios that include yoga and meditation, really for anyone.

I've gone to many different fitness classes in the Central New York area, and I can honestly say that you just need to kind of find your niche, find your group. There's lots of individuals who are practicing and doing different things, and if you're looking for a group that's maybe in your similar age demographic, then there's definitely something for you.

Host Amber Smith: Do people need to do anything to prepare themselves or bring any equipment or certain clothing?

Rebecca Carey, DPT: I would say, if you are going to be attending a class, take a look at the class that you're going to attend and the description. Especially with regard to yoga, unless it's chair yoga, plan on getting up and down from the floor.

You always want to wear typically loose, comfortable clothing. And just make sure that you can keep an open mind, and follow the instructor. So the instructors will typically also give different guidance in terms of making modifications and giving some different ideas, especially if you are a beginner. And sometimes I share with patients and even myself when I was a beginner, know that it can be helpful to let the instructor know that you're a beginner so that they can keep a special eye on you, to give you some additional information if it's necessary, and to kind of keep an eye in case you have any questions.

Host Amber Smith: Now, are there any common mistakes that you can help us avoid?

Rebecca Carey, DPT: So in general, I think that sometimes when we think of certain poses or certain movements, some individuals will wonder, you know, am I stretching in the right way? Am I moving in the right way? Am I doing this correctly?

Again, I would really defer to, if you're working with an in instructor, take their guidance, take their lead, and that's so much of what any type of mind-body practice is, is really focusing on a little bit of that letting go aspect. The tuning inward gets easier the longer that you practice. But at first, it feels kind of clunky, and that's pretty normal. So it won't necessarily feel natural unless you've done something like this before. It may feel a little bit extra physical, so you may feel it in your body a lot: "Wow, this is a big stretch. Wow, we're really holding this position for a long time." Or "What am I really getting out of this?" But again, the benefits, you have to stick with it, and then you see the changes that happen. And they've all very frequently, so there's many studies where they've looked at MRI (magnetic resonance imaging scans) and brain changes that have happened over a period of time in individuals practicing yoga, practicing meditation, tai chi. And there's changes in the brain that happen in terms of memory, cognitive function, and even how we regulate our emotions.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith.

I'm talking with physical therapist, Rebecca Carey, and we've been talking about the benefit of mind-body exercises.

One of your other research interests is pelvic health, so I'd like to ask you, what's important about pelvic health?

Rebecca Carey, DPT: Yeah, so pelvic health applies to everyone. Everyone has a pelvic floor. It's comprised of muscles. And there's three layers of skeletal muscles, which means that we have the ability to control these muscles, and we have voluntary say over what they do.

So the reason why it's so applicable, especially if someone has, let's say, had a child, is that it's similar to a postoperative state, right? And if someone has had a C-section, it really is a postoperative state. The muscles in the pelvic floor often need different types of rehabilitation to return and maintain good function. Every population benefits. It just depends on what symptoms someone is experiencing.

Host Amber Smith: So particularly women who've had children may know the term "Kegel" exercises, that sometimes they're told to do Kegels during their pregnancy.

Rebecca Carey, DPT: Mm-Hmm. Yes.

Host Amber Smith: Can you describe that, and is that the same thing as pelvic exercises?

Rebecca Carey, DPT: Really that's a very interesting question because Kegels are a contraction of the walls of the vagina. And so oftentimes we think of squeezing the pelvic floor muscles and that that's an exercise. The thing is, that is not the only exercise that exists for the pelvic floor.

So one of the benefits of seeing a pelvic floor physical therapist, for example, is that we can assess the muscles to see, is it something that you do need to do? So if an individual is performing a Kegel, and let's say they're actually doing it the wrong way, then that gives us information about what we might need to work on.

Now, other times if an individual's going to squeeze the muscles in this way, and nothing happens, so they think that they're sending the signal, right? Then there's a connection or coordination piece that's missing. And again, we would know where to start in terms of giving you instruction on how to do this.

But oftentimes I've found that there's often more flexibility that's actually needed at the pelvic floor muscles rather than toning or strength training. So that's a very common one that I hear from lots of patients in our community as well.

Host Amber Smith: So what happens naturally to the pelvic area as we age? Do we become less flexible? What else happens?

Rebecca Carey, DPT: As we age, very normally, our hormones change. So the tissues that are in our pelvic area also change. So these skeletal muscles are relied upon by a couple of different organs to function, and organ systems, right? So all our bladder function, our bowel function, sexual function, occurs within this region and is reliant upon these muscles.

So the other part that comes into play, right? Hormones, and so there's genitalia in the pelvic area as well. In terms of aging, there's a term called sarcopenia, which is the slow loss of muscle tissue. And that happens, again, very naturally. It's normal to happen as we age. So what can happen then is we may see a bit of atrophy or a change occur to the muscles that are in the pelvic floor. So it may be that there's more weakness there, or there's more difficulty to access the muscles. And so individuals might experience different things, like a whole slew of different symptoms.

I can go through some of those -- urgency, frequency, urinary or bowel incontinence, constipation, IBS (irritable bowel syndrome), difficulty starting the urine stream, pelvic pain. You know, anyone who has a history of abdominal surgery, abdominal pain, any type of cancer of the colon, bladder, rectum, ovaries, cervix, uterus, prostate, anything in that area, will typically benefit from pelvic floor rehabilitation. And that's to give someone an idea of a program that's tailored specifically to them in particular exercises so they know what to do and when to do and why.

Host Amber Smith: So do people come for the pelvic exercises only as rehab, or do you recommend people start doing these moves before there's ever anything, any problem that they have in that region?

Rebecca Carey, DPT: That's a really great question. I'm often asked that. So, everyone owns their own body, right? So we can always take note of what control do we have over these muscles, right? So you can assess yourself and see.

One of the most common ones that I like to use with patients is taking a little washcloth, rolling it up and just sitting on it, like as if it were a bike seat. And then you can squeeze the muscles and then see, do I feel less pressure? Do I feel more pressure? Does anything change? Does nothing change. When you have that feedback, then the brain gets a little bit more information about, OK, the muscles are squeezing, I'm sending the signal. I did that correctly. Right?

You may notice that nothing changes. So then if you notice nothing changes, you can try again. And so that's the way that our brain learns, and then our bodies can transform that way.

Host Amber Smith: At what age would you recommend men and women beginning exercises, or becoming aware of perhaps the need for exercises for their pelvic floor?

Rebecca Carey, DPT: I do think that it really is for every age.

Here at Upstate, our pelvic floor team consists of six doctors of physical therapy with additional training in pelvic floor muscle function. And we treat all populations, including all genders, all ages. We see children who are having recurrent bedwetting, some other symptoms as well, sometimes constipation, other things going on.

But the more that we are in touch with this area of the body, it can really only help us. Then, if we notice that we're having symptoms, we can oftentimes try to address that on our own. And with a little bit of that biofeedback or proprioception tool with using the washcloth, which just means that we're training our brain and the nerves to send the signal to the muscles.

We can try something like that. Or we can seek out care and assessment. So if we don't have an idea of what our baseline is to know how we typically function and how we feel, then it's hard to know, then, when we need help, right? And that's really what any type of rehabilitation is, is we're helping and guiding people along to restore their function, help them get back on their feet, always seeking to empower them to focus on taking control of their own symptoms.

Host Amber Smith: And can these pelvic floor exercises be incorporated into the mind-body exercises that we talked about earlier?

Rebecca Carey, DPT: Yes, absolutely. So there is a wide body of research in particular related to pelvic floor dysfunction and pain, urinary incontinence as well, and yoga, the benefits of practicing yoga, so in particular the type of yoga that's been used in these studies is what we call hatha yoga, H-A-T-H-A, but that's a very umbrella term for yoga, as much of the yoga that is practiced in our country is some form of hatha yoga.

So, practicing these pelvic floor exercises can be incorporated and blended into the mind-body exercise. It just depends on how you want to do it. So much of the benefit of yoga is on hip openers, and openers for the low back, and all of these areas we know are correlated with pelvic floor health. So if we're doing a stretch, like a child's pose or a stretch, like a pigeon pose, or happy baby -- if anyone wants to look these ones up -- those are all beneficial for the pelvic floor.

And so, many times when we think of exercise we might think of as strengthening, oftentimes flexibility training, mobility is usually where we need to start when it comes to the pelvic floor. And yoga really meets the bill for that.

Host Amber Smith: And again, that would be for men and women, is that right?

Rebecca Carey, DPT: Yes, absolutely.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Carey. I appreciate it.

Rebecca Carey, DPT: Thank you so much for having me, Amber.

Host Amber Smith: My guest has been Rebecca Carey. She's a doctor of physical therapy at Upstate and the lead physical therapist in the oncology program. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Sharon Brangman, chief of geriatrics at Upstate Medical University. What can a person do if they have mild cognitive impairment?

Sharon Brangman, MD: We have a lot of non-pharmacological approaches, but as a society, we always want a pill. So we don't want to hear things unless there's a pill. But there's a lot you could do for brain health, and as I mentioned, some people with MCI, it gets better.

There are a number of things that we encourage people to do. The No. 1 is exercise. Exercise is probably better than any prescription I could write. And we try to tell people that they need about 150 minutes a week of good activity. And that could be walking. You don't have to run a marathon. It could be swimming. I recommend that my patients figure out a way to take a walk for a half an hour a day. You could break it up into 15 minutes, twice a day. But it's very important that we figure out a way to incorporate exercise into our life, just like we brush our teeth every day.

The other thing you want to do is make sure you get a good night's sleep, because when we are sleeping well, that's when our brain cleans up all these little abnormal particles that build up during the day. And research shows that when we're in deep sleep, that's when our brain cleans up all of these little particles. So it's important to get a good night's sleep.

The other thing that people usually don't like to hear too much is that alcohol really isn't good for your brain. You know, there were a lot of studies -- many of them were supported by the alcohol industry -- that said red wine was good for your brain. And we're starting to understand that alcohol is actually a toxin to nerves, and there is really no safe level of alcohol for our bodies in general and for our brains. So I try to encourage patients to keep alcohol use to a minimum and to stay away from the very high alcohol content beverages if they have to have a drink. But maybe just save it for special occasions.

The other thing is to not smoke, to control your blood pressure. If you have diabetes, control diabetes, and to eat a heart healthy diet. Any diet that helps your heart stay healthy helps your brain stay healthy because it's the same blood vessels that we're working on. And what they call the Mediterranean diet, minus the wine, is probably one of the healthiest diets you can have.

And then the other piece that's important is being socially engaged. If you have connections with people around you, if you volunteer in your community, if you have friends that you meet with regularly, it's important that you maintain social connections. And we're just coming out of a period where everybody was very isolated, and that took its toll on a lot of people and their brain power.

And then the final thing that's important is to make sure that you can hear well and that you can see well. Because if you don't get good sensory input from your ears and your eyes, then your brain has less to work with. And studies show that that can be a risk factor for developing dementia. And a lot of people don't want to wear hearing aids or they deny that they have a hearing problem. It's very important to get your hearing checked and have your vision checked and to get them corrected if needed.

The majority of people with mild cognitive impairment never advance into dementia. About 80 to 85% may just have this aggravation where they just feel like they're not quite up to speed in terms of their brain power, but it doesn't get any worse, and sometimes it gets better over time.

Host Amber Smith: You've been listening to chief of geriatrics, Dr. Sharon Brangman from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Poets often break down actions or emotions into smaller components, so the listener or reader can really see or feel. I have two poets here to demonstrate how artful their ability is. First is Jerome Gagnon from Northern California, whose first prize-winning full collection of poetry, "Rumors of Wisdom," appeared last year.

Here is "Invisible Ocean":

It's sometime around 5 am

when I wake him for medicine and water.

Each sip has become a struggle

confounded by almost constant thirst.

Small sips, I say, to minimize choking.

How could I have forgotten how essential it is to swallow?

How we take the world in daily, an act as vital as breathing?

How the world will swallow us whole and expel us

into measurelessness?

How water receives water, a process so pervasive

it becomes almost invisible?

Jasper Kennedy is a trans organizer and avid crocheter whose poem "Starling's Law of the Heart" reveals the miracle that is our heart muscle's function.

The heart is a machine

in a circuit of vessels.

Pump more out, more will return,

get back what you put in,

reap what you sow,

as if anything works that way.

It's a nice idea.

I close my eyes

and my fist is a ventricle

that I tense and relax,

systole and diastole

in the palm of my hand.

I pop up my thumb

and audibly suck in air,

extend my fingers like

I'm holding a water balloon

filling with blood.

Behind my eyelids

I see sparks as I clutch,

current arcing at my wrist

and feel what it's like

to hold the magnitude

of what I've been served

in the flat of my hand

and dish it back out

with a squeeze.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," how the heart failure program operates.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.