The Autonomic Nervous System - What It Is and How We Can Train It

The nervous system is incredibly complex. Everything we do, think and feel involves the nervous system at multiple levels. In this blog, we are going to focus on one specific area - the autonomic nervous system: what it is, why it’s important and how we can train it.

What is the autonomic nervous system?

The autonomic nervous system (ANS) plays a pivotal role in regulating vital functions, doing so unconsciously. It serves as the body's autopilot system, controlling involuntary actions such as heart rate, digestion, respiratory rate, and glandular secretion.

It consists of two main branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS), which work together to maintain your body in homeostasis (in other words, to keep everything in balance, from body temperature and heart rate to the amount of oxygen and carbon dioxide in your blood).

1. Sympathetic Nervous System (SNS):

• Often referred to as the "fight or flight" system, the SNS mobilizes the body's resources during times of stress or danger.

• Functions include increasing heart rate, dilating airways, and redirecting blood flow to vital organs, preparing the body for action.

• In rehabilitation, an overactive SNS may contribute to conditions like high blood pressure, anxiety, and muscle tension, requiring interventions to promote relaxation and stress management techniques.

2. Parasympathetic Nervous System (PNS):

• Known as the "rest and digest" system, the PNS promotes relaxation, digestion, and energy conservation.

• Functions include slowing heart rate, constricting airways, and stimulating digestion, facilitating restorative processes.

• In rehabilitation, enhancing PNS activity can aid in promoting recovery, reducing stress, and improving sleep quality, through techniques such as deep breathing exercises, meditation, and progressive muscle relaxation.

(Note - for those of you with an in-depth knowledge of the nervous system, you understand that this is an incredibly simplistic way of talking about the ANS and misses a lot of things, like how poly-vagal theory challenges this framework and the concept of the freeze response. But hey, we all have to start somewhere, right?)

Like anything else in the human body, the ANS can become dysfunctional, leading to wide-ranging effects. Autonomic dysfunction, or dysautonomia, is well documented in spinal cord injuries, Parkinson’s disease, traumatic brain injury and long COVID. There is more and more research looking into stress-induced dysautonomia as a cause for heart disease. Dysautonomia has also been suggested as one of the mechanisms underlying chronic fatigue syndrome and complex regional pain syndrome.

When ANS dysfunction occurs, a multitude of symptoms may result including:

• Balance problems

• Nausea & vomiting

• Brain fog, forgetfulness or trouble focusing

• Fatigue

• Fast or slow heart rate

• Feeling like you cannot regulate your temperature

• Sweating more or less than usual

• Fainting or passing out

• Shortness of breath

• Dizziness or lightheadedness

• Heart palpitations

• Headaches

• Exercise intolerance

• Mood swings or anxiety

• Vision issues

What can I do to help my autonomic nervous system?

While we cannot consciously control much of the ANS, certain practices and interventions can influence its function. Here are some techniques for training the ANS:

1. Breathing Exercises:

• Deep breathing exercises, such as diaphragmatic breathing or box breathing, can stimulate the PNS, leading to a relaxation response.

• Techniques like coherent breathing, where inhalation and exhalation are paced evenly, can improve heart rate variability and promote ANS balance.

2. Mindfulness Meditation:

• Mindfulness practices involve non-judgmental awareness of the present moment, which can help regulate ANS activity by reducing stress and promoting relaxation.

• Regular mindfulness meditation has been shown to increase PNS activity, decrease SNS arousal, and enhance overall well-being.

• New to mindfulness practice? Try an app like Calm, Headspace or Insight Timer to get started!

3. Physical Activity and Exercise:

• Aerobic exercise and physical activity can have profound effects on ANS function, promoting cardiovascular health and improving autonomic balance.

• Moderate-intensity exercise, such as walking, swimming, or cycling, can enhance PNS activity while reducing sympathetic arousal.

4. Relaxation Techniques:

• Progressive muscle relaxation and guided imagery are relaxation techniques that can help reduce ANS activation and promote relaxation.

• These techniques involve systematically tensing and relaxing muscle groups, visualizing calming scenes, or inducing sensations of warmth and heaviness in the body.

5. Yoga and Tai Chi:

• Mind-body practices like yoga and tai chi combine physical postures, breathwork, and mindfulness, promoting ANS balance and stress reduction.

• These practices have been shown to increase heart rate variability, improve baroreflex sensitivity, and enhance overall resilience to stress.

If you’re looking to add some ANS training into your day, try one! These simple options can help improve sleep, reduce stress and help heal and recover from injury.

Looking for help with your autonomic nervous system, or anything else rehab-related? Book online with us - physiotherapy, massage therapy or kinesiology!

Don't Call It A Mild Concussion

Devon Konrad, MPT, is one of our physiotherapists at Ladner Village Physiotherapy. She has a special interest in vestibular rehabilitation and concussion management. She also has some opinions, if you couldn’t tell. Read about what’s annoying her in the field of concussion rehabilitation below!

The concussion world moves fast. It wasn’t long ago the first line treatment for someone with a concussion was to sit in a quiet, dark room until symptoms had completely abated. Only then was the sufferer allowed to crawl out of their hiding hole and into the world, often to be bombarded with a complete assault on their senses: everything was BRIGHT, everything was LOUD, and it was all TOO MUCH.

While many advancements have been made in the world of concussion rehab, there are so many myths and old school ways of thinking that still persist. In the past few months, I have heard people say you need to lose consciousness to have a concussion (you don’t), helmets prevent concussions (they don’t) and if the CT or MRI is normal, it’s not a concussion (imaging can’t see a concussion. Yet.).

While these myths annoy me, most health care practitioners now understand they are, in fact, myths. However, I still see too many people that have been given out-of-date and just plain wrong information from health care practitioners.

There Is No Mild Concussion Anymore

Just yesterday, I ran into a very common one: the concept of a graded concussion, either mild, moderate or severe. We used to grade concussions based on a few factors: if someone lost consciousness and for how long; if they had any amnesia; and the presence of certain symptoms that supposedly indicated if the concussion was more or less severe.

In the last few years, this concept has been thrown out the window.

We no longer discuss the grade of the concussion. Instead, we discuss the domains affected by the concussion. The research world still hasn’t figured out exactly how to break this down and different models exist. In general, researchers (see links below) consider these 8 areas to be ones of importance in concussion rehabilitation:

• Ocular / visual - how your brain is taking in and processing visual information as well as how your eyes are moving. Problems with your visual system may result in blurry vision, difficulty reading or missing objects when you try to grab them.

• Vestibular - how your brain senses your body’s movement and its relation to gravity. Problems with your vestibular system tend to be dizziness, vertigo or imbalance.

• Cardiovascular / autonomic - your brain is implicitly involved in heart rate and blood pressure and how these respond to changes in posture and demand. Problems here may show as an elevated or blunted resting heart rate, inability to tolerate exercise or lightheadedness when standing up.

• Anxiety / mood - emotional lability, irritability and anxiety are very frequently seen after a concussion. Often these symptoms dissipate as brains heal but it’s common for people to see a psychotherapist trained in brain injuries to help treat this domain.

• Cognitive / fatigue - difficulty thinking, multi-tasking, remembering items and words, and navigating spaces are all common complaints after a concussion. This can be secondary to other domains (for instance, if you are having trouble with your vision, it’s going to be much more difficult to focus on reading a book and thinking about what you’re reading) but it may also be a problem all on its own.

• Headache / migraine - one of the most common symptoms after a concussion, this is typically caused by any of the other domains or it could be a domain of it’s own.

• Cervical - also known as the neck, people typically get some type of neck injury after a concussion. If necks aren’t treated properly, they can exacerbate the symptoms from all the other domains.

• Sleep - this can often be thrown for a loop after a concussion, either with too much sleep, too little, or both at the same time. Sleep hygiene is imperative for a healing brain and, just like the neck, impaired sleep can exacerabte all the other domains.

At this point in concussion rehabilitation, health care practitioners who claim to treat concussions should be very well versed in this concept. They should be doing multi-domain assessments and referring to appropriate health care practitioners because one practitioner cannot possibly treat all these domains. Concussion rehab is a multi-discilpinary field and all practitioners involved in concussion care should understand this implicitly.

Get Out Of The Dark Room

I heard this one a few weeks ago - someone came in with a concussion and one of their health care providers told them to stay in a quiet, dark room until their symptoms went away.

The research on this one is super clear. No one should be living in a dark room for days or weeks on end.

Rest is great for the first 24-48 hours, but that’s it. In this time, people with concussions are allowed to sleep as much as they want and be relatively subdued. Even in these first two days, however, they need to be exposed to some level of stimulation. It is often as simple as a walk around the block with sunglasses and a hat, and that’s ok! But staying full time in a dark room for days and days is simply not allowed anymore.

After those first 2 days, exercise needs to start. However, when I say exercise, I don’t mean go for a 10km run. Here are the parameters I use in returning to exercise after a concussion:

• Before exercising, take note of your symptom level out of 10.

• Aim for 20 minutes of movement. Breaks are fine, especially initially!

• During and after exercise, it is normal and safe for your symptoms to be slightly exacerbated. We want to keep those symptoms within 1-2 points of your baseline.

• Once you have finished exercising, your symptoms should return to their pre-exercise level within one hour.

If you find that your symptoms went higher or lasted longer than they should have, that’s ok! Use this as a guide for next time and try your best to stay within this range.

Typically, people start exercising with walking around their neighborhood. It’s a great way to keep control of symptoms as well as get some visual and auditory stimluation. As brains heal, people find they can gradually increase their pace, intensity or how long they’re exercising. As long as symptoms aren’t peaking too high and coming down within an hour, then it’s all good!

The Resources Are Piling Up

There are lots of up-to-date concussion resources out there for practitioners, parents and people who have suffered concussions. Here’s my curated and definitely not complete list:

For People With Concussions & Their Loved Ones:

VCH My Guide: Concussion - a wonderful, up-to-date resource that everyone with a concussion should visit.

VCH My Guide: Teen Concussion - the same as above, but focused on adolescents with concussions.

Concussion Online Training Tool - a wonderful tool for athletes, coaches, parents, teachers, medical professionals and anyone who may come into contact with someone who has had a concussion. This one is much more focused on recognizing an acute concussion and what to do immediately after it happens. I recommend everyone take this training.

For Health Care Practitioners Wanting To Get Deeper Into Concussions:

There are so many weekend courses focussed on concussion management as well as units on concussion as part of another specialty (for instance, the CCVR course through 360NeuroHealth has a large unit on concussion from a vestibular perpsective). If concussion rehab is where you want to be, check out these:

Consensus Statement on Concussion in Sport - published in 2023, this is our guiding document in how we currently treat concussions.

University of Calgary Online Concussion Course - run by the world renowned Kathryn Schneider, a free online course that takes a deep dive into concussion pathophysiology and introduces rehabilitation strategies.

Concussion Nerds - a massive course designed to go as deep as possible into concussion rehabilitation as we know it. Facilitated by the amazing physiotherapist Natasha Wilch.

Canadian Concussion Network - for those wanting to stay up to date with concussion research, I implore you to join the CCN. The leading brains in Canada run this organization!

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Looking for those research articles? Here they are!

Kontos AP, Sufrinko A, Sandel N, Emami K, Collins MW. Sport-related Concussion Clinical Profiles: Clinical Characteristics, Targeted Treatments, and Preliminary Evidence. Curr Sports Med Rep. 2019 Mar;18(3):82-92. doi: 10.1249/JSR.0000000000000573. PMID: 30855306.

Lumba-Brown A, Teramoto M, Bloom OJ, Brody D, Chesnutt J, Clugston JR, Collins M, Gioia G, Kontos A, Lal A, Sills A, Ghajar J. Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery. 2020 Jan 1;86(1):2-13. doi: 10.1093/neuros/nyz332. PMID: 31432081; PMCID: PMC6911735.

Craton N, Ali H, Lenoski S. COACH CV: The Seven Clinical Phenotypes of Concussion. Brain Sci. 2017 Sep 16;7(9):119. doi: 10.3390/brainsci7090119. PMID: 28926944; PMCID: PMC5615260.

How To Recognize A Concussion

Concussions have been getting a lot of media attention lately, and rightfully so. If you’re an ardent or casual consumer of American football, you likely heard about Tua Tagovailoa. The 24 year old quarterback of the Miami Dolphins seemed (to my eyes) to show symptoms of a concussion on Sunday, September 25th. He was cleared to play in the Thursday, September 29th game where he sustained a head injury, just four days later. Tagovailoa was carted off the field on a spine board and transported to hospital where it is reported he was diagnosed with a concussion. The NFL has since been under fire for its handling of Tagovailoa’s initial hit.

Repeated concussions within a short time frame are a big problem and can be fatal. Second Impact Syndrome occurs when someone suffers a second head injury before recovering from their first, leading to swelling of the brain. It is thankfully rare but it does happen.

Since this occurred, there’s been a lot of discussion around concussions. Can you tell from a video that Tagovailoa suffered a concussion? What signs are you looking for? Most importantly, what do we do about it?

Before We Start: Things To Know About Concussions

Parents, partners, friends and teammates need to be aware of the common signs and symptoms of a concussion. For people not in health care, the Concussion Recognition Tool is a handy document to have readily available. It lays out everything I review here: the basics of how to recognize a possible concussion and some basic tests anyone can do to help figure out if someone suffered a concussion.

These are hard and fast rules about concussions that everyone should know:

1. When in doubt, sit them out. Concussions are no joke. They are brain injuries, full stop. Most heal well but they need to be given the time and space to heal. If you think a concussion has occurred, stop and seek medical help.

2. You don’t have to hit your head to suffer a concussion. While most concussions occur through a blow to the head, a force to the body can produce enough jarring force to the head to cause a concussion. Do not blow off concussion symptoms simply because the head did not physically hit anything.

3. You do not need to be knocked out to suffer a concussion. In fact, most concussions do not result in a loss of consciousness.

4. We cannot see a concussion with imaging. While research is getting closer to finding something that can definitely diagnose a concussion, we aren’t there yet. X-rays, MRIs and CTs are not able to diagnose a concussion.

5. Baseline testing is not needed to diagnose a concussion. A concussion can be appropriately diagnosed by trained medical professionals without baseline testing.

6. Return to sport/work/play protocols are important to follow. Medical professionals involved in concussion care are well versed in these protocols.

7. Always have your primary medical practitioner involved in concussion care. This may be a doctor or nurse practitioner, but they need to be involved from the start.

How To Recognize A Potential Concussion

If you have just witnessed someone hit their head or take a large, jarring force to their body and you’re concerned they have sustained a concussion, watch for these signs:

• Unconsciousness or lying motionless after the hit

• Slow to get up

• Confusion, disorientation and inability to respond to questions

• A blank or vacant look

• Imbalance, poor coordination, stumbling and gait difficulties

• Any facial or head injuries

If you see these signs, call 9-1-1:

• Neck pain or tenderness

• Double vision

• Weakness, tingling or burning in the arms or legs

• Severe or increasing headache

• Seizure or convulsions

• Loss of consciousness

• Deteriorating conscious state

• Vomiting

• Increasingly restless, agitated or combative

Watch Tua’s first injury on September 25th - how many of these can you see in the video? Now watch his second injury four days later - what do you see?

Immediate Signs And Symptoms Of A Concussion

If you suspect someone has had a concussion, you should check in with them for their symptoms.

Signs and symptoms of a concussion can be cognitive, behavioural and/or physical. The most common signs and symptoms to watch out for include:

• “Don’t feel right”

• More emotional

• More irritable

• Sadness

• Nervous or anxious

• Neck pain

• Difficulty concentrating

• Difficulty remembering

• Feeling slowed down

• Feeling like “in a fog“

• Headache

• “Pressure in head”

• Balance problems

• Nausea or vomiting

• Drowsiness

• Dizziness

• Blurred vision

• Sensitivity to light

• Sensitivity to noise

• Fatigue or low energy

If they complain of or display any of the above, assume they have had a concussion and seek medical attention.

It’s not uncommon for people who have had a concussion to just waive everything off and say they’re fine, especially for athletes in the middle of the game. In this case, it’s important to check their memory with a few basic questions. Some great options include:

• Where are we playing today?

• Which half/inning/period is it?

• Who scored last?

• What team did you play last time?

• Did your team win the last game?

If you are still unsure, remember Rule #1: When In Doubt, Sit Them Out.

After A Concussion

If it’s pretty clear someone has a concussion, they need to be seen by a medical professional. If symptoms aren’t severe, an appointment with their GP or NP can be made in the next few days.

People with concussions shouldn’t be left alone initially in case symptoms worsen. They don’t need to be woken up every 1-2 hours like we used to do but they do need to have someone keep their eye on them. People with concussions should not drive, drink or self-medicate with drugs. Seek medical attention from a GP, NP or pharmacist for recommendations on medications.

In the first two weeks after a concussion, most people heal well. We have come a long way in our understanding of how to treat a concussion, which you can read about in our blog So You’ve Had A Concussion, Part 1: The First 2-4 Weeks.

All of this information is laid out in the Concussion Recognition Tool and is free to download.

If you’ve suffered a concussion and need follow up care, book an appointment online, email us or give us a call at (778) 630-8800.

Five Simple Strategies for Symptom Management Post-Concussion

Stephanie Yip is one of our vestibular therapists here at Ladner Village Physiotherapy. Since her own concussion many years ago, she has been passionate about learning as much as she can about concussion rehabilitation. Here, Stephanie shares a few of her favourite strategies for symptom management post-concussion.

Have you (or a loved one) suffered a concussion? Are you finding yourself struggling with day-to-day tasks? Are you constantly overwhelmed by the onslaught of bright lights, noises, and people coming and going? Are you hiding in a dark room by late afternoon?

If you’ve answered yes to one or more of these questions, you are not alone. There are over 200,000 concussions diagnosed in Canada annually, and those are only the ones that are reported. When healing from a concussion, symptoms can be difficult to control.

Only about half of people know what to do when they or their loved ones suffer a concussion. For what to do in the first days and weeks after a concussion, check out Part 1 of our series So You’ve Had A Concussion and download Concussion Recovery 101.

Here are a few simple strategies that you can start implementing right away to start easing your symptoms when you’re having a bad day.

Full disclaimer: these are tools for symptom management, and can be used throughout the day to help you cope. These are not meant to replace concussion treatment/rehabilitation.

Five Strategies for Post-Concussion Symptom Management

1. Palming

This is my personal favourite strategy. Let’s say you’re at the grocery store because you desperately needed eggs but it’s a lot busier than you expected, and you are suddenly hit with a wave of dizziness as you scan the aisles. You want to run and hide in a dark room except there’s nowhere to go.

What do you do? Create your own “dark room”! Cover your eyes with your palm and bathe your eyes in darkness. Look forward into the black and count as you take 10 deep breaths. This works as a recovery tool and you can use it anytime you need a quick break from your surroundings.

2. Musician’s Earplugs

After a concussion, your brain becomes very inefficient at filtering out background noise. This is why you’ve probably noticed yourself yelling at the kids for playing their video games too loudly, or maybe you’ve suddenly developed a newfound loathing of the lawnmower. It can be tempting to start wearing earplugs or noise cancelling headphones to cope. The problem with this is if you start perpetually living in silence, you’ll never learn to tolerate noise again, which will stall your recovery.

Instead, give musician’s earplugs a try. These earplugs have varying levels of filter, so you can choose the least amount of reduction that you can tolerate. You’ll still be able to hear the lawnmower and hold a conversation with a friend, but you won’t want to rip your hair out.

3. F.lux

Do your eyes fatigue easily after using your computer or phone? I promise I’m not sponsored by F.lux but I do love their software.

F.lux is basically a fancier version of the “night mode” setting on your phone. F.lux makes your computer screen look like the “daylight” depending on the time of day, so it will be a warmer glow at night, and then brighter like sunlight during the day. You can adjust the settings to your bedtime so it gradually changes as your day progresses. You can also just keep it “warm” all the time if that’s what you’re able to tolerate that day. (But as your physio, you know I’ll be getting you to gradually increase the brightness over time...’cause that’s the only way we get better!)

4. Reading Tips

Reading is hard after a concussion! But that doesn’t mean you can’t still read and enjoy all the books you used to.

Try placing a piece of paper under each line as you’re reading. This reduces the amount of visual input that your eyes have to take in and filter and allows them to track the letters with less difficulty.

Large font books or enlarging the font on your kindle can be another lifesaver.

Audiobooks can also be a great option, and can even be used as a restful activity. I know they can seem daunting, but try starting out with some easy teen lit (think Harry Potter, Twilight or the Hunger Games) and make sure you like the voice of the reader! Before you know it, you’ll be listening to audiobooks every night.

5. Surface Orientation

Do you ever feel like you’re floating or walking on clouds? I’ve had clients also describe it as walking with pillows for feet. Or maybe you just get hit with waves of dizziness throughout the day. This one is for you.

You can do this sitting, standing, or lying down, depending on the situation you’re in. Whichever position you’re in, find something very firm and solid to stand, sit, or lie on. If you’re near a wall, press your full back against the wall. Focus on the feeling of your feet on the ground, your bum in the chair or the wall on your back. Really focus on each part of your skin that is touching the surface. Take a few deep breaths. Continue focusing on the firm surface you are supported against, and tell yourself that you are not moving. Imagine that gravity is gently pulling you straight down into the surface of the chair, wall, or floor. Check in with yourself. You should feel more grounded.

There you have it – five simple, easy strategies you can start implementing right away. And don’t forget the importance of sleep hygiene, exercise, and pacing!

Remember that concussion rehabilitation does not come with an instruction manual - there is no one-size-fits-all approach. A person dealing with persistent concussion symptoms needs a team experienced, knowledgeable and up-to-date with the latest evidence. Surround yourself with a good team to help navigate your way out.

If you have any questions about concussion rehabilitation, feel free to contact us through email or phone us at (778) 630-8800. If you would like to book an appointment, you can do so online.

So You've Had A Concussion, Part 3 - Persistent Symptoms

Devon Konrad is a registered physiotherapist and vestibular therapist. She has taken several post-graduate courses in concussion and is a true believer in the multi-disciplinary approach to concussion - in other words, it takes a team and she is but a part of it.

In her final instalment of a three part series on concussion, Devon focuses on persistent symptoms after a concussion and what to do about them. Part 1 looks at what a concussion is and how we approach it in the first 2 weeks - if you have recently suffered a concussion, start at Part 1 first! Part 2 discusses how to approach returning to work, school and sport.

This is where we hope no one ends up - the world of persistent concussion symptoms. The latest research suggests 15-30% of people still have symptoms after their concussions after 2 weeks for adults and 4 weeks for kids.

People have prolonged recoveries for a lot of reasons. There are risk factors that cannot be changed; for instance, being born female or suffering a concussion as a teenager increases the chances of developing persistent concussion symptoms for reasons we still do not understand. Having ADHD, dyslexia or sleep disturbances prior to the concussion are also linked to persistent concussion symptoms.

In other words, while following the guidelines outlined in Part 1 and Part 2 help reduce the chance of developing persistent concussion symptoms, it is not a guarantee. There is no blame here - there is just a problem that requires a different approach.

Types of Persistent Concussion Symptoms

People suffering with persistent concussion symptoms need to discuss their symptoms with their family medical practitioner to ensure they are getting the right care. These symptoms often fall into one or more of the following categories:

1. Headaches - arguably the most prevalent symptom post-concussion, the best treatment approach for headaches first requires us to figure out what kind of headaches they are. Are they migraines? What about tension headaches? Do they actually come from your neck? The type of headache will determine the best treatment approach.

2. Dizziness and/or visual disturbance - another very common one, this is usually the result of an affected vestibular or visual system, or both! In order to treat dizziness and visual disturbances properly, the root of the problem needs to be sussed out first. Depending on the source of the problem, several different team members may be involved including vestibular physiotherapists, neuro-optometrists, neuro-ophthalmologists, neurologists, ENTs and more.

3. Sleep disturbances - to heal, one needs to sleep properly. Sleep hygiene needs to be addressed first. If that doesn’t work, your medical practitioner will often refer to sleep specialists, psychologists and/or try some medications to help normalize your sleep/wake cycle.

4. Cognitive Function - problems here can show themselves in a variety of ways: poor memory, inability to multi-task, difficulty with word finding or word swapping… I could go on! Luckily, neuropsychologists, psychologists and occupational therapists are equipped to help.

5. Mental Health - depression, anxiety and other mental health disorders are more prevalent after a concussion. Psychologists, psychiatrists and occupational therapists are your friends here.

6. Exercise Intolerance - for some, the inability to exercise without symptoms continues well past the initial healing period after a concussion. We tackle this a bit differently in the post-concussive phase but still gradually and carefully.

The Role Of The Physiotherapist

Given the multitude of ways a concussion can affect the brain, a physiotherapist has a huge role in concussion rehabilitation.

The Neck

Everyone has seen a concussion occur, usually watching professional athletes on TV: the head snaps back after hitting the boards, the ground or another person. That amount of force is huge! When you think about it, how can you suffer a concussion without also suffering whiplash? In my clinical practice, I see the two combined - I don’t think I have ever seen a concussion without a neck injury at the same time.

Just like most injuries, whiplash and other neck injuries often heal normally. However, they can also persist and cause symptoms that look a lot like concussion symptoms: headache, dizziness, head and neck pain, fatigue, blurred vision, sleep disturbances, irritability, difficulty concentrating, memory problems… are you seeing a link here? Most symptoms of concussions and whiplash are the same. This is not to downplay concussions (or whiplash, for that matter) - it simply highlights the need for an in-depth assessment of the neck and treat it appropriately.

Exercise

Beyond the well established health benefits of exercise in general, exercise is crucial for a healing brain. Aerobic exercise encourages the growth of new capillaries, bringing more oxygenated blood to the brain. Exercise improves sleep, enhances cognitive function and can help boost mental health.

For those suffering from exercise intolerance, physiotherapists with extra training in post-concussion care are key to getting the body moving again. In the first few weeks after a concussion, exercise is kept at a level in which symptoms do not worsen. Once someone has more persistent symptoms, we are a bit more flexible with this - we gradually and slowly push into the symptoms.

This does not mean that someone with persistent concussion symptoms has license to just suck it up and push through symptoms - on the contrary! The goal here is to safely increase exercise while being mindful of symptoms. A physiotherapist is your best guide.

Vestibular Rehabilitation

Dizziness, vertigo, blurred vision, imbalance, motion sensitivity… these are all indicators of a poorly functioning vestibular system.

Your brain receives information of where it is in the world from three main systems:

1. Vestibular - through two tiny organs in your inner ear, your brain detects gravity: where it is and how much it’s pulling you down. No wonder astronauts have so much difficulty when they come back from outer space!

2. Vision - uses cues from the environment to tell you where “level” is, often from the horizon. Your brain also loves trees and things that are vertical to help orient that part of your body in space. The visual information usually matches perfectly with the vestibular information.

3. Somatosensory - aka touch, this system is used in feeling things outside your body (ie. the floor! The wall!) as well as things inside your body (ie. whether your knee is straight or bent). This helps your brain place your body in the space it has verified with the visual and vestibular systems.

The main problem I see is when these systems no longer match - your ears say one thing but the eyes disagree, and now you have no idea where to put your body.

Vestibular rehab involves a lot of weird exercises - looking at targets while moving your head, balancing on one foot while tracing a box with a laser beam attached to your head, throwing balls side to side while squatting - all with the goal of making your vestibular system work with your visual and somatosensory systems to make sense of your world.

Physiotherapists with extra training in vestibular rehabilitation are few and far between - you can find one in your area from the Canadian Balance and Dizziness Society’s member list or the Vestibular Disorder Association’s member list.

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For some simple strategies to help mitigate symptoms, check out our blog on Five Simple Strategies for Symptoms Post-Concussion.

Concussion rehabilitation does not come with an instruction manual - there is no one-size-fits-all approach. A person dealing with persistent concussion symptoms needs a team experienced, knowledgeable and up-to-date with the latest evidence. Surround yourself with a good team to help navigate your way out.

That’s it! If you have any questions about concussion rehabilitation, feel free to contact us through email or phone us at (778) 630-8800. If you would like to book an appointment, you can do so online.

So You've Had A Concussion, Part 2 - Returning to Life

Devon Konrad is a registered physiotherapist and vestibular therapist. She has taken several post-graduate courses in concussion and is a true believer in the multi-disciplinary approach to concussion - in other words, it takes a team and she is but a part of it.

In her second instalment of a three part series on concussion, Devon focuses at return to sport, school and work. Part 1 looks at what a concussion is and how we approach it in the first 2 weeks - if you have recently suffered a concussion, start at Part 1 first! Part 3 discusses persistent concussion symptoms.

If you’ve had a concussion, you’ve likely heard that you need to return to activities slowly. But has anyone ever defined that for you? What does “slowly” mean? What “activities” are we talking about? Why is everything so vague?!?

It’s a fair point, dear reader - the concussion world is a vague one. Thankfully, there’s been a huge push in the past decade to answer these exact questions and give a solid framework for return to school, work and sports.

Remember: most adult brains heal wonderfully within 2 weeks and kid brains within 4 weeks. We expect most people to progress through their recovery even if things aren’t smooth the whole way.

Regardless of how progress is going, everyone should have a follow up appointment with their medical doctor or nurse practitioner within 2 weeks of their concussion. This allows any potential problems to be identified early and dealt with in a timely fashion.

First, A Word On Symptoms

We used to say you should not increase your activity level until you were symptom-free. Well, we were wrong. If you broke your leg, we would expect some pain and crankiness from your leg as it healed. The same goes for your brain - we do not expect you to progress through your recovery symptom free.

In these first few weeks, what we avoid are worsening symptoms. If you go into a day with your head feeling like a 3/10 (with 0 being completely symptom free and 10 being the worst symptoms imaginable), we want those symptoms to generally stay at a 3 or below. When symptoms start to increase, the activity needs to be changed and symptoms need to be actively managed.

Starting A Return To…

Here are the general points of any return to school/work/play plan:

1. Before starting a return to anything, a day or two physical and cognitive rest are needed.

2. Returning to work and school take priority over returning to sport (I know I’m breaking some hearts when I say that - I’m sorry!).

3. Each plan is broken down into specific stages that must be achieved before moving onto the next stage.

4. If a person feels ready to move onto the next stage and symptoms spike, they are brought back to the previous stage. This does not mean they fail, it just means they take a bit more time at the previous stage.

5. Every person will progress differently through the stages. Brains are complex and no two recoveries are the same!

Return To Work

It is important for all groups involved - the client, the employer and the medical team - to collaborate and work together in getting someone back to work safely. We follow the same guidelines for work as we do for other activities:

• Take a day or two off work. Make sure your brain is able to rest, both physically and cognitively.

• Work on you first. Keep your normal work day routine. Get dressed, make simple meals, go for walks. Make sleep at night a priority and keep a schedule during the day.

• Start gradually adding work activities in (for instance, working on the computer or reading). Start in short bursts - no more than 15 minutes in one sitting - and pace yourself!

• As you heal, gradually add more time, amount and intensity of the activities. Remember: the goal is to keep your symptoms from worsening.

• If your symptoms worsen, back off. Go back a stage and stay there another day or two. An increase in symptoms is not a sign you are doomed, it just means you went a little faster than your brain was ready for. Listen to your body and try again later.

The decision of when to return to work is very job dependent. The administrative assistant may need to make sure their symptoms are controlled with a lot of computer work while the electrician may need to be comfortable working at the top of a ladder while looking overhead. Each job presents its own hurdles.

As physiotherapists, we are integral to the return to work plan, breaking down tasks into manageable components and gradually increasing these safely. The collaboration between the medical team, the employer and the client is crucial to ensuring a safe and successful return to work.

Return To School

We are very lucky to have the GF Strong Rehabilitation Centre, a leader in the field of traumatic brain injury research and treatment, in Vancouver. One area in which they have invested significant resources is the GF Strong School Program, a collaboration between teachers and medical professionals to get kids back to school after concussions (as well as other injuries and illnesses).

Their Return to Learn protocol outlines specific stages for return to school after a concussion. Every student needs to have a return to school plan with accommodations depending on symptoms. Teachers, principals and counselors need to be aware of the student’s concussion and the plan that has been set in place.

Here’s a snapshot of the Return To Learn protocol:

1. Physical and Cognitive rest - just like for everything else, this is max 48 hours or when symptoms start to improve

2. Light cognitive activity - working up to 30 minutes of reading, drawing or TV without an increase in symptoms

3. Stage (2) plus school work at home - working up to 60 minutes of school work in 30 minute chunks.

4. Back to school part time - with the return to school plan and maximum accommodations in place, working up to 120 minutes of cognitive activity in 30-45 minute intervals

5. Part time school - moderate accommodations, working up to 240 minutes of cognitive activity in 45-60 minute intervals plus up to 30 minutes of homework per day

6. Full time school - minimum accommodations with no limits on cognitive activity at school and up to 60 minutes of homework per day

7. Full time school - no accommodations or limits

If you are teaching kids with concussions, GF Strong created a Guide for Classroom Teachers with links to more resources.

The CDC also has a great document for returning to school - it outlines who at the school should be involved in the process and some great strategies when running into specific concussion-related roadblocks. They also have some great information about concussions aimed at school nurses, educators and parents.

Return To Sport

Good news for the athletes! Almost all of the research in concussions has been done in the sports world. As a result, several sports have tailor-made return to sport guidelines. A return to sport strategy can be started after the first 24-48 hours of physical and cognitive rest. Generally, it’s recommended that at least 24 hours pass between stages - no skipping ahead!

In general, the guidelines follow 6 stages:

1. Symptom-limiting activity - before the athlete can start back into their sport, they need to get back to school or work without worsening symptoms.

2. Light aerobic activity - here, the goal is just to get the heart rate going without worsening symptoms. Concussions can have a significant effect on heart rate and it’s important to get this under control before introducing anything else. Resistance training is not allowed in this stage.

3. Sport-specific exercise - now, movement is added in the form of running or skating drills. Resistance training is still a no go, as are any head impact activities (no tackle practice!).

4. Non-contact training drills - it’s time to add a bit of thinking to the physical exercise, making it significantly harder on a healing brain. Resistance training is generally allowed to start at this stage.

5. Full contact practice - after medical clearance from the athlete’s family doctor or nurse practitioner, contact is added into the mix.

6. Return to sport - goal achieved!

For sport-specific return to sport guidelines, scroll on down to Sport-Specific Return-To-Sport Strategies for everything from rugby and hockey to badminton, canoe and water polo.

Parachute Canada is a fabulous organization with a lot of sport concussion resources, including the Canadian Guideline on Concussion in Sport. It includes the Concussion Recognition Tool, a handy print out aimed at coaches and parents without a medical background to help figure out if an athlete has suffered a concussion.

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Once again, I urge you to visit the Concussion Awareness Training Tool website - it has specific information for parents, coaches, athletes, educators and workers. It includes much more information than I am presenting here and is a fabulous road map to concussion recognition and recovery.

Next up is Part 3: persistent concussion symptoms - what they are and what we can do about them.

If you are looking for some help with your concussion (or anything else!), book online, email us or give us a call at (778) 630-8800.

So You've Had A Concussion, Part 1 - The First Two Weeks

Devon Konrad is a registered physiotherapist and vestibular therapist. She has taken several post-graduate courses in concussion and is a true believer in the multi-disciplinary approach to concussion - in other words, it takes a team and she is but a part of it.

In her first instalment of a three part series on concussion, Devon focuses on what a concussion is and how we approach it in the first 2 weeks. Part 2 looks at return to sport, school and work. Part 3 discusses persistent concussion symptoms.

I’d love to say that concussions are rare, but they’re not. A large study out of Ontario found 1.2% of Ontarians suffer a concussion every year, suggesting concussions are way more common than previously thought.

Before you learn anything else about concussions, learn this:

Most concussions heal fully and normally.

For adults, this means a full resolution of symptoms both at rest and at normal work/school/activity levels within 14 days. For kids, it’s a bit longer - 4 weeks. How we approach diagnosis and treatment of concussions has changed dramatically in the past decade, especially in the first few weeks after a concussion.

Not so long ago, “getting your bell rung” was a normal part of sports and life in general. Unless you were knocked out for a good period of time, it was brushed off and people were told to “get back out there”.

Thankfully, those days are gone.

A concussion is a form of a mild traumatic brain injury. It can result from a hit to the head OR forced transmitted through the head, neck or body causing acceleration of the brain within the skull. Translation:

You do not need to hit your head to have a concussion.

Concussions can occur as a result of car accidents, sports or an assault. They can happen at work and at home. Across all age groups, falls are the most common cause of concussions.

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Signs and Symptoms of a Concussion

There’s a saying in the concussion world: when you’ve seen one concussion, you’ve seen one concussion. This is because of the sheer number of signs and symptoms seen with concussions (there’s a lot!) and the fact that each person will show different ones.

In general, we divide the signs and symptoms into three different categories:

1. Physical - headache, nausea, blurred vision, balance problems, dizziness, sensitivity to light or noise, ringing in the ears

2. Behavioural - frustration, anger, feeling down or depressed, anxious, sleeping difficulties (either too much or too little), tearful

3. Cognitive - feeling “slowed down”, difficulty concentrating, feeling dazed, memory problems, difficulty multitasking, feeling foggy, “not my self”

Remember: it’s totally normal to have some in one category and none in another. Every concussion is different!

We do have a few red flag signs and symptoms to keep in mind. If these are present, a medical assessment is required immediately to rule out more serious problems:

• Double vision

• Seizures or convulsions

• Vomiting

• Progressively worsening headache

• Deteriorating consciousness

• Weakness and/or tingling in the arms and/or legs

• Increasingly restless, agitated or combative

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Diagnosing a Concussion

A concussion by itself is not considered a structural injury of the brain but rather a functional one. What does this mean for diagnosis? It means that with our current level of technology a CT or MRI will not be able to show that your brain has a concussion.

A concussion diagnosis requires two things:

1. A clinical history - is there reason to believe there was some serious force through the head, like a car accident or a fall? Do the signs and symptoms line up with a concussion?

2. A physical exam - this includes testing different aspects of brain function (including balance, reflexes, muscle tone and coordination, eye movements) as well as a full neck assessment

This diagnosis should be made by a doctor or a nurse practitioner. Why? There are several reasons for this:

1. They are able to rule out more serious injuries forms of traumatic brain and spinal injuries as well as other medical conditions that can present similarly to concussions

2. They can order additional exams, if needed

3. They have the ability to refer to different health care practitioners and specialists, such as neurologists, otolaryngologists, ophthalmologists, physical and occupational therapists, etc.

4. They can (and should!) fill out a Medical Assessment letter for you - feel free to print it off and bring it with you

It is also for these reasons that your family doctor should always be involved in your concussion care, no matter who else is a part of your medical team.

While you’re there, book another appointment for 1-2 weeks later. When dealing with a concussion, it’s important to ensure you are healing as expected and if there are any concerns, they are addressed in a timely fashion.

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The First 14 Days

We can break down this critical period into two big parts:

THE FIRST 24-48 HOURS

In the first day or two after a concussion, it is crucial the brain rests. There are a whole bunch of changes that happen in the brain after a concussion (termed the neurometabolic cascade), but they basically boil down to this one concept: energy needs skyrocket at the same time that blood flow decreases. For the first 1-2 days, the brain needs some time to adapt to these changes. Sleep is great in these first few days - don’t be afraid or worried about this!

So what does rest actually mean? Two things:

1. Physical rest - this means keeping your heart rate in check. No exercise, weight training, heavy lifting or physical exertion.

2. Cognitive rest - this means not doing anything that demands concentration and focus. School and work are out for this day or two, as are video games, computer use, texting and driving.

The goal of these first 24-48 hours is to allow your brain to get to a level of stability so you can figure out where to go from there. Symptoms of concussion can take hours to develop - it’s important you rest and allow your brain to do its thing so you and your medical team can figure out what you’re dealing with and up against.

Ideas for Rest

That is a whole long list of things you aren’t allowed to do! Here are some ideas for activities the first few days after a concussion:

• Meditation - if you’ve never tried it before, why not now? A few great apps are Calm and Headspace - both offer introductory programs for meditation. There are also a tonne of Youtube videos if you’d rather go that route.

• Podcasts - there are some great ones out there. My favourites focus on politics/current events (The NYT’s Daily Podcast, CBC’s Front Burner), comedy (NPR’s Wait, Wait, Don’t Tell Me, The Daily Show with Trevor Noah - Ears Edition) and stories (Serial, This American Life). There are some great and amazing options out there!

• Colouring or doodling - for some, this is exactly what they need and crave. It’s gentle, slow and therapeutic in a lot of ways. There are lots of colouring sheets to download as well if that’s your thing.

• Music - whatever feels good and easy to listen to. For some, the thumping of drums can be hard. Classical may be the way to go for now, but do what is right for you.

• Audiobooks - most local libraries (including our Fraser Valley Regional Library) have a large bank of audiobooks that can be downloaded for free. I usually recommend listening to a favourite book so you already know the plot and don’t have to think too much.

• Gentle yoga - as long as you don’t get your heart rate up and you can relax and breathe fully and deeply, yoga is a great option. New to yoga? You can try an app (Down Dog is my current favourite) or feel free to follow this basic program, specifically designed for beginners after a concussion. Tip: avoid inverted postures - no downward dog or handstands!

• Simple board games - for me, this would be cribbage. I don’t have to think when playing crib - my hands can play without much thought at all.

THE NEXT TWO WEEKS

The goal of this time frame is to get slowly and progressively out of rest and back to normal activity levels. Remember - most adults get there in this time frame!

Since every brain is different, there is no perfect outline for what to do on every given day. Normal activity levels differ human to human, and one person’s concussion symptoms are usually totally different than the next person.

The Four P’s

When planning this phase, we look at the Four P’s:

Prioritize activities - pick what’s important for you to accomplish. That may be reading books to your toddler, getting back to work or walking your dog.

Plan activities - need to get to your doctor’s appointment? Schedule in 30 minutes after that for a brain break and a cup of tea. Take an honest look at your day, schedule your activities and plan in time throughout your day to allow your brain to rest.

Pace yourself - If you have a medical appointment in the morning, wait until the afternoon to get that grocery shop in. Spread out your activities to give yourself the best chance of getting them done with the least amount of symptom aggravation.

Position yourself in a calm environment - This is not the time to take your laptop into Starbucks for a “working hour”. Keep your environment calmer than normal. That does not mean sitting in a silent, dark room! If you normally listen to talk radio all day, throw on some soft classical music instead.

Do your best and be prepared to change your plan! You may find that you didn’t give yourself enough of a break after grocery shopping - that’s not something to beat yourself up for, it’s just something to be mindful of for later. As you progress through your recovery, you’ll find you are able to do more with less pacing and in busier environments.

Headache Management

Finally, headache management is a huge part of concussion recovery. Here’s how to manage them:

1. Identify and eliminate triggers - you may notice that loud noises seem to trigger headaches or watching hockey really does you in. Whatever it is, eliminate your trigger. That doesn’t mean you’ll never be able to do that thing again, it just means it’s not an option right now.

2. Eat and drink well - make sure your nutrition is where it should be and you’re drinking enough water. Maintaining a healthy diet is important all the time but especially so when you’re healing from an injury.

3. Sleep - this one is often a tricky but important one. Brains heal during sleep - it’s important you are allowing yourself enough time to sleep. (For more information on sleep hygiene, visit our blog on sleep.)

4. Speak to your doctor or nurse practitioner about medications - if the first three tricks aren’t keeping the headaches under control, it’s important to speak to your medical professional about options for medication. This may be over the counter options or prescription medications. Either way, have the conversation.

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In Conclusion…

That’s a lot to remember! Here are your bullet points:

• See your family doctor as soon as you suspect a concussion, even if you get a diagnosis in the ER

  • Have them complete the Medical Assessment Letter

• Ensure physical and cognitive rest for the first 24-48 hours

• Gradually up your activity after the rest period, keeping your symptoms in check

• Book a follow up appointment with your family doctor for 1-2 weeks after your diagnosis

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Coming Up Next!

In Part 2, I will outline how to safely get back to life - work, school, sports and everything in between (dying to learn more about this now? Visit Parachute Canada for some fabulous resources). Part 3 will focus on persistent concussion symptoms - what they are and what we can do about it.

If you would like more information than what this blog dives into, Vancouver Coastal Health has released two online tools for free:

• My Guide: Concussion - an evidence-based guide for adults with a concussion or those who want to learn more about it

• Concussion Awareness Training Tool (CATT) -an introduction course for medical professionals to ensure appropriate and evidence-based treatment of concussions

Both contain the latest evidence and best treatment advice and are well worth a look.

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If you have had a concussion and could use the help of a vestibular physiotherapist, book online, email us or call at (778) 630-8800.

Headaches - The New Guidelines

When I came across these clinical practice guidelines, I was a little giddy - you may have noticed the excitement in my instagram post. When the Veteran’s Affairs/Department of Defence Clinical Practice Guideline For The Primary Care Management of Headache dropped a few weeks back, I poured myself a glass of wine and settled into my favourite patio chair for a quiet evening of evidence-based practice. Here are some facts I pulled out of the 150 page document:

1. 66% of people will experience a headache disorder in their lives. Sixty-six. SIXTY-SIX. That number blew my mind. I knew it was a common thing to experience, but I never would have guessed THAT common.

2. Women are more likely to experience migraines (15-18%) than men (6-10%). These migraines are often triggered by hormone fluctuations and are most prevalent in women of childbearing age.

3. The three most common types of headaches are:

   1. Tension-type headaches - these can last anywhere between 30 minutes to 7 days and are characterized by pain on both sides of your head and a pressing or tightening feeling. Tension headaches do NOT pulse and are typically not aggravated by life - they just happen.

   2. Migraines - lasting typically from 4-72 hours, migraines usually take over one side of your head with moderate to severe pulsing or throbbing pain, sometimes with a whole host of other symptoms (nausea, vomiting, light and noise sensitivity, visual or auditory auras and more!). Migraines are often triggered by physical activity, such as climbing the stairs, or other triggers in foods or the environment.

   3. Medication-overuse headaches - I’ll be honest, this one surprised me as making the “Top Three” list. These are a result of overmedicating with anything from over-the-counter meds like Tylenol or Advil, or the heavy hitters like opioids and triptans. (If you think this may be you, please speak with your doctor before changing your medication use)

So what kind of headache do you have?

Headache Diary

First things first - you need a headache diary. By tracking the time, medication used, triggers and patterns of your headaches, we can figure out what kind of headaches you’re experiencing and the best method of attack for your headaches. To make an accurate diagnosis, you should track your symptoms for at least a month - this gives us enough data to identify patterns and come to a more accurate diagnosis.

Now, for the big question - what can you do about your headaches? Let’s go through migraines and tension-type headaches separately.

Migraines

The best treatment option for migraines we have right now is the right medication. There are a whole host of them out there with various levels of evidence behind them - in fact, most of them are listed in this clinical practice guideline! If you have a migraine diagnosis or think you should, I urge you to speak with your physician - they can help you decipher your symptoms and figure out the right meds for you.

The other big treatment approach for migraines is trigger modification. Has your headache diary helped you figure out something in your diet is causing your headaches? Or maybe you’ve realized reading in the car can bring one on? Identifying and removing or dealing with these triggers is huge!

Tension-Type Headaches

With tension headaches, medications are also great. We have other non-pharmaceutical options with research behind them, including:

1. Physiotherapy for your neck - research is supporting more and more the use of manual therapy and exercise for the neck to help reduce headaches. This could mean traction, release of muscles in your neck, strengthening of the deep postural muscles or stretching of the tight muscles in and around your neck - it depends on you!

2. Aerobic exercise and progressive strength training - it turns out that getting your heart rate up and your body strong is one of the best things you can do for you head. For starters, any exercise that gets your heart rate up also gets your body making new blood vessels including in your brain. Add general body strengthening to that and your head becomes easier to hold up all day, reducing the tension in your neck.

3. Mindfulness and meditation - we are finally at a place in the medical community where mindfulness is mainstream! We know thought patterns can influence our bodies and the pain we perceive. We also know we can harness this for our own benefit through mindfulness practice. Not sure where to start? Apps like Calm and Headspace are a great place to get your feet wet - I like anything with a body scan!

Wondering about acupuncture and IMS? Right now, the research hasn’t come down on one side or the other, instead saying “more research is needed”. I interpret that as follows: if you’re someone who typically benefits from needling, it’s worth a try. If it doesn’t work for you, we have other options!

If you suffer with undiagnosed headaches, print out the headache diary, fill it out for a month and discuss the results with your family practitioner. If tension-type headaches are the problem, give us a shout - we would love to help you get your headaches under control!

As always, if you’d like to book an appointment you can do so online, via email or by phone at (778) 630-8800.

How Do We Learn? Neuroplasticity, Of Course!

One of the biggest myths about physiotherapy is we only work on bodies. It’s true, we do that a lot! We use manual therapy, soft tissue massage, modalities like LASER, ultrasound and dry needling (aka IMS - intramuscular stimulation) - all to help your body heal and perform at its best. However, the most important thing we do is prescribe exercises. Why?

The number one thing we are trying to change is your brain.

Whenever we learn a new skill, be it playing a guitar or performing the perfect squat, we need to start with activating the right muscles in the right sequence to get the right outcome. And that, dear reader, doesn’t happen at the muscle level - that all starts from the brain.

So what is this brain change we speak of? How does it work? More importantly, how do we make it work for us?

Neuroplasticity is the brain’s ability to change. This change can be harnessed for good (that guitar chord progression is amazing!) or evil (stop leaning over to pick up that box - squat it out!!).

As a physiotherapist, we harness the power of the brain’s ability to change itself through specific exercises. If I want you to improve the range of motion of your shoulder, I’m going to give you exercises that force your brain to engage a specific muscle and build on top of that. Those silly movements we ask you to do? There’s a method to the madness, we swear!

So what makes for good neuroplastic change? Kleim and Jones wrote THE paper on neuroplasticity back in 2008. This became the guidebook with how we influence neuroplasticity for the forces of good. Here are their ten principles and how we relate this to our exercises:

1. Use It or Lose It - want to still be able to squat in 20 years? Squat now. Your brain is very good at eliminating circuits that aren’t being used. If you want to keep a skill at a certain level, you need to practice it regularly.

2. Use It and Improve It - when you practice a task, your brain becomes more efficient at that specific task. It strengthens the neurons and their synapses, prunes off the inefficient pathways and creates a faster circuit.

3. Specificity - if the goal is to improve your golf swing, working on your tennis form isn’t the best way to do it. Sure, some of the muscles used are the same and you’ll see a cross training effect. But to get the best results for your golf game, we need to focus on your golf swing - break down those movements, improve them and put it all back together.

4. Repetition Matters - how many times does an baby fall before they master the art of walking? Almost 14,000 times! (Thanks, Dr. Lara Boyd, for that nugget - I’ve been keeping that number in my head for 10 years!) Keep this is mind if you’re getting frustrated - “brains are stubborn, but so am I”.

5. Intensity Matters - when you’re working out or practicing a new skill, work hard and make it count. Sweat! Fail! Make it hard! The more you push it - either physically or mentally - the faster you’ll see change.

6. Time Matters - we know we get faster neuroplastic change if we start rehabilitation shortly after an injury. The sooner we start, the better.

7. Salience Matters - you need to care about what you’re doing to get change! You know that adage, “You can’t make a person change”? It’s true for the brain, too! If the person doesn’t care, they will not see neuroplastic change. This is why we ask you what you love to do - we need to make sure the exercises we are prescribing relate to something that matters to you and helps you get to your end goal. Otherwise, what’s the point?

8. Age Matters - younger brains are better at neuroplastic change. We used to think younger brains were the ONLY brains that could change, but research has blown that out of the water. Older brains change, too - here is no age limit to neuroplasticity!

9. Transference - this is the cross training effect. Let’s go back to the golf/tennis example. Both games demand good shoulder control, a strong core and good hand/eye coordination. If we focus only on your golf game, your tennis game will improve a bit as well.

10. Interference - I’ll use a personal example with this one. I have spent so much time playing ultimate frisbee that I cannot play tennis without flicking the tennis racket. I can’t do it! My wrist just flicks every time I hit the ball. The neuroplastic change I have developed to throw a frisbee has interfered with my ability to hit a tennis ball properly. I could put in the effort to induce enough neuroplastic change and separate these circuits if I wanted to, but it’s not salient for me (see what I did there?).

Want to have more neuroplasticity in your life? There are two things you can do to make your brain more efficient at neuroplasticity: aerobic and mental exercise. Both have shown to increase the brain’s ability to adapt and change. All the more reason to get out for that bike ride and rock that crossword puzzle!

As always, if you’d like to see one of our physiotherapists, give us a call at (778) 630-8800, email us at clinic@ladnervillagephysio.com or book online.

Happy learning!

Visual Vestibular Mismatch - Why Do I Feel Motion Sick in the Grocery Store?

Have you ever been sitting at a red light with a car beside you and the other car starts to move? We’ve probably all experienced that panic where we think we are the ones moving and jump on the brakes with as much force as we can muster. Only then do we discover it wasn’t our car that was suddenly taking on a life of its own but our brain playing a trick on us, telling us we were moving when we were sitting perfectly still.

That feeling is a result of Visual Vestibular Mismatch, a conflict in your brain where the visual information coming from your eyes does not match the vestibular information coming from your ears. Visual Vestibular Mismatch (otherwise known as VVM) is something that happens to us in every day occurrences. Think of that feeling you get when you’re watching the latest blockbuster movie and the only seats left were in the front row - sometimes, you’re not sure if it’s you or the screen that’s moving. That nauseous, unsteady, motion sick-like, gross feeling is a direct result of the VVM experienced in that moment.

When you have a concussion or vestibular disorder, VVM can be much more severe and affect every aspect of your life. Whenever you experience a lot of visual stimulation (especially if that stimulation is of the moving kind), the symptoms of VVM may rear their ugly head. Common situations for VVM include:

• The grocery store - aisles upon aisles of colours, from floor to ceiling, with people moving in and around you

• Crowded areas - think the mall at Christmas time. People without vestibular deficits feel gross there, never mind those of us who have vestibular deficits!

• Places with kids and pets - all that movement in your peripheral vision can really play tricks on your brain

• Patterns on the floors and walls - high contrast patterned wallpaper and rugs should be banished, in my humble opinion

Why Does This Happen?

We know our sense of balance comes from three main sources: the vestibular system, the visual system and the somatosensory system, also known as your sense of touch (for more information on these systems, check out my earlier blog on the vestibular system or head to the Vestibular Disorders Association). Our brain likes to use the vestibular system as the leader of the balance trio - it tends to be the one utilized most for figuring out where we are in the world.

With vestibular dysfunction, the brain will often switch to a vision-driven system - it doesn’t trust the information coming from the ears so it goes to it’s second choice. Now, the brain is using primarily visual information to figure out where it is in the world. Without having a trusty vestibular system to double check its information, the brain has a really hard time figuring out what is moving - you or the things around you.

What Can We Do About It?

A lot, actually! Vestibular rehabilitation can be very effective at treating VVM through balance exercises in eyes closed (if you can’t use your visual system to stay upright, you have to use something else!) and desensitization exercises to visual stimulation.

If you’re suffering from VVM, give us a call at (778) 630-8800 or book online at ladnervillagephysio.com.

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Interested in learning more? If you’re nerdy like me, take a look at Dr. Art Mallinson’s thesis on Visual Vestibular Mismatch.

I Need More Sleep!

I don’t get enough sleep. Quite frankly, I don’t know anyone that does. That bake sale for the PAC? No worries, I’ll just stay up until 3am to get those cupcakes done. A huge presentation at work? I’ll have extra coffee tomorrow - it’ll be fiiiiine. Everyone I know is guilty of sacrificing sleep to get all those little things done.

Chronic fatigue is also a huge component of chronic injury. Simply put: you need sleep to heal. Without sleep, it is nearly impossible to recover from anything - it’s when we sleep that our bodies are able to dedicate the resources needed to repair the tissues. Sleep is one of the most underrated aspects of rehabilitation from any injury.

If you need a shake up in your sleep hygiene routine, here are some tips to help get you started:

• Keep a regular sleep schedule. It is vital to healthy sleep hygiene that you prioritize getting to bed at roughly the same time every night and waking up at roughly the same time. Your brain thrives on routine and getting into these circadian rhythms help your brain heal. Aim for 7-9 hours of scheduled sleep every night, preferably more than less.

• Expose yourself to natural light during the day. This helps your brain set those circadian rhythms and regulates the melatonin (the sleep hormone) circulating in your brain.

• Promote a sleep friendly environment. Keep your room dark when you are sleeping, using backout curtains if necessary. Block ambient noise by either using a sound machine, fan or ear plugs. Keep your room cool but comfortable.

• Make a bedtime routine. With babies and kids, we usually have a bedtime routine to help them get ready for sleep. Why not do the same for us? Get in some kind of bedtime habit – a shower, a book, meditation, etc. Do what works for you.

• No naps. Napping disrupts these rhythms you are working so hard to build. Instead, take a brain break during the day – do some yoga, meditation or listen to a podcast.

• Avoid alcohol, caffeine, nicotine, heavy meals and lots of liquids in the evenings. Aim for none of these things in the last 4-6 hours of your day.

• Avoid exercise before bed. If you can, get your exercise in the morning – it will help wake you up and keep you going through the day.

• Avoid screen time in the two hours before bed. When you look at bright lights, your melatonin levels decrease and your brain wakes up more. If you need to look at screens, add the night filter to your phone – it helps decrease the blue light and reduces the effect on your circadian rhythms.

• Use your bedroom for sleep and sex – that’s it. Don’t turn your bedroom into your gym, your office space, your afternoon lounging area. You want your brain to associate your bed with those two things; everything else is a distraction and will hinder your sleep.

• Can’t sleep? Get up. We all have those nights where we just can’t sleep. When that happens, give yourself 15-20 minutes to try and get to sleep. If that fails, get out of bed and go into another room. Read a book, do some meditation, have a light snack. When you are sleepy again, go back into your bed and try again. Do not turn on the TV or try to use that time to get some work done – keep those hours you have reserved for sleep as quiet, non-stimulating time.

Sometimes, these strategies are not enough. If these strategies are not working for you, talk to your doctor about medications or supplements that may help you find the sleep you need.