• Dr. Nathan Keiser

Concussion Recovery In A Rut? 3 Strategies For Breaking Out.

Every time he turned his head to the left, his eyes would shake.

Whenever he closed his eyes, he felt like he was an astronaut falling through space.

As a 24-year-old who made a living working outside and caring for animals, this was not sustainable. For months he had been startled out of bed every single morning at 4 am to run to the bathroom and throw up. The only relief was to sit up straight and try not to move. He was nauseous constantly and could barely eat. His skin looked a ghost colored gray and he was sweaty. Like he had just come from the pool and hadn’t fully dried off yet. He had a hard time turning his thoughts into words and his parents or fiancé would have to bring him to appointments to speak for him and help him remember what had happened.

I did my tests and measurements. I walked through my findings and plan for how to help. He listened and reciprocated where he could and his parents helped a lot.

If he was going to have a chance at feeling better, we needed to help him improve the function in his central vestibular system. Simply put- he needed to be able to turn his head to the left without his eyes shaking.

While cases like his were not easy, they were also not uncommon and we went right to work. By the end of the first day, I was the one sweating. I progressed through the strategies I knew to stabilize his eye movement, but they weren’t working. So I added more. I changed the variables, but nothing was working. Nothing I was doing could help him get control of his eyes and he was getting exhausted. It was as though everything we did drained a bar of his battery life.

I stepped away to check in with another patient and on the walk over to the other exam room, my mentor Dr. Carrick’s words wafted into my mind-

“Don’t put too much salt in the chili.”

It was an expression he was fond of using and in this case, it was exactly what I was doing.

I went back into the room and stripped everything else away. I was going to break down this movement into its smallest parts and start there.

I moved a little green frog sticker that served as his visual target across the room so his eyes could make a minimal arc. He would not have to rely on any accommodation of his lens. I held his head in my hands and helped him make the turn to the left. It was the smallest turn I could physically help him make. All said and done, his head moved less than an inch. But he nailed it.

We finished the exercise and we both looked at each other in excited disbelief. Like Will Ferrel and John C. Reilly in the movie Step Brothers, “did that just happen!?”.

It was perfect.

We did it again, then again and he continued to hit it perfectly. For the next 3 days, we would sit in that exam room and practice leftward head turns. Slight movements at first then growing larger and faster as he gained strength. There was nothing glamorous about it. No fancy tools, no high tech equipment. Just two people a chair and a little green sticker on the wall.

Over those 3 days, his hands became less sweaty, he started to talk and he came back to life. His Mom cried on the first morning he didn’t wake up to a vomiting spell.

We practiced so he could do his exercises at home perfectly with his fiancé and I asked him to check in after a week to update me on his progress.

A week later, his email came from a cabin in Colorado. He had decided he felt well enough to go with his family on their annual ski trip and he had just gotten back from a day on the slopes.

I think about this case on a weekly basis. It is a constant reminder of how small details make the biggest changes. Our gut response is always to try to add more or go bigger. In this case, I was even doing the right thing. Just too much of it.

The most symptomatic cases are often the ones that require the smallest doses of work, require the most precise interventions, and have the least room for error.

So this message is speaking to the doctor and the patient. If you are stuck. If the symptoms aren’t getting better, the following 3 strategies can show you how to get back on track with your recovery.

1. Start at the foundation- foundational skills transfer into complex skills.

In order to better solve complex problems, it can be effective to break down complex skills into smaller parts and find where the breakdown occurs. If you are having trouble with balance or feel weird when you are moving or the world is moving around you, a deeper dive is required.

Coordinating your eyes and head to work together is a simple skill, but think of how many of the tasks you do in a day that don’t require you to aim your head and eyes at something. Eye-head coordination is the foundation for more complex skills like walking, driving, paying attention, and even thinking. Eye-head coordination is one of those simple skills you have required effortlessly in your lifetime, and if it breaks down, it can disrupt function for any other process that is using eye and head movement information (almost everything requires head and eye movement information).

How much loss of coordination does it take to cause problems?

Very little.

Subtle loss of function in eye-head coordination can lead to major symptoms.

If you are still having trouble in your recovery, do this: Go back and evaluate the subtleties in your eye and head movements.

When you measure your eye movement, what are the tiny errors you see?

Are the errors different when your eyes go left vs right? Up vs down?

When you turn your head one way or the other, does it affect the way your eyes move?

What about if you stand up?

Notice everything. These errors are your roadmap to using foundational skills to rebuild the complex ones. You will be amazed at what can be achieved by focusing on the subtleties.

2. Training through an injury

When I was in High-School, I injured my shoulder making a tackle (it was still a great tackle) in practice. I went to the weight room after practice to get my workout in. I put the prescribed weight on the bar to do a bench press. It was not particularly heavy, so I didn’t bother to wait for a spotter. As soon as I lifted the bar, my shoulder decided this was a bad idea and gave in. I dropped the bar to my chest and was stuck there embarrassed trying to wrestle my way out from under 205 lbs.

Eventually, I was able to call over a friend to hoist the bar off my chest, and the lesson is still part of my practice today. Injured tissue, whether it is muscle or brain or a joint, tends to be weaker. When I prescribe exercises for someone’s brain, I do it with the understanding that the pathways are weakened. In many cases, small, precise therapies gain traction far better. Bigger, more aggressive therapies are like dropping the bar on your chest.

When you do your exercises, are you starting in your range of what you can tolerate?

Are you able to build strength, or are you doing a therapy that outreaches your current capacity?

3. Stay in Your Therapeutic Window

In pharmacology, getting the correct dosage of a particular medicine is critical for the safety of the patient. Too little and there is no effect on fixing the problem. Too large of a dose and it causes toxic effects that can harm the patient. The range of a dosage that is in the sweet spot between too little and too much is called the therapeutic window.

When I prescribe exercises for the brain, I view them as also having a therapeutic window. In our case, we are looking for the dose of exercise that will induce long-term potentiation.

Long-term potentiation is the mechanism for causing new connections to grow between neurons and build pathways in the brain.

We also want to make sure the stimulus isn’t too strong for the neurons in their weakened state. Overdosing exercise, or “exceeding metabolic capacity” can have very detrimental effects and cause injury to your brain cells.

Too little stimulation to a pathway and long-term potentiation isn’t triggered.

Too much stimulation and the cells are overworked and harm can be done to the pathways you are trying to help.

When you think about your brain exercise prescriptions, are you in your therapeutic window?

Are the exercises taxing enough to require the brain to make a change, but not exceeding the neuron’s metabolic capacity?

These are the questions we are navigating every day to make sure training prescriptions are tailored. Not only to the nuances of identifying specific injuries, but also the moment to moment changes in energy and function. The clues to recovery can be very subtle, especially if your symptoms are really bad or have been lingering for a long time. Be willing to dive deep. Hunt down the subtleties and take the time to make sure the treatment matches. If what you are doing now is not working, strip everything away, go back to the basics, and focus on the little things.

Remember, “Don’t put too much salt in the chili.”

If you have found this article useful, check out “The 5 Mistakes That Slow Concussion Recovery.” for more useful strategies to solving your persistent concussion symptoms.

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