Concussion Recovery and Autonomic Fitness: How to Master Your Nervous System

what we noticed was that people with Long COVID, around 70% of people with Long COVID, are slightly hypocapnic, meaning they have low levels of carbon dioxide. Usually we think of carbon dioxide as a waste product, and we don't realize that it's actually very important for maintaining metabolic balance in our bodies. And so this finding that it's actually low in people with Long COVID was really interesting. Even more interesting was the fact that it appears to be low despite people with long COVID having within normal limits or regular respiratory rate.

What does it take to do the impossible? What does it take to level up your game like never before? What does it take for individuals, organizations, for even institutions to achieve paradigm shifting? Nothing is ever the same again. Our mission is to decode the neurobiology of flow and cognitive peak performance, access the the minds of maverick scientists, groundbreaking innovators, and world-leading experts to understand what it takes to achieve ultimate human performance so you can feel your best, perform your best, and accomplish your boldest goals. I'm your host, Rhian Dorris, and together with bestselling author Stephen Kotler, I present to you Flow Research Collective Radio. Dr. David Petrino, welcome to Flow Research Collective Radio. Really great to to be here.

Oh, thanks for having me.

Yeah, so I'm going to hopefully elicit some pride in you by reading out your incredible bio here for a second, and then we'll dive into the interview. So, David, you are a physical therapist with a PhD in neuroscience, having studied computational neuroscience at Harvard Medical School, MIT, and NYU. And you're currently the director of rehabilitation innovation, which we're going to talk more about in a moment, for the Mount Sinai Health System. And an associate professor of rehabilitation and human performance at the Icahn School of Medicine at Mount Sinai. And you've developed innovative rehabilitation solutions for adults and children in need of better healthcare accessibility and have worked with high-performance partners like Red Bull, the Brooklyn Nets NBA team, and the US Olympic team to use evidence-based technologies to improve athletic performance. And then there's a book you've written as well, which we'll also talk more about called Hacking Health: How to Make Money and Save Lives in the Health Tech World. And then my favorite part of your bio is that in 2019 you were named the Global Australian of the Year, which is pretty damn cool for your contributions to healthcare. So yeah, welcome to Flow Research Collective Radio. Really, really great to have you here, David.

Oh, thanks. It's awesome to be here and be chatting.

Alrighty. So the first thing I wanted to ask you about is the Rehabilitation Innovation Center and the focus there. And before we started recording, you mentioned something really interesting, which is that the specialty is innovation. Sometimes people maybe aren't fully clear on the focus there, but could you break down to us the sort of work you do at the rehabilitation at Mount Sinai overall and within that center? And then we'll go from there.

Yeah, you know, it really all came about through, through one statistic that was bugging me across the US, which was the idea that it takes to go from bench to bedside with a new health technology. I'm not talking about a drug here, I'm talking about an app, I'm talking about a wearable. Going from bench to bedside, from conception of the idea to the point where clinicians are commonly using it in their, their daily practice is 17 years on average in the United States. So that is an outrageous number. It's a number that shouldn't exist. It's a number that exists because we're very change-averse in the way that we practice medicine, and it means that a lot of people don't get the care that they deserve or the care that they could be getting, um, because of you know, silly bureaucratic process. And so that gets me pretty fired up. I dug into it a little bit. Why is this happening? And why is this the case? Lots of people like to blame the FDA, like they, they go straight to regulatory, they're like, oh, it takes so long. But I started to realize, yeah, you know, regulatory issues are issues. And You know, necessarily the government has structure around what you can and can't do and what you can and can't call a medical device, which is reasonable. But some of the biggest issues I was seeing was amongst my own people. You know, it was the academic medical centers that were slowing things down. They would, you know, cause companies to die in many different ways. You know, most notably you know, we call it death by pilot, where a company would, you know, show up to a hospital with a really cool device and the hospital would say, great, but we need to do a clinical trial. Then they spend the money to do a clinical trial and then the hospital says, yeah, well, the clinical trial worked, but we're still not so convinced, so we're not going to do it, you know. And what we started to notice was most companies in their lifespan would just bounce from clinical trial to clinical trial, and then just die, run out of money. They don't have any clients, and off they go. So we wanted to create this division of rehabilitation innovation where we said it's our job to shrink that number. It's our job to get a company in the door, run a clinical trial if they need a clinical trial, but at the end of that clinical trial, if we like what we see if the data really speaks for themselves, we implement the technology. No messing about, just straight into implementation. We become a client of the company. And then the idea is that hopefully we can promote some change within the health system and say, well, we're using the technology and our patients are loving it and it's making money and, you know, and insurance is paying for it and all of these different things. Which then accelerates the path of the technology forward to the point where so many more people are using it. And I'm fortunate to be at a place like Mount Sinai because it's a big health system. So if you get one of those, you know, on, on the list of your, your client list, that's, that's a big deal for a small startup. And that can, that can generate enough income for them to move to the next phase of their process as a startup. So that was how we started. Um, the, you know, the initiative kind of, uh, went quite well. We started off with a single, uh, clinical research center that turned into a research center and a clinic, and then that turned into another research center and another clinic and another and another. So we now have 3 different hybrid academic clinical centers within Mount Sinai. One deals with high-performance athletes, one deals with kids and pediatrics, and the other deals with adults with neurological conditions.

Amazing. So you guys are, are really accelerating the validation of the safety and efficacy and kind of providing an authority transfer role to these technologies. Is that Am I tracking that correctly?

Yeah, absolutely. And then, and then also some pragmatic stuff, you know, there's, there's a difference between making it through a clinical trial and, and showing statistical significance and actually having a product that patients and clinicians want to use. And we, we center the voices of the people with the conditions that we're treating a lot because You know, so often, um, a company will just assume, okay, if you've got a traumatic brain injury, you want our intervention, you know. Um, but they never actually speak to a person with a traumatic brain injury who says, yeah, well, yeah, of course I wish my cognition was better, but I don't want to spend 4 hours a day working with your product to get a small boost in my cognition, you know. Um, and so that's the difference between a company that can do amazing things in clinical trial But when you bring them to a real-world clinic, they'll fall flat. And, you know, and those are some of the things that we navigate with companies as well. I mean, the main idea is, is fail fast in our clinic. It's like, show us what you got, and, uh, and let's see if, let's see if everyone really loves it.

What are some examples of startups or technologies within those 3 different divisions that you mentioned over the last whatever number of years that are, that are the most compelling, the excited about?

I think on the, the adult track, so our neurological clinic, we're currently entering into first-in-human trials for a novel brain-computer interface for people with ALS. The company we're working with is called Synchron. And these guys have developed a device called a Stentrode, which is a word that is— that means a stent and an electrode smushed together. So a stent is usually something that is placed into a blood vessel to hold the vessel open. They use— it's used in stroke and in cardiology and, and other, other conditions. And In this case, what, what these guys at Synchron have done is they've built electrodes into this endovascular stent. So the device enters the body through the jugular vein, moves into a blood vessel called the superior sagittal sinus, which is a big blood vessel that sits between the two cerebral hemispheres of our brains at the point of the, the primary motor cortex, which is the part of the brain that controls all of our voluntary movement. That's where we stop the stent. So we place it there. At that point, the stent heals into the blood vessel and can record brain activity from that vantage point. And what we're looking into is the ability for someone who's completely locked in with ALS to gain complete independent control of a personal computer through thought processes alone. So super exciting clinical trial happening there, um, out of the Abilities Research Center, which is our, um, our, our center for, um, adult, uh, neurological conditions. Um, so that's, that's one project. Wow.

Yeah, that's, that's an incredible example. Um, if you have any other examples, feel free to share them. I know people would love to hear them. Then I want to, I want to touch on, on Hacking Health after that, and then we'll come to some of the work you are doing right now on, on Long COVID as well and autonomic rehabilitation. Consultation.

Yeah, you know, a couple other examples in the pediatric space. We've got an incredible— we actually imported an incredible postdoctoral fellow from Australia that we call our Innovator in Residence for the Charles Lazarus Children's Ability Center, which is our kids center. And what he's done is he's designed a device for airway clearance for people with, for kids with cystic fibrosis. So cystic fibrosis is a chronic lung disease. And if you have good care, you can live, life expectancy can, it can be well into your 40s. If you have poor access to care, life expectancy drops down to into the 20s, 21, 22 years of age. Typically, the difference between good care and bad care is access to airway clearance devices and good education on how to use those. That's expensive. Most airway clearance devices cost around $200. So Dr. Jamie Wood, who's joined our team, developed a device that costs about $2, which, because it's such low cost, we're giving it away for free to developing countries. And just teaching local therapists how to implement the device, get the kids using airway clearance technology, and hopefully living longer and healthier lives. And that, that technology has gone from, from bench to bedside in 3 years. So it's something that we've been really excited to see go from a basic concept to a clinical use case in, in a 3-year time span. So super excited about that project as well.

Amazing. And I'm going to suggest people go to patrinolab.net, and you've got a page there of current projects. Is that the best place to go deeper on some of the current pieces?

Yeah, that, that's, that's actually an old website, but they can also Google the Abilities Research Center and the Charles Lazarus Children's Ability Center to get a sense of what's most up to date. The Petrino Lab website was kind of something that we, we threw up when we were sort of still hustling between, between different institutions and so on and so forth, but we wanted people to see the work. But it's still, it's still great, and, you know, love that it's there.

Got it. Yeah, that's great. So I'm going to segue into the book here for a moment, then I want to come back to, to long COVID and actually briefly concussion as well. That's something we get a lot of clients suffering from at different points and not really having much clarity around how to recover from or navigate. And so we can bundle those before we do that. So from my research, I see that you dedicated Hacking Health to Dr. Gene Coppola. Hopefully I'm pronouncing that correctly. And before we dive into the book, what was it that led you to making that dedication? And what were some of the big things that you learned from Dr. Gene?

Well, yeah, the book dedication to Gene was really when I got my first faculty position I started working on a community-based program called TIPS, Telehealth Intervention Programs for Seniors. And it was this— while, you know, I was getting exposed to all of these crazy technologies, you know, over-the-top augmented reality and robotics and brain stimulation and all the rest of it, I met Jean at a community college, a local community college. She was a computer science lecturer, and she had just pulled together a bunch of young first-year college students, and she was getting them into just settings that were caring for older adults, you know, like community centers and public libraries and churches. And she was just getting them to take blood pressure and take their vitals and chat with the older adults and, and, and effectively they created this, this beautiful telehealth center, telehealth network really called TIPS, that when we started to study it, it, it dropped the number of hospitalizations in these older adults, high health risk older adults by up to 60%. So it was just this wildly effective way of using telehealth technology to keep older adults and keep the community healthy. And I met Jean at a conference, she and I hit it off, we started working together, we expanded the program until it was, you know, it's the program tips is still going, but, you know, it's now in 7 states, it's, it's looking after thousands of older adults. It's held the sustainability of keeping people out of hospital. And it's all— what it has never lost over all the years is it's still about using technology to make people feel more connected. So it's not using technology to reduce healthcare costs or using technology to get better data from older adults. It's keeping people connected through technology, building authentic social connections that then encourage older adults to do a lot of high, you know, high-value health behaviors that keep them out of hospital. And so I just learned a lot from working with Jean. Unfortunately, just before we published the book, she passed away. And, you know, it was— she was the first person to really show me what an effective health technology solution could look like, um, and really teach me that it was all about, you know, you can have all the technology in the world, but if you're not making it about the people, if you're not centering the voices of the people you're trying to help, then you're not going to have a success at all. So, um, that was really special to me.

Yeah, that, that's one of the things that's really just cool about what you do is bridging academia and research and the emphasis in entrepreneurship and startups around utility and the user and application. So in the book, you mentioned that there's 4 case studies which the book is centered around. And I would love if you could give a breakdown of what is focused on within one of those case studies. Yeah, one of the technologies that you, that you cover that is, that is most compelling there.

Yeah, in, in the book, we, we try to cover all the different ways you can integrate novel health technologies into, into the health system. Some of them can be profitable, some of them are maybe just more about social impact or Driving impact and driving change. So I think that definitely the one I'd like to talk about because it's way more my style because I'm, you know, perennially broke. It's not about making money for me. But, you know, one of the examples that I touch on is working as part of a social good organization. And one of the projects that you know, has been a real highlight in my career was, was working with a group called Not Impossible Labs. So the project I touch on in, in that particular, uh, in, in the book is, is really about, um, we needed a solution to an issue that was happening in Sudan where we had a bunch of kids, uh, who were missing limbs as a result of terrible civil war that was going on, and there were constant bombings, and there was one beat-up old hospital in the middle of it all that was trying to provide care to these, you know, single and double and sometimes triple amputees. Um, and they had no access to prosthetic devices, but they also had no access to anything else. You know, this hospital had been cut off in every way that you could imagine because, you know, the warlord that was leading things, who thankfully has since been deposed, Bashir, was cutting, cutting off access. You know, this was just the way warfare was being done to make sure that the hospital had no way of serving their population. So we had to get creative with a solution. I was fortunate enough to meet two really amazing folks, Mick Ebeling and Elliot Kotek, who pulled me into the fold and said, okay, how do we build a prosthetic from trash? You know, like from anything we got lying around. We started tooling around with that, and we really got to the point where we understood that this hospital was so isolated, there was no way that we were going to get anything in or we were going to be able to use anything that was around. Like, we, we had a couple of Skype calls with, with the, um, and yes, it was Skype back then, uh, um, with the, the head of the hospital. And, and we kept thinking that we had the greatest idea, and we were like, you know, Coke bottles, everyone's got Coke bottles. No, no Coke bottles. You know, wood, fabric, they're out of everything. So we said, okay, we can't build from what we've got, so we need to do something additive. So, um, 3D printing was just becoming a thing back then. Um, and so we pulled together a bunch of designers and myself as a physical therapist. We started planning out how to build a 3D printed prosthetic, and we finally had a design that we really liked. And we tried it out a bunch of times. It seemed to work okay. And so we sent a team out into the middle of a war zone. They sort of airdropped in, got snuck across the border, the South Sudan border from North Sudan, and made it into the hospital, set the, set the kit up, taught the locals how to build the prosthetics and does, and how to print. And within about, within about a week and a half of being there, the, the kid who kicked all of this off. This, this young boy named Daniel, who had been picked up by a Time magazine reporter, showed up to the hospital, tried on his two prosthetics, and fed himself for the first time in 3 years with his new prosthetics, which is pretty awesome. Then the community came in, learned how to build, and started building one prosthetic a week for, you know, for one patient. And that was a, that was an incredible project. What was especially amazing from that project, you know, was that we took, you know, those plans that we initially made, we threw them on, at the time it was called the Thingiverse, for all the projects that you would put on a MakerBot platform. And we, you know, everything being open source, like the community came around and built way better prosthetics, you know, like, but everyone sort of, everyone, everyone sort of hearkened back to that one design that we put up on open source and said this was, this was the inspiration. And now, you know, there's, there's companies that, that do 3D printed prosthetics and make a good living of it. But it was one of the first, first designs out there, first designs available. And it just showed how when you do this sort of crisis-based innovation and you create something and you, you don't worry about money, you just put it out there, it can give people permission to do more. And then suddenly you can sort of spark a bit of a movement. And so that's, that's a big— a favorite project of mine just because of the level of— seeing Daniel feed himself was one thing, But seeing 100,000 prosthetics made with this core design was quite another. And that was quite cool.

That's amazing, David. Thank you for that breakdown. It's phenomenal. So our focus at Flow Research Collective is peak performance and flow, two things that I know a lot of our clients are hampered by when it comes to optimal cognitive performance and thus flow are long COVID. More and more people, obviously, as you know in your research, have been suffering with long COVID. And I think a lot of people who are listening to this either are concerned about getting long COVID themselves or maybe know someone who has had it. And then concussion is another big one. So what I would love to do is to hear a breakdown from you, given that you are an expert in autonomic rehabilitation, as to what you recommend to people firstly who have suffered from concussion maybe in the past and it's distorted their mood or cognitive performance. And then afterwards we'll go to, we'll go to long COVID with a, with a similar question. But let's start with concussion.

Yeah, absolutely. Um, and you know, it, they're eerily similar for sure. Um, but, um, I mean, I think one of the first things and You know, if we take— if anyone listening takes anything away from, from this, when it comes to concussion, um, we need to move right away from this idea of, oh, you took a hit to the head, sit in a dark room, don't speak to anyone, completely go into hibernation, um, for 2 weeks. You know, somehow that is still advice that is being thrown out there, and that sort of advice needs to go. We're, you know, we're well beyond that now, and what we need to do is think about activity as tolerated from day one to make sure that we don't cause any additional issues. But that's, you know, a pet peeve that I had to get out the way when we talk about concussion.

Where did that come from?

Sorry, that sort of myth So, you know, I, I think that, um, it was kind of the, uh, overabundance. It's an evolution of this overabundance of caution of like, if you have it, if you take a hit to the head and you're concussed, of course you could have a brain bleed. And so then you're going to be photophobic, you're going to be, you know, going into all sorts of, um, serious medical consequences as a result of a brain bleed, and we need to get you to the hospital, get a CT scan, and do a surgery if indicated to, you know, to relieve the pressure on your brain. And so I think early on people said, well, okay, if you've taken a hit to the head, you need to like stay in a dark room because you don't want to stimulate any of those, you know, any of those terrible symptoms that could come from a brain injury. Whereas, you know, well, if you're that sick, you should be in the hospital immediately getting a CT scan. You shouldn't be sitting in a dark room hiding from it. And if you're not that sick, then a different set of rules apply. And so when we talk about concussion, a different set of rules are applying. And so we should just throw away that old-fashioned you know, sit in a dark room and, and hide from the world. Now, as I, as I said, you know, I need to temper that with activity as tolerated, because anyone who has had a concussion will attest to the fact that, you know, the first few hours to even days after a concussion sometimes can be really rough. And so you need to be extremely careful about not overextending what you're doing, um, and, and managing, you know, checking in with yourself, managing your symptoms, making sure that you're doing okay. So, you know, the— these are the sorts of lines that need to be walked. And, and this is why, in my opinion, the concussion research and concussion clinical care suffers so much, because everyone wants a protocol, right? Everyone wants like you know, tell me precisely what to do, um, so I can replicate it and I can turn it into a factory and I can, you know, um, you know, sell it as a pipeline. But, um, concussion doesn't work that way. What, what you need to do is, um, we need personalized care. And I mean, across the board we need personalized care, but there are certain conditions— concussion, long COVID— where you need to be even more focused on treating the person in front of you, hearing what they're saying. I mean, um, when it comes to a concussion, you're going to have different symptoms based on which part of your brain got hit, you know. And, and often that's not even considered by, by a treating professional. Um, you rarely even— you know, often when you go to a clinic I hit my head. Well, tell me what happened. Basic, so, you know, basic history, subjective history. But you, when you think about it, you don't actually really go into the mechanics of, okay, well, which, which way did your head go? And, you know, um, did, did you bounce back? And do you feel like you have whiplash? And so on and so forth. These things kind of get left out of the examination. So when we're dealing with a concussion, we try to be as objective as possible. So, you know, I'll start from the very beginning, which is we manage the care of hundreds of school kids and young adults. And so wherever possible, we already have baseline measurements on the people that we're seeing, so we understand what is normal for them. Because there's nothing more frustrating, especially for a high-performance athlete, when they sustain a concussion and they come to me and they say, I'm concussed and I'm not I'm not thinking the way I used to. And you send them to a neuropsychologist to get a full cognitive battery, and the neuropsychologist says, well, yeah, they're scoring, you know, they're scoring within normal limits. And the athlete says, you know, well, I'm usually above average, like, I'm not, I'm not within normal limits, you know, I'm a high-performance athlete. And you see the neuropsychologist writing down, okay, narcissist. And, you know, and I'm sitting there going, no, like, this is the you know, best fencer in the world, like, he's probably pretty smart, um, and, and he probably should not be scoring normal in reaction time and, um, you know, executive function. He's probably meant to be way up here. Um, and so obviously having a baseline mitigates that because you can say, well, this is where you were before. I don't care what what's normal, quote unquote normal. I just care what— where you were before and where you are now. Um, so in our baselines, of course, we'll do a cognitive battery. We will, um, uh, we'll take measures of autonomic function. Um, depending on the athlete will depend on how detailed and granular we get with measures of autonomic function, but at the very least, we capture heart rate variability. And, and, uh, you know, and make sure that we're capturing it at the same time every day and the same levels of stress and so on and so forth to get a good sense of what their autonomic nervous system is doing. We look at, you know, balance ability, um, musculoskeletal range of motion and, and things like that, because often a lot of concussion symptoms can simply be cervicogenic. They can just be, you know, you took a hit to the head, you've got whiplash, and now you're getting cervicogenic headaches and cervicogenic dizziness, which is dizziness and headaches caused from dysfunction of joints in your neck as opposed to a brain injury. And you need to differentiate those two. Um, and so— oh, go ahead.

Yeah, what I'm hearing there, David, is it's almost analogous— saying I'm concussed, what do I do— is almost analogous to saying I have a pain what do I do? You gotta personalize the diagnosis and the treatment based on the specific nature of the concussion rather than viewing it as a— as its own specific syndrome.

Is that right? Exactly, exactly. I mean, concussion is an umbrella term, um, and you need to understand what's happening that's causing, you know, persistent symptoms after a knock to the head.

Got it.

Yeah.

Okay. No, that's super helpful. On the long COVID front, so Nassim Taleb, in his book Skin in the Game, one of his bits of advice when speaking with doctors is to not ask what they recommend you do, but to ask what they would do if they were in your situation to try and simulate skin in the game. So I'm going to ask you the equivalent question, David. I'm curious if you woke up in a week's time crippled with long COVID, with the brain fog, the inability to exercise, the joint pain, whatever the constellation of symptoms were, what would be your approach to tackling that and getting back to peak performance and full cognitive function?

Yeah, what a, what an awful question to ask me. It's a, it's a tough one. Um, I mean, what I can say for absolute certain is that we are still, we're still trying to understand underlying pathology, right? So I have, I feel I have a good handle on symptomatic control of Long COVID because so many of the Long COVID symptoms that we're seeing as we said, they're analogous to concussion because I feel like there is a, a dysautonomia element to what's going on. It's not everything, um, where certainly, you know, I can tell you for, for a fact now, um, because the— we're starting to get the research out, but we're seeing signs and symptoms of mitochondrial dysfunction, we're seeing signs and symptoms of autoimmune dysfunction and we're seeing signs and symptoms of vascular dysfunction with some of the work that many have been reading about from Rhysia Pretorius around microclots and, and so on and so forth. So everything I say here is tempered by we need to understand what's causing these symptoms, whether it's autoimmune, viral persistence, vascular issues, because that's where, um, the real interventions are going to start, uh, happening. But if it were me, you know, the, the most effective things that I've seen in the short term, um, are certainly these lifestyle, um, alterations for getting dysautonomia symptoms under control. Because regardless of anything else— so dysautonomia is once again Like concussion, it's an umbrella term, um, which really defines dysfunction of the autonomic nervous system. The autonomic nervous system is a part of our nervous system that controls all of these things that are just on the back burner in our bodies under autonomous control, you know, just like an autonomous vehicle where you don't need to think about anything. Autonomic nervous system controls your breathing rate, your heart rate, your digestion, sweating, you know, um, response to stress. Anything that you don't need to think about that your body does automatically, uh, to keep us moving and keep it— keep us going, um, is under autonomic control. And, um, and it can get quite fine-grained, you know, like we, we don't think about any of this, but if you go from sitting to standing your heart needs to do more work to pump up against gravity to get more— the— to get the same amount of blood into your brain. And your autonomic nervous system handles that. It, it increases your heart rate, it increases stroke volume, and it allows that to occur. Things like a viral infection or a knock to the head trauma can knock this thing out of balance, and that's where you get dysautonomia. And we have been seeing so many patients with, you know, very clear-cut symptoms of dysautonomia, you know. And when I say clear-cut, I mean, uh, just in that example I get— I gave, you ask them to go from sitting to standing, and rather than having a 2 or 3 beat per minute increase in their heart rate, we see a 45 beat per minute increase in their heart rate. And they of course start to feel dizzy and, you know, and don't know what's happening to them. Their heart feels like it's fluttering in their chest, which makes them think they're having a heart attack. Of course, by the time they go to the cardiologist, everything's within, within normal limits— that awful phrase once again— and they're told, go home, there's nothing wrong. Um, so, you know, there are a number of strategies that can just calm the autonomic nervous system down right from the outset, you know. And these range from, um, wearing, uh, compressive tights around the lower half of your body, so like from, from waist down, in, in order to encourage more blood being squeezed back into the chest cavity. This helps to regulate blood pressure and heart rate when you're, when you're doing positional changes. Really being passionate about hydration and making sure that you're getting a lot of hydration paired with sodium intake. Because, uh, you know, so long as it's indicated by a doctor and you don't have blood pressure issues, this is also really helpful in regulating blood pressure. Um, understanding the, the impact that autonomic regulation has on different things, like getting into a hot shower can trigger an autonomic attack because the hot water increases your heart rate. The increase in heart rate switches you over to a sympathetic nervous system state, and all of a sudden you're having a dysautonomia flare. Um, so understanding, okay, when I have a shower now, while I'm managing my dysautonomia, start off at a tepid temperature, step in, slowly ramp up the temperature in a way that isn't going to shock my body. Same with meals, making sure, you know In short, making sure that things are planned and intentional takes a big edge off of symptoms. We've also had good success with breathwork. We've worked with a group called Stasis. They, they developed a breathwork protocol to improve CO2 tolerance and, um, uh, and retention, because what we noticed was that people with Long COVID, around 70% of people with Long COVID are slightly hypocapnic, meaning they have low levels of carbon dioxide. Usually we think of carbon dioxide as a waste product and we don't realize that it's actually very important for maintaining metabolic balance in our bodies. And so this finding that it's actually low in people with Long COVID was really interesting. Even more interesting was the fact that it appears to be low Despite people with long COVID having within normal limits or regular respiratory rate. So usually if I see someone with hypocapnia, I'm like, oh, you're panting, you know, you're blowing off too much carbon dioxide. But in this case, comfortably sitting, you know, not, not apparently breathing in any dysfunctional way, and yet CO2 is low. This tells us something metabolic is going on. This tells us, you know, something like the mitochondrial dysfunction that we're seeing. So mitochondria are the, the batteries of our cells. They, they produce energy. And what we've started to see in long COVID is that mitochondrial function is lowered. So we're producing— our cells are producing less energy. Now, the byproduct of cells producing energy carbon dioxide. So maybe what we're seeing here, uh, with, with these hypocapnic individuals is that their body isn't producing as much energy as it used to, and so CO2 levels start to, start to drop systemically. So breathwork, lifestyle changes, um, really, really big deal. As you mentioned, uh, at the beginning of the question that I've been rambling on for a while now, um, You said I wake up tomorrow and I've got it. Well, I'm going to take a leaf from the amazing research that Risi Pretorius has been doing out in South Africa, and her and Jaco Labusch who is also in South Africa and has been seeing hundreds of long COVID patients have shown fairly good success with early cases, first 6 months of long COVID, working on medical— a medication protocol for anticoagulation and adjusting platelet pathology. So they use 3 medications. For general safety reasons, I'm not going to name the medications, but this is published, and so it can be researched, and I named the authors. But they use a triple therapy for addressing platelet pathology and hypercoagulation. And so long as it's applied early, people, people tend to have a very strong, uh, response to it. Now, I wouldn't, um, I don't recommend this lightly. It's, it's no, it's non-trivial to jump on an anticoagulation protocol. Like, um, it comes with many risks. But they're not so risky that we don't give them to every single person who's had, you know, a stent placed after a heart attack. So it's an acceptable level of risk, and I think it's, uh, if it were, if it were me waking up, that's, that's something that I would, um, I would be investigating and, and consulting with my physician on as to whether they thought it was a good idea for me to try out. You know, the, the other thing that I would be interested in trying, you know, because of my work with folks like Amy Pearl and Saurabh Mahendru, who have been incredible researchers looking into the element of viral persistence in long COVID, the idea that that long COVID symptoms may be occurring as a result of the virus sticking around in the body and not being adequately cleared by the body. I would also be looking into antivirals, things like Paxlovid and, and others, because I don't think, you know, acyclovir, for instance, has broad antiviral properties. But once again, this would be a conversation with a physician about what they thought, you know, a request for tissue biopsies in particularly symptomatic organ systems. So for instance, if I'm having very intense GI symptoms as a result of my Long COVID, I would ask my gastroenterologist to biopsy and look for viral persistence. And if they see viral persistence, wouldn't it be a good idea to try a COVID-targeted antiviral to see if it improves my symptoms? So with all things, you know, just like we were talking about with concussion, I think Long COVID, necessarily the diagnosis for Long COVID has been broad. And so lots of things come under the umbrella, under the, you know, the camp of Long COVID. Depend— what I would do would depend on what I asked my physicians to do and what comes back from those testing to, you know, to make the next step. But I understand that that's a highly privileged position to take because we are living in a country right now where millions of patients are being gaslit by their physicians and being told Long COVID isn't even real. So take what I just said with a grain of salt, I guess.

Thank you, David.

That was a phenomenal answer.

I appreciate it. And I know it's going to be useful to a lot of folks to at least give the trail that they can start to investigate for themselves. The final question, David, that I would love to ask you is about the concept that we hear a lot about in the peak performance space of autonomic fitness. So if dysautonomia is one end of that spectrum where the autonomic nervous system is dysfunctional, to the degree of standing up and having heart rate radically elevate. Is there such a thing as autonomic fitness to the point where your autonomic nervous system is more well-regulated than normal? And if so, what are the mechanisms underlying that and how autonomically fit can you theoretically become?

This is a great question. And, you know, it's an unanswered question, so I, I'm definitely going to just be throwing, um, conjecture here. Um, I think, you know, my, my best definition, if you were to ask me what autonomic fitness would look like, uh, because this isn't even a concept that we usually think about, my, um My best answer would be actually having voluntary— the ability to exert voluntary control over things that you ordinarily do not have voluntary control over. So, um, the ability to, you know, as we train with biofeedback, to be able to train heart rate or train heart rate variability to do certain things. The ability to alter breathing patterns to match the environment that you're in so that you can actually regulate your breath patterns as a result of, you know, of the environment that you're sensing. Even right down to what we know from individuals who do a lot of cold exposure and things like that, the ability to change skin temperature and prioritize blood flow to areas that need more blood flow. So that's, to me, that's what autonomic fitness looks like, is, is kind of a, a mastery of different organ systems as a result of intensive training of, you know, of biofeedback style work. Once again, I, I think there are only so many hours in the day, so you, when you if you were to endeavor in something like this, you need to be really mindful of what you're trying to achieve. You know, like, do you really need to be able to change your heart rate or, or put more blood flow to your hand if you're not going to use that? Probably not. You know, like, you, you need to understand, um, what you're trying to achieve and why you're trying to achieve it in built into your training goals. Um, otherwise it's just another, you know, you know, canned computerized training program that will promise to change your life because X, Y, and Z super athletes are using it, but really it won't because X, Y, and Z super athletes used it for a reason, um, and you know, you don't have that reason. So to me, that's what autonomic fitness looks like. Um, as to whether that increases your resilience your autonomic resilience to a challenge like something like COVID, that remains to be seen. You know, I would like to think that it does, but at the same time, you know, a novel virus tearing through your body, you know, that no one saw coming, you know, our systems never saw this coming. We've not had this, this virus in our bodies before, it's likely that in a scenario like that it has a backdoor to breaking stuff that you can't protect against. And, you know, hence why 30% of the population who went on to get COVID are having persistent symptoms now, because their body hasn't seen it before and doesn't quite know what to do with it.

I love that description of what autonomic fitness would be around taking the autonomic nervous system, which within the name autonomic suggests non-controllable, and then making elements of it within one's control. And that being kind of what defines that spectrum of autonomic fitness. What in your experience, as far as a practice or behavior, is the most effective way to increase that sort of control over your autonomic nervous system?

Oh God, this is, this is a no-win answer because I feel like I'm gonna piss off 5 people no matter what I say. I, I will, I will answer personally, uh, because I do think it is personalized, um, you know, and I'm not one very much for mindfulness meditation and things like that. I don't do well with them. Whereas I am one who does really well with things like cold exposure and breathwork, which I would almost class as active meditation. You know, when you get it to the right, you know, it's moving meditation as opposed to static meditation, but there's still a meditative practice and process to it. So speaking for myself, I find those things more effective, things that like put my body into a state that I have to react to. So I'm doing something and I can conceptualize what I'm doing. And it's not, am I meditating? Am I not meditating? It's okay, I'm cold and I'm going to do my breathwork and I'm going to, you know, and I'm going to work through this. Um, and that is— that has good evidence behind it to be a great primer for building a strong autonomic nervous system. Um, that works well for me. I think other things would work well for others depending on, you know, personality types and, and body types and nervous system types, for sure. Got it.

Well, thank you so much, David, for sharing all your expertise and wisdom with us today. And I just want to say thank you on behalf of all of us for all the work you're doing as well. You're doing incredible, incredible work in the world. So I appreciate it, and I know a lot of people do as well. So thank you so much for your time and for all that you're doing.

No worries. Thanks so much. This has been so much fun.

If what you've heard on Flow Research Collective Radio has been helpful, please consider doing us a solid and leaving us a review on Apple, Podcasts, Spotify, or wherever you are listening to this. Reviews help us connect to a wider audience so we can get these peak performance principles out to more people.