Concussion Fundamentals

UPHILL ATHLETE PODCAST
CONCUSSION FUNDAMENTALS WITH DR. ELIZA SAMPEY

COLD OPEN

Eliza Sampey:

Like you can literally just die.

So I really can’t stress enough the importance of not getting another head injury within those first six weeks.

Because it tanks your blood flow and it tanks your metabolic system so deeply that it causes brain cell death. And you can literally die.

Steve House:

Wow. Okay.

Eliza Sampey:

And, yeah, like I said, like we said in the beginning, we don’t want to scare people, but I kind of do. Like, don’t hit your head again in the first six weeks.

Steve House:

Okay. Yeah.

COACHING CTA — GET READY

Steve House:

Whatever your next big objective is, there’s a version of you that’s ready for it, and a version of you that shows up simply hoping for the best.

Coaches don’t personalize plans around your specific goal, your life, and most importantly, your physiology. No pre-built programs here. Real coaching from people who understand mountain performance.

Whether your objective is 12 weeks out or 12 months out, the best time to start is right now.

So go to uphillathlete.com/getready and let’s get to work.

MAIN EPISODE

Steve House:

Hey, welcome to the Uphill Athlete podcast. I’m your host today, Steve House. And we are going to talk about how endurance athletes are comfortable with pain. Maybe this is you. We all know the difference between discomfort and danger. But in the case of head injury, it’s something different.

The brain can be injured without leaving a mark that you can see, and the cost of guessing the extent of that injury can be a problem for months or years.

If you are running trails, riding, mountain biking, skiing, climbing, or spend time just moving fast in the mountains, you are in the concussion business whether you want to be or not. You may not get one, but you will very likely be near one.

Today we’re talking about traumatic brain injury, including concussion. We are going to get specific about what happens in the brain when it is jolted or hit, why symptoms can be so strange and inconsistent, and what a smart recovery should actually look like.

Our guest is Doctor Eliza Sampey. Our guest is Doctor Eliza Sampey. Eliza was a professional endurance athlete herself for over 15 years, and she is also a Doctor of Physical Therapy, specializing in head and brain injury rehabilitation. She also knows this topic from the inside, having suffered a concussion herself and lived the long arc of recovery.

Doctor Sampey, welcome to the podcast.

Eliza Sampey:

Thanks for having me, Steve. I’m excited to be here.

Steve House:

Well, let’s dive in. We’re really glad to have you here. I want to kind of generate a little bit of awareness for people, of course, without generating fear. And I think that this is a real topic in our communities.

So in mountain endurance culture, what are the most common ways that people talk themselves out of taking a head injury seriously?

Eliza Sampey:

Well, Steve, I would say to start, for most of us outdoor athletes who end up having a head injury, this is going to happen in the backcountry. All right. It’s not going to happen walking down the street. Although I certainly, you know, have a lot of mountain athletes where that does happen. But generally it’s happening in the backcountry.

Steve House:

Yeah.

Eliza Sampey:

And so, you know, if we’re on a trip or even just out on a day trip, like we don’t want to quit. And also a lot of times we can’t right away. Like we’re in the middle of nowhere. We can’t just call for rescue, call our buddy to come pick us up.

So I think that’s a big deal – the kind of the start of the big way that we talk ourselves out of actually taking this seriously is because we’re in a place where it’s really tough to just stop moving.

And so we tell ourselves, like, okay, well, the other thing is it’s an invisible injury, right? So if you crash skiing and you break your leg, that’s a little more obvious. But a concussion, or any TBI, really, you can’t see it. It’s inside your skull. And so when we can’t see something, we don’t take it as seriously.

So I think the combination of not being able to see the injury and being in the middle of nowhere is kind of the two biggest things that lead outdoor athletes to not taking concussion seriously.

Steve House:

Yeah.

Eliza Sampey:

And then also, you know, what you already spoke to about: we’re conditioned to push through pain. Like, we like sufferfests, you know. And so we are just predisposed to not taking any injury seriously.

I know so many adventure athletes that push through pain and push through injury and, you know, myself included. Before I knew better, before I became a physical therapist, my young years as an athlete was full of that.

And so I think, you know, kind of our predisposition plus those two qualifiers of, hey, we’re in the backcountry, we can’t actually see this injury, makes it harder to take it seriously.

Steve House:

So what symptoms do you most often see in athletes who say they were fine at the time?

Eliza Sampey:

Oh, okay. So do you mean like months, weeks later, or kind of in the moment where they think they’re fine, but then they’re actually experiencing some?

Steve House:

Yeah, I think let’s talk about in the moment first, because I think identifying that there could be a potential problem and that people need to go into being patients rather than just, you know, suffer ”what is it? Hammerheads kind of like just going for it.

Eliza Sampey:

Hammerheads. Yeah. Yeah.

Steve House:

What would be some things that would come up?

Eliza Sampey:

Yeah. So the initial, like, I’m fine.” You know, like we get in a crash, we’re talking on skis, we smash off our bikes, whatever it is. We have a lot of adrenaline, right?

Steve House:

Yeah.

Eliza Sampey:

And so that will mask symptoms nearly every time. And so what I encourage people to do when they either hit their head or they get a big enough body blow that they’re really shaking around because we don’t have to hit our heads to get a concussion.

We also don’t have to lose consciousness to get a concussion. Only 10% of people that get concussions lose consciousness, right?

So, you know, if we have a hard hit, the best thing to do is to just chill out for, you know, ten, 15 minutes. Take some deep breaths, calm your nervous system, try to get that adrenaline down, right? Because that’s going to mask symptoms.

And so once people can do that, what I typically see with people is the physical symptoms tend to be a headache, especially if you’ve actually hit your head. But even if you haven’t, you can still get a headache, feeling pressure in your head, some kind of dizziness, lightheadedness.

A lot of people will just say like, Oh, I feel kind of woozy. I feel kind of off.

Extreme fatigue is a big one, and that’s not something that comes on right away. But say you think you’re okay, shake it off, get up, keep doing whatever you’re doing, and you start feeling really tiredlike more tired than you normally would that’s a big one.

Sensitivity to light and sound. So your buddies are around, your buddies are talking, and all of a sudden you’re like, “Shut up, people. I can’t stand to hear you talking,” you know, that kind of thing.

Balance issues, clumsiness. That kind of like, I’m skinning on the skin track and all of a sudden I’m falling off the side of the skin track, or I can’t make a kick turn properly, you know, things like that.

Another thing that I see a lot is irritability, right? So that’s kind of the biggest emotional symptom, because we have physical, cognitive, and emotional symptoms of concussion.

So irritability is a big one. A little bit of memory loss or confusion, right? That’s kind of more of the cognitive piece. And that should get better over the course of a few minutes. If it gets worse, that’s one of our red-flag signs, which we can talk about if you want.

But those are kind of the first things that I’ll typically see with people.

Sometimes nausea and vomiting will happen. You know, if somebody gets nauseous and they vomit once, like, yep, that’s a sign of a concussion. Persistent vomiting, that’s a red flag, right?

Steve House:

Yeah.

Eliza Sampey:

So, you know, those are kind of the big ones.

Sometimes people get neck pain. If you have a concussion, you also have whiplash just because of the force that it takes. The force to concuss the brain is a lot more than the force it takes to give you a whiplash injury. So you’re probably going to have some neck pain.

You might see some stars, or you might lose consciousness, but typically people don’t.

Steve House:

Okay. I think that’s important for people to remember, not just for themselves, but also if they’re a partner or a ski partner or training partner with somebody who, as you said, tomahawks down the run or trips on the trail and hits their head and gets themselves a nasty cut, and, you know, to keep these symptoms in mind.

Walk us through the first couple of minutes or hours after a concussion. What is the neurometabolic cascade in plain terms?

Eliza Sampey:

Yeah, okay. So I love talking about this.

So when a concussion injury happens, it used to be thought that it was the brain sloshing and bumping against the skull. You know, it’s called the coup-contrecoup injury. That has actually been pretty much debunked at this point. So that is not what causes the injury.

What causes the injury in that neurometabolic cascade that you’re referring to is a stretch injury of all of the nerve cells in the brain.

So when we take a head hit, when we take a body blow, if you think about putting Jell-O on a plate and you shake the plate around and the Jell-O wobbles on the plate, that’s what your brain does in your skull.

And when that happens, all of the tiny little nerve cells stretch.

Steve House:

Oh, okay.

Eliza Sampey:

And those axons, if I can paint a picture for people, so nerve cells, we’ve got a head, we’ve got a long little body, and we’ve got a tail. Okay? And that’s not really what they’re called.

But the long little body is called an axon. That’s the middle of the cell. And that axon has a bunch of little tiny doors inside of it.

Steve House:

Okay.

Eliza Sampey:

And under normal circumstances, those doors will open and close selectively based on what our brain needs our body to do, right? So they release ions, they release neurochemicals, little bits at a time.

So when those axons are all stretched all at once, all of those doors get stretched open.

And so what happens is neurochemicals that are in the brain cell flow out and ones that are outside the brain cells flow in. And so you’ve got this conglomerate of neurotransmitters and hormones that are not supposed to, they’re in bad places, right? They’re not where they’re supposed to be.

And so that is what actually causes the symptoms initially. And that’s what causes, you’ll hear the phrase “the brain is having an energy crisis,” right? And that is exactly why.

Steve House:

Yeah. That’s different.

Eliza Sampey:

Because all of those neurotransmitters are being released all at once. And they cause altered blood flow to the brain. They cause inflammation in the brain. That then trickles down to the rest of the body.

So that’s how the injury happens. And so that’s like the first minutes, right? The first couple minutes after an accident. That’s what’s happening.

And so then over time, over the first, you know, 24 to 48 hours, glucose travels to the brain via blood flow, right? And when the blood flow is altered, we can’t get enough glucose to our brain. And that’s how our brain makes energy.

And so the brain cannot make energy in the pathways that it is normally used to making energy. It has to go a different way and make energy through a different pathway.

Does that make sense?

Steve House:

Okay. Yeah.

Eliza Sampey:

Yeah. And so that secondary pathway that the brain uses in order to keep you alive is much less efficient. So it’s keeping you alive, but it doesn’t have much energy left for other things.

And so the fatigue that people feel after a concussion in those first 48 hours, most people will just want to sleep a lot.

That’s why. The brain is not able to effectively make energy in the way that it normally does. It has to do it a different way.

And so this microstructural injury, this injury to the axons the main crisis is in the first 48 hours. But it actually takes somewhere between three and six weeks for this energy crisis to fully resolve in the brain.

Steve House:

Oh, wow.

Eliza Sampey:

Yeah. And so this is where a lot of people get into trouble, because a lot of people have resolution of their symptoms within the first week to two weeks, and they think, “Oh, okay, my concussion’s over. I’m fine. I can go back to skiing or cycling or whatever it is.”

But really, their brain is still in that energy crisis for anywhere between three to six weeks, and there’s no way to know if you’re a three-week person or a six-week person.

And so what I tell the people that come to me—

Steve House:

A quick question: is that three-to-six-week person is it by person, or is it by injury? Are some injuries like my intuitive sense is that a bad injury would take six weeks to recover from and a less bad injury would take three weeks to recover from. But it’s not that way.

Eliza Sampey:

By person.

Right. No. That’s what you would think.

And so back in the day, we used to grade concussions grade one, two, and three.

Steve House:

Right.

Eliza Sampey:

And they would say grade-one concussion is the mildest form and it’s only going to take two weeks, and grade three might take six weeks, right?

That has been debunked. That is no longer used.

Because over lots of different studies of this over time, what the research has shown is no matter how, quote unquote, severe the concussion is initially, it really doesn’t matter. It’s anywhere between that three- and six-week time frame.

And sometimes the more mild-seeming injuries take that full six weeks to resolve, and sometimes the more severe-seeming injuries are more around the three-week time frame.

And no one knows why, right? Like, we know that that is the case with research, but we don’t know why.

And so the best way to proceed functionally is to assume that you are a six-week person, because you don’t want to hit your head again in that time.

If you hit your head again in that time or even if you don’t hit your head, as an endurance athlete, if you’re going back to intense training within that time and your brain is still having that energy crisis, you’re just digging yourself a hole.

Steve House:

Interesting. Okay.

Eliza Sampey:

And especially if you hit your head.

Steve House:

Yeah. And I want to come back to that, but I need to ask a question.

You don’t know if you’re a three-week person or a six-week person, so everybody should treat themselves as if they are six-week people. That’s what I heard.

Eliza Sampey:

That’s yeah, that would be the conservative approach.

Steve House:

How do you know when a brain injury is healed, so to speak? Like you said, it doesn’t seem like there’s an easy way to gauge that.

Eliza Sampey:

Yeah. So you just, I mean, based on the research, that’s what we use, is all of this research that has been done on actual metabolic and physiologic healing time.

That’s how we say three to six weeks.

But people that have persistent symptoms past that six weeks, that is no longer due to the actual structural injury. That has now become a functional injury of any of the seven—

Steve House:

Okay. Let’s get to that in a second. We need to go back to the reinjury question, because this is super important, right? Like, to not reinjure the brain in a certain window.

I want people to understand this because I think this is one of the most as a community, we need to understand and support one another when invariably some of our friends and partners have these injuries.

That we are not calling them up like, “Hey, let’s go skiing,” but rather calling your loved ones, being like, “Hey, how are you feeling? I hope you’re getting enough sleep and rest,” or whatever.

And seeing a qualified concussion specialist.

But why is the brain more vulnerable to a second injury in the early window after the injury happens? Why is that?

Eliza Sampey:

Yeah. So let me try to paint this picture for people.

When I’m in person or on Zoom with someone, I draw a graph, right? And I can kind of you know, maybe people watching on YouTube.

So we have this baseline, right? We’ve got this baseline kind of ceiling of where our brain’s neurochemistry normally is at, and where our brain’s blood flow normally is at, and where our inflammation level is normally at.

And we all like, exercise causes inflammation, right? That’s normal. So it’s okay to have a little bit of inflammation happening. But that’s part of our baseline.

And so when we have the concussive injury, we’re going along our baseline, and then the injury happens, and then the curve drops way down.

And we only have about, you know, 60% of our available energy, blood flow, metabolic structure, all of that stuff, right?

And the curve doesn’t just come back up quickly. The curve takes a while to come back up. That’s that three to six weeks.

And so if you get an injury again before your energy and blood flow and inflammation curve comes back to your baseline, it exacerbates what’s going on and it amplifies what’s going on.

It can drop to the point where you are missing 60 to 80% of your brain’s available energy stores.

Steve House:

Okay.

Eliza Sampey:

And now that mimics less of a concussion and more of a moderate to severe traumatic brain injury.

And then an even worse, another thing that can happen, and this is rare, but it does happen, is something called second impact syndrome.

And that is where, when you have a second impact within that window before the energy balance is restored, it amplifies it so much that it can cause sudden death.

Like, you can literally just die.

Steve House:

Oh my God. Oh, okay.

Eliza Sampey:

Yeah.

Because it tanks your blood flow and it tanks your metabolic system so deeply that it causes brain cell death.

And you can literally die.

Steve House:

Wow.

Eliza Sampey:

And, like we said in the beginning, we don’t want to scare people, but I kind of do. Like, don’t hit your head again in the first six weeks.

You’re probably not going to die, but you might.

And if you don’t, what can happen is it can prolong it from all of a sudden you’ve got, you know, you have a six-week recovery to a six-month or more, six-to-nine-month recovery.

So research has shown that if you get another head injury in that three- to six-week window, whichever one of those people you are lucky or unlucky enough to be, that metabolic recovery now stretches to a six-to-nine-month metabolic recovery.

And then you’re out for a while.

Steve House:

Yeah.

Eliza Sampey:

So I really can’t stress enough the importance of not getting another head injury within those first six weeks.

Steve House:

Okay. Okay. I’m not going to forget that personally.

Eliza Sampey:

Yeah.

Steve House:

So let’s shift a little bit, if we may, to sort of the first 48 hours.

We’ve kind of understood some of the risks and what’s going on physiologically. But an athlete is out for a run and they trip and hit their head on a log. What are the danger signs that mean sort of say to me or to my partner stop everything and go seek an evaluation?

Eliza Sampey:

Yeah. So red-flag signs.

And your trail-running example is a good one. And I also like to tell people, if you’re out on a backcountry hut trip, these are the things that mean you should call a helicopter, right?

So red-flag signs: sharp neck pain or tenderness of the cervical spine your neck that continues to get worse. That could signify a neck fracture.

Seizures and convulsions. That’s a red-flag sign.

Double vision that doesn’t resolve within a couple of minutes. So it’s normal with a concussion to have some double vision, but it should resolve quickly. If it continues on, that’s a red flag.

Loss of consciousness for me, well, this is a tough one because there’s mild, moderate, and severe TBI, right?

Concussion is mild TBI. Moderate and severe are worse. A delineator for concussion is loss of consciousness under 30 minutes.

That’s a long time to not have consciousness, right?

Steve House:

I would be freaking out.

Eliza Sampey:

And during that 30 minutes that someone’s not conscious, a lot of other bad things could be happening.

So what I like to say and this is me but loss of consciousness more than a few minutes, that should be an evacuation. You should be going to the hospital.

Weakness, or tingling and burning in your arms and legs. That’s not a concussion. That’s worse.

Repeated vomiting. You know, you throw up once or twice, that’s okay. If you’re vomiting and vomiting and vomiting and can’t stop vomiting, that’s a sign that you’re compensating pretty badly.

Severe or increasing headache. So yeah, you crash, you hit your head, of course you’re going to have a headache. But if that pressure and that headache just increases, increases, increases—

Deteriorating consciousness.

And this next stuff is kind of like any type of injury in the backcountry, right? Somebody deteriorating with consciousness, increasingly restless, become agitated, become combative.

Posturing. Decorticate or decerebrate posturing like, that’s immediate heli evac.

Or a visible deformity of the skull. And I’m not talking about, like, a goose egg on your head. You can have a goose egg on your head and not even have a concussion, right?

But if you have a visible skull deformity, you need to get out of there.

Those are the big ones.

Steve House:

Okay. So let’s leave the kind of first-responder-type stuff behind for now and come back to some of these points that I find confusing, one of which is rest.

What does the evidence support now for the first 24, 48 hours in terms of risks of doing too much or doing too little?

Eliza Sampey:

Yeah. So relative rest for the first 48 hours is what’s recommended. That’s best practice at this point.

Steve House:

What does that mean?

Eliza Sampey:

So relative rest doesn’t mean do nothing, right?

Basically, a good way to think about it is don’t do anything that’s making your symptoms worse.

So you can walk around your house, walk around your neighborhood. Light, light, light exercise is fine. But if it increases your fatigue, if it increases your headache, your dizziness, any of that stuff, stop and go take a rest.

It’s also relative cognitive and emotional rest. Cognitive work takes energy. Emotional work you know, maybe a hard emotional conversation—that takes energy.

And so it’s okay to do little bits of those things, but if it’s increasing your symptoms, you should take a rest.

Sleep is really important. So it is a myth that you should not let someone sleep after concussion. That is not true.

In the first four to six hours, that’s when it’s important to be looking for those red flags and that deterioration. So that’s important.

But after that, you should sleep as much as you can, right? That’s when our brain does its best healing.

And so part of that relative rest is taking naps, letting yourself sleep 14 hours a night if you need to.

What you don’t want to do is get on your bike and go for a ride. Even on your stationary trainer you know, you can sit on there and spin real easy, but if you start to get any symptom increase, you stop.

Does that make sense with that relative rest, first 48?

Steve House:

Yeah. And one of my questions was about cognitive load, work, screen time.

I mean, a lot of people might be like, “Oh, I’m going to the office on Monday. That’s my rest. It’s such an easy day.”

But we’re talking about the brain here. What does the cognitive work so many of us engage in this.

Eliza Sampey:

Yeah. Totally.

Steve House:

Yeah, that’s an area where it’s unclear. But now that makes a lot of sense.

Eliza Sampey:

So first 48, ideally you take that time off work. If you get injured in the middle of the week, take two days off.

And we switch screens real quick.

So research has shown that reducing screen time in the first 48 hours does make a huge difference. And if you’re on screens too much in the first 48 hours, that can prolong symptoms and prolong recovery.

I’m not saying don’t be on screens at all, but significant reduction of screen time in the first 48 is important.

Steve House:

And when rubber meets the road, it’s clear: I can’t go to work for these 48 hours, right?

What about some of the you know, you mentioned sleep, which is great to clarify, because I think I got so much of my education in these recommendations that are now 20 years old.

What about caffeine, and what about alcohol?

Eliza Sampey:

Yeah. So I recommend avoiding caffeine and alcohol and sugar and processed food for at least the first 48 hours.

But really, for that whole window, that three- to six-week period when your brain is healing, that is my recommendation as a provider.

Try to limit I mean, you know, some people are like, “I can’t survive without my coffee,” right? At least try to cut back.

Don’t drink alcohol in the first month after your concussion. Really try to limit sugar, processed foods, caffeine in that first month, and definitely not in the first 48.

Steve House:

Okay. And this one I’m going to put in the category of asking for a friend.

How do you handle the athletes that want to test it with a hard workout? Like you mentioned spinning on the bike for a second.

Because that’s something that I would hear. You know, me, I might be a person that would do that.

But also, as a coach, I deal with this all the time. Even when somebody gets a cold, right? And they want to test it with a hard workout.

So I know what I answer with regards to a cold, for example, or the flu or something.

But what about in the TBI world? I’m hearing that this is like a hard no.

Eliza Sampey:

Hard no.

Yeah. And I get this question all the time, too. And I say, with all due respect and with all the love in my heart, don’t be an idiot.

And, you know, as a coach, explaining that energy-crisis thing to them. Explaining that their brain is trying really hard to just keep them alive right now.

And if they try to test it with a hard workout, this just doesn’t make any sense, right?

You’re taking the resources away from your brain that it needs to just keep your guts functioning and your heart and lungs functioning.

It’s working really hard to rebuild that pathway, because like I said, within that first three to six weeks, it can’t use the pathway that it normally uses to produce energy. And so it’s got to take a different pathway.

If you think about driving to work and you normally take a certain road to work and it’s an easy road and you go on it every day, and then that road gets under construction, so you’ve got to find a new way to work.

It might take a lot more twists and turns. It might take stop signs, stoplights. There might be other construction you’ve got to avoid. It might take you a while to figure out what’s that new route to work.

It’s the same with your brain when it’s trying to figure out how to produce energy. It can’t use that normal pathway until that’s healed. That can take six weeks.

And if you make life harder for your brain, it’s going to just make everything worse for you and it’s going to prolong your recovery.

So kind of the same thing as being sick, right? If you try to train hard through sickness, your recovery is going to be a lot longer than if you just take it easy and do other things.

Steve House:

The reality.

Eliza Sampey:

Yeah, exactly. And it is hard to accept the reality.

I went through this myself, and it was really hard.

Steve House:

Yeah. And coming from a place of being a professional endurance athlete and being someone who suffered a concussion and had to rehab from that—

Speaking of rehab, rehab is active. And there are specific recommendations.

When you say concussion rehab, what are you talking about? What systems are you assessing and treating?

Eliza Sampey:

Yeah. So initially let’s take it to the beginning.

After the first 48 hours, the most important rehab is low-intensity, sub-symptom-threshold, steady-state exercise. That is the number-one most important rehab piece after the first 48 hours.

Steve House:

Why is that?

Eliza Sampey:

That is because it helps that healing process that your brain is going through.

So it helps your brain to re-regulate the blood flow. It helps to clear inflammation. And it helps your brain to, I guess, find that new pathway to work more quickly.

And all of those hormones and neurotransmitters out of balance it just helps that healing process, as long as we don’t overdo it.

Steve House:

It’s interesting. I mean, there’s an obvious parallel with endurance training where it’s a zone-one recovery workout.

And why does that help? Why does it help to go out?

I think it’s probably the same reason, right? All the things that you mentioned, and just probably increasing the blood flow to the damaged areas, getting more of the good stuff in and the bad stuff out.

Eliza Sampey:

Yeah.

And real quick you mentioned zones.

This is something that I have to wipe out of athletes’ brains all the time, because all of us have our heart-rate training zones, right? A lot of us have our power training zones.

This is not helpful in concussion rehab, right? It’s great for training.

But a lot of people will say to me, “Okay, so I can just spin on my trainer in zone one.”

No, not necessarily. Don’t look at zone one. You’re looking at sub-symptom threshold.

So it’s probably going to be even easier than your zone one. Like the very bottom of your zone one.

If someone’s like, Okay, I’m going to stay in zone one,” then they might start getting symptoms when they get kind of in the middle of their zone one, and they’re like, “Well, I’m in zone one, so it’s okay.

No, it’s not okay.

Steve House:

Good catch. Thank you for corralling me on that one.

Eliza Sampey:

I’m glad you brought that up because every single client that I have ever had comes to me and they’re like, “So, with my zones…”

And I’m like, okay, back up.

So I’m glad that you mentioned that.

So, kind of derailed this a little bit, but the very first rehab is that exercise piece. That is super important.

A big piece of misinformation about concussion that is still given to people by a lot of ER staff, urgent care, general practitioners, is that you are supposed to go and lay in a dark room and not do anything until your symptoms go away.

That is 100% damaging and dangerous and not correct at all.

That’s what we used to think 20 years ago.

But that has been debunked in the literature so many times. So don’t do that.

The other piece of misinformation that people get with, quote unquote, rehab is, “Oh, just go back to your normal life and return to your sports and your work and everything like normal, and you’ll be fine.”

That’s the opposite end of the spectrum. So you don’t want to do either of those things.

Within that first, I want to say, week or so: low-intensity, sub-symptom-threshold exercise, and then returning to the cognitive and the emotional work a little bit at a time.

So that is rehab, right? Gradual increase in activity.

And what we say in that initial four- to six-week period is you want to have a two-point symptom-increase threshold for everything except exercise.

Exercise, you’ve got to keep sub-symptom threshold in that time frame because of the energy-crisis thing.

But for everything else, say you’re returning to work, it’s okay to get a little bit of symptom provocation within like two points from your baseline.

That’s increasing that threshold very gradually. But it’s not blowing through that threshold and making things worse.

So two-point increase, okay. A little bit over two points, back off. Stop for a while.

And that’s a subjective scale, so it can be tough. But people really need to do their best to feel what’s going on in their body and keep that threshold.

So that’s kind of the basic, basic basics.

But what the research has shown is that the best predictor of people not having prolonged problems with concussion is getting in to see a concussion-literate provider within that first week to get guidance and education and early rehab activities and a plan.

And so you asked about systems. Should we go into that?

Steve House:

Okay.

Eliza Sampey:

You have any questions about what I just talked about?

Steve House:

Well, quickly, how do you I wouldn’t know how to know if someone is qualified in this area.

What do people look for? Is there a resource we can put in the show notes or something? Is there like TBI.com?

Eliza Sampey:

I wish it was that easy.

No. Okay. So this is really the hard part.

And for the acute phase, it is really normal to do a consultation with somebody virtually.

So I do virtual consultations, I do virtual rehab and management. That doesn’t necessarily mean that you have to find someone in your area.

If you want to find someone in your area, the best thing to do is talk to somebody that maybe you know has had a good experience with concussion rehab in your area.

And if you don’t have that, go to Doctor Google and Google “concussion clinic” in whatever town you live in. Concussion clinic Tucson, or whatever it is, and see what comes up.

And when you’re looking at people’s websites, you want to make sure that they actually list concussion as a service, because if they don’t, then it’s just like, oh, it’s kind of this ancillary thing that, yeah, we can do it but they don’t really specialize in it.

So if they do offer it as a service, then look at the bios of the providers in there. They should have something about concussion and why they like treating concussion and what their approach is.

You really want to try to vet these places.

And so that can be a good way to find somebody.

There’s really not a good database, but we’ll put in the show notes my website. I do virtual consultations.

I get a lot of people that call in that are from wherever in the world, and they don’t have any local resources—or they do have local resources, but they can’t find anyone that specializes in endurance athletes.

Because the rehab is different and more, the return-to-sport is different.

Acute rehab isn’t really different, but the return-to-sport process for an endurance athlete is very different than for a team-sports athlete.

And so, you know, that’s what I specialize in.

All of this can be done virtually. But if you want to try to find someone in your area, that’s the way that I would recommend going about it: really vetting that person and that clinic.

The other tough thing about this is there’s no certification in concussion, right?

Steve House:

Okay.

Eliza Sampey:

You can’t look at someone’s credentials and see “concussion-certified specialist.” There’s no certification.

And specialist education courses and programs can range from a weekend course to multiple years.

I’ve had literally two years of concussion-specialist education that’s postgraduate beyond my doctoral program, and some people just have a weekend course.

So ideally you want to get somebody who has been studying concussion for a while more than just, “Cool, I took this weekend course. Now I treat concussion.”

And maybe if they took a weekend course, at least they’re getting mentorship, they’re increasing their education and their knowledge.

So it really takes vetting the providers.

Steve House:

Right.

COACHING CTA — TRAIN SMART

Steve House:

Hard work alone doesn’t get you to the summit, but smart work does.

A lot of athletes are grinding without a real plan built around their body and their goals. Coaching changes that.

Our coaches build a personalized training structure around your life, your objective, and most importantly, your physiology.

Stop guessing and start progressing.

Go to uphillathlete.com/trainsmart to get matched with a coach that’s right for you.

Train smart.

MAIN EPISODE CONTINUES

Steve House:

Now let’s go to systems. I mean, that was a great answer.

And I think it’s important to answer because a lot of these things, it’s really hard to know.

It’s really hard, as someone who doesn’t have a deep knowledge of this any area that’s specialized. You could say the same thing about law, but certainly medicine.

It’s really hard to evaluate the competence or the experience of providers and make these decisions.

So that’s super, super valuable.

But let’s go to the concept of rebuilding systems. Let’s go into that. I think that’s super interesting.

Eliza Sampey:

Yeah. So this is a good kind of blend, because a lot of providers that you will go to will not do comprehensive, integrative care. And you want to make sure that they do.

So there are seven systems impacted by concussion.

The first one is autonomic, or physiologic. So that refers to our physiology, our autonomic nervous system, which controls every unconscious process in our body.

The oculomotor system, which is our visual system. And that’s not like visual acuity, like, “Oh, I have 20/20 vision.” That is the way that the brain processes input coming in from your eyes.

That’s very commonly impaired in concussion. And 60% of our brain is in some way or another devoted to vision. And so that’s a really important one. That’s something I see all the time.

And even if you don’t think your vision is impaired, it’s really important to get checked out because the tests that we do as specialists can pick things out that you might not necessarily notice.

All right. So visual system, oculomotor.

The vestibular system is the next one, and that deals with balance. That deals with proprioception, which is basically our body’s internal GPS. Like, where are all my body parts in space?

That can create symptoms like dizziness, things like that.

So vestibular system is another one.

The cervical spine, or the neck, is another system that’s impacted. We already talked about that a little bit with the whiplash.

And that doesn’t just mean neck pain, right? Our neck, our eyes, and our vestibular system integrate together in real life. And so the neck isn’t just on its own. It affects those other components as well.

And then the last two are cognitive and affective.

So the cognitive system is kind of obvious, right? And then the affective system is emotions and mood.

Those last two pieces are not the physical pieces, but all the other ones are.

And now headache and migraine that is commonly talked about as a subtype of concussion. But headache and migraine can be caused by any of these systems that I just talked about.

It can be caused by the autonomic system. It can be caused by the neck. It can be caused by visual dysfunction, vestibular dysfunction.

So headache isn’t really a subtype of concussion. It’s a symptom.

And then the last system that is affected is metabolic. And we talked about that already the neurometabolic cascade that happens. That is a system that’s impacted.

So to recap, we’ve got autonomic or physiologic, metabolic, visual, vestibular, cervical, cognitive, and affective.

Steve House:

Okay.

Yeah, I mean, obviously the brain is involved in basically everything, right?

Eliza Sampey:

Yeah.

Steve House:

We’ve talked a little bit about aerobic exercise in concussion care.

How do you I mean, you mentioned that it’s different than how we train the heart-rate or power zones and so on.

There are, my understanding is, kind of a similar ”I don’t know if it’s zones or some sort of grading of aerobic exercise.

And you mentioned that it’s below the level at which there start to be symptoms.

Is there more nuance there, or how do you prescribe it? How do you progress it? How does that look?

Eliza Sampey:

Yeah. So it is very nuanced.

And actually, before I go into that, do you want me to go into at all the importance of assessing all of those seven systems in the concussion evaluation?

Steve House:

Yeah. Yeah.

Eliza Sampey:

Okay.

So with the seven systems that we were just talking about and this kind of goes into how do you find a good provider—silo care, what we call silo care, so dealing with one of these systems at a time, does not work.

If you’re just dealing with your neck pain like I said, the neck, the eyes, and the vestibular system are all integrated.

And so if you’re just doing therapy for your neck, if you’re just doing therapy for your eyes, if you’re just doing vestibular therapy, if you’re doing these things in a silo, you might get a little bit better.

But you have to be able to integrate all of these systems together in order to resolve the injury.

And so when I do concussion evaluations virtually ”and when any good provider does a concussion evaluation you’re looking at all of those systems individually and how they’re playing together.

So a good rehab process should take you through isolating those different systems first.

And it doesn’t mean you’re only working on one, then when that’s resolved you’re working on another, then when that’s resolved—

It’s like you’re working on all of them simultaneously, but in isolation.

And then as you start to progress, you start integrating those things together.

So I will give someone specific rehab for their autonomic system, then specific for their visual, specific for vestibular, and for their neck.

And so they’re doing these things. And then as they start to progress ”because they’re doing all of these things, say, within the same day, or maybe every other day they’re doing cognitive and autonomic, then they’re doing visual, vestibular.

As they progress, then we tie them together.

So then I’m giving them exercises where they’re working their autonomic system at the same time they’re doing visual, or autonomic plus cognitive, or visual plus vestibular plus neck.

Does that make sense? Like how we deconstruct which systems are involved and then reconstruct it back up to make them integrate.

Steve House:

Yeah. That makes a lot of sense.

Can you give me some concrete examples of what some of these therapies is that the right term? Especially in the beginning when they’re siloed from one another, and then maybe an example of something that’s more integrated later on?

Eliza Sampey:

Yeah.

So autonomic and this kind of goes back to the question you asked on exercise.

An example of autonomic rehab is that heart-rate-guided steady-state exercise.

And we can dive way more into that, but I’ll just leave that there for a second.

Steady-state, low-intensity, sub-symptom-threshold exercise. That’s autonomic.

Visual: an example of a very basic beginning visual exercise would be something called, like, a thumb push-up, I like to call it, where somebody is going to have their arm out at arm’s distance from their face and they’re focusing on the creases of the knuckles in their thumb, keeping them in focus, and then bringing that thumb closer to your face.

Your eyes are trying to converge. This is a convergence exercise.

And then you’re trying to keep that in focus, and then you’re bringing it further away from your face, which is working on divergence.

The eyes contract in, the eyes relax out. Convergence, divergence.

That is one very tiny example of visual therapy. Lots of other things.

Smooth pursuits, saccades very basic starting visual therapy.

Vestibular: a really good example of a basic vestibular exercise would be tandem stance.

So that basically means you’re standing like you’re standing on a tightrope or a slackline or something like that.

You’ve got one foot right in front of the other, heel to toe, and you’re focusing on your breathing. You’re grounding through your feet. You’re feeling your feet on the ground, equal weight between both feet.

You’re effectively repositioning your body’s GPS. These are where my feet are on the ground. I’m noticing my breath.

So balancing in that position and trying to recenter your body’s vestibular process, basically.

And an example of basic cervical therapy very, very basic one chin tucks.

You’re laying on your back, your head is against the ground, and you’re tucking your chin. You’re not lifting your head off the ground. You’re just going to feel the back of your head kind of rotate on the ground as you tuck your chin.

You gently hold for a few seconds while you’re breathing, and then you relax.

Very, very basic starting cervical exercise.

So those are does that answer your question? Some very basic exercises.

Steve House:

Yeah.

And then what would be an example that would integrate several of those, or two of those?

Eliza Sampey:

Yeah. So let’s take autonomic and visual.

Maybe you’re on the bike trainer and you’ve gotten to the point where you’ve increased your heart rate with some steady-state things. You’re at the point where you can integrate.

So maybe you’re sitting on the trainer, and then you hold your finger out at arm’s length, and you keep your head stable, and you follow your finger from side to side with your eyes.

So this is called smooth pursuits.

You’re doing this while you’re getting your heart rate up a little bit more. So your brain is having to work harder. You’re managing your heart rate that’s the autonomic nervous system and now you’re involving this visual component.

Visual-vestibular integration could be you’re standing in a tandem stance and you’re doing that same visual exercise.

And cervical integration might be you’re standing in a tandem stance, you’re turning your head 45 degrees to the side, and you’ve got a headlamp laser on your head, and you are tracing the outline of a piece of art on your wall.

That’s a more advanced integration of visual, vestibular, and cervical.

Steve House:

Okay. Interesting.

One of my questions had been to talk about cervical injury overlapping with concussion symptoms and how to differentiate those.

But what I’ve learned one of the many things I’ve learned is that I was thinking about this all wrong. It’s also integrated.

And I really, really appreciate that.

Eliza Sampey:

Yeah.

And when you’re vetting a provider, too say, okay, I’m someone who got a concussion, I need to find a provider. I listened to the Uphill Athlete podcast with Steve and Eliza. I know about these things. I know that I need to have an integrated approach.

Ask your provider questions about these systems.

They should be able to answer your questions, and they should be able to tell you where you’re going in your rehab.

Like, we’re starting here, we’re progressing to here, here’s our goal for integrating these systems in this way, these are the systems that you have involved.

Because everyone’s a little bit different.

It’s uncommon for someone to only have one system involved, but people don’t always have all the systems involved.

And so a good examination and evaluation teases out which of the systems are actually involved.

So your provider should be able to explain that to you after the assessment and over time.

Concussion is a really confusing injury to people that don’t know the nuances of it.

And even my clients right now I’ve got clients that I’ve worked with for a few months now, and they still ask questions. They’re like, “Okay, I’m understanding this better, and now I still don’t understand this component. Can you explain it again?”

Absolutely.

Your provider should always be willing to explain things to you in different ways and from different angles and at different points along your journey.

So don’t be afraid to ask your provider questions.

And if they can’t answer those questions, they should either say, “I don’t know. Let me go find out for you,” or they should be humble and understand that they’ve reached the end of their scope of care and they need to refer you.

Steve House:

Yeah.

And I think that’s also a good reminder for all of us to be very proactive whenever we’re engaging with rehabilitative or any kind of medical care.

It’s super, super important to just be proactive in this way.

And I think a lot of us are afraid to be. I’ve certainly felt that in the past.

Eliza Sampey:

Yeah.

You know, we’re like, “Oh, they’re the doctor. They know best.”

Not always.

Steve House:

Yeah. And questions are always valid.

So what are some of the mistakes that you see endurance athletes making during the rehab process?

You’ve mentioned several of them, perhaps, but are there some common ones that you want to highlight for us?

Eliza Sampey:

Yeah.

So the biggest thing is going back into high-intensity or long-duration training too quickly.

And this can maybe go back to your other question about what does that process look like.

When I do autonomic rehab with somebody, it’s not quite as simple as just exercise under your symptom threshold.

It is that simple in the beginning, you know, for the first 48 hours.

But when somebody comes to me, even in that acute phase between 48 hours and six weeks, I’m doing exercise-tolerance testing with them.

And so the gold-standard way to do that is called the Buffalo Concussion Treadmill Test or the Buffalo Concussion Bike Test. You can do it on a treadmill or on a bike.

Usually I prefer to do it on a bike.

Here’s a funny thing with endurance athletes: walking on a treadmill is probably not going to give you symptoms because you are highly, highly fit, and it’s likely that your brain is going to be able to compensate during that time.

High-level athletes that are very active you have a very healthy brain and body. Normally you’re going to be able to compensate better than most people.

And so a lot of these things won’t show up in this standardized testing.

If you’re running on a treadmill, that’s going to exacerbate your visual system, your vestibular system, your neck, right, when you’re bouncing up and down.

So I prefer to do this on the bike because it takes that out of it.

And so what this is, is it’s a test that can take up to 20 minutes, but it ends when somebody has symptoms over two points.

We start at a very low heart rate, a very low rate of perceived exertion, and a low cadence.

Then I ask people every two minutes, how are you feeling? What are you at? What are your symptoms?

We ask them that at baseline. So what are the baseline symptoms?

And then every two minutes we increase the heart rate. Every two minutes we increase the heart rate, I ask them the same questions.

And I’m talking to them a little bit because I want to see them decompensate, especially endurance athletes. We compensate so well.

But if we put that cognitive piece in, we’re going to catch it.

Maybe you’ve gotten to a heart rate of, say, 140, 145. You’re doing fine.

And then I start asking you questions and all of a sudden you’re fumbling over your words, or you can’t talk, or all of a sudden your headache shoots up.

That’s a failed test.

That’s a sign that you cannot sustain regular-person activity, like talking, while you were trying to maintain this heart rate.

So we find the heart rate at which you get that over-two-point symptom increase.

And then what we do is we go back to anywhere between 85 to 90% of that heart rate, and that’s where we start the rehab.

Makes sense?

Steve House:

Yeah. So it’s very personalized.

Eliza Sampey:

It’s very personalized.

And the way that I do it virtually most of my athletes have bike trainers at home. But the ones that don’t, they go to a gym and sit on a spin bike and we do the test together.

If someone absolutely does not have access to a spin bike, we can do it walking and jogging. I don’t prefer that, but it’s fine.

And so then the protocol and this is from the research the protocol is 20 to 30 minutes of that steady-state exercise at that heart rate.

We’ve got warm-up first. Normal protocol is a five-minute warm-up. For endurance athletes, I usually go to ten to warm up the autonomic nervous system.

And then it’s 20 minutes at that heart rate that I have prescribed. And then you have the cooldown.

And you’re doing that five to seven days a week.

So that is the initial protocol for exercise.

And so where endurance athletes get it wrong is either their provider doesn’t pick up on this because of what we just talked about.

They get through the testing and they don’t have any symptom exacerbation.

Usually I don’t see this early on, but I do see it in people that are in that three- to six-week margin.

And I definitely see it in people that are after that six-week margin. They still have autonomic issues, but they’re not flagging during that test.

And so we have to test harder.

Part of this is on us as providers: when you get an endurance athlete into your clinic or into your virtual practice or whatever it is, you really have to test these people hard.

And sometimes it’s not about testing them in the moment.

I have a current client that I just signed who I guarantee would pass that test with flying colors.

Her symptoms come on after exercise.

She went out for a three-hour gravel ride on, I think, New Year’s Eve. She felt totally fine. She sent me her heart-rate data. She was getting up into the low 180s. She felt totally fine.

But then she was tanked for three days afterwards.

That is a common thing that I see with these endurance athletes.

And so sometimes it’s not the testing you’re going to do in the clinic or on a Zoom session with me.

It’s that provider saying, okay, we’re going to dig harder into this because I’m seeing these things that are giving me flags that your autonomic nervous system is not working properly.

And so it’s going into TrainingPeaks, looking at their TrainingPeaks files. What are their heart rates doing during their exercise? How are they feeling afterwards?

How are they responding if they’re training with power?

Are their heart rate and their power consistent? Or is their heart rate way higher than it should be when they’re putting out that amount of power? Or is their heart rate way lower than it should be when they’re putting out that amount of power?

The autonomic nervous system regulates our heart rate and our blood pressure.

And if the heart is doing something that it shouldn’t be doing, that’s inconsistent with your output, that is a sign of autonomic dysfunction.

So a lot of what I see the autonomic nervous system rehab getting missed is actually on the provider.

And when you’re the athlete, you don’t know, right? Because a lot of times exercise feels good.

So I get a lot of athletes that come to me and they’re like, “I don’t understand why I’m starting to feel so bad. I don’t understand why I’m starting to feel so fatigued. I thought I was just deconditioned, but I started training harder and now I feel worse.”

Going back to your original question I know I kind of went off here but this is something that I’m very passionate about with endurance athletes.

Coming back to sport too hard and too fast, with intensity and duration, will dig you a hole that can take months or years to get out of.

Steve House:

Yeah. Yeah.

And that’s one of the big take-homes from today for me: that truth, and then we need to manage for it.

Eliza Sampey:

Yeah.

And it’s not that we have a concussion problem. It’s that we have a concussion-management problem.

A concussion is a treatable injury that can fully get better.

And the reason, typically, that it persists and persists is a problem with the management of the concussion, especially early on.

Steve House:

Yeah. Okay. Interesting.

So if you could hand an athlete a one-page good-patient checklist one page, not 26 or whatever you said you have what would be on it?

Eliza Sampey:

Well, the very first thing that would be on it would be what not to do.

And that is: don’t hit your head again in the first six weeks.

Don’t go home and lay in a dark room till your symptoms go away.

Don’t go home and go back to your regular intense training, even if it’s just on a stationary bike or a treadmill.

Those would be the first things.

And then the things to do:

Relative rest in the first 48 hours.

Let yourself sleep.

Cognitive, emotional, physical rest.

After that, steady-state, low-intensity, sub-symptom-threshold exercise.

Get a lot of really good sleep.

Get yourself in to see a concussion-literate provider within the first week.

I would say those are the things that would be on my note card.

Steve House:

What would you like to see patients athletes communicating with their clinician?

Are there metrics or things that they should track, like hours of sleep, emotional mood triggers?

Are there things that they need to be bringing to that provider’s attention and keeping track of?

Eliza Sampey:

Yeah. So I love this question.

Symptom tracking is important.

And tracking writing down when you have symptom flares and what you were doing so the provider can help know what could potentially have caused the symptom flare, and then revise your rehab accordingly to address that thing.

So that’s the physical stuff, the emotional stuff, the cognitive stuff. That’s all important to track.

In terms of data, every provider is different.

But for me, because I am so focused on endurance athletes, I want to see people’s resting heart rate in the morning. I want to see their heart-rate variability in the morning.

I make everybody that I work with download an app called HRV4Training.

And that checks heart rate, heart-rate variability first thing in the morning before you eat, drink, before you scroll social media, before you talk, before you whatever.

First thing when you wake up, I want to see how well your autonomic nervous system has recovered from a night of sleep, from the stressors the day before.

So you don’t have to do that before you come in to see me, but first time I get to you, we’re going to be doing that.

If you hear this and you want to be proactive like, if I ever get a concussion, this would be good for a provider to know start tracking that every single morning.

Energy levels are an important thing to talk to your providers about.

Sleep is really important. And that’s another thing that’s commonly missed.

A lot of people don’t equate that to concussion, but it 100% is impacted by concussion.

So talk to your provider about how you’re sleeping.

Sleeping too much, sleeping too little, having trouble falling asleep, waking up in the middle of the night these types of things.

Mood. Anxiety and depression are really common after concussion, especially if you have a history of that.

So the brain that you bring into the injury matters.

And anything that you have going on before, whether that’s psychological or physical, that is going to be amplified after a concussion.

So you want to make sure that you tell your provider those things and that you track those things over time and let your provider know.

The way that I work personally is I do treat concussion rehab in a coaching framework.

So it’s not just you’re coming to sessions with me once a week or every other week or twice a week, and that’s the only contact I get with you.

I am your coach, and we are talking every day not on the phone, but with TrainingPeaks comments and with WhatsApp.

So asynchronous communication.

I want to know, after my clients do their rehab workouts, how those went, how they felt, what their heart rate did, if they got symptom exacerbation.

So they’re leaving me paragraphs of TrainingPeaks comments.

And then I go in and I look at that, and if I have a question on that, I ask them, and I use that to guide their rehab.

So in real time, I want people to be telling me how they’re doing.

I check my messages twice a day except for on Sundays.

And so concussion isn’t just the rehab that you do in a clinic or in a session if it’s virtual.

It’s the rehab that you’re doing in your life.

It’s when you’re getting back into your skiing, when you’re getting back to work, whatever that is.

Life is rehab.

And it can be really productive rehab if you do it in the right way, guided by a concussion expert.

And so all of that stuff is super relevant, at least from my perspective, because that’s how I know when people can start integrating, when people can progress, all of that stuff.

Steve House:

Okay. Lots of good stuff there.

Are you wanting a friend or a partner to support someone who potentially has a concussion in these ways, too?

Or is this part of the evaluation?

Because it’s a lot. It’s a big cognitive load just to keep track of all this stuff.

You’re telling me this is something where people need support.

Eliza Sampey:

Yeah. Oh yeah. Totally.

Steve House:

And how do we do that in a way that helps rather than pressures?

Eliza Sampey:

Yeah. Ideally, it’s definitely helpful to have support.

In my intake forms for people, that’s one of the questions I ask: what is your support system, and how are they able to help you through this?

And so if you do have a partner or a close friend, family member, that can help you keep track of all of the stuff, that is super useful.

With partners, it can be tough.

I know when I went through this, my partner didn’t really know how to help me. He’d never really been around somebody with a concussion.

Fortunately, I knew how to tell him what to do.

But be gentle with that person.

If you’re a partner or a friend of someone with a concussion, you can’t see their injury. It’s inside their skull.

Encourage them to rest. Encourage them to get small amounts of exercise in the beginning.

But don’t expect them to be who they were before the injury right away.

They’re going to need more rest. They’re not going to be able to get up at sunrise and go on that long bike ride or ski tour.

You want to support them in their recovery.

And the best thing to do is ask them, “How can I support you?”

Because the answer is going to be different for everyone.

For me, one of the hardest things on my brain, cognitively, was making meals.

That was so hard the executive function of managing all the ingredients and when things needed to go places.

I couldn’t even make a sandwich at the beginning.

And so I told my partner, “The best thing you could do for me is take over the meals while I focus on recovery.”

And then I also told him, “I don’t want you to do everything for me. Let me do things. But here are some things that are really challenging that would be really great if you could just take over for a while.”

So if you’re the person with a concussion, advocate for yourself.

If you’re the partner or the friend, ask, “How can I support?”

Steve House:

One of the questions I have and this is a little bit of a change of topic but how much are brain injuries additive or cumulative when they’re spaced out from one another by more than six weeks? By maybe years?

I got hit on the head by a big piece of ice four years ago. And then I took a bad ski fall one year ago.

Is there a connection, or is that something we need to understand as active people?

Eliza Sampey:

Yeah.

And I’m really glad you asked this question because this is really important.

It is less important how many concussions you get, and it is more important how well you rehabilitate those concussions.

Steve House:

Oh, interesting. Okay.

Eliza Sampey:

Yeah.

So when you get a concussion we already talked about all the things that happen.

Back in the day, it wasn’t common to go to rehabilitation for a concussion.

So maybe four years ago you got hit in the head by a piece of ice and you think that thing’s resolved and you’re going about your life.

Things could have resolved, but what’s likely is that your brain has learned how to compensate.

So, again, like I said before, high-level athletes our brains and our bodies are really, really good at compensating.

So if you have another concussion later, years later, and you’re feeling all of these symptoms, that could be that your brain has been compensating for a long time, but it really had this stuff underlying and now it’s coming back out.

So I get a lot of people that are like, , I had this bad concussion years ago and I’m pretty sure I recovered and I was fine. And then this concussion—I don’t know why this is so bad. I just kind of bonked my head and it wasn’t really that awful.”

That’s likely why.

Because your brain was compensating all this time, and then all of a sudden it can’t anymore with this new head bonk.

So it’s really important to effectively rehabilitate every single concussion that you have and make sure there aren’t things lurking under the surface that are going to come back to bite you if you get another head injury or even if you don’t.

I had a person that I was working with who has graduated.

He had a concussion, I think, a year and a half ago. And it resolved quote unquote resolved.

Then he decided he wanted to get into bike racing. And so he started training harder than he ever had.

And all of these symptoms started coming back.

And because it had been so long and he hadn’t had those symptoms in a year and a half, he didn’t equate those symptoms to that old concussion.

And so he went through this whole journey in the medical system with his GP and with neurologists and psychologists and all these people trying to figure out his symptoms, and they couldn’t figure it out.

And he heard me on a podcast actually talking about my own experience.

And he emailed me and he’s like, “Hey, I’m having all of these things. Could this be this old concussion?”

And I said, “Absolutely.”

Got him on Zoom. We did an evaluation.

And sure enough, he had all these things in the visual system, the autonomic system, the vestibular system that were now cropping up.

And he hadn’t even had another injury.

He just had that added stress of all of a sudden trying to train at a high level when his brain had been compensating for quite a long time.

And all of a sudden, with this new stress, it couldn’t compensate anymore.

So it’s not so much about the amount of injuries.

It’s that the brain you bring into each injury matters.

Steve House:

That’s a super great example.

And I’m sure that there’s going to be listeners with lights going off in their brains right now, having heard that.

Because, I mean, I would have never thought of that.

Who would think of that?

And obviously, a whole bunch of medical providers for this individual didn’t think of it either.

And in hindsight, as is often the case, the solution was relatively simple.

But you just needed the right piece of knowledge to fit the key to the lock.

Eliza Sampey:

Yeah.

And I guess, real quick with that, can I add something real quick?

So a concussion specialist is typically going to be a rehab provider.

So a physical therapist, sometimes a chiropractor.

Sometimes a physician, if they are like, “I am a concussion-specialist physician,” but they’re not doing the rehab.

So if you’re in this situation like my client and you go to a GP or even a neurologist, they’re not specialists in concussion.

They should not be expected to fix your concussion symptoms.

Their job is to refer to someone who can.

Steve House:

Yeah. Yeah.

The neurologist is doing brain surgery, or not doing the rehab after the brain surgery, for an extreme example.

Eliza Sampey:

Right.

And they can prescribe medication for some concussion symptoms.

But they’re not going to do the rehab.

Steve House:

Yeah. And I think it’s important to say we will create a blog post that will have a lot of this content, and you’re going to help me with that.

And we’ll look at a bunch of these definitions for those who are taking all of this in a podcast or on YouTube.

There will be a reference and we will link to it in the podcast notes, because there’s concussion, TBI, complicated concussion, severe TBI, post-concussion—

Eliza Sampey: Post-concussion syndrome.

Steve House: syndrome.

And these red flags, and decisions to seek emergency care, and all of these different things.

And we’re going to just put this out in black and white for people.

So I have one to wrap this up.

What can be one of your final take-home messages?

What’s maybe a thing to stop doing or a thing to start doing around concussion rehab, concussion treatment, concussion awareness?

What comes to mind?

Eliza Sampey:

I guess the first thing that comes to mind, especially for our demographic that you and I are both in backcountry athletes is take this injury seriously.

It’s really important that you do.

And if you’re out in the backcountry, if you’re on a trip and you or your buddy has a suspected concussion, take it seriously.

Get out of the backcountry safely.

If you’re on a hut trip, maybe you’re resting in the hut instead of going touring.

But get out of the backcountry safely. Get evaluated quickly.

Take it seriously.

Don’t just ignore it because you’re pushing through the pain. You’re a hardcore athlete that can push through anything. You can’t see the injury. You’re in the middle of nowhere.

Take this stuff seriously.

Kind of going back to what we talked about at the very beginning, that would be, I guess, my takeaway message.

Because it is serious.

It’s your brain.

It’s a brain injury.

Steve House:

100%.

Well, thank you so much, Doctor Sampey.

This has been super educational for me and absolutely changes the way and updates a lot of the outdated education that I was still walking around with.

So thank you so much for that.

And for all those that are listening, as Doctor Sampey said, if you suspect a concussion, take it seriously and get assessed.

And we’ll add a bunch of resources, including how to get in contact with Doctor Sampey, in the show notes.

Eliza Sampey:

Yeah, absolutely.

Steve House:

And in that blog post.

Thank you so much for listening.

Remember, together we are all athletes.

Have a great day.

Thank you, Doctor Sampey.

Eliza Sampey:

Thanks, Steve.

Thank you.

That was awesome. Awesome. Thanks so much for having me.

COACHING CTA
Steve House:

I’ve spent a lot of years in the mountains learning what it actually takes to reach really hard goals.

And one of the biggest things I learned is that you don’t have to figure it out alone.

Having a coach changes the way you train, but more than that, it changes the way you think about what’s possible for you.

That’s what Uphill Athlete coaching is built around.

Not just building fitness, but building the belief that your objective is within reach and giving you the specific science-backed path to get there.

Our coaches have guided athletes from their very first alpine routes to the top of the world, and at every level in between.

If there’s something you want to do in the mountains, go to uphillathlete.com/believe and let’s figure out what you are capable of.