Measuring Brain Blood Flow and CO2 in Real Time—Why This Changes Concussion Recovery with Dr. Nate Keiser (Part 1) | E57

What if the missing piece in concussion recovery isn’t just the brain—but blood flow to the brain?

In this episode, I sit down with Dr. Nate Keiser to explore how real-time measurement of brain blood flow is changing the way we understand persistent post-concussion symptoms, dysautonomia, and neurological recovery. Using advanced tools like transcranial Doppler ultrasound and CO₂ monitoring, we break down how the brain regulates circulation—and why that system often fails after injury.

We dive into the role of carbon dioxide as a key driver of blood flow, why breathing patterns matter more than you think, and how subtle dysfunctions in these reflexes can leave patients stuck, despite doing “all the right things.”

If you’ve been struggling with dizziness, fatigue, brain fog, or unexplained crashes after activity, this episode will give you a completely new lens on what may be happening—and what can actually help.

If you’re navigating concussion recovery, dysautonomia, or exercise intolerance, subscribe for part two, share this with someone who feels stuck, and leave a review so more patients can find it. 

Dr. Keiser: website

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Transcript

Dr. Nate Keiser 0:38

Everything we know about surviving is that like you got to have oxygen. And your body's like, but you know what we're gonna measure? Carbon dioxide. And it's like we're gonna judge if we're living by CO2. And it actually makes sense because it's the it's like the exhaust of the cell. So like the same way a gas car is going to give off exhaust fumes, that is the exhaust fumes of our cellular respiration. So like any cell that is working, it gives off water and it gives off CO2. And so the way your body is measuring if something is active and working is by detecting the CO2 that's coming from it. So it's like looking at exhaust coming out of the exhaust pipe as a way to know how hard that cell is working. And then the reflex to that is like the more CO2 there is, the more we're gonna open up and flush more blood in. But the less CO2 there is, the more we're gonna restrict the flow because we're not using it. And so, in a lot of people that we see, there there are errors in the way that these reflexes are correlating to each other.

Welcome And Guest Background

Dr. Ayla Wolf 1:40

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. Dr. Nathan Kaiser is a board-certified chiropractic neurologist specializing in non-surgical, non-pharmaceutical treatment of dysautonomia, traumatic brain injury, and movement disorders. Dr. Kaiser was certified as a diplomat in chiropractic neurology by the American Board of Chiropractic Neurology in 2010 and has since served patients from across North America and around the globe in private practice. In addition to his clinical practice, Dr. Kaiser serves an assistant professor of clinical neurology for the Kerrick Institute, which provides postgraduate instruction for doctors of all disciplines in the field of clinical and functional neurology. He is actively involved in ongoing research and presents regularly across North America and Europe. Please enjoy this conversation with Dr. Kaiser. Dr. Nate Kaiser, welcome to Life After Impact, the Concussion Recovery Podcast.

Dr. Nate Keiser 3:34

Absolutely. Thanks for having me. It's good to see you again.

Following A Mentor Into Neurology

Dr. Ayla Wolf 3:37

Yeah, I've been wanting to have you on the show for a while, so I'm glad we made this happen. I'm excited to have you explain a little bit more about what you do and your unique specialty, which is very much at the crossroads of helping people with autonomic nervous system dysfunction, dysautonomia, and also dealing with persistent post-concussion symptoms. But why don't you start out and just give us a little bit about your background and how you got into this?

Dr. Nate Keiser 4:05

Sure. I'll do probably the quick one or everybody will tune out. But yeah, I got into neurology. The earliest story was actually I was in college and was headed down the road of going into prosthetics and orthotics. I don't know if I've talked to you about this before. But uh I had a friend who was really struggling. And back in and, you know, I'm not that old, but I'm a little bit old. Um like internet wasn't great. And so we were looking, trying to help, and just see like, is there anybody we can help her out? And I came across these videos on a PBS broadcast of Dr. Kerrick and ordered them, DHS, got them in. And at that point, it was kind of like he was doing something that, especially at that time, was so foreign from anything that seemed like what anybody else was doing. And so I was like, I gotta figure out what this guy's up to. So I kind of dropped my whole life at that point. Learned he was a chiropractor. I went to chiropractic school to just follow what he was doing. And I just kind of kept doing that for a really long time. And that ultimately led to me being able to teach for the Kerrick Institute and teach neurology, and then had the opportunity to work with him in Atlanta when that was available. And just like the biggest gift of my professional life was just being able to get to work with him. And um, and in the process of that, like he was, as you know, probably a lot of your audience knows, was just like on the such a forefront of what was being done in concussion. Most of what anyone in any profession does now in the field of concussion comes from that work. And I got to watch him do it. And um, but in that time frame, one of the things that we noticed was that in that cohort of people, the ones that had the longest duration, they were the most stubborn symptoms, were the ones that had this corollary of having these autonomic compromises. And that is usually evident for a lot of people. If the easiest place to notice it for them as a patient was in their heart rate, like these high heart rate spikes, you know, and then kind of like the ancillary things that would come with that, but but that we were kind of charged with we have to figure out what it is about these cases that we have to modify what we're doing to get to the same outcomes that we are with the other people. And that kind of that's like the second phase of my journey came with trying to understand that difference. And then that led to kind of what you're talking about the pursuit of using some new technology that was available, trying to understand a little bit more depth about what's happening in people when we see these, you know, tachycardic responses. But it's not really just tachycardia, it's kind of a whole slew of things, but that's where it stemmed from. And so that's kind of what brings us to today is just the continued pursuit of trying to solve that problem for as many people as we can.

Dr. Ayla Wolf 7:04

Yeah, amazing. And in your clinic, you typically do five-day intensives, right? Where you get to spend a lot of time on the front end doing some pretty comprehensive testing and then see people through an entire week of care. And so um, why don't you talk a little bit about what is the process when someone comes to see you? You use transcranial Doppler ultrasound, which I just love. I think because when I was in my doctorate program, I had to do a, well, I didn't have to. I decided for my thesis to do a clinical, a clinical trial as, you know, just a student. Why why not? And um so I actually hired a transcranial Doppler ultrasound technician, and we enrolled a lot of MMA fighters and we were comparing uh blood flow changes in MMA fighters compared to other people that were just exercising to see, okay, when they're actually sparring and receiving head contact, how is the blood flow changing? And uh so that was my kind of doctoral thesis. And so I'm familiar with transcranial doppler ultrasound. But when you were um demonstrating how you use it in the clinic, I was just so fascinated. I thought that was really cool. So why don't you talk about that too?

Intensive Care Built Around Measurement

Dr. Nate Keiser 8:17

Sure. So there's a few pieces I'll try to time together. Um actually, a lot of people that see us end up staying, you mentioned five days, end up staying with us a longer period of time. Um so if that helps level set for people, a lot of people stay two and three weeks with us because so there's this element of if you are a person that is dealing with an autonomic problem, it's not your choice. It sucks. But also all of the healing requires blood flow. It requires adequate circulation. So when if we're in this group of people that we're demonstrating like it is not going great in that field, we have to like rebuild and restructure that whole thing first to get then on the road of healing. So it's almost like we have to bolt on this whole first section before we can start to really like push them toward health again. And so I think if we just understand the problem we're trying to solve for people and are like able to measure it, measure improvement, then then you kind of open up to like, well, what is the problem we're trying to solve? And then we'll just help you do what it takes to solve it. That's where we start from. And then our process kind of looks like we we do a lot related to transcranial doppler ultrasound with people, both in terms of autonomic findings, but then you also see people that don't necessarily know they have those problems, but may have just like persistent symptoms and things, like you've seen, like concussion. But even people with neurodegenerative conditions, there's a lot of orthostatic, or like when I stand up, a lot of problems that come with that. So we really try to pin that down for a lot of people. We use transcranial power ultrasound, and we use that in a dynamic way. And actually, there was like the route, you'll appreciate this because you did it in the research. Like the route to get there was not obvious because a lot of what was done when we started was you had people using spec scans of the brain, which is pretty cool. And that kind of gives you, you can follow a radioactive tracer around and kind of see where it's being uptaken in the brain. And that's pretty cool because it gives you a like a secondary sense of that. And we looked at, okay, fMRI and bold technology, that's kind of cool too, because you can you can look at changes in blood flow in that moment. But then we came like the crux of the problem was we couldn't move people. We couldn't, you we couldn't have people doing things in the fmri. We couldn't have them stand up. We couldn't have them stand up in the spec scan. And then we found uh other people that had been using transcranial Doppler, and you can you can put people on a tilt with it, you can have them up and moving around, you can do different tasks and see things change, you can have them move head positions and change. And so you got to do all this dynamic testing. So you're like, this is sweet. But then I was kind of I had the moment, and maybe you can maybe you can relate where it was like, why isn't everybody else doing this? And I thought there must be something wrong with like something I'm I'm missing, something about this technology. And so I just went back through every piece of literature I could find, like from early days when they were, you know, just figuring out how to like you know, duct tape it on people's heads and see what would happen. And I couldn't figure it out. Um, obviously, there's you know, people will talk about some relationships with capnography, so we buckled that in and say, okay, we'll solve for that problem. And then like with vessel changes with, you know, middle cerebral artery flow, but like we're doing it dynamically, so we're gonna have those anyway. And then so we just work through it like that and have gotten to a point where that has become kind of a core feature that we are comparing against our functional exam, same way a lot of other people do. Um, but it helps us to correlate the two things and understand. Um, one of the big problems we were trying to solve early was when you look at somebody and you look at a test. So if we're looking at an eye test, we're looking at an eye movement, that's pretty common, or we're looking at the way you move your hands, the way you balance. We want to understand is that something that is wrong because we've had that injury to that pathway in the brain? Or is that circulation failing and then not feeding the pathway? So the pathway will fail. So in other words, is it a healthy pathway that is just running out of gas and failing? Or is it in a damaged or injured pathway that we want to correct for? And we're trying to understand that. So in most of the cases we're looking at, we're really trying to make that distinction for people.

Transcranial Doppler Explained Simply

Dr. Ayla Wolf 12:34

Yeah. And I guess maybe let's take a few steps back. If people have no clue what we're talking about when we say transcranial Doppler ultrasound, why don't you just uh explain what that is and what that looks like when you're hooking people up to these devices and what you're actually measuring?

Dr. Nate Keiser 12:50

I'm gonna blame that oversight on you for taking me straight into research nerd turf.

Dr. Ayla Wolf 12:53

Yes, yes. That's important.

Dr. Nate Keiser 12:55

My fault. But transcranial Doppler is so most people are familiar with like an ultrasound. You might hear a baby's heartbeat or get some imaging from. And so you take those and you just take two little ones and you put them right on this little window of your skull where your bone's a little thinner. And you can actually shine that, or shine is a loose word, but you can send that ultrasound in and it will reflect back a sound image of what's going on. So we can measure the velocity of the blood flowing through, and we measure it through these two arteries, the middle cerebral arteries that are like the main tree trunks going into your brain, which is pretty slick. Um, you can do it in other places as well, but we put you in kind of like a headgear so that those probes stay fixed so that if you move around, it travels with you. So we can always measure you against you. So we get a baseline of you laying down, and that's you. And then we want to measure that against what happens when you're upright and what happens when you move and what happens when you do math, and all these things. So we can see relative to your baseline, do doing these things make you better? Do they make you worse? And then does it change one side versus the other? What's going on? Does it come back? All these sorts of things. And we look at all those variables. So that's transcranial Doppler in a nutshell. Um, anything to add from your days?

Dr. Ayla Wolf 14:14

I think that a lot of the reason why we see neurological improvement in people after an acupuncture treatment is because of certain acupuncture points that help to improve blood flow through that middle cerebral artery. And so I feel like just more, again, more like the research nerd in me would love to be able to do more studies looking at transcranial Doppler ultrasound and the effects of acupuncture on blood flow to the brain, because I think that so much of the beneficial outcomes are related to that. And like you were saying earlier, it's important to tease out if somebody has certain symptoms and they're struggling with certain um movements or there's some kind of deficit in their output. Is it because they don't have enough gasoline? You know, is it that they're not getting enough blood flow, or is it more of just a functional pathway that needs to be corrected? And so answering that question is so important because I'm assuming that once you have that information, it really changes your treatment strategy.

Dr. Nate Keiser 16:17

It has changed profoundly how how I practice now, um, to be fully honest. Um everything changes a lot because in two ways. Number one, in terms of the outcomes that we're after and being able to change that that product for people to be able to get blood flow to their brain. But then also in terms of you can recognize things in a different way when it's not going well. In other words, if people are doing the things that seem right, you can catch these little anomalies that are really hard to catch otherwise. Like you would have no basis for understanding them without being able to kind of look into the system, um, which is humbling because it also kind of shows you where a thing that you might have leaned on a lot as a way to like, I think this is how we solve this, it can change that that relationship where you go, ooh, I mean I need to look at this differently. And so that's been rewarding because it's made me it it helps me to kill my assumptions that I'm going on that I, you know, things Charlie Munger always said, um, your most dangerous assumptions are the ones you don't question. Right. So like the things that you know for certain are the things that are the most dangerous things for you to think about. So it has helped me a lot in being able to understand like the things I thought I knew, maybe I don't know. And then now I can solve that problem better because I have a new way to look at it. If that makes sense, I don't know.

Neck Mechanics That Cut Brain Flow

Dr. Ayla Wolf 17:55

It it does, yeah. And I think the other question I had, and this also ties into the fact that in addition to looking at blood flow to the brain, you're also measuring carbon dioxide. Um, and so I wanted to have you talk a little bit about that too, because people end up kind of in a cardiology office where a lot of times things are looked at from a how do we pharmaceutically try to stabilize the system? And then there's obviously all kinds of different approaches and avenues. But one of them being, I think as a chiropractor with that background, you're probably also looking at uh your your C1 vertebrae and rib excursion and breathing mechanics, and you're also looking at it from a structural and an orthopedic perspective. And so I imagine that having these data points also informs you on gosh, like how much is someone's breathing mechanics impacting blood flow to their brain and impacting oxygen and carbon dioxide and all of these other aspects of function. So I'd love for you to touch upon some of those findings too, and how you've been kind of playing around with treatment and observation with that data.

Why CO2 Controls Cerebral Blood Flow

Dr. Nate Keiser 19:08

That's a really good point. There are two separate things there. One's with the carbon dioxide that we should cover, but first I want to cover like the structural side because because I went into chiropractic school with full intentions on like I was interested in neurology. And so the skew in my mind was really a lot more toward what is happening in the brain. And over time, I've actually come around a little bit and noticed, and because of this, really, uh what we talked about with the Doppler, have noticed that there is so much more happening in people with neck injuries than we give them credit for. So a lot of times you get a whiplash or you fall on the ice or you have a sports injury or pick your thing. We think about brain, or we think about your neck, but we don't think about like, well, maybe you know, your neck isn't like the main like complaint that you have. But also when you turn your head to the left, the blood flow in your right middle cerebral artery goes down by 40%. So like it's kind of both. It's like it's in your neck, but it's also your brain. And we have to like we have to match these things together because if we don't resolve that for people, I mean that's where people get stuck, is you can do the exact right thing in two different places. I can go to my chiropractic neurologist who's doing their thing and like giving me these great eye movements, but then I and I can go to the PT who's helping me, you know, do chin tucks and help my neck. And I can do those separate, and then they just never get to the point where we address like, well, actually, it happens here when you turn your head because there's an asynchronous movement, and that breaks the whole thing down, and you have complex migraines and you can't talk and your hand goes numb, you know, and you can't walk. And so that was that was a humbling experience in terms of like coming back to that structure in a major way. Um, and it has been unbelievable. If I if you were to ask me 10 years ago, like what percentage of the people do you think have problems just with kinematics and the movement of their head and neck, I would have said, I don't even want to give I don't even want to embarrass myself with a number. But relative to like what it actually is, is profound. We see so much of it, it's incredible. And um I would have never I would have never guessed that. And then the second part of that was talking about CO2. Um one of the things I think is really cool, and for anybody that's a clinician or a or just an interested patient, as you mentioned, with acupuncture, being able to change a feedback loop changes that reflexogenic control so much. And but what we don't think about with blood flow is like it's all reflexogenic, it's all just reflexes. Like it's really actually hard to like in your mind shift your blood flow. There are some monks that can do it, there's some people that can do it, but they don't do it by saying I'm gonna bring blood flow here. In a lot of ways, they do it by what they think about and where, like if I if I imagine a place enough, I can stimulate blood flow to the area of my brain that's gonna represent space. Or if I move my arms, I can do those things. But it's really hard to do it and then just I'm only gonna think about I'm gonna pull blood here and do it. It's so reflexogenic. And the two main reflexes that are are in autoregulation, which is the actual vessels themselves respond to how much stretch is being put on them by the blood inside, which is amazing. But then that's coupled to the level of CO2, which is just wild to me because everything we know about surviving is that like you got to have oxygen. And your body's like, but you know what we're gonna measure? Carbon dioxide. And it's like we're gonna judge if we're living by CO2. And it actually makes sense because it's the it's like the exhaust of the cell. So, like the same way a gas car is going to give off exhaust fumes, that is the exhaust fumes of our cellular respiration. So, like any cell that is working, it gives off water and it gives off CO2. And so the way your body is measuring if something is active and working is by detecting the CO2 that's coming from it. So it's like looking at exhaust coming out of the exhaust pipe as a way to know how hard that cell is working. And then the reflex to that is like the more CO2 there is, the more we're gonna open up and flush more blood in. But the less CO2 there is, the more we're gonna restrict the flow because we're not using. It. And so in a lot of people that we see, there are errors in the way that these reflexes are correlating to each other. They can be for lots of reasons. We saw a huge influx of them when people had both viral catalysts, but then also iatrogenic catalysts, which are coming from trying to solve the viral catalysts. And, you know, these things where it actually damages the endothelial lining of the tissue of the cells. So people will talk about endotheliitis or problems with the endothelial system. And they'll talk about nutrients moving across and I'm inflamed and talk about those things. And those things are all valid. But maybe the more important part is like the fundamental reflex of the endothelial system is to control how much blood is going in and out of, especially brain tissue at any given moment. And and being like when I got to read about that for the first time, that was something that completely broke my brain, first of all, in understanding the profundity of it. But then also it was just kind of like I can still remember where I was sitting in my office reading, I was preparing for a class to give a class and reading this thing. And I just like sat on the floor. And I was like, this why don't we not talk about like why aren't we talking about this all the time? And um, and then the second part of that was like, this is the thing that you can change. Like very like you could change this to people. So why aren't why aren't we doing this? And um, and that's kind of been consuming ever since that that moment on the floor.

Dr. Ayla Wolf 25:09

Yeah, I mean, I would say I had a similar response to when I was watching you during that clinical theater and watching these changes in carbon dioxide levels and and seeing these uh low carbon dioxide levels on people. And I in my mind, I'm like, why is he like the only one in the country looking at this? Um and so talk a little bit about how do you change that? When you when you see these reflexes that are that are not working correctly and the the whole entire system's wired in a way where it's not responding appropriately to carbon dioxide changes, what what do you what are you doing? How are you kind of unraveling this?

Dr. Nate Keiser 25:50

That's a great question. It's been it's been a journey because most of the work that's tied to that um with CO2 levels is tied to breathing rate and rhythm. And that makes sense, right? So most people have seen somebody hyperventilate. It's like if you breathe really fast, or if you breathe really deep. So a lot of people, I bet you've you've had people relay this like you breathe really deep, but then I feel lightheaded. And so both of those are instances where we're breathing too much. And when you breathe too much, your CO your carbon dioxide levels, you're breathing it out. So you're breathing it out too much. But like the magic of your brain, of these reflexes, is that your breathing should just be tied to that number. So whatever your current breathing rate is should be in support of managing that CO2 level. And so we think about all the ways that we manipulate breathing, and we think about all the ways that we experience shortness of breath, or we experience air hunger, or arrhythmia in breathing. It doesn't feel right. I can't catch a deep breath. But they all should be tied to just like one kind of very simple reflex. And so if our body isn't able to use that chemoreceptor, like the ability to sense that chemistry well, the whole thing gets skewed. And so when you see these breathing arrhythmias, then you're you're looking at whether it's subtle or huge, you're looking at an error in the way that your body is trying to manage the system, which is a great tell, but it's also a great thing to be able to point to because you've got these big territories in your brainstem that are in charge of being able to calibrate it. And their job is to calibrate it dynamically. So it's not this thing like your brain's set up and then it just stays that way. It's supposed to calibrate it all the time. You know this, this is the basis of neuroplasticity, right? So it's supposed to be constantly fluctuating. And if it's not, it's telling you like it has lost the ability to constantly fluctuate. So we can use this as an example, but it kind of extrapolates to kind of all neuro rehab in a way, is this concept of dose matching. So you have to match the dose of the activity to what somebody can do now. So even if I can't, so you take somebody that's dizzy, right? If I'm dizzy all the time, but maybe I like lay down in a certain position and breathe a certain way and I can get like a moment. Okay, that is the amount of gravity that that person can tolerate. Okay, so there is a, there is an amount that they can tolerate. And same thing with breathing. So maybe it's not enough, like you can't tolerate walking around. Okay, fine. But can you tolerate laying down? Or can you tolerate if I, you know, arch my back in a certain way, or if I tilt my head in a certain way and I can breathe like that? That's your starting point. Just like, you know, Ayla, I know you're strong. But like if you were going to try to be like, my next goal is I want to bench press 300 pounds, we wouldn't stick you under the bar with 300 pounds and say, you know, no, we got it. We would say, like, where are you starting at? And then we would start there. And then we would build it gently bit by bit, but you would be able to do it. And if you wanted to and you wanted to work hard enough at it, you could probably do it. And so it's the same thing when we think about any dose response, whether it's with acupuncture, and you know this, and whether it's with neural rehabilitation or it's physical fitness, or it's learning math, or it's learning a new language. The dose is the thing. So we want to do just above what you can do, and then let you get enough rest to where you can assimilate it and then do it again with another space of repetition. And then you do it again and do it again and do it again until it's easy, and then you make it harder. And it's so simple, but we don't really do it. Most of our rehab techniques in the in like general world are built on like fitness level. Like we're just gonna try to do a lot. And if we can do a lot, hopefully that lifts you to that point. But if you're not there to where you can do a lot, then the dose is too big and we make you feel worse. And um, so I think for most, like if you've got practitioners out there or if you've got patients that are kind of like in that struggle, the first question is like, am I getting the dose right? And a lot of times we're just doing too much. And we have to back down and like do the easiest, simplest version until you can do it well, and then build up from there. Um that's a bit of a tirade and a rant. I apologize. But hopefully it's useful for somebody.

Dr. Ayla Wolf 30:26

Yeah, it and it's very on point as well. Uh, I would say that when I started to really dive into dysautonomia, that's when it started to make sense to me, all of these patients that would have what I might think is a paradoxical reaction to a therapy. And it was like, you know, there that was just the dose was too much. Um, and then it all of a sudden things become crystal clear on why somebody can't tolerate X, Y, or Z, and you gotta kind of back off and rethink your strategy and start over again.

Dr. Nate Keiser 30:58

Yeah. But you can do the like I'm guilty of this, especially, especially early on. Most, I mean, most health care practitioners, as you know, are governed by this like intense desire to help. And like if you are doing a thing and it is not helping, the reflex is to do more. And then you just watch, you just watch it continue to uh work its way down. And I expect I've experienced that too. And yeah, more is never is not usually the answer, unfortunately. It's usually almost in when we think about chronic cases, it's almost always less than you're doing right now.

Dr. Ayla Wolf 31:39

Yeah. And so does that mean that um while you're monitoring all this information that you are trying to find certain breathing rates that work best for certain individuals?

Using CO2 Feedback For Pacing

Dr. Nate Keiser 31:53

Yeah, that's a good question. Sometimes yes, and sometimes no. But my ultimate goal for most people is to make it so you don't have to think about breathing. Because if you got to control your own breathing, it's not quite working. And so we will use it sometimes as ways to like augment the moment. Like if we've if we've broken it to a point and we've got to pull things back in, we can give them different different breathing things that we do. It's not always just like you know, breathing in and out at a certain pace. A lot of times it's changing the position of their body. Um, so like getting like accentuating a lumbar curve or accentuating a cervical lordosis that allows you to be able to use your rib mechanics better. Um, that's a big feature of what we'll do because so many people, when they don't feel well, just get into these positions where it's just really hard to catch the breath. So we'll actually change position more than we change rhythm because we want the rhythm to be a little more natural. But feedback has been really helpful in terms of we can give someone a CO2 monitor and have them just breathe how they're normally breathing, but see what that looks like, referenced through through the CO2. And then, like, can you find a way to just slow your breathing pattern down a little bit? We'll usually give them some somatic cues like what you're doing with your body and see if we can pull those values up. And then once they're back up again, we'll kind of move back into whatever we're doing. And we might use that as a way to say, like, all right, we're gonna do this. Once that level drops, you're just gonna focus on it, let it come back up, and then we'll come back in. And we just work back and forth like that, trying to keep people in that tight range, which, especially for people with MECFS, um, things where like energy is at a premium and they don't have a lot to give, uh, we will use that a lot of times as ways to just start to cope people back into their life again. But then also use it as a way to man, because so many people had the experience of, I don't know I went too far until tomorrow. And and so giving them a way to be able to measure that moment before they actually do go too far uh is really useful and it's empowering because you you have something you feel like you can kind of trust a little bit that's out outside of like the way I feel, and that can be um helpful to feel comfortable pushing your pace a little bit.

Dr. Ayla Wolf 34:22

Absolutely. Yeah, you're right. So many people uh know that they want to be able to kind of achieve a certain goalpost, but then there's that fear of, well, gosh, you know, it's like I feel like the line in the sand changes every day. And how do I know where it is today and how that's gonna maybe throw me off tomorrow? And then I feel like I have a huge setback, and it could be a very frustrating process for people.

Dr. Nate Keiser 34:48

Yeah, you get that well, for sure.

Dr. Ayla Wolf 34:51

Are there uh CO2 devices that do you have certain ones where people can just go buy them, use them at home?

Dr. Nate Keiser 34:59

It's a good question. It's kind of a gray space because for a lot of them, you're supposed to be a medical provider. Um but there are there are a couple that you can, if you are savvy with the internet that you can find um that are really useful. And we will let people know that they exist, but again, it's kind of a gray space. Sure as a way to kind of manage that at home. It's actually a really good tool. I wish it was more available. We need in your spare time, if you want to build one that is like a patient-facing one. I would love that.

Dr. Ayla Wolf 35:36

I'll I'll just add an eighth day to my week and we should be good to go.

Dr. Nate Keiser 35:39

That would be great. That'd be great. So we'll get that out like next month then. And uh Okay, great. Um but it is a useful tool, especially as you're pushing pace and getting more capacity. Looking at that CO2 monitor can be really helpful. Um, it's kind of like a go-no-go, especially wake up in the morning one day and it's like a little low to start with, you know, tend to get back to work, bring that in and and get going that way. So um, yeah, I like that tool. I like a lot of tools. We've been we've been actually in the role of improving things. We're always trying to figure out more things that we can give people to go home with that are objective rather than relying on the way they feel um so that they know like day by day as they're working through these skill sets, um they have their own ability to chart their path, which is obviously really useful because we want to get people to autonomy as fast as they can. I'm sure I'm sure you're in the same boat. So giving people things that are objective, say, okay, it's gotta stay, you know, keep it in this range, or you know, your eyes shouldn't deviate when you move this way, or and then just helping them stay in range like that.

Dr. Ayla Wolf 36:50

This was part one of my conversation with Dr. Nate Kaiser. Tune in next week for the second half. Medical disclaimer. This video or podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice, diagnosis, or treatment, and consumers of this information should seek the advice of a medical professional for any and all health related issues. A link to our full medical disclaimer is available in the notes.