My toolbox for brain injury recovery

How I think about recovery interventions, and what's been helpful to me so far.

Last week I wrote a post outlining my recovery to date from a Traumatic Brain Injury (TBI). This is post #2 of a short series covering my journey and learnings. Today, I’m going to walk through what’s been helpful to my recovery. As a heads up, I use the terms ‘brain injury’ and ‘concussion’ interchangeably.

Disclaimer — I’m not a doctor, and everything I’m writing is for informational purposes only. It’s not intended to be a substitute for professional medical advice, and shouldn’t be relied on as health or personal advice.

Some initial caveats

For a few reasons, it’s hard to say with full conviction that any specific change I made directly improved my symptoms:

1. Small sample size - I’m just one person, so there’ll always be a large margin for error with my conclusions.

2. No control group - I don’t know how recovered I’d be if I’d done nothing, i.e. how much of my recovery is simply due to time passing.

3. Intervention noise - Trying lots of things at once makes it hard to know what had an effect and what didn’t.

4. Cognitive biases - You really want things to work (confirmation bias), and momentary pain skews your perception of recovery level (availability bias).

All in all, it’s very possible that some of my conclusions are wrong. To help address this, I’ll call out my views on whether an intervention has a strong evidence base, and how confident I am that it helped me.

Concussion frameworks I live by

My recovery activities in dealing with my brain injury are informed by two overarching frameworks.

Framework 1 - The Threshold

We all have a ‘threshold’. If you work like crazy and don’t sleep for two days, you’ll probably start to get headaches and feel like shit. With a concussion, that threshold comes down to a much lower level.

Many doctors will advise that you completely avoid activities that exacerbate your symptoms - e.g. until you’re symptom free when exercising, don’t go to the gym.

There’s strong consensus that in the first 48-72 hours after injury, it’s important to rest as much as you can, stay away from screens, and avoid anything that exacerbates your symptoms. It’s also critical to not get another concussion while recovering from the first. However, specialists such as Dr. Cameron Marshall and Cognitive FX will tell you that after the 48-72 hour period, inactivity is the enemy, and instead you need to slowly but methodically “push the threshold up”.

While you need to avoid doing things that cause prolonged or major exacerbation of symptoms, if you sit around and do nothing, your tolerance will decrease.

Framework 2 - The Pyramid

Dr. Marshall, founder of Complete Concussion Management, argues that recovery will be held back by relying only on concussion-specific interventions, without also addressing psychological state and diet.

Level 1: Mental health

Recovering from a brain injury can be fairly anxiety inducing. You need help taking care of yourself, you can’t work, you’re in pain, and you worry about whether you’ll get better. You also need to constantly question whether you can do something, how to do it, and whether you should stop once you’re doing it (e.g. going for a walk). This means that you’re often on high alert, which overactives the anxiety response.

The main way that anxiety and depression prohibit concussion recovery is by creating self-reinforcing negative feedback loops. Stress causes symptoms such as headaches, nausea, and dizziness, which overlap with other concussion issues. Sleep, which is critical to recovery, is the next domino to fall. When your symptoms start feeling worse and you’re not sleeping well, everything goes downhill ⛷️.

Fear-avoidant behavior makes it hard to get better at the daily life activities required for recovery. If I’m really stressed about whether I’ll be ok going to the grocery store, I’m more likely to have a bad experience when I go. If this causes me to avoid going to the grocery store in the future, my nervous system ends up becoming more sensitive over time. In a similar vein, it also becomes very difficult to manage setbacks as you end up buying into the catastrophizing narrative of “Everything’s completely fucked forever”, which continues the downward spiral.

Patients with concussion who have high fear avoidance in the weeks following injury are more likely to experience adverse health outcomes - Dr. Cameron Marshall

Level 2: Diet & nutrition

Concussion is often accompanied by chronic inflammation in the brain and the gut. You might be surprised by the later, but it turns out that the brain and the gastrointestinal (GI) system are deeply connected. Chronic inflammation leads to a range of issues including a heightened stress response, sleep deprivation, and digestive problems. Your diet plays a big role here, so it’s important to maintain a balanced and nutritional diet that helps fight inflammation.

Healthy eating won’t make post-concussion syndrome go away. But it will give your brain a better shot at recovery and help it function as best it can - Cognitive FX

Level 3: Concussion-specific interventions

After taking steps to address mental health and diet, you can then expect greater success in other concussion-specific interventions.

Interventions

For the rest of this post, I’m going to talk through the specific interventions that I believe have helped my recovery.

Meditation and living mindfully

• Evidence-base supporting this: Very strong.

• Confidence that it helped: 95%

• Confidence that it helped A LOT: 90%

• What I did: I practice both Insight Meditation and Zen, typically doing 30-45 minute sits daily. I also work hard to maintain awareness in my life outside of formal sitting. During my recovery, I became involved in local meditation communities, worked one-on-one with a Zen teacher, and attended a 7 day silent-retreat at Spirit Rock (highly recommend!).

• Benefits I’ve experienced: Reducing stress, increasing gratitude, lowering the intensity of fear, greater ability to ‘ride the waves’ of overwhelm, and giving me a positive perspective on my injury.

More to say here - I’ll be writing about this topic extensively over the next few weeks in a non-concussion context!

Talk therapy

• Evidence-base supporting this: Very strong.

• Confidence that it helped: 75%

• Confidence that it helped A LOT: 20%

• What I did: Weekly therapy with a neuropsychologist experienced in working with TBI patients. I’ve done a lot of therapy in my life - I found it helpful to work with someone who deeply understood TBI suffering, and had advice and strategies that had been battle-tested with other TBI patients.

• Benefits I’ve experienced: Shift in perspective, working through fears around remaining disabled, taking a wider view when distressed, and learning tools such as functional analysis and tactical deep breathing.

Anti-inflammatory diet

This diet involves going long on fruits, veggies, nuts, whole-grain carbs, and certain animal products (chicken, turkey, fish, eggs), while avoiding added sugars, processed food, refined carbs, unhealthy oils, red meat, and alcohol.

• Evidence-base supporting this: Strong, but still nascent in a brain injury context.

• Confidence that it helped: 75%

• Confidence that it helped A LOT: 30%

• What I did: I adopted a version of this diet, adjusted to also exclude concussion specific items (caffeine and artificial sweeteners). I tragically had to also adjust the diet further to avoid acid reflux triggers, as thanks to my injury I now have acid reflux (yay!).

• Benefits I’ve experienced: Majority of my GI issues slowly faded away. Surprisingly, the asthma that I’ve had since childhood also improved.

The more I’ve learned about the association of chronic inflammation with serious longer-term health issues, the more I’m set on staying on a version of this diet indefinitely.

Cardio

• Evidence-base supporting this: Very strong.

• Confidence that it helped: 95%

• Confidence that it helped A LOT: 80%

• What I did: Stationary bike every day for 30-40 minutes (1 minute high intensity intervals), targeting specific heart rate thresholds. I underwent the Buffalo Concussion Treadmill Test (BCTT), which determined I could safely exercise up to a heart rate of 145. I gradually increased this over time, and I can now exercise at a heart rate of 175-185 (which I measure through a fingertip monitor).

• Benefits I’ve experienced: Mental health boost, improved sleep, and generally feeling better overall.

It’s worth noting that after the initial 48-72 hour period post-injury, cardio is one of the most important things to do for recovery as it promotes blood flow to the brain.

If running and other movement-related cardio causes you no issues, go for it. If like me, you struggle with movement related dizziness and nausea, a stationary bike is the best bet.

Weightlifting

• Evidence-base supporting this: Still nascent in a brain injury context.

• Confidence that it helped: 80%

• Confidence that it helped A LOT: 25%

• What I did: Weightlifting 5 days a week. Lifting was a key part of my fitness routine pre-concussion, which meant that not being able to lift weights really sucked. My physical therapist encouraged me to try lifting at low weights, and over several months I slowly got back up to ~90% intensity.

• Benefits I’ve experienced: Major mental health boost in getting some of my old life back.

Vestibular Physical Therapy

This treatment addresses dysfunction of the vestibular system, which for me has caused pretty debilitating dizziness, as well as blurry vision, nausea, and exercise intolerance.

• Evidence-base supporting this: Very strong.

• Confidence that it helped: 80%

• Confidence that it helped A LOT: 65%

• What I did: Vestibular physical therapy 2-3x a week. This involves identifying triggering activities, and then slowly and methodically building exposure and tolerance to those type of activities. One example of this involves overloading your senses by doing head turns while walking on a treadmill, while also catching a ball and doing maths equations at the same time.

• Benefits I’ve experienced: Improved tolerance for movement and exercise, greater ability to deal with chaotic physical environments, lots of useful techniques such as ‘gaze stabilization’, and tactical deep breathing.

Acupuncture

• Evidence-base supporting this: Still nascent in a brain injury context.

• Confidence that it helped: 70%

• Confidence that it helped A LOT: 45%

• What I did: Weekly acupuncture sessions. My acupuncturist set expectations well by saying that it wouldn’t fix all my issues, but that it’d likely lead to small, noticeable improvements to my Autonomic Nervous System (ANS) dysfunction.

• Benefits I’ve experienced: Significantly improved sleep quality and GI issues.

Melatonin (extended release)

• Evidence-base supporting this: Still nascent in a brain injury context.

• Confidence that it helped: 70%

• Confidence that it helped A LOT: 45%

• What I did: 3mg Extended-Release Melatonin an hour before bedtime. For a few months after my injury, I would oten wake up between 2-4am and be unable to fall back to sleep. I first tried taking standard-release Melatonin, and then switched to the extended-release version.

• Benefits I’ve experienced: Significantly improved sleep length and quality.

Deep breathing

• Evidence-base supporting this: Very strong.

• Confidence that it helped: 90%

• Confidence that it helped A LOT: 65%

• What I did: 20-40 minutes of focused deep breathing daily. During the months when my symptoms were at their worst, I defaulted to breathing this way whenever I was present enough to do so. This form of deep breathing focused on targeting the abdominal region just below the lower rib, and having each exhale (6 seconds) be longer than each inhale (4 seconds).

• Benefits I’ve experienced: Symptom relief across nausea, dizziness, and anxiety. Also much better tolerance at withstanding challenging stimulating situations such as going to the grocery store.

A note on why this works - ANS dysfunction post-concussion usually takes the form of ‘sympathetic dominance’, meaning that the ‘fight or flight’ response gets stuck in overdrive. The way to counter this is to index on activities such as deep breathing that stimulate the parasympathetic (‘rest and recover’) system.

Other stimulation of the parasympathetic nervous system

• Evidence-base supporting this: Still nascent in a brain injury context.

• Confidence that it helped: 60%

• Confidence that it helped A LOT: 10%

• What I did: Cold showers and Wim Hof breathing.

• Benefits I’ve experienced: Immediate symptom relief for nausea during a very difficult time in my recovery.

Both cold showers and Wim Hof breathing activate the parasympathetic nervous system through stimulating the Vagus nerve. During the rapid breathing phase of Wim Hof breathing, the sympathetic system is activated. As you switch into the non-breathing phase, the ‘rest and recover’ response takes over. Realistically, I don’t think I did these two activities consistently enough to reap more substantial benefits.

Up next

In my next post, I’m going to walk through some of the emotional insights I’ve gained from my journey. That will be my last concussion specific post for a while until I have more meaningful updates on my recovery. I plan to shift gears and dig deeper into some of the topics that I’ve already covered, such as psychology and meditation. I’ll also explore other interesting ideas in finance and technology!