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  • Dr. Nathan Keiser

Concussion and Dysautonomia: How to Avoid the Energy Crash.

As soon as she came in and sat down that morning, I could tell she was frustrated.


“I felt so good yesterday. Why am I so exhausted today?”


I knew at this moment, explaining the depths of neurocardiology was not going to be useful to her. It is tough being 19 years old and wanting to feel normal again. So I took a different path this time.


I reached down and clipped a little black pulse oximeter device around her middle finger. The wave of her pulse flashed in the lines on the screen and then the number 65 popped up. 65 beats per minute.


She looked at me like, “yeah and…”


Then I asked her to stand up. For the next 90 seconds, we both quietly watched the number climb until it settled at 119 beats per minute.


I told her to remember those numbers.


I put the pulse oximeter on my own finger. My number was 66.


I pulled out my phone and scrolled to my Polar beat app. I have recently become one of those people that wears a heart monitor around my chest while I work out. My wife says it looks like I’m wearing a man bra and I am inclined to agree.


I scrolled to the information from my 3 mile jog the night before. I showed her my average heart rate was 122 beats per minute.


I told her, “Right now your body is working just as hard to stand up as mine works to run 3 miles.”


Her shoulders relaxed and she nodded her head hiding a little smirk.


I think she got it.

I think she got it because she got right to work.


I don’t mean just that day.


4 months later (actually closer to 3.5 months later) she sent me a screenshot of her own workout. She jogged for 3 miles. Average heart rate: 118.


So why do some days feel great and then other days feel like you were hit by a bus?


If you are working on regaining your fitness after a concussion or while recovering from POTS/dysautonomia, you have probably experienced the same boom and bust of energy that can vary day to day. One day you feel like things may be turning a corner. You feel pretty good, you are able to complete a full workout and then the next day it feels like you are right back where you started.


The ups and downs are all too common, and to a large degree are part of the healing process.


There are 4 fundamentals concepts you can put to work today. Learn how to smooth out some of the ups and downs and be prepared for whatever tomorrow might bring.


Where are your short-circuits?

Remember in the case of concussion, there are actually injured areas in your brain to deal with. Injured areas don’t function perfectly so your brain creates a work-around. It’s like trying to throw a ball with your non-dominant hand. It takes way more effort and doesn’t work as well. Adaptations like this cost a lot of energy and are often linked to the symptoms we experience.


The first step for anyone that is experiencing concussion symptoms should be to go back and find the specific malfunctioning pathways. Once you know where the problems are, work to restore function in these injured pathways. This is the vital first step to decreasing energy expenditure and improving energy production. Blurring in your vision, misfiring in your balance systems, uncoordinated movement, or slowed thinking are all signs that something isn’t working right in your brain. These problems MUST be addressed first or they will continue to soak up extra energy when performing simple tasks.

Hear me when I say, DON'T SKIP THIS STEP. It is by far the most important and produces the best results in the fastest time.


When your autonomic nervous system is stuck in overdrive, decrease workload, and increase recovery.

You may have noticed that since your injury, life has become more effortful. You feel run down and exhausted more quickly. You might even notice that your heart rate is faster or you feel out of breath during easy activities like climbing a flight of stairs or even unloading the dishwasher.


In athletic competition, there is a concept called overtraining. Overtraining occurs when a person exceeds their body's ability to recover from strenuous exercise.


Overtraining includes one or more of the following symptoms:

  • Persistent muscle soreness

  • Persistent fatigue, even after adequate rest.

  • Elevated resting heart rate, even after adequate rest.

  • Reduced heart rate variability.

  • Irritability

  • Depression

  • Burnout

If you are suffering from dysautonomia after your concussion, these symptoms should look familiar. The concepts from overtraining apply to dysautonomia as well. Dysautonomia directly impairs your ability to recover and adapt to stressors in your environment, including exercise. The equation is actually pretty simple. If you train more than you recover, symptoms develop.


So you can look at the problem 2 ways. You can have too much training or too little recovery:

  • If your training load is high, then lower your volume. Train at a level that doesn't produce symptoms and allows you to recover after workouts.

  • If your training load is low and you are still feeling like you overtrained, your recovery is impaired. You need to reduce training volume, focus on improving brain function, and optimizing sleep and recovery.

Concussions often create problems in the recovery side of the equation.

What does this mean practically? Once you are confident in your brain training regimen, focus on your recovery strategy.

Are your exercise, work, school, or social routines exceeding your recovery capacity at the moment?

If so, start low and slow. Find the right training, socializing or cognitive dosage for you in this moment. Build from there. Make sure you can accomplish each of these tasks throughout the day without causing symptoms or energy crashes the following day.


Modify your activities based on how well you are recovering. Don't create a rigid schedule and hope your body will keep up.


Create your energy budget.

Everyone has a limit of how much activity their autonomic system can tolerate before tipping into overtraining. If you are taking longer to recover from activity it is smart to honor that reality rather than ignore it.

Plan your day around your most important tasks. Your energy is valuable. Spend it where you get the best return. This can mean doing your highest value work in the morning when you are most likely to be fresh.


Strategic Recovery

It's a fact. healing takes place when you are at rest. We advocate building "strategic recovery" periods into your daily schedule. Strategic recovery comes in two types. The first is wakeful rest. This is when you are awake, but your mind is intentionally disengaged from your environment. The second type of strategic recovery is restorative sleep. This can come in the form of brief nap periods during the day or in extended periods of sleep at night. If you are waking up in the morning still exhausted, you need to stop and consider:

  • Am I getting to sleep early enough?

  • Am I sleeping through the night?

  • Am I waking up refreshed in the morning?

You may need to reevaluate your sleep hygiene or flat out sleep more. The common guidelines of 7.5-8 hours per night may not be enough during this phase. You may need more. listen to your body if it is telling you to sleep more. Sleep is powerful. It is the mechanism for consolidating memories, building synapses, and removing waste from your brain.

Periods of strategic recovery are the most valuable resources in your arsenal when it comes to brain healing.


Remember the role of exercise in recovery.

The goal of exercise for brain rehabilitation is different than for general fitness. In her senior year of high school, star USA women's soccer player, Alex Morgan tore her ACL and underwent surgical repair. When the surgery was over, she didn’t take two weeks off and head straight back to the soccer field. She spent 5 months in intense physical therapy working on one thing. Her knee. Thousands of people go through this process every year in the US and the experience is painstaking. In the beginning, just stretching and moving the knee is difficult. Then learning to control it again on your own. Lifting just 10 pounds causes your leg to shake and become exhausted. Slowly but surely the knee becomes stronger. Struggling to lift 10 pounds turns into jumping squats. But it doesn’t happen overnight.


When you are exercising for your brain, you are working to improve focused areas of function and restore blood supply to the brain. The goal at this stage is not physical fitness, its brain fitness.


So start slow. During physical exercise, the mechanisms to optimize blood flow and restore function work around the “ventilatory threshold.” A deep dive into this subject is for another article, but generally speaking, this means you should be able to hold a conversation while you are exercising. Once you can do this without symptoms, you can start to expand your capacity slowly (This is always best to do under the guidance of someone that is experienced in the process).


Managing energy in your concussion recovery is not easy, and as you know, it is not an overnight process. Going from 119 beats per minute just to stand up to being able to exercise at the same rate isn’t magic. It takes a plan and some effort every day. Recovering from an ACL injury is the same way. When you are struggling to lift 10 lbs and your legs are shaking, playing soccer again feels miles away. But if you start the process and make a little progress each day (some days the progress feels rough) it adds up to major changes over time. Being consistent and intentional with how you recover and how you spend your energy will help you smooth out the highs and lows in your energy management. These fundamentals are fundamental for a reason. Start with these strategies first. Build up your energy capacity and increase your workload day by day so you can get back to living your life.


If you found this article helpful, check out “The 5 Mistakes That Slow Concussion Recovery.” for more useful strategies.


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