SUB SYMPTOM THRESHOLD 

Sub Symptom Threshold

00:00:00:14 - 00:00:25:10
Speaker 1
Hello and welcome to your Sub Symptom Threshold Exercise Program. Congratulations on finding the program for you and doing your testing. So what you're going to learn in this video is why exercise intolerance is happening. You're going to meet your program and then we'll show you exactly how to rehab, exercise and tolerance effectively and safely. So first things first is why is this happening?

00:00:25:10 - 00:00:48:19
Speaker 1
Why is every time I increase my heart rate, I'm getting symptomatic. And it's essentially a cerebral blood flow issue. And cerebral blood refers to blood flow in the brain. So any time we're getting our heart rate up for exercising or any other thing, our hearts obviously pumping faster, which is pumping more blood and we should be getting more blood flow to the necessary areas like the leg muscles for running.

00:00:48:19 - 00:01:15:21
Speaker 1
And of course, the brain. So in exercise and tolerance, we're not getting proper regulation and control of cerebral blood flow. Yeah, that's why that's happening. So this can cause symptoms like headache, dizziness, you can feel nauseated, all of those things. That is what is causing that. So it's time for you to meet your program. It is the sub symptom threshold exercise program.

00:01:16:05 - 00:01:44:00
Speaker 1
It was developed by Dr. John Leddy and his colleagues out of the University of Buffalo, New York. And I would say it's one of the most researched treatments for concussion out there. And it is very known to be very effective for exercise and tolerance. So this is a highly, highly evidence based program. And here's how it works. I'm going to give you a general overview and then we're going to go into how to do it for yourself.

00:01:44:10 - 00:02:00:03
Speaker 1
So basically, what's going to happen is you're going to start at your therapeutic heart rate. Everyone's heart rate's going to be different. And I'll show you how to calculate that on either a bike or a treadmill. And what you'll do at the beginning of each session is you'll say, okay, where are my symptoms at on that 0 to 10 scale?

00:02:00:18 - 00:02:28:14
Speaker 1
You will begin the exercise program at your heart rate, and then once your symptoms increase by more than two points, you'll stop for the day. Do your cooldown and record it. The goal is to be able to do 20 minutes at that heart rate without an increase in symptoms three times in a row. Once you can get that, we say, okay, blood flows, regulating properly at that heart rate, we can progress.

00:02:29:08 - 00:02:51:18
Speaker 1
And to progress it's pretty simple. We add five beats per minute to your heart rate and then you repeat the steps above. You're going to do this until you reach 80% of your max heart rate, which I'm also going to help you calculate. And then I will say some people like to do retest again. So either that bike treadmill or the march test you did every three weeks or so when they're ready to progress rather than doing the five beats per minute.

00:02:51:19 - 00:03:08:04
Speaker 1
So what that would look like is it's like, okay, I'm ready to progress. I've done a few sessions of increasing five beats per minute. I kind of want to see where I'm at. You could do the test again and then that would give you your starting heart rate. I think for the simplicity of home, we'll just keep adding five beats per minute until you reach your 80% max.

00:03:08:04 - 00:03:28:17
Speaker 1
But if you feel comfortable, that is an option. So to get started, we need to calculate your heart rates and we're going to do this together. So we're going to start with calculating your starting heart rate. So the heart rate, you're going to start exercising. So remember when we fit, we did the test and you finished the test, you recorded all your stuff.

00:03:28:17 - 00:03:45:20
Speaker 1
And at the end there was a spot where you wrote your heart rate at symptom exacerbation during your test. And I said, Write that down. We're going to want to use it. We want you to take that number and record it in this first box. So this is basically the number. AT Okay. My symptoms went over three points.

00:03:45:20 - 00:04:12:14
Speaker 1
I stopped the test trains my heart rate at symptom exacerbation, and I recorded that heart rate. So once you have that, you're going to take that number and you're going to multiply it by point eight. So multiply your your heart rate from the box above by 0.8, and then that number is going to be your starting target heart rate.

00:04:12:14 - 00:04:37:21
Speaker 1
So that is 80% of your heart rate at symptom exacerbation on your test. Now, what I will say is the only exception to this is going to be if you are an athlete and you are someone who is, you know, obviously moves a lot, is in great shape, very conditioned. And you haven't become too d conditioned. So say I was extremely active before my accident, but by the time I got this stuff, I'd been bedbound for like a year.

00:04:38:22 - 00:05:03:21
Speaker 1
So if that's you stay at 80%, but if you are athletic, you're a little bit conditioned, but not too much. You can start at 90%. So you would take your heart rate from box one and you would multiply it by point nine to get your heart rate. Everyone else, we're going to start at 80%. So as you calculate that number, that'll be your starting heart rate.

00:05:03:21 - 00:05:21:19
Speaker 1
The next heart rate you're going to calculate is the heart rate at which you end, because we're not going to have you keep progressing forever, right? There is a point where it's like we've reached normal physiologically were normal. Again, we're getting regular blood flow. So to calculate your ending heart rate, what you're going to do is take 220 and subtract your age.

00:05:22:24 - 00:05:48:01
Speaker 1
You'll write it on the line in the first box. That is your heart rate, Max. So to 20 minus your age. Write it down on the line in the first box. That is your heart rate, Max. Then you'll go down to the next box and you'll take that number and you'll multiply it by point eight, and that will give you your ending heart rate.

00:05:48:21 - 00:06:11:19
Speaker 1
So you'll go ahead and continue progressing through the stages until you reach this ending heart rate and you're able to do it for 20 minutes without symptoms increased three times in a row. Not to us. Signals physiologic recovery, meaning the cerebral blood flow in the brain is regulating properly. Okay, so those are your two heart rates are starting in your ending.

00:06:11:19 - 00:06:29:24
Speaker 1
The next thing you going need to do before you get started is your choose your exercise type. So do you want to use a bike or a treadmill, essentially? And you can see on page four there, there is some stuff that we're going to talk about it. So you have it. And then on page five, you're going to write down your choice.

00:06:30:09 - 00:06:49:04
Speaker 1
So you're going to decide if you want to use a bike or a treadmill For this. I highly recommend a piece of stationary equipment because we're going to want to keep your speed consistent. And it's really hard to do that if you're, you know, like out on a walk or something. So using a bike or a treadmill helps us keep your speed consistent.

00:06:49:04 - 00:07:17:20
Speaker 1
It helps control your environment. So in case you know, you're outside and there's a big fire truck or noise or, you know, anything that could increase other symptoms, it really just helps us focus in on stable blood flow, like how can we just retrain you physiologically? So a bike or a treadmill is most recommended. I tend to say if you are someone who has balance issues and if you have significant neck issues or vision and vestibular, you get dizzy and nauseous real easily.

00:07:18:07 - 00:07:34:22
Speaker 1
Bike is going to be the way to go. Any stationary bike, it could be recumbent, it could be your peloton, your upright bike, any bike, or if you feel like, you know, I have a little neck fish to maneuver, but it's not too bad. And I just really prefer walking. I just enjoy it. Then you can use a treadmill.

00:07:35:01 - 00:07:54:06
Speaker 1
Either one is up to you. So whatever choice you choose, you're going to write it in the line on top. And then what we'll do next is I want you to decide where you're going to be doing this out. So it is going to be at home, friends house, a gym, your physical therapy clinic, etc. I would say if you are able, it's really nice to have this at home.

00:07:55:10 - 00:08:16:19
Speaker 1
When I did this, I got like a $100 super cheap old used bike on Facebook marketplace, so you'll have to buy anything new. You don't have to buy anything fancy. It just literally has to work, you know. So that's a great option. And it comes like pre-assembled because you can just pick it up or someone help you pick it up.

00:08:16:19 - 00:08:38:14
Speaker 1
I think that's a really great choice because then you're not having to worry about driving or anything like that. So at home, if you can buy a used bike, it just needs to work. You could also consider maybe a friend has it. Maybe you can go to a gym at a quieter time. So maybe not, you know, the noon rush, but maybe a little bit after that.

00:08:39:17 - 00:09:10:14
Speaker 1
Or if finances are an option, like in the States, we have the YMCA, which is like the community gyms that you can get low rate or free access. You could also consider your physical therapy clinic. Sometimes they will allow you to use the equipment if you sign a waiver or they have a maintenance program, anything like that. So once you decide where you're going to do this, so now you have your starting heart rate, your ending heart rate, you know what type of exercise you're going to do like or the treadmill and you know where you're going to do it at.

00:09:12:00 - 00:09:35:23
Speaker 1
Once you have these things, you are ready to begin. So let's talk about what each session will look like. So for each session, you're going to wear comfortable clothes, be well-hydrated. Remember to prepare your environment like we talked about in preparation and you'll have your heart rate monitor on and then you'll take your baseline symptoms. So each day you're going to say, okay, where are my symptoms?

00:09:35:23 - 00:09:54:00
Speaker 1
That on a scale of 0 to 10 and you'll write it down on your recording sheet, then you'll begin a 3 to 5 minute warmup. And this can really it's it's think of this as easy. So this can be anything. It'll be a little bit above your resting heart rate of course, but below target heart rate. So anywhere in there is fine.

00:09:54:00 - 00:10:15:24
Speaker 1
But I just want you to do an easy pace. 3 to 5 minutes. Then you'll begin to exercise and you'll increase either your speed and or your intensity until you reach your target heart rate. Once you reach your target heart rate, you're going to exercise there until your symptoms. Your symptoms increase by more than two points, just like we did on testing.

00:10:16:08 - 00:10:33:15
Speaker 1
So say you had a two out of ten when you started and you got to a five out of ten. That's more than two points. So you would stop there and begin your cooldown. Or let's say you started out of five out of ten, and once you got to an eight out of ten, you would stop there, begin your cooldown.

00:10:33:15 - 00:10:54:17
Speaker 1
And then once you're finished, your record on your workout, hand out and tell yourself how awesome you are. So here's your handout. You can see it has the day, the target heart rate for that day, your symptoms before your symptoms got during and then how long you were able to exercise. So you're going to do that until you're ready to progress.

00:10:54:17 - 00:11:18:17
Speaker 1
So here's how you know you're ready to progress. Oh, actually, I take that back first. We're going to do this 5 to 6 days a week. So the research shows that daily or nearly daily is appropriate. We tend to call this 5 to 7 days a week. If you are exercising at the proper heart rate for the proper amount of time, you shouldn't be needing recovery days because we should be meeting you where you're at in the beginning.

00:11:18:17 - 00:11:35:16
Speaker 1
If you're just generally fatigued, maybe you take a day off in between. But the goal is five to, I say 5 to 6 days a week. I like everyone to have one rest day. That's my personal preference. Research says 5 to 7 days a week. I say for this program, let's do 5 to 6. Give yourself a day off.

00:11:36:00 - 00:12:05:16
Speaker 1
One rest day. So when and how do I progress? How do I know I've reached my stage and I can progress? So here's how this is going to work. You were able to progress when you're able to complete 20 minutes of your exercise at your target heart rate per session, not including warmup and cooldown. So 20 minutes at your heart rate without rest and without symptoms increasing during or after or after exercise.

00:12:06:21 - 00:12:30:16
Speaker 1
And you need to do this three times in a row, able to exercise for 20 minutes at that heart rate without symptom increase during or after exercise three times in a row. And I'll tell you a little tip here to once you get in, once you're you know, you're exercising, you're about your target heart rate, I say turn your phone over or turn whatever.

00:12:30:16 - 00:12:44:03
Speaker 1
You're checking your heart rate on over and then just go by symptoms. Because what I don't want to do is some people will like they're like, okay, I'm at my target heart rate and that'll change a little bit. So they'll try to slow down and then they'll try to speed up and then they'll try to slow down and then they'll try to speed up.

00:12:44:12 - 00:13:00:17
Speaker 1
I just want you to get to that heart rate exercise there. Once your symptoms go up more than three points, you stop. Because what happens when we're doing that, like it's almost like we're self-correcting and it doesn't give our body a chance to adapt on its own. And we really want your body to be able to adapt on its own because it will.

00:13:01:10 - 00:13:25:03
Speaker 1
So that's just a little tip for you there. So once you're able to do this in 20 minutes, three times in a row, you're ready to progress and to progress to the next stage. All you do is simply add five beats per minute to your heart rate. So now you'll start again. You'll start the next day. You'll exercise five beats per minute over where you were before, and you'll repeat the same process.

00:13:25:03 - 00:13:51:10
Speaker 1
So again, symptoms increase more than two points. You stop, do your cooldown. If that is all going well, you can continue with that heart rate. If, however you increase to the next stage and you still do what you're supposed to do and you stop at the two at a ten, but you're getting a significant increase in symptoms more than three points an hour later, 2 hours later, 3 hours later, whatever it is, then we want you to go back to that easier.

00:13:51:10 - 00:14:20:09
Speaker 1
Stage four, I would say 3 to 5 more days and then try again. Okay. So that's how that works. So you will continue progressing your heart rate until you reach your 80% heart rate, max. So that is the finish line. That is when you are done. That is when we say, okay, this signals physiologic recovery to us. We're getting blood flow like we should, and we could begin exercising kind of in whatever ways we would like to.

00:14:20:09 - 00:14:43:05
Speaker 1
So that is what that looks like. So that remember that the ending heart rate number that you that you calculated so you'll exercise until you get to that point. A few tips for success for you is remember your mindset. So remember, we're exercising the nervous system. We're not exercising for fitness. So I don't want you to like, oh, this feels too easy or I'm not sweating or whatever it is.

00:14:43:05 - 00:15:07:20
Speaker 1
Remember, we're exercising for where your body is needing to regulate blood flow and then we're gradually increasing. So think of it as exercising for your nervous system and not exercising for fitness quite yet. More is not better. We go based on our symptoms. Right. The other thing I want to note here is some folks say, you know, I get delayed symptoms and if that's the case, we can do two things with it.

00:15:07:20 - 00:15:31:09
Speaker 1
If we're getting delayed symptoms and it's like, you know, we're getting a headache, it's an hour later, it's not too bad. Well, let's decrease 5 to 10 beats per minute for your for your current heart rate and then go from there. If you were doing that and it's like it's a lot of neck or it's, you know, way delayed, that tends to be more neck and we'll cover that in the neck exercise.

00:15:32:01 - 00:15:50:10
Speaker 1
If you are exercising the next day, you feel like you kind of have the flu that's post exertional malaise and we would want to take it way down and start slower. So I would say reduce ten beats per minute, be well-hydrated, make sure you're getting a good warm up and we're going to take it slow. Okay. So that's how to manage those things.

00:15:50:19 - 00:16:11:24
Speaker 1
And then the last tip is always remember, prepare your environment like we talked about in your preparation in lesson three. So keeping heat in mind, not having, you know, the TV on, not being interrupted, being well-hydrated, all of those things are going to be really, really supportive in feeling success. And then the last thing, remember, it's going to go up and down.

00:16:11:24 - 00:16:30:18
Speaker 1
You're going to have a day where you do 15 minutes and then maybe the next day you do ten. That's totally normal. Remember, we're looking at the overall trend. Overall, we should be trending up, but a little forward and back is a completely normal part of human function, brain injury or not. So I just want you to know that that's normal.

00:16:30:18 - 00:16:58:08
Speaker 1
It doesn't have to be perfectly ever better, better or better, better every time. It just needs to overall be going in the right direction. Okay, so that's it. What we've learned is why exercise intolerance is happening. You're talking about like cerebral blood flow control. You've met your sub symptom threshold exercise program and you now know how to begin your exercise program to rehab your exercise intolerance safely and effectively.

00:16:58:08 - 00:17:18:17
Speaker 1
This program works. So if anything is coming up along the way, please feel free to let me know. And of course, if you still have any questions, head over to the community for support. We are here for you every step of the way. I am so excited for you to be able to get moving again. I know how good that can feel and I just can't wait.

00:17:18:17 - 00:17:25:13
Speaker 1
So cheers to you for being here and working through this module and I hope you enjoy your whole exercise program.