Running After an Injury: The Proven Step-by-Step Guide Part 2

Initial Measurements   stopping at onset of symptoms or muscle fatigue

Single Leg heel raises; Right: 30 Left: 30

Single Leg bent knee heel raises: Right: 20 Left: 20

Knee to wall: Right: 16.5cm Left: 17cm

Single Leg Sit To Stand: Right: 21 (foggy brain) Left: 13 (lost balance)
     -No significant muscle fatigue
     -Right hip adduction, Right foot external rotation
     -Left knee valgus
     -Balance decreased bilaterally
     -Hip abduction Resisted Isometric Movement decreased bilaterally

Translation:
Tyler tested my strength and balance to make sure there were no major deficits before beginning to run. Single leg heel raises there was no difference from one side to the other, and the appropriate averages were met. Measuring ankle flexibility with ‘knee to wall’ no issues present, and the average was surpassed by 7cm. During single leg sit-to-stands, concussion symptoms became present. There was also a decrease in strength on each side.

After taking these initial measurements and testing hip strength, Tyler gave me some homework to do before I could start running, to make sure my muscles were completely up to the task:

• 2 sets of 15 single leg heel raises
• 2 sets of 15 single leg bent knee heel raises
• 2 sets of 10 single leg bridges, per leg
• 2 sets of 15 hip abductions
• 3 30sec. wall sits

I was to do these 4 times a week for 3 weeks, and then we would take the next step.

Meanwhile, we also had to sit down and do a vestibular screen, which tests your vestibular system for alterations in balance, vision, and head movement. This isn’t something that would typically be done when measuring someone’s preparedness to run, but was necessary given my particular concussion history.

Vestibular & Vestibulo-Ocular Screen

You are going to see quite a few terms here that seem made up. Don’t worry, we will describe what each test entails as well as explain the terminology. The vestibular screen focused on my eye movements first, and my ability to visually track an object:

1.  Spontaneous Nystagmus
   In normal room light, look straight for at least 10 seconds. This tests for a peripheral or central dysfunction. I passed the test, meaning I did not show a spontaneous nystagmus. Therefore it was a  Negative Test.
   This is what a nystagmus looks like (the eye should not be darting to the side if you are looking straight ahead):

2. Gaze Holding Nystagmus (eccentric gaze)
   This test is similar to the previous, where Tyler watched for that jolting or darting that you see in the video above. This time, instead of looking straight ahead, I look 30 degrees to the right, left, up, and down, holding my gaze in each spot until Tyler tells me to change my gaze.  This was also a Negative Test.

3. Smooth Pursuit
   While keeping my head stationary, my eyes had to follow Tyler’s finger as he traced an ‘H’ pattern in the air. This test checked for a ‘refixation saccade’, which is similar to a nystagmus where the eye jolts or bounces, but this is while following a moving target. 
   While I did test Negative,   I did show a single refixation when going top to bottom on both sides. Since there was only one, we did not consider this enough to be a positive test. 

4. Saccadic Eye Movements
   Here I was to look quickly back and forth between to targets 30-40 degrees to either side, or up/down. For this test to be positive, I needed to have more than 2 refixation saccades. I had a single refixation saccade going up, and a single going left, so this was a  Negative Test.

5. Vestibular-Ocular Reflex (VOR) cancellation
   While maintaining focus on Tyler’s nose, I tilted my head forward 30 degrees and moved my head side to side; keeping his nose straight in front of me. Tyler was again looking for refixation saccades. This was another Negative Test, although it felt strenuous on my eyes.
6. Vestibular-Ocular Reflex (VOR) Slow
   Tilting my head down 30 degrees, Tyler turned my head  back and forth while I had to keep looking at his nose. Here we were no longer looking for refixation saccades, but for double vision or similar visual symptoms. This was a  Positive test.
   

7. VOR Rapid Head Thrust Test
   Adding a bit more to the previous test, while tilting my head down 30 degrees, my head was turned back and forth while still looking at Tyler’s nose, then without warning my head was moved very quickly to one side. This tests for a gaze stability problem, and does monitor once again for those refixation saccades.  This resulted in a Positive test for me as well, as when my head moves quickly to the right, Tyler can see refixations. To my credit, I apparently did improve the more times we did it.

   • After this particular test was completed, we noted my overall symptoms: 
     • Dizziness 3/10;
     • Eye ‘pain’ (possibly from the muscles of the eyes), rated 4/10
   • Ten minutes after testing, noting any change in symptoms: 
     • Dizziness 2/10,
     • Eye ‘pain’ 4/10

8. Optokinetic video
   While watching a series of optokinetic videos, I experienced increasing nausea and double vision as the videos increased in difficulty. There isn’t a particular positive or negative score, rather observing my symptoms was the main objective. Here is a brief clip from the first video:
   
   

Results: 

Based on this vestibular screening, I have a mild gaze stability deficit (a common symptom in Post-Concussion Syndrome). A “gaze stability deficit” means that my brain has trouble making sense of the information my eyes are seeing during tasks that involve head movement.

When we move our heads, our vestibular system senses it, and sends that information to our brains. When our eyes move or see something, our vision system sends that information to our brains. When all is functioning perfectly, the brain agrees that the information from the vision system and the information from the vestibular system match, and all is well. For me, my brain thinks the information from the 2 systems is different (likely due to a vestibular system dysfunction), resulting in the onset of symptoms.

This information is useful for us because we can use it to track improvements in my vestibular function over time. It also shows us that I most likely won’t enjoy running near traffic or crowds, as there are too many moving objects. This also means, however, that running on a treadmill may end poorly if I look down.  

Heart Rate

Resting Heart Rate: 92 beats per minute (bpm)

• Measured with my FitBit
• “Normal” is between 60-100bpm

Predicted Maximum Heart Rate: 195 bpm

• Agreed upon estimate is to use 220bpm minus age; therefore 220-25 = 195bpm

Heart Rate Reserve: 103bpm 

• This is the available difference between resting and maximum heart rates; therefore 195-92 = 103 bpm

Using my FitBit, I hopped on an exercise bike 6 times over 2 weeks and worked up my heart rate. Whenever I experienced symptoms, I noted what they were, how severe they were, and what my heart rate was at when the symptoms started. My most common symptoms were nausea, headache, and eye pain.

• This “symptom-onset” heart rate is approximately 160bpm

These measurements are valuable so that we can do our best to keep me comfortable while running (ha!).

We also want to see what percentage of my maximum heart rate I am working at (approximately). So:

Given this information, I get symptoms when my heart rate reaches approximately 66% of my predicted maximum. Our goal will be to alter my running to try and stay below this level of work (especially in the first few weeks), to hopefully decrease the likelihood of symptom onset. 

• (Here’s that math in case you’re curious: 160bpm max tolerable rate MINUS 92bpm resting = 68bpm above resting. 68bpm divided by the available 103bpm is 66%)

The last thing we did was a very short treadmill session just to see what paces I found comfortable. All this means is I hopped on the clinic treadmill and Tyler increased the speed until I was at my comfortable walking and running speeds, then we made note of each.

• Preferred walking speed: 3.5mph
• Comfortable run speed 6.0mph

What’s Next?

After doing the recommended strengthening and conditioning exercises, testing out my heart rate and symptoms with the stationary bike at the gym, and getting the official all clear from the vestibular screening… I’m off to the races!

Sort of.

I’m off for my first run! 

Since it is winter, I won’t be running outside yet. I’m not that crazy. So I will start with a treadmill at the gym. To satisfy my own curiosity, after a sufficient warm up I will run at the set comfortable pace and see how long I can go for – and what comes first, my symptoms or my body screaming at me to stop trying to do cardio.

After getting that out of the way, I am going to start running in a pattern of two minutes run, one minute walk. By alternating between these two, I will be able to slowly build up my cardio and tolerance. 

Now the real question is, which podcast do I listen to? Which Spotify playlist? Which one do you recommend? Let me know by leaving a comment below!

Stay tuned for my next progress report!

Chelsea Simo
Strive Physiotherapy & Performance