Nov 3, 2016Back on the Mat
When an Upper Iowa University wrestler suffered a stroke, it thrust the school’s athletic trainer into uncharted territory. The athlete’s subsequent rehab and return to competition proved to be a valuable learning experience for everyone involved.
This article first appeared in the November 2016 issue of Training & Conditioning.
On Nov. 1, 2015, Upper Iowa University redshirt freshman wrestler Maleek Williams won a shared title at the team’s season-opening tournament. On Nov. 2, he had a stroke.
In the three months that followed, he underwent open-heart surgery, a painful recovery, and countless hours of rehab. It was never clear if Maleek would return to the mat as the same athlete he was on Nov. 1.
Yet on Jan. 30, 2016, he not only wrestled competitively, he scored a victory. Somewhat unbelievably, just one month later, he was wrestling at the NCAA Division II championships.
As Head Athletic Trainer at Upper Iowa, I accompanied Maleek on every step of this journey. Obviously, an athlete suffering a stroke is not something you expect to deal with in our profession. But what was even more unexpected was how much those four months being by Maleek’s side affected me personally and professionally.
SOMETHING’S WRONG
The morning of Nov. 2 started like any other in the Upper Iowa athletic training center, but that changed when Maleek arrived shortly before 11 a.m. Assuming he was sore from the previous day’s tournament, I asked what he needed. He replied, “I think we have a problem.” At first, I thought he was joking. But then I noticed he was slurring his words.
Maleek proceeded to tell me he woke up early that morning to work out before class. At the time, he had trouble putting his shirt on because his arm felt numb, yet he didn’t think anything of it. During the workout, his symptoms became much more pronounced, including a headache, blurred vision, fatigue, and slurred speech. Thinking he had a concussion, and not wanting to miss the team’s upcoming dual meet, he went back to his room to sleep.
While Maleek was relaying his story, I monitored his speech. As he continued to talk, I noticed his face was drooping and his speech seemed to be getting worse. My gut feeling was that I was dealing with a stroke, or at least something I couldn’t care for in the athletic training center.
At this point, I decided we needed to go to the emergency room immediately. However, I didn’t want to alarm Maleek or the other athletic trainers. So I simply told my staff that I was taking Maleek to the emergency room without providing any details, and we left.
DIFFICULT DIAGNOSIS
Our ride to the emergency room was full of conversation. My goal was to keep Maleek talking so I could get more information about his symptoms and any possible explanation for his current status. I tried to use my best poker face, but Maleek could tell I was worried. Thankfully, he never questioned why, although he did ask what I thought was going on. I said some of his symptoms were concerning but didn’t elaborate further.
As soon as we arrived at the hospital and the staff understood the situation, we were rushed into an examination room. After taking into account Maleek’s history, my observations, blood work, and X-rays of his head and chest, the doctor returned with an initial diagnosis of Bell’s palsy. While that made sense given Maleek’s facial drooping, it didn’t account for all of his symptoms. I was just about to ask the doctor for a moment outside the room to discuss the diagnosis when he said he was ordering a CT scan to rule out any other possibilities.
Maleek had a spot show on his CT, which was consistent with a stroke and explained all of his symptoms. Once a stroke was diagnosed, the doctor left to consult with the neurology team at Gundersen Hospital in La Crosse, Wis. Maleek chose to be taken to Gundersen because it was the closest large hospital, and Upper Iowa has a good working relationship with its providers. Neurology had arranged for a helicopter to airlift Maleek to Gundersen, and we were told it would take 50 minutes to arrive.
While we waited for it, Maleek tried to contact his family in Florida, and I called Upper Iowa’s Head Wrestling Coach Heath Grimm. Maleek and I also discussed the next steps in the process and began preparing for what his future might be like without wrestling. This was obviously a tough conversation, and emotions were high. Although Maleek understood the situation, he couldn’t imagine life without wrestling-the sport defined him and gave him an opportunity to earn an education. It was all in jeopardy due to something he had no control over. He was frustrated and upset, so I listened and let him vent to me.
Further testing at Gundersen showed Maleek had an atrial septal defect (ASD) in his heart. The ASD is a hole in the septal wall between the atria, which normally closes in early childhood. Usually benign, Maleek’s ASD allowed blood to bypass the normal flow, possibly leading to the clot that caused his stroke.
Despite the severity of this diagnosis, Maleek was released from the hospital on Nov. 3. He was given general instructions for discharge-don’t lift heavy objects, keep his heart rate down, and return if he had any issues. Stroke patients are at a high risk for subsequent episodes, so Maleek, Coach Grimm, and I were all educated on the signs and symptoms to watch for. Maleek also made a follow-up appointment with a cardiothoracic surgeon for Nov. 6 to determine whether medication or surgery would best address his ASD.
TREATMENT OPTIONS
Leading up to the appointment with the surgeon, Maleek and I had daily check-ins. Although I couldn’t attend the appointment with Maleek, he called afterward to explain what decisions had been made. The surgeon felt it was best to make certain the ASD was corrected, and the only sure way to accomplish that was with surgery, so Maleek’s procedure was scheduled for Nov. 10.
When I got off the phone with Maleek, the surgeon called me to explain the procedure and answer any questions I had. I will never forget how surreal it was to receive the call on my way to pick up my kids and talk to the surgeon about the “simple open-heart surgical procedure” he would be performing on my athlete.
Prior to the surgery, Maleek and I discussed what he should expect. We were both nervous, but I was confident that Maleek could handle whatever came his way.
The surgery was successful, and Maleek spent the next three days following a regimen of pain medication and walking to start his journey to recovery. He was discharged on Nov. 13 with instructions to keep his heart rate down, remain prone with his legs elevated as much as possible, and avoid standing or walking for long periods of time.
ROAD TO RECOVERY
The first week of Maleek’s rehab started out well. He had pain, tenderness, and swelling around his two incision sites (one near the right axillary region and the other in the right groin) that we monitored closely every day, and we kept a chart of his daily weight, activity, temperature, and medications to keep everything on schedule.
To start his return-to-activity progression, he walked for 15 minutes several times a day. He did at least two of those sessions with me in the athletic training center, where we kept his heart rate low and made sure he could always pass the walk-and-talk test.
Unfortunately, we hit a bump in the road on Nov. 19. Maleek texted me at 7:50 a.m. noting intense chest pain that didn’t go away after taking his pain medication. I instructed him to come to the classroom where I was teaching for a checkup. Once he arrived, he explained that the pain was centered in his chest-not just around his scars. We then called the cardiac care nurses at the hospital, who suggested that he head to the emergency room.
After a battery of tests, Maleek was diagnosed with costochondritis that the doctor attributed to doing too much too fast. He was discharged, sent home to rest, and took the next few days off. Although unnerving at the time, I think this experience gave Maleek focus and a sense of ease that he had felt pain again and everything turned out okay.
On Nov. 25, Maleek had a follow-up with his surgeon and got some good news-we were allowed to moderately progress his cardio workouts until his next appointment in two weeks. Specifically, we were instructed to practice interval training while keeping his rate of perceived exertion between six and 15. He was even permitted to start light individual wrestling movements on the mat once he got back to campus after Thanksgiving break.
After getting this news, I immediately started searching for different bike interval workouts to keep Maleek interested and progressing in rehab. We chose the bike as our mode of exercise because it was easy to control, adjust, and utilize in interval training. The bike is also available in our wrestling room, which allowed Maleek to be around the team. This helped his recovery and showed his teammates that he was okay.
We began interval training on the bike with two workouts a day for 15 to 25 minutes each. Maleek was so excited to do something different and more strenuous than walking that we had to watch him early on to make sure he didn’t overdo it.
Over the next two weeks, Maleek kept progressing his rehab and building his cardio. On the bike, he advanced to sustained long sessions and harder interval work. We began including extended rest periods between sprints and moved to varied timed work and spin cycles that got Maleek out of the seat. (See “Ride Along” below to see how we progressed Maleek on the bike.)
Beyond interval training, Maleek was advancing on the mat and had even started to work out in the weightroom. We had to watch his lifting closely due to his scars and the pain he still had in the incision areas. Each lift was performed step by step to make sure he could handle the motion without issue.
RETURN TO ACTIVITY
At Maleek’s second follow-up with the surgeon in early December, he was cleared for full activity. Of course, just because he was cleared didn’t mean he could immediately wrestle at full speed. He couldn’t compete for at least one more month, and he was instructed to take one baby aspirin a day to lessen the risk of further blood clotting. The doctor also noted that we needed to look out for internal bleeding and head injury, as the stroke put Maleek at a higher risk for both.
Maleek’s partner work on the mat began with light drilling soon after he was cleared by the surgeon. He did well, but we had to keep a close eye on his scars, which were still very painful. We communicated during workouts about how he felt, and I pulled him if I thought he was doing too much.
To protect Maleek’s head during any partner work, he wore a rugby scrum hat. This is part of our policy for wrestlers returning from head injury. We have found the scrum hat gives more protection than regular wrestling headgear because it provides full padding.
When Maleek left for winter break, he was instructed to maintain his cardio workouts and continue with light drilling. Yet when he returned to campus on Dec. 28, he weighed as much as he had when he came out of the hospital and didn’t look like he had done much training over break.
From a recovery standpoint, I didn’t mind that he had rested. However, at that time, we were debating whether Maleek would try to wrestle that season, and his lack of physical fitness wasn’t a good sign. He was still too heavy for any weight class he might compete at, and time was running out. If he wanted to wrestle that season, he needed to descend in weight slowly while remaining hydrated, which could be a slow, exhausting process.
The next few weeks were hard since Maleek was playing catch-up from his relaxing winter break. He was often very tired from the workouts and from cutting weight.
Still unsure if Maleek was going to compete that season, we kept progressing with his cardio and weightroom work so he’d be ready if the time came. Not knowing when that decision would be made, we did extra cardio in the mornings or after practice. His lifts were progressing near normal weight and effort, and his pain while lifting had dissipated.
It was during this stage that Maleek started to get his confidence back, which was a welcome sight to see. He was doing well in practice and feeling better on the mat. Plus, he was giving me a hard time in training, so I knew he was getting back to normal.
All signs were pointing to Maleek competing that season, but it still wasn’t certain. There were plenty of talks between Maleek, the coaches, and I to figure out the best plan of action. That plan changed every week for a while as we struggled with the different options.
We finally decided that Maleek would wrestle in our dual meet on Jan. 30. It was one of our last home duals, and everyone wanted Maleek’s return to be at home in front of all those who had supported his recovery.
At the meet, Maleek was so excited and nervous that he could hardly sit down. His entrance onto the mat was a special moment for all of us. In his first match, he nearly recorded a pin and came out with a victory. He went on to compete in our two remaining meets, finishing as a regional runner-up and ending his season at the Division II national championships.
UPON REFLECTION
I never expected to rehab a college athlete from a stroke in my athletic training career, but I am grateful to have been a part of the process. It was so rewarding to watch Maleek progress from simply walking to competing at the national tournament.
That being said, there were some struggles along the way. The hardest part was the mental toll the experience took on everyone involved, especially Maleek. Keeping him mentally engaged through the recovery and rehab was a big hurdle. There were a number of times where he felt depressed, and we would have to talk to him about the big picture-not only to remind him of what he had been through but also what was waiting for him in the future. During these times, I tried to be logical with Maleek and listen well. I never questioned that he knew what he wanted to do, but I think he had moments where he needed to vent to someone.
Other times, Maleek doubted himself and his return to wrestling. It was heartbreaking to see this usually super confident young man in such an emotionally vulnerable state. He had some very dark moments when he was struggling, but I found that he often responded well to a reassuring talk. Usually, we would talk about what we needed to do to right the ship, but we would also just talk about whatever came up. Regardless of the subject matter, I always tried to get him to laugh. It may not have helped him any, but it made me feel better to see him smile.
In that vein, I was surprised at the mental toll Maleek’s rehab had on me. I had a hard time dealing with his stroke at first. There were days when I felt drained from constantly reminding him that he wasn’t ready for certain activities. And once he got back to wrestling, it was unnerving to think about the worst-case scenarios that could occur.
To get through it, I always tried to stay positive and think about how I could help Maleek accomplish his goals. Another way to cope came from working and keeping busy, which kept me from worrying about Maleek all the time.
Throughout his rehab, I feel I had a few lessons reinforced. The first was that even though general medical conditions can be different from the orthopedic injuries athletic trainers normally see, they still follow the same guidelines. We are still dealing with the human body, and that body is still affected by the same principles, whether you’re dealing with an ACL rupture or a heart condition.
The second lesson was that regardless of the problem, my training could get me through it. I had a very limited background in general medical conditions before working with Maleek, but when it came time to evaluate, treat, and rehabilitate, I knew what to do and how to progress.
Finally, Maleek’s rehab reinforced the importance of teamwork and communication. Throughout this case, I dealt with a lot of different people and had to coordinate many different elements-from doctors’ visits to training schedules. I couldn’t have done it without the help of many wonderful people who took care of Maleek in their own ways. From the coaches to the sports medicine staff to the doctors in different departments, we all worked together for the common goal, and it went smoothly due to our open lines of communication.
In the end, I think everyone who was involved with Maleek’s recovery is better off. There was nothing better than seeing Maleek’s smile when he got back on the mat. And now I realize that you never know what you’re going to get as an athletic trainer, so you have to be prepared for anything.
RIDE ALONG
Below are three bike workouts that show the progression Upper Iowa University wrestler Maleek Williams followed during his rehab from a stroke. We advanced the intensity of Maleek’s training based on how he was feeling.
EASY
- 15 sec sprint (90 to 100% effort)
- 15 sec recovery (Slow pedal)
- 30 sec sprint
- 30 sec recovery
- 45 sec sprint
- 45 sec recovery
- 1 min sprint
- 1 min recovery
- 45 sec sprint
- 45 sec recovery
- 30 sec sprint
- 30 sec recovery
- 15 sec sprint
- 15 sec recovery
- Repeat pattern x2
- Cool down
MODERATE
- 1 min sprint (90 to 100% effort)
- 30 sec recovery (Slow pedal)
- 2 min sprint
- 1 min recovery
- 3 min sprint
- 1.5 min recovery
- 4 min sprint
- 2 min recovery
- 5 min sprint
- 2.5 min recovery
- 5 min sprint
- 2.5 min recovery
- 4 min sprint
- 2 min recovery
- 3 min sprint
- 1.5 min recovery
- 2 min sprint
- 1 min recovery
- 1 min sprint
- Cool down
HARD
- 4 min adding resistance, standing
- 4 min adding resistance, mogul intervals (30 sec crouching, 30 sec sitting x4)
- 4 min recovery
- 4 min adding resistance, flat ride
- 3.75 min hill surges, increasing resistance (15 sec sprint, 30 sec recovery x5)
- 4 min fast flat, easy resistance
- 4 min steep climb, increasing resistance (30 sec sitting, 30 sec standing x4)
- 4 min steady cruise, reduced resistance
- 8 min speed play (10 sec sprint, 10 sec recovery; 20 sec sprint, 20 sec recovery; 30 sec sprint, 30 sec recovery; 40 sec sprint, 40 sec recovery; 50 sec sprint, 50 sec recovery; 1 min sprint, 1min recovery; 1 min sprint)
- Cool down, low resistance
