I have a client, whom I’ll call Jim, who suffered a concussion during an ultimate game this summer. He has had concussions before, and suffered post-concussion symptoms for many weeks. He took 5 or 6 weeks off from training with me during the post-concussion period while he was under the care of athletic therapist and osteopath Richard Gregory. Richard is the head therapist at Ottawa Osteopathy & Sports Therapy and is one of the best manual therapists in Ottawa. I learned a lot from him when he used to be my boss, and I continue have a great relationship with him.

Jim returned to training once his post-concussion symptoms were gone. He enjoyed several weeks of training that felt great, but then after one session, some of the symptoms returned: By the time he got home he felt nauseous and had to go to bed. This happened again the following session.

I wasn’t sure what to think so I reached out to Richard to see if he could suggest anything. The following emails share some context and Richard’s amazing explanation of what was likely going on and some guidance on addressing it:

Email from me to Richard Gregory:
“Hey Rich,
Jim was in Tuesday and again last night and both times ended up with post-concussion symptoms returning. He had had several training sessions prior to that without problems. Tuesday I think he was fine during training but then felt a bit off that night and very off the next morning.

Thursday we talked about it and the plan was to backtrack to the workout he had done the previous time, which had been fine, but by the end of his power section (kb swings and push presses) he was done.

Any thoughts? I was wondering if it might be one or more of:

• Maybe the rapid vertical to almost horizontal head movement in swings is complicit? (he has been doing them without problems for a while – with no weight increase). He’s also been doing single leg RDLs which of course have that same vert to horiz motion. But those are also not new this week.
• Tuesday we upped the intensity on a few of his exercises a bit. I put him on a protocol called 5-3-1, where basically set one is pretty easy, set two is moderate, and then set 3 is hard as you do as many reps as you can with good form at that weight. Then we use that to calculate future weights. It’s cool as it is very responsive to fluctuations in ones energy/strength/ability. And the calculations use 1RM percentages but applied to 90% 1RM weights, meaning they are not aggressive. His reps ended up in the 8 to 12 range on the last set. Maybe too much volume? Or maybe the intensity of ‘as much as possible’ was too much?
• Maybe it’s combined volume of work over the week that is now putting him over the edge? He’s doing twice weekly and I think playing Frisbee once and maybe biking etc? Hopefully he’ll clarify. If this is likely, should we go with either less intense both days, or do 1 intense day, 1 easy day?
• He mentioned that he stopped doing the vestibular exercises once he no longer had symptoms – so maybe 2 months ago? Is it worth bringing those back in and then planning to do them in some maintenance capacity even after he feels fine?

I welcome any thoughts that could help with Jim’s programming/training so he can train at the optimal level and with reduced likelihood of more symptoms.

Thanks!

Els”

Richard Gregory’s response:

“Hey guys,
Here’s my DIY sleuth guide for getting rid of post-concussion symptoms. The symptoms are sometimes very specific and sometimes very vague. Hopefully this info will help you figure out what the issue was.

Cerebral BP Changes:
Post-concussion brains lose their ability (temporarily) to regulate the blood flow (pressure) to the brain amidst rapidly fluctuating body blood pressures. The control of cerebral blood flow (cerebrovascular autonomic regulation) is run on both negative (factors that decrease brain BP) and positive (factors that increase brain BP) feedback loops. If HR spikes too rapidly, pressure sensors in the aorta and the brain’s middle cerebral artery adjusts and dials down blood flow to the brain. The reverse also happens. After a concussion, abnormal blood flow control gives the owner of this brain a very vague malaise feeling of just not feeling right. The recipe to make this go away is to train the vascular system to be more efficient. As you exercise at lower or moderate intensities for steady state (no intervals), you get new arterial growth in the brain (arterioles). This allows a larger number of vessels to provide the same brain tissue with blood flow thus decreasing irregular flow issues. Additionally, the regular steady state cardio (ideally 5/week for 20-35 minutes) “resets” the ability of the brain to regulate blood flow amidst changing body BP. Setbacks which occur months after the concussion usually happen for the following reason.

Brain owner says “I feel good. Thank God that rehab is done. I did at least 4-5 weeks of cardio like 5/week. Now I’m gonna just live my life.” Frisbee happens, a couple of workouts but the steady pace cardio fades off. The effect of the auto-regulation can fade but over time, the more consistently that cardio is trained (over weeks and months), the fade of efficacy of the auto-regulation will stop happening.

How to test it:
Smart way – start doing cardio steady pace at least 20-30 minutes 5 days per week and wait 3-4 weeks before doing heavy weight days or cardio intervals. If you feel better, that was likely the issue. You’ll also know it was the issue if you relate to the brain owner that did considerably less cardio than during the rehab stage at the time you felt the set back. Remember to avoid the breath holding when you go back to the weights and the interval workouts.

Painful way – go to Els’ gym. Do no warm up, drink a Rockstar energy drink to prime your adrenaline. Do 5 sets of heavy squats with lots of breath holding. Then immediately lie down. Feel the wave of nausea wash over you. Feel crappy the rest of the day and possibly the next day. (I don’t recommend you do this). If you feel not so good, you have a temporarily altered cerebral auto-regulation.

I recommend completing the “Smart way” of 3-4 weeks of cardio.

Vestibular Dysfunction:
The improved vestibular dysfunction attained from completing a methodical and specific vestibular rehab program often needs to be reinforced. If the concussion happened several months ago and you did vestibular rehab for about 3-5 weeks, then you may need to “top up” your neuro-vestibular synapses. It is common to achieve a normal or sometimes even greater than normal level of vestibular function but then have this function fade imperceptibly over the course of 2-6 months. This can leave you feeling vaguely nauseated and very low energy. If this is the case, do the following test:

Vestibular test: (Jim knows this test)
Stand in place with eyes focused on a spot, rapidly turn 180degrees and stare at a spot straight ahead of you. Repeat the same test 2-3 times on each side with about a 10-20 second break between reps.

Video of the test:

If you feel woozy, your field of vision feels like it’s moving but you’re standing still or you see blurry, your vestibular function isn’t up to snuff. You can play the same game from lying to sitting rapidly or standing to looking at the floor. Jim only had a rotational dysfunction at the time we tested for it so it’s unlikely that a new vertical issue arose and also unlikely that the rotational dysfunction was stimulated by the gym exercises. Regardless, this is a harmless test and is worth doing. The rehab is to repeat the test for 3x2minutes at a pace that is sustainable and doesn’t provoke symptoms. Do this daily for 5-10 days. I got concussed in 2012 and I still break out a little spin-o-rama 3x2minutes every 8-12 months. I feel like it fades, then I do it for like 2-3 days and it pops back to normal. The need to top up my vestibular function has significantly decreased over time and I feel normal for 12 months at a time. This is not a finding that is available in the literature yet but leading researchers and concussed athlete practitioners (like me) have observed it in the clinic.

Additional vestibular training exercise video:

Global Neural Fatigue:
The concussed brain doesn’t distinguish well between too much exercise, too much work or too much emotional stress. It just knows when it’s been too much. Some researchers are using the term brain bucks. Every time you do work, exercise or experience an emotional stress, the brain pays using a finite amount of brain bucks. The better you sleep, the better you eat (fish oils, healthy fats, low simple sugars) the more brain bucks you get. If you’re sleep deprived, drinking lots of alcohol and eating poorly, then you might have a few less brain bucks. The workout may have been the same, the intensity may have changed only slightly but there may have been other factors such as travel for work, perceived emotional stress etc. Try to think back and see if you felt perhaps you worked a bit more, slept a little less or had other factors that might have made the same well thought out workout cost the last available brain buck. This would leave you feeling like you’re just done and you really don’t want to do the next set. If you think this was the issue, the solution is to monitor your overall brain expenditure by doing a little less (when possible) on the days you’re going to work out. You can also significantly increase your brain’s function and ability to tolerate stress, sleep better, get more out of relaxing etc by doing 10 minutes of mindfulness training. I particularly like Headspace. It’s easy, realistic and doesn’t require wearing silk pants and chanting. Not that there’s anything wrong with that. It’s also been shown that changing one’s perception of negative stress (distress) into a positive stress (eustress) which will embolden you for future stresses can significantly lower the correlated cortisol spike, BP spike etc and consequently, it would cost you less brain bucks to live through the same life stress. Cool Ted talk on this here. Kelly McGonigal: How to make stress your friend.

These are the three most common issues I see that cause setbacks in my post-concussion athletes. Hopefully, you’ll find a solution to the issue. If you hit a barrier you can’t get past, give me a ring. Sorry for the essay.

Hope you guys had a good weekend!

Rich”

My email back:
“Wow, that was amazing. Thanks for the essay! So really this is:
1. back to cardio for 3 to 4 weeks and no gym (what about Frisbee?)
2. Figure out a good frequency to continue some vestibular test/training – likely will need less often over time.
3. Sort out if there is a stress/perceived stress aspect.
4. Start back at the gym again in 3 to 4 weeks with a similar approach, although perhaps this time we hold off on intervals a bit longer and probably if it will be twice weekly, we make one a light day for a while.
Sound right? Thanks again Rich. Obviously this is helpful for Jim, but this is also super helpful for me to get this great explanation and insight.
Els”

Richard’s email back:
“Hey Els,
I suggest 2-3 weeks of no heavy lifts, no strength tests, no max reps, no valsalva etc. I suggest cardio 5xweek for about 20-35 minutes steady pace. If the ultimate has been feeling fine, then continue. I’d suggest the ultimate be played as a poachy D and handler and possibly skip the odd point while taking one of the weaker players to cover on D. Gym can probably continue at lower intensities in 1-2 weeks depending on how Jim feels. Also worth doing the vestibular tests as they’re easy and safe.

My guess is that it’s a BP issue that just needs a bit of priming. Let’s let Jim chime in on how he feels and go from there.

Have a good day guys. “

Jim’s reply:

“A Huge Thank You to both of you for taking the time to discuss this with me and with each other. I honestly can’t put into words how much I appreciate it. It feels really good to know that you both care enough about how I’m doing to take the time to exchange all these ideas by email. I know it takes a lot of time to write all this down and it would be easier if I just made appointments and came into the office, so I appreciate the time spent on these emails a lot!
I suspect the reason for the relapse is just what Richard said: “I feel good. Thank god that rehab is done. I did at least 4-5 weeks of cardio like 5/week. Now I’m gonna just live my life.”

From early March until late April I had a really good routine of doing my vestibular pen-following and rotation exercises. From mid-April until late May I had a really good routine of 4-5x per week cardio for 20-30 minutes – a lot of bike rides along the canal in the morning or evening. I wasn’t a huge fan of the pen-following/rotation exercises and was happy to let them go, but I really enjoyed biking along the canal. The only reason I stopped biking was a customer event that required me to be at work much earlier and later than usual each day for the last month, which made it hard to find time for biking during reasonable daylight hours. That customer event is over now, and I’m happy to get back to biking in my free time.

Until last week, I was feeling really good. I was playing ultimate once per week, having two really solid workouts with Els, and doing some interval training 1-2x per week on my own. Last week for the first time I felt symptoms again – super barfy and dizzy after workouts with Els. On Friday night I “tested” myself with one set of 60 seconds of pen-following, and I could only make it through 30 seconds before I got barfy and dizzy and I had to lie down. The good news is that last night I was able to do two sets of 60 seconds with no ill effects.

I will get back to my cardio bike rides (which I really enjoyed anyway), and more of the vestibular exercises to top that up.

Thank you both, again, so much!

Cheers,
Jim

PS “poachy D and handler and possibly skip the odd point while taking one of the weaker players to cover on D” – that sounds like a lot of fun, I should try that!”

Richard’s reply:
“Good luck with the barfy exercise. You’ll bounce back way quicker the second time around. Keep your eyes peeled for a tiny relapse in another few months and do the cardio and the barfy thing again.

Have a great day!”