Why Traditional Balance Therapy Often Fails Concussion Patients with Natasha Wilch | E16

Natasha Wilch, physical therapist and concussion specialist, breaks down why traditional balance therapy often fails concussion patients and explains her approach to addressing persistent vestibular issues through a functional neurology lens. She shares insights from her five-day intensive treatment program and reveals the missing links that often prevent full recovery.

• Dizziness after concussion isn't always a spinning sensation, but rather feeling unsteady, dissociated, or bothered by everyday movements
• The otolithic system is frequently overlooked in vestibular assessment yet crucial for sensing linear movement and gravity
• Simply practicing difficult balance positions doesn't address why balance is compromised in the first place
• VOR (vestibular-ocular reflex) exercises may be inappropriate without first stabilizing eye movements and addressing asymmetries
• Balance requires proper integration of visual, vestibular and somatosensory systems

For free resources including twice-monthly group coaching calls and a library of educational materials, visit Natasha's Concussion Mini School program or contact her through Instagram @Natasha.Wilch.

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Chapters

• 0:32 Understanding Non-Spinning Dizziness
• 9:40 Demystifying Balance Problems Post-Concussion
• 19:01 The Misunderstood Otolithic System
• 25:41 Introduction to Natasha's Journey
• 33:20 Vestibular Exercises: Beyond the Basics
• 43:58 Trauma's Role in Concussion Recovery
• 53:26 Resources and Community Support

Transcript

Natasha Wilch: 0:00

That dizziness feeling that people tend to complain about it is I feel unsteady. I feel kind of dissociated. Escalators bother me. Elevators bother me. Getting up and down off the ground bothers me. It is very much those other movements, and it's never described in my least, for most of my clients, as like I'm spinning,

Dr. Ayla Wolf: 0:24

welcome to life after impact the concussion recovery Podcast. I'm Dr Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go to resource for actionable information, whether you're dealing with a recent concussion, struggling with post concussion syndrome, or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. Natasha Welch, welcome to the life after impact podcast. I am so excited to have you, because when I met you several years ago, I was so impressed with how you just kind of launched all these amazing programs and took all this information on, functional neurology approaches and applied it to your physical therapy practice, and now you've built this incredible machine where you've got seven and full time PTS working for you, and you've got all these amazing programs. So I wanted to share with the world everything you are doing, which is so fabulous, and also for the purpose of this episode, really have you shed some light on the aspect of balance, vestibular disorders. And these are so common, but I think they can become very complex, and people are often, you know, trying out different therapies, and they're still left wondering, you know, why is my balance still poor? What can I do next? So I wanted to have you just kind of shed your light on on this complex topic. So welcome to the show. Thank you for being here. Thank you so much for having me. Yeah, why don't you start by giving us a little bit about your background, your kind of professional journey, how you got interested in concussions in the first place, and then kind of where you took it from there? Yeah, I'm going to try and do this in a cliff note version, because sometimes when I share this story, like everything just like, comes out.

Natasha Wilch: 2:49

So I've been a physical therapist since 2011 and initially it's always so funny, like, you know, when you go into any sort of profession, you're like, This is what I'm gonna do. And so initially I was like, I'm going to work with athletes, which is, I think what every person goes into physical therapy thinking they're going to do. And I actually had a really amazing mentor who was the physio for the Vancouver Canucks and the and the Vancouver white caps at the time, and he let me shadow him and kind of see what his work looked like. And I was not enthralled. It was interesting, but it wasn't like, yes, like, I wasn't super excited and, like, fiery about it. And then the reason I actually went into physio school, when I thought about it after is I had a cousin who'd had a motorbike, motorcycle, motorcycle accident and became a quadriplegic, and he talked a lot about the people who really helped him get to where he was were the therapists. It was the OTs, the PTs and that piece of things. And so that's what kind of led me into the PT world to begin with. When I graduated, I worked in public health, so I worked in the hospital system in a general rehab unit, and I split my time between public and private, and I fell in love with the neurological population, specifically, more stroke, Parkinson's, MS and spinal cord was kind of what made up what I did. And then my husband at the time and I moved to Nanaimo, and which is where we are now. And when I was trying to find a job, I couldn't find one. I mean, I mean, I could have gotten a job at the hospital, but you walk, I'm a big person on like, I need to feel good in the space I'm in. And I walked into that setting and did the interview, and I was like,nope. Like, this is that Nope? And didn't want to spend 40 hours a week in that building. Absolutely not. No, no. And in Nanaimo at the time, there was no clinic that was doing neuro from a private practice perspective. And it's interesting, because we, before we hit record, we talked about the population of Nanaimo, and I was like, Is there just no is there no work? And I was like, this is an old person city, right? There has to be strokes.

Dr. Ayla Wolf: 5:03

There has to be people here who need my help.

Natasha Wilch: 5:06

So I started to do some research, and I was like, You know what? Like, this is silly. So that's what led to actually starting a symphony, which is my clinic, was that there was, there was this huge void in care. It was the most terrifying thing in my life. I never thought I'd be a business owner. I never thought which, when you look at me, now, I can't imagine not being an entrepreneur, but I never like thought I would be in my life. I was raised to be like, go to work, work an eight to four, get a pension, have a secure job. Like, that's how I was brought up. And so opening my clinic was probably the most terrifying experience of my life. Zero regrets ever. And so that's how I kind of moved into the entrepreneur space. But then the concussion space was by fluke. I always say, like it was never. I remember sitting in a neuroanatomy class, like, we, you know, when you can, we went back to UBC, and they had, like, as physios, you could, like, refresh your neuroanatomy and play with brains and stuff again, which was amazing. And I remember I had a colleague at the time telling me that she was working with concussion and she was describing it, and I was like, oh gosh, I couldn't do that. And then fast forward a couple years later, and this an OT in town referred me a concussion client, because they're like, well, concussions, the brain, brains the neuro, neuro. And Natasha is the neuro physizzie, I know. So she sent me this client, and I was probably looked like a deer in headlights as well, to be honest, because I looked at this client. I'm super honest and transparent with my clients, and I just said to her, I said, Look, I have no idea what to do. I said, but if you're willing to work with me, I'm willing to learn. And I always say, I'm like, Thank God she stayed. And I actually think she stayed because she had no other option, to be honest, but she stayed, and I enrolled in my first course that weekend, and I've never looked back, and it's almost because I started getting these other referrals, and the more I started hearing people's challenges, not their symptoms, their life challenges, and how it was impacting how they lived. It's like my dad had a brain injury when I was 17, and it turned my family's life upside down. And it's like it kind of re woke that version of me up to be like these people don't need to be going through what my family went through. There's no reason for it today, yet it still happens all the time. And so it's a mix of like, that piece is my fire, as well as just the continuing to hear the stories that our clients go through, because they are prevalent. And that's kind of what keeps me going today. There's Cliff Notes,

Dr. Ayla Wolf: 7:51

okay, amazing. And then you have a really, you know, unique, unique way as a physical therapist where you're actually doing five day Is it five day intensive with your patients? Yeah, so talk about kind of what that looks like from a PT perspective. And let's say somebody comes to you for a five day intensive, you know, where do you start with them? And I think also, I would love to hear kind of that functional twist that you can put on, maybe balance testing, because balance testing can be super basic or it can be incredibly comprehensive. So yeah, let's kind of see what that looks like in your clinic.

Natasha Wilch: 9:32

So what's funny is, I've actually been doing intensives since I graduated PT school, and I would, but I would do that with my strokes, and I would do them with my spinal cords, but completely not through a functional neurology lens, because I didn't have any training. It was all throughout was all through I was an advanced bow bath practitioner, so it was all through like neuro PT lens. But we were, I've been doing intensives my entire career, but started doing them with concussion in 2019 more. So balance is absolutely a piece that we talk about and that we assess in it. So a little bit deeper to that in a second, because I have my I have my qualms with how balance is done a lot. Sometimes that's what I want to hear. But an intensive is, yeah, so it's five days. Ours is three hours of a day. Ultimately, day one is comprehensive, deep dive assessment. We're looking into all the systems, what's working well, what's not working well, I would say what's playing nice in the sandbox, and where are things falling apart? Because, I mean, and you see this too, I feel like so much of especially the PT world, but so much is done in silos, and then it's not integrated. And I don't believe you can treat concussion that way. It just doesn't work. So day one is assessment, and then we treat Tuesday, Wednesday, Thursday, Friday, depending on how the person's feeling. We might have a treatment session in the morning or a three assessment day. And then I actually also follow people then for three months, virtually after they leave the clinic, because what I found. Found was, yes, we get wins in that week in the clinic, but when you come for an intensive, you're in this beautiful little bubble where the only thing you have to worry about is you, and then you have to go back to life. And so there's this transition period from intensive back home that some people need support in and, you know, they leave the clinic with a home program, but we almost always have to modify it once they get home based on life demands. And I didn't want people to have to try to figure that out on their own, because then it was just going to impact the changes we had, and what I found they might just give up entirely, yeah, and then it's like it then it was, then what did we get out of it? Right? And so what I found was that if I support someone for those three months, virtually after we are continue, we are able to support them in that transition, and then we continue to help them move forward over the next three months, and we're celebrating wins the three months down the road that we weren't able to celebrate when they left me. Um, so that's our that's how our intensive format looks like in terms of balance. So in the PT world, generally speaking, when we assess balance. So some clinics have forced platforms. So we have a force platform in our clinic. So we'll assess. We use the modified CAPS a lot. So you know, what do they look like on firm foam? Eyes open, eyes closed, that sort of thing. We'll use like a tandem gate balance test as well. We do a bunch of different balance testing as awhole and in the PT world. And what I see happen a lot is that they assess balance in that way. But then if the exercises to treat balance are balance exercises, so let's just practice tandem, stand in a corner and see how you do. And I'm just It infuriates me, like it actually gets under my skin and grates because all you're doing, in my opinion, is helping fuel compensation strategies when you treat balance in that way in the beginning. Because when we look at balance, we know that balance is made up of how the systems integrate. The balance is made up of how your visual component of your visual system, your vestibular system and your somatosensory system. So I very much take a macro to micro approach in my assessment and my treatment. And macro is when I think macro to be functional to like, super specific. And so, yeah, I could just put someone in a corner and have them close their eyes and, like, do things, but if their vestibular system is shit. All you're doing is driving somatosensory compensation or vice and like vice versa. So for me, it's okay, let's have balance as a measure for sure. And it's my favorite thing to show clients, because we have the force platform measures on day one, they my clients do not get a singular balance exercise ever. And then we assess the ocular motor system, we assess the vestibular system, we assess the somatosensory system. Also, sorry, I contingent on so many things here. The somatosensory system isn't included in concussion research, a ton. It's there, though, like if people actually go digging for how the somatosensory system is impacted after concussion, it exists, but it's not in the phenotypes. It's not in the profiles. When you look at the big research, it's not in there really yet. So you have to go digging for it. But it exists. And so my job is as I look at those systems, amongst the other ones, very specifically and into those micro components, and I treat those pieces, and then as those pieces improve, then you can go back into balance. And I love it, because my clients who have like we talked about earlier, I'm never practitioner number one, I'm practitioner double digit, take your pick. And so they've been given balance exercise after balance exercise, and they come to the clinic and we do their fourth platform on day one, and their vestibular scores in the hundreds or two hundreds, or goodness knows what. And then we don't do a singular balance exercise, and you watch those numbers change by Friday drastically, and they're like, What? What'd we just do? And I was like, because balance is the combination and the integration of these other systems stepping up to the plate their way they're supposed to step up. And if we don't figure out why your balance is terrible, and we're just training balance, all you're doing is training a compensation and you are going to plateau because you can only compensate so much. That's my viewpoint on it.

Dr. Ayla Wolf: 15:40

Yeah. Well, and I see too, you know, you mentioned like, you know, people have a hard time in tandem stance, and so then their therapy is stand in a tandem stance and practice that. Or someone has a hard time standing on one foot. Let's practice standing on one foot. How are your How do you feel about the habituation exercises? Because I see a lot of people come in and they basically have hyperactivity in their system. Are given exercises that drive the hyperactivity by, like, And then. let's walk around and move our head in a bunch of different directions and bend forwards and pick things up, and if you get dizzy, maybe, if we just do it over and over again, your dizziness will go away. Talk about that.

Natasha Wilch: 16:18

Yeah, I mean, and that's, that's what most of vestibular rehab is in my world, right? Like, that is a big piece of it. And I think, do I think there's a time for habituation exercises? Yeah, is that? I'm I always though, I'm always going back to, why are you getting dizzy to begin with? And I think that, like, habituation is okay. We know you have dizziness. We don't necessarily really know why. Or, like, we know we there's these. So let's just train it out of you, which is like, exactly what you talked about, right? So your brain can be like, it's just now, you just can basically ignore it. You get used to it, versus, let's pause and let's take a step back, and let's figure out what's not working in this system, or systems that's making you dizzy first. Like, I think the biggest thing when people come for an intensive is therapists struggle to do that piece right, and so therapists feel the need to just keep layering pieces on or making things more complicated. And a lot of the time I have, like, the first thing I'm doing is peeling it back to the most simplistic piece. And because that's the piece that's missing, I always say gates are really people can, like, relate to gates. Like, okay, you broke your ankle, and your cast comes off, and the ankle is weak, so you can't plantar flex, you can't toe off very well, so your gait looks funky Well, as you know that your gait is funky because your plantar flexors are weak and you can't toe off. And so let's strengthen your plantar flexors and then put that back in gait. But for some reason in the concussion world, we lose that macro to micro mindset, and we go, oh, well, let's just practice the game. And so when I teach is very much that piece of like stop, because I think in the concussion world too, and there's certain people that you look at very much, not in the functional neurology world, that are like concussion rehab needs to be functional. And I'm like, Well, I agree with you, when they're ready for it to be functional, because you need the smaller pieces and the reflexes and like these micro pieces to work, to do the functional tasks, because those micro pieces working is what our body unconsciously uses to know where we are in space. And if we have to consciously try to know where we are in space, we're always going to be using more energy and more thought process and more cognitive power to do a functional task than if we don't have to.

Dr. Ayla Wolf: 19:01

Yeah, so let me put you on a spot when somebody says, when I bend forwards, I immediately get, like, the head pressure, the headache, and then I stand back up and I get dizzy. Talk about your kind of, like, differential of, like, what are the exams you're looking at? What are you thinking about, and what are you possibly seeing, kind of you know, if there's ever a pattern with the people that come in, because that is such a common thing people have,

Natasha Wilch: 19:30

so instinctively, I go to two areas. I know I'm going to want to look closer at one. I'm going to want to look at autonomics. So is this a blood flow issue? Is this like when we bend forward and we come back up? Are we seeing a drop in blood pressure that we can't maintain blood flow to the brain? So it's bringing in. It's bringing in that light headedness and that feeling of syncope. So I'm also going to dig deeper into what those symptoms are too. So it's like, is this dizziness? Is this? Do you feel like you're going to faint? Is this like, does your world feel like it's going tunneling and dark? Like, let's dig deeper into I hate dizziness is a terrible description, but it's the word everyone uses, right? So then I always dig deeper into those symptoms, too. So there's one piece that I'm definitely like, Okay, so we're changing postural demands. Like, there is an element of gravity, like, what is happening autonomically with blood flow? I want to look at that. The other piece is that forward tilt movement is a component of the Olympic system, otolith of the vestibular system. So then I'm going to be like, Okay, well, what's happening in my otolith, what's happening in my saccule, what's happening in my utricle, what's happening in the rest of the vestibular system. That when I do this tilt of what should be those organs kind of processing and helping us know we're now getting these symptoms. So instinctively, those are the two flags, let's say that go up for me, and then I'm going to go deeper into each of those systems in my assessment. Talk a little bit about, you know, what else are you doing when people you mentioned the otalist, the the utricle and the saccule.

Dr. Ayla Wolf: 20:59

So for our listeners, the saccule tells us whether we are going up or down, like when we get into an Elevator, utricle, are we moving forwards, backwards, side to side. And so when people often, like you said, dizziness is one of those words that you hate, because people use it to describe all kinds of things. Now we have, kind of, in the literature, this concept of non spinning vertigo symptoms like the rocking and the bobbing and the swaying. And so a lot of times, those are the symptoms that I think often get missed and overlooked and just kind of like, you know, they're just not paid attention to as closely as they need to, but they can really affect someone's quality of life, because they just always feel off. And so talk a little bit about, kind of, again, your assessment of, you know, the otolithic system, and how do you talk to people about these symptoms? And let's just kind of dive into that, because that's also something, a topic I love, and something that, like I said, often gets on overlooked in standard therapies.

Natasha Wilch: 21:59

The otolith gets missed all the time, like all the time from people who are vestibular specialists, it gets missed all the time. Um, you know, people are comfortable doing head shake tests. They're comfortable doing head thrust tests for the semicircular canals, and they don't know how to assess for the otolith and so and people also tend to equate the vestibular system with dizziness, as in, like, maybe that spinny feeling. And if that doesn't happen, then they're like, Oh, the vestibular system is fine, but when the old is involved, it's not actually that dizziness feeling that people tend to complain about. It is, I feel unsteady. I feel kind of dissociated. Uh, escalators bother me. Elevators bother me. Getting up and down off the ground bothers me. It is very much those other movements, and it's never described in my at least for most of my clients, as like I'm spinning. And so when I'm looking at the otolith, I'm looking at a bunch of different things. But what I'm looking at skew deviations, I'm looking at so is, you know, is one eye higher than the other, the otolith plays a huge role in our relationship to gravity as well blood pressure too. We had, I just had a client who has been diagnosed with pots. So of course, the postural orthot, the postural orthostatic tachycardic syndrome. There we go, such a tongue twister, because when she stands up, her heart rate changed by 40 beats per minute, and it sustained. Except that when you also look at her blood pressure, she's actually got orthostatic hypotension. So of course, her heart rate is spiking at right, and then when you do so again, I think when we're assessing, we always have to have that, like, curious thing of like, Why? Why is she orthostatic? Well, the otolithic system has a reflex that links into our medulla that help trigger the sympathetic system to help with postural responses to blood pressure that we don't go hypertensive. Well, when you dig deeper into her assessment, she had significant dysfunction of one specific of her otolith, and so her rehab to help with her orthostatic hypotension was to help with that otolith. She didn't complain to dizziness when she was standing up, she was lightheaded because she was tachycardic. But and understanding those links. And so for me, when I'm looking at the otolith specifically, it's, you know, what is happening with skew deviation, what is happening with subjective visual vertical what is happening with ocular tilt? And then what else are you telling me in terms of, if I'm sitting someone on a plinth, and I go to move the plinth down, and they're like, Oh, I'm like, okay, the only there's nothing postural changing here, the only thing I'm doing is a linear input or like, and it's like, okay. So there's things in the assessment kind of that we do too, but then also always listening to the to the client response and the specificity on when they're like, we're just paying attention to be like, Oh God, right, yeah. But it is absolutely a piece that gets missed over and over and over again.

Dr. Ayla Wolf: 25:14

And do you do a lot of therapies where you are translating people forwards backwards?

Natasha Wilch: 25:19

Yeah, it depends. So every, every client is different. It really, truly depends on if, well, it depends on kind of where they're at and where we're seeing the dysfunction, right? So we do use linear translations for sure. Um, it just depends in which context and all those pieces, yeah, yeah, yeah.

Dr. Ayla Wolf: 25:39

I had, I had a patient the other day who I'm working with on motion sickness, and I kept wanting, now that we like done all these different therapies, I was like, okay, was like, Okay, I need you to, like, get in the car and have your wife drive you around the block, because it's always when he's a passenger, right, right? And it, it's always because he's wanting to do something on his phone when he's a passenger in a car, and immediately that triggers the the motion sickness. And he kept forgetting to do that. So finally, I'm like. All right, we're putting you in the wheelchair. I'm gonna have you play games on your phone. We're running around the parking lot in the wheelchair.

Natasha Wilch: 26:09

We have this one exercise. It is literally I have, so I have a rolly stool, and, you know those like, really long, like, bungee things. It is so fun. Oh, and now we have my hallway. So I've said it literally. This is my we did this with my last intensive client, one of my last intensive clients. And so he's sitting on the stool, and he holds one end of the bungee. And then I have the bungee on there, and I like, lever my body, and basically slingshot, but like, not with tremendous speed, him forward down the hall, okay? And it's and then I, as I like, run backwards. And it's quite fun, because then it's not self initiated, so it's kind of that they have to respond to it and all those pieces. But it was hilarious, because I don't get a lot of my clients are too symptomatic for us to take to be there, and he was quite high functioning in a lot of levels. So we got to do some really fun different stuff with him that I don't get to do a lot, to be honest. And so we where we like slingshot them to such a bad term today, not actually slingshotting anybody was into my reception area, my receptionist and my my clinic manager like, Well, that one's new, looks like fun! All our stuff, because we have this one main hallway in our clinic, and the one end is the reception area and then the treatment rooms. And so we use that. People are constantly, like, walking back doing different things. Yeah, that hallway gets used for so much stuff. They were like, That's a new one.

Dr. Ayla Wolf: 27:43

Well, and that's what I love, is the creativity that, you know, so many people with that functional neurology mindset apply to their therapies, is it's, you know, I just love the creativity. I love the things people come up with. So bungee cords and slingshotting people forwards, awesome. Because, like you said, it's, you know, it's passive in the sense that they're not pushing themselves, or it's like they're not necessarily in charge of the speed, and so, like, that kind of unknown element has a big impact too well.

Natasha Wilch: 28:11

And I think, as someone, because I educate other clinicians as well, I think that what happens, and I when you come into my program and the functionality space too, but I don't give my clinicians a library of exercises I'm not like, here's your vestibular exercises, here's your exercises for those, we will talk about it, but what I really try to teach is the concept of you need to understand how this system works. You need to understand what its job is and how it should be presenting, so that you can truly understand how it's not. And then you and when you understand those pieces, you can build an exercise to help it bridge back, versus, because I was the therapist, however, many years ago that was, like, was did a course, and it was a great beginner course, and they give you a stack of, like, here's a bunch of vestibular exercises, here's a bunch of vision exercises. But in truth, Ayla, it's like, you don't know why you're getting them. You don't know why you're doing them. You're just going back and, like, here's a vestibular exercise. I'm going to use this one. And so unless you take the critical thinking skills to be like, Why would I use this one? And this is, honestly what led me to functional neurology, was because I recognized that I was like, I was having great change, and we were happy. We were becoming the go to clinic for like, our area, except that I was like, why am I doing this this way? And I started asking, why a lot, and no one could answer my questions. I was like, why are we doing this bilaterally? Why are we doing this this direction, like, why are why are we doing this exercise here and not here? And I started asking a ton of whys, and I couldn't find the answers. And that's what kind of led me down to the functional neurology rabbit hole in that aspect of it. So, yeah, yeah. And so on that topic, let's talk about the VOR because that's another hurdle that I see, is that lots of patients that come to me that still have a lot of balance issues and disequilibrium and they just feel off. And like you said, kind of these dissociative sensations. And they said, Well, yes, I already did. I was already referred to pt. I already did PT, and it didn't help me. And usually when I asked them, what did they do? Well, they gave me vor exercises where I had to shake my head back and forth, really, really fast. So let's talk about why that doesn't always work for people, and also maybe talk about the importance of like, what needs to be the foundation first, before somebody can even do those exercises. And when are those exercises appropriate versus when are they not appropriate? It is the. To exercise in my world, and I'm sure, and it has its place, I'm sure. And I should perhaps this would like, I don't treat any peripheral vestibular stuff really, like everything I do is concussion and central I should just, like, caveat to that piece. But it comes back to Okay, so when we're thinking that, like micro to macro, normally, people think of the VOR as the micro to something else. But let's actually now think of the VOR as the macro, and it's like what is required for us to even be able to do, okay, a vor exercise. Well, one, you gotta have stabilize, and you gotta be able to fixate on a target, and you have to be able to, in the context of, we're talking about this exercise, move your neck. So if you can't do those three things, you're not going to be able to do a vor exercise. I had a client once, so he travels to the island from Boston, and and he had failed out. I put in quotations because I can't know if there's video of several vestibular rehab exercise programs, because the second that you took this man's eyes off midline, he'd go into a flutter his like his eyes were an interesting thing, and so what his so you can't do a vor exercise because your eyes don't stay in ortho alignment when you're right. So he couldn't do it. So he couldn't do any of the vestibular rehab, and so he failed out. And he was taught to compensate. So he was taught to basically move with vor cancelation eyes and head together. And really like, he had great peripheral vision, and he was taught to compensate. And so it's kind of that piece again, of being able to look at the task and break it down to its components. And then the dilemma is, then people get stuck on like, Well, if there is involuntary eye movement, what is it? Is it a square wave jerk? Is it nystagmus? Is it ocular flutter? Like, what am I seeing? And then, if I see that, what do I do about that? Right? So we have so again, stabilize. We have to be able to fixate and we have to be able to move our necks. If we can't do those three things, we can't do a vor exercise. I think the other thing the PT world that we sometimes recognize, don't recognize in concussion, is it can be asymmetrical. And so if you're having someone, and I don't know if it's actually but the way I think about it is, like, if we're way down low on the left side, say, hypo functioning, and we're like, up on the right the way, I think what is we can train asymmetrically to bring them to the same level, and then we can train symmetrically to continue to build and grow. But if we're just doing everything bilaterally, how are we

Dr. Ayla Wolf: 33:57

you're reinforcing the difference.

Natasha Wilch: 33:59

Exactly? Um, so yeah, from a from a vor perspective, the like, you have to be able to turn your head like it's never, it's never an exercise, ever an exercise. In my clinical practice, and I've treated, I don't know how, when you put our Jane, we're on client, like 5000 something or other, not all my clients, obviously. But it's never an exercise that I give ever, and we're always paying attention to the asymmetries, and we're treating the asymmetry. I always say, too in concussion, whether it's a vor you're looking at or an OTR, whatever it is, it's not black and white. It's not that it's there and not there, it's I always say, we play in the gray. What is the nuance? What is the asymmetry we're treating the asymmetry? It's not that it's going to be present. It might be present and not present, but you can't let that be the case. It was interesting. I was going through over a vog with someone, and the I'd said to the therapist, I said, Tell me what you see, because we use vog a lot to look at vestibular system, to look at cerebellum, to look at where do you know where you are in space, because you're in the dark, right? And and the person was just the the client or the therapist that I was working with was like, oh, it's, it's normal. And I was like, Okay. And I was like, Well, let's look at it together. And again, I think just both, honestly, functional neurology trained clinicians and those who are deeper concussion know where to see the nuance, right? It's like, when I pull up this vog and I'm looking at a therapist, I'm like, Do you Do you see those beats in nystagmus? Like, those shouldn't be there. And it's like, well, it's not continuous. I'm like, No, but it doesn't have to be. Look at what happens when this person goes right versus when this person goes left. You're looking at two completely different stability. Completely different stability levels of eyeballs. When they go up, are they going up? No, they're looking off to the right. Like that tells you where they think up is, like, all these pieces matter to build these treatment plans. And I mean, vor is so when we're moving into the traditional like, okay, let's just move our head. And go there, sure after we know that they have stabilized, that they can fixate on a target, that they can move their head and that that asymmet At the end, they're symmetrical. Then go challenge the system and push it and go into more that level of it. But don't do it until you at least get there.

Dr. Ayla Wolf: 36:26

No, I think that is so important. And like I said, I hear that story over and over again that people are like, I did physical therapy, it didn't work. And it's like, well, there physical therapy is such a huge field. There are so many different people, specialists, and even people who maybe you can speak to this too. Like, within PT, you have people who call themselves vestibular specialists. But even within that subcategory, there is also a huge amount of variability between what that means,

Natasha Wilch: 36:57

yeah, it's and you nailed it in the sense of, like, it's a huge scope of practice, huge. And what happens is, because vestibular is such a significant component of so many people with concussion, right? When you look at the profiles, they say about a third of the people with concussion have a vestibular ocular phenotype. Vestibular therapists kind of were like by default, whether they wanted to or not, had had to start treating concussion. And I always say a vestibular therapist is not a concussion therapist, and a concussion therapist is not necessarily a vestibular therapist. And when you look at the vestibular system, and I'll say, like, if you have many years, if you have like the different, some, honestly, even like some of the different, all the maneuvers to treat BPPV Oh, my God, I've lost track. There are so many. It's insane. There's always a new one being invented, right? So when you look at the vestibular system, we have like our peripheral system, which are like our neuritises, our bppvs, our meniers. Are all these which are affecting the end organs of this system, which we know is going to then eventually have a central impact, but then you have something like concussion, who I've just that with concussion, if there's not that doesn't mean there needs to be damage to the actual structures of the system. Concussion is more a central issue and how the vestibular system information is being integrated in into our kind of brains and function. And so so many vestibular therapists. I have a vestibular therapist, I believe a bunch of them in my clinic, um, but a couple of them who've gone through kind of the PT gold standard. So the PT gold standard in vestibular specialization is through Emory and and it is like, if you're a vestibular therapist like that is that's what we do. I have not done that program, but I have two therapists in my clinic who do. They would kick my ass in treating a peripheral dysfunction, guaranteed they don't when it comes to concussion, because concussion is so much more centralized, so there's absolutely difference. And that other piece too is a vestibular therapist. Their knowledge is deep in the vestibular system. But a concussion doesn't just affect the vestibular system, and it comes back to we need to understand how the neurophysiology is so important and understanding that piece of it, because we need to understand how that vestibular system interact interacts with every other system. And it's, again, it always comes back to it's the integration of all of it together that makes the difference. So you probably say this to vertibilisi, like, if you've seen one PT, you've seen one PT.

Dr. Ayla Wolf: 39:49

Fair, very fair.

Natasha Wilch: 39:51

We know that with concussion and any like chronic illness there is, there is a mental health component to it, because it's freaking hard, right? Your life gets turned upside down. And like, there's grief that needs to be processed, especially if it's persistent, like, you need to go through grief, you need to go through some anger, like, guaranteed you're gonna need to do some mindset work. Right? For a lot of people, with persistent there's an element of trauma history, and if not before, the experience of trying to navigate this system has likely led to some trauma. And this same kind of conversation came up with someone too, of, even in the mental health space, you're seeing the same thing, right? And so I can speak to it from a level of, like, I have, I'm gonna say I've, actually, I feel like I've completely moved through it at this point. But like, one point I had PTSD that was horrible, right? Like I was having intrusive nightmares, and intrusive, intrusive names, having nightmares, intrusive thoughts, like on the regular My short term memory was terrible. I was forgetting stuff, left, right and center, brain fog, like I would wake up and wake up nauseous and stay nauseous until I went to bed at night, like it was horrible. And the same concept is happening in the mental health space. Of you just need. To do the breathing, and you just need to do the cold plunging, and you just need to do these tools to help regulate your nervous system, which, again, 100% and if you don't address the root of the trauma. And I'm not saying that there's just one way to do that. There's multitudes of waves for me. EMDR was a godsend. But if you don't address the trauma and do the work, you're always going to have to do this. And it's I always say to people from that mental health piece like it is, and even probably from a treatment perspective too, from like in a concussion or chronic illness, is doing the work. I'm going to swear for a second, doing the work is fucking hard, and it can be terrifying, because if you make the decision to do the work, whatever that work is, there's a huge element of unknown. I don't know how this is going to make me feel. I don't know what else might come up that I'm unprepared for. I don't know how this is going to impact my job. I can full on to say, from my personal experience, that I was I knew I needed to do the work, and that unknown was what stopped me from doing it for years, because my clinic was doing really well. My it was, it was booming, actually. And, like, I was in a good spot, and my marriage was going really well, and all these things. I'm, like, if I start to deal with that, I don't know what's gonna come up. Like, I don't, I don't want to do it. Why would I stir the pot when the pots pretty bad, right now, right? So I, like, pushed it and shoved it and shoved it. And by the time to the point where it was seven, it was 17 years later from, like, the major incident that led to my PTSD, wow, I could it was like, fuck you, Natasha, like you don't get to shove me down anymore. And it was in my face, and it was destroying my life. And so it's that piece of whether it's therapy for your concussion, because people get impossible. This bubble right, like you probably see it too, like they know what makes them comfortable. They know what doesn't flare their symptoms. But when you do that, your world just shrinks more and more and more. And it takes a decision to decide to do the work, and it's terrifying, and I don't think we acknowledge that enough for our clients, because there is so much uncertainty and unknown, and we like to be in control, right? Like we like to know things. And so not only is there, like, there's the potential, this is going to make me feel like shit, because it probably is guaranteed, but I don't know what else is going to come up. I don't know if my job's going to be impacted. I don't know if I'm going to like what comes through? What if I don't like the person that I discover who I truly am? And I don't think we as clinicians, I don't think we give our clients enough recognition of that as well.

Dr. Ayla Wolf: 44:01

Yeah, and that's a really big topic. I mean, I've certainly had people where it just became really obvious to me that they were trying to do all the right things, but because of the trauma and where their nervous system was stuck in the trauma, they were their nervous system wasn't in a place to really be able to do visual vestibular integration work, because they were still stuck in the trauma. And their systems like I can't I can't integrate any of these other wonderful therapies yet, like, I've got to get this other stuff figured out first, absolutely. Yeah, yeah. You know, I think sometimes that's the nice thing. Like, you have your, you have your kind of isolated community. When I, when I lived in Bend, Oregon, that's also very much like an isolated community. You're surrounded by mountains and desert in all directions, and you had all your great referrals for things.

Natasha Wilch: 44:47

Well, I have them in my team too, right? So, like, I have chiropractic, kinesiology, Speech Pathology, occupational therapy, physical therapy and counseling in my own clinic.

Dr. Ayla Wolf: 44:56

Oh, wow. Okay, so you've built out all of that within your awesome yeah.

Natasha Wilch: 45:00

And then we have, obviously, we have a network as well that we can refer out to you.

Dr. Ayla Wolf: 45:03

Need an acupuncturist?

Natasha Wilch: 45:05

Do you want to move to Canada?

Dr. Ayla Wolf: 45:09

Living on an island? Sounds great.

Natasha Wilch: 45:12

It's a beautiful island. It's a beautiful island. But yeah, I know it's the you know, it's, I very much practice a holistic approach to care, because you're not treating a diagnosis, you're treating a person. And the same way we talk about how our systems integrate everything of who we are as a being needs to integrate. And so when I built my clinic from day one, that was always the vision of where it went, and it's just become that much more prevalent, and the necessity of it all when I shifted into more concussion and vestibular stuff, yeah, yeah.

Dr. Ayla Wolf: 45:45

You know, I refer out for EMDR a lot, and I wish that I had somebody like in my same office, because it means a lot of those people have huge waiting lists. They're booked out. I actually am bringing somebody on the podcast here in a few weeks who, like she specializes in adapting EMDR to people with brain injuries. So I'm super excited about that.

Natasha Wilch: 46:04

I'm gonna listen to that one.

Dr. Ayla Wolf: 46:06

Yeah, I think you know when it's available.

Natasha Wilch: 46:08

I did a conversation with a it was with a therapist. So I after my intensive, clients leave, if they have teams in their home community, I will do a call with whoever on their team they want me to do a call with to help that process. And so one of my clients had said, Would you speak with my therapist? I was like, absolutely. And it was amazing, because this therapist was like, she opened my eyes to she's a trauma therapist. She's like, but we don't learn. And I was like, well, you need to be able to shift it and adapt it. Like, if here's like, and I was like, here's the process or the hierarchy that I would take leading to EMDR with someone with concussion and like, here's the adaptations, here's the things that I would do. Here's how you can work with their therapist to know which sensory stimulation to use more. And that was the cool thing with our clinician, is it's like, don't use eyes. It's just a general rule, don't use eyeballs. But even with like, because I assess like, how does our person process vibration, left versus right? How do they process pressure? And because the next go to for a lot of EMDR therapists is that is the vibration little tacky things in their hands, right the others. But I can't help but think, and again, I'm pretty sure this has never been researched, but I can't help but think, if we are not processing vibration through one side of the body as well as the other then, how is that going to impact the processing of the trauma? And so what I would do with my EMDR therapist is I'd be like, okay, vibration is good. Or it's like, vibration is not great, but their pressure sense is good. So she would use pressure as the sensory stem bilaterally, through tapping or tapping, okay, tapping. And then when I can as as her modality, or because even they could do auditory too, or it'd be like, their auditory localization is great. They seem to they don't have hypersensitivity like so we would communicate, based on our assessment, to help guide her to know which sensory stimulation to use for her EMDR intervention. And I think that's where our professions can can communicate and learn more from each other as well.

Dr. Ayla Wolf: 48:05

Absolutely. I love that. That's amazing. Well, why don't, I mean, we covered a lot of different topics, why don't you let people know where they can find you? Because you also were just telling me you have all these amazing free resources too. So would you, would you be willing to share?

Natasha Wilch: 48:19

Yeah, so for those, I so I would say those on a healing journey. I don't ever use the term concussion survivor ever. So for those on a healing journey, I have a program called concussion mini school. So it is completely free. It is two live group coaching calls, a month with me. And then you have a private community it's on, which is on Facebook with other with all the other mini schoolers. And then you actually have, like, a members library that is chock a block full of resources, so topics, so past video topics on elements of like, clinical focus, so exercise intolerance, dysautonomia, the vestibular system, which is what we're talking about today, actually in mini school, more like mindset focus type things. We're talking about boundaries and communication and self compassion and those elements of things, and then we have like, lifestyle type things, so nutrition, that sort of thing. And it's completely free. So if it interests anybody, honestly, if you're on Instagram. So my Instagram is just at Natasha dot wilt, I'm the only one in my DMs. Feel free to send me a DM, and I will send you the link. I can give you the link too to go on show notes as well. So okay, yeah, those are probably Instagram is the best way to reach me or email, but I'll give you, I'll give you some links.

Dr. Ayla Wolf: 49:36

Awesome. I know that people will appreciate that, and how I know how much time it takes to make even just a short video. So kudos to you for finding the time and making that happen and putting all that free content out there. That's incredible.

Natasha Wilch: 49:49

Thank you. Yeah, my I say my big my big mission, and like my big evolution, my big, big mission is to elevate and set a new standard for concussion education and treatment in the world. And we do that by things like this, right, by having conversations with other people who share that

Dr. Ayla Wolf: 50:14

You know, I stumbled on a Reddit thread passion and continuing to spread the word and work together, once, and it was titled, you know, something about, like, I'm so tired of my doctor not knowing what POTS is. And because that is not, not one person is going to make that somebody had said they came in, they're like, I have pots. And happen. Yeah, absolutely. their doctors like, what you're growing marijuana? No, I'm not talking about pot. Talking about pots. I was like, on an exercise bike reading this. Just dying laughing.

Natasha Wilch: 50:44

I would have first start laughing if I read that one too. That's a Yeah.

Dr. Ayla Wolf: 50:50

So you're right. We, you know, everybody in the field needs as much knowledge as possible because it's so complicated. And like you were saying, you know, dysautonomia is like all the rage on social media and Tiktok, but it's like. It's such a complicated thing. You can't just, you know, there's not much you can do in a 30 second video if you're trying to talk about the autonomic nervous system. And that's the problem when people are getting their information from social media, is there's a bunch of stuff out there that is. It's, it's just not specific. It's too short. It may captures, like, 100, 10th of the pie. Like, you know, it's just, it's a, we have to really appreciate the complexity of it. And I think that's what gets missed in the social media craze of trying to make little, short videos on topics. No, I'd agree with you that it's a think too. It's like you're never, you never see me do a how to for that exact reason. Oh, well, this has been great. I appreciate your time. Thanks for coming on the show.

Natasha Wilch: 51:47

Oh, thank you so much for having me. We'll have to have you come onto mine, because I want you to talk a whole lot more about acupuncture.

Dr. Ayla Wolf: 51:54

Okay, let's do it.

Natasha Wilch: 51:55

Okay, thank you so much.

Dr. Ayla Wolf: 52:01

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