Rotator Cuff Pain with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum. He's the chief guy at Insync Physio in North Burnaby. He's an expert in many things physiotherapy. And today we're going to talk about fairly famous kind of thing. If you're into baseball at all, rotator cuff pain. What is the rotator cuff Iyad?

Iyad: Hey, Mark. Yeah, so the rotator cuff simply put is a collection of muscles that we have in our shoulders. There's four of them and they attempt to form a bit of a sling around their ball and socket joint. As you know, the shoulder is a ball and socket joint, and it moves through a big range of motion, more than any other joint in our body.

So when you have that much movement in a joint, you need some way of controlling and stabilizing it when you move and you initiate things. So simply, but that's what the shoulder needs is a nice sling of muscles that support it and help it do its function. So that's shortly put what a rotator cuff is and what it does.

Mark: So I know that there can be a lot of different symptoms. What are the typical symptoms that you see when somebody comes in and you start to diagnose what's going on with their shoulder pain? 

Iyad: Yeah. So rotator cuff related pain is very, very common, and you have like so many different things. So for example, you can have a traumatic injury, where somebody has a fall or some kind of direct impact on it, where it gets injured that way. And they tend to present very differently than the ones who, which are non-traumatic, which happened slowly over time. So typically, what we'll see is like in an acute case of traumatic or non-traumatic, they tend to present a bit differently.

So for example, in a non traumatic case, they'll tend to tell you that they are slowly feeling that their arms getting a bit weaker and they can't lift the coffee mug up anymore, can't pour the tea kettle, just basic things like that. And then over time they feel like they've lost more and more function and they feel like they can't use their arm the same way they did, and it's incredibly painful, tends to be anywhere around kind of this area. I can actually go down to the elbow even sometimes. And that's just where the structure tends to refer. Usually there's a complaint of weakness. So they can't be as strong as it used to be with shoulder pain. 

We don't see so much pain here. So this is kind of where a lot of people confuse shoulder pain with with the neck. You can actually have the neck referring to the shoulder too. And that's one of the things we'd want to rule out in the clinic. That it's not a neck that we're treating that it's actually just shoulder. 

And I guess the most common thing that we will see is that for non-traumatic shoulder pain is that people suddenly will tell you, Yeah, I did nothing different. And then when you dig into a bit more, It turns out that, you know, somebody had been out of the gym for two months or three months and then went back in or somebody out of nowhere, suddenly upped their weight or they were doing the usual stuff. And then if it's an elderly person, for example, who's not as active, they could be like, Oh, I did just all the weeding in my backyard, all at once. So it tends to be things like that where there's a sudden change in activity level. And then that kind of spike, you can think of it, that sudden spike in load and it can take a few weeks for it show up in some kind of injury.

Mark: So how does that differ from like throwing injuries where people are getting that, that rotator cuff problem? We've heard a lot about it in baseball pitchers and football quarterbacks, et cetera. Anyone who throws. What's the difference? 

Iyad: So the difference is, I guess in like, like you said, like the, the cuff has to do so many different things. So one of the things that we think about is think of a baseball pitcher. They have a huge amount of demand on that shoulder to launch a ball at a hundred plus kilometres, miles an hour. Like depending on what level you're working with versus let's say a break dancer has to be able to jump up and down on their arms. 

So both of these people will demand a lot of good shoulder strength and stability, but their uses tend to be a bit different. So in the throwing athlete, one of the things that we see a lot is we see deficits in the chain. So think of the throwing movement, nobody just grabs her arm and just kind of launched it this way without kind of a full windup of their body.

And that's where the assessment of a throw work tends to be a little more complex because we want to look at them from the legs up. And we want to see where along that force transfer chain, does this you know, is there something missing. The shoulders having to pick up the slack more, for example? And it could just be a matter of throwing too much. Full-stop. So even if you have great form, ultimately there's a limit to how much we could kind of handle. And that's where you're seeing a lot of little league and like organizations controlling pitch counts, which is how much people are throwing. And that's really important I think, so that you're not getting a an adolescent, you know, completely destroying their shoulder by the time they're 18, just cause they threw too much at once.

So then in the thrower, if you think about it, what that shoulder's doing is it's trying to transfer force from your body into the shoulder. So from the hips, from the trunk, from your kind of core and then from your kind of rotational movement of your kind of upper back into the shoulder.

So think of it like a sling that transfers force versus generates the force. Meanwhile other things like think of like a powerlifter where they might have to just hold their position very stable when they're kind of pushing big weights. So it tends to be a bit different. But the principles are pretty similar. Shoulders really good at transferring force versus generating all of it on its own. It can still do quite a bit of it. 

That's why we still see somebody with a bit of, let's say a bit missing from their back and hip mobility, still be able to throw a really fast ball because that's their compensation mechanism, is that they could still kind of launch it that way. But yeah, that's where I would say it's a bit different than let's say the more sedentary population where they're doing just home-based stuff or think of like chores around the house and they start to develop these issues.

Mark: So when you're diagnosing it, obviously history is really important, but what are some of the other things that you're looking for when you're digging into what's actually going on in the rotator cuff? 

Iyad: Yeah, the history is the most important thing for sure, because it kind of helps you figure out where to go. We would want to measure a few things like their range of motion, obviously. And we want to look at just how they move, the quality of the movement. We tend to look at shoulder blade, the shoulder, their are upper back. We want to look at the movement that bothers them too. So there are tests that we do use for the shoulder specifically, but sometimes the most important test is that the person comes and tells you, they're like, I can't reach up to do this. I can't pour my thing. So that tends to be quite significant. 

So we would look at that and see what about that movement we could modify. What about that movement we could kind of identify issues with. We'd want to look at strengths for sure, if we're suspecting a rotator cuff issue. And then we kind of want to get them on a program to help address those deficits.

Mark: So what is a typical course of treatment? What does that look like? 

Iyad: It depends on where along the spectrum the person is. So some people tend to be very high functioning and they tend to actually just have, you know, kind of like a, like we said, last time about the Achilles tendon, like the person who hurts a 10 K versus, oh, I, I can't get out of bed and walk, are kind of different. So that's the same thing with rotator cuff related shoulder pain. You're not going to give a one size fits all treatment because you might be either under dosing someone or overdosing someone. 

So we'd want to look at obviously if there's mobility deficits, we'd want to get that back. Get the range going. We would want to look at their shoulder blade muscles. Tends to be a lot of strength work. Because we see actually pretty good value for resistance training. And a lot of the time, it's just the fact that people are engaging in resistance training really, really helps especially for shoulder pain.

So they'll tell you that they feel better even before that a strength comes back, which is really kind of good news. So you're not going to have to suffer too much through it. So it's a bit of that. We want to look at the functions that they need to do. And it's kind of trying to mimic that in an exercise program.

So think of, for example, if it's a thrower, we would want to do a lot of whole body conditioning and like working on that kind of pattern of throwing. So from the legs up. If it's somebody, like an example, we had a break dancer who couldn't just hold a handstand. We do a lot of work in weight-bearing and we want to work on that stability in weight-bearing and that strength in weight-bearing. And we'd kind of start with two arms progress to one, and we got really creative with how to apply resistance in those positions.

So that's kind of where we would start. We'd want to figure out where you're at and just start to take you to where you want to be. And it, but tends to be a lot of strengths work for the bulk of the program, if they have good range and they have good control. 

Mark: And recovery times? 

Iyad: Great question. According to a lot of studies, we're looking at, if it's the first time people have had this, for proper recovery, we're looking at 12 weeks. So the good news is a lot of people will recover their, let's say their pain and day-to-day use of the shoulder early on. But that might not mean that they're ready to go and throw you know, a full inning, for example.

So we would want to kind of give it a proper healing time and we also want to give it a proper rehab time. So the biggest mistake we could do is just stop when it's not painful anymore. Because most of the time when we see our athletes they're always dealing with some kind of pain. So they're not really averse to a bit of pain. So that's not why they're seeing it, they're seeing it because they're seeing a different performance. And they tend to see us because they're like, I can't throw as fast as I could before. And that's more distressing to them then, oh, my shoulder hurts a bit after I throw. If you would tell an athlete that they could just do whatever they want, despite the pain, they would probably push through it. They tend to be wired differently. 

But yeah, we would want to give it about 12 weeks. If this is the first time they've had a rotator cuff problem. What we see is when somebody had recurrent problems, the recovery tends to be a bit longer for them to regain normal function, but the good news is they'll be pretty busy. Like, so if you're an active person, you could be very busy with exercise and activity, despite your rotator cuff pain. And that's where I guess we come in. To kind of just put up a nice structured program for them to kind of follow. 

Mark: How important is the split between getting in to see you and getting diagnosed and getting a prescription of here's, how to exercise and making sure that they're actually doing the exercises right and seeing you once a week. Compared to the work they do at home. 

Iyad: Both are really important. So work is really important at home. Because even if you're seeing us weekly, the thing is, you got to remember it's half an hour a week, you have 23 and a half hours in that day. And then another six times 24 hours to do a lot of good or a lot of nothing.

So I think you can't really prop one up without the other. So home exercise is non-negotiable with this population for sure. Where we can help for example, is sometimes we're seeing people a lot less frequently. But one of the things that we can't do is for example, progress them without assessment.

So we're not going to just give them an arbitrary 12 week program all at once. We kind of want to see how they're at. Because some people progress way faster. And so we don't follow the time based measure specifically. Tends to be more by milestone. So if you're able to kind of clear the first hurdle, we get you into the second one right away.

So we don't have to wait two, three weeks to do that. And by that same token, and you're going to get some people who are slower responders. And if I was to progress you, yeah, it's been two weeks, let's push you to the next one. And you're actually going to not do as well because we're not following your own trajectory.

So each person's a bit different and that's where we need to be very aware of what every person's tolerance is. And it tends to also kind of carry a host of other things. We're not looking at just the shoulder with the shoulder. It tends to be a whole upper body assessment, versus assessing the whole upper limb.

And if it's a thrower, we're assessing literally anywhere from foot mobility, all the way up to shoulder, back and neck. So, so yeah, I would say most people will tend to have Googled a lot of exercises when they come in. And some of them have a bit of success, but then they say I hit a plateau and it tends to be because it's hard for you to self-assess your whole body.

And you don't have eyes in the back of your head to watch you from the third person point of view. So that's where we can add a lot of value and help out with quality of movement and just like proper programming. 

Mark: So if you want to get better, fast and permanently, the guys to see are Insync Physio in North Burnaby, you can book online at Or you can book at the Vancouver office they're on Cambie, (604) 566-9716. The North Burnaby office is at (604) 298-4878 to book. You have to call and book ahead. They're always busy and they get a lot of fantastic reviews. They're multi time winners of best in Burnaby. Best in Vancouver at physiotherapy. Get yourself in there. Get some expert advice and get better quicker, permanently. Insync Physio. Thanks Iyad. 

Iyad: Thanks Mark.

Low Back Pain Sciatica with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum, he's the chief clinical director of Insync Physio in North Burnaby. And we're going to talk about a really common thing. A lot of people call it sciatica. It's actually low back nerve pain. What's going on here typically, Iyad?

Iyad: So sciatica is kind of a broad term to describe pain along the sciatic nerve distribution. And I mean, if you think about it, the sciatic nerve kind of runs through the entire back of your leg. So it starts in the gluteal area and it goes down through your hamstrings, into the calf, into the foot. So broadly speaking, anytime you have pain on that distribution, it's called sciatica, but the sciatic nerve doesn't just come out of the back.

You have a bunch of little roots that joined together to form the sciatic nerve. So any disruption or injury or sensitization in any of those nerve roots could contribute to sciatica. And then after that, it travels through a bunch of tissues, so it goes through your gluteal muscles into the hamstrings down behind the knee, into the calf. And then it also feeds the front of the leg, like kind of your shin in the back of your calf. 

So once you think about it that way, you can have sciatica from multiple, multiple things. Typically the most people associated with some kind of diagnosis of a low back injury or a disc herniation with pressure on a nerve root. We don't see that being always necessary. That's not the only way you can get sciatica. There's a lot of reasons why a nerve can hurt. 

I'll tell you the funniest one I've seen in clinic, which is a person sitting on a toilet seat too long playing candy crush and their feet go numb. And then they're diagnosed with sciatica on the phone. But it's really simple for that person. We just don't need to apply direct pressure on that. And then there's the more kind of traumatic injuries. For example, somebody fell, hit their back on a post and then they start to develop these what we call radicular sites, where the nerve root is getting impacted. And they tend to lose a bit of the function in that nerve.

Mark: So what would the typical symptoms be that somebody would, it's just a low back pain? Is that, or is it a low radiating into your butt and your legs? 

Iyad: So it tends to be that exactly. We're looking at the low back cluster of sciatica or let's call it the nerve root issues. Yeah. You'd have a bit of low back pain or sometimes a lot of low back pain. It really depends on the person. Some people complain more of leg symptoms than back symptoms. And the pain radiates down the leg. And that's a really good sign that you should probably get it checked out. If you're getting some kind of sensation, it could be tightness, numbness, tingling, burning. Those all kind of tend to be nerve symptoms. 

Some people just have pain and they're like, it just hurts. I just don't know what to describe it as, it's just painful and it's uncomfortable and I can't sit. So that's what we'll end up seeing. But back pain tends to be usually associated if we're looking at the nerve root issues that contribute to sciatica. 

Mark: And generally, does it show up more when people are sitting or does it show up in movement and in walking and standing? 

Iyad: Excellent question. You have both. That's the confusing part. We used to think that it was only in sitting because when we used to think of things very mechanically and only that way. Yeah, we were like, oh, so if it hurts with sitting and it feels better with standing that it's gotta be this. And then what we're finding is, the more we study people and the more we look at it, it's not quite as simple as that. So it tends to be varied. You can have actually two people with the same injury presenting in exactly the opposite pattern.

So one feels better when they're standing and one feels better than you're sitting. And then vice versa. And then you have people who say, I love it when I walk by pain goes away. And some people say I can't walk because anytime I straightened my leg, I got a bit of a zinger going down my leg. So it really depends on that. Tends to be just like, if you just get assessed properly, we would be able to figure out what kind of way we can kind of manage that person, because again, you could have the exact injury in completely different presentations. 

And the other thing that's kind of confusing about this is, and this is where people sometimes, if you go on a kind of a wild chase to see what's going on with my back and you get imaging and people will come in, for example, without any symptoms of, let's say sciatica or pain down the leg, but then they're showing on an MRI that they have a disc bulge and they're confused. They're like it says here that I should be feeling leg pain, but I'm not, well that also can happen because a lot of people can have abnormal findings on scans and not present with any symptoms.

And that's the biggest breakthrough that we've had in learning about how to interpret imaging findings. You know, when we're seeing a disc bulge or degenerative disc disease on scans, they don't always correlate with symptoms. And that's where if you're just going hunting for something and you try to find something, you might find it, but we still can't say confidently that that's what's causing it.

So it tends to be largely a diagnosis done in clinic, based on what we find. We move you through a bunch of stuff. We do a bunch of tests, and then we will treat you that way. Regardless of what your scan says. 

Mark: So the diagnosis becomes critical then in terms of determining what your course of treatment is going to be?

Iyad: Yeah, because like we said, imagine if let's say two people have a symptomatic disc bulge, especially on the nerve, but one of them feels really good when they bend forward. The other one feels really good when they bend backwards. If we were to just treat based on just the imaging findings and not actually assess that person in clinic, we could be really making them suffer. One person really suffering the other person feeling good, for example. If we had just kind of like progressively pushing somebody into that sore spot. 

So what we ended up finding is usually the first assessment tends to be trying to figure out what's affected. So we would do a very thorough exam, like of the back. We would scan their nerves. We would do a bunch of testing for reflexes to see if the conduction spine. We're always vigilant for any potential red flags that we would need to send out to the ER, in cases like where and those tend to be very rare, but we're always vigilant for those obviously. And then we will try to figure out what positions and what movements that person's comfortable with. Get them moving slowly and kind of gradually. And they tend to do really well with the rehabilitation program, which is the good news, I guess.

Mark: If you have some back pain and you're not sure exactly what's going on, get to see the experts at Insync Physio. You can book in North Burnaby online at You can also book for the Vancouver office if you wish to go there. If that's closer for you. To call the north Burnaby office they're at (604) 298-4878. Get in to see the experts. They'll look after you and make sure that your back is doing better, properly and for the long run. Insync Physio. Thanks, Iyad 

Thanks Mark.

Achilles Tendon Pain with Iyad Salloum

Mark: Hi there internet people, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, near Vancouver, and the outskirts of Vancouver, the soul of Vancouver in North Burnaby. And we're going to talk about Achilles tendon pain. How are you doing Iyad?

Iyad: Good. How are you doing Mark? 

Mark: Good. So what's Achilles tendon pain. I have a sore ankle. How do I know it's the Achilles tendon? 

Iyad: That's a good question. Usually one of the first things we'd want to do is talk about how it started and the history and all that kind of stuff. And that usually helps us kind of figure out if we're going to look at the Achilles tendon or not.

And with most tendon issues, it tends to happen slowly over time. It's not like a sudden trauma. Obviously there is some of this kind of where I took a step and I felt something go and those tend to be a little different. So if we think about the classic Achilles tendon pain, it's either somebody who had taken lots of time off, I'm gone away on vacation. You know, just a bit of walking and then I come back. I'm like, okay, maybe I'm going to hit the gym at the same level I used to hit before. And that big spike from a big rest. So it's a period of disuse. And then you come back to where you used to be that sense tends to look like a spike on load on our body. And then we can kind of start to develop some of these issues. 

And where the issue happens, honestly, our best bet now is to do with maybe the resilience of that area or the training history. So for example, if this person's very well-trained they might have a bit more buffer, and they can withstand that jump in activity more, or not. 

The other really important one is the pain location. So tendon pain, you know, we expect it to hurt especially in the lower limb. So like the Achilles tendon, if somebody comes in and says, well, my foot hurts. I'm not going to be looking at the Achilles. Or if they feel painted like high up in their calf, we're going to look at something else.

So we'd like it to be in and around the tendon for us to have a pretty good confidence, that it is that. And then the other one, which is really, really important is how localized the pain is. So tendon pain is very localized. It doesn't really present where it jumps up and down and moves around a lot.

So if they have that, it doesn't mean necessarily that they don't have tendon pain, but maybe it's not the only thing that's on their plate that they're dealing with. So that's where we would want to dive in and assess all the things that could contribute to sensations there. 

Example, I had somebody who said, oh, I feel it when I run. And it turns out that they have some issue with their low back and we treated the low back and their leg pain right away. So it could look like a tendon, but if it doesn't behave like it, that's where we'd want to look a little more in depth. 

Mark: So let's just dig in a little bit deeper. Is there any relationship with pain the plantar fasciitis that pain down in the middle of your foot and tendon. Is this particular Achilles tendon pain.

Iyad: Could be. They're kind of connected, the two structures and you know, the name plantar fascia makes it sound like it's not a tendon, but it kind of behaves like a tendon. It's like a flat tendon. So they could be related or it could not be related. And sometimes you don't have to have one to have the other.

So some people only have heel pain, plantar heel pain, which is pain just at the inside of their heel, and that could be related to the plantar fascia getting a bit effected. So we would treat that with a multitude of ways, including figuring out why they're just so easily triggered with certain activities and try to modify that. We could do different shoe modifications for these people just to kind of help them continue to stay active, just because, you know, you're unable to maybe exercise the way you normally do doesn't mean you should stop exercising altogether.

And that's usually what happens, is people stop for a long period of time because they try to rest it. Then they lose function in other areas, and then all of a sudden, you know, they'll tell you I gained a bit of weight and I've lost my strength and all of this stuff that happens with just prolonged rest. 

So really our job as physios is to see okay, great. So you have this injury, how can we keep you as active as possible, while also trying to treat this injury at the same time. Instead of just completely cutting them off of any activity? So yeah, they can happen together or they can happen separately. But just because they're connected structurally, they don't necessarily have to go one and two, you can just have Achilles tendon pain sometimes.

And it's because the Achilles tendon is really important. We use it through our lifetime as a spring to help us recycle the energy that we use. So for example, when we walk or when we run, we're able to kind of recapture a lot of that energy that our body puts into the system and into the floor through this nice little spring function that it has.

Mark: So how related is an ankle sprain, say like a high ankle sprain or something like that, to this Achilles tendon pain? 

Iyad: They're pretty different. They're remarkably different I would say. High ankle sprains will happen from impact. They'll happen from some kind of trauma, some fall. You know, some people say, oh, I rolled my ankle, but then it happens usually from some kind of mechanism and direct episode.

I've rarely seen it happen just from a slow buildup, an insidious onset like that. The Achilles tendon also functions very differently. It's an active structure. It's a contractile structure. Meanwhile, in the high ankle sprain, the job of that structure in the front of our ankle just the top, is to hold the two bones together. So it's literally just acting as a binding so that we don't get excessive wiggling between the two bones. Meanwhile, our Achilles tendon is constantly contracting and releasing in conjunction with our calf. 

Mark: They're opposite of each other then, really? 

Iyad: Yeah. So you could think of them as one of them is kind of like connecting bone to bone, the other one's connecting muscle to bone. So functionally very different. Structurally very different. Location very different. One's going to hurt primarily in front, the other one's going to be at the back. And one of them is primarily like, again, the key thing with Achilles tendon pain is there has to be some kind of load change that we see and it doesn't have to happen last week. It could happen weeks and weeks ago. 

But then the idea is you do is huge kind of spike in activity. And then you kind of maybe go back to normal, but your body might not have enough time to repair and adjust and it slowly builds up where you start to become symptomatic. And then in that case, what we would do is just try to see what are we actually dealing with?

Is this actually the Achilles or is this something else? We can have, for example, pain in the structure, just around the tendon tissue itself, like the sheath, which could look very different. And this is where you can get something like a cyclist saying my Achilles hurts, even though what we consider biking is not really that heavy on the Achilles tendon. Not quite like running or jumping. It's not considered a high elastic activity. It's not a high springing activity. 

Meanwhile, if you have a jumping athlete, you're kind of going to look at that a bit more or a soccer player, or even a runner where they have to constantly be using that tendon. So yeah, we would look at that first and then we would kind of figure out where their symptomology is. And then we can modify lots of things. 

Same with the plantar fascia. We can modify the load. We can put them on a different exercise routine to keep them healthy, but also do some small modifications that we can again, modify footwear. That's a temporary solution obviously, that's not going to fix the tendon, but it helps them continue staying active and training. Especially if somebody, for example is training for a marathon and their time is a little limited. So they don't have this big window of opportunity to drop six weeks off their training program.

Mark: So if we kind of narrow down to the core here, the history is really important. That's how you're going to get to the exact diagnosis and where the pain is, of course. And then you got to keep moving is basically the other message. 

Iyad: Absolutely. So the way we diagnose tendons is it's mostly functionally diagnosed. So we have a bunch of tests and the idea is you'd expect it to hurt more, as I progress the load on you, I'd expect you to be more symptomatic if it's actually a tendon that's hurting.

So progressing load is just as general term, but it means if it's heavier, if it involves maybe more pressure on the tendon, if it's faster, those are all considered higher loads, but those are the parameters that we tinker with when we're designing, for example, somebodies running program within the Achilles tendon.

We would definitely want to keep you as active as possible, but also we want to put you on a loading program for the tendon. That's how we think the tendon restores its function best. It's not an inflammation only problem. You don't just want to rub an ice cube over it and let it rest. If it's actually a tendinopathy we're dealing with, so we want to kind of put you on the best regiment and it's not necessarily just doing heel drops, because you can think about just if you're a runner, how just doing heel drops off a stair might not be enough to get you back to full function.

So we need to start restoring some of that activity. Obviously we can definitely do lots of calf strengthening and we can work on muscles of the knee and the hip to kind of help support the chain a little more because that just helps any runner. And it can definitely help people with Achilles tendon problems.

And then we could do things like gait retraining, if it's that, that we suspect caused it. Somebody's a new runner, they haven't run before. We can kind of do some modifications to how they run and that could help them continue training, but ultimately they need to load the tendon. And that's where we come in and we design a program that's appropriate for that.

Most people are quite surprised by how much they could do load wise with a tendinopathy. And that's where, you know, sometimes getting the confidence from somebody who's telling you this is safe and here's how we do it. That could be very, very useful to kind of get things started. 

Mark: There you go. If you need some help with your Achilles tendon pain, you've got pain down your heel, around your heel. Get it diagnosed, know exactly what's going on and get expert help on what to do to get it better. You got to keep moving, but you need to know what the heck's going on and how to do it properly. And the experts, they've all been trained in this extensively at Insync Physio are the people to see. You can book online at their website or you can call the Burnaby office at (604) 298-4878. They're also in Vancouver at (604) 566-9716. Get in there and get some help. Get back fully active. Thanks Iyad. 

Iyad: Thanks Mark.

Tendon Pain with Iyad Salloum

Mark: Hi there, internet people. It's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. And we're going to talk about tendon pain. What's going on with pain in your tendons. Can even feel pain in your tendons? 

Iyad: Hi Mark. Good question. So we have tendons all over our body. In the upper limb and the lower limb. And it's kind of I guess the function of a tendon is to transmit the force of your muscles to your bone. And just saying my tendons hurt is probably doing the condition a disservice, because it's oversimplifying it. Because if you think about how we use our shoulders, it's nothing like how we use our legs and our Achilles tendon.

It's very different. You know, just all you need to do is see what a baseball pitcher does versus a hurdler, for example. And then you'll see how markedly different the structure is and the function is. And if you think about also the uses that tells you that the problems that you get in one is very different than the problems you would get in another. And this is kind of where I was hoping to explore with that today. 

Mark: Okay, well, let's compare and contrast then. What's the difference with Achilles pain versus knee pain? 

Iyad: So we have two different tendons there, like the knee gives a lot of structures there, but if we want to compare the tendons specifically, so we have patellar tendon, which is where our quads would be acting primarily. We see this primarily in adolescent males with a patellar tendon. And that's usually in adolescent males doing lots of jumping sports because that's where you need a lot of that explosive power to come in. It does affect females as well. But where we see in the data is that they show a market kind of selection towards that group.

And it tends to be just like repetitive jumping, and it tends to be tons of stuff involving like group of activities that involve the stretch shortening cycle of the muscle, where the muscle has to kind of start at a stretch contract and then explode out, think of like how you would compress the spring and let it recoil.

That's kind of what we use our lower limb tendons primarily as. And then the Achilles tendon will affect everybody from the adolescent, all the way up to our seniors and geriatric population. So it tends to affect everybody. But because we use them differently through the lifespan. You need your Achilles tendon to walk. That's a good way to kind of think about it. So imagine when you walk around a 5, 10 K walk, you're doing a few thousand steps. The way we're able to do that is a lot of that energy that we put into our system gets recycled by our tendons. So we don't have to put external energy all the time to carry over that function.

But then at the same time, I can't ask somebody to do 10,000 calf raises in a row because that won't work that same way. So this is where you differentiate the function of let's say the calf muscle versus the Achilles tendon. So yeah, it'll affect things differently. The function is different, which is really, really important because we always want to think about the function when we're thinking about how does this issue develop, but also what can we do to help them after a tendinopathy develops.

Mark: Right. So is tendon pain, always tendinopathy, which is basically the inflammation of the tendon? 

Iyad: So good question. And it's not inflammation. We used to think it's inflammation. So we used to treat these with rest and anti inflammatories and ice. The traditional kind of approaches and lo and behold, it didn't really work out so well.

And we know this, we have a ton of data now showing that the tendon itself starts to lose its ability to do that job that I was talking about, that springy job, where you get to compress it and spring out of it. And we think the way it happens is it goes through, like the healing is just, it's not a normal repair, it's a disrepair.

So it doesn't fix itself in a proper way. When it doesn't fix itself in a proper way, you lose that organization of the structure, which makes it not be able to do its job so well. And we know also the other thing about the, that it's not entirely inflammatory from this fact that exercise actually, and doing lots of exercise could be very helpful to fix the tendon and to help people with tendon pain versus making it worse. Because when you think of something that's really, really inflamed, you know, we'd want to usually just give it a bit of a rest, back off a bit. That seems to work in the short term only. And the only thing that rest from what we see in the data seems to do is just gets people better at rest. 

And I can talk about from the group of people that we work with at Insync, a lot of them are seeing us because they can't do their sports anymore. So it's not because they have pain when they're sitting and watching TV. It's usually you know, I can't walk as much anymore. I can't hit that hill. I can't run. I've lost the ability to jump. It depends on that. 

So I think making an important distinction that it's not inflammatory is really important from that point of view. And then, yeah, tendinopathy is the more accurate term to describe this because it describes all tendon pathology.

So first of all, when people would see us, we've got to figure out, is this actually the tendon or does this hurt somewhere near the tendon? So for example, if you have a patellar tendon issue, it would hurt just under your kneecap, but there's a lot of things that hurt in front of the knee. So that's where we want to test them, when we test their function. We test a few different things to make sure that we're actually dealing with the tendon problem. Because you wouldn't treat a tendon, a patellar tendon, the same way you treat a meniscus tear. Even though both of them can hurt them in front of the knee. 

So it's really important to differentiate the two. But yeah, tendinopathy is the term we would describe this general condition. And tendinopthy again, it just means tendon pathology and it could be for the upper limb or the lower limb.

Mark: Yeah. Or your digits, even your toes, I guess there's tendons everywhere throughout her body. 

Iyad: Absolutely. And then the other thing that we can have a tendon pain is sometimes an inflammation of the outer cover of it, which is a little different. And in that case you would treat it completely differently because like we said, inflammation needs its own kind of management strategy. So that's where you know, we've all done extra training on treating tendon pain and that's where we were able to just differentiate what we're actually dealing with. Is this just a an irritation of something that's near the tendon? That's looking like a tendon, but not behaving like a tendon.

So that's where you need a little more sometimes help. Because the stock approach of just ice and rest doesn't seem to help. And if you do sometimes general exercise, some people will tell you, yeah, I tried this thing that I found online and it worked. And then you get the same for one-to-one where the other person says it didn't work. It actually made it a bit worse. So this is where knowing what you're dealing with is really important. 

Mark: Absolutely. So one of the things I know from weight training, and being coached in that, is that the tendon now, is this true or not? I guess it's the first question. The tendon takes longer to get strong than the muscle does. And so that's why you need to be careful with your training regime and increasing the load. 

Iyad: That's a great question and it's true. So tendons and bones and muscles and all of our structures actually adapt to load. That's what we know about now. So for example, when you have a power lifter lifting really, really heavy weights they are keeping in mind, not just that their muscles need to grow and adapt, but also like that their bones need to be able to handle maybe a thousand pounds on a squat.

So that's where we don't want, for example, people to develop fractures and stuff like that, just from lifting weights, which again will happen with the powerlifter group maybe. And yeah, the tendons are a completely different structure. So you would imagine that they don't respond the same way as muscles. Muscles seem to be the quickest adapting of all of them, but then that's also generally speaking, there's always an individual that just struggles with this. And it could be a bunch of other factors, but yeah, a tendon is different and it takes longer to adapt. And this is really important when we're trying to program somebody who's exercise routine, that we don't just spike their volume willy-nilly, because that's a great recipe for an injury.

Mark: And what about the treatment options? You mentioned, it seems like there's a lot of exercise that can be done. And that's important depending on what the tendinopathy is. What kind of exercise would that be typically. 

Iyad: So we start with a different, it depends on the person, first of all. So some people where it's primarily a pain dominant presentation where they just can't do anything because it hurts so much. We would start them really light and the exercise tends to have a pretty decent analgesic painkiller effect. So we could pick something appropriate to that person. 

We have lots of different exercise options that have been studied. And the good news is a lot of it works, but it works differently. So for example, it's not a one size fits all. And if you come and see me and you're like, Hey, I hurt at kilometre 10 of my run when I'm trying to train for my marathon, I'm not going to treat you the same as the person who can't just walk down the street. And that makes a lot of sense. So this is where we want to avoid protocolized doing this thing and just making it a cookie cutter recipe. 

The exercises, there's all a whole bunch of stuff where we just train sometimes the muscle at the beginning to make sure that the muscle that helps scaffold the tendon almost, is able to do its job properly and help the tendon.

And then there are tendons specific things where we would try to train that ability of the tendon to absorb energy and release it. And usually we will do that depending on the person's tolerance and function and where they are in their training history as well. 

Mark: Is that more of an eccentric exercise?

Iyad: So eccentrics are useful for the muscle primarily. They do work a bit on the tendon, but they're not enough to get the tendon to restore its elasticity. And the first training program that came out was by Dr. Alfredson who tried to use eccentrics to tear his own Achilles tendon. So you can get a surgery on it and in doing so he ended up helping his issue.

So that's how we kind of first delved into this. Because nobody wanted to operate on him. He had achilles tendon pain and it was hurting him a lot, but then nobody's going to operate on it and then it's not sore. And so he tried to do this really aggressive eccentric program. And then eccentric is when a muscle starts really short, then it has the contract as it's stretching out as it's stretching out.

So that's what he tried to do with lots and lots of reps and ended up helping his condition instead of tearing his tendon. So, which takes me to my other point is that this is the other issue where people get scared. You know, especially when you see videos of, for example like in the NBA where somebody is doing a crossover and their Achilles just snaps and it makes them very fearful of movement and fearful of putting actual stress through the tendon. But we know it's pretty safe. We know it's the way forward. As of yet, as of where are our evidence is.

Mark: Tendon pain. It's complicated. Basically you need an expert to make sure you're being treated in the appropriate way. Because is it tendinopathy? Is it something else? What's actually going on? And the experts at Insync Physio in North Burnaby can drill into exactly what's going on and prescribe a course of treatment that will get you better quickly. As quickly as possible. So you can book online at You can book at both locations. They have one in Vancouver as well. And the Cambie office is at (604) 566-9716. The North Burnaby office is (604) 298-4878. Thanks a lot Iyad. 

Iyad: Thanks Mark.

Running Injuries, IT Band Knee Pain

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto, he's the owner, the chief cook and bottle washer at Insync Physio in Vancouver and in North Burnaby. And today we're going to talk about running injuries, IT band knee pain. What's this all about Wil? 

Wil: Yeah, so the weather is getting really nice here and we're starting to see people running outside and and I'm seeing a lot of more running injuries coming into clinics. A lot of our physios are seeing a lot of runners coming in. So basically what it is, is the IT band is a strong connective tissue that basically connects a lot of the muscles on the outside of the thigh. It starts actually in the hip all the way down to the outside of the knee. And what it does, it actually adds extra stability to your knee. 

Now, the problem with running and especially as you start off, like you're running season, a lot of people were training for things like the Sun Run. That's just happening. It's just coming up here this coming weekend. And just as the running, season's starting to peak here, you know, they start to overload. And so what IT band injuries are usually a more of a repetitive type of injury.

Mark: So that's just overuse training, training too hard, too soon, basically? 

Wil: That's a part of it. Yeah. That's a huge part of it. I mean, it's certainly one of the biggest factors. There's a few other things that also can contribute to it as well. But like as you put on the mileage and if you don't get enough rest and let your body recover, that certainly can lead to the overstretching of the IT band because then the muscle that attaches on to them can really pull them and cause a lot of abnormal movement patterns kind around the knee. And so then you ended up getting this knee pain on the outside of your knee, which can also lead to like a clicking sound that can happen there as well. 

Well, you basically would do a bunch of different tests. You were on obviously, like I said, the IT band is part of the knee that provides stability to the knee. And what you want to do is you want to rule out all the other ligaments and see, you know, how that is. Now if you've had a pre-existing injury then you could have these imbalances happening in your knee too. So the IT band syndrome, there's specific tests for it, for looking at different muscle tightness and how that could be pulling on it abnormally. And so essentially if those tests are positive then you're looking at the pattern of how things are moving in the knee.

Then you can determine that it is IT band syndrome. And a lot of the times you have like a few factors involved. Like I said, if it's an overuse thing, but then you may have sort of inclination with like your body type, if your feet are a little bit more flatter, which is called pronation and if you're running in shoes that are worn out, that can basically provide less support for the running and mechanics of it.

And then the other thing is also you know, the really important aspect of this is, is looking at like, are you running on a lot of flat, versus like Cambridge Services or you're doing a lot of trail running and then it's causing your knee to really buckle. And if you're doing a lot of like hill training, then you're getting your hip flexors really tight. And so then what happens is that those muscles end up being really pulled and it causes pulling out of the IT band, which then can give you the pain that you can experience the knee.

So I think the other aspect to looking at IT band injuries and knee injuries with running is how do you treat it? So one of the big things for treatment is really looking at rebalancing everything around the knee. And so part of that rebalancing is in doing things that are basically going to take the load off of it in terms of mechanics.

First thing you want to do, though, is definitely unload what's causing it to give it pain. And so if it hurts with running, then you want to basically take down your training a little bit more and let it settle down because when it's really bad, you can actually have quite a lot swelling and then you can't even walk. So you want to look at the training load and really decreasing that. And the things we talked about footwear. And then looking at recovery, are you recovering enough?

And then are you getting too much training at a high intensity and then not letting your body recover. And so the other aspect too, is we talked a little bit about if you had a preexisting injury, then you can start to compensate with like your hip flexors and some other muscles.

So then you might want to start to look at, okay, so do I have other deficits or do I have other issues that I want to address. Like, so maybe I have a weak core and I'm compensating with my hip flexors to basically stride and really push through. And that's the other issue is my stride. Am I always overstriding? So then maybe I want to look at that in terms of my running mechanics. 

So we would actually do a running mechanics. We have a treadmill that we can actually look at a bunch of different factors involved in terms of your posture and how you run. And also you know, part of that posture is like making sure that your cadence. So your cadence is like how many steps are you taking per minute? And then they've done research studies and they showed that if you're under a certain amount of steps per minute, you're actually more prone to the injuries. And so that's another factor.

Mark: If you need help with any kind of running injury, knee, or anything related to your running program, see the expert trained sports physios at Insync Physiotherapy. You can book your appointment at Or you can call the Vancouver office. They're on Cambie and King Edward. You can reach them at (604) 566-9716. Or the North Burnaby office they're on Hastings near Willingdon, at (604) 298-4878. Insync Physio. Get feeling better. Get moving right and running. Enjoy this beautiful summer we've got coming.

Vancouver Physio Nirushan Guruparan – Sports & Knee Focus Injuries

What inspired me to become a physiotherapist? Well, when I was a kid, I grew up playing a lot of sports. I played a lot of soccer. We were playing tennis, I did some TaeKwonDo, I did swimming as well. And so I was really immersed into athletics as a kid. And if I wasn't playing the sports, I was either watching them on TV, reading about them, I would read sports autobiographies.

I would read about fitness, dieting, nutrition. Those are always the things had me interested in what was a kid. And when I went to university, I took a lot of courses in physiology, biology, biomechanics and sports psychology. Those are the type of stuff that really was driving me to learn more about my profession and different professions in general.

And I also knew for myself that I want to be in a field where I can actually help people in person and learn about people's stories, where they came from. And I know I wanted to help them in some way or form and physiotherapy became the ultimate profession that had basically everything I was looking for in one.

And that's what inspired me to become a physiotherapist. If I wasn't playing or watching sports. I was actually doing a lot of drawing. I would draw anything from like buildings to humans, to animations, to cartoons. Drawing was what I did for a long period of time. I mean, if you talk to any of my friends before I was 18, they would know me as the art guy and the drawing guy. 

So when I finished university, the other profession that was looking at was something called a medical illustrator. It's basically a combination of anatomy, physiology, type of human biology and art together. So if I have to choose another profession, that's not physio. That would probably be the best fit for me. 

In my free time, I like watching a lot of movies, new TV shows. I love listening to music, R&B and hip hop are some of my favourite genres. So if you know some good R&B music right now, please give me some recommendations.

I love going to concerts. I love hanging on my friends. I just recently moved here from Toronto. So you'll find me calling my friends in Toronto quite often throughout the days, these days. And I love traveling a lot and I've gone to Mexico. I actually grew up in Italy for a couple of years. So that's something, so that's a place I would like to go back. I'm originally from Sri Lanka as well. So I definitely need to head back home at one point, but I'm new to BC and I'm excited to go hiking. So that's going to be a new hobby that I can't wait to explore. So if you have any suggestions on hiking trails and you come see me, please let me know some recommends. 

I like treating all areas of the body and everything is unique and I love learning about the human body, but if I had to pick one area, it would probably be the knee. I've always been interested in with the structural integrity of the knee, either loaded and the different injuries that affect the knee.

It's always interesting to kind of figure out how like your feet and basically your hips kind of all impact the way your knees are moving and working. The knees are actually commonly injured in sports. So obviously when I was growing up, that's one of the things I'm always curious about, like how long is it gonna take for my favourite players has come back from injury.

As well on a personal level, I actually had knee pain. That's probably one of the first exposures I had to physical therapy. I had a hard time just accelerating, decelerating, moving quick, and I knew how debilitating it felt to be able to perform at a good level. I couldn't catch my next man. So the knee has always been close to my heart as an area that I like to treat.

Shoulder Rotator Cuff Climbing Injury Rehab Resisted Bear Walk

Start in 4 point position on your hands and the forefoot or the balls of your feet with your knees greater than 90 degrees with 4 feet Resistance bands tied diagonally from opposite thumb webspace to ankles.

As you place one hand forward bring your opposite foot forward as well. Do this while you also keep the shoulder blade muscles and your neck position in neutral. Repeat this for 30 seconds 3 sets 2x/day.

This is a great progressive core stability muscle strengthening exercise for rehabbing your shoulder and rotator cuff injuries. 

Physiotherapist Pelvic Health with Mecca Clipsham

Mark: Hi, it's Mark from TLR. I'm here with Mecca from Insync Physiotherapy in North Burnaby. She's a physiotherapist for pelvic health, and we're going to talk about pelvic health. How are you doing Mecca?

Mecca: Yeah, so I treat people with pelvic floor dysfunctions and that would be, you know, anyone who's experiencing pain in their pelvis region or someone who pregnant or post-pregnancy. There's quite a lot of things. The pelvic floor is a group of muscles that forms the underside of the pelvis.

So you imagine that area between your seat bones, your tailbone, and kind of the front of your pelvic bone. That's the pelvic floor and it helps with bowel function, bladder function, sexual function, support of all those internal organs. So anyone who is experiencing any sort of bladder or bowel problems such as leakage, like unwanted leakage or incontinence, or sexual function dysfunction could benefit from pelvic floor physiotherapy. 

Mark: So how common is this? 

Mecca: It's more common than you think actually. A lot of women experience incontinence, which is an unwanted leakage of urine throughout their lives, kind of from early adulthood, all the way to older age. Quite common around pregnancy as well as with older age. And it's something that people kind of think that is a normal thing, which it actually is something that's not normal and something that there is possibly a solution too. And pelvic floor physiotherapy can definitely help with some of those symptoms.

Mark: So what would be some of the other symptoms that somebody would come in and get treatment? 

Mecca: So any sort of pain in the area. So pain with sexual intercourse or any sort of sexual activity. Pain with even like rectal pain. That could be something that could benefit. Pain with urination or bowel movements.

Some other pain conditions such as bladder pain. Even the conditions such as endometriosis, we can't treat medically, but we can actually help with some of the symptoms that are related to that. 

Mark: So what's causing some of this stuff? 

Mecca: So some of the stuff that causes the pain and causes the symptoms is actually the kind of dysfunction of the pelvic floor muscles. So sometimes they can be too tight and people are unable to relax that area. And that can cause quite a lot of pain. Sometimes they're not strong enough or people are unable to coordinate that part of their body. And that can cause some unwanted leakage of urine or pre and post pregnancy, for example. 

As we understand, pregnancy puts a lot of stress on that area of the body. It's a lot more weight on that area of the body and that can cause some unwanted leakage and also even some pain in the area. That can be treated by pelvic floor physiotherapy. 

Mark: So how do you go about diagnosing what actually is going on and maybe a course of treatment?

Mecca: Yeah. So what we do is we take a really thorough history from a patient. So just finding out a lot of information about what's been going on and what their symptoms are and what their history is, what sort of other medical treatments they've had. And just kind of get to know them and who they are.

And then we go into an assessment. So an exam. So we look at them kind of as a whole person. How do they move? How do they breathe? All that kind of thing. And then the real difference between pelvic floor physiotherapy and regular physiotherapy is that we've actually been trained to do internal exams.

So what that looks like is similar to like a gynecology exam. It's actually an internal vaginal exam or internal rectal exam. So that's kind of the difference between a regular physio and pelvic floor physio, is that we have the training to do that. And that actually gives us a really good sense of what's going on with some of these muscles. Because a lot of these muscles are more internal and we can't really see what's going on or understand what's going on without doing that internal exam. 

Mark: And what would a typical course of treatment look like and how long does it take to have some improvement. If that's even possible sometimes. 

Mecca: Yeah. So that will vary from patient to patient, just like any sort of treatment. It's very unlikely that it's a one time treatment. Sometimes it might take several weeks to several months, depending on how long the person has been experiencing their issues.

Mark: And what are the things that you're giving people to do or you're getting them to do when they're in office.

Mecca: Yeah. So it's very similar to regular physiotherapy. There's a lot of education and a lot of information that is actually, things that people don't necessarily realize that should be common knowledge. So lots of education, lots of even like some lifestyle modification, exercises. So pelvic floor exercises. The most common thing that people think of is kegels, which can be part of it, but it's not everything. Because there's a lot of people that can't actually relax their pelvic floor. So instead of needing kegels, they actually need more relaxation exercises. So yeah, those are kind of the main things. There's also some manual techniques that we can use to work on people's pelvic floors as well. 

Mark: So if you have some issues with your pelvic floor, if you've got pain there, if you've got problems with incontinence, the person to see in North Burnaby is Mecca Clipsham. She's at Insync Physiotherapy in North Burnaby. You can book online at or you can call to book at (604) 298-4878. Get in to see Mecca. Get better. Get moving better. And get those issues looked after. Thanks, Mecca. 

Mecca: Thanks Mark.

Persistent Post Concussion Syndrome with Iyad Salloum

Mark: Hi, it's Mark from Top Local, I'm here with Iyad Salloum he's the clinical director of Insync Physio in North Burnaby. And we're going to talk about persistent post-concussion syndrome. What is this Iyad? 

Iyad: Yeah, so there's the common tale of like, you have two different kinds of populations that get this potentially. So you have the athletes who, you know, is playing a contact sport like anywhere from soccer to hockey, to lacrosse. They get an impact. They suffer from a concussion and then a few weeks on they're still unresponsive. They feel like they're not improving, they're not improving in the same trajectory. You'd expect it to with just time. 

Then you have another group that we see quite commonly, which is after a motor vehicle accident. So anything that involves a sudden movement to the head, a rapid acceleration deceleration kind of will potentially lead to a concussion. And then, you know, a few weeks on these people seem to struggle specifically coping with things like screen work if they’re office workers or if they're students like reading and studying. If they're athletes going back for a job, for example. 

There's all these things. And then the interesting part about it is the symptoms are so varied. As we know about concussion, no two are the same. Heterogeneous group. So some people have an issue with a light sensitivity. Some people will get dizzy. Some people get a headache. So really it's a whole kind of gamut of symptoms that we assess and treat in clinic.

And in this group, particularly where it's really confusing for them because you know, usually you'd expect things to just get better with time as like when you roll your ankle or a few of those things. But here it seems to kind of lag a little past where they think it is and you know, the reason that is, is because A, the brain's a bit more complex and B, sometime as we kind of delve into these maybe maladaptive patterns where we try to protect ourselves a bit too much, or maybe we go a bit too hard into our return.

So there's the two extremes where you do very little or your do too much. And this is kind of where we come in to help regulate that system a bit more. 

Mark: So, is there an obvious cause as to why one particular person with a similar injury would get better quickly and another person wouldn't? Is there anything that's been defined in science before? 

Iyad: Million dollar question. So far we know there are a few risk factors. So things that make you more likely to get it. So people who have had several concussions seem to cause this. If you have involvement, for example, of a few other things like the neck and the vestibular organ, which is in our inner ear, which helps us kind of balance and kind of track objects through space.

Those are very simple things that we talk about, but they actually are quite complex neurological processes. So it all depends, I guess on the person too. So it's like sometimes if they've had several concussions, that's a factor. There's some genetic reasons that we think it is. Sometimes the severity of the initial injury and then sometimes it's just the lack of education on this area where people return to quick or don't return at all. 

Sadly, we still see some bad advice out there where people sit in dark rooms for a week, which is crazy because I don't know when the last time you had to sit in a room without your phone, without reading, without running, without walking in a dark room and just do nothing. Sounds like solitary confinement to me. So I think that's a big reason why we see persisting symptoms too is it's just outdated advice, let's call it. 

Mark: So when you're diagnosing this, does it make any difference what the symptoms are when you're going through the history of someone? Do they have a history of a lot of concussions? What actually happened? How severe was it, et cetera. I guess it's graded in terms of the injury then. Okay. Someone's really light sensitive. Is that a different course of treatment than somebody who's having balance issues? 

Iyad: Yeah, that's a great question. And yes, the answer is yes. So if your main impairments are visual in nature, we'll try to target that system a bit more. If your main kind of impairments that we pick up as the vestibular impairments, we try to target that too. I usually will consult an occupational therapist on this too, where they are really good at planning and pacing.

Like this is kind of the grand scheme of things. It's like, you need to be able to preplan things in concussion, because there's a bit of a battery life that once you exceed, it seems like the symptoms go a bit way off kilter. And doing this where you're just kind of trying to mentally track things is really, really tough.

So we have a foundation of just like people being more aware of their symptoms and planning their days out and trying to separate their activities until, let's call them mentally draining intense activities, to let's say something that's light and easy. And then the exercises or the treatments will be focused on what are the specific impairments.

If you have a primarily balanced deficit, we'll try to target that a bit more in treatment. Versus if you have a visual deficit, try to I'll start with that in treatment. It'll rarely be a solo practitioner working on this. I usually will consult several team members like even optometrists if there's a lot of visual disturbances. Or occupational therapists are pretty easy one to kind of tag in here, but then often people might have some other kind of ongoing mental health issues where we actually really need to tag in our colleagues too.

So yeah it's quite complex, but it's also what makes it kind of fun. Cause it's not really a cookie cutter thing. I'll never be able to hand a printout of here's the five exercises to get rid of your concussion. We're not there yet at least, where we can classify people like that. Based on a cookie cutter recipe or we just hand it out. 

So for now, yeah, we have to treat the impairment and it tends to be very, very different person to person. 

Mark: So clearly no typical course of treatment. What are some of the things that you would do for instance, that for light sensitivity and the vision system being impaired or impacted by the concussion as compared to say a balance issue?

Iyad: Yeah, the balances should be pretty straightforward. We've got to figure out what's causing that. So it's going to be one of three things. The three systems could be a visual impairment, so like some people will actually perform better when the visual system is a bit clear, let's say. So there's different therapies we try. For example, seeing if we can optimize their visual field, get them to focus on certain things while they balance, or even maybe get them to focus less sometimes. Sometimes we try to get a little too tunnel vision. 

There's other things for vision could be as simple as where we try different tools, like some of them are called binasal occlusion and a few other things, or even prism glasses that an optometrist would recommend sometimes.

While we train that system, we definitely want a great screen exposure. So if you had just tell somebody to go stand in front of your laptop for 12 hours, I'm expecting them to fail there. So we suggest different filters, for example, like a lot of technology nowadays has a night shift mode and that could be very helpful. So we'll do that. We'll be very specific. And then the amount of screen time that we do. 

And then obviously we'd want to pay attention to sleep hygiene because initially we'll get a lot of sleeping habits where people want to sleep more. But then as that kind of throws the entire sleep cycle off, we actually see people kind of fall down a bit of a slippery slope and then we need to address that system a bit more too.

So, yeah. Meanwhile balance, I mean, we'll figure out if it's a vestibular problem. Sometimes it could be due to BPPV, which is where you have a crystal gets out of place into one of the surrounding canals in the ear. And we can treat that very easily with an Epley maneuver or a barbecue roll. Those are just two different treatments that we use for that. 

But if it's just an impairment in the system, there's lots of exercises that we could use to target those. We actually have a lot of tools in our toolbox here and that's the good news because sometimes it feels like when people have been in this for awhile, that it's just never ending. And it is quite taxing to feel that way. So we try to help whatever way we can. 

Mark: All right. If you've got any kind of persistent post-concussion issues going on, you need expert help. And the guys to see are Insync Physio in North Burnaby, (604) 298-4878. And you can also book online at Or the Vancouver office. There's also experts at (604) 566-9716 to book. Got a book ahead. They're always busy at Insync Physio. Get some help. Get some expert team work on your concussion syndrome and get feeling better quickly. Thanks Iyad. 

Iyad: Thanks Mark.

Pre and Post Pregnancy Physio with Mecca Clipsham

Mark: Hi, it's Mark from TLR. I'm here with Mecca from Insync Physiotherapy in North Burnaby. She's a physiotherapist for pelvic health, and we're going to talk about pelvic health. How are you doing Mecca?

Mecca: I'm good. Thanks. How are you Mark?  

Mark: Good. So I've never been pregnant. Thank God. But I guess there's some things that happen to women when, before and after they've had a baby. Why would they want to see you specifically?

Mecca: So when someone is pregnant, there's a lot of stress and pressure on their pelvic floor. And there's a lot more weight in their pelvic region due to their pregnancy. So coming to see a pelvic floor, someone who specializes in pelvic floor physiotherapy, can be helpful just to get an assessment before the baby comes.

So in pregnancy, usually in the second trimester would be a good time to come just to get an assessment of how their pelvic floor is functioning and a little bit of education on how to keep it healthy. And you know, there's some things that we can go over. Prepping for birth. And then after birth as well after having a baby, your pelvic floor can change.

And it's good to get that assessed and looked at because there are a few things that can happen. A lot of people experience pain in their pelvic region while they're pregnant. And that's something that we can work on. Some people who are pregnant experience incontinence, which is just unwanted leaking. May happen before or after pregnancy.

And coming to see a physiotherapist who works with pelvic floor can help mitigate some of those symptoms. Another thing that happens with pregnancy is there's a possibility of prolapse. So prolapse of pelvic organs, and that's another thing that we can address.

Mark: If you're pregnant, thinking about getting pregnant or have been pregnant and you've got any of these issues going on or want to be prepared, because this is fairly common. The person to see in North Burnaby is Mecca Clipsham at Insync Physiotherapy. You can book online to see her at or you can call the office at (604) 298-4878. You got to call ahead. She's busy. Thanks Mecca. 

Mecca: Thanks Mark.

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