The Path Back To Work After a Concussion with Nate Pope (Part 1) | E46

Your brain isn’t broken; it’s rerouting. We sit down with neuro‑occupational therapist Nate Pope to unpack why so many people with post‑concussion syndrome get stuck despite doing “all the right therapies.” Nate explains how functional MRI reveals a network problem—under-fueled pathways and overworked compensations—and why isolated sessions can accidentally train the detours instead of restoring efficient routes. If headaches spike during vision drills or screen time wipes you out, this conversation will reframe what effective rehab looks like.

We walk through a practical model of whole‑brain, multi‑sensory integration that engages visual, vestibular, proprioceptive, auditory, and executive systems at once. Picture standing balance work while tracking targets and answering questions—tasks that block unhealthy shortcuts and demand true coordination. Nate  shows how intensity and variety drive neuroplastic change that holds up outside the clinic. You’ll hear why once‑a‑week tune‑ups fall short and how a two‑week intensive plus eight weeks of aftercare creates momentum.

The toughest bridge is getting back to work. We outline a smarter ramp that prevents relapse: simulate job tasks in therapy, expand screen time and cognitive load only when symptoms stay stable, and follow the golden rule that slow is fast. For many, the difference comes down to advocacy—clear communication with employers about reduced hours, planned breaks, moderated visual demand, and why that approach gets employees back to full capacity sooner. If you’ve felt unseen because your symptoms are invisible, this episode offers language, tools, and a roadmap for real progress.

If this helped, follow the show, share it with someone navigating concussion recovery, and leave a review so others can find these strategies. Got topics you want us to tackle next? Email lifeafterimpact at gmail.com.

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Chapters

• 1:15 Why Isolated Therapies Fall Short
• 2:51 Welcome And Mission Of The Show
• 3:52 Meet Neuro‑OT Nate Pope
• 4:53 From FMRI Insights To New Rehab Models
• 7:41 Networks, Not Spots: Mapping Disruption
• 9:46 The Brain’s Detour And Remapping
• 11:32 What Occupational Therapy Really Does
• 14:42 Whole‑Brain, Multi‑Sensory Integration
• 15:32 Day One Assessment And Testing
• 19:04 Why Intensity And Integration Matter
• 22:34 Building Activities That Block Compensation
• 23:14 Returning To Work Without Relapse
• 25:31 Aftercare, Pacing, And “Slow Is Fast”
• 27:24 Simulating Job Demands In Therapy
• 28:36 Advocating With Employers
• 30:37 Invisible Symptoms And Workplace Barriers

Transcript

SPEAKER_01: 0:38

When you go into isolated therapies, many of the patients who have come to us have they say, Well, we've been doing vision therapy, we've been doing physical therapy, we've been, and they list all the therapies. I've been going to counseling because I have some emotional stuff too. Um, and I'm taking sleeping pills and headache pills and ADHD pills. I never had ADHD before, but now they say I do. And so they come in with a lot. And and what really is happening is when your brain is compensating. If you go to an isolated therapy, if I go to vision therapy, because one of my bigger symptoms is vision, I'm sitting in a chair and I'm not moving my body and I'm not engaged in conversation or any cognitive challenges per se. I'm mostly just focused on vision. And so they may be doing the exact right things for the vision piece, but the brain has figured out a way to compensate already for that area. So when you're doing an hour of vision therapy, you're working the compensation harder. So the brain generally learns how to uh deal with the fact that certain areas are disengaged and it's overworking other areas. Those are the areas that will engage. That's the habit right now. The brain's habit is to compensate for these other areas that are not designed to do those tests. So those areas will engage at a higher level. It's like revving an overheating engine in a car. Um, and so symptoms usually go up and don't get a lot better.

Dr. Ayla Wolf: 2:14

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. Nate Pope, welcome to Life After Impact, the Concussion Recovery Podcast.

SPEAKER_01: 3:21

Thanks for having me.

Dr. Ayla Wolf: 3:22

Yes, you are a neurooccupational therapist, and in your clinic, you run uh two-week comprehensive rehab programs for people with post-concussion syndrome. Isn't that right?

SPEAKER_01: 3:35

Yes, that's correct.

Dr. Ayla Wolf: 3:36

I would love to talk to you about kind of what that two-week program looks like. And then also one of the things I really wanted to dive into today was this idea of after people have a brain injury, a lot of them have to go back to work. And that whole process of what that looks like is so individualized. And then what I see is a lot of people are forced to go back to work and go back to work full time. And that really seems to delay their recovery, especially when they have to stare at computer screens eight hours a day. So let me first give you the room to kind of explain your background, what brought you to what you do now, and then we can talk about this whole concept of um, you know, recovering from brain injury and still having to do your job.

SPEAKER_01: 4:23

Sure, sure. Well, um initially it all began, I guess, with with me just wanting to. I I love helping people and seeing people recover. Um and uh when I realized that brain injury was an area that was often treated just like the rest of the body. Um and uh but it was really inadequate and and people weren't recovering and and a lot of times they were jumping, in my opinion, uh very prematurely into hey, let's just deal with this, uh, figure out how to deal with this. And kind of those compensatory live with it approaches was prevalent with so much brain injury. And so um I was fortunate enough about uh 12 and a half years ago, I guess it was, to get involved with one of the lead uh research clinics for post-concussion syndrome or minor uh TBI, and they were using functional MRI results to that data was helping them to drive a new way of treating the brain. And basically they were seeing areas that were disengaged, getting less blood flow to certain neuropathways that should have been more active. Um and they could see because you're a functional MRI essentially is like a video of the brain instead of a snapshot. And so you're kind of following the blood trail and seeing what's happening, and you're doing that while you're performing uh cognitive tests. So they had figured out what normal should look like. And when they realized that those who had suffered brain injury or a concussion that hadn't resolved, which is post-concussion syndrome, that their brain patterns and where the blood was going was very different than someone who had not been injured, had not been concussed. And so they also were figuring out that the traditional approaches of an hour a week or a little bit here and there was falling far short. It was mostly strengthening the areas of the brain that were trying to uh compensate for the areas that had disengaged. And so with the functional MRI, they realized that certain neuropathways and areas were getting less blood. It's called neurovascular coupling, but there was just a less of a blood supply going to those areas than there ought to have been. And at the same time, they were seeing an increase of blood going to other areas that normally would not be engaged in those tasks. With a with a head injury or a concussion, you have the stretching of the dendrites. It's kind of a, you know, certain parts of the brain are more dense than other parts. So when you have this acceleration deceleration, you know, your brain's going so fast and then it stops, or vice versa. Um, it was creating like an electrical storm that would affect uh many areas of the brain and not just the the prefrontal cortex, although a lot of what disengaged was in those areas. So yeah, there were it was heavier in those areas, but there was a lot of other areas, areas responsible for um, you know, the autonomic nervous system, um, areas responsible for like superior colliculus for a lot of uh visual motor uh functions. And so a lot of areas that weren't necessarily suspected because we we kind of thought, well, we get hit here, this is where things get affected. But we were seeing symptoms all uh related to neuropathways that were crossing multiple areas. I guess it's just it's not as simple as it's this area versus this area. It seems to be a neural uh network that gets disrupted. Um, so you have many neural pathways that cross multiple areas of the brain that get disrupted, and the brain has to remap and figure out okay, what areas are we going to engage now to compensate?

Dr. Ayla Wolf: 8:35

Yeah, yeah. I mean, I've seen some of these schematics of you know, the dorso-lateral, prefrontal cortex and all the different areas of the brain that it's connected to, and uh it's huge. And so, yeah, when you take that part of the brain kind of offline, and then the rest of the rest of the brain is trying to figure out how do I how do I do life when this key area, this key hub is not necessarily talking to all of the areas it's supposed to.

SPEAKER_01: 9:02

Yes, yeah, yeah, essentially I I explain it often to patients, um, and maybe your listeners would appreciate, but it's it's like if you um came to you're driving on a road and you came to a a roadblock, um road closed, and there's a detour sign and you have to take a detour. And um the the crazy thing is is there's no damage behind that roadblock sign. No, no permanent damage. Um, with most concussions and minor TBIs, there's usually no permanent damage going on, but the brain has had to figure out how to remap um the pathways, and that takes more time and more energy for the brain. So you have all of this uh symptoms associated with taking these detours with everything that you do, and it's the reconnecting of those pathways or re-establishing. We don't always know if we're reconnecting the exact same neuropathways or if we're just re-establishing another effective neuropathway. But when the symptoms get better and things start working better, we know we're doing the right thing.

Dr. Ayla Wolf: 10:48

So and could you maybe just give a brief explanation of um how occupational therapy is different from physical therapy? Because I know most people are familiar with seeing PTs for all kinds of different ailments, and you've got, you know, neuro PTs and vestibular focus PTs. And so now um it sounds like within the world of occupational therapy, there's also different disciplines and areas of focus where yours is neurological. Um, but maybe give people a bit more background on what your role is and and what occupational therapy is really focused on.

SPEAKER_01: 11:25

Sure. Um so occupational therapy is kind of the in Western medicine, we're more of the I hate using the word holistic because it kind of brings up all sorts of um ideas, but it is essentially taking a step back and looking at the physical uh limitations, the mental limitations, emotional limitations, environmental factors. It's looking at everything that goes into someone's ability to do or or now maybe their inability to do the things that they care about and want or need to be able to do. And so it's a lot of creative problem solving because you're kind of putting the pieces of maybe multiple therapies together or multiple areas of of life functioning together. Because often when we have something go wrong, it's not just one area. In fact, it's usually several things that get affected. So I think in Western medicine, especially, we needed uh a therapy that could look at all of everything and how it needed to fit together. Whereas everyone else is quite specialized, like getting more into the details of that one particular area. Occupational therapy does kind of the opposite and is saying, no, we need to look at everything and how everything is affecting everything else. Um, and then neurological occupational therapy is another step into more how did the brain is involved with that. As we know, the brain really is involved in all of that stuff, you know, our physical uh ability to, you know, balance and move and motor planning stuff, but also our emotional regulation from you know being able to process and um and you know, people who have depression and anxiety and apathy, or uh we have a lot of patients that um have uh that are very um irritable, their irritability levels go through the roof. And uh so there's a big emotional regulation side of things, um, there's a social aspect uh and the communication side of things. So it kind of delves into physical therapy and speech, and then we do a ton of visual motor and vision therapy stuff, which occupational therapists are are one of those uh as well as PT, you know, that can do um some of the visual motor stuff in addition to the physical stuff. So um from my perspective as an occupational therapist, it's a a very um useful therapy if you're trying to look at the whole brain and how to engage many areas of the brain simultaneously so that they're forced to integrate. Um, and I can talk about more of that. That's a lot of what we do in our clinic is is engaging what I call whole brain activities or multi-sensory integration activities where multiple major areas of the brain are needing to do their job, but do it at the same time, which forces them to integrate and and it's harder for the brain to cheat and compensate in unhealthy ways when you're making when you're challenging the whole brain at the same time.

Dr. Ayla Wolf: 14:48

So do you want to walk us through how extensive your initial examination day is, like when a new patient is coming in for one of these intensives, what does day one look like in terms of assessment?

SPEAKER_01: 15:03

Sure. For for post-concussion syndrome, it's the biggest factor that helps you know that it's probably um post-concussion syndrome is just the chronology of I didn't have any symptoms, I hit my head, and now I have all these symptoms. And they didn't go away. And so, I mean it's it sounds oversimplified, but really that is the the biggest uh indicator that something is connected there. You know, you've hit your head. And a lot of them have had MRIs which have shown zero, almost always they come back and say um the there's nothing remarkable here, there's no no issues. And so you know if symptoms exist and have continued and are lingering despite the fact that you have a clean MRI, that you have more of a neuroconnection disruption that's going on, and you are likely in post-concussion syndrome. So when someone comes into us, we're usually saying, okay, uh, we suspect that this might be the case. Let's go into some specific post-concussion syndrome symptoms. We have about a 40-point uh symptoms checklist, and we go through all of those from brain fog and headaches and blurry vision and balance and emotional regulation stuff, depression, anxiety, et cetera, sleep pattern disruption, lightheadedness, dizziness, um, light sensitivity, noise sensitivity. It's a quite a pretty exhaustive long list, but they're typical symptoms that you might see if you had post-concussion syndrome. And then we um have them rate each one of those on a zero to six scale of severity to say, hey, okay, this one is this one's a pretty bad one, it's a five or a six, and and we go through so we get a list of all the symptoms that they're experiencing that have not yet been resolved, and it's usually post one month from their concussion. They're out of that acute stage, you know, um where they we're often it just resets. And then we also get a number with all of those symptoms to know how severe things are. Um after that, we'll do the buffalo treadmill test to see how exertion um affects their uh exacerbates their symptoms. And then we we do the VOMs for the um the visual motor to look at how visual motor is going, and then we have a couple balance tests that we do. We also use the Brock string for visual motor stuff to see how their convergence and divergence and all of that stuff is. So we we kind of look a little bit of uh the visual motor stuff, the balance stuff, and then especially look at the symptoms. That's kind of what someone does when they come in to our clinic to get an initial evaluation. We're already suspecting usually if they've hit their head and it's been post-one month and they have all these symptoms that haven't gone gone away. Almost all of them end up falling into that post-concussion syndrome category.

Dr. Ayla Wolf: 18:14

And then you mentioned this multi-sensory aspect to rehab. So talk a little bit about what that looks like or maybe some examples of what that looks like.

SPEAKER_01: 18:24

Sure. I guess two of the aspects that I feel makes rehab for post-concussion syndrome and minor TBI effective is doing enough of it, the intensity, and I can talk more about that later, but then doing the right things. And when you go into isolated therapies, many of the patients who have come to us have they say, Well, we've been doing vision therapy, we've been doing physical therapy, we've been, and they list all the therapies. I've been going to counseling because I have some emotional stuff too, um, and I'm taking sleeping pills and headache pills and ADHD pills. I never had ADHD before, but now they say I do. And so they come in with a lot. And and what really is happening is when your brain is compensating, if you go to an isolated therapy, if I go to vision therapy, because one of my bigger symptoms is vision, I'm sitting in a chair and I'm not moving my body and I'm not engaged in conversation or any cognitive challenges per se. I'm mostly just focused on vision. And so they may be doing the exact right things for the the vision piece, but the brain has figured out a way to compensate already for that area. So when you're doing an hour of vision therapy, you're working the compensation harder. So the brain generally tr learns how to uh deal with the fact that certain areas are disengaged and it's overworking other areas. Those are the areas that will engage that's the habit right now. The brain's habit is to compensate for these other areas that are not designed to do those tests. So those areas will engage at a higher level. It's like revving an overheating engine in a car. Um and so symptoms usually go up and don't get a lot better because we're not engaging the area that's actually supposed to do that task. When we do what I call multi-sensory integration, we're engaging multiple areas of the brain. Vision would be one of those areas for that person, but we would make sure that they were like we may be standing on a bosom ball for balance challenge, right? And then we would be engaged in uh conversation. And we would be really heavy on the visual side, but they're gonna their brain is gonna have to process auditory, verbal, vestibular, and proprioceptive, like balance, body movement uh information at the same time that it's being challenged at a high level for the visual motor, convergence, divergence, tracking, etc. So when engaging all of those areas at the same time, it makes it really difficult for the brain to continue in that compensation pattern. So almost everything that we do when a patient comes into our clinic, they are Engaging multiple major areas of their brain simultaneously. But every activity is very different from another in how it does that. So they're rotating through many activities, all of them engaging uh more of a whole brain experience and trying to make it so that we really target those areas that are less engaged at the same time while including other areas. So they're not really able to compensate very easily. If that makes sense.

Dr. Ayla Wolf: 21:49

Absolutely. The thing I wanted to really highlight today was this concept of when people get a concussion and, like you said, their brains are compensating, then they're also often having to still go back to work. And so I've had people who have really had the opportunity to take a decent amount of time off of work to kind of focus on their rehab. And I've had other people with the exact opposite where maybe their doctors have approved they take two weeks a month, and then they go back for two hours a day, and then the next week four hours a day, and then the next week eight hours a day. And I've seen this like very, very feminist ramp up back to working full time. And I've seen how that can really affect people in terms of worsening their headaches, their brain fog, their cognitive fatigue, their neck pain, their nausea, their dizziness when they've got to sit at a desk for eight hours and bang away on a computer. So how are you equipping people to be able to go back to work? And are you often finding that your recommendation is that people really do need to take a significant time off work? How are you stepping in and managing that piece of it?

SPEAKER_01: 23:00

Sure. Well, it could never be an all or none. So you don't want to just take a whole bunch of time off and then jump right back in full time. That is like the worst plan. The brain has memory of working the right way and the wrong way, unfortunately. It'll remember um some of those bad habits and patterns, and we'll have relapse. We'll have almost full recoveries where someone's symptoms are just, you know, they have been years with having these symptoms. We go through our two-week of intensive therapy, which is seven hours a day for two weeks. It's really intensive program. Their symptoms have plummeted, they're almost zero now. And then they are like, but I have no choice. I have to jump back into work, and my work's not gonna let me, you know, ease back into it. And it's just one of the saddest things because they're feeling so good. Jump back into full-time work, and then we're getting a I know we're getting a call, you know. Hey, I don't know what's happened, but I've got all these symptoms coming back.

Dr. Ayla Wolf: 23:59

Yes, yes.

SPEAKER_01: 24:00

We have an eight-week aftercare uh program as part of our program, but that's where they are doing an hour to an hour and a half a day just to engage and and maintain what they've gained through our two weeks of intensive program. And part of the aftercare is trying to coach them into how to ease back into things and to not jump back into either work or school or sport. You there's this jump back into um mindset. And so we we try to help them see if you want to recover and fully recover, you're gonna get there quicker. If quick is your goal, you will get there quicker if you go slow. If you and it's in this in this case, uh slow is faster. And you have to think that way. Slow is fast, and fast is slow. If you want to slow your recovery down, then then jump back into everything. Um, because it almost inevitably will um be difficult for you to handle that transition. Now, in tr in helping them transition during our our aftercare, we try to do a symptoms exacerbation, really help them with their self-awareness of how am I doing, how much can I do that's a just right challenge? Because we know that doing nothing is is just as bad or worse than doing something or doing too much. So we have to find the just right balance. If you push too hard, the brain kind of has this shutdown effect, and that's where all these symptoms come back and they have relapse. But if if you don't push enough, if you don't push at all, and it's just like I'm gonna take a break, and I'm just sitting at home in a chair and I'm not doing that. Maybe I'll turn the lights off because it kind of still feels good to have dark. So I'm gonna go dark and quiet and not not move a whole lot. That's that's gonna be equally bad. So you want to be sure to ease back into work. I we try to start simulating elements of their work even during our two weeks of intensive. So anything that we if we know what kind of job they're doing or what sport they're gonna do, or or what they're studying in school if they're a student, um, we will try to find elements of that and simulate it for short periods of time during our intensive experience. And and then help them ease into that when for the aftercare. As soon as they're out, like, okay, here's how much you do. And then monitor, see how it goes. And that's where we're touching base on a weekly basis, you know, with them and saying, How did it go? Was it too much? Was it just right? And and often, you know, we're getting good reports when they're easing into things and we're getting um symptoms flaring up when they're not. So sure.

Dr. Ayla Wolf: 26:51

Yeah, yeah. And do you often have to take on the role of kind of being a patient advocate so that their employer and their other healthcare team understands that if they go too fast, it's gonna be uh not not go so well for them?

SPEAKER_01: 27:07

Yes, for sure. Yeah, and I I'm happy to talk to any employer or write letters saying as much and basically saying if your goal and their goal is the same, uh getting them back to work full-time, getting there will happen a lot more effectively and sooner, most likely, if you do it the right way. And that means helping them ease into it. When an employer figures that out, I mean it is selling them because the patient is it's easier to sell them on this. They're like, yeah, I I know it. It's my employer that's the problem. So, but when you can get the employer to realize I'm gonna get more out of this employee if I do it the right way. And I just have to do it the right way because if I don't, um I'm gonna lose them for another period of time, you know, probably.

Dr. Ayla Wolf: 27:56

So yeah, I think that's a huge missing gap in this whole big picture of concussion recovery, is that so many people maybe have employers that have never had a concussion, have no clue what that means or looks like, or just how different that can be from one person to the next. And because all of these symptoms are invisible and you can't just look at somebody and say, Oh, I can tell, you know, that you've had a brain injury. Um, I think for some people it this is a very difficult process. And I think sometimes they don't always recognize uh that they need those advocates or or how to kind of get those advocates to to help them navigate that.

SPEAKER_01: 28:37

Yeah, I agree. It's some uh some patients um, and I understand, don't want to divulge their personal what they're going through, you know. Yeah. Um and so that's a barrier a little bit sometimes. And I I do tell them, I I understand that if you can get to a point, and it does depend on how open your employer is, of course. But if you feel like you have an okay relationship with them, this might be one of those cases where you let them know more than you would normally be comfortable letting them know. Because uh, I've had so many awesome employers also be like, once they understood, they're like, wait, okay, you've got you've got headaches all the time, and you've or you've got all these symptoms that are and um and so they've they've really been helpful, some of them, and then some of the opposite, unfortunately.

Dr. Ayla Wolf: 29:31

Sure, sure.

SPEAKER_01: 29:32

Yeah.

Dr. Ayla Wolf: 29:34

Join us next time for part two of my conversation with Nate Pope. Thanks again for listening to Life After Impact, the Concussion Recovery Podcast. If you have any topics you'd like us to cover, please email us at lifeafterimpact at gmail.com. Medical disclaimer. This video or podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare 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.