Navigating Exercise Intolerance After Concussion with Dr. Mike T Nelson | E22

Dr. Mike Nelson shares his expertise on exercise intolerance after concussion, explaining that neurological limitations, not metabolic fatigue, are the primary barrier to resuming physical activity. The key difference is that your nervous system acts as a brake on performance, preventing your body from accessing its existing physical capabilities.

• Exercise testing should be individualized, focusing on symptoms rather than rigid heart rate parameters
• Different exercise modalities (rowing, biking, walking) can produce dramatically different symptom thresholds
• Morning heart rate variability (HRV) measurements provide objective feedback on recovery and exercise tolerance
• Repeatedly pushing past symptom thresholds creates negative neurological associations that worsen exercise tolerance
• Breaking the connection between exercise and symptoms may require changing equipment, environment, or exercise type
• Isometric exercises and proprioceptive training can help recalibrate the nervous system's response to movement
• Recovery isn't linear—success comes from tracking aggregate trends while accepting daily variability
• Focus on raising your "floor" (minimum exercise capacity on bad days) rather than chasing pre-injury performance levels
• Consistency in showing up for subthreshold exercise is more important than performance on any single day

For more information, visit miketnelson.com or listen to the Flex Diet Podcast.

Find Dr. Nelson on instagram @drmiketnelson

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Chapters

• 2:54 Understanding Exercise Intolerance vs. Deconditioning
• 7:24 Measuring Symptoms and Exercise Capacity
• 14:47 Heart Rate Variability as Recovery Tool
• 24:48 Breaking Negative Exercise Associations
• 31:48 Body Remapping with Resistance Training
• 41:56 Managing Progress with Moving Thresholds
• 53:18 Episode Closing and Preview

Transcript

Dr. Mike T Nelson Ph.D.: 1:10

Now I also look at what is your floor? What is a lift or endurance performance? You could go out like half asleep, had three beers a night before, on four hours of sleep, and you know for sure you could absolutely do and you could probably go back and do it the next day. Great. So now we have your peak. Now we have your floor. It's the same thing if you have exercise intolerance, right? Okay, your worst day is maybe it's only two minutes now, great. When you first started, you can do anything. Maybe your best day is 15 minutes. Cool, right? So over time, I want that gap to kind of close down a little bit.

Dr. Ayla Wolf: 1:44

Welcome to Life after impact the concussion recovery Podcast. I'm Dr Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go to resource for actionable information, whether you're dealing with a recent concussion, struggling with post concussion syndrome, or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless or like no one understands what you're going through. Know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. Dr Mike Nelson, welcome to the life after impact Podcast. I'm so excited to have you on here. I first met you and heard you speak at the Carrick Institute's international clinical neuroscience conference. I think that was maybe back in like 2017 Yeah, that sounds about right, yeah. And so since then, I've gotten to pick your brain a little bit about your specialty. You're an extreme human performance specialist, a fitness and nutrition educator, a researcher, a speaker, and you have your own podcast called The Flex diet podcast. Yep, that's right, okay, and you're already, you've been doing that for like, four years. You're on episode 320 something

Dr. Mike T Nelson Ph.D.: 3:26

Yep, yeah, it's been fun. Yeah, it's been a good time.

Dr. Ayla Wolf: 3:30

Great. Well, today I wanted to talk about exercise intolerance. Since you are an exercise physiology specialist and many of the patients that I see with post concussion syndrome, what's interesting is that when I have athletes, it seems like there's a big emphasis on the exercise intolerance piece for them, but when I have just your average person who was rear ended in a car accident, got a concussion, also maybe some some neck trauma, they come to me, and it might even be months to years afterwards, and they clearly have exercise intolerance. But because they're not a professional athlete. It's like everybody else just kind of ignored that. And that always bothers me, because the ability to exercise is so important for everybody, for longevity, for overall health, for blood sugar control, for sleep, for stress management. And so I pay close attention to that. And so I wanted to bring you on the show and talk about your experience, because I know you've been sent some some pretty difficult cases. You've worked with people with post concussion syndrome exercise intolerance. So why don't you start out by maybe differentiating between exercise intolerance, what that means, versus somebody who's maybe just deconditioned or has a lot of kind of general fatigue.

Dr. Mike T Nelson Ph.D.: 4:52

Yeah, the simple way of thinking about it is, post concussion. A lot of people, it's the nervous system. It's going to be their rate limiter on exercise, not their metabolic system. So an example is, if you have a high level athlete who has a horrible concussion, something like that, and they start to get a little bit better, and all of a sudden they're extremely intolerant of exercise, meaning even a couple minutes, sometimes can be just a horrible experience. It becomes symptomatic, etc. They didn't spontaneously. D trained that to that level in those two or three or four days, or whatever it was, like, they're all mitochondria, and then go screw you. We're going out to lunch. We're not doing it anymore. Like they have a lot of those residual properties still there, but it's their nervous system. It's like this huge break that is making them symptomatic because of the other things going on, and it gets harder to sort out a little bit with someone like you mentioned, who maybe has not had this diagnosed, maybe hasn't really done a lot of formal exercise in 123, years, etc. Yeah, in those cases, you probably have a combination of stuff. You've got still those nervous system effects, and you probably have a lot of massive like just physical D. Training at the same time. But I think it many times gets confused as, oh, they're just out of shape now they don't want to exercise. That type of thing, where it's actually which we'll get to do. It's a nervous system that's putting the brakes on exercise. It's not due to metabolic fatigue or even energy systems or anything related to that.

Dr. Ayla Wolf: 6:32

Yeah, that's a great differentiation. And then in terms of, like, diagnosis, obviously our gold standard is the buffalo concussion treadmill test, yep. And then a lot of times it's also, I would say, the case where you have people that come in that are like, Well, I just know that if I get on a treadmill and I start walking, or I try to go for a walk, all of a sudden, within maybe that, you know, they have a time limit. They say I can walk for maybe 10 minutes, or I can walk for 20 minutes, and then all of a sudden, I get the headache, the dizziness, the nausea. And then for some people, that might actually throw them off for the rest of the day. For other people, they can recover within 30 minutes. But what are the metrics that you're looking at when you're working with people like, Are you paying close attention to working within a certain heart rate zone for each individual or kind of, what are the metrics you're paying close attention to?

Dr. Mike T Nelson Ph.D.: 7:26

I mean, I think you can use heart rate, you can use respiration rate, you can look at HRV, you could there's a lot of things you could look at, but in reality, I just primarily use RPE, the rating of perceived exertion, and then tell me about your symptoms, because what I found is it's so wildly different from one person to the Next, even if they have a air quotes, heart rate, where they become affected again, that's a real thing. But sometimes, when you change modalities, what they were tested in is completely different, right? So you may have someone who did a treadmill test and they say, Yeah, you know, I'm good to about 140 beats per minute, or, you know, whatever the number is, they get on a row, or they get on a bike, they barely hit 85 beats per minute, and they're like, oh my god, I felt horrible. This is like the worst experience of my life. So I tend to just go by symptoms of where they would run into issues, and then in my head, I'm trying to figure out, is that a time thing? Is it an intensity? Is it a heart rate? Is an RPE, or is it a modality? Or maybe they did some neural drills beforehand. Maybe it was a bad day. Maybe their HRV is dog crap, so they're already highly sympathetic. We'll get into some of those things. And that's the hard part. Is a lot of times it's not it's not super stable, so I'm just looking for those patterns. So let's say, Oh yeah, every time I go for a walk, when my heart rate hits around 110 you know, 10 minutes in, that's it. Okay, if we can find that that's kind of the hard limit, repeatedly. Cool. Okay, now we have something to work with. We're gonna try to stay under that limit, and that could be very different across the board. So I tend to, as basic as it is, just use primarily, what are their symptoms? And then back out from that, okay, how long were you able to go? What was your heart rate? What was your RPE? What was the modality? Once we can then figure out patterns. Oh yeah. Every time I get on the bike, I hit this certain heart rate. Within five minutes, I'm toast. Great. Now we know that that's kind of our for the time being, that's kind of our new new Max, so to speak. We want to try to stay sub threshold, because one every time you run those symptoms, not only is it harder to recover from, but it's very similar to how I think of it, like a lot of the pain science stuff, if you looked at like morning Mosley's, and you know, more of the neurologic end of that spectrum, if you just kind of keep people out of pain, a lot of times they get better, because every time they do a certain pattern, it becomes painful. You're literally via neuroplastic changes associating, oh yeah, every time I move my right elbow this far, it's painful, right? So you you run that neurologic loop pattern. Also the same thing happens, I think, in these cases of exercise, is, are there true physiologic changes that happen? Yep, are there true neurologic changes that happen? Yep. But I want to stay away from the association pattern that I don't want them to learn this is their limiter. So if I told them, okay, bro, just to go out every day and just, I don't know, run until you get symptoms and then stop. Yay. They're learning that, Okay, at this point, I'm always going to have symptoms, and they'll actually start regressing like that'll become sooner and sooner and sooner, because their brain's trying to protect them. It says, Hey, you idiot, we told you this was a bad thing, so we want a bigger safety margin. So now eight minutes is not going to be good. Now six minutes is not going to be good, right? The same thing. You have people repeating the same pain patterns over and over. It's really hard to get them out of that loop, because they have that constant association all the time. So part of what I'm trying to do is to not have that association. Have it go the reverse. Ah, see you. Can do some exercise, even if it's only five minutes without symptoms. This doesn't mean that every time you exercise you have symptoms. It means that we may have to change, that we may have to work around it. We have to progress towards it, but trying to, well psychologically and neurologically, not kind of build a bunch of poor habits and poor associations that eventually, at some point you're going to have to undo.

Dr. Ayla Wolf: 11:33

Yeah, I really like that. You said that about, well, a not necessarily needing to, like, always do the gold standard testing for everybody, and that it's perfect you, you can still help someone to a very profound degree by really just kind of paying attention to the basics and heart rate, breathing, pain, symptoms, and also that idea that their response on a treadmill might be completely different from their response on a bike, or I know, for me personally, put me on a row, or put me on a bike, or make me run, and I'm okay, but if you make me swim, I will be hyperventilating, and I will, like I will fatigue so fast. And there's some kind of psychological thing that I have about being in the water and having my head under the water and not being able to breathe whenever I want to. And so I could see that even for myself, that if you were going to try to test me my my whole physiology would change if you suddenly threw me in a lake and said, go swim and then monitored my heart rate.

Dr. Mike T Nelson Ph.D.: 12:37

Yeah, and we see this, you know, not post concussion, right? You know, Lance Armstrong ran a marathon, didn't win, right? It wasn't because his VO2 Max wasn't real high. It was just, he's not trained as a high level runner. He did well, you know, did good, but yeah. So unfortunately, in these kind of post concussion cases, that's just drastically exacerbated,

Dr. Ayla Wolf: 12:59

yeah, yeah. And then so when you have patients, you know, a lot of times, I find that when there is an exercise intolerance and there might be this rapid elevation of heart rate that some people, you know, you want to start them out seated versus standing, so doing something like a recumbent bike or a like you mentioned a rower. So are you often, when you have these patients come in, you've kind of established maybe kind of a heart rate parameter with which they can function pretty well. Are you typically working with them, kind of either in a seated position or arm bike, or what are you doing?

Dr. Mike T Nelson Ph.D.: 13:37

Yeah, typically, I mean, if I had a choice, my modalities would be stationary, not moving right, because, especially if they're new, they may become symptomatic faster than what they think. So you don't want them to, you know, tip over when they're running or have an accident or fall off their bike, or, you know, just from a pure safety standpoint, I'm not a big fan of the treadmill overall. Like even go to most gyms and watch people their first few steps off of a treadmill. It looks like they were drinking. They're like, Oh, well, like their brain is trying to literally recalibrate, because the proprioceptive system says, hey, look, we're moving. And then the visual system says, No, we're not, you dumb ass. We haven't gone anywhere. We're in the exact same spot. Like nothing around us is moving. There's no peripheral movement, there's no changes, etc. I can't I don't have any data to show this, but my gut feeling is, in this population, like I think a treadmill would be harder for their brain to figure out, and they might cause them to be more symptomatic. Plus they're moving through space, there's more of a chance of an issue, etc. So mostly I would do rower, you know, upper arm ergometry is fine. Bike is fine, something like that, in a seated position, and for whatever reason, like those things seem to be such a different motor pattern. There isn't as much of that confusion. I think the treadmill is a little bit too similar to walking that you get signed to some some goofy stuff.

Dr. Ayla Wolf: 16:11

Yeah, I think you make a really good point there, that when you're on a treadmill, there is, in a sense, kind of a vestibular visual mismatch between you think you're moving and yet you're the environments not moving and you're you know, you are translating forward, but the actual image in front of you is not. So those are all really good points in terms of why a treadmill might actually be a more problematic than other types of equipment, where you can be stationary and moving, yeah.

Dr. Mike T Nelson Ph.D.: 16:40

And as far as I can tell, and I'm not 100% sure on this, I think the use of the treadmill was just the crossover from the exercise fizz world, where early on, all they really had was treadmills, and then they had bikes. So a lot of labs now still, like their main mode of of exercise testing is just treadmill,

Dr. Ayla Wolf: 16:58

yeah, yeah, that's interesting. And then I know that you, you do some heart rate variability, um testing, or how are you kind of paying attention to that with people? Because I know you, you do some work in person with people, and some work remotely.

Dr. Mike T Nelson Ph.D.: 17:13

Yeah. In this population, the hardest part is basically just figuring out what is the cost of the thing you had them do, right? And you can grade that by looking at acute symptoms. You can grade that by looking at symptoms after sometimes they're delayed 20 or 30 minutes. Sometimes they don't really know until the next day, in rare cases. So I always have them do an am heart rate variability. So for people listening, heart rate variability is a marker, a status of the autonomic nervous system. How much are you on the parasympathetic versus the sympathetic side? And while it's not perfect, it gives us an idea of, did we really kind of overcook their system the day before, right? So if their HRV the next day is very low. So when you lose fine scale variability, that is a sign of more sympathetic stress, then okay, it could be a lot of things, because HRV won't tell us what the thing was, but it is very accurate saying, okay, due to your autonomic nervous system, something was very stressful yesterday, so I'm probably going to move back what we did for exercise again, see if we can get under that threshold to make sure HRV is relatively stable day to day. And I think that works well to determine the cost, and then also to kind of because I want something that's not always symptomatic, like I want to know how they're feeling, but at the same time, I don't, in a perfect world, I don't want them to be focused on that all the time. It's like, the the check oil light on your car. Like, I only want to know if the oil is low. Like, don't tell me every day the oil is fine, right? I don't need to know that. Like, yeah, we want to know your symptoms, but I don't want to be so hyper focused on that. That's the only thing we look at. And it's like, don't look at a like, don't think of a Purple Cow. It's like, oh shit, I thought of a Purple Cow, right? The thing you're constantly talking to them about, subconsciously, you're just gonna be reminding them. So sometimes I'll tell them, like, hey, you know, they're like, I don't feel so good today. How do I do it? I'm like, just, just try it. And we'll look at your HRV the next day and see how it goes, right? So I want to try to give them some other marker or some sort of safety net that, yeah, if this is not going in the right direction, we're not just going to tell you to suck it up and watch for more David Goggins videos and just try harder, right? We're going to look an actual physiologic marker to see, oh, wow, for whatever reason, it says your physiology is stressed. Okay? If that goes on for a couple more days, let's, let's look at it. Let's try something else. It could be nutrition related. It could be some of the neuro drills are doing. It could be the exercise. Could be modality. It's a little bit tricky to figure out what it is, but we're at least going to look at it, because we have very good data to show that the cost was high, and we know if we keep running things with the costs that are high, eventually the wheels are going to fall off. You're going to be in a worse state, and then you got to figure stuff out from there. So I like using a lot just am HRV measurement each day. There's some, I don't know if there's really a lot of utility to do it post exercise. This is too much affected by the exercise and the state and everything else. If they are kind of an anomaly, and they can get up to a higher heart rate, you can do a two minute heart rate recovery test. Just have them sit for two minutes and then monitor how fast the heart rate recovers in the first minute versus the second minute. That's a very accurate test for what's called parasympathetic reactivation, you can see if that's normal or abnormal. So even sometimes, I'll use that if people are not really getting to a true Max, just to get a little bit of an idea of, you know, kind of what is the status of their autonomic nervous system. How is it responding? And it only takes two minutes. You can just do that right after the test.

Dr. Ayla Wolf: 20:55

Yeah. I've certainly had patients who, the they have, you know, a heart rate elevation during the workout, but then they say, yeah. But then when I stop the workout, like for 30 minutes after, my heart rate is still higher than it should be, yeah? It's like, okay, well, that's abnormal. So I could see how paying attention to those recovery rates kind of afterwards is also important.

Dr. Mike T Nelson Ph.D.: 21:17

Yeah, they get kind of stuck in that sympathetic loop, yeah? So they can't, they can't access the parasympathetic side of the equation, so they can't get their heart rate to come down again. It's not, in this case, it's not necessarily a conditioning thing. It's how their nervous system is operating. But that's good to know, right? So if it's like, Hey, man, it's like two minutes later, your heart rate only recovered by 15 beats per minute. Okay, yeah, so on the parasympathetic side, you're having a hard time turning that system back on. So now we may modify the exercise prescription. We may do things that are more parasympathetic in general now to try to train that system more, because if we look at people not post concussive, we do know that heart rate recovery is a very good marker for parasympathetic reactivation. We know that the more trained they are, the higher their baseline level of parasympathetic tone is, the more. Or they can use that to recover faster after exercise. So it makes sense that in this population, maybe we can do, you know, some breath work, or, you know, certain types of vagal stim or whatever. There's lots of other things we can do to try to increase that parasympathetic tone. You combine that with, if their heart rate variability measurements normally a baseline or just dog crap. They're very, very sympathetic, cool. That gives us some data now of a direction that we we kind of want to go.

Dr. Ayla Wolf: 22:43

And do you have a certain favorite device that you recommend to people who want to keep track of their heart rate variability? I

Dr. Mike T Nelson Ph.D.: 22:51

mean, the device I've used for the longest time is a system called ayfleet. So instead of athlete, it's iThlete. It works really well. I've known the CEO there for quite a while. It's debatable how long it'll be supported, since he has another job and stuff right now. Jason Moore, who runs Elite HRV, is pretty good. HRV for training, is good, which is Marco Altini. The thing I don't like about those systems as much, and I've, I've told them this, I'm not saying anything bad by not telling them, is, if you're really into HRV, it's useful. If you're not, it gets to be a little bit confusing, because there are different ways of measuring heart rate variability. What I like about the eye fleet app is it's just one minute, one way time domain takes 60 seconds, and you can have the slider switches on the bottom that tell you context. So they'll say rate your nutrition, rate your recovery, rate your pain, you know, whatever. And so when I get the data, I can see resting heart rate, I can see HRV, and I can see context indicators of what they reported. And there's nothing else on the app. There's no way to do any other measurements, or look at any other data. And the other is, other apps are good, but there's almost too much data in there, and you just get all these crazy questions, because people are like, Oh, but my, my, you know, my, you know, frequency method was this, and it said this, and my total power was this, and it's like, oh, it's even, if you it's just, it's just too much, and some of it's conflicting, to be honest. You know, some of it goes one way, some it goes the other way. And I didn't, so far today, I haven't found anything where that's value added. There are other devices, like, I have a Garmin watch Apple does HRV. I have an aura ring aura does that. I'm testing like, two other devices right now too.

Dr. Ayla Wolf: 24:34

Yeah, I got the Morpheus.

Dr. Mike T Nelson Ph.D.: 24:36

Morpheus is great tell Joel. I said, Hi, I love Joel.

Dr. Ayla Wolf: 24:41

I used to have the iThlete, and then I lost it. So the the iThlete is, like the little blue, like finger sensor thing, right? That you plug into your phone, yeah, it used to be a finger sensor, like 2016 when I had mine.

Dr. Mike T Nelson Ph.D.: 24:55

but yeah, you can just run it off a Bluetooth heart rate strap. Okay. One caveat I will say is that the hard part about HRV is everyone and their brother is sticking HRV into everything now. And if you don't know how the measurement is done, when the measurement is done, and what are the limits of the measurement, it gets to be kind of hard. So for example, Aura has published data showing that their HRV algorithm is actually really good, like they sample the right amount. I've looked through the whole technical paper. I've talked to the former CEO, all that kind of stuff. The downside is it's collecting it over the course of the night. So it's collecting it during sleep. So if your sleep time is a little bit different, or conditions of sleep vary, it can affect your HRV a little bit, and then, if not so much in this population. But if you're listening to this, and you're a very trained person, especially on the aerobic side, if you have a very low resting heart rate, odds are you're going to have a higher HRV. You're going to be more on that parasympathetic side, and at night, you can have something called parasympathetic saturation, which just means that your heart rate variability is so high it doesn't move around a lot from the sympathetic stressors during the day, because you're laying down right. So the cardiac system doesn't even work much against gravity. So the emails I get from these people all the time are, yeah, you said aura was good. This thing's a piece of poo. It doesn't do anything. And I went out and I had three beers last night, my HRV didn't change at all. And I'm like, All right, what is your resting heart rate? Oh, it's 37 I'm like, okay, yeah, you probably don't need to use aura for that. So I do still like command and measurement. First thing in the morning, most people in a seated position, it is going to be much more sensitive to stressors that occurred the previous day. You know, aura, Garmin, you know Apple. Apple still won't disclose what the hell they're doing with HRV. It seems like it changes every day, but Garmin and Oura have been pretty stable, like they'll get you in the ballpark for sure. Ballpark for sure. And I think they are useful, but I still like a once in the morning command and measurement, if you're really trying to kind of more tightly dial things in,

Dr. Ayla Wolf: 27:07

sure. And then, you know, with Morpheus, for example, you you know your apps gives you a heart rate variability nine. Number anywhere between zero to 100 and so can you talk a little bit about, like, what that number means? And, like, what is a good, you know, what's a range that is okay? Like, when do you start to get worried?

Dr. Mike T Nelson Ph.D.: 27:27

Yeah, that's the other hard part. Is, everyone has their own way of doing HRV. So not only do you have the time of when it's collected, the method of when it's collected? Was it overnight, or was it commanded? Measurement. Now, even most of them are doing what's called a time domain measurement, which do not spend time talking about within the time domain measurement, there are a couple ways you could do it a little bit different, granted, they are relatively similar. And then, like, iflate Does this also, they're like, Well, you know, if I tell someone, Hey, your heart rate variability last line, just 23 milliseconds or whatever. What the hell does that mean? I don't know. It doesn't doesn't mean anything to me. And so Joel did the same thing when they did bio force. He got it to match the omega wave system more. So it's basically a one to 100 scale. So they take the HRV in the back and they have a transmutation equation that changes it to one to 100 so 100 is like highly, highly parasympathetic. A one, you're probably dead. Like, the lowest HRV score I've ever seen on athlete was Simon. 71 was 33 and this is at rest. And I'm like, holy crap. I said, what happened? He's like, he's currently in the hospital with bird flu in the ER, in the UK. So I'm like, oh, okay, yeah, he's not doing well. Okay. So you have to know each system and know kind of what is a air quotes, good range or not so good range. And that's what also makes it harder. It's like for me on the athlete scale, like, yeah, you know, if you're in the 70s, you're pretty good. 80s are probably really good. You know, 60s, yeah, it might be passable. 50s, you definitely need work. 40s. Like, something's really bad going on. If you look at aura, you know, my bias is, most people should probably be in at least the 40s. You know, 50s would be a little bit better. You know, Garmin is pretty similar, and that's the hard part. Is it's you have your number where you should be related to the population, but then you really want to look for from your baseline, are you going up or down? So I'm much more interested in the change from your individual baseline. That'll tell us kind of more the day to day stuff where your number is will kind of give us an idea of, you know, health parameters and things like that. Like, I've seen some pretty scary low numbers on aura where I'm like, okay, yeah, you're I saw one two weeks ago that was in the single digits. I'm like, you're scaring the crap out of me, like there's something going on. He talks to the clients. Oh, he sleeps four hours a night, and he travels east coast, west coast. And I'm like, okay, yeah, he definitely needs to work on that.

Dr. Ayla Wolf: 30:08

Definitely in full, full on sympathetic mode.

Dr. Mike T Nelson Ph.D.: 30:10

Oh, yeah, yeah,

Dr. Ayla Wolf: 30:13

yeah. Okay. Well, that's really helpful, I think, to know and for people to hear that like device to device, there are differences in what these kind of numbers and algorithms might mean. And I think with ayflate, don't they kind of code it as, like, red, yellow, green. Like, when you're in the green, you're good. Don't worry about it. So there's also a bit of a color coding system that just makes it a little bit more easy to just say, All right, I don't have to worry

Dr. Mike T Nelson Ph.D.: 30:37

about this, yeah. And most of those are doing that, comparing your number now compared to an average. And I think one is that is pretty accurate. Like, green's always been pretty good, you know, Amber, yeah, caution, like, you know, you might do your same training, you might change something, and then red on that system is definitely red. Like, rarely have I seen red on that system be, be an error. Aura does some stuff a little bit different, because it's looking at multiple different things that go into the total readiness score and that type of thing. I don't use that score, to be perfectly honest. Clients like it. They're like, Oh, look at this. But you have to know what goes into that score. That score, and certain things are weighted more heavily than other things. So for example, on aura, if you fall asleep watching TV, it may say you weren't asleep, but it may give you, like an hour and 10 minutes latency. And that may not be a true latency, because you didn't technically go to bed at that point yet. But the heavily weight latency in the algorithm. So just by you can edit that and change that, you'll see your score, you know, go up quite a bit. So I like looking at just the raw numbers. What's your respiratory rate, resting heart rate, HRV, body temp on there is super, super useful. And once you know how to interpret those and just kind of generally what they mean, just look at those, and you're probably

Dr. Ayla Wolf: 31:56

Yeah, got it. And then I know that you often work with people who have already seen maybe a number of different physical therapists, and so then they come to you. They're referred to you for exercise intolerance after a concussion. And so now you have to kind. To troubleshoot with these more complex cases, like, okay, they've kind of done, you know, some of the sun, like, the kind of standard protocols that might be done in physical therapy. So how are you approaching like, those more complex cases differently? When you've got somebody who doesn't necessarily, they're not able to tone their their nervous system so quickly or with these kind of standard return to exercise protocols?

Dr. Mike T Nelson Ph.D.: 32:39

Yeah. I mean, my my biggest pet peeve, and I understand why we have protocols. It's not that all protocols are bad. It's that, you know, hey, we did the treadmill test and we found another symptomatic at this rate, and then they have a protocol that says, oh, you should be able to do 20 to 30 minutes at x heart rate. The person's like, No, I get symptomatic doing this. And it a lot of times. It's unfortunately, the healthcare provider enforcing a protocol that clearly is not working right. And yeah, not necessarily their fault, per se, but then, because of the negative associations, you're actually, you know, tending to make people worse, you tend to drive up their sympathetic tone. Sometimes, by the time I get people there, there's been more than one case where I've been like, Okay, Bob, your job today is you have a rower at home. Great. I want you to sit on the rower. Don't even put your feet in the straps. I don't even want you to row today. I just want you to sit there and do a long exhale and monitor your heart rate, and do that for two minutes and then let me know. And then, like, What the hell are you talking about? This is the stupidest thing I've ever done in my life. How is it gonna help me with exercise? I'm like, because everything we've tested so far makes you symptomatic. Like 30 seconds made this person incredibly symptomatic. So let's just get your nervous system acquainted with the machine, the environment, the thoughts of potentially doing exercise. Let's make sure that's stable first, and then we'll actually have you start to exercise. And I think I'm just a complete looney tune, but you have to again. You have to go sub threshold. You have to get under the threshold they're doing if they're becoming intolerant and massively symptomatic within 10, 20, 30 seconds, there's not really any lower you can go right, or I might change modality, or I'll tell them whatever device you were using before, if at all possible, like, don't use that again. I don't want any neurologic associations with that piece of equipment. I get it if it's only one you have, there's not much you can do. But if that was at your gym and you have access to one at home, use the one at home, change the music, change the environment, anything to make it to literally tell your nervous system this is something different. So we can kind of like, erase the little Etch A Sketch thing, and just kind of start over again. Most people won't go far enough down to start like, I've had people refer to like, I don't know what to do. Man, I they can't even do 20 minutes of exercise. I'm like, 20 minutes. Man, that might be, might be a shit ton for that person. Have you thought about maybe trying 18 or 10 or five, like, oh, but they're not gonna get any effect. Then I'm like, Well, true. I get it. Like, you can't have someone only exercise for 30 seconds a day the rest of their life and expect miraculous things to happen. But if they're becoming symptomatic and they're having issues, like you have to, you have to go and regress the thing to some degree somewhere. So that's just like my biggest pet peeve.

Dr. Ayla Wolf: 35:36

Yeah, so you're really paying attention to this mind body connection between seeing that people have been trying to exercise, they've and now they have these negative associations with, say, a treadmill, where now it's like they go to a treadmill, and it's almost like their exercise intolerance is getting worse due to this kind of psychological stressor and association of the treadmill essentially with failing or with feeling like they're not getting better. And so there's so you're kind of approaching this and saying, Okay, we're going to do something other than a treadmill, and we might just need to, like, sit on the rowing machine and just be comfortable with sitting there and not doing anything first before even attempting to start an exercise program.

Dr. Mike T Nelson Ph.D.: 36:22

Yeah, and if, if they're a former athlete, a lot of times it's even harder, because they keep comparing themselves to what they could do even, like two weeks ago. They're like, I don't get this like two weeks ago, I could do a 5k on the freaking road with the sub 20, and it was amazing. I'm like, I get it. Like, it's frustrating, but wherever you're at now is where you're at. So I literally tell them, like, get a new training notebook. Like, everything at this point is like, a new PR. Like, just don't compare yourself to where you were before. I'm not saying you can't get back there at all. I'm just saying that if, if you're always trying to compare yourself to where you were before, you're going to constantly just keep torching yourself every day, and you're going to go backwards, and you're going to be more frustrated, and it's going to be harder. It's like digging a hole, like, the first step of, you know, hey, I'm stuck in this hole. It's like, we'll just stop digging, right? You know? Just, trust me, just do this first. I know it's frustrating. I know it sucks, but you know, you've kind of clearly shown that the other approach isn't working, because all your symptomology and everything is getting worse so and and I get it, it's a hard thing to realize, and it doesn't, it doesn't make sense, because they understand that they haven't lost capacity. You know, they know they're not that detrained, but it feels like they're incredibly detrained and they can't do the output. So I get that it's incredibly frustrating for them.

Dr. Ayla Wolf: 37:49

And do you find a benefit to emphasizing isometric contractions versus other types of therapy. So in some cases, you know, all have people, you know, practice more isometric holds or simple things like a wall sit instead of trying to go for a walk or go on a treadmill.

Dr. Mike T Nelson Ph.D.: 38:11

Yeah, 100% like, if they're if they're really bad and really intolerant. The next question I'm asking myself is, is it escalating heart rate? Is it some sort of, you know, neurovascular coupling? Is it moving blood flow around the body, or is it just simply, their physiology freaking hates that position, right? And so I'll literally, if I, if I can, you know, test them here. You know, as simple as it is, Hey, Bob, let's get on the treadmill. Okay, let's put your hands up on the rower, cool, and I'll just muscle test them if everything goes to complete crap. Ooh. Okay, so now we know we've got an issue that this position for whatever reason your nervous system absolutely hates we haven't even done exercise yet, right? So my next thought is, okay, how can I get them? How can I get their nervous system okay with that position? So I do some RPR, reflexive performance reset. It might be isometrics. It might be just proprioceptive drills, you know, cerebellum drills, anything I can get so that when I retest them, their brain goes, Oh, okay, this is an okay position. Now we're okay. So that would be like step one in a perfect world. A lot of times to get that, I find isometrics are super beneficial. You can set up an almost any type of isometric. I have a new device here. It's a vulture, one from beyond power. It's basically a box with a drive in it, and it has a little cable on it, and you can set it up to 200 pounds of resistance, and you can set concentric and eccentric changes. So I could say, Okay, let's just, let's have you sit down on the floor, and let's just have you practice just the rowing motion. But I'm going to give you some resistance now for it using the machine, so they would sit down, they would be in that position. And if that goes, Well, okay, cool. I'm actually then going to play with a faster, concentric and higher eccentric load, so maybe make the pulling towards them really easy. And then I'm going to add 10 pounds of load pointed back to the machine. It just seems like the eccentric component when you overload it. I don't know if there's more proprioception or what changes, but after they're able to do a isometric I find that that's like, super beneficial. And usually, if you just watch their form, like their form will will clean up quite a bit. Normally, you retest them. Normally, it's a little bit better. The cool part about the device is that I have an output on peak watts, so I can see how fast they pulled and I can see the load that they resisted against. So you can get fancy and use, you know, some type of equipment like that. You don't necessarily need it. You could do any other types of exercise and things like that. So I'm trying to find a similar position and do some movement in that position, and then hopefully that position will be better. Okay. Now, Bob can get on the rower, great. His nervous system doesn't hate me just sitting on the rower. Cool. He can do movement. He can pull the rower towards him. Nervous System likes that. Okay. Now we can start to play with a little bit more of an elevated heart rate on top of that.

Dr. Ayla Wolf: 41:14

And do you ever play around with using weights like either ankle weights, arm weights, weighted vests? I know sometimes weighting somebody down actually has a therapeutic effect on their nervous system, just like the a weighted blanket. And so by changing people's relationship to gravity and kind of what how their limbs feel, can also make a big change in their their physiology. So do you play around with that as well?

Dr. Mike T Nelson Ph.D.: 41:40

Yep. So you can do like weighted, vast, weighted implements you can do. I stole this from Dr Jeremy Schmoe too, but I can't remember who camera, who came up with the device system where you have a little laser and you have to hit certain targets and stuff. And stuff. I'll think of this system, but basically, just take a cheapo laser, you can even add weight to their hand, and then just have a figure eight on the sidewall. Okay, I want you to trace your hand with this figure eight. But when you're doing that, you have a laser that's following the figure eight, so they have a. External cueing to determine where they were. Okay, so now I want you to stay within this lane. Just move your arm up and down. You'll see it, you know, kind of all over the place, but it's crazy how fast they learn because they have visual feedback as to where their limb is. So now they're coordinating the visual feedback to the proprioceptive where I find that that was actually much faster than just having them only do it proprioceptively. So if there's anything I can incorporate like that that tends to be helpful, especially with head movements and stuff. I have an iron neck device that looks like this weird Halo you put on, and it just provides just enough resistance so now they have a little bit of resistance to play against, and that sometimes will clean up different movements and stick a little laser on the top of there, and you can, like, okay, rotate your head to the right. It's like, oh, oh, wow. That wasn't really rotating, was it like? Because they can see, there's something about them seeing their own movement and getting feedback that they can auto correct a lot faster. Or I'll just do a lot of video, you know, okay, I'm gonna video you doing this. Okay, cool. All right. How clean Do you think your head rotations were? I think they were pretty good, okay. Like, all right. Do you want to see the video? Sure, their heads, like, you know, doing this number. Like, oh shit. That was bad. I didn't realize I was doing that, right? So anything just to to get them to be more aware themselves, just to kind of clean up some of those patterns. Other thing you can do too is, I have a K box also, so flywheel. So anything with that eccentric load, doing a squatting pattern. More of the vulture. One same thing, a little higher eccentric. Have them hold on to something. Again, you're just, you're playing with hyper gravity, right? So as they come up, they have to go faster up, and then they come up, it's going to try to crush them back down. So again, just having that more kind of hyper gravity effect, and again, it doesn't have to be a huge load at all. Like these loads generally tend to be pretty light. Just that difference appears to be pretty beneficial for a lot of people,

Dr. Ayla Wolf: 44:15

yeah. So there's a lot of kind of remapping of the body and how the body moves through space, and having different aspects of resistance in different planes can make a big difference in terms of how the nervous system is then responding to movement,

Dr. Mike T Nelson Ph.D.: 44:30

yep. And the big thing with that is, I'll, I'll test them after, like, everything, right? So I just do simple, kind of old school AK muscle test, but you could test range of motion, you could test eye movements, and then I actually teach them just how to do their own biofeedback. So I'll have them measure their own range of motion just to flex, forward, bend, stop, wherever you feel first resistance, cool, okay, because a lot of people I work with online. Okay, so when you go home, okay, now you know how to test your own exercises. We played with a bunch of stuff. Your stuff is probably going to work, but because your nervous system is not stable, I can absolutely guarantee that this drill we just did is not going to stay for three weeks. I can, I can tell you it's not going to so each time you do it, just do a range of motion test. Is it better or worse? If it's worse, great. Here's your top two modifications to change it. If all of those are still bad, just skip it that day. And if we see a pattern of you know, this exercise isn't really testing, well, ever again we're going to drop it and go in a different direction. So I'd like a lot of time teaching them how to test their own range of motion so that they can then start to problem solve on their own too.

Dr. Ayla Wolf: 45:38

Yeah, I think that's great when people know that they can check in with themselves to say, Did I did I do something my body didn't like? Did I push myself too hard? Or am I okay? And can I actually maybe push that boundary a little bit more? I think one of the hardest things for people when it comes to exercise intolerance after a concussion, is the fact that the line in the sand moves every day, and sometimes it moves around every hour. And so a lot of people feel very frustrated, where maybe I could do something for a certain number of minutes on Tuesday, and also on Wednesday, I can't. And so how do you work with people or give them tools to kind of figure out that, like said, that constantly moving line in the sand that can make it so hard to know what to do when

Dr. Mike T Nelson Ph.D.: 46:24

the biggest thing that I do is review all their data to look for aggregate trends over time, and I'll tell them, like, I don't really give two hoots. Like, what you do on a daily basis. The only thing that I'm really monitoring you on is, did you show up and try something? Because I understand it gets very easy and demoralizing to be like, Oh man, Wednesday was amazing. Thursday sucked ass. Friday sucked too. Saturday is going to suck. It's like, well, maybe not. Saturday might be really good, right? You may have overdid it on that day. Who knows what's going on. So looking at the aggregate trends, Oh, all right, we'll use Bob again, right? Bob, when you started like five minutes of exercise on the road, a heart rate of 110, was a max you could do now on your best day. I'm not saying you can do this every day, yet you were able. Able to do 15 minutes right over the last two months. So that's a huge improvement, even though it won't feel like it when, when you're there and then so showing them that like their their output is actually physically better. And the second part I'll look for then is it's just like training. So in training, you have an absolute PR on my absolute best day? You know, snorted too much caffeine and did my pre workout and all this stuff. And, hey, I got this number. Cool. Does that mean you're going to hit that number every day? Now, oh, god no, you're not going to, but it's possible, like you showed your nervous system, that on if the stars and moons align, I was able to hit this number on this day. Cool. Now I also look at what is your floor? What is a lift or endurance performance? You could go out like half asleep, had three beers a night before, on four hours of sleep, and you know for sure you could absolutely do and you could probably go back and do it the next day, right? So now we have your peak. Now we have your floor. It's the same thing if you have exercise intolerance, right? Okay, your worst day is maybe it's only two minutes. Now, great, when you first started, you can do anything. Maybe your best day is 15 minutes, cool, right? So over time, I want that gap to kind of close down a little bit, and I want the floor to go up so that the minimum thing you can do is something you could execute every day. I'm more interested in the floor than I am the absolute peak. And so getting them to understand that, the only way you'll figure that out is you have to show up every day and at least try something. So here's our progression of where to try. Here's Okay. Does it movement test? Okay? Was it heart rate? Was it thing? And if you just keep showing up and and going in a direction you can like you're you're going to get better. And so the question I have them ask is, not, what am I able to do today, but what can I do today? Right? And at what cost, like you for psychological reasons, you may feel like you need to do an absolute kind of quote max test, knowing you're going to pay for it for two days. I'm actually fine with patients doing that, if that's their decision, and they're okay with that decision, and that's what they needed to feel like an athlete, again, cool. Am I going to have them do that every week? Oh, hell no, right. But sometimes, just purely on the psychological side, they want to see that peak, because that's what they're equating their performance to, as long as they're not going to injure themselves, cool, as long I'm probably going to make them brutally aware of the cost that they paid to do for it, you know, in terms of awareness. But again, I think they have to decide. And so the biggest thing is just the this is like training, just like the violent consistency of trying something every day. And I'm more interested in, did you show up to try something, even if you walked out of the gym that day, other people call, like, hey man, like I did the three progressions you said, and I literally had to walk out of the gym because nothing tested. Well, nothing was good. Great. That's awesome. Like, what do you mean? That's awesome. This sucked. I hate this. Anything you probably would have done that day probably would have set you backwards for who knows how long. So that was the best you could do on that day. If this pattern happens, we'll look at it and we'll change something. But you know, you still give yourself the win and the pat on the back for for doing the thing. Because I've, you know, honestly, I've lost multiple clients because they get so frustrated. They're like, you know, it's been like, you know, four weeks, and I can only do five minutes on the rower. Now, I've used to do 20 minutes. And, yeah, when you started, you did nothing, right? You can do anything right. So five minutes doesn't feel like it's progression, but you're actually still going forward, and it's, I don't know what you've seen, but what I've seen is it's a super non linear like the variability is very high. Some days are amazing, some days are absolutely freaking horrible. But over time, the variability should get less. Your floor should go up and your peak performance should go up, and the difference between your floor and your peak should get less so on a day by day basis, you're becoming air quotes a lot more functional. But the hardest part is when you have a bad day, it feels like all your days are bad days, right? It's hard to remember all the progress you've made when you're like, Man, I just drove 20 minutes the gym, I did all this stuff, and I just, I have to walk out now, right? So a lot of it is just getting them over, you know, some of those peaks and valleys just to keep going. Because the beautiful thing about physiology, both from physiology and neurology, is that it's everything is more plastic than what I think we realize. Like, the one thing I've learned over the years is that it's hard to understand how freaky freak athletes are until you've been around them and it's on the other end, it's always amazing how much plasticity there is in the human organism, given the right stimulus, like how much you can change concussions, you can change outputs of people who you know sometimes can't even freak. Can stand up right and, you know, riding their bikes across Nebraska and shit later, you know. So it's amazing to me just how much plasticity and how much the organism can change given the right amount of of inputs.

Dr. Ayla Wolf: 52:30

Thanks for listening in to part one of my interview with Dr Mike T Nelson. You can find out more about Dr Nelson at Mike T nelson.com and you can also check out his podcast, which is called the flex diet podcast, in part two of our conversation, Dr Mike shares his perspectives on things like ketones, creatine, cold plunging, all in the context of concussions and brain injury recovery. If there are topics you'd like us to cover on the show, please email us at life after impact@gmail.com or you can click the Text us button in the show notes, links, medical disclaimer. This video or podcast is for general informational purposes only, and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice diagnosis or treatment, and consumers of this information should seek the advice of a medical professional for any and all health related issues. A link to our full medical disclaimer is available in the notes you