Dizziness and Concussion – Essential Physical Therapy

July 14, 2020August 19, 2020

The Most Misunderstood Molecule, and How to Harness Its Power

Deeper, quieter, regular, slower.

Those are the general guidelines for focusing our attention on the breath. This awareness makes us feel calmer, more relaxed, and releases tension from our bodies.

But How? Why does changing our breath change our mood, and many other factors?

Research has shown that slower, deeper breathing reduces heart rate and risk for cardiovascular disease, as well as improves athletic performance. (yes, all you athletes out there, breathe slower to go faster).

The reason all these magnificent changes occur within us when we deepen our breath, especially our exhales, is because of a very special molecule that usually gets a bad rap.

I’m talking about good old carbon dioxide, CO2.

I know what you’re thinking…is she talking about the very same carbon dioxide that we are trying to reduce in our atmosphere to slow global warming? The same carbon dioxide that is considered a waste product of our bodies- something useless to to be rid of as soon as possible?

Well, yes, I am.

But what if I told you that this special little molecule was not only a useful component in improving your health, but an essential one for you to be able to thrive?

You see, for our bodies to get oxygen from our lungs to our tissues, we need carbon dioxide. To get a proper inhale, our receptors in our neck need to sense a certain amount of carbon dioxide in our bodies.

Not to mention, carbon dioxide is stored as bicarbonate in your blood stream, which is essential for maintaining the pH balance of your whole body.

Did I mention that carbon dioxide is critical in weight loss? Most of your body mass lost is due to breathing out carbon dioxide. In fact, more than 80% of weight loss is due to breathing out CO2, and only 15% or so is lost via sweat and urine.

So, if you’ve been dieting, exercising, doing all the right things and still not losing weight… you may want to look at how you’re breathing.

Let’s explore some of these in a little detail…

Firstly, how the heck does carbon dioxide help your body get more oxygen?

Think of carbon dioxide as the Fedex guy, and oxygen as your packages. When outside air hits your lungs, it makes it’s way down to alveoli, the tiny air sacs that interface with the blood stream. The oxygen molecules (packages) get loaded from the alveoli onto the red blood cell, which in this analogy is the Fedex truck.

The truck travels all over the body, delivering oxygen to all the cells as they all need oxygen to survive and flourish. When exercising, certain muscles need even more oxygen more quickly.

This is where our good buddy carbon dioxide comes in.

Oxygen cannot get off the truck unless there is a carbon dioxide molecule there to unload it.

When the oxygen gets to its destination, the carbon dioxide triggers the packages (oxygen) to be unloaded off the Fedex Truck (red blood cell), and be delivered to the cells (your mailbox).

The more carbon dioxide present, the more efficiently the oxygen can be offloaded to cells.

So, when you’re exercising and you really need to get oxygen to those tissues, perhaps try breathing slower instead of faster.

Why does the amount of CO2 in your body determine how you inhale?

I’m constantly telling my patients, don’t worry about the inhale! If you get a good exhale, the inhale will just come.

This is for two reasons, the first of which is purely mechanical.

When you exhale completely, the lungs become essentially “empty” of air, which creates a vacuum. New air has to flow in. It must follow the laws of nature! It must flow from the higher pressure (outside your body) to the lower pressure (inside your lungs). You don’t have to use your accessory muscles (aka your neck) to pull air in, it just goes in! Easy.

The second reason is neurological.

Deep in the reptilian brain, the most primal part of our brain that was present when the first creature crawled out of the primordial goo and decided to walk on land, there is a simple neural network that says, “breathe.”

This network senses levels of oxygen and CO2 in your body to decide when to inhale or exhale. Basically, when your body senses a certain level of oxygen in your body, that circuit makes you exhale. Similarly, when a certain level of CO2 is sensed, the circuit makes your body inhale.

Unfortunately, for many of us, this circuit gets messed up.

We breathe shallowly because we are less active, or stressed, or both, and we do this so much that we end up overriding the part of the circuit that senses CO2 and tells you to inhale.

We get stuck in this cycle of inhaling without ever getting to the bottom of our breath; we lose that primal trigger to inhale, so our inhales get all wonky, a.k.a. you end up pulling your ribcage up with your neck.

In addition to all these important factors, carbon dioxide is the main reason that you feel relaxed with deeper breathing.

Carbon dioxide makes you chill out.

Think about it. What do they tell you to do when you’re having a panic attack? Breathe into a paper bag. You’re breathing back in the CO2 you exhaled. Get that CO2 flowin’ baby!

Carbon dioxide relaxes you by causing your blood vessels to relax, which allows blood to deliver oxygen to all your tissues more easily.

Also, as mentioned above, CO2 lets your body unload oxygen from red blood cells to tissues.

These two factors together mean that your brain gets more oxygen and blood flow. This tells your body that you are safe, and you feel calmer and, well, more chill!

So how to insure that you get more CO2, but not too much?

The answer is simple, and I think you know what I’m going to say.

Breathe deeper, quieter, regular, slower.

5-6 seconds for each inhale and exhale, resulting in about 5-6 breaths per minute, is the ideal for balancing the CO2 and O2 in your body.

Below is a short video on how to do just that and harness the power of this special molecule.

Are you ready to breathe better to move better, to improve the health and resiliency of your lungs without any medication or procedures? Click the button below to find out if will benefit from working with Dr. Derya.

Book a FREE WellBody Screening Session

References

Aakash K. Patel; Andrew Benner; Jeffrey S. Cooper. Physiology, Bohr Effect.
https://www.ncbi.nlm.nih.gov/books/NBK526028/

Anders Olsson Blog https://www.consciousbreathing.com/anders-olsson/carbon-dioxide-training-extremely-harmonious/

Nestor, James. Breath: The New Science of a Lost Art. May 14, 2020 http://www.pathwaymedicine.org/control-of-respiration

January 20, 2020February 18, 2020

3 Systems that Help You Balance (and What Happens When They Fail)

We rely primarily on three systems to tell us where we are in space and in relation to gravity. Basically, they keep us from falling over!

Visual System

One of those systems is our vision. Have you ever been parked in your car and slammed on the brakes because the car next to you started to move? Nothing else changed except your visual perception, which made it appear you were moving. As a result, your body reacted. These reactions are constantly happening on a smaller, subconscious level as we negotiate our environment. Don’t believe me? Try balancing on one foot. Now, try that again, but close your eyes. Once we take away the visual input, balancing is much harder.

Human Eye — The visual system is one of the ways that we balance.

Somatosensory System

Another way we balance is with our somatosensory system. This system is the information we get from our body of where we are in space, primarily our feet. All of our joints have specialized nerves in them that tell our brain their position relative to a surface. There is a high density of these nerves in your ankles. To experience the somatosensory system in action, try again to balance on one foot. Notice how much harder your ankle is working, with little micro adjustments, to balance when you have only one foot on the floor instead of two. That’s because you’ve reduced your “somatosensory input” by reducing the amount of contact you have with the ground. Just like our vision, our somatosensory system is constantly sending signals to our brain and making micro adjustments based on where we are relative to a surface. This is happening whether we are standing, sitting, lying down, doing a handstand, walking or running.

Vestibular System

The third system in our body that keeps us from falling over is our vestibular system. This system is usually the hardest to understand because we can’t see it, and we don’t notice that it is working. However, when it is not working, we really feel it.

The vestibular system is a small organ that lives deep to the ear, and you have one on each side. It is often referred to as the “inner ear” for its location, but you cannot get to it from your ear because it is separated by a membrane (the ear drum). It shares a nerve with the part of your body that manages hearing, called the cochlea.

Vestibular organ relative to ear. — The vestibular system or “inner ear,” shown above in blue, is located deep to the membrane of the ear drum.

The vestibular system consists of three semi-circular canals that are filled with fluid. When we move our head, this fluid is displaced. This displacement activates nerves within the vestibular organ and sends a signal to your brain with information about which direction your head is moving and how to adjust your eyes to account for this. This is a crucial function for daily activity. Think about walking. When we are walking, our head is constantly bobbing up and down with each step. However, we do not perceive this because of the vestibular system communicating with your eyes to account for this.

When Systems Fail

These three systems, visual, somatosensory, and vestibular, all have to work together. When they don’t, we can feel dizzy, off balance, or “not quite right.”

The system that is usually affected in feelings of dizziness is the vestibular system. A common cause of dizziness is called benign paroxysmal positional vertigo, or BPPV for short. This is when a small crystal of calcium-carbonate becomes displaced from another region of the vestibular organ and ends up in one of the fluid-filled, semicircular canals. Because the inertia of the crystal is greater than that of the fluid, the brain and eyes receive a signal that you head is still moving when actually it has stopped. Therefore, this type of dizziness usually occurs with head movements and creates a spinning sensation. It can be very uncomfortable, and is treated by a maneuver that positions the crystal back to its original location. Crystals can become dislodged during a head trauma. Also, as we age the crystals do not adhere as strongly to their original location and can come loose all on their own.

The vestibular system can also be damaged by a virus. Usually, someone who has this issue had a stomach virus or head cold up to two weeks before they started feeling dizzy. This person also gets dizzy with head movements due to the virus affecting the nerve that sends information from the semicircular canals to the brain, body and eyes.

Inflamed vestibular nerve — Our sense of balance can be affected by an infection that makes its way to the nerve transmitting signals from the vestibular organ.

When our vestibular system is damaged or not functioning as well, we rely more heavily on other systems of balance, usually our vision. We usually don’t rely as much on our somatosensory system because in our day to day we are far more used to using our eyes to stabilize (computer work, driving, watching TV) than we are to using our somatosensory system (walking on uneven surfaces, balancing, crawling). This can make us feel dizzy when we are in an environment with lots of visual stimulus, or make us feel off balance or dizzy when we are in the dark or low light. After a while, we might notice that our neck becomes stiff, because we also avoid head movements that may make us feel dizzy.

Our bodies and brains are extremely good at compensating, but we can only compensate for so long. For individuals who have dizziness or imbalance and try to “just deal with it,” their problems often become worse as the compensations only grow stronger. This is because your body will always take the path of least resistance, which means it will always preferentially use the systems that are already strong (usually vision) and therefore the ones that are weak (vestibular and somatosensory) become weaker and weaker. This creates an imbalance that affects us negatively in many ways, because there are many moments in life we need all three systems to be working well and harmoniously.

So what to do if you suspect your balance systems are, well, out of balance? The best thing to do is to strengthen those that are weak. You can do this by performing balance activities with eyes closed, or incorporating head motion into your activities. This way you will stimulate the somatosensory and vestibular systems, and with eyes closed the visual system will not be able to take over.

January 6, 2020February 18, 2020

Am I still dealing with My Concussion?

When we think of a concussion, we often think about football players or someone who has taken a blow to the head. While this is where a lot of concussions happen, many more happen in ways that are less talked about. Whiplash, such as from a car accident, can cause a concussion as the brain strikes forcefully against the skull and shears neurons that descend from the brain. In the same way, a fall can cause a concussion – even without a blow to the head, especially in older adults.

Who Gets Concussions?

Concussions can occur in older adults who slip or fall (even without hitting their head!), children, athletes at all competitive levels, military personnel who sustain blast injuries, adults who slip on the ice getting into their car…etc. Basically, anyone can get a concussion.

What is a Concussion?

A concussion is a trauma to the brain significant enough to cause a brief change in mental status or consciousness. Recovery for a concussion has a natural healing time of 4-6 weeks. That means that unless you have signs that you will need rehab immediately, often the best course of action to take during that time is resting appropriately under observation of medical provider.

That said, in my experience there is a lot of confusion about what appropriate rest means, and furthermore what is appropriate is unique to each individual. Too much rest is not helpful, and too little is certainly not helpful, and either of those could be harmful or delay recovery. So please, if you or someone you know has had a concussion (or you even suspect they had one) get clarity on what “rest” means from a provider who is well versed in concussion rehab.

Symptoms of a concussion can be vague and are different for each person. Many people never end up seeking care or are misdiagnosed. Catching a concussion early is very important because the research supports that early intervention results in much better outcomes.

Early Symptoms of Concussion

Headache
Neck Pain
Mood changes
Fatigue
Sleepiness
Nausea
Dizziness
Difficulty Sleeping
Sensitivity to light/sound
Double/blurred vision
Confusion
Balance deficits
Focus/memory deficits

Post-Concussion Syndrome

Many patients, especially those who were not diagnosed or did not receive rehab or proper guidance early on, end up with long lasting symptoms that they just accept as “part of their life now.”

Once it has been 3 months since the original injury, these patients technically no longer have a concussion, but rather post-concussion syndrome, which indicates chronic symptoms. However, patients often don’t realize that these symptoms are still treatable and are not something that they have to live with!

So why do symptoms persist for so long with post-concussion syndrome? The body and brain find ways for you to keep doing what you have to, by compensating for deficits rather than addressing root causes. For example, when you have a deficit in the part of your nervous system that tells your brain where your body is in space, you compensate by relying on vision for balance. This works okay for a while, but dizziness occurs when your vision is over stimulated, such as when you are trying to look around while hiking, or are in a visually stimulating space such as the grocery store, or when you can’t access your vision well, like in a dark movie theater.

Symptoms of post-concussion syndrome

Dizziness
persistent headaches and/or neck pain
reduced tolerance to lights/sounds
feeling unsteady, especially when walking or in busy environments
fatigue
a sense of fogginess or feeling “not quite right.”

What can be done to help?

When a person experiences dizziness or balance deficits, the affected systems need to be trained with specific exercises at optimal dosages. Over time, these treatment strategies reduce your symptoms by teaching your body to move away from compensation and strengthen the parts of your system that have become weakened.

As I mentioned before with rest, knowing exactly how much to do and when is key for achieving recovery. Doing too much can overwhelm your system, whereas not doing enough will not result in any gains. That’s why working with someone trained in concussion rehab is essential for you to continue to improve without exacerbating your symptoms.

Longer-term Symptoms of Untreated Concussion:

Loss of libido
Low blood pressure
Loss of mensturation
Fatigue
Muscle weakness
Growth problems (children)
Weight gain
Early dementia
Chronic headaches/dizziness

Long term symptoms of concussion can affect multiple systems of the body.

What to do if you experience a concussion:

Decrease your screen time.
- Try to spend less time looking at a computer screen, phone, or i-pad.
Allow yourself rest.
- After a concussion, most people feel the need to sleep more than usual. This allows the brain to heal. Give yourself permission to spend extra time sleeping.
Continue to engage in light aerobic exercise.
- While vigorous physical exertion may worsen symptoms and delay healing, light aerobic activity can help you heal faster. If you are not sure how much to exert yourself safely, a physical therapist can perform an exertion test to determine how you respond and give you guidelines for how to exercise on your own.
Listen to your symptoms.
- Stimulating environments and even changes in head position can provoke symptoms. If you notice triggers like these, allow yourself to experience mild symptoms but avoid situations that cause symptoms to become severe.

Important Note: Depression and anxiety are one of the most common symptoms following concussion. In 90% of cases these symptoms resolve with time. However, in some cases these symptoms can be more severe or persistent, especially if there is a history of depression or anxiety, or presence of stressful life events. Many patients benefit from more in depth care in this arena, such as meeting with a psychotherapist in addition to physical therapy to achieve full recovery.

Dr Derya Anderson has extensive experience working with patients who have had a concussion. She also has attended continuing education courses (below) that are specific to concussion management:

May 2019 Stress, Movement and Pain. Speaker: Seth Oberst, PT, DPT

July 2018. Concussion: Vestibular System Abnormalities and Ocular Motor Examination. Taught by Susan L. Whitney, DPT, PhD, NCS, ATC, FAPTA

March 2018. Concussion Basics. Assessment, Screening and Risk Factors. Taught by: Anne Mucha, PT, DPT, MS, NCS and Susan Whitney, DPT, PhD, NCS, ATC, FAPTA

March 2018. Clinical Subtypes Following Concussion: A conceptual Framework for Evaluating and Managing Concussion. Taught by: Anne Mucha, PT, DPT, MS, NCS and Susan Whitney, DPT, PhD, NCS, ATC, FAPTA

October 2017 Vestibular Dysfunction- An algorithmic based Evaluation and Treatment. Speaker: Barry Morgan, PT

March 2017 Innovative Approach to the Management of the Cervical Spine: Maximizing Outcomes in Fewer Visits. Speakers: Jeff Ryg, PT, DPT, OCS, FAAOMPT. Kristen Carpenter, PT, DPT, OCS, FAAOMPT

November 2015 Orthopedic and Neurologic Perspectives on Concussion/Mild Traumatic Brain Injury Management. Speakers: Wendy Kriekels, PT, DPT, NCS, David A. James, PT, DPT, OCS, SCS, CSCS, Michael R. Greher, Ph.D., ABPP-CN, Katherine S. Dahab, MD, CAQSM, FAAP

Nov 2015 APTA SIG Event: The Role of Physical Therapy in Concussion Care. Speaker: Ann McNamara, PT, MPT, CCCE