Lauren Z. Transcript

My name is Lauren Ziaks. I’m a physical therapist, and I started out as an athletic trainer. I worked in sports initially. I did a lot of football. So my initiation into concussion was actually as an athletic trainer. And back then we didn’t really do very much for concussion, right? So it was like put them in a dark room and hope for the best, essentially. There wasn’t really any therapy back 400 years ago when I was an athletic trainer. 

I went to physical therapy school. I wanted to become a rehab coordinator for an SEC college, so a school in, like, the higher levels of football. At the time when I went to PT school, there were only six rehab coordinators in the country. They were all men, and they were all dual certified athletic trainers and physical therapists. So the fact that I’m now a neurological physical therapist is a highly strange experience. That was not at all my career goals at the time. I moved out to Utah when I graduated from PT school to work for the US Ski and Snowboard Association. So I traveled with our Olympic athletes for a little while, and in that process, I collected nine concussions. 

So from childhood up until my last year with the ski team. It was not related to my work there. It was out on the hill snowboarding. But that really started to change the trajectory of my life — the symptoms, dizziness, headaches, exercise intolerance. I ended up leaving sports, and I went into outpatient orthopedic physical therapy practice. At that time in 2014, I had my sort of bottom falls out of the bag concussion. So I had a pretty severe head injury. I went from being a 4.0 student at a top 100 university to not being able to read. I had to use a lot of strategies to be able to do my paperwork. My patients were all safe. I had a lot of good strategies. I just was suffering. 

And traveling through the medical system, you know, back in 2014, no one was doing anything still for concussion. So I was told a lot that they were psychological problems, and I do have a history of anxiety, but I also know — like many of our patients do — what my anxiety and my depression feel like versus what profound fatigue feels like or headaches feel like. I got lucky in my unlucky journey where I found a few really key people who changed my life, and I discovered what vision therapy was. I was able to have some of my attention issues addressed, and it opened my eyes to this totally different area of practice in physical therapy and in emerging science, right? Because in physical therapy, we, again, we really weren’t doing very much back then for patients with concussion. 

So as I found this new interest and my own recovery started to improve, I was about a year out from my actual injury at that point, suffering, and traveling through the medical system and not having any answers. That’s around the time that I met an occupational therapist, and she introduced me to vision therapy. And I immediately said, “I don’t really wanna do this therapy, but I want you to train me, and I now want to do this.” And so I had a little problem with committing to the process and doing things in order, which is a historic problem for me, only worsened by my many, many head injuries. 

And so she started training me. We became very good friends. She became a mentor. And my boss at the time in this little outpatient clinic allowed me to sort of follow this passion, which I’m eternally grateful for. And I then went on to get vestibular or inner ear certifications. And what I started to realize was the physical therapy perspective was inner ear first, vestibular first. And that tends to still be the method that we treat, although the systematic reviews — the big studies that put together a lot of research in one pool — are showing that some of those old ways of doing things aren’t necessarily as effective as we would like them to be. 
And in my pattern recognition skills, I really found that vision should be first. And so in this process of just being a patient who received failed treatments, receiving patients from other places where maybe they weren’t getting the outcomes they would’ve liked, I started to sort of put together this frame of reference where the vision piece really needed to come first, and merged occupational and physical therapy together. And that’s the foundation of the protocols that we have developed. I’ve had incredible teams that I’ve worked with over time. We started to learn about the primitive reflexes and the motor control domain, which is like how your brain and body coordinate with one another. So we integrated that into the protocol. And then more recently, just prior to the pandemic, we started learning that this subset of patients who just weren’t getting better — you know, we were able to get about 80% of them to where we wanted to get, and there was still this section of patients left over — and I just refuse to say it’s psych only. You know, psych is a very important piece of this puzzle, but I refuse to believe that that was the only thing left over. 

And that’s when we started to learn about dysautonomia. And in learning about dysautonomia, which is a disruption of your autonomic nervous system — your, like, fight or flight, rest and digest system — I learned that a mystery illness that I had been suffering with for about 12 years, that had been really taking a toll on my quality of life. At that point I had gotten to a place where all I could do was work. So I would work, and I couldn’t do anything physical. I would come home. It would take me the entire weekend to recover, and then I would go back to work. And I honestly thought I was just gonna die young. The outcomes for a lot of head injuries and neurodegenerative diseases are not great, and I had a lot of those symptoms already in my late 20s. And so I just decided I was going to dedicate my life to solving this problem. 

And then unfortunately, once I learned what my mystery illness was, I’ve discovered I probably have a lot more years left, unless I don’t look both ways when I cross the street. So now I’ve gotta figure out a little bit of better balance. But learning what dysautonomia and POTS — postural orthostatic tachycardia syndrome — is, really gave me my life back. And so now in my very winding journey, my practice is predominantly concussion still, but also a lot of long COVID. There’s a lot of shared similarities, both in the treatment needs and the symptom presentation. And I’ve gone back to school for my PhD. And so I want to become a researcher and just further dive into this neuro area. So short version of that story is I wanted to work in professional sports and SEC football, and somehow now I am going for my PhD so I can do research on chronic debilitating neurological conditions.

So as far as the dysautonomia piece, I thought that a lot of my symptoms — which I now know are dysautonomia due to my brain injuries — I thought that they were just sort of the cost of doing business of having had so many head injuries. I couldn’t exercise. Standing up against gravity was really hard. I had chronic dizziness, chronic fatigue syndrome. So I meet the qualifications for a condition called ME/CFS, myalgic encephalomyelitis and chronic fatigue syndrome. And so basically, we have an energy related illness, and what we’re learning is that the patients who have chronic concussion symptoms — not the people who have symptoms for a month. Those are the normies. We love that, right? We love those people who get better right away. Not the people who have symptoms even for about three months, but it’s these people who get a lot of the way there, but they never regain full function, or people who have a debilitating condition. 

And what we’re learning is that there’s this secondary condition that comes out of that. So we believe that dysautonomia is an autoimmune condition. We believe people are genetically predisposed. They have not been able to prove that yet, but it makes a lot of sense once you’re in that space, that those two things would be true. And so you have this concussion, and it causes this neural inflammation, and then you have this acute early on exercise intolerance which sort of makes the whole thing worse because the less you exercise, the more deconditioned you become, and the more deconditioned you become, the worse the dysautonomia becomes. And so it becomes this really vicious cycle. 

And so what we’re now learning is that there’s a lot of us out there, way more than we ever thought, and that the concussion can be a provoking event. And so you have to treat the concussion. You have to treat their reading problems and their inner ear problems and their neck and all of that, and their concentration, focus, mood, whatever it is. But you also have to treat the secondary conditions that come up because of the concussion, and they really should go in parallel, ideally. Ideally, you’re treating them all at the same time, but that does require a substantial amount of continuing education for the provider or a nice rounded team. “Hey, you’re gonna take the vision. You’re gonna take the neck. You’re gonna take the dysautonomia.” And that way people can really live in the skill sets that they enjoy, and that they’re good at. 

A lot of the research was on acute concussion. And then we just sort of said, “That’s what we should do for everybody.” And we sort of forgot that, like, girls are different than boys and that chronic injuries look different than acute injuries. And the longer the injury goes, the more the brain will actually change its predictive networks in the face of pain. So we know this from, like, chronic pain, central sensitization to pain. And so a big movement right now in concussion literature is actually looking at this functional neurological disorder component. But you wanna be really cautious because that’s a heavy statement. FND itself is a pathological problem. It’s a change in pathways to your brain in the face of these chronic symptoms, and it’s actually a faulty prediction network. So the brain gets out of learning mode, and it gets into this protection mode that actually increases our impairments over time. So it’s a pathway problem, okay? 

But sometimes people end up conflating that with a psychological problem. And so as the research is evolving for chronic injuries, you’ve got these really interesting camps that are saying similar things, but they’re just missing each other. And so you’re starting to see a little bit more of this — like, if they’re not getting better, it’s the psych bucket. And that’s really — that is a piece of it because you’re going to have the disability model and the fear avoidance and things like that. And also, like, it stinks to live with chronic illness and be isolated and, like, not be able to achieve your goals. Like, yeah, you’re gonna have a mental health component if you had to drop out of school or change your work or whatever. You can’t have a family because you don’t think you could keep up with your kids, right? Like, there’s a huge mental health component to that, but that’s not the reason that their brain isn’t getting better. 

And so we wanna just be cautious as we are — luckily expanding our point of view in the research — that we don’t start to jump to these conclusions that are a little bit easier or more palatable to us as clinicians. But we start to realize that this FND component is likely a big piece of the puzzle, and that is a real diagnosis that needs to be treated with the respect that it deserves.

The visual system encompasses about 90% of your brain pathways will interact with your visual system. So if your visual system is inefficient, you’ll have less cognitive reserve. So when you try to read in a busy environment, you’ll break down. When you have to step off a curb and turn your head, you could start to break down. And if I only do habituation, if I only get you used to moving your eyes between targets, and I only have you turn your head from side to side, I’m neglecting to respect the brain changes that have happened, the prediction networks that are involved, and visual inefficiency, which is present in — by far — more patients, more than 50% of these patients, but by far more than we ever thought was true. And then that vestibular piece starts to come in a little bit more on the back end. But that’s still considered a controversial opinion.

I think that being able to say, “I don’t know” is a strength that not everybody has because you can’t… You know, I’ll say to a patient — a patient might have a very specific question. Sometimes they’re gotcha questions. Sometimes it’s that they don’t have hope that this is actually gonna work, so they’re testing you. Sometimes people just need to, like, ask a million questions — you know, there’s lots of different reasons people will ask you specific questions. But sometimes patients will ask really, really specific, minute questions, and they feel like if you don’t have the answer to that question, they can’t get better. I’ll be told that sometimes by a patient. Like, “Well, until someone can explain this to me, there’s no way I can get better.” And the luxury for me is I’m on the downstream. Like, whatever you find in a lab somewhere in a Petri dish is not functionally gonna change anything that I do because the billions of brain connections that have happened by the time they reach my stuff — there could be any little pivot and it’s not gonna change the downstream functional effect. So the cool thing about physical therapy is that if we can say, “I don’t know,” and we can stay open-minded to reading and understanding the new information coming out, and we can stay open-minded about flexing our past beliefs, we can sort of remember that we are treating the functional downstream impairment. 

So the answer in a lab isn’t fundamentally going to change — whether it’s this portion of the cell or that portion of the cell isn’t fundamentally gonna change the balance strategy that the person needs to build. So being able to just say, “I don’t know the answer to that,” isn’t a hit to our ego, but it allows us to stay open-minded and it allows us to change. This is a rapidly evolving field. If you as a patient go to a clinician who feels completely confident and makes you promises, you should probably run in the opposite direction. Because you cannot be that confident. 

On the other side, if you’re seeing somebody who is one-offing everything — like there’s a big saying in the concussion world, “If you’ve seen one concussion, you’ve seen one concussion.” Well, then you’ve probably seen five concussions, right? Because like once you see 300 of them, 1,000 of them, 2,000 of them, you know that there are boxes. There are prediction models in our own brains as a clinician where we can start to figure out what to prioritize.

So yes, each person has their own unique factors, and there are shared traits across groups. And so when you start to truly listen to what your patient is saying, I can start to pick up on — ooh, I think the neck might be a driver here. I don’t treat orthopedic stuff anymore really. It’s not a great use of my skillset. I have a teammate who will treat the orthopedic injuries, right? Oh, I’m really hearing that fear avoidance and anxiety or depression or isolation is a big part of this. Okay, I have a counselor that I’m gonna send you to and I have a list of people that I’ve had good interactions with. Oh, okay, I’m hearing that, like, you’re having temperature regulation issues and you’re having some hormonal fluctuations. Okay, I need to send you to a gynecologist. So it’s not that I have to have all of these answers, it’s that I should be able to use a Rolodex in my brain if I’m gonna call myself an expert in the field. And I should remember that, like, my piece of the puzzle isn’t the most important necessarily for every patient, but it might augment. They might need to have their thyroid checked because they have an issue with, like, their HPA axis. And they also need vision therapy.

And so it’s more about being able to be a collaborative environment and a team. It’s about staying open-minded to emerging science. It’s about not staying to the old science because nothing has been proven to be better. So this is another big problem in our field — the research is coming out saying the old stuff doesn’t necessarily work for the more chronic patients the way we thought it did. But we’re in a paradigm shift. So a true paradigm shift means the old regime is cracking, and we are in a black hole of we have no idea what to replace it with. That’s a true paradigm shift, right? And so we don’t know what the second part — what part two of this — is going to look like. So if you live in a place of “I’m not gonna try that new thing that is reasonable” — not some of the nonsense that you hear, but the reasonable stuff — because you haven’t proven that it works, but I’m going to continue to practice in this way that we also know doesn’t work, right? 

You’re sort of just rooted down into your own sedimented beliefs, and you’re not necessarily helping your patients because you’re not willing to flex. And so I think that’s the biggest gap — it’s really just if we become too set in our ways, then we are now not open to things that are new and emerging in a rapidly changing field, and we’re sticking to the old stuff out of our own ego or safety or whatever that thing is that holds us in that place.

When I mentor clinicians, I tell them, “If you’re practicing the same in one year as you are today, you are not doing it right.” Like, I have been wrong about more of my theories than I care to discuss, but the functional stuff that we do hasn’t really changed, right? It’s been the underlying theory of what drives it. And so just staying open-minded, and filtering through the garbage. There’s a lot of just preying on desperate people in this area, and fundamentally that upsets me — maybe because I have some — I don’t remember the term in ADHD, but that thing when you get just a sensitivity dysmorphia or something. But I really don’t like it when overpromising, high-cost desperation models start to take the place of real science, because real science just moves slow, and real therapy for your brain requires you to work on it every single day. Neuroplasticity is nerves that fire together, wire together. 
The number one thing is you have to put in a full force effort. So when I send a patient to counseling, I always tell them, you get what you give, right? And so the same is true for neurological therapy. Like, if you are not able to truly commit to the homework and put in the reps, the brain isn’t fundamentally going to change, right? So part of it is that we have to show up as a team. The patient and I both have to show up to the table ready to work. I as a clinician have to be willing to adapt to their unique needs. They have to be willing to commit to the process. On the other side of that, if you’re a patient who’s been seeing somebody for months and months — or, I don’t know, sometimes, like, people have seen 20, 30, 40 visits — and there hasn’t been a remarkable change, we really wanna think, “Is this person, regardless of their name or the shingle on the wall, serving me?” So you also as a patient need to hold the clinician accountable. We should be producing results. The brain changes fast if you target it in the right way and if you have a collaborative relationship with your patient. So I shouldn’t need 20, 30 visits to get a significant outcome. So if you’re not getting what you think you should be getting, it’s okay to get a second opinion. Where you wanna be cautious is a lot of doctor shopping and a lot of just looking for this magic silver bullet that I promise doesn’t exist yet. I’m sure once there’s a pill, that will be magic, but for right now it really doesn’t exist.

The other thing is sometimes a type of therapy can come into your life for a portion of time. So sometimes you might get to a certain place, a certain benchmark with one type of therapy, but that doesn’t mean that you are done healing altogether. It might be time to end that relationship and then date somebody new, right? It might be time to go onto the next type of therapy and look for more answers. You want to be cautious about not having hypervigilance or internalizing your diagnosis, or things like that that patients can start to do where they really start to search for these answers. And also, you have to find that balance where the brain will keep changing as you keep targeting its weaknesses. So healing doesn’t stop at one year, it doesn’t stop at 18. All of that’s nonsense. It’s just slower, right? The more sedimented a pathway is, the slower it’s going to change.

But if you’re three years out and you’re like, “Wow, I never knew what vision therapy was before,” you can go to vision therapy. It’s available to you, right? If you’re like, “Oh, wow, I am having exercise intolerance,” or, “I have some of these upright intolerance pieces,” you can still go and do those treatments. So the brain can always keep changing across our entire lifespan. If you are struggling with something, go see what new science is available, right? Like, I’m treating differently today than I did before the pandemic, than I did 10 years ago when I first started. And so sometimes I’ll have a patient come in and say, “I just wanted to know if you found out anything new in the last couple of years. Will you do a reevaluation on me?” And like, heck yeah, I will. Like, let’s play around and figure it out, right? And so those are all really important pieces. It puts a lot of the onus on the patient. That’s not fair. 

That’s just also the way it is, right? And so the more informed you are as a patient, the more you can check in with your own hyper attunement to your impairments, right? The more you can not perseverate on your impairments, but the more that you can kind of drive your care by knowing what to look for, the better access you’re going to have until there is a standardized approach. Right now in concussion, there are a lot of companies who teach clinicians how to treat, but there is not actually an evidence-based superior — this protocol over this protocol. We don’t have an actual meaning for the word concussion specialist. It doesn’t have any real meaning to it. And so you really just don’t know what you’re getting until you sit down with them and you listen to them. And if something doesn’t feel right to you, you have every right to go somewhere else. It doesn’t matter how important that person seems. I want my patients to hold me accountable, but I also expect them to show up and fully participate in the therapy as well, and I’m totally fine when they wanna add something else or change their focus over time.