How the athlete's mindset can help and hurt brain injury recovery
Recalibrating the impulse to keep pushing
The Olympic motto is “Faster, Higher, Stronger.” In order to embody that motto, athletes push themselves to do more. When an athlete suffers a brain injury, they might attempt to apply the same approach to their recovery, but this can actually prevent recovery or prolong its timeframe.
Athletes have clear ideas about what it means to train, and those ideas assume a healthy nervous system and brain. With a brain injury, those ideas need to be adjusted, attenuated, and recalibrated, in order for the recovery training (and the mindset during that training) to be helpful rather than hurtful.
The problem of “no pain no gain” when there is no pain
An athlete uses the experience of pain as a way to monitor their ability to exert themselves or continue performing. Pain can also tell you that you’re injured. Even something as simple as turf toe comes preinstalled with a highly useful pain gauge.
With a brain injury, there’s often no pain gauge and no further pain information available at any point in the process. The scale, severity, and state of the injury is decoupled from pain, as is any information about how far you can or should push yourself during rehabilitation.
If you aggravate the injury, and there is no pain feedback, you have no way of knowing (based on pain at least) what activity is too much or whether it’s too soon or where you are in the timeline.
This pain-free reality makes it all too easy to do too much.
People who prolong their brain injury recoveries are typically people who do too little (not enough neurological stimulation, movement, exercise, etc) and people who do too much (too much stimulation, nervous system overload, etc). Athletes are especially prone to the latter.
Redefine incremental gains
When one has a generally healthy nervous system and brain, one can make significant gains in a short period of time. An athlete expects to steadily increase the resistance in a given exercise, or massively increasing the total volume of repetitions to produce a certain result.
When it comes to recovering after a brain injury, those expectations are out the window—principally because you no longer have a generally healthy or properly regulated nervous system.
While it might technically be possible to push yourself in one or more areas in the moment, you will likely feel worse for many days afterward. Your brain won’t be able to deal with the kind of training volume increases you’re used to making in the gym—or the kinds of incremental escalation of effort you’re used to making.
What kind of incremental gains can you expect?
There are two ways to think about incremental gains. The first is the way you’re used to thinking about them. You perform an exercise, and the next time you perform that exercise, you add more weight, do more volume, or push yourself a little more. Over time, this leads to various increases in performance (strength, endurance, etc).
When recovering from a brain injury, you can cautiously apply that familiar framework to exercises that don’t provoke your symptoms. Walking, for example, might be possible for you. Pushups might be possible. You might do these exercises to maintain a general level of fitness—but if you do, you’ll want to take it way more slowly than you’re used to when it comes to increasing resistance or volume.
A general guideline would be: If you can do a low level of exercise without provoking symptoms for two weeks, try increasing the resistance or volume of those exercises by 5 to 10% and see how that goes. If that increase provokes your symptoms, scale back and start again. If you’re okay for another two weeks, then escalate by another 5 to 10%.
For example, if you can walk for 30 minutes with a heart rate of 130 beats per minute, after two weeks, you might try increasing the total time or the BPM by 5 to 10%.
This is an important caveat: Any exercise you’re doing adds to the total volume of nervous system stimulation you’re receiving. If you add too much exercise volume (even if the individual exercises aren’t provoking symptoms), you’re likely to experience overstimulation at some point—maybe even days later. That’s why it’s important to closely track what you’re doing so you can pull it back if you redline your nervous system.
Shift from focusing on incremental external (visible) gains to incremental (hidden) neurological gains
This is hard. Athletes are used to thinking about incremental external gains in terms of easily measurable improvements in performance or how they look in the mirror 30, 60, or 90 days later.
But there’s a different kind of incremental gain that can be achieved by doing an exercise the exact same way every day with no increase in resistance or volume (or where the eventual increase takes much longer than you’re used to).
Let’s say that doing an about-face motion makes you dizzy. Perhaps you start by walking in a box pattern, taking a right-angle turn at each corner. Maybe you do one box, take a minute rest, then do another box. Maybe you do four boxes to the left, then four boxes to the right. If you can handle that, maybe you do it every other day or 5 days a week for 90 days, at which point doing that is easy—you’ve made incremental gains neurologically by doing the same exercise the same way for a long time.
Neurological recovery requires you to shift your focus from making easily measurable (and rapidly escalating) external gains toward making less easily measured (and slow to develop) invisible ones.
Neurological gains (including recovering from a neurological injury) have a much longer time horizon. If your symptoms improve ever so slightly each month, and if you see significant improvement within three to six months, then you are moving forward.
When the slow progress feels depressing (in part because the dopamine release from slow progress is probably far below what you’re used to), it helps to remind yourself of the significant gains you’re making internally.
Visualize a stack of weights in your head. Each day, as you do the same old exercise with no incremental gains in resistance or volume, imagine that you are dropping that pin to a higher and higher weight in your brain. Because that is effectively what you’re doing. You’re rehabituating and rehabilitating your nervous system incrementally by doing the same thing for a while.
Train to reach the minimum effective dose, not to failure
As an athlete, you’re used to training to failure in the gym—pushing yourself until you cannot do one more repetition. In athletic training and in medicine, there’s another concept called the minimum effective dose. This approach hinges on doing just enough to stimulation to get the result you want. Importantly, any less than that amount won’t work.
For example, according to the latest science, it’s thought that the minimum effective dose for weekly physical activity is around 180 minutes (this is the current World Health Organization guideline). Less than that produces entropy of one kind or another.
During the course of your recovery, you will trigger your symptoms—if you’re not triggering your symptoms, you’re not recovering. The key is to trigger them just enough. It’s important to see this level of stimulation as the minimum effective dose, and switching into a training to failure mentality.
This might feel very uncomfortable and unnatural if you’re used to giving it your all, but when it comes to recovering from a neurological injury, the minimum effective dose is also about as much as you can take.
Your best effort no longer means maximum output. Your best effort now hinges on two things: pushing yourself just enough to reach the minimum effective dose, and consistency.
Beware delayed onset of symptoms
As an athlete you’re used to delayed onset muscle soreness. Well, the same kind of phenomenon happens with your nervous system and brain.
The delayed onset of post-concussion symptoms can be very frustrating. You might feel fantastic while you’re doing the exercise, but feel terrible for three days afterward—dizzy, irritable, unable to deal with any further stimulation, such as going to a grocery store or loud environment. You lose those days and it feel like you’re back to square one.
I once went to a physical therapy session and felt fine during the treatment, but about an hour later I was so dizzy I could barely stand, and I had to take it easy for about three days before resuming training. Needless to say, dealing with any additional stressors during that time was a bummer for all involved.
After you’ve recovered from this kind of overstimulation, resume your training at a slightly lower level than before.
Consider adding transcranial magnetic stimulation (TMS) to prevent overstimulation and to shorten recovery time from overstimulation
In times when I’ve done too much or overstimulated my nervous system by exercising too vigorously, I’ve found some measure of relief (and a shortening of the recovery time) from using transcranial magnetic stimulation (see “Treatment Option: Transcranial Magnetic Stimulation (TMS)”).
I don’t receive this treatment in a clinical setting. Rather, I use a personal device called NeoRhythm. I’ve had good results with this device. During the day, I often use the Energy & Vitality mode (a mix of higher frequency waves, including Gamma) while working. I’ve also used that mode after training, and it seems to keep me from tipping too far into overstimulation, possibly by helping with top-down control. I also use the Improve Sleep mode (a mix of slow waves including Delta) before bed. It’s a fantastic sleep aid. As with anything else I mentioned here, “your mileage may vary.”
Where a background in athletic training becomes an advantage
While having a background in athletic training comes with the challenges outlined here (principally the danger of habitually doing too much and setting yourself back), there’s no question that it also comes with many advantages.
For starters, people who’ve trained for any length of time have developed a mind-body connection that will serve them well. Experience tracking what you do and when you do it is also useful. As is the focus on diet and supplementation.
Lastly, if dozens of exercises are already in your repertoire or “muscle memory” (really your nervous system memory) you’ll eventually be able to bring that to bear on your upward climb.
Eventually, you can move toward making such things as vision, hearing, and vestibular exercises part of your overall exercise regimen.
Remember the slow progress and good cheer (and distress) of infants
There’s a series on Apple TV+ right now called Becoming You that’s all about the process of human development from infancy, and how we acquire various skills such as the ability to stand, walk, or make a friend.
Episode two is called “Moving” and it’s highly relevant to what we’re discussing here. In one amazing timelapse sequence, we see an infant learn to stand, falling down thousands of times in the process over a period of months.
It’s a poignant reminder of the incredible volume of work we once put into developing the abilities we came to take for granted. To stand, walk, hold a pen, write, read, or filter all the different forms of information coming at us and make sense of it all—these were monumental tasks.
When we have a brain injury, we may lose some measure of those abilities, and we’ve forgotten how much work it was to acquire them. Remembering this can help us deal with the timescales involved in a neurological recovery and be gentle with ourselves.
Yes, reacquiring emotional regulation is part of recovery, too, one that shouldn’t be overlooked. A qualified therapist should definitely be on your team.
The importance of the right goal and frame
Even though we may initially want nothing more than to get back to normal, I strongly believe that one’s goal should not be to get back to normal.
Normal probably meant taking your brain and nervous system for granted. If you’re like me, normal involved being in denial as entropy took hold. By many measures, including cognitive health, eye health, cardiovascular health, and more, my trend-lines were on a steady downslope.
The toolset you’ll acquire during your recovery (including the knowledge you’re acquiring right now) will help you surpass normal in many ways—even if certain abilities remain unrecovered. That toolset will help you continue to sharpen or enhance other abilities, to surpass your previous baseline in many areas. In all likelihood, it will help you become healthier overall.
So why make getting back to normal your ceiling? The ceiling could be higher than that. Or it might be higher in some areas, lower in others. You don’t know yet. Focus on developing the toolset. It will serve you in many ways.
About that Olympic Motto…
In 2021, the Olympic Committee changed the Olympic motto to: “Faster, Higher, Stronger — Together.” The addition of Together is meant to emphasize the importance of solidarity. I think it’s also a good reminder that no one—including and perhaps especially high performing athletes—does it alone.
If you approach your recovery as you would training for the Olympics, there’s no question you would need to assemble a team of helpers, including a trainer, coach, dietician, neurofeedback trainer, therapist, physician, ophthalmologist, acupuncturist, chiropractor, masseuse, and many others. I encourage you to add all the members of the team you need.
I also encourage you to celebrate your milestones. As the Olympics shows us, celebration is vital and it helps move us forward to the next milestone and the next.
Brainwave is an informational resource for people whose symptoms haven’t resolved after a concussion or mTBI. I endeavor to present this information in a clear and concise way, spelling out what’s backed by science and what remains unknown. Nothing here is meant as a substitute for professional medical advice, diagnosis, or treatment. I am not a physician or a healthcare practitioner of any kind; I’ve simply had a lot of sports-related concussions and had to learn this stuff the hard way. If you found this information helpful or know someone who might benefit from it, please share and subscribe to Brainwave.