Arthritis with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. One of the top physiotherapy clinics in Vancouver, and one of the best physios in Vancouver. And we're talking about arthritis and how physiotherapy might be able to help you. How you doing Wil? 

Wil: I'm doing good. Thanks Mark. 

Mark: So I thought that, you know, arthritis was just, you take pills to try and make the pain go away and you just, you, you live with it. Am I wrong? 

Wil: Well, let's say you can break it down a little bit more. So let's talk about like one specific type of arthritis that we actually deal with a lot with our physio group at the clinics. And that's called osteoarthritis. So there's all these other different types of arthritis, which like rheumatoid arthritis and then all these other arthritis is that are basically kind of more systemic in origin. And you take pills for that as well.

And, you know, sometimes with the osteoarthritis and I'll explain to you what that is in a second, but like with osteoarthritis, you know, sometimes the doctor will actually also prescribe Tylenol as a pain reliever. And so what osteoarthritis in very simple terms, It's just basically a degeneration of your joint, based on wear and tear. So there's not a systemic issue going on in terms of like the same type of rheumatoid arthritis. So with rheumatoid usually affects multiple joints and it's not like isolated to one area because of wear and tear.

Now, if you've had like an injury per se, so I'll give you a specific example. Like let's say an individual, an athlete, tears their ACL and their meniscus, and they have to get that meniscus that little cushiony part in the knee removed and the ACL repaired. Now they lack more of that cushion. Now it is true that you will have a higher chance of developing osteoarthritis cause it's the wear and tear of the joint.

So this is where, you know, the question of how does physio help with this type of arthritis. That's a very good question. And ultimately, you wanna look at the joint being like, so in the joint you have what's called synovial fluid. Synovial fluid is basically like the oil for your joints.

And so you essentially wanna keep the joint moving and that's gonna keep joint healthy. And what you also wanna do is you wanna keep all the muscles around that joint functioning and healthy too, which will keep the joint moving in equilibrium. Because the other thing you don't wanna do is that you don't wanna have excessive amounts of force pulling on that joint because there's imbalances in those muscles.

So for example, going back to the ACL example. Let's say I get super, extremely tight in one of my quad muscles, my rectus femoris, because you know, like I compensate post injury or whatever. And so now I'm gonna get a lot more increased excessive forces on my kneecap, which is called the patella. And it's gonna come up, causing a condition called patella alta. So what happens is then you're gonna get that rubbing and you're more prone to a degenerative effect in your kneecap. So we want balance things out. We don't want to have things imbalanced. And so that's important too.

Now, going back to what I said about that synovial fluid. The more, we keep the body moving, the more that we pump the fluid in and out. So that fluid carries nutrients to the joint, because usually in the joint, you don't really have a rich blood supply. So then you would need to rely on that synovial fluid and you need to have a pumping mechanism.

So merely getting the joint moving, pumps out that old synovial fluid and then pumps in fresh nutrients for that joint, keeping in healthy. So that's how physiotherapy can help. Prescriptive exercises looking at what exactly is tight, what exactly is weak, to support a more optimal alignment. Either of the joint. So in your knee, for example, if you're like a runner and you're trying to get back to running post injury. Maybe your hip muscle, called your gluteus medius is weak and it's causing this alignment issue when you're running in your knee. 

So we address that, then that's gonna make things move more smoothly in the knee, and you're not gonna get an abnormal biomechanics happening in the knee. And so that's the really important thing is we're also retraining your neuro muscular system. So neuro being the nerve, muscle skeletal system. So getting that all, working together properly. Helping you develop a more optimal way of moving those muscles around that joint for better joint health.

Mark: So bottom line, if you've got some arthritis showing up, pain, it needs to be diagnosed by doctor first. Correct? 

Wil: Yes and no. We get a lot of people that come in that haven't been seen by a doctor. And we're like, yeah, that looks like osteoarthritis. And, you know, you can confirm it with a scan, but if it's really kind of borderline, you're not really sure. Then we send in the doctor for more additional tests, maybe rule out other types of arthritis. So that's possible too. 

Mark: And you work in conjunction with doctors all the time? 

Wil: Absolutely. Our whole team does, yes. 

Mark: Referring back and forth. So if you've got some joint pain, And you want expert analysis and you wanna see if it can get better or you've been diagnosed with osteoarthritis and you want to not have it get worse. Cause if you don't do anything, it's gonna get worse. But if you start moving in a proper way, you're gonna get that synovial fluid in there. You're gonna have a longer expectation of good movement in your joints. And a lot less problem when you're 90 years old, like my dad, and can't really move all that well. And so you want get into Insync Physio. Where to book Insync physio.com or you can give them a call. The Vancouver offices, (604) 566-9716. And they also have an office in North Burnaby. Thanks Wil. 

Thanks Mark. And remember motion is lotion.

Exercise after Covid, Short of Breath

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. And we're gonna talk about exercising and COVID. How you doing Iyad? 

Iyad: Good Mark. Thanks for doing this. 

Mark: So I'm sure you're starting to see people who've either had COVID, are still perhaps recovering from COVID and they want to get back to exercise. So how do you start diagnosing what's going on and what they can actually do and is there guidelines. 

Iyad: Yeah, so it's a newer disease, as we all know that kind of came outta the blue a couple years back. And we initially had no idea what we're dealing with. So the initial approach was in a lot of hospitals was they were treating it like any other respiratory disease and kind of seeing what sticks.

And we found that some things were pretty helpful and some things were not helpful at all. So one of the things that we found was not helpful was to push people past their, let's say, into symptoms into their threshold a little bit more. We found that they actually didn't cope so well early on. And then there's other things, for example, that we found work pretty well.

So for example, if somebody has a disrupted breathing pattern and we can kind of go over how to kind of breathe a bit more regularly for them and practice that, that seems to regulate a few things. And then the other thing also, like I said, in my last video is that there's so many symptoms that COVID has that impair your ability to exercise.

So what we're talking about today, maybe we'll focus a little more on the respiratory stuff. You know, the feelings of shortness of breath. We have a multitude of people who come in, some who come in and say, look, I got a chest x-ray and it's clear. And doesn't say that there's anything with my lungs. I just can't tolerate any exercise. I walk for a few seconds and a few minutes, and I feel like I'm just winded and feel tired. Some of them even will tell you, I feel a little bit nauseous, just because they're kind of struggling to regulate their own body when they're exercising.

And for that kind of person, we would tend to look at a few things. We'd start with just seeing how do they breathe when they're lying down, when they're sitting up, and then we get them to walk and we monitor a few things like heart rate. We can look at their oxygen saturation, which we can measure with a small pulse exhibitor.

And usually most people have tried to do their own research on that. And they'll try to buy one in the pharmacy, which is great. And then they say, yeah, it stays at 98%, which is awesome. It means you're not, you know, your blood oxygen levels and dropping, but yeah, we tend to look at that. And then what we'll try to do is also figure out what's the number that they can exercise in safely. What's the speed. What's maybe the pace. And for some people who don't like tracking that stuff, we can just kind of go over an exertion level. We'll give them like, okay, you can actually do pretty well at maybe for example, 2 out of 10 level of exertion. So we're gonna just try to build them a program around that.

Breathing exercises seems to help a lot in this population. And one of the dysfunctions you could see is some people will tell you, they feel like the upper part of their neck and chest gets really tight from their breathing. And it's because they're trying to focus the breathing in the top part, maybe a bit more.

So if you imagine using only part of your ability to breathe and not the full capacity of your lungs to kind of expand, I could see why you would get tiring, just to breathe. Because you'd be breathing a lot harder to just try to get that same kind of volume in. So yeah, we'd want to assess that for sure.

And we would kind of then give them a program of different types of breathing and sometimes, it's still a sense of panic when you feel like you're losing air. I'm sure like a lot of us have had this kind of feeling of being winded and it's not really a comfortable one psychologically.

So some of the exercises are to also improve their ability to just kind of tolerate that kind of slow down their breath a bit more instead of hyperventilating and doing these shallow, rapid breaths. So yeah, we, we kind of work a lot more on that. And then also try to build a safe aerobic program that they can kind of start at because it's tough when you're just guessing every time.

Sometimes you walk two blocks and sometimes you walk 10 and then you're kind of tired afterwards and you're feeling a little nauseous or maybe some other symptoms. So it's a bit easier when we take the guesswork out. 

Mark: So what's happening is that people are feeling that when they have COVID, when they're in the actual disease and they learn to try and deal with it in a way where they restrict their breathing. They don't expand their lungs as much as normal. And so then they get into a habit where now they're kind of not breathing properly anymore after they're better. And they need to retrain theirselves. Kind of like we have to retrain after an injury, if we've had an ankle injury or whatever, is this something similar?

Iyad: That's potentially one of the things that happens, we actually don't know. This is the interesting part. Now there are cases where you actually have findings on a chest x-ray, like if you do a chest x-ray and you see that the lung has actually been affected. And then that could actually impair the lung's ability to behave like its elastic kind of self. Where it can actually inflate and recoil. And you might lose a bit of the recoil sometimes. Or in some conditions you can't inflate as much.

So it's so variable person to person. Luckily, we're not seeing as much of that these days, which is good, but we still are seeing some of them just because it's spreading at such a fast rate. That even if the percentage is small, we're still seeing that. But you can imagine for that person who, for example, literally could not expand their lung the normal way because of potentially some the disease process going on. You will have to find another way to do it. You have no option, but to get some oxygen in to kind of go day to day. 

So it could be that. It could be a learned behaviour. It could be also a sign of the disease or probably a mix of the two. We actually don't know why this happens still. I can't tell you the, the cause. So we can't really like pinpoint that, but I mean, they seem to do pretty well with breathing exercises.

Even the World Health Organizations rehabilitation guidelines include breathing exercises. And they also include certain. Things that we will teach our patients. And this is something we teach everybody on the first session is what they call the rescue position. So if you're feeling really short of breath and you're feeling like you know, there's a bit of respiratory distress going on, there's certain positions that can actually help control about a bit more. And this is something that's really powerful to teach someone. 

They're freely available on the World Health Organization's website in their rehabilitation guideline. But most people won't think of looking at, and we will definitely be like one of the first things that we go over with them. And just teach them about, well, this is actually, it's gonna happen and especially in the first few days, as they try to do this and try to kind of expose themselves a bit more of that. And we will teach them how to control that, because it's really, really powerful for them to have at least a bit of symptom management, let's say. Because that's a really awful symptom to feel like you're gasping for air.

Mark: Yeah. So what should someone not do? 

Iyad: One of the things that we don't think helps so much is pushing really, really hard, really, really fast. And this is when it comes back to guesswork and we find it really valuable in these cases, especially when people don't recover the way they think it's gonna be, two weeks and it's gone.

Actually how much they're doing and to monitor their symptoms and according to how much exercise they did and to see how long it takes for them to recover. That's a really useful thing to do. What you shouldn't do is just to try to go arbitrarily and just say, I'm gonna go to kind of end of my fatigue limit and things like that right away.

We don't think that seems to help so much. Some people and the jury's still out, if it actually can affect you negatively. Some people say it does. There are reports of that happening where people actually don't do well after really, really heavy exertion. And then, there's always the person who likes to wait and see, and that's perfectly fine.

But the population we will see and that's from a younger 20 year old, all the way up to a senior who likes to just get moving and get walking and do their social interactions with their friends. We want to get them back as soon as possible, safe as possible. So that's really the kind of person that we tend to help. Instead of somebody who's just for example, would say, oh, it's gonna be fine. I'm gonna just wait it out. Which could help a lot of people too, because you know, our body has a great ability to heal. 

Natural history can be a factor here, but yeah, it all depends on how you're responding and what you're, I guess motivation is, if you just want to get out and exercise earlier, then you would want to get some exercise guidelines from one of us. 

Mark: So softly, softly on your recovery, in a way. Breathing exercises of some kind, I would assume belly breathing. 

Iyad: That's one of them. Yeah. But that's not the only thing that they could do. Some people belly breathe well and they don't breathe well, for example, from other areas. So like there's different versions of breathing that we would just, again, we just see what's happening there and what's not happening there. And the funny thing is you could breathe really well on the bed and then you go for a walk and all of a sudden it changes. So then it would be actually breathing exercise with movement a bit more. 

Mark: Perfect. And basically get some expert help so, you know what's going on while you're tracking your progress rather than just experimenting because you can cause yourself some injury and that might be permanent. Is that fair?

Iyad: I don't think we could say that confidently. I don't want to scare people in that sense, but I think you could definitely just make it longer. You can just prolong the process by guessing so much. So we would be able to even identify certain things that often, if there's something that's not quite right, we would flag it up and pass it on to our medical colleagues for further assessment. And this is, again, some things that people just aren't aware of, because it's hard for you to kind of figure out what's going on with your body sometimes.

So. Yeah, that's what we tend to look at more. We want to see is this safe for you? That's our first priority. Always, obviously. Can I get you safely doing something? And can we progressively do this in a way that doesn't necessarily have a yo-yo effect where you're a good one day and down the other day and good one day and down the other day.

Again, we can't say anything about long term damage and any of that stuff, because we just don't know if that's actually how it happens. I think that'd be a bit too simple of an answer. 

Mark: Perfect. So if you've had COVID and you want to start getting back to exercise, but you want to do it safely. The guys to see are Insync Physio in North Burnaby, you can book online or you can give them a call. Thanks, Iyad. 

Iyad: Thank you.

Exercise After Covid with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. We're gonna talk about a really relevant, timely thing, exercise after COVID. How you doing Iyad? 

Iyad: Good Mark. How are you today? 

Mark: I'm good. So my wife had COVID when she should go back to exercising.

Iyad: That's a great question. It's something that we kind of we’re learning on the go because of how new this disease is. And, you know, we thought we could maybe extrapolate from previous diseases like that. We used to do, for example, like with the flu and with the common cold and other respiratory viruses.

But one of the things that's really interesting is, it seems that we can probably start exercise soon, within a few days after the majority of the major symptoms settled down. But the exercise parameters are not well understood. Like, so for example, we can't just say, oh, you're day five here, go do this thing. Pass a handout to the general population, because everybody seems to be very different. 

So the way we are kind of doing this now, we're realizing at first was when we tell people to push into symptoms and push into their exertion, is that they actually would have contrasting reactions. So some people would actually get a bit worse and some people responded well.

So general idea now is you should kind of do a little sub-threshold exercise in the early days. So don't go into those symptoms where your heart rate's racing, or you're hitting that shortness of breath in the first few days. And that's kind of something that we're starting to see more and more of in the clinic. And the interesting part is I haven't seen two people that present it the same way.

Mark: So it's very individual. I guess it depends on a myriad of factors depending on, you know, what your original fitness level was or who knows, I mean, it hits everyone. Even really well trained athletes sometimes get pretty severe symptoms. 

Iyad: Yeah. And that's really significant actually to note. Everybody's symptoms have been so different. So you have people who say, oh, I had a lot of headaches and kind of fogginess and maybe some kind of nausea with different movements. Some people have developed heart related symptoms. So like a popular example is Alfonso Davies, a soccer player had inflammation of the heart muscle tissue, which again, it happened. It's not luckily as common as we hear about it, which is good. So that's a cardiac symptom. And then you have the common one, which is the shortness of breath where people feel like they just can't inhale and exhale properly. 

So depending on what presents to us, we basically would do an assessment of just very basic things. Like, you know, some breathing assessments. We do an exercise tolerance test where we monitor the heart rate, we would monitor a few things. And then depending on the impairment, for example, if you have some respiratory kind of issues, we would start everybody almost on a breathing program.

And it sounds kind of funny. You almost have to relearn how to breathe again. And that's something that we've seen work really well for a lot of people. And it's not too different from other respiratory conditions where we find breathing exercises to be very helpful. And then some people will need a prescribed walking program where they stay within a certain heart rate or a certain exertion level.

And that's something that we would determine just from the, you know, we get you to do this kind of think of like a exercise test. And then we kind of adjust the parameters according to that. And then sometimes, you know, in cases where there's something a little more severe, we would want some medical intervention there.

We had one person in the clinic where we needed to work closely with the cardiologist office to make sure that they're safe to just move and walk and get their heart rate up a bit. So, and again, it's so different person to person and that's kind of what makes it, I'm sure hard for a lot of people to self-manage and you know, like even us healthcare professionals, we're trying to kind of learn about this thing every day and just trying to do the best. But yeah, that's why we can't just make these concrete statements say everybody should be doing X, Y, or Z, because it seems to vary a lot between the people.

Mark: So you mentioned something earlier as well. When we were talking prior to recording where you had COVID and in your recovery process, it was a little bit problematic for you. What was that like? 

Iyad: Yeah. So for example I had no symptoms at rest, but one of the things that we noticed is with a bit of activity, I would get different responses. So it'd be like a bit of you know, shortness of breath sometimes, or sometimes you'd feel like a little dazed, but generally that seems to have improved pretty well with just a gradual program. But that's the piece where it's so different again. So I've had lots of people who just their primary symptom is just respiratory.

And that's basically the only thing they have. Is they just have shortness of breath and then it takes them a while to kind of settle that kind of sensation that they're gasping for air afterwards. So really, really depends. And one of the things we obviously want to make sure when we are getting people to exercise, is they're staying safe, for example. Like we monitor things like blood oxygen level. 

And this is something you could just do with a pulse oximeter from the pharmacy where you just kind of see, are you actually losing oxygenation in your blood, because then it's a different story. And obviously the exercise guidelines would change significantly and we'd want to work pretty closely with our medical colleagues for some of those cases.

But, yeah it's just so different person to person. And this is, again, I want to stress that it's not the same when we're talking about with cases of long COVID, which tend to be a little different and we could probably do two hours on that thing, because it's not the same. Long COVID is we're learning more and more about it, but it's not the same as recovering from an acute infection.

Mark: Thanks Iyad. So if you are looking for some great support in recovering from your COVID experience and it's still happening folks. I was out yesterday, I was the only one wearing a mask in all the stores I went into. And there's another wave happening. I mean, we can be tired. The COVID ain't tired. It keeps doing stuff. It's still there. If you need help with your recovery, with getting back into exercise, with doing it smart and safe and in a way that increases your abilities and brings them back, the guys to see are Insync Physio. Insyncphysio.com is the place to book or you can call them at (604) 566-9716 in Vancouver. Or in North Burnaby (604) 298-4878. Again thanks Iyad. 

Iyad: Thank you.

Arm Pain Related to Neck with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. And today we're gonna talk about arm pain coming from your neck. How you doing Wil? 

Wil: I'm doing good. Thanks. How about you, Mark? 

Mark: Good. So this doesn't seem to make sense really. How can you have arm pain from your neck?

Wil: Yeah. So I guess the first thing to really understand is the different kinds of neck issues that you can get. And you can have four basic types, I guess, to really narrow it down. And you look at what's called standalone neck pain. So you have this type of nonspecific neck pain that doesn't affect anything else. And so you have this pain that's happened, whether it's like a traumatic injury, you know, or something like that. Or you wake up in the morning and you sleep wrong on it. And you kind of have this neck pain that you're experiencing. And it's just neck pain, so there's no other symptoms. And it could be stiff. And it could be not be stiff. 

And then you have neck pain, with a headache related symptom, like you have neck issue, neck pain related with headache stuff. And that's quite common when you have this referral of the things going on with your neck joints that refer up into the head. And so that neck joint related pain or the technical term is called cervicogenic headache. Because the headache is coming from referral points from joints in your neck. And so the muscles get all really tight too as well. And they can also refer right into the base of your skull. 

And then the third type is sort of like this whiplash type of associated neck pain or disorder and there's all these classifications with that where it's like trauma. So I did mention trauma earlier, but I meant like more trauma.

That's kind of like, you know, you wake up, that's still, I consider that trauma, but it's not like acute trauma where you've had an accident. Right. So with the third type. The whiplash associated trauma is like a specific sort of acceleration and decelerated force. And basically you can either have pain in your neck without issues with motion, but you have pain. Or you can have limited range of motion. Or you can also have that with now it goes into the fourth category, which is neck pain with arm pain.

And so the technical term of that, I guess is, ridiculopathy or neuropathy. And so when you look at the neck pain with ridiculopathy or neuropathy, that's when the actual pain in your arm you know, and we've had this on our physio team where clients have said to our physios. Yeah, I think I've got tennis elbow and then they've been treated for, with some other healthcare providers and, you know, and it didn't help at all. Like they're treating their tennis elbow or what supposedly thought was tennis elbow or some kind of overuse thing going on in their arm. But in fact, if you do a thorough assessment and you do this clinical examination and look at where is their arm pain coming from, it's actually coming from their neck.

And so when you start treating that and you look at you know, the cause of that, and you start putting the pieces together and you treat that whole picture, then you start to actually affect that arm pain. Because you can get referral from your neck all the way down in your arm. And especially if, you know, someone that it may not even be an accident, it could be an accident, but it may not be an accident. And it may be like something that's just gradually happened over time. 

So I can think of a client that one of our physios had. Who said, yeah, you know, like they were talking about this patient who had arm pain. They said, yeah, the other healthcare provider was basically treating them for tennis elbow and it just wasn't getting you better. Well it was because it wasn't really tennis elbow is what she told me.

And started treating this client for their neck issue. And within a few treatments, their arm pain was dissipated from like an eight out of 10, which they would feel, for like a 3 out of 10. It's a process. Because these things developed over time for this person, and it was something that wasn't just over like a traumatic incident and this person didn't have any issue with them to begin with.

I mean, like traumatically speaking. They did have other non sort of repetitive going on. Cause they were on the computer a lot, and they did some sports that probably wasn't super helpful, like boxing, but never had an injury that they could remember. So the proper diagnosis or the proper assessment of what's causing the arm pain is really important. It's the first step.

Mark: So as an athlete, can I diagnose this myself? Is there something that's obvious so that you could point to and say, well, this is often what it feels like that's different than just regular tennis elbow or arm pain that would indicate it or do I have to come and see you really to get the testing done to find out?

Wil: No, that's a good question. So I think one of the biggest things is like you know, you can confuse it. It's very confusing because you're like, oh yeah, you know, I'm hurt because sometimes that area, it becomes more sensitive. So you have this sensitization of that arm, so that's why it legitimately feels like it's just arm pain and you may not actually have neck pain.

Like it just maybe neck stiffness until we start poking around in there and be like, oh yeah, my neck hurts a little bit. It hurts a little bit there. And so some of the things that you can sort of just rule out quickly for yourself is you can just do a lot of like resist detecting. So if it's like a tennis elbow thing, you know, like aside from the fact that it feels more sensitive and it's a little bit sore.

Like with this person, they were, it was interesting because there's like two things really hurt it the most, like doing weighted chin ups and doing pushups. And so, oh, that's interesting. So then I was thinking, yeah, it could be maybe like something related locally. Around that area of their arm. But then when I actually put them through the test, which you can do on your own or an athlete can do on their own, like just test yourself, do some simple, wrist resistant testing with your arm bent, arm straight. And then do what I call like sort of the P symbol with the arm straight and then resist. And then do that with it bent. And if you're getting the reproduction of that pain that you're experiencing when it's sort of that yeah, when you touch it, then that's usually a good indication. Oh yeah, maybe there's something going on. Because that's actually testing the structures related to tennis elbow.

So I don't know if that helps if it's sort of a initial thing. Cause that is actually a really quick test that you can do. Because sometimes if you just touch it, it can be sensitive. But if you're doing specific things to test for if it's sore and weak, then it could be maybe a tennis elbow thing. But if it's just weak and it's not sore, then it might not be. 

So the other key thing too, is if it is a tennis elbow thing, if it's an overuse thing, and if you're doing exercises to work on releasing the muscles, like tough massage and stretching, And then you're doing some specific strengthening for, and that doesn't get any better in like a couple weeks. And that's when you want to get it looked at. Maybe there's more to this that meets the eye. And you know, as great as Google can be, in terms of being a good resource you know, sometimes you just gotta get it looked at you know, if it's beyond that stage of like two weeks and especially if you're like, yeah, I want to start to play more tennis. I want to start to play more Ultimate Frisbee or rock climb or whatever it is that, you know, using your arm more. 

Mark: When you're working on a person's neck to reduce the stiffness or the pain that's referring down into that person's arm. What kind of stuff are you doing?

Wil: Yeah. So really good question. So one of the biggest things is, so there's three things that we're looking at in terms of the rehab process. So there's increasing mobility. So we want to increase the mobility of like the whole thing that's affecting the arm. 

So there's the neck. And the things that basically come up in attach neck, so the nervous system. So if we inspect the mobility to the neck and allow it to move better, then that's gonna allow things to move better all the way down. And then also the muscles around the neck. So if the muscles are just basically really super tight, if everything is always on like this. And then that's also gonna add more compression and also affect the movement patterning of how you rotate or how you flex or how you extend your neck. And so that's gonna also affect what's happening all the way down with the nervous system and how you use those muscles.

So that mobility issue with the muscles and the joints and the nervous system. And then being able to get your core strength to stabilize all that. And so then that way we can now focus on the third thing, which is basically the functional strength. So really getting in there and mobilizing and increasing mobility is one of the first key things to start.

Mark: There you go. If you suspect or been told you've got arm pain and it's not going away because you're doing the right things to heal it, come into Insync Physio and get it looked at. It might be something else. It could be referred from your neck for instance. And this is pretty common. I'm guessing is that accurate Wil?. 

Wil: Yeah, it's actually very common. I can't give you the exact percentage, but our team, our physio team, we see it a lot. 

Mark: There you go, if you want experts helping you out. They can diagnose this and get you on the right path so that you're feeling better and can get back to your sports sooner rather than later. Insync Physio. You can book at insyncphysio.com or you can call the Vancouver office at (604) 566-9716 to book or in North Burnaby, (604) 298-4878. Get in there. Thanks Wil. 

Wil: Thanks Mark.

Vertigo from Vestibular Neuritis with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with the Iyad Salloum of Insync Physio in North Burnaby. He's the partner, he's the clinical director. And we're gonna talk about something that causes vertigo and dizziness for people that's a little bit different. How you doing Iyad? 

Iyad: Good Mark. How are you today?

Mark: Good. So big words, vestibular, neuritis, and labyrinthitis. What is this stuff? 

Iyad: Yeah, so the vestibular organ is kind of like an accelerometer in our inner ear. And what it does is it helps our brain figure out what our head's doing in space. So whenever we move our head, we get signals that go from the left ear and the right ear to our brain. And this is really important for us to maintain our balance. 

So the vestibular neuritis condition is when we get, usually we think it happens after a viral infection, as it's inflammation and swelling of the nerve. That swelling is pretty bad because it exerts just physical pressure too, on some of those cells. And you can actually get a bit of loss in function in those things. 

And then the labyrinthitis is, think of it as the bony house of the vestibular organ which is attached to our hearing organ. So you can get an inflammation of that whole thing. And it's the same idea, like you have an inflammation, swelling, and pressure, which can cause a disruption of those systems. 

And then from that, because usually it'll affect one side, it can affect both. But most commonly, we see it on one side. You'll see some people struggle with things like vertigo, dizziness, occasionally they get hearing symptoms or ringing in the ears. Those are pretty common too. Because of that, you'll have severe disruptions to balance and ability to function. 

Mark: So those are the symptoms. You mentioned viral things, is that the main cause? 

Iyad: That's what we suspect. Our best thought now is that you have a viral infection that affects those areas. And then the immune response that's associated can cause a bit of swelling in that area and inflammation of it. And that kind of can cause downstream losses of function. 

Mark: So if I'm feeling dizziness and vertigo and those sorts of things, is it my best course of action to just come and see you? Or is there a better plan? 

Iyad: That's a great question. Typically, what we see is people have been to their physician first because there's a lot of things that can cause dizziness and vertigo and another thing. And most people when they have it, because it happens so suddenly, might think they're having some kind of event in the brain. So think of potentially like a stroke. So we see the after effect of it. 

Obviously I encourage everybody who's having unexplained symptoms like this that are not just lasting in short periods of time, to consult their physician right away, just to make sure that it's just let's say, limited to the vestibular organ and not something bigger. But yes, we are able to kind of assess these. And if somebody requires more, let's say of a workup, we will send them to their physician when they come see. 

Mark: Well, it's it's can also be caused by the medication you're on too. If you're on certain heart medications, this is a side effect, is that right?

Iyad: Dizziness could be a side effect and maybe lightheadedness could be a side effect. However some things can cause vertigo. Yes. But typically we'll assess that in the history and we'll figure that out. Some medications are bad for your vestibular organ, but most of the time, the people we're talking about, it comes out of the blue.

Mark: So what's your typical treatment course that you're gonna put somebody on, once you've diagnosed this is what's going on. 

Iyad: So we would start by figuring out if their symptoms are mostly dizziness or vertigo related. We could help with things called the gay stability exercises to address that certain impairment. So we would figure out where is this deficit first? And then put 'em on a regimen of exercises. In some cases you can have somebody having BPPV on top of this. So we would also be able to figure that out, which is where you have one of the crystals being dislodged in the canals in the vestibular organ. That could be treated with a repositioning maneuver. 

It doesn't happen to everybody, but it's good to do a thorough assessment. And then we would also do a set of exercises to help them desensitize to things such as, usually get people saying whenever I tie my shoe and I come back up, I get burst of dizziness or I feel like I'm gonna fall. So those are things that we can address. And it's really functionally dependent on what they can and can't do. And that's where the program is very specific. So you'll almost never see two people with this condition get the same treatment because it affects us so, so, so differently. And it'll depend on lots of things. 

So for example, If you get this when you're younger, usually people don't have bad balance. Like generally when they're a bit younger. So if somebody let's say in their eighties, when they're already kind of struggling with balance and then like maybe vision and then a few other things, so you'll see a different treatment regimen for somebody like that.

Mark: If you're having some dizziness issues, vertigo, feeling like you're falling, the guys to see in North Burnaby are Insync Physio. You can book online at insyncphysio.com. They have two offices. You can reach the Burnaby office at (604) 298-4878. If you want to call somebody and book. Or in Vancouver at (604) 566-9716. Thanks Iyad. 

Iyad: Thanks Mark.

Do I Have Scoliosis

Mark: Hi, it's Mark from Remarkable Speaking here. I'm with Wil Seto of Insync Physio in Vancouver. One of Vancouver's best physiotherapy clinics, many time winners of best physios in Vancouver and we're going to talk about scoliosis. How you doing Wil? 

Wil: Hey, Mark. I'm doing well thanks. How about you?

Mark: Good. So scoliosis, now we were talking ahead of time and you mentioned a couple of things. Functional versus structural scoliosis. What's the difference? 

Wil: Yeah. So structural scoliosis is usually a type of scoliosis where the bones and the spine form unevenly. And that usually happens earlier on in childhood. And so it's something that you develop and as you become an adult, it kind of sticks with you. And so there's very noticeable curvatures that when you do certain tests, you look at whether it is a functional or a structural scoliosis. You can determine pretty quickly from that. And if you get to be more specific, then you can actually measure like, you know, technically the curvature in terms of how badly it is.

Versus a functional scoliosis, really is a deviation or a normal sort of curvature in the spine, this lateral curvature. And that can be a result of like an injury that you have, and then you have like muscle spasms and you can have things that are pulling on the spine, in the bony segments and it rotates it. And then in that rotation or in that process of the injury that you're going through in the healing process, then that can look like you have the scoliosis, but then when you do certain tests that evens it out and you can see that it's less structural and functional.

Mark: So how often do you see the difference, those specific differences when someone comes in with scoliosis? 

Wil: Yeah. I see a lot of the second part, which is the functional, where it's sort of this like the nerve muscle stuff going on, where it's just an imbalance. And those things are quite common especially if you've undergone an injury.

And I think that's really the hard thing to really understand from most people is when, you know, they may have seen another healthcare professional or someone else that's looking after them. Or they may have heard the term scoliosis. Or they may have a neighbour or friend that has had scoliosis and they've talked about it.

And then, you know, they feel like, Oh man, is that what I have? I feel like I'm crooked. And then they automatically think about, oh, maybe I have scoliosis. And without even really, you know, thinking more deeply or really trying to understand what that is, then, you know, that sticks in your head. And that functional part of the scoliosis, is definitely more common in an adult. Because like I was saying before with the structural scoliosis, you usually get it developed as a child and it becomes sort of a congenital thing where you're born with. And then you have that throughout your whole life.

Whereas if not just like, as an adult, one day you wake up and you're like, oh, I got this structural scoliosis. Unless you go through you know, a major accident where things happen and then you get some of the major degenerative changes happening in the spine as it ages, but it's actually quite less prevalent.

Mark: So you can treat both as a physio who specializes in some of these things, you can treat both of these to make them, less painful. Is that a good assumption? 

Wil: Yes. Yes, for sure. So essentially, you're looking at obviously localizing the pain and trying to manage that for both scenarios. Now, when it's something that's more structural, you want to really look at increasing the blood flow and blood supply to certain areas and getting the muscle strength where it's really imbalanced, when it's a structural thing going on. A lot more success, obviously, you know, when you it's functional. And you really correct those imbalances and you do things to facilitate the healing process of whatever's going on in there.

Mark: So you mentioned you had a client that came in that had a structural, but that you actually helped. Walk us through that, please. 

Wil: Yeah. So you know, with this specific client, I mean this person had actually an issue in childhood, something surgical procedure done. And basically as a result, as they got older, you know, like it caused a deformity into the lower segments of the spine, where it was more than a certain amount of degrees that you can still physically see. Caused a lot of muscle imbalance as a result of the surgical procedure. And to be more specific, it was like basically removal of a kidney.

And, and then over the years, this person's been really active, and really managing, you know, their problem but has had some back issues, now and again, but still being really active, like skier and runner and cyclist and all that stuff. So still able to do all those things at a very high recreational level. And at a level that the person really wants to enjoy. 

And so, you know, things that can happen over the course of the period, actually we've treated this person for all those things, is basically pinched nerve. Basically a strained back and then just like a shifting of the pelvis. And then pinching in the hip flexers and then sort of issues relating from the back that basically refer around in the hip. 

And so we want to just correct as much of the things that are going on that are really imbalance and pinching because we can still really unload a lot of those specific segments at the middle back or sort of the middle to lower back and the whole lower back area. Because that way it helps with more general movement mobility into those areas, which will allow more freer movement throughout the whole spinal segment, like basically from the neck all the way down to the pelvis and then even in the hips.

And as a result, then this person actually successfully has been able to get normalization and optimization of muscle control and muscle activation patterns to to be able to function, get back on his bike and to be able to work out and do CrossFit. And instead of like being able to just do like a burpee that looks really like what's going on in that burpee to like being able to actually do a full on range with the burpee, because now they've got more mobility and things aren't pinching anymore.

Mark: So other than accidents or a childhood illness or malformation of the spine, are there other possible causes of scoliosis? 

Wil: Yeah, and I think I talked about basically age related things. That's another factor and that's actually a huge part of it. And then like between in the growing years, you know, of like 11 to 18, even up to 20 years old, that can account up to 9% of the cases of scoliosis because they're still growing, then there may be sort of some of the scoliosis happening, but then it resolves after they finish growing. So then that is very treatable. 

I think in those growing years, that's also where we work with athletes, you know, where they're doing competitive sports, that we want to be a lot more cognizant of what they're doing to be able to maintain mobility and do recovery stuff, to be able to make sure that they're not imbalanced.

 I'll just giving you an example, a 16 year old and he was competitive rower and he was getting back pain. Had a little bit of scoliosis and we started to look at the imbalances. And over time we treated him for a couple years where he's like 19 now and he no longer has any more back pain.

Mark: So what can be the kind of course of treatment. The diagnosis sounds pretty complicated. You're looking at muscle function throughout all parts of the back, I'm sure and into extremities. Once you've diagnosed, whether it's functional or structural, what actions do you actually start getting people to do? And how long is it going to take? 

Wil: Yeah. So timeframe wise, it's a little bit harder to really say, you know, this is exactly when this is gonna get better. It's sort of a range. And then that's also considering that it's under a physical therapy or physiotherapy management sort of perspective. And in a physiotherapy perspective, you're also considering the possibility of using bracing. If it's a milder form of scoliosis with respect to the structural. And there's still things that you can do manually, you know, like segments that maybe are stuck and you need to do adjustment and manipulations to kinda get those moving. And that's important too. 

And then not just the joints, but manipulation of the soft tissue. Looking at what is tight and what's not. What's not moving properly. And then proper movement reeducation or proper muscle activation patterning, which is through exercise prescription. And that's really important. And then through that training, maybe using other modalities, like some muscle stimulation and to get these muscles going. Some taping to facilitate the activation of this, and then maybe like, I don't know, maybe like some insoles or whatnot to support the arches. Those are some things that we can do to influence the healing process and the rehab process of a person that is experiencing back pain. Upper, middle, or lower back pain because of scoliosis. 

Mark: And is it fair to say like, always, if you're feeling the pain don't rest and just wait for it to go away, get in, to see a physio sooner rather than later, because that will really accelerate your healing process.

Wil: Yeah, for sure, because there's other specific techniques and methods that can be used to help with the scoliosis. There's certain breathing exercises because we all know that in the mid back, if you breathe, then your rib cage expands and then it moves the vertebrae in certain ways.

And so just things that we can do, there's a lot of things that we can help with that will either, you know, lengthen the spine or get certain muscles moving and get certain joint facilitate a lot better. And then just having that education for you, having you become more aware of what things you can do at home.

Mark: If you've got some back pain and you're suspecting this, or you don't know, and you wanna find out, or you've been diagnosed and you wanna actually take some active participation in healing your back to the best that's possible. Get into see Insync Physio. You can reach them at insyncphysio.com, book online for either the Vancouver address or in North Burnaby. You can reach the Vancouver office at (604) 566-9716. Or you can book in Burnaby at (604) 298-4878. Thanks Wil. 

Wil: You're welcome Mark.

Wrist Injuries Rocking Climbing with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. And we're going to talk about wrist injuries from rock climbing. How you doing Wil?  

Wil: Hey, Mark. I'm doing well. Thanks. How about you? 

Mark: Good. So what kind of symptoms would someone have other than just pain? Like how do you hurt your wrist? I can see fingers, all kinds of things, but your wrist, rock climbing. 

Wil: Yeah. So, so the symptoms would be other than pain, would be like some swelling, obviously like you're saying, and then some loss in range, but also with this kind of injury, you can get some clicking in the wrist. So what I'm thinking more specifically is when you have the type of injury where you say, if you're rock climbing and bouldering, and you basically fall down and then you land with your hand outstretched and wrist extended kind of thing, to try and soften the blow of the fall. Then that can cause a strain into your cartilage and this side of your wrist, which is called the ulnar side.

And so that cartilage, that whole area is called the triangular fibrocartilage complex, TFCC for short. And so basically the reason why it's called that is because there's the cartilage and then you also have ligaments in your capsule in through there. And so it's a complex in the fact that they all work together to stabilize that area of the wrist.

And so in rope climbing or league climbing, or more specifically like what's called traditional climbing, you're doing a lot of crack climbing and hand jamming. You basically have over rotated wrists. So you can either basically over-pronate is what it's called, where you turn it that way and you jam it in a rock. And then you're like basically trying to hang all your weight off the wrist. So you can now imagine all the forces that are basically being put on the wrist in that motion. And then also the twisting where we may try and just do anything to hang on. So you can see how the wrist can also be injured in that area.

So those are very common ways of doing. And the other way is also when you're climbing, whether it's on a rope or bouldering or whatnot, and you're trying to like push up to a really hard move. And you're now once again, you're kind of pushing off and extending your wrist and putting pressure through that palm and that's called a mantling move. So you're just essentially trying to like push off this way and now you're super extended. 

Mark: Sort of like if you're climbing up onto a ledge and you're trying to mantle yourself up over that with all that pressure being right on your wrist. So one of those things, we don't really necessarily understand that the wrist is incredibly complex with all the bones, ligaments, tendons.

There's eight bones in there, plus all your metacarpals that make up your wrist. So we think of our shoulder as being complex, but you know, our wrists are actually possibly more complex. So putting all that pressure on there without training for it can be a really interesting situation. So how do you go about diagnosing what's actually going on and then what the course of treatment's going to be? What are the steps. 

Wil: Yeah. So with these type of injuries, these type of cartilage injuries in your wrist, there are a few specific tests. That will either rule it in or rule it out. And you don't want to just do one of them because you want to do a few of them to just sort of, you know, get sort of a battery of them. And then that'll give you a good idea. And also, you got to hear out what's the, okay yeah, I did this or I did that or I landed like this. And then you add that with a test and then you can sort of figure that out. 

And so the other important component that's missing here is that especially with so once again, I talked about this in previous podcasts or different videos where competition climbers tend to have less of those injuries versus climbers here are just more, you know, beginners or just avid, but don't really take care of their bodies or really look at trying to balance things out and be strong overall. And so why I bring that up as an important point is because if you climb a lot and you don't look at recovery, and you're really imbalanced and you're just always training, climb, training, climb, training, climb training. You're not doing other things. Then you can get really tight in your flexors and so those flexors, especially certain flexors that attach from your elbow, forearm all the way down to that wrist area. By that cartilage, that complex area, it can cause a lot more sort of compression strain already.

So even pre-loading before you even start climbing, you're already at a disadvantage. Now, because of that, then you go to like, you know, all of a sudden you have to like catch yourself, because you're going to fall or you have to do one of these maneuvers where you mantle or you have to like hyper pronate and hang and really tension that joint. Then you're already at a disadvantage because everything's more compressed. And now you're going to torque that cartilage complex area even more. 

And I see this quite a lot. And the other thing I found too, you know, you look at stuff that's going on in the neck and all the way down. Usually related. Usually there's stuff related to that. So that's why I say that with competition climbers, there tends to be less wrist type of stuff like that, you know? Beginner climbers, you go hard at it, and they fall a lot or they do those maneuvers and without a lot of muscle balance and recovery and looking at okay, you know, I got to train this part of my body a little bit more and having more balance in that way. 

Mark: So once I guess, get the swelling down, but then what's the typical course of treatment. Once you get the swelling down for somebody with this kind of injury?

Wil: Yeah. So you also want to consider, okay, what's the healing timeframe for something like this. Because that's important to look at, how well is this doing? So typically, these things can be minor and you can function and you can still keep climbing and it's not like, oh man, I can't climb ever again. Yeah you can. So four to six weeks, you should start to see some good improvement and it takes about that length of time for it to heal.

And so during those four to six weeks, what are we working on? Working on making sure that you increase your mobility. So you want to make sure that you get the mobility back in your wrist in all directions and also strength. So strength, you want to work on many different aspects of strength.

So there's three types of strength. So there's what's called isometric, concentric and eccentric. So isometric is when you develop strength, tensile strength in your muscle where that force of that muscle, it is tensioning up, but there is no lengthening of the muscle. There's no movement in the joint. A concentric force is basically when you're tensioning that muscle and then you're shortening the muscle and shortening the joint or flexing the joint or extending the joint. So the key is the shortening of the muscle versus isometric, there is no change in the length of muscle. Eccentric strength is the constant tension strength of the muscle while it's lengthening, whether it's inflection or extension in whatever movement. So you want to focus on all those different aspects of strength. And the last thing then is really focusing on your functional movement.

So for climbing, it's very functional for like these different types of holds that you start to need to be able to grasp again, you know, from crimper hold to pincher holds and to even like lock offs, and there's another term called gaston, where basically it's putting your wrist in a specific position.

So there's all these different type of positions in different holds in different ways that you want to start to build that functional strength. And here's the other key thing too. You want to do that building your core, building your, not just like your AB core strength, but also your lower extremity strength. Because research showed that when you start to work on your lower core, then you start to get more core strengthening in your upper extremities.

And you have more core strength in your scapular muscles, which is your shoulder blades. Then you're going to be relying less on your forearms all the time. And this is important in the rehab process. We don't really think about that in climbing, you know in volleyball it's a given because you got to run and jump and then hit. You get a wrist injury or shoulder injury yeah, you got to work on core. Seems more obvious. But in climbing, we don't really think about that as much. So we got to also focus on that. 

Mark: If you've had a wrist problem from climbing, the guys to see are Insync Physio. You can book online at insyncphysio.com. They have two locations to serve you. One in Vancouver on Cambie Street and King Edward, you can call them (604) 566-9716. Or in North Burnaby on Willingdon and Hastings (604) 298-4878. Get expert help from expert climbers so that you can get back doing the sport you love. Thanks Wil 

Wil: Thanks Mark.

Knee Injuries Rock Climbing wi Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physiotherapy in Vancouver. They're on Cambie Street and we're going to talk about knee injuries from rock climbing. How you doing Wil? 

Wil: I'm doing good. Thanks. 

Mark: So knee injuries, rock climbing. That doesn't make sense. How do you hurt your knees rock climbing? 

Wil: Yeah. So typically we injure our knees through like running sports mostly, and sports like Ultimate Frisbee, things that involve cutting. And quite commonly, you know, it's either a ligament or more specifically in what's called your meniscus. And so in rock climbing, the most common way to injure your knee and the structure that gets injured is the meniscus. And I'll explain to you what that is in a second. 

And so there are three ways of injuring it, really. Three main ways. So you're doing these maneuvers and essentially it's like now, when you look at the evolution of rock climbing, you have these moves that you make that are so much more dynamic, so much more involving the whole body.

And we're still used to training mostly just with our upper body. When you think of rock climbing, you think of just mostly upper body strength. And so when we don't have a strong, lower body and we're not tensioning through the lower extremity and through the knee in that way, then this is how we can injure the meniscus.

And so when we do things like what's called a heel hook where you bring you heel up high, and you're trying to use that as a lever to offload your upper extremities. Then basically what happens is that then you know, that can really injure meniscus and cause damage to there. 

Another maneuver is basically doing what's called a drop knee. And a drop me is basically when you're rotating, like you're, you're basically pivoting off of your toe, and you're internally rotating your hip in such a way where that rotation gets magnified in the knee. And if you don't have like a tension in that knee to hold it in, then it's a lot more wonky and wobbly, and then you tend to torsion it right at that meniscus. So if you can imagine that. 

And the third way is basically, as you imagine, when you're climbing, you're doing this maneuver called a high step. And so with high stepping, it's like bringing your, it's just basically exactly what it sounds. You're trying to bring your foot up high and then you're trying to reach and climb and you got your foot up high.

And at the same time, you're trying to push off that knee and balance yourself. But if you don't have the proper tension, once again, that that knee can get a little wobbly and cause some torsion on the outer edges of that meniscus. 

So what is a meniscus? So the meniscus is basically that spongy part that fits between the two bones between what's called your femur, your thighbone, and then your tibia, which is your lower leg bone. And it's provides protection in terms of a shock absorber. And it also provides stability in your knee. It's not like a cushion cushion, flat cushion per se, where it's like, you know, you absorb all the impact right in the middle. It's kind of more C shaped. So, what that means is that the outer edges and that's where it tends to get torsioned. So because of that sort of makeup of that meniscus, and when you don't have tension strength the knee holding it, then that's where you can really start to have that torsional strain on it.

Mark: So what kind of symptoms would someone have? What would lead them to, other than just it hurts? Are they going to have swelling? What's it going to look like?

Wil: Definitely. So swelling and obviously pain, but the loss of mobility, and one of the biggest ones would be like clicking and popping. Especially if you tear the meniscus and it gets caught in there. So the next step then is really looking, well, what do you do for it? So you always want to look at, you know, three main things really. Like you want to look at, okay, how do you regain your mobility? So there's things that you do for that. 

You know, and then strength, maybe number two. Okay. And then third thing is basically your functional movement. Now obviously proceeding all that, depending on how bad it is, if it's really swollen, the first thing that you do, you want to control that swelling. So there's things that you can do for that. 

But obviously you want to start to get the knee moving and that mobility is super, super important. And in terms of figuring out, okay, well, is this a meniscal injury or is this something else? Or is it like, you know, maybe like something else that that's not as sinister, like maybe just like an overuse sort of imbalanced thing.

So there's certain tests that we can actually perform on the knee. And usually you want to do a battery of them. So you don't want to just do one, you want to do a few of them to really test out whether or not it's a meniscal injury or even like, is it a really bad one, or if it's a minor. So you can sort of do that with some of these tests. 

Mark: So diagnosis, I imagine the history of how this happened becomes really important as a diagnosis tool to tell you okay, as an indicator of how bad it might be?

Wil: Yeah, usually, and it can sometimes present like a little worse and you don't really know until you go through that rehab process and doing the right things to work on those three things that I was talking about. Well, I guess four, if you add decreasing the swelling, and then mobility, and then strength, and then the functional movement. 

So typically that should take about six weeks, four to six weeks. If there is very, very little progress. In that four to six weeks, then I'd be wondering, Hmm, maybe we need to actually look at this a little bit further. And I would recommend a referral for you know, see your doctor and get some scans done. And especially if you're wanting to get back climbing and it's just not getting any better, you know, and it's hampering your lifestyle.

Mark: Yeah, swollen, hurt knee is going to limit a lot of things. Couldn't I just stop doing what I do, how I hurt myself, let the swelling go down and have it heal up. Isn't that going to make it better? 

Wil: You do want to actually have a period of time where you don't climb or do any activity, but then after you know, it settles down. It could be a couple days or maybe a week or something like that. And then you do want to get it moving though. So there is a process. There is a process to this rehab where you want initiate, where we'll help it get better. So you do want to start to get it moving in that way and that way you know, you're working towards that recovery. Working towards that rehab process.

Mark: And what about, you mentioned movement retraining. Is that basically okay. This is, if you have to do heel hooks, knee drops, high stepping, et cetera for your climbing. Here's how to do it properly. So you don't hurt yourself again, or at least lessen the chance that you're going to hurt yourself in the future. Is that part of the training that you're going to provide? 

Wil: Yeah, for sure. And I think the other important thing to add to this too, is that there is definitely some research that's showing that when your knee stronger or when you have more strength and conditioning in the lower extremity, then you don't tend to actually have as many injuries. And they've looked at a sample of a bunch of climbers where, I think like climbers who weren't in very good shape, or weren't very strong in their lower body, tend to have these kind of injuries more in their knees. 

And so I'm alluding to more competition climbers. Competition climbers tend to have more strength in their lower extremity in their conditioning. And because of that, you know, they use tension strength, tension forces appropriately, to protect their knee versus, climbers that are not as strong and don't have the same strength in their knee and their lower body. And then as a result, it doesn't stabilize the knee. And then that's where the injuries tend to happen a lot more. So that's, that's another huge part of it too. 

Mark: And what would be an example of the kind of strength training that someone would do? Just maybe just one exercise as an example. I don't imagine it's just going to the gym and doing squats. It's probably a little more complicated than that given how your body is being used while you're climbing. 

Wil: Yeah, for sure. So if you're rehabbing it from an acute injury. Then it's really getting certain things activated and then progressing through that sort of activation muscle pattern, of say your hamstrings with your glutes and that core.

So doing two-legged bridges or, or one-legged bridges, as a very simple, basic exercise. To progressing to doing things like a bridge on a ball with a hamstring curl. Those are just some examples kind to you know, throw right off the bat here. But then there's some other complicated things that you can start doing.

And the other aspect of it is what do you do in your warmup? So when you're climbing and you're about to get on a climb, whether it's like a roped climb, a lead climb or a bouldering climb, how are you warming up, like even your hamstrings properly? How are you warming up like your knee? How are you warming up your hip? And how are you engaging things in your core? Because those are all important things because we quite often forget that we think, oh, you know, this is mostly upper body warmup stuff, finger warmup stuff. 

Mark: If you've had a climbing injury, the guys to see are Insync Physio. You can reach them on their website to book at either location in Vancouver or in North Burnaby at insyncphysio.com. Or you can call. The Cambie location is at (604) 566-9716 to book. Or North Burnaby, (604) 298-4878. Get expert climbing help from expert climbers who can help you be back out there and climbing well. Thanks Wil.

Wil: Thanks Mark.

Carpal Tunnel Syndrome with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum. He's the clinical director at Insync Physio in North Burnaby. And we're going to talk about something fairly common, something that I have just learned that I had thought I had, but I didn't have, carpal tunnel syndrome. How are you doing Iyad?

Iyad: Good, how are you doing Mark? 

Mark: Good. So what is it? What is this thing? Carpal tunnel. 

Iyad: Yeah, that's a good question. Probably a good place to start. So most people with carpal tunnel syndrome or people who have been told or think they have carpal tunnel syndrome will present with symptoms along their hand, tends to be a little more kind of towards above the wrist and it'll effect, usually the palm area towards the thumb side.

So usually they'll tell you these three fingers and to go a little fuzzy or numb on occasion and it'll present for different reasons. So people tend to have like different jobs, maybe that involve a lot of wrist work or repetitive work, and they could present that way. We see it in the pregnant population actually, just because of the overall swelling that happens in the body.

So if you have a bit of swelling at the wrist, for example, you could have that. And there are potential also trauma. If you have an impact on that area where it affects the nerve that passes through the carpal tunnel, you can also get that. What it is is it tends to affect the nerve structures most of the time. 

You have a thing called the transverse carpal ligament that goes right through here, and it's really like, not stretchy. So the tissue tends to be very strong and you need it to be strong and rigid and right under there, you have your, your finger tendons that help you do all kinds of stuff with your hands. And then also you have like, you know, your blood supply and your nerve. And then the nerve kind of feeds this fleshy part in your thumb that helps you control your thumb.

So if somebody has had carpal tunnel for awhile, usually we'll see a bit of wasting here. If it's been a long, long time and it's gotten progressively worse. So that's one way we can kind of figure that out if it's been awhile. But in the kind of early onset, acute phase tends to be numbness or burning along this kind of distribution where the thumb, the index and the middle finger are affected.

And sometimes it goes to the ring as well, because there are people, people's differences. Now what it is, and sometimes where people really confuse it. And this is kind of, I guess, to go back to your point, because they say, oh, I have it in the backside of my hand that doesn't tend to be carpal tunnel. It doesn't really go there.

You know, we tend to look at something else because there are other tissue and nerves that can get affected. Or sometimes they'll tell you, yeah, it starts with the elbow and it goes all the way down, you know, where we're starting to probably suspect that there's something else. Even though it feels exactly like carpal tunnel, which is like, all my hand eventually goes numb.

But if it's not a little more restricted to the hand and the assessment will be like only positive on the hands assessment, I would tend to look elsewhere and try to see if there's another area where that nerve is getting sensitized and then giving the people symptom scenarios. 

Mark: So we've talked about the shoulder being a really complex joint, but the wrist is probably right up there with being in terms of all the bones. That even just in the wrist itself, let alone in your hand, et cetera. So there's a lot of stuff trying to glue that all together. 

Iyad: Yeah. Yeah, absolutely. So we have eight bones just in the wrist alone. They're very small called the carpals. And then we have our metacarpals, which are kind of these bones here. And then we have the phalanges which are the fingers. So, yeah, there's layers of muscles. So we have multiple layers. And that kind of layering systems, kind of get to know if you're trying to think of treatment and also trying to think of the movements that the person needs to be able to do with their hand and wrist.

So, yeah, it is complicated, but it also doesn't need to be, as far as treatment goes, like, you know, we will usually try to simplify it as much as possible. We need to make sure the person's able to move safely and normally as possible through that hand and wrist complex. 

Yeah, you're right in that sense, but we don't complicate it. You don't need to be as a patient wants to seek treatment, you don't need to be an expert on how the wrist biomechanics move to actually get that better. 

Mark: So when we're talking about causes, is it generally, or can we almost infer that it's almost always an overuse injury that causes metacarpal tunnel syndrome?

Iyad: I think so. For carpal tunnel syndrome, there are overuse based stuff. There are other things too. So I'd say there's different subsets. So there's the kind of, let's call it the more mechanical irritation group, where it would tend to be from overuse or impact or prolonged positioning in certain areas.

You have other causes, other things that could just sensitize your nerves. Like, so we talked about just, if you have overall swelling in your body, like usually we see this in a pregnancy, especially after second, third trimester, you know, times we'll see that. It doesn't mean it's gonna affect everybody. But if it does happen, you know, not to be too, too alarmed because we could do some treatment for that. 

And then like, obviously there are some conditions that will predispose you to having more nerve related issues. So think about like if you have somebody with diabetes, with diabetic neuropathy, it might present with these symptoms and they tend to start at the fingertips, work their way up and it affects the hands and feet primarily. But that's more of a systemic issue. 

So yeah, I think if we simplify it and say, it's just overuse, I think that's also being a little unfair because sometimes you get people coming in, they're like, I did nothing. I work like, I'm on the phone all day or I'm on this and I'm on that.

So this is where it's kind to useful for us to get a good, detailed history on how it started when they started noticing it. And also the pain pattern, because some people will just tell you, I get got at night. I don't get it any other time except at night. 

Like I had a patient to only got it when she falls, go to sleep and she would sleep like this on her wrist. So she imagined being here for six to eight hours without moving. So you could get that. But then there's the others who, again, look like they have carpal tunnel, but you assess everything. And you're like, there's a little more going on here. So most common one would be potentially an issue in the neck. Where you have sensitized nerves through here, but they feel it in the hand. So if we can change it from the neck, it's probably not carpal tunnel syndrome, even though it's carpal tunnel like.

Mark: So just a point of interest, the carpal tunnel really is that ligament around your wrist? 

Iyad: So there's a cavity under that ligament is the canal. But once you cover with the ligament, it's called the tunnel and you have the structures through it. So that's what it's referring to. And you know, usually people will tell you, yeah whenever I put any pressure here, I start to get symptoms. Again, that's not enough for us to just say, oh, it's only due to this because in some cases we don't have a lot of evidence on this but it happens. But if you have a nerve that's sensitive somewhere else, it could become a little easier for it to get irritated further down. 

So imagine if you have a neck issue at the beginning, that's contributing to this nerve. I'm going to be probably, based on just like our, some studies on animals, we don't have a lot of human data, that it could spread to other areas and it could make it easier for you to develop an issue further down the same line. 

But usually what we do with somebody like that is we will tend to treat both areas together, instead of just saying, oh, we're only going to do the wrist. We'll splint your wrist and we'll do all kinds of mobilizations to that and tendon sliding exercises and stuff. No, we'll tend to treat neck, shoulder, and wrist at the same time.

Mark: So diagnosis is fairly critical. Like always. 

Iyad: It is. It's just good to know, because I mean, I've had two patients now who have had confirmed electric conduction studies, when they actually study if the nerves conducting properly and they've confirmed carpal tunnel syndrome because of reduction in the conduction in the wrist, but they've never had anything else assessed.

They have the surgical release and yes, it helps potentially reduce their symptoms, but they're like, why is it not gone? And it tends to be because that nerve is probably sensitive somewhere else. So, you know, with those two people, we ended up, one of them, it was more somewhere in the neck. So we treat the neck, we gave them a neck and kind of a shoulder rehab program and it eliminated it completely. 

And the other person was a little more persistent. So we needed to do a lot more kind of overall change, I guess. So we had to change just the way they did things and teach them different movement strategies, and treat the neck, treat the shoulder with the mix of therapy and exercise and IMS and different kind of strategies to help them get out of that kind of vortex that they kind of get stuck in sometimes. 

So yeah, you would want to know what you're treating first, instead of here's the three thing to do for carpal tunnel syndrome, because you might have something that looks like it feels like it but probably isn't it.

Mark: And I'm sure there's a range of treatment. So what is that what's included in the range of treatment options that you provide people? 

Iyad: So most important is we try to identify, this is usually what I do in the first days. We'll try to identify what's actually provoking the symptoms. And we try to see if we can modify those stresses. So if it's with changing the way they do things, if it's basically with a mix of maybe bracing and some other exercises, we could do that. So I'll give you an example. I had a tennis player who had it, so we just had to teach them to hit the racket a little more like a tennis racket and a little less like a badminton racket where they would do an extra wrist flick at the end.

So that was a lot of what we did with them. And then there's other people where we would tend to so for example, my client who would sleep on their wrist. We're like, okay, how do we make them not sleep that way? We put them in an overnight brace to prevent that bending. So you got to just identify what's the potential trigger and maybe figure out ways to modify the stress on it.

So that's, I guess, what you could do from a, let's call it a reduction of stress, on the area. The other thing we could do, obviously there's tons of exercises that tend to help a lot here. So the exercise doesn't have to just hand specific. Let's say the tennis player, we'd work a lot on shoulder and upper back, so they can actually learn to swing through their body.

If you have somebody who has a stiff hand, the tendons don't move so well, so we mobilized those, in the planes that they need to move. So it tends to be a mix of that. And then obviously, we have our hands-on techniques where we can do sometimes some mobilizations in their just within their tolerance. And it tends to kind of help with pain relief and with improved range of motion. We just try to match the treatment to what's actually missing because whenever you hear the word syndrome after a condition, it doesn't mean that it's a specific singular contributor, just to kind of like a cluster of symptoms that get presented. So we try to figure out what's causing this here and kind of match the treatment to that. 

Mark: And treatment time range? 

Iyad: It all depends from, I guess, how long you've had it. Whether we can actually stop temporarily or modify the provocative factors, it'll depend on, for example, overall health. So if this person potentially has multiple co-morbidities, and then diabetes and these other things, obviously the recovery tends to be a bit slower, even if they're doing everything right.

So there's a lot of that goes into it. And then if you find it early and you intervene early, you're probably able to move on pretty quick versus if you wait, wait, wait. Until that sensitivity builds up to the point, we probably are looking at longer. So we've seen in clinic anywhere from four weeks to six months to a year, even sometimes. It just depends on the job.

So I'll give you an example of one person. We had a cashier who had this issue, so constantly scanning things. And we just had to change the way they did it, so it would be like move the whole shoulder instead of moving just the wrist. So it's really tough to throw a number on it.

But yeah, some people do really well without anything, which is also the funny part. And some people just persist even six months after the ground zero first day when they experienced symptoms. 

Mark: If you're experiencing any kind of numbness, pain in your hands, the guys to see are Insync Physio. Get experts diagnosing exactly what's going on so you can get it back on the path to recovery and health and feeling better. Insyncphysio.com is where you can book to see them. They have two offices, one in Vancouver at (604) 566-9716 or in North Burnaby, (604) 298-4878. Get, get in there. Get feeling better. Thanks Iyad. 

Iyad: Thanks Mark.

What is Carpal Tunnel Syndrome with Iyad Salloum

Mark: Hi, 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 specifically, what is carpal tunnel syndrome. How are you doing Iyad? 

Iyad: Good, Mark. How are you today? 

Mark: Good. So, what is it? 

Iyad: So yeah, carpal tunnel syndrome. It happens to be the most common type of entrapment neuropathy out there. It counts for about 90% we think of all neuropathies, because it's so prevalent in their population. And what it is, it's some form of compression of one of our nerves called a branch of the median nerve that feeds the thumb and of our first three or four fingers, depending on the person. So people will tend to come in presenting with varied symptoms, like tension, numbness, tingling, burning. I usually tell people it's kind of what you would feel when you'd hit your funny bone. Those kinds of symptoms, maybe a little less severe, but it tends to be a little more recurrent and debilitating for some people.

Mark: And what do people typically, if people come in and they think, okay, the back of my hand hurts or it hurts when I do this. Is that carpal tunnel? 

Iyad: So the back of the hand tends to be something else. We have another nerve that supplies the back of the hand. You could have something from the neck that affects both. And that's a different story. This position can compress the carpal tunnel, but then we would for us to have what we think is carpal tunnel, we'd have to have some sort of sensory symptom or even maybe a weakness of the thumb for in the palm area. So that's where we would assess because that's what the nerve that passes through the carpal tunnel will innervate and feed. So backside, you know, it could be related to something else, but it definitely wouldn't present that way with carpal tunnel syndrome.

Mark: And so, you hear it a lot about people using mousing and doing that, is that, are they getting it in here or are they getting in like more of the along, in the forearm? 

Iyad: So you could have stuff in the forearm because your nerves have to travel through here. So that same median nerve has to travel through the front of your forearm. So you could potentially get stuff there from repetitive work. For mousing again, on its own, like, I mean, there's a lot of people who can mouse and not have symptoms. And then there are some who just can't cope with it. So there's some individual variability. You can get that. But this is where I think us being very good at looking at where is this thing coming from?

Is really crucial because you have a lot of people who think they have carpal tunnel, but it's actually somewhere else in the forearm, in the neck and the shoulder, where the nerves is getting sensitized. And they just happened to feel a little extra in the hand. But if it's not kind of more limited to that hand and kind of isolated to testing that we do specifically in the hand. We wouldn't be able to just conclusively say that it's carpal tunnel syndrome because they could feel it there, but it's not coming from there.

Mark: Are there any instances where people are kind of in a specific position of some kind that will cause this carpal tunnel syndrome? 

Iyad: Yeah, you can have a lot of compression. So if you're kind of doing a lot of this, which stretches the transverse carpal ligament on the neural structures and the blood supply of the hand and wrist. You can get some of these sensations. Obviously getting tingling once isn't carpal tunnel syndrome. You would have to get this thing where the nerve and the tissue gets repeatedly sensitized, and then you develop a bit of a, let's call it like a lower threshold to, like you'd need a little less to kind of aggravate your symptoms. And then it comes to the point where it's day to day stuff. Some people will tell you like doing day-to-day stuff like brushing their teeth becomes tough sometimes and gripping and basic things like that.

Some yoga athletes that we've seen who are very, you know, dedicated and do this regularly and hold long, long positions. Yeah it's possible, definitely. But again, it's one of those things where just doing it once or feeling it once it doesn't necessarily mean that you're going to have, or that you have carpal tunnel syndrome, but it's definitely something that we would assess.

That's one of the key things we would look at is what is actually the provocative movement or movements and how do we change or offload that potentially as we take them through a treatment.

Mark: Carpal tunnel syndrome. If you need some expert help, the guys to see in Vancouver or in North Burnaby, are Insync Physio. You can book at insyncphysio.com. Either location. Or you can call them. Vancouver's (604) 566-9716. North Burnaby is (604) 298-4878. Get expert help on your hand issues. Thanks Iyad. 

Iyad: Thanks, Mark.

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