Rock Climbing Elbow injuries with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Phsyio in Vancouver. We're talking about elbow injuries today. How you doing Wil? 

Wil: I'm doing well. Thanks. Yeah. I wanna talk about elbow injuries and elbow pain with rock climbing. 

Mark: So is there something different about elbow injuries from rock climbing?

Wil: Yeah, well, I think one of the things that we need to appreciate, and our team of physios see this quite often with rock climbers that come into our clinic, is that rock climbers actually bear a lot more load in their arms when they're climbing. In terms of like the repetitiveness of it and also the power and the nature of climbing itself is quite stressful on the forearms. And so there's typically two types of overuse injuries that can occur. And they're very synonymous to the ones that are probably familiar and that are out there and basically the first one is what I like to call it climbers elbow.

And so climbers elbow is when you get like an overuse, to the inside of the forearm muscles. So those are the forearm flex. And as you can tell with climbing, there's a lot of this sort of motion where you're using those for our muscles. And it's important to identify that and I think quite often, like when we're climbing, your arms really burn right out and you really wanna attune yourself to how your arms feel at the end of each climbing session. And even the next day. Because sometimes we have hard climbing sessions where we're either training or we're just climbing for fun or whatever, but then they start to feel sore and they're like, Oh yeah, that was because I climbed really hard. But if it's still hard and usually if you just touch, then you'll start to feel the pain in there and that's not necessarily normal. 

And the other rock climbing elbow injury that you can get is basically on the outside. So that's on the extensor part. So quite commonly, the inside one is called golfers elbow, that we all know about. And then the outside one is tennis elbow. And so the reason why both of these can happen with climbers is because when you're climbing there's a lot of like, so with the gripping, but then if there's also different types of holds that you're using. So if you're using holds that are larger and there's all of the antagonists, all those opposing movements. And so that can get overused. And we see this quite a bit. 

And I think the biggest thing with rock climbers in terms of preventing these from happening is really looking at warmups, doing a proper warmup. And really not jumping back into climbing if you've taken a lot of time off. Or if you're a beginner climber, trying to pace yourself at the beginning, because we see this a lot with beginner climbers, where they jump into the sport and they climb way too much.

And then part of that too is then learning how to recover. Understanding what recovery is because and once again we see this quite a bit too. We see either beginner climbers or climbers that have taken some time off and they jump right back into it and they don't start to incorporate recovery into their training, into their climbing sessions. So recovery means looking at doing things to, you know self release, mobilize and get things moving and really like allowing it to rest as well. 

If you have a climbing session in the morning, or you do a climbing session at night and you go to do your computer job, that's a lot of repetitive strain. So that means you have to take extra care and time to focus on mobilizing and getting things working in terms of the movement and blood flow and all that stuff after your climbing session.

Mark: If you're having elbow pain from your climbing sessions, don't just ignore it. Don't just tough it out. Get in and see some experts about what's going on to see if there's help that you can get to train properly, to recover properly, to make sure that you're not getting that repetitive stress type of injury that will affect your climbing for a long time. is where you can book for either the Vancouver office or North Burnaby. You can call them at (604) 566-9716 in Vancouver or in Burnaby (604) 298-4878. Thanks Wil. 

Wil: You bet. Thanks Mark.

Wrist Pain Cartilage Injuries with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physiotherapy in Vancouver. They're sports physiotherapy experts. And we're gonna talk today about wrist pain and cartilage injuries in your wrist. How you doing Wil? 

Wil: Hey, I'm doing good, thanks Mark. 

Mark: What's going on with this kind of stuff in your wrist? I got such a sore wrist, man. 

Wil: Yeah. I wanted to actually touch base on this because it seems to be something that's also more prevalent with a lot of rock climbers. And we treat a lot of rock climbers in our clinic and myself being a rock climber. And I have a lot of friends at rock climb that quite often you know, end up injuring this part of the wrist and they'll have the wrist pain and then it goes away and it's sometimes undiagnosed.

But the recovery of the type of injury is quite good. So basically, what we're talking about specifically is the cartilage portion on this side of the wrist and the cartilage, it's actually more accurately called the triangular fibrocartilage complex. So in the abbreviated form, we call it the TFCC or EFCC injuries, the triangular fibrocartilage injuries, or cartilage complex injury.

And the reason why we call it that is because it's made up of the cartilage, the ligaments and the capital, and then there's also the bony structures in there that houses it that actually impact it quite a bit as well.

And so quite often with rock climbing, it totally fits that presentation in terms of the mechanisms of injury. But like, I'll talk about a little bit about the presentation of the type of injury as well. And mostly like I was saying, the complaint of the symptoms are usually on this side and it gets worse when you're moving it or going back into climbing and trying to stress it.

There may also may be like weakness in that whole hand, in the grip strength and it'll click maybe. And there might even be some instability in the wrist. Some actual instability and perceived instability. It's usually directly related to some kind of trauma. So like with rock climbing, you know, it's that hyper extension sort of like if they're like mantling and pushing off in a really, really extended wrist position and trying to push off, they might injure that part of the cartilage.

Or if they're doing a hand jam or you're doing like jamming into a crack, but then you're like, not just jamming like this, but then you're like this, and now you're putting all your weight on that wrist now. So that's another way of injuring it. Give you some other examples from like you know, baseball or whatever.

Like you're trying to throw the ball and you end up cocking it or you're doing like a certain throw and then you flick it or whatever, and you hyper extend and put too much compression on the side of the joint that can cause it to basically compress. If you injure the ligament in there too, because then it's infinitely connected with that cartilage area. 

The other thing that actually is interesting is on a sort of more structural level so you have two bones that make up the forearm. And the inside bone is called the ulna, and that ulna bone, basically what the ulna and the other bone here called the radius.

They both connect to your wrist bones, you have eight muscles that make up wrist bones, and they kind of basically go in two rows. Like the first row is four and then another row four on top kind of thing. And so typically, if there is a change in the anatomical length of your ulna bone, then that can also add more compression, it'll put a little change, how your wrist can move physiologically. And so that's another thing to look for too. So they call that in a physiological term, like a positive ulna variance. 

And stuff like gymnastics, you know, a lot of impact, you know, you're doing all these flips and stuff like that where you land and you're compressing. So that's another way of injuring it. So usually you feel like it gets inflamed. You know, it feels really inflamed in there. And some people can experience it like, oh, maybe I got tendonitis. So anything that's involved in gymnastics, you're on those bars. 

Or you're doing anything where you're like repetitively, like say you're carpenter. It's that competitive where, oh, you start to feel pain in there and they think it's a tendonitis and you could often misdiagnose it as just a wrist overuse or a wrist, like a ligament sprain. But you know, it's usually a little bit more involved. 

Mark: So diagnosing this, what are the steps to kind of narrow it down to what exactly is going on?

Wil: Yeah. So there's a couple of really specific tests that you can do for the TFCC. You can do what's called a compression test. Where you have the arm in a certain position and then you try and move basically the ulna, like basically relative to the little wrist bone in here called the pisiform to see if it actually produces any symptoms. So that's like a compressions test and we can do other stress testing on that TFCC. The triangular fibrocartilage complex. By applying that force through that ulna bone. 

You can do other rotational tests. We call the supination test and whatnot, and basically grabbing the underneath side of the table. You can do a little home test where you rotate, that's called supination, and then grab the under side of the table and that load of just doing that, if that causes pain in there, then that may be an indication that you have some kind of tear or pathology in that TFCC. 

There's also another test where you look at, so this is kind of like a more growth instability, which is called a piano key test where you try to press the hands on the table. And then as you're pressing the hands, if that ulna bone that I talked about on this side, if it pops up, then like, oh, there's something going on there. And then if there's instability plus positive symptoms, then that's another indication of a positive test. 

And then there's like other tech where you're just compressing, grinding the radial portion and the ulna portion where you're just trying to really reproduce the symptoms of that TFCC. So if there's a tear in there and you're grinding and may indicate that yeah, there's something going on, but maybe degenerative process or something like. 

Mark: So what's the typical course of treatment once you've narrowed down to what's going on? 

Wil: Yeah, so it's it's something that's really rehabitable. So it's really good with rehabilitation. Prognosis is usually really good. Especially with minor ones. We've seen some success with definitely more mild ones. And then where, you know, you get into for more of the extreme ones where people can't even like, it's really swollen and an acute injury. And it's looking you know, probability of it being really high that it's TFCC injury. Then as we get the swelling down, then you know, on some of these more rare cases, or I guess on the lower percentages where it's more serious than maybe getting medical intervention where surgery may be an option. To repair it, to debride it or to do something if it's like a physiological thing, then doing something with the bone. It is a very good success in terms of the actual surgical procedure as well. 

The rehab is also very, very successful. It is a bit length when you're looking at considerative treatment because of it being a cartilage tear and the fact that you're using your hands all the time and also the nature of the injury. And especially if it's something that's causing a lot of swelling in there. Because usually if there's swelling and especially if there's any kind of bruising and bleeding from the trauma, then it usually indicates that there's a little bit more soft tissue injury involved. 

So really let me just sum up. Basically, number one, you really wanna look at being able to immobilize it for the first week, if it's any kind of injury that has swelling and is more than just mild because you need to really give it a chance to heal and let the swelling settle down.

Getting a brace for it would be really helpful to not use it because you really wanna just let that settle right down. That's super important. So no using it. No playing sports with it. And once it's settled down for maybe even two weeks or three weeks, then you can start to you know, do a functional splint where you're now able to do some stuff. And then maybe at this point you start to actually work on the range, start to work on the strength. 

If it's more mild, then you might not even need a splint or a brace at all from the get go. And we want to address the mobility right away. We wanna address the strength issue right away. We do a lot of things to activate the core of wrist. Just like in the neck and your lower back, you have core stability muscles of your wrist. So you wanna work on these muscles that help rotate your arm and stabilize the wrist. 

Now here's been a really interesting thing that a lot of people don't really realize when you have an injury in there because there's tendon attachments down into that wrist area. And this is why people quite often think that it may be a tendonitis or an overuse injury, or it gets misdiagnosed as an overuse injury, because what happens is that we get really tight too. But then if we actually accurately diagnose it and look at well, what is the true cause of your wrist pain? And we figure it's that, you can still have this adjacent or this combined tightness into your forearms because of its intimate connection with that wrist joint and TFCC. 

So what can happen is that you may not actually have a dysfunction in this forearm muscle or the forearm muscles, there's more than one here. Like your flexor carpi ulnaris muscle, for example, or your flexor digitorum superficialis or the flexor digitorum profundus. So these are just some of the muscles I'm naming here that are getting more specific here, that can be involving it really tight. Now why I'm mentioning this is because if that gets really tight, especially that one that's connected to the wrist, then it can cause more compression.

Then it can actually impact the healing and the rehab of that wrist injury of the TFCC. So then what that means is that we have to address the tightness here, to allow this to decompress, give it more space, more of a chance to work on that mobility because when things start to compress, then it's just gonna irritate that a little bit more. So that's another thing to consider. 

Another thing to consider too, is what caused all that to begin with? Why did you have to start to hyper extend like with whatever sport, activity that you're doing. If you're a carpenter, are you getting issues in your neck and shoulder that is causing you to really get into the hyper ulnar deviation, is the motion right? That then you can't bring your shoulder right up because maybe there's an existing shoulder issue that was never really addressed by yourself or by even acknowledging that there's something there going on maybe. So those kind of things, to really take into consideration. 

Mark: How's your wrist really? If it's hurting, get into Insync Physio. They can help you. You can reach them at their website They have two offices to serve you .One in Vancouver, one in North Burnaby. You can call them the Cambie office is at (604) 566-9716 to book or in North Burnaby, (604) 298-4878. Get expert help for your wrist pain. It can heal. So get in there and get some help. Thanks Wil. 

Wil: You bet, Mark. Thank you.

Hip Pain Cartilage Injuries with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. He's the head clinician, the expert, the guy many time voted best physiotherapist in Vancouver. Of course his clinic has also been voted the best physiotherapy clinic a number of times. And we're gonna talk about hip pain today. How you doing Wil? 

Wil: Hey, I'm doing well, thanks Mark. Yeah, hip pain. More specifically cartilage related type of hip pain. 

Mark: So what kind of symptoms, I mean, it's pain in your hip, but how would you know that it's the cartilage versus arthritis or a growth in your hip or, or? 

Wil: Yeah, no, those are good questions. So the technical term, when we talk about the cartilage in the hip we refer to it as the labrum. So quite often, if you get an injury or a tear in the cartilage of your hip, we call it a labral tear. And you're right about like how do you know that it's not like a tumor because it could be right. And that's one of the causes and actually. 

I'm glad that you actually brought that up because we had a patient that came in to see one of our physios, this is a while back now, a few years ago. And he was having hip pain that just wouldn't go away. And these are the kind of things you wanna look for, like there was no trauma and he didn't do any sports or any exercise in particular that brought this on. And I remember one of our physios who was treating him, you know, was telling me about him. And he brought me in to kind of take a look at it and and I was like, yeah, like, this is interesting. It's strange. Because there was no real mechanism of injury, number one. And when I say that, there was no trauma and there was no like acute trauma and there was no like repetitive type of trauma and there was no incident. And so we said, you know, go see your doctor and get some scans and get it checked out.

So he did that and it turned out that he ended up having a tumor, the size of a baseball in his hip. And so I'm glad that you brought that up. So it could be that, but I mean that was very rare, like that happens probably less than 1% of all hip pain and these type of cartilage type of errors that we see.

But that's what we thought it was initially because it was acting a lot like a cartilage tear, like a labral tear. And you know, we get the classic symptoms of it catching and clicking but you can imagine finding a tumor the size of the baseball, of course, things are gonna pinch in there. You know, of course things are gonna not move right in there. 

So some of the other symptoms, if there is more of a tear in the labrum, that cartilage portion, then there'd be specific movements that cause it like if you ended up getting in a car accident. And that can cause sort of the shearing force and you're already in this you know, flex position or something like that, and it can damage sort of the back top side versus the posterior superior portion of that labrum. Or if you're in a hyperflex position, if you're just doing a lot of stair climbing and for some reason the stats show that the Asian population tend to have a lot more of that.

I don't know if it's because you know, they tend to squat more or something like that. So doesn't have to be an acute trauma. It can mean it's sort of this repetitive thing. And so they found that they have more of that tearing on that posterior superior side. But then they also found that the highest incidences seem to be related to kind of more in the anterior superior, which is on the front top part of that hip labrum. And so anything that involves twisting compression, in terms of the mechanism of an injury. 

So on a repetitive and on longer sort of chronic scale and maybe even things like, okay, let's say I do a lot of training and I suddenly add stairs to it. And then I just start to feel a little bit of a low grade ache and that builds. So it can start up as a small injury, a small tear and start to build into a bigger tear and then escalating into a bigger one and then causes a lot more symptoms and eventually dysfunction where you can't even walk. And so you experience pain whenever you try to run and even walk and even just standing. And even bringing up your knee in hip flexion, try to put on your pants, put on your socks. 

We have a couple physios that are seeing a couple of patients that have that exact problem right now. An older gentleman that came in, very active, likes to swim. Took some time off. Didn't feel comfortable going in the pool during this whole pandemic. It's been a long stretch. Went back in January for the first time in like, you know, year and a half or whatever. And started swimming four days a week. And it was actually kind of a funny injury. He tried to, you know, prop himself out of the pool, like mantling pulling out of the pool and put his right hip into this hyper hip flexion and tried to get himself outta the pool with his leg up. Felt a little tweak. He thought he just pulled the muscle kind of went away. 

So this is sort of how it starts. It went away and then he tried to do the same thing again the following week. And then it got worse and felt even sharper. And then it started clicking more. We haven't sent them in for scans yet, but our physio team sees a lot of this.

And what ends up happening is that you know, for quite a majority of them, there's stuff going on in the labrum, at the cartilage area. That's usually the presentation. There's some kind of trauma, whether it's like an acute type of trauma or some kind of micro trauma or repetitive type of trauma. 

And another cause is if you have like, so related to trauma, let's say you injure the hip and you don't injure the cartilage and you have a hyper mobility. So there's all the laxity in there. Or maybe a little bit of laxity. And because of that, then it's more unstable. And then the hip joint, so you have sort of like, it's a ball and socket, and so what ends up happening is that ball portion, because more unstable, then as you twist and turn in a ball and socket type of joint, then it can cause some injury in that hip, if it's more unstable. 

If there's a lot of multiple imbalances, like we were talking before then yeah you add that to the mix. Then that can cause more compression. And then you go to try and get into the range that you're used to for flexion or extension. Then you will tear that labrum. 

So there's also certain conditions that you're born with. Let's say you have what's called, like when you're a child, you have certain diseases in the hip where it's just more lack or congenital hip dysplasia where you know, when you're born, your hip kind of gets dislocated and gets put back in. That can be something of an issue that can cause a type of labral tears.

But there's also like the degeneration component, like as you get older, it's just tends to wear a little bit more and you're more prone to having it wear out. If you have other preexisting injuries to maybe your back or, you know, things that are related to the function of your hip.

Obviously we know how the back is really connected with that hip. So if you've had, you know, certain back issues or certain back conditions and that can affect the hip and usually the symptoms are right in your hip joints from the front. We call that the anterior right to the lateral, and it feels like it's deep inside and it feels like there could be like a locking and catching type of pain. And it can be from like a constant diffuse ache to a sharper type of pain sensation in there. And usually that will progress a little bit more as that degeneration occurs more and more. 

Mark: So what kind of things do you do to diagnose this? 

Wil: Well, it's kind of tough to actually say that it's a labral tear, but we can always say that it's like probability that it is. And there's certain things that we do in our examination procedures to look at it's the probability is likely that it's this, based on these different tests that we're doing. And quite often people will think, oh, like when they have this especially in the initial stages, that they might have pulled the hip muscle.

And so we obviously wanna rule out any of the muscles if they've been sprained. And then we also check out whether or not if there's a hyper mobility or instability natural joint. Because like I said earlier, like that laxity and that hyper mobility can play a factor in this.

And then sometimes there's like, there's a condition called Ehlers Danlos syndrome where you're just sort of locked through all the ligaments in your body and not just ligaments, but through other parts of your body that can also lead to issues with the labrum. And some people have gone on living into like, you know, their fourth or fifth decade of their life, not knowing that even had Ehlers Danlos syndrome. So it can be mild to more severe.

And so these are things that you do specific testing, you go back to the doctor, but you know, it's sort of these genetic markers that you look for that can add to that. So these are all things to consider. 

Mark: And how bad does it get to be before you are, or when's it the best course of action, is to refer someone to the doctor for scans and whatever treatment the medical doctor might provide. 

Wil: Yeah. So basically, we are seeing patients sort of like first line. So what that means is that we see them before they've even gone to the doctor, quite often. We have about like 25% of the patients that will see a doctor first because you know, they're not really sure. And they go to their family physicians who they trust. But usually we see them first and we'll diagnose it or we'll look at what's going on based on the tests.

And then we wanna treat that. And we wanna treat it, especially if we think it's an orthopedic thing. If there's other sort of signs that if it's really obvious, like, oh, that sounds like it might be something more going on on that initial assessment. Then we will refer you back to see your doctor and to get more testing done. Because I think that it's important to work with your family physician to really solve and get at the root cause of your aches and pains of what's going on in your hip. Because there could be more going on. 

Even though we may be suspecting that it could be like a possible labral thing, but if there's other things going on, like there's unrelenting pain. And pain that's like a 10 outta 10 without any relief with any kind of positioning or movements, you know like there should be some kind of relief, if it's biomechanical issue. Unless it was just a fresh injury. 

So those are really sort of warning signs right away like if it was like a gradual thing, like there was no true mechanism of injury. But they're having this 10 outta 10 or 12 outta 10 pain. That's a huge warning sign that something else might be going on. And especially like, there's no lead up to this. 

Mark: And let's say it's not that bad, and so you're moving forward with treatment. What is a typical course of treatment? 

Wil: Yeah, really addressing if there's a hyper mobility or instability, stabilizing the joint. And that also means that looking at okay, well what's imbalanced. Because usually if there's instability, there's also an imbalance in the muscles, but let's say if there's no instability, we wanna look at what's not working properly.

So we want to start to address the movement to function. So quite often the hip flexors are super tight and not functioning properly and they're not allowing the extension mechanism to work properly. But it becomes a bit of a dilemma because let's say like I was saying earlier that it's the anterior top portion, which is the anterior superior portion of that cartilage that usually gets damaged.

And usually what happens is, it's a hyperextension compression type of injury. But then quite often you need to activate those muscles in that range. Like your glutes, because they're not activating properly. So then what happens is we gotta start to address the movement function of it. So we have to look at how do we get your hip moving better without aggravating it?

Because even the act of getting it moving, if we produce pain, that's gonna shut everything down because pain will also cause things to not work properly. Swelling will also cause things not to work properly. So we wanna address those things. We wanna settle it down, if it's acute. Take the swelling down. Do whatever it takes for that part of it.

And then now we wanna start addressing okay, the mobility issues. And then we can start addressing the strength issues and then kind of doing that together maybe. And then the functional mobility. So now we've gotta work on the core aspect in getting what is overactivated and what is underactivated.

And then part of that is addressing, okay, well can we walk on this now? Can we go upstairs? Can we even just put on your pants? Can we even put on your socks first thing in the morning? So those kinds of things.

Mark: Does it change when someone's had a hip replacement?

Wil: So that's a good question because slightly different. It does change because there's a lot of positions that you want to avoid. And when you have a hip replacement you essentially have like automatic instability. And so usually with the hip replacement, the cartilage is all worn out. So there is no cartilage. And so you're not really looking at rehabilitating the hip with respect to a torn cartilage that you're trying to maintain and keep intact. Cause now there's basically no cartilage there. And now you're just replacing it with a total new hip or partial hip or whatever you decide to choose. And now you're looking at strengthening and trying to maximize function and avoiding certain positions and letting the postoperative part of it heal first.

Mark: So if you're having hip pain, the guys to see are Insync Physio. You can reach them on their website at You can book for either office. You can call the Cambie office at (604) 566-9716. Or the North Burnaby office, you can reach them at (604) 298-4878. Get in there, find out what's going on with your hip, and if there's more going on, then they can look after it, they'll refer you to your doctor. Or they'll get you started on the path of recovery and get your hip working properly again. Thanks Wil.

Wil: Yeah, you bet, Mark.

Radiculopathy with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with the Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. And we're gonna talk about radiculopathy, which is as funny name for when you have pins and needles in your shoulder. Maybe going down your arm, even a dull ache in your arm, and it's coming from your neck. What the heck is going on Iyad? 

Iyad: Yeah, radiculopathy, it's a bit of a mouthful and a lot of people use different terms to describe it. That's the medical term. The general population sometimes calls it a pinched nerve, which might or might not be accurate because nerves get sore for lots of reasons beyond just pinching.

So, basically people with this present with, usually we tend to see them quite acutely in the clinic. Either in physician's offices or in physio practices, if they've had this before, so they'll kinda come to us directly. And it presents with them being, you know, suddenly over like a very short time, being unable to move their head and neck because of quite intense pain.

And they report sometimes that the pain's actually worse in the arm and in the shoulder blade, then it is in the actual neck. But they can't move so well. They get fuzzy sensations in their arm. And then one of the things that we are trying to look for in the clinic is to try to figure out, does this person actually have just a sore nerve, let's say a nerve that's quite sensitive or is it something that actually has a bit of loss of conduction?

Because you can actually impact the nerve to a point where you lose a bit of its ability to send electricity through. So we would do a pretty thorough assessment with these and try to figure out what we're dealing with. But yeah, pins and needles is a common complaint. You sometimes can get dull aching. You can sometimes get burning sensations. Some people tell you, I feel like I've just left the dentist here. You know, like it's kind of completely numb. So it depends, I guess, on what nerve from the neck has been sensitized or affected. And then, you know, that kind of can manifest in a multitude of ways for symptoms.

Mark: What causes this? 

Iyad: So lots of different things. You can have a cumulative, it's like a bunch of stuff can actually make a nerve sore. So for example, your general health is quite significant here. And your overall kind of I guess overall health is quite significant. And in determining whether you develop symptoms or not.

So give an example, somebody who is potentially like a longtime diabetic with type two diabetes can have an easier time to kind of synthesize the nerve because of that condition. Meanwhile, somebody else who might not have that might need a bit more, let's say of an attack on that system before they can kind of experience symptoms or loss of function.

So most of the time it tends to be either chemical irritation from inflammation in the neck or a direct pressure. So it could be things like disc bulge, could be a bunch of other things that could just kind of directly put pressure on it. So the compression can happen and that can cause symptoms.

And there are other less understood things like, let's say gradual narrowing of the spaces in the spine that seem to sometimes matter. And sometimes don't matter at all. And that's kind of where it's a bit confusing. If we just follow, for example, x-rays to diagnose this and MRIs because lots of people have these abnormal findings and have completely fine necks and no arm pain or loss of function.

So it really seems to be an unnecessarily complicated area, but the diagnosis tends to be a mix of clinical, which is basically what we would assess in clinic. And we do a physical exam along with sometimes we would do something called a nerve conduction study where our physician colleagues would trying to figure out which areas specifically is affected by testing how well that nerve is conducting electricity. And usually we would do that when we were expecting some kind of loss of function in that system.

Mark: And would this be from sleeping wrong? Would this be from picking up somebody the wrong way, like your grandkids?

Iyad: I think that would be an oversimplification to say that one can cause it, you know, these things tend to happen gradually over a long period of time. And then, you know, just because something happened, let's say the one night you slept wrong or like the time you picked up your grandkid and they kind of kicked out at you, doesn't mean that specific thing was caused. But yeah, it seems to be kind of a gradual process over time. And then eventually you become aware of it and some people go on to develop really debilitating symptoms and other people somehow can shrug it off quite easily and never really even know that something's there. Even when we scan them and we see something, and then they say, Hey, I've never had neck pain. 

So that's usually what happens, but if it's progressed to the point where we're getting symptoms down the arm, usually yeah, most people will kind of report that it's been happening, you know, in the last week or so. And it's just kinda started outta the blue. That's most of the time. I've had somebody who said one time, they were reaching over to their phone to turn off their alarm and then they felt this. So I'm pretty sure that they've done that every day for the last 20 years as a working professional and it can't be that this one time was the one that they did it wrong. So it's kind of happens. 

And that's probably the most confusing part of these injuries is that you're kind of wondering why did this happen? It just seems to happen over time from an accumulation probably of stresses on the body. 

Mark: What's a typical course of treat? 

Iyad: Great question. So, first thing we wanna do is figure out what we're dealing with. So if you're dealing primarily with a painful nerve versus an actual nerve that's lost function, we would kind of do things a bit differently but not also that differently. So if a nerves lost function, we wanna kind of monitor for any other signs that we would warrant a referral out.

We just wanna make sure that that person is progressing in the right direction and not kind of losing more function. If somebody has, let's say a painful condition only where we assess the conduction ability and they'll have normal strength, they have a little more sensitivity in the skin where the area's hurting, but everything else seems to be fine. The reflexes are fine. We would treat them with a multitude of things. We have lots of things that we could do. Our most important thing seems to be at this point is just telling them what to do at home, because it can take quite a bit of time for it to resolve fully. But if you know how to control certain symptoms and to actually move through some things and maybe avoid certain things for a temporary period of time, you do a lot better.

So that's what we would do on the education side. Try to identify those provocative movements, the things that feel good and getting people to just stay, you know, as active as they can be to help the healing. The other thing is, we would counsel them on, like, for example, sleeping positions and things like that.

Those are all really important because if you're not sleeping, you could do everything right. And that's gonna just basically be the equivalent of running to stay healthy and then smoking a pack of cigarettes after, it's just gonna cancel each other out kind of thing. And then we would do a bunch of stuff in the clinic.

So we have lots of tools from manual therapy. We would do anything from mobilizations on the neck to help desensitize it. There's nerve mobilization that can also desensitized nerve. And then we also can work on the affected soft tissues. We could do certain taping, embracing that can actually help certain things.

Again, it would just depend on what area and how bad their symptoms are in the beginning. And maybe if it's just that thing in isolation, or if they have five other things going on, that would probably change the course of treatment. But that's kind of the stuff we would do. And it would take, usually most people will see kind of a bit of an improvement after first four to six weeks, but then the full recovery process can be quite a bit longer.

And that's something that's really important for people to know. Because sometimes they think they're not recovering if it takes them three to six months. But that's actually what a typical recovery can be sometimes. It's just the body needs time to adapt back to normal. 

And I guess I'll give you an example, if you are wanting to go back to wrestling, as a sport versus wanting to go back just to walking your dog every day. I think your recovery's gonna be quite different. We'd need to build you up a lot more if we want you to be able to handle the stresses of wrestling versus just walking around the block a few times. So all of that stuff kind of factors into the planning of the treatment and the timelines and all that stuff.

Mark: So if you want some expert treatment, if you've been diagnosed or feel like you have some issues with radiculopathy or numbness, burning pain, pins and needles in your shoulder and arm and you want to get back to jumping off the top rope and giving the people's elbow to people. The guys to see are Insync Physio in North Burnaby. You can reach them at their website, Or you can call in book (604) 566-9716 is the Cambie office. Burnaby is (604) 298-4878. You have to call and book ahead. They're always busy. Thanks Iyad. 

Iyad: Thank you.

Vestibular Migraine with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum, he's the clinical director of Insync Physio in North Burnaby. And we're gonna talk about vestibular migraines. Wow, big words. What does this mean Iyad? 

Iyad: Yeah. Hi Mark. First of all, thanks for doing this. Yeah, so we've been seeing quite a few of these more recently. A lot of them don't know that those headaches are migraines because I think the word migraine's so commonly used, you know, people say, oh, I had a headache, but it's not a migraine. Oh, I have a headache and it's a migraine. A migraine isn't necessarily just a severe headache, but it also has to follow certain kind of criteria.

So usually in those cases, people suffer from, you know, diagnosable migraines, and then those migraines seem to have an additional kind of cluster of symptoms, which involve a bit of dizziness, a bit of vertigo. And you know, identifying those things is probably the first most important step. And we see a lot of people kind struggle with that.

Before the migraines, you know, from our physician colleagues, we tend to create a program that helps address any of the vestibular impairments that have created from the migraine. 

Mark: So I guess the obvious thing would be you've got a headache. The symptoms would be you've got a headache, but you are feeling vertigo. What's the difference between dizzy and vertigo?

Iyad: That's a great question. So dizziness is just the general term that we used to describe any feeling of being unsteady, being uneasy, like you know, people will have different descriptions for that. So they'll say, oh, I feel lightheaded sometimes.

And then some people will say, I feel like the room is spinning. That room is spinning phenomenon, that's vertigo. Because it's the illusion of movement in the environment when we are not moving. And then we have different types of dizziness too, where people say, I feel like I'm floating on a boat, that's another kind of complaint. Like you're riding a wave. Those kind of things where you feel a bit of unsteadiness when you move. All of those things could be called dizziness, but vertigo is specifically when we have that perception of things spinning or that the room is moving when you're not. 

Mark: So I imagine this is pretty upsetting for people to have the amount of pain that they're possibly having with the migraine and then the bloody room is spinning. Yeah. So what's what kind of causes, what are the possible causes? 

Iyad: We actually don't know what causes migraines. We know it'll affect certain people more than others. Women seem to be more susceptible to this. But we actually have, and there's been a few kind of theories about it, but there's no real kind of magic bullet that we could say, oh, this is what causes this. However, you know, whenever I see somebody in clinic and they've been complaining about spinning or dizziness or vertigo or whatever, one of the first questions we ask is to rule out headaches. And the reason we wanna figure out headaches is well, there's also the neck.

The neck can cause headaches sometimes. You can get something called the cervicogenic headache. But the neck can also be a source of dizziness where we have a bit of this, let's call it a mismatch with our senses, where let's say your vision tells you one thing, your inner ear tells you one thing and then your neck telling you something else.

So that kind of loss of position sense could cause that too. So that's why we wanna figure out what kind of headache they are now. Lucky for us, the neck headaches, most of us physiotherapists, even the ones who don't treat vertigo are quite adept at treating and assessing for neck related impairments that cause the headaches. But we tend to go a little step further into vestibular work, where we try to figure out what kind of headache it is. And if it is, let's say a migraine or if we're suspecting a migraine, we will pass them on to our physician colleagues, get them the help they need. And then we would treat the resultant after effects of that migraine. 

And I think it's really gonna worth noting that this is the thing that I see equally, over and under diagnosed, if there is such a thing. Again, a lot of people who say they have migraines when it could be a tension type headache or a cervicogenic headache where we treat their neck and they never have a headache again. And again, a lot of people who think it's tension and think it's stress, but it's actually just a migraine.

And so we would wanna kind of take our time and actually get a good idea of what type of headache we have. And we have certain criteria that help us kind of give clues as to is it this thing or this thing. The good news is, some people with just the treatment of the migraine completely lose their vestibular symptoms, which are the unsteadiness, the dizziness, the vertigo potentially.

And that's a good sign. So we try to really get those let's say differentiated, what type of headache we're dealing with and then try to get them the proper help, because it is very treatable. 

Mark: So what is the treatment? What do you do? 

Iyad: So our physician colleagues will prescribe the adequate medication for that. And that seems to be quite effective. At least the people that we've worked for in the clinic seem to respond quite well to that. Usually afterwards lets say we will assess things like, are they able to maintain their gait stability? We will assess for if they have certain movements that they're sensitive to, and then we give them a program to address those impairments.

There's really no one impairment or two impairment thing that you kind of say that, oh, people with vestibular migraines get. But they do get vestibular impairments that look a lot like some of the other things that we've talked about in the past, like inability to focus on an object while they move, sensations of the room spinning with the head turning so quick, you know, things like that.

And we try to just rule out what are we dealing with here? And then the most important thing is giving a program that's specific to the impairment that we see. Because the impairments are so wide, it's just really important for us to figure out what's the biggest contributor. Because some people just need to work on their balance and postural control and they get better.

And some people need to do more retraining of the reflexes, like the vestibulo ocular reflex, and a few other things that we would prescribe exercises for, to help figure out their impairments there, like if they have a gait stability issue, for example. 

Mark: So this does not sound like a candidate for Dr. Google to figure out what's going on. 

Iyad: It could be a good way to kind of figure out if you should talk to someone about having a migraine potentially and getting the help you need. But it's kind of hard for you to diagnose your own gait stability issues. I mean, it's really hard for you to see your eyes when you're trying to move your head side to side. So it is hard for you to self-diagnose. And it's way easier for somebody just to have a quick look at it, assess you and move on instead of trying to throw random treatments at the wall and see what sticks.

For the most part, if somebody has a migraine spectrum, they can't get medication unless they get a prescription for certain things. So it's not like you can just go to the pharmacy, just try random things. But yeah, I would just strongly encourage people who have this, to just get a workup and see, are you actually dealing with migraines or is this another type of headache? And if it is another type of headache, is this something that could respond to just regular treatment of manual therapy exercise and advice. 

Mark: So if you want expert help, if you're feeling dizzy, if the room is spinning, if you've got headaches along with it, the guys to see are Insync Physio in North Burnaby. You can reach them at their website, or you can call and book (604) 298-4878. They also have an office in Cambie (604) 566-9716. Thanks, Iyad. 

Iyad: Thank you.

Injury Prevention with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto. He's the owner of Insync Physio in Vancouver, one of the best physiotherapists clinics and physiotherapists in Vancouver. And we're gonna talk about injury prevention. How you doing Wil?

Wil: Hey, I'm doing good. Thanks for the shout out Mark. 

Mark: So I know we've talked about this before. People get a program of recovery and then they promptly after a week or two feel better and stop. That's not exactly a prescription to not get injured again, is it? 

Wil: No, it's not. I think it's also not looking even more long term. Where you know, you may have been on the program now for six to eight months and you feel great. And it's kind of like similar to, you know, you go to the dentist cuz you have a cavity, and you haven't really been brushing your teeth all that great. You mean miss a couple nights, three nights a week kind of thing. Well, you know, let me ask you what happens when you don't brush your teeth for four nights in a row.

Mark: I don't know anymore. I haven't done it for a long time. 

Wil: What do you think would happen? 

Mark: Well, you'd get gunk on your teeth and they feel kind of ucky and I would just feel too guilty. 

Wil: And it would probably smell a little bit. And your family and your friends would probably say something to you about it, right? Maybe, right. So that's the thing, like we brush your teeth and we prevent that from happening. And so when we look at rehab, we wanna think about it in the same way, in terms of preventing the lack of mobility, the lack of the way our muscles function and help support our body. Our muscle, bone, which we call muscle skeletal, muscle bone system.

And then you wanna add the nervous system and all that, which coordinates the muscle bone. So that's called the neuromuscular system. Or the neuromuscular muscular skeletal system. Now the biggest difference though, however, is that if you missed a week of not doing your rehab or your physio exercise or you're strengthening, whatever it is, then you're not gonna necessarily feel it, especially if you've been doing a program for like six to eight months or up to year.

The thing is that it sets you up though. It sets you up to now going back to certain patterns or if you're engaged in either a sporting activity. Definitely with sporting activity, our clinic and our physios see a lot of athletes, from weekend warriors to more the athletes. To your grandmother or your mom that wants to just lift up the baby, or your grandson.

It's the same model and the same process. You gotta work on mobility of the joints, mobility of the muscles, your core strength, or what I call the stabilizing strength and what we call also the mobility strength or the functional strength. And that starts to get altered. And you don't really feel the effects and symptoms of your issue.

And especially if you've had a colourful history with your body with previous injury or injuries. Then what ends up happening is that lack of exercise commitment will add up and then it will lead you more prone to having a relapse of your pre existing thing. It may not be as serious, but you'll have something going on and you start to feel pain and pain is when you cross that threshold when things go wrong. When you start to have pain in your teeth and you get it tooth ache, when you get cavities. 

Mark: So the short answer to this is if you've got a program, you want to keep doing it. But what about if I haven't been hurt? What can I do? Say, I don't have any knee problems, but I don't want to have knee problems. What would be the prescription to prevent? What do I need to be doing? 

Wil: That's a great question. So in sort of our day and age and how we like do things now and just this modern time of sitting a lot and the lifestyles that we live and lead and how active we are. We tend to have certain patterns that our body like to go through. Especially if you're sitting and certain muscles, like in your hip flexors will get tight and your posture will get really adaptive, maladaptive I should say.

And so what happens is that then your muscles start to remember, sort of okay, that's how I wanna be. This is where the resting position is. So your hip flexors normally, if they're nice and relaxed, resting position should be like this, your hip flex will then be in a resting position like this maybe, especially if you're sitting all day long. And then you add on the effect of like, you know, then you 're training. And you're now trying to like, push your body and now you're doing these things and you're sitting eight hours a day or you could even be like a painter and you're doing this eight hours a day or something like that.

They're all repetitive movements, whether it's sitting repetitively, standing repetitively or doing something where your body is adapting a certain neuromuscular skeletal pattern. And then you add some kind of activity, whether it's like a high performance activity, a sport, or even just like playing with your kid, I just wanna look forward to having that time off after my work shift of eight hours on the computer and just play with my son or my daughter, whatever.

Then what happens is then your muscles that have become more maladaptive and you have to work on opening it, getting it back to the normal before that. And this is part of that whole like preventative, this is the self-care that we need to really do. There's certain movements. You don't necessarily have to do physio per se, but there's a lot of like things that, let's say, oh, you know, I wanna start to run my first half marathon. I wanna run my first 10 K. And you start increasing. That's when you usually run into trouble. And especially if now you're approaching late twenties, early thirties and you may not have had an injury, but you decide to go on a goal, some kind of physical activity goal. That's where you could potentially maybe come in in bit of trouble with your body, cuz you start to push it. And especially with things that are repetitive and always the same kind of movements. 

Mark: So again, what would help me? What are some of the suggestions that you would have for somebody for injury prevention? What things could they do, since they might not wanna come into a physio? 

Wil: Yeah. So there's a lot of things actually. Like number one is looking at your posture. So posture for sitting and standing. So if you work at home a lot, or if you're working like on a desk or on a computer a lot, research has shown that you wanna basically mix up your stance. Like you don't wanna be sitting all day long. You don't wanna be standing all day long. So you wanna have a sit to stand workstation.

You wanna make sure that you have the optimal posture for sitting and the optimal posture for standing. So you could, you could hire somebody or you might have a kinesiology friend or maybe a son or a daughter that's studied kinesiology or something like that to give you some basic tips on posture. Or you could get a more professional approach towards hiring, like maybe an ergonomics team or something like that through an occupational therapy consultant. Come in for a physio assessment to look at your posture if you want to. 

But short of that, you really wanna be more aware of like your posture, but also how your body feels. You're like, yeah, I feel a little tight, but then, you know, like a massage, and then yeah, there's something there. Okay maybe pay a little more attention to that. Maybe look at addressing certain things like, oh yeah, there's this stretching thing that I used to do when I used to run and, and I wanna get back into running. Maybe I should address that a little bit.

Or maybe I should roll out that part of that hip muscle a little more with a ball and then stretch it. Like there's all these proactive things that you can do. You can look up a lot of things online, but just be really careful with that too.

You wanna listen to your body? You wanna really like look at the alignment and not be in one prolonged stance or posture, especially if it's not optimal.

Mark: So, if we could encapsulate this a little bit, it's keep active. If you're gonna ramp things up, ramp it up slowly, so your body can adjust, but also your core is gonna be really important. So you talk a lot about activating your inner core and all those kinds of things. But also say something like Pilates or any other stretching type of exercise, yoga. I'm sure that, you know, in moderation, like always cause you can hurt yourself doing anything, I guess. 

Wil: Yeah, for sure. And you made really good point about you wanna keep active, and if you ramp up your activity level, then you wanna do these things. But most importantly, though, if you ramp up your activity level, you want to be more aware and self-aware about what's going on in your own body. And if you don't have a history of any kind of injury, you still want to be aware, you want to be like, okay, after a workout or a training session or a run or whatever it is that you engaging in, just pay attention to what your body's feeling cause is telling you something. 

And then these things like yoga and I'm not trying to endorse like yeah everyone to do one thing, you have to figure out what it is for you. And we have physiotherapists that are trained and basically able to assess looking at, oh, what's tight, what's weak, you know, and that's what we do.

And we can, we can do a functional assessment. So you're gonna do your first half marathon and you're just engaging in training. Great. So then we're gonna take everything into account. We're gonna look at what you do for work and your sitting position. And then we're gonna assess everything related to what you need to train successfully.

And so for you, you need to be able to, as someone that's partaking in your activity, be sort of looking at your activity, well, what am I doing? Okay. I'm gonna be playing volleyball. I'm gonna be jumping a lot. Okay. So right, hips, knees, ankles. And I'm gonna be hitting the ball, shoulder. So just be more aware of those parts the body that you're using. And take an inventory of it. And if it gets tight, maybe do some of these sketches that maybe some friends or coaches or whatever are suggesting, or that you may know from your repertoire.

If you start getting pain, monitor that, is it more than just, oh, I had a hard workout pain. And if it lasts for more than three to five days, that's when you definitely need to get it looked at.

Mark: So if you're in Vancouver and you have an injury, the guys to see are Insync Physio. You can book online at for the Vancouver office. They also have an office in North Burnaby or you can call them (604) 298-4878. Thanks for watching. Thanks Wil. 

Wil: You bet.

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 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. 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 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.