Improving diagnosis and recovery for mild traumatic brain injury


Traumatic brain injury is one of the leading causes of disability in the United States, and 80% of traumatic brain injuries are classified as ‘mild.’ But, these can have serious and long-lasting effects.


Dr Jacyln Stephens, Associate Professor in Health and Exercise Science at Colorado State University specialises in brain injury, rehabilitation, and neuroscience. She discusses her research into the injuries of student athletes who are particularly prone to mild traumatic brain injury, and how research is helping to improve both diagnosis and recovery.


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Image Source: Pixabay / Mitrey





00:00:06 Will Mountford 

Hello. I’m Will. Welcome to researchpod. 


00:00:08 Will Mountford 

Traumatic brain injury is one of the leading causes of disability in the United States. However, 80% of traumatic brain injuries are classified as mild traumatic brain injury, but even mild injuries can have serious and long lasting effects. 


00:00:23 Will Mountford 

Of these, a common cause is sports related concussion with contact sports, including American football among the most hazardous. 


00:00:31 Will Mountford 

Doctor Jaclyn Stephens, associate professor in health and exercise science at Colorado State University, specializes in brain injury rehabilitation and neuroscience. She discusses her research into the injuries of student athletes who are particularly prone to experiencing mild TB eyes and how research is helping to improve diagnosis and recovery from brain injury. 

00:00:55 Will Mountford 

And joining me today, Doctor Jaclyn Stephens. Hello. 

00:00:58 Dr Jaclyn Stephens 

Hello, thanks for having me. 

00:01:01 Will Mountford 

Can you tell us a bit about yourself and your research, kind of what led you to working in Bioscience and recovery and brain injury and all of the stuff that we’re about to cover? 

00:01:11 Dr Jaclyn Stephens 

Yeah, absolutely. So I’m currently an associate professor at Colorado State University. I’m primarily situated within the Department of Occupational Therapy, but I do have an affiliate faculty position within the molecular cellular integrated Neuroscience program. 

00:01:27 Dr Jaclyn Stephens 

I’m trained as both a cognitive neuroscientist and as an occupational therapist. Brain injury is really nicely situated between those two fields. Neuroscientists are very interested in the brain, and they’re interested. Of course, what happens to the brain after injury, like traumatic brain injury, and then from a rehab perspective. 

00:01:49 Dr Jaclyn Stephens 

Traumatic brain injury and stroke and things like that are, you know, one of the leading causes of disability in the United States and probably worldwide. I’m more familiar with the. 

00:01:58 Dr Jaclyn Stephens 

United States statista. 

00:01:59 Dr Jaclyn Stephens 

And so a lot of the patients that I saw when I was working as an occupational therapist did have a brain injury. And I was actually a certified brain injury specialist while I was practicing clinically. So it really works out nicely that my research can lean on to my clinical expertise and that the work that I do hopefully. 

00:02:20 Dr Jaclyn Stephens 

Has good clinical implications for their people who are continuing to work in rehab settings. 

00:02:27 Will Mountford 

And why get into this field of research at all in the 1st place? Was it always a matter of being interested in health and biology, or did something lead you to it? 

00:02:37 Dr Jaclyn Stephens 

Yeah, so very practically training opportunities, funding opportunities often kind of dictate sometimes what we do with scientists. So as a PhD student, I actually studied healthy aging, and I studied working memory and Doctor Marion Berry Hills Lab at the University of Nevada, Reno. 

00:02:57 Dr Jaclyn Stephens 

We did brain stimulation, so noninvasive brain stimulation to support working memory capacity of healthy older adults, and that was a pretty interesting field. Although it’s a relatively small field, there’s only a number of researchers who are doing this work, and there’s only a market for a smaller number of people doing this work. 

00:03:19 Dr Jaclyn Stephens 

When I got my postdoc opportunity at Johns Hopkins and Kennedy Krieger Institute, under the mentorship of Doctor Stacy Zuschauer, it was in pediatric brain injury. It was an interesting position for me to take on because it was going to allow me to enhance and add on to some of my neural imaging skills and. 

00:03:39 Dr Jaclyn Stephens 

And then it worked out well for her because of my clinical understanding of a population having both the clinical and the research training made me a good fit for that fellowship. 

00:03:50 Dr Jaclyn Stephens 

So again, it was kind of a practical thing, but again being an OT you know, I would see healthy older adults that had some cognitive impairments in the morning and then I’d go to see a patient with a traumatic brain injury. So it didn’t feel like a huge jump for me as a clinician. And so the pediatric traumatic brain injury ended up being the the area, the focus of my postdoc. 

00:04:11 Dr Jaclyn Stephens 

And interestingly enough, and this aligns. 

00:04:14 Dr Jaclyn Stephens 

With the the statistics. 

00:04:15 Dr Jaclyn Stephens 

That we see out there about the majority more than the majority of our patient population, we’re experiencing mild traumatic brain injuries. 

00:04:23 Dr Jaclyn Stephens 

So we know that there’s mild, traumatic, moderate, traumatic brain injuries and severe traumatic brain injuries, and about 80% of people are experiencing the mild TBI category, which led nicely into when I started my faculty position. Being able to really look at that mild traumatic brain injury population. 

00:04:43 Dr Jaclyn Stephens 

Within the athletes that are at Colorado State University, we are a Division One NCAA. So we have a large number of student athletes and those student athletes are more susceptible to mild traumatic brain injuries in the general population because they’re playing contact sports. 

00:04:59 Dr Jaclyn Stephens 

That can elicit those types of injuries. So again, it aligns with my interest as a neuroscientist and an OT. But it’s also quite practical that my populations were available to me and available to study, which is it’s a big challenge in research if you’re in the location where you know, for example, if you’re not in the stroke belt of America. 

00:05:20 Dr Jaclyn Stephens 

It’s really hard to study stroke. 

00:05:22 Dr Jaclyn Stephens 

So there’s the part of the southern half of the United States is considered the stroke belt. So if you’re situated outside of that, it’s hard. You don’t see as the stroke incidence is lower. And so you don’t see as many strokes happening in your area. So it’s harder to study a population where the incidence is quite low. 

00:05:40 Will Mountford 

To come back to some of the statistics you mentioned, obviously you’ve got the NCAA team right there and all of the kind of very. 

00:05:47 Will Mountford 

Close first hand experience. They’ve got to look maybe more Interstate and across the US where a lot of your experience has been working. What are kind of the statistics for sports injuries, not just in football, but broadly across athletics and then the statistics related to brain injury because to me, every brain injury. 

00:06:08 Will Mountford 

Downs severe. So how are those scaled? How are they rated? What’s you know, a good brain injury to have? 

00:06:15 Dr Jaclyn Stephens 

Yeah. So a good brain injury to have is no brain injury. Of course, the milder injuries are of course much. 

00:06:23 Dr Jaclyn Stephens 

Better for people to experience than not. Most people do actually recover from a mild traumatic brain injury, which I tend to use interchangeably with sports related concussion or concussion. Others do as well. Some people like to differentiate between a sports related concussion and a mild traumatic brain injury, but most of the time that’s a an overlapping. 

00:06:43 Dr Jaclyn Stephens 

Says and that typically looks like if we use the American Congress of Rehabilitation Medicines definition, what that looks like is that you know that person experienced some witnessed blow to the head, the body, the trunk that caused a rapid acceleration and deceleration of the brain inside the skull. 

00:07:04 Dr Jaclyn Stephens 

It’s associated with a number of concussion like symptoms, so like nausea, vomiting, headaches, things like that. Those are concussion related symptoms. And then we typically do not see anything on your traditional scans that you get in an emergency room or an emergency department. 

00:07:22 Dr Jaclyn Stephens 

So a CT scan or an MRI will come up negative, and that’s actually kind of a hallmark of these milder injuries. When you have more severe injuries, you might see bleeding inside of the brain. You’ll see lesion. You see all these things that are very clearly indicative of the damage that has happened. 

00:07:43 Dr Jaclyn Stephens 

In the brain. So those are obviously much more. They often tend to have longer recovery times. They tend to have really profound deficits that are obvious to the naked eye. So you’ll see somebody clearly walking with a limp or something. 

00:08:01 Dr Jaclyn Stephens 

That what’s interesting about the mild traumatic brain injuries, I promise I’ll come back to your statistics question, but what’s interesting about the mild TBI is, is that people typically look OK, you don’t typically see them, you know, not being able to use one side of their body or that their gait, their their walking pattern is significantly impaired. 

00:08:23 Dr Jaclyn Stephens 

But if you do compare them to a healthy cohort with tasks of enough difficulty, you can start to tease these things out. And this reflects what are the people that have experienced. This will tell us they’re like I’m just not myself. I’m just not. 

00:08:38 Dr Jaclyn Stephens 

Myself and from a athlete perspective. 

00:08:42 Dr Jaclyn Stephens 

You know, we have these high performing athletes and if you study really high performing athletes, their reaction times are standard deviations faster than an average person. So if their reaction time is now normal after a mild traumatic brain injury, slash or concussion, using those terms interchangeably, if they look normal. 

00:09:02 Dr Jaclyn Stephens 

That’s actually not good for them at all, and is possibly related to them experiencing more injury when they return to play, and I can come back to that in a moment because that’s a lot of where my research is situated around that return to play decision making. 

00:09:18 Dr Jaclyn Stephens 

So statistics wise, it’s really hard to for researchers to gauge how many concussions mild TBI’s are happening. There’s some estimates that 41 million M TBI’s mild trend of brain injuries happen across the globe each year. 

00:09:35 Dr Jaclyn Stephens 

It’s estimated that up to 3,000,000 are happening in children under the age of 18 in the United States. 

00:09:42 Dr Jaclyn Stephens 

Something in the like 15 to 16,000 range are happening with NCAA athletes. If I’m remembering those statistics correctly. 

00:09:51 Dr Jaclyn Stephens 

And so the sad thing is everyone is at risk of sustaining a brain injury. Unfortunately, you can get in your car and get into a car accident and sustain A traumatic brain injury. You can slip on ice and hit your head. Contact sport. Athletes are, of course, at a slightly higher rate of having these. And as you noted, American football. 

00:10:12 Dr Jaclyn Stephens 

Is the the sport with the highest incidence for male athletes? For female athletes, it happens to be soccer. 

00:10:20 Dr Jaclyn Stephens 

Or your football over over across the pond. And so we understand these things are happening to both male and female athletes. There’s a lot of really interesting research on the prevalence of concussion in female athletes. A lot of my work has actually exclusively looked at some female athlete participants because female. 

00:10:40 Dr Jaclyn Stephens 

Athletes have a higher incidence of concussion than their male counterparts, even though overall traumatic brain injury is higher in males. 

00:10:51 Dr Jaclyn Stephens 

So some of that is testosterone. Some of that is behaviors that males engage in that are a little more risky. So overall, like men, are more likely to engage in activities like Cliff jumping or something that could elicit A traumatic brain injury than women. However, women are more likely to get the mild traumatic brain injuries, and there’s some thought that that’s related to. 

00:11:12 Dr Jaclyn Stephens 

Neck strength. 

00:11:14 Dr Jaclyn Stephens 

And and some of the things that are that maybe women do not have strong as strong of muscles around their neck that prevent their head from jerking around so much when they impact. So there’s really some really interesting stuff out there. And then the trajectory recovery looks different for male and female athletes and so. 

00:11:34 Dr Jaclyn Stephens 

There’s lots of really, really interesting work around. Incidents and epidemiology of of MTV. And that’s not my area of research. I’m not an epidemiologist studying prevalence, but I’m pretty familiar with those prevalence statistics that I’ve just shared and I’m pretty sure they’re accurate, at least for the last couple of years. 

00:11:51 Dr Jaclyn Stephens 

But again, we there’s so many injuries that are happening that we are that are not getting diagnosed or marked. So most of the time the incidence levels. 

00:11:59 Dr Jaclyn Stephens 

That we are. 

00:12:01 Dr Jaclyn Stephens 

Citing are actually lower than what is probably happening. 

00:12:10 Will Mountford 

Yes, before we get on to the return to play decisions as kind of part of recuperation recovery of that. 

00:12:16 Will Mountford 

That’s if we can come back to the the undetectable injuries that you’ve mentioned, that it won’t turn up on CT scans or X-rays. What kind of tests scans you mentioned some of the task based operations, how can then those injuries be detected in a way that can inform treatment? 

00:12:35 Dr Jaclyn Stephens 

I feel like we’re doing a much better job of identifying concussions when they happen, particularly when they’re witnessed in sport or practice. 

00:12:46 Dr Jaclyn Stephens 

Coaches, athletic trainers, everybody’s doing a much, much better job of identifying that it’s happening and almost to the point that we’re being overly cautious. We’re pulling athletes out who maybe haven’t actually had a concussion, but that’s better, right? It’s better to be safe than sorry. There is something called second Impact syndrome where if you have two concussions back-to-back, it can. 

00:13:06 Dr Jaclyn Stephens 

Actually illicit really, really long term disability or even death. 

00:13:11 Dr Jaclyn Stephens 

So it’s again, it’s quite important to be, you know, err on the side of caution with detecting A concussion. So you know, I I mentioned those definitions that we use. So the symptoms are really, really helpful in identifying that a concussion has occurred. The trouble with symptoms, though, is that you must rely on the athlete. 

00:13:32 Dr Jaclyn Stephens 

To report them. So we do a really good job with a number of sideline tests, again witnessing injuries. 

00:13:41 Dr Jaclyn Stephens 

And and getting someone to the ER to see that they don’t have anything further. They don’t have brain bleeds or something that suggests a more severe injury. However, if an athlete gets hit in the head and nobody sees it, and then they don’t report that they have headaches, they don’t report that they’re nauseous and vomiting at night, that’s when we start to see some of these issues. 

00:14:01 Dr Jaclyn Stephens 

Happening. And then you also have lots of recreation related concussions that you’re like, is this a concussion? Is it not a concussion? You know, I fell one time while I was skiing, and I went backwards and ****** my head. 

00:14:14 Dr Jaclyn Stephens 

Is that a concussion? I mean, I don’t think so because I didn’t have all of those symptoms. I was wearing a helmet. Which public service announcement wear your helmet? Big advocate of wearing helmets, of course. But those are the kinds of things that become much more ambiguous if you’re not playing an organized sport or you don’t have an athletic trainer. 

00:14:34 Dr Jaclyn Stephens 

On the sidelines and you don’t have somebody who knows how to administer a test. Of course there’s going to be a lower incidence where people have had a concussion and it doesn’t get diagnosed. 

00:14:43 Dr Jaclyn Stephens 

But back to the the bigger concern is what do we do after we know that someone’s had a concussion? Because even when athletes are being truthful about symptoms and we can talk about symptom reporting and the the limitations of of some of that, even when they are being truthful about it, their symptoms might go away in five to seven days. 

00:15:03 Dr Jaclyn Stephens 

Like a weak post injury, but they might still have some residual deficits that are difficult to detect with some of the measures that we have right now. So there’s a lot of work being put in. 

00:15:15 Dr Jaclyn Stephens 

To develop better measurements, there’s a researcher who does. He’s just incredibly prolific. He publishes more than able to publish. His name is Doctor David Howell. He’s amazing. He’s an athletic trainer and a PhD, and he’s a head of a sports concussion clinic and a nearby university. And it’s also. 

00:15:34 Dr Jaclyn Stephens 

Actually, and also in Colorado and he does a lot of work with dual task evaluations and he’s able to really detect some of these subtle deficits that people are experiencing after concussion that are really probably quite informative for return to play decision making. So. 

00:15:51 Dr Jaclyn Stephens 

To kind of summarize what I’ve been saying, I think we’re doing a much better job of detecting concussions. Of course, there’s some that are being missed. It’s really hard. If you go to the ER and they’re like, oh, your your CT scan is clear, your MRI is clear. You’re probably fine if you don’t have an emergency department doc that is aware that that’s kind of a hallmark of the milder injuries. 

00:16:12 Dr Jaclyn Stephens 

But overall, I think as a as a country that the US is getting much better at globally, we’re getting much better at it. We’re being much more cautious and aware and I think. 

00:16:22 Dr Jaclyn Stephens 

A lot of credit belongs to everybody on the ground who’s working with these athletes, right? All the athletic trainers and the doctors and and everybody who’s being really cautious and the coaches who are, you know, prioritizing their athletes health over playing time. I think that that is fantastic. And we’re like, we’re moving in the right direction for that. 

00:16:41 Dr Jaclyn Stephens 

I think where we’re getting where the challenge is now and where I’m, I’m really lucky that my research is situated is that return to play decision making and. 

00:16:51 Dr Jaclyn Stephens 

OK, it’s been a week and you no longer have headaches. Or maybe you think you don’t have a headache anymore because your headache is so much better or so much milder than it was initially after injury. So you’re saying, yeah, my headaches better. And that’s a truthful response. But in reality, there’s still some lingering stuff happening. I think that’s really where the challenge is for us now. 

00:17:12 Dr Jaclyn Stephens 

Because there’s some data out there showing that athletes are up to three times more likely to get reinjured when they return to play. 

00:17:20 Dr Jaclyn Stephens 

Even when we’re following all the protocols that are out there where we’re assessing them not just with symptoms, but doing objective measurements of their cognitive function. So like their memory, their attention, their reaction time, reaction time is also kind of a cognitive motor. So also looking at motor performance like their balance and their gait and things like that, even when we’re doing the. 

00:17:40 Dr Jaclyn Stephens 

Best job that we have with the best tools that we have available to us right now, athletes are still getting reinjured when they return to play. That suggests that our our tests that we have right now are maybe not as sensitive to some of these subtle residual deficits that are really impactful on the plane. 

00:17:56 Dr Jaclyn Stephens 

Field for your average person who gets a concussion in a car accident, for example. 

00:18:03 Dr Jaclyn Stephens 

When they start feeling better and they start feeling like they can go back to work and they gradually return to work, they’re not going to get reinjured with their stapler, there’s much less risk for the average person, but these high performing athletes you can imagine if their reaction time is off just a little. 

00:18:21 Dr Jaclyn Stephens 

That the ball that they would normally dodge right with, or the opponent that they would dodge, that’s coming in for a tackle, they’ve missed that movement away from it by just a couple milliseconds or something and they get hit. So perhaps that’s part of it, is that we’re just not able to get that degree of sensitivity for those really, really high. 

00:18:43 Dr Jaclyn Stephens 

Performing folks that our tests are saying, yeah, they’re normal. Well, they’ve they’ve never been normal. We’ve got to get it better than normal. 

00:18:53 Will Mountford 

You mentioned in your introduction that a lot of your experience in your imaging and scan types was kind of what set you apart from the pack in having a unique perspective and you’ve given a list that some of the research you’ve done of F, MRI, FN, IRS, ASL, EG I mean if it’s not coming up in the standard operating procedure. 

00:19:13 Will Mountford 

Of give someone a CT scan, look for brain injury not there. 

00:19:17 Will Mountford 

You know, knowing what you know that it is, then a sign that there is probably an injury if there’s nothing. 

00:19:22 Will Mountford 

Else wrong. How are those scans? Either giving more information or could be incorporated into that detection method. 

00:19:31 Dr Jaclyn Stephens 

Yeah. So I actually am using Doctor David Howell’s work to kind of integrate neural imaging into my research, which again is not clinical. Everything that I do from a research perspective is not, I’m not telling athletes you can’t go back to play. That’s not my role, but the work. 

00:19:51 Dr Jaclyn Stephens 

So I’m I’m just going to back up for a moment and talk about the behavioral things that are. 

00:19:55 Dr Jaclyn Stephens 

Helping me think about the. 

00:19:57 Dr Jaclyn Stephens 

Where neuroimaging could play a role, and then I’ll kind of talk about how that translates into a clinical realm again. So what Doctor Howell has identified is that. 

00:20:08 Dr Jaclyn Stephens 

When you ask athletes to do a single task, let’s say balancing right balancing on one foot, even if it’s quite challenging or even dynamic, they look pretty normal as compared to healthy athletes who have either had no concussion or no recent concussion. They look pretty comparable, but then when you ask them to multitask. 

00:20:29 Dr Jaclyn Stephens 

So balancing while doing some sort of cognitive distractor task, that’s when we start to see the performance degrade to a greater degree than their healthy counterparts that don’t have a recent concussion. So you know how you’re not supposed to be texting while you’re driving? Of course, right. So everybody’s performance when they multitask gets worse. 

00:20:50 Dr Jaclyn Stephens 

It’s a matter of how much worse. 

00:20:53 Dr Jaclyn Stephens 

This to me suggests that there’s the attention resources that athletes with concussion have are more limited than what their healthy counterparts have. And So what my angle with my neuroimaging has been. 

00:21:10 Dr Jaclyn Stephens 

Is to actually systematically evaluate attention networks in the brain while people are multitasking and single tasking. I have a theoretical model that I put into one of my grant proposals that was funded. That’s to say that what I think is happening is at a single. 

00:21:29 Dr Jaclyn Stephens 

Ask the athletes behavioral performance. The concussion compared to no concussion, looks nearly identical, but that athlete with a concussion is using all or almost all of their attentional resources in order to do that behavioral task. When we just measure behavior. 

00:21:49 Dr Jaclyn Stephens 

We’re unable to see that, right? We don’t know how much of your attention you’re using. The way behaviorally that we can start to detect that is throwing another task at them that requires they divide their attention. So that’s exactly what the dual tasking or multitasking does. 

00:22:07 Dr Jaclyn Stephens 

And then we see the performance degrade. So what my neural imaging angle has been, what the purpose of my neural imaging has been is to quantify the amount of attention people are using for simple tasks and more complicated tasks to see if indeed athletes with concussion are using more attention for the single tasks. And then when we get to the more. 

00:22:27 Dr Jaclyn Stephens 

Complicated tests. They don’t have enough resources to execute those tasks at the same level as their non injured counterparts. 

00:22:34 Dr Jaclyn Stephens 

So what I believe this will do is give us more insight into the mechanisms behind the deficits. So what is a listening the deficit because that gives us a target for intervention if we think, you know, we see the deficits appear in a motor domain. So we might think, oh, we need to, you know, practice the motor. 

00:22:54 Dr Jaclyn Stephens 

Tasks and certainly practicing the motor tasks will help, but for the most part these motor tests are really well learned and they’re relatively automatic. I think we’re losing some of that automaticity with the concussion. We lose some of that automaticity. And so you’re focusing more. 

00:23:12 Dr Jaclyn Stephens 

For cognitive effort to do those tasks, and I believe it’s within the attentional domain. 

00:23:19 Dr Jaclyn Stephens 

So I’m actually a good majority of my research is using and this hasn’t been published yet, so we’re working on getting a publication out within the next six months, but we’re using the F nears. That’s one of the ones that you mentioned. So it’s functional near infrared spectrum. 

00:23:38 Dr Jaclyn Stephens 

It uses near infrared light to detect how much oxygen metabolism is happening in the brain, which is an indirect way of us understanding how active the brain is. So just like your muscles, just like other parts of your body, when they’re more active, they use more oxygen, they use more all sorts of things, but we are actually measuring that. 

00:23:58 Dr Jaclyn Stephens 

Oxygen metabolism directly when they do single tests and when they do dual tests, and we’re comparing athletes with and without concussion to see if at the single test level at the dual task level, if we can just really detect where those attentional resources are happening. I’ve been really lucky to have acquired a. 

00:24:16 Dr Jaclyn Stephens 

Mobile F years device. So my participants actually wear on their back. So it’s like a backpack, it weighs less than 900 grams or 2 lbs. For those of us who don’t use the metric system, so they can walk, they can move, they can do all sorts of things with it, and that those data are wirelessly transmitted to my laptop. And then I can analyze exactly which regions of the brain. 

00:24:37 Dr Jaclyn Stephens 

Or more active, less active during the single versus dual tests versus a rest period to really get at that theoretical model that I’m testing. So I have these hypotheses, I have these ideas, they come a lot from the behavioral work that Doctor Howell has done and others have done in this area. 

00:24:55 Dr Jaclyn Stephens 

And I’m trying to show a lot of the neural underpinnings that are, I guess a listening some of the behavioral patterns that we can that we can detect. So all of this to say, I don’t anticipate in the near future, maybe in the later future that neural imaging will be available. 

00:25:16 Dr Jaclyn Stephens 

In clinical settings in this kind of way, a lot. 

00:25:19 Dr Jaclyn Stephens 

Of what I do takes many, many, many many years understanding you know how to acquire the data the right way, how to analyze the data the right way and then interpret the data the right way, which isn’t something that I think clinicians are going to do. I think if you’re going to introduce something technical. 

00:25:39 Dr Jaclyn Stephens 

In a clinical setting, you want it to be like a Saturday that they can come in, learn how to do it, and learn how to interpret the data. And we’re not there yet. I think that is an area where I see science moving is is taking some of these like really technical application. 

00:25:55 Dr Jaclyn Stephens 

Relations and making it so that the data is transferred to their cell phone. The data are processed with the standard processing pipeline and generate results that are easily interpretable until we’re there. This isn’t going to be in the clinical settings, but what it can inform and what I alluded to earlier is where the the deficits are coming from and if they’re coming from the attentional. 

00:26:17 Dr Jaclyn Stephens 

System like these athletes are just struggling with attention. 

00:26:21 Dr Jaclyn Stephens 

Perhaps it’s more of our intervention should be around attention, more of our evaluation should be around attention, so we don’t necessarily say they’re ready to return to play when their balance is better, but when they’re divided, attention capacities are back to a baseline. 

00:26:39 Dr Jaclyn Stephens 

That’s just one possible example, and there’s lots of people doing a lot of work in return to play interventions. 

00:26:46 Dr Jaclyn Stephens 

And so I don’t want to say that my idea is better than what they’re doing. I’m sure that this has come across in a lot of the work that they’re doing. And I have seen dual tasking being introduced and returned to play protocols. So it’s in there and it’s coming. But I think the more we understand about why the deficits are happening, the better we’re able to detect them. 

00:27:08 Dr Jaclyn Stephens 

Develop behavioral tools that are like, aha, there we’re getting at what we’re seeing with the brain. 

00:27:13 Dr Jaclyn Stephens 

Just in a behavioral way, right? We’re manipulating the task to make sure that it’s challenging system X so that we can really capture that deficit. And then our interventions are like, OK, we need to target X right to make sure that these athletes are ready to return to play. I also see a lot of potential in virtual reality. 

00:27:33 Dr Jaclyn Stephens 

Which I’ve dabbled in a little bit of generating virtual or augmented reality sports. 

00:27:40 Dr Jaclyn Stephens 

Comments so we can actually put them back into play and see if they get tackled by a virtual opponent who can’t hurt them or see if they dodge that virtual opponent. And so I think there’s lots of potential ways that we can improve our evaluation and our interventions to support a safer. 

00:28:00 Dr Jaclyn Stephens 

Return to play. I don’t think any of the ways forward are canceling. 

00:28:05 Dr Jaclyn Stephens 

Sports. I definitely think there’s ways to make sports safer and just be more mindful that a subset of people are not recovering on the timeline that we originally thought. And because of that, we just need to be more intentional about how we assess and intervene with that subgroup so that they don’t get reinjured when they go back. 

00:28:27 Dr Jaclyn Stephens 

Because we don’t want somebody to tear their ACL and be out for the entire season, we don’t want somebody to get another concussion that they have symptoms for two months after their injury. 

00:28:37 Dr Jaclyn Stephens 

No coach wants that. Either they want their players performing and not getting reinjured. I also think that most coaches want their players coming back at, you know, the best possible capacity that they have. They don’t want them at 80%. They want them back at 100%. And if our tools and our measures can say, aha, OK, we’re back, right, we’re back to 100%. 

00:28:58 Dr Jaclyn Stephens 

Then I think we’ll be doing a better job both for the athlete’s health and also for the sports performance. And I think we need to be mindful of both of those very important features when we’re thinking about return to play. 

00:29:14 Will Mountford 

Just to check, I know we’ve covered DTS. Have we talked around but not given the full name of PANESS. 


Oh yeah. 

00:29:22 Dr Jaclyn Stephens 

So that is the physical and neurological evaluation of subtle signs. So this is one of the measures. And then the DTS is the dual test screen. These are two measures that I’ve used in my work. So the panels was actually developed by Doctor Martha Dinkla at Kennedy Krieger Institute and Johns. 

00:29:42 Dr Jaclyn Stephens 

It was originally used to detect really subtle deficits, like subtle motor deficits in children with developmental disabilities like autism. However, we’ve expanded use again with my mentor Doctor Seth Kauer, also at Kennedy Krieger and Johns Hopkins. What’s what’s really interesting about the panels and what we’ve seen with the pan. 

00:30:01 Dr Jaclyn Stephens 

Is it kind of gets to those subtle deficits just like dual task assessments or multitasking does, and there are elements of multitasking in it. What we can see in this are just some patterns of motor performance that are not. 

00:30:16 Dr Jaclyn Stephens 

Typical. And that’s a really simplified way of putting. 

00:30:19 Dr Jaclyn Stephens 

It but we. 

00:30:20 Dr Jaclyn Stephens 

See things like Motor Overflow where if you have somebody who’s tapping their fingers as quickly as they can, what they think we’re assessing what we are assessing is the number of taps that they can get. But what we’re also looking for that motor overflow piece is that the other hand. So let’s say they’re tapping with their right hand. 

00:30:37 Dr Jaclyn Stephens 

Their other hand is also moving and mimicking that movement. 

00:30:41 Dr Jaclyn Stephens 

So to some extent, a lot of us have this. So if you look at pictures of Michael Jordan when he’s shooting dunking a basketball, he’s got his tongue out of his mouth. That’s actually motor overflow. He doesn’t need his tongue out of his mouth to dunk the basketball. Right. But he’s got it there, so motor overflow can be quite normal. 

00:31:01 Dr Jaclyn Stephens 

And support extremely good motor performance. Nobody’s going to say that Michael Jordan had impaired motor performance. 

00:31:08 Dr Jaclyn Stephens 

Of course. But when we have too much of it, it suggests that the nervous system isn’t fully integrated, fully recovered from injury, things like that, that there’s a pattern. So your body, your motor system, generates movements, cortical and subcortical motor regions of the brain. So just motor regions of the brain simply said. 

00:31:28 Dr Jaclyn Stephens 

Generate motor movements, but they also inhibit motor movements that are not necessary, so some of what the pans is able to detect is an absence of inhibition. Where these motor movements that aren’t necessary aren’t being inhibited by those the motor networks. The motor regions in the brain. So some of that can also be indicative. 

00:31:48 Dr Jaclyn Stephens 

Of residual impairment from injury. So we’ve seen a bit of that in some of our work with adolescents, with sports related concussion trying to think if there’s anything else I want to to really say about that. So there’s lots of different components to the Panas. So you can look at things like gate and movement and there’s there’s balance, but there’s also lots of fine motor stuff. 

00:32:08 Dr Jaclyn Stephens 

And again, we’re looking at like how quickly they’re tapping their fingers, but also if they’ve got extra movement happening, you often will see people doing like a heel to toe. 

00:32:17 Dr Jaclyn Stephens 

Gate task so they have to walk heel to toe, heel to toe, and then you’ll see their wrists curl up or flex out, which could be indicative that they’re, you know, they’re working extra hard or they’re maybe that absence of inhibition so. 

00:32:33 Dr Jaclyn Stephens 

You know, and I may not be completely correct with all of my interpretation of what? 

00:32:38 Dr Jaclyn Stephens 

Extra motor movement is there’s lots of motor control experts out there that know more about this than I do, but I think what’s important is if you have an athlete who, let’s say preseason is able to do all of these things without any of those extra motor patterns. And then after they get a concussion. 

00:32:58 Dr Jaclyn Stephens 

You see all this extra stuff? It’s really informative and what’s really great about this and something I haven’t spoken to yet is that athletes are really, really smart and they always they often want to get back to their sport, especially as you get into the higher levels when you get into collegiate sports and professional sports, they want to go back. 

00:33:17 Dr Jaclyn Stephens 

So we often see athletes if you ask them to do like a baseline test, they’ll intentionally underperform on it because they know that that’s they have to get back to that level. So if it’s a lower level, they’ll know they can get back. So you also have to have measures like this where you’re like, OK, tap your fingers as fast as you can, and that’s what they think that we’re assessing. And we’re assessing something else. 

00:33:38 Dr Jaclyn Stephens 

Together. So we have to be tricky about what we’re assessing. We have to be mindful that they want to get back to their sport and as an occupational therapist who understands that occupation. So anything you do to occupy your time, occupations are so important to people, it’s how they define themselves. 

00:33:56 Dr Jaclyn Stephens 

Selves, they become depressed and anxious and all sorts of things go sideways when they can’t participate in their sport. So we understand wholeheartedly why they want to do this. This is not a criticism at all. It is something that is is totally understandable as an athlete myself, who continued playing in a volleyball game. 

00:34:17 Dr Jaclyn Stephens 

With a very injured ankle hopping to my position after I served because I didn’t want to come out of. 

00:34:23 Dr Jaclyn Stephens 

The game I get. 

00:34:24 Dr Jaclyn Stephens 

It I totally. 

00:34:26 Dr Jaclyn Stephens 

Get it? Not good for my foot long. 

00:34:28 Dr Jaclyn Stephens 

Term health not good for your brain’s long term health to keep playing when you’re injured, but I get it. So we need tools like these dual task assessments that Doctor Howell has developed. I took a lot of what he did and created a dual test screen. 

00:34:45 Dr Jaclyn Stephens 

That’s the DTS and we also need and I’ll say more about that in just a moment, but we need measures like the panels, like these dual task assessments that capture lots of different. 

00:34:57 Dr Jaclyn Stephens 

Components of performance, because if we’re simply looking like, can they stand on their right foot for 30 seconds without losing balance? 

00:35:06 Dr Jaclyn Stephens 

Sure, they can do that, but that’s in a, you know, sterile clinical environment where there’s not crowd noise and opponents coming at them and teammates who want them to throw the ball. Like if you think about the dynamic environment that athletes go back to, our assessments need to follow suit. Our assessments need to be dynamic, they need to mirror. 

00:35:26 Dr Jaclyn Stephens 

The environment where athletes are returning to to ensure that they are being adequately challenged. 

00:35:34 Dr Jaclyn Stephens 

And that we’re capturing all of the different components of motor performance and the cognitive capacities that go along with being an athlete, so to speak, just briefly to the dual test screen, the DTS I took a lot of the work that that Doctor Howell had developed. And I thought about, you know, a lot of the work that. 

00:35:52 Dr Jaclyn Stephens 

He had done used. 

00:35:54 Dr Jaclyn Stephens 

Instrumented assessment tools, so like motion capture systems, ways of measuring changes. 

00:36:01 Dr Jaclyn Stephens 

In vertebral movement like center of mass changes, as you balance. So like I’m mimicking this right now, which isn’t helpful for a podcast. But if you’re swaying right. So let’s say you we asked somebody just to balance for 30 seconds and I’m just simplifying this and they do it. And so you tick a box that says, yes, they did it. 

00:36:20 Dr Jaclyn Stephens 

But if they’re wobbling all over the place, you can see that and some instruments can tell you more about that. Unfortunately, some of these instruments that have been used in some of this work and and I know that his work has evolved beyond this, and he’s got more low tech assessments as well. But a lot of that. 

00:36:38 Dr Jaclyn Stephens 

Is not feasible for your everyday physician or your athletic trainer. They don’t have access to the equipment or they don’t. Again, we go back to doing all these data come in and it takes somebody specialized to process, analyze and interpret those data. We’re not asking an athletic trainer who has expertise in concussion. 

00:36:58 Dr Jaclyn Stephens 

And ACL tears. And you know every all the things that they do to also learn how to be a computer scientist who knows how to analyze complex data that are novel. So my dual test screen was designed to be administered and scored in under 10. 

00:37:15 Dr Jaclyn Stephens 

Minutes with some tasks that could be done really anywhere, so we have people walk over obstacles. Those obstacles are yoga blocks. We have them throw and catch tennis balls with alternating hands. So you need a tennis ball. 

00:37:30 Dr Jaclyn Stephens 

And a wall. 

00:37:31 Dr Jaclyn Stephens 

We have them do cognitive tasks that don’t require like a computer screen or something like that. 

00:37:35 Dr Jaclyn Stephens 

That display the tasks, so we asked them to do mental subtractions. We asked them to do months of the year in reverse. We asked them to do verbal fluency tasks where it’s like, say, as many words as you can. 

00:37:46 Dr Jaclyn Stephens 

That begin with. 

00:37:47 Dr Jaclyn Stephens 

The letter B something like that while doing the motor test. So we’re we’re really leveraging that foundational work. 

00:37:54 Dr Jaclyn Stephens 

To try to find a way to simplify this and make it feasible for clinicians to use in a practice setting. Of course, as you simplify things and lose some of the instruments, you lose some of the sensitivity you introduce measurement error. We’re aware of that as well. So we’re trying to tease some of that out and we’re always working to on ways to enhance. 

00:38:14 Dr Jaclyn Stephens 

Our dual test screen to make it even more sensitive to some of those deficits that could originate from concussion. 

00:38:20 Dr Jaclyn Stephens 

But again, it’s it’s all with the idea of moving this field forward and also keeping in mind the practical limitations that clinicians experience. Clinicians and athletic trainers and other providers of concussion. So that has been a good amount of my work. And then again, the neuroimaging piece that I spoke about earlier. 

00:38:40 Dr Jaclyn Stephens 

We’re using that dual test screen with simultaneous neuroimaging to really look at the brain and be like, OK, what’s happening here? Where are they using their resources, their neural resources, and how do we how do we interpret that to really understand what’s happening after concussion? 

00:39:01 Will Mountford 

And then you mentioned yoga blocks as one of the obstacles you’re using there. Yoga is also one of the interventions they’ve been using a long chronic brain injury. Maybe we could chat about that and some of the interventions and kind of the long term care and long term recuperation as well as just the immediate return to play kind of care. 

00:39:20 Dr Jaclyn Stephens 

Yeah, absolutely. So one of my goals, as you know, I’m an I’m currently an early career scientist. I go for tenure this year. So then I would lose that title. But one of my goals as part of my career development is to be an expert in traumatic brain injury to really understand the. 

00:39:40 Dr Jaclyn Stephens 

The injury really well and what it looks like for people both from a neural perspective. So what’s happening in the brain? 

00:39:47 Dr Jaclyn Stephens 

And what’s you know, what are all those limitations from a very clinical perspective and neuroscience perspective, but also to really understand the lived experience of these folks and really understand what it’s like for them to be living with these injuries. And then you know, my goal is to be the person who can. 

00:40:08 Dr Jaclyn Stephens 

Add neuroimaging into both our understanding of something like concussion so you know, really pushing the field forward by looking at the neural characteristics of death. 

00:40:20 Dr Jaclyn Stephens 

Visits or using that information to detect deficits that can’t be detected with behavioral measures that often are less sensitive than our neuroimaging measures, and then also to partner with interventionists. 

00:40:31 Dr Jaclyn Stephens 

Who have these? 

00:40:33 Dr Jaclyn Stephens 

Really well designed and really well developed interventions and they want to understand why they’re working so over the past. 

00:40:40 Dr Jaclyn Stephens 

Three or four years now, I’ve been working with Doctor Arlene Schmidt, who is a full professor in the Department of Occupational Therapy, also at Colorado State University, and she is a yoga intervention expert. So she has been working with a number of different populations. 

00:40:54 Dr Jaclyn Stephens 

And providing yoga interventions to support all sorts of different functional capacities. 

00:41:01 Dr Jaclyn Stephens 

One of those functional capacities that we’ve been really focused on lately is balance. And so she was very generous to share some data with me that I was able to look at and interpret and write up a manuscript that we published together along with a couple of cool. 

00:41:16 Dr Jaclyn Stephens 

Years where we showed that eight weeks of group yoga intervention improved balance performance in adults with chronic brain injury to the point that all of them on average were falling at a score. That suggested that they were a fall risk and then after intervention, the group mean. So the group average was above that. 

00:41:36 Dr Jaclyn Stephens 

All risk so. 

00:41:37 Dr Jaclyn Stephens 

Their performance improved to a point that as a group. 

00:41:40 Dr Jaclyn Stephens 

They were no longer at a fall. 

00:41:41 Dr Jaclyn Stephens 

Risk. And then it was such a small sample that we could actually detect how each individual person improved, and so all but one person got to that threshold where they were no longer a fall risk, but the person who didn’t actually have the greatest degree of improvement. So their performance was so low that they got, like, right up to that threshold and didn’t quite get over. 

00:42:01 Dr Jaclyn Stephens 

That threshold. 

00:42:02 Dr Jaclyn Stephens 

So that was really, really interesting to see that. And you know, one of the things that I think a lot of federal agencies, one of the federal agencies that we submit our grants to is the National Institutes of Health. What they’re quite interested is not only the interventions work. Of course that’s important, but they want to know why they work and if we’re seeing these dramatic improvements in balance. 

00:42:25 Dr Jaclyn Stephens 

In a population that is chronic. 

00:42:27 Dr Jaclyn Stephens 

So that’s an important distinction because we anticipate a lot of spontaneous recovery and then intervention supported recovery in folks that have had traumatic brain injuries that have had strokes. So cerebral vascular accidents that have had other types of insults to their brains like brain tumors or if they’ve had a cardiac arrest and they didn’t get enough. 

00:42:48 Dr Jaclyn Stephens 

Oxygen to their brain, so anoxic brain. 

00:42:50 Dr Jaclyn Stephens 

Injuries we anticipate that in the early days, weeks and months post that injury, they’re going to have a lot of recovery. They also have a lot of access to services to support their recovery once they get about six months post, they’re not necessarily seeing a whole team of providers that are helping them recover. 

00:43:10 Dr Jaclyn Stephens 

And for a long time, we thought six months was like the cutoff. Like, if you haven’t made gains by 6 months, you’re not going to get better. We now know that that’s not true. And we see lots of recovery for many, many years post these injuries. But it’s a lot less dramatic than it is in those early stages where you see a lot of change which make. 

00:43:26 Dr Jaclyn Stephens 

Since and. So what’s been really cool about this is that we have been working with this chronic population and we can’t see these improvements that are not only statistically significant, but they’re clinically significant. You know, when you go from being at a fall risk in the community to not a fall risk, you feel more confident going to the grocery store. You know, you don’t worry that you’re going to trip over the curb. 

00:43:48 Dr Jaclyn Stephens 

And you fall and, you know, have break a hip or have something else awful happen. So we’re really excited about that. And we really want to understand what’s happening neurologically that are supporting these behavioral measurable. 

00:44:00 Dr Jaclyn Stephens 

Changes so our more recent work has been to pair some neuroimaging with this. 

00:44:07 Dr Jaclyn Stephens 

Here’s where I’m using the functional magnetic resonance imaging fMRI, so I’m using resting state fMRI to look at the entire brain to look at connections between regions of the brain and seeing if there’s connections that are improving or if there’s connections that are there that shouldn’t be there. If those are kind of scaling back a little bit. 

00:44:28 Dr Jaclyn Stephens 

So we know that after brain injury in general. 

00:44:32 Dr Jaclyn Stephens 

You have all sorts of things that are happening in the brain where you have communications between regions of the brain that are disrupted. They’re either overactive or under active and so we’re able to kind of look and see if yoga is helping to kind of return those to a more typical pattern, which may be what’s causing these changes in performance. So we’re able to detect. 

00:44:53 Dr Jaclyn Stephens 

Simultaneously, we’re using the functional near infrared spectroscopy again to measure changes in the brain while they’re doing balance postures before and after yoga. So because we know behaviorally their balance is getting better, we’re really curious to see. All right. So if you’re standing on one leg before yoga and your brains doing X. 

00:45:14 Dr Jaclyn Stephens 

And then you do this yoga intervention. What happens in your brain when you do that same posture after yoga? And so that’s been our most recent area of inquiry. We recently got a $235,000 grant from the Better Foundation to continue some of this work. 

00:45:32 Dr Jaclyn Stephens 

Work and we’re really hopeful that we can continue to explore a lot of the behavioral things and a lot of the participant experience things that are so important. So that’s another big part of it. We interview all these people and they tell us things like, you know, my hand, which has been clinched in a fist for the last 15 years. 

00:45:53 Dr Jaclyn Stephens 

Opened during the. 

00:45:54 Dr Jaclyn Stephens 

Yoga like it’s so amazing and these people are telling us these things like it’s changing my life, right. And as a scientist and as a former clinician, that’s the kind of stuff you’re like. All right, This is why the early mornings, late nights, This is why it’s worth it. Unfortunately, you can’t always capture that in a way that it’s publishable. 

00:46:14 Dr Jaclyn Stephens 

So we’re also trying to disseminate this in our traditional scientific ways, you know, with conference presentations and manuscripts and things like that. And then further grant publications so that we can continue doing this and deliver this to lots of people in our community and then also show the efficacy. 

00:46:32 Dr Jaclyn Stephens 

That’s efficacy is a big word. We’re not there yet, but the efficacy of certain interventions, that’s a long term goal. So that it can be used across the US across the world. So that more people benefit from this work. 

00:46:47 Dr Jaclyn Stephens 

And by demonstrating how something works with neuroimaging, we’re providing the the mechanism to the federal government. We’re providing those mechanisms to insurance companies when they’re saying, why should I? Why should we pay for eight weeks of yoga for you? Right. But if we can say, like, this is changing all of these things, and This is why. 

00:47:08 Dr Jaclyn Stephens 

Those things are changing. It’s actually improving their brain function. 

00:47:12 Dr Jaclyn Stephens 

I think that’s a really amazing way to support people. I I do miss the everyday interaction with clients, but this really feels like an awesome opportunity to impact lots of people, you know, not just the eight clients that I would see on a Saturday when I’m in the hospital. 

00:47:32 Dr Jaclyn Stephens 

Setting but you. 

00:47:33 Dr Jaclyn Stephens 

You know 8008, you know, 800,000 people that benefit from and again this is this is all collaborative. It’s not my work, it’s our work, it’s you know, a whole team of people who all have amazing expertise and passion for the work that we do and really whether it’s mild traumatic brain injury, concussion. 

00:47:53 Dr Jaclyn Stephens 

Whether it’s these chronic injuries, really just making sure that people can return to the things that they love and care about. 

00:48:00 Dr Jaclyn Stephens 

With success and without risk for another injury is really what we’re most passionate about and then we have lots of different tools that we use to get there. 

00:48:10 Will Mountford 

And if anyone like to see the most recent papers, or if there’s any ongoing project so we can direct them to, you’ve mentioned there’s that paper coming out soon. Where can they find those? What kind of website links would be good to mention now? 

00:48:22 Dr Jaclyn Stephens 

So I am on Google Scholar so if you search on Google Scholar you’ll be able to find articles that I’ve published. Conference abstracts are also on Google Scholar, so that’s a really easy way to find the articles if they are not publicly available. Interested people are are welcome to reach out to me, and I’m happy to share my work with them. 

00:48:43 Dr Jaclyn Stephens 

So yeah, I would love for people to look me up on Google Scholar, the National Institutes of Health also has the database pub Med. Most of the work can be found on PUB Med as well, for the most part. A lot of these articles should be publicly available because they are supported by federal grants. But again. 

00:49:03 Dr Jaclyn Stephens 

People can definitely reach out if they’ve got questions about the work that I do, or if they’d like to access some of the the work that I’ve. 

00:49:12 Will Mountford 

And I suppose by way of closing, are there any words of wisdom for anyone listening to this if they are affected by well, if they are possibly going to be affected by brain injuries? If they’re athletes, you know, parents, patients, other people around them, maybe for other care providers, practitioners, anyone who’s listening to this, what can they take away? 

00:49:33 Will Mountford 

From your work that they might not have known. 

00:49:34 Will Mountford 

Before they listened. 

00:49:36 Dr Jaclyn Stephens 

Well, they should do yoga and they should wear their helmets. That’s the simplest, simplest advice that I have. I mean, we’re seeing so many benefits of yoga. Doctor Schmidt says all the time yoga is for everyone. And you know the yoga interventions that we’re doing are adaptive yoga. So they’re a lot of these folks. They’re sitting in chairs. 

00:49:56 Dr Jaclyn Stephens 

Doing postures and they’re still getting so many benefits from it. 

00:50:00 Dr Jaclyn Stephens 

So finding ways to keep your body moving is amazing. So if that’s yoga, if it’s something else, keep your body moving. That obviously keeps us healthy. And then if you’re moving your body in ways where you could hit your head, please wear. 

00:50:13 Dr Jaclyn Stephens 

Your helmet so I. 

00:50:15 Dr Jaclyn Stephens 

Think that is? That’s probably the best advice I have, I think. 

00:50:20 Dr Jaclyn Stephens 

You know if if it’s somebody who’s had a brain injury who’s had a stroke, who’s had something like this and they’re, they’re still struggling. 

00:50:27 Dr Jaclyn Stephens 

You know have hope that there can still be recovery for many, many years. We we have one of our participants is 30 years past. 

00:50:36 Dr Jaclyn Stephens 

Stroke and she’s seen improvements. Meaningful improvements from the yoga interventions. If you’re somebody who’s had a concussion and you’re not feeling quite right, know that that’s normal for a number of people and that there are ways to get better. And there’s great providers out there who can support you in getting back to. 

00:50:56 Dr Jaclyn Stephens 

All of your meaningful occupations, and I think you know. 

00:51:01 Dr Jaclyn Stephens 

Yeah. Overall it’s just, you know, keep keep, keep doing things, stay hopeful and and wear your helmet. 

00:51:11 Will Mountford 

I couldn’t ask for a better way to wrap up this episode than that. 

00:51:14 Dr Jaclyn Stephens 

Thank you. 


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