Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync Physio in Vancouver, one of Vancouver's top physiotherapy clinics. And we're talking about elbow pain in little leaguers. How are you doing, Wil? 

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

Mark: I'm all right. So little leaguers, elbow pain, how common is this?

Wil: Well, it's very common in a specific sort of like demograph. And so you usually see this in kids under the age of 10. And in particular kids that are really active in, you know, sports that involve like overhead throwing. And so, you know, the typical sport they usually think of is like baseball, right?

So that's why they call it little league elbow. But it's not restricted to just baseball. It could be like, maybe be a little person, they're taking up tennis or something like that, and they're doing more you know, dedicated playing and training or whatnot at that age. But it's the overuse aspect of this injury that's been more prevalent.

Mark: So why does this happen? 

Wil: Well, this happens because you have an overload. And so you think about the young and developing tendons and ligaments and also the bony structure where basically the ligaments and the tendons attach to are right on the growth plate. So growth plate is sort of that area of your bone where it's not fully fused yet. And so the reason why it's not fully fused is because it's a little person, you know, it allows more room that way you can keep growing. 

So as an adult, you and I, our bones are fully fused and we no longer have growth plates. So the growth plates, I think full physical maturing of our growth, I think it happens somewhere between like 16, 18 or maybe a little bit older. But in the little kids, this is even more of a problem because it's so immature.

And so because of this delayed growth in the little people. Then when you look at sort of the elbow pain, the inside, we call it the little leaguers elbow, it's sort of like it can mimic sort of this aspect of a golfer's elbow. The type of the injury of severity, really depends on what stage, so like the seven year old would present maybe a bit different than say someone that comes in who's 12 or something.

And there's a lot of evidence to show that this is quite prevalent when you look at kids engaging in these type of repetitive activities and really overloading their arms and really starting to present with this type of issue. 

Mark: So how do you go about diagnosing what exactly is going on?

Wil: Well one of the important things is that when we assess it as a physio group at our clinics, you know, we take them through a bunch of things. We want to make sure that there's not a fracture and ultimately you can't really know until you get scans done. And so if we suspect it, then we would definitely refer to podiatrist, which is basically a child doctor where they specialize in looking at child development and stuff like that. And so you want to confirm that there isn't like an emulsion fracture or anything like that. That's really important.

And then the other thing is that we want to make sure that there isn't any other things going on with respect to like, you know, ligament instabilities, because like I said, the ligaments can be injured or overstretched. And so that's super important because that can affect as, you know, they become a teenager and become an adult, if it's a lifelong sport that they're going to enjoy or even like maybe not that sport specifically, but let's say they want to do another sport or just general functioning, it can affect that in the long term. 

And then maybe the elbow won't be an issue, but then it can affect other aspects because you get all all the compensation patterns happening at that young age that can carry forward right through adolescence and into adulthood. And so you really want to make sure of those big things. And then as you look at the overuse things and look at, okay, so what's happening here in terms of the overload?

So is it one specific area or a couple of specific areas and you want to definitely let them rest. You got to let them rest and not have any of that pain onset coming on when they're doing any of the activities. I think that's huge. Because if you do and you bring 'em back too soon, then that can be disastrous.

Then you can get you know, all these things in the disturbance of how the growth plates actually start to develop and bone starts to develop. And then an emulsion fracture. Long-term instability. And then the integrity of the actual tendons and the muscles themselves. So those are all really important things to consider.

And then you're not even considering the other aspects of that that can be affected like the nerves because you have nerves that run through the elbow, you know, on the inside and the outside. They can cause irritation and that can have long term implications. So it's quite a complex thing if it's not dealt with properly, you know, these issues that can potentially pop up. Yeah, so those are huge. 

Mark: So what does the course of treatment look like? 

Wil: Yeah, so definitely like if it's on more of the severe end, we want a medical management and rest, like I said. And so the medical management would be looking at, okay, so, honestly very like low percentage, like this is going into the more extreme side of things, like maybe they need surgery. Which is very uncommon. But you know, usually we don't see kids being pushed that far.

I mean, rest, like I said, is number one. And then maybe medications to help with the inflammation and swelling. You know, really, the best thing in terms of a conservative physiotherapy approach is looking at what needs to be balanced out here. Okay. So they need to have a stronger core as well. Usually you can identify weaknesses in their core, and you're probably wondering, well, what does that have to do with like the overuse in the elbow? 

Well, you know, if they're really not leaning in and using the core when they're throwing, or they're just all arm heavy, then that's also an overload just on that one system. And they're not using their core to really be a strong base. And so they're going to not utilize everything from that aspect. And so then that's how they overuse can happen a lot more. So there's specific exercises that you can do.

There's things that we can do to help in terms of getting things moving away safely. Mobilizing things in a way safely. So we want to address not just the elbow, the wrists and the shoulder and the neck and everything. And that progressive strengthening is important, but we don't want to push it. So we only want to start getting back to those things and that helps promote like the circulation into that area again and does help with healing, but it has to be the proper amount. It has to be the right amount.

And then obviously getting them back into the functional things. So those are key because if we can really also look at the function and all that stuff, you know, and the aspect of like, how do they throw, like maybe the mechanics are off.

When we look at for little leaguers and pitchers, they instituted this I think about a decade ago, called the pitch count for age. So, if you're like this old, you're not allowed to pitch more than this. And it's very specific. And I think the biggest thing is educating the parents and also even the kids. You know, identifying what the symptoms are and then how to like set the treatment on your own. Because that's super important. And I think we need to pay more attention to this. 

Mark: If your child is having some problems with pain in their elbow, the people to see in Vancouver are Insync Physio. You can book online at insyncphysio.Com Or you can call the Vancouver office at (604) 566-5716. They have an office in North Burnaby as well. Call them at (604) 298-4878. You can book either place online at the website. Thanks so much for watching. We appreciate it. Thanks Wil.

Wil: Thank you, Mark.

Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync Physio in Vancouver. And we're going to talk about something we haven't talked about this before. Heel pain in children. How are you doing, Wil? 

Wil: Yeah, I'm doing good, thanks. 

Mark: So what causes children to have heel pain and what are the symptoms?

Wil: Yeah, so essentially heel pain in children and this is a condition called Severs Disease. And so the reason, it's called Severs is because it was actually a term coined by a doctor back in 1912. His name was James Warren Sever. So Sever's disease is, when you have this issue in kids where their bones are not fully mature, what happens is that in that attachment point where the tendon is the Achilles tendon you know, basically because of the repetition and the overuse and the overload or the microtrauma where it attaches, it starts to traction so much so that it basically starts to kind of pull off and cause this inflammatory process that's right at the detachment point.

And so in some ways, if you really think about the actual, like, sort of mechanism and what's actually going on in there, it's like tiny little micro fractures that is pulling it off the bone kind of thing. 

Mark: So is this associated typically with a lot of running?

Wil: Yeah, just basically a lot of overuse. Running is definitely a huge one. Anything that has repeated impact pressure you know, like on the heel. And the reason why too, is because like I was saying, it's not like the bone is not fully formed and developed. And so bone is kind of more, like when it's mature in an adult, fully grown person, it's definitely a lot harder and it's a different makeup versus when in a child, it's more cartilage like, so they call that a fibro cartilage, which is a lot softer.

And so this is quite typical around when in a child who's seven to nine years old because the bone isn't fused yet. So the Achilles tendon, which inserts onto that lower portion into the heel, there's the pull off of it. And so the pulling, like the growth plate, and because of that high stress from whether it's running, it's that impact loading essentially.

Mark: No worries. So dancing jumping of any kind, like skipping rope or anything that's going to load that heel part of the foot could be a cause of this? Like doing a lot of something at a younger age? 

Wil: Yeah, exactly. And how it's usually presented as a, again this is what's actually really good for, like, in terms of having it assessed because they usually don't have any pain in the morning.

So when you look at people that have heel pain, like as a grown up, you know, when bones are fully mature, it's like looking at, Oh, I got this heel pain. You do your internet search or whatever, and you look for that kind of symptomology and they find that it's like a plantar fasciitis. Well, plantar fasciitis is when you usually have pain in the morning. And so there's all these things like where some things are similar and some things are not, and then we need to assess it too as well.

You know, and obviously you're gonna have more pain as you do more activity and weight bearing on it. There's usually no swelling in there as well, but the pain is increased with those activities. And it can also be associated with a foot malalignment and whatnot. And then typical too is, like, you know, your child will have more limping at the end of whatever they're doing. And there'll be limited range of motion as well. 

The biggest thing with this is that rest is really important, and then initiating, like, physiotherapy. If it's assessed properly, will be able to influence that healing process even more. 

Mark: What is the typical course of treatment?

Wil: Well, the first thing is that if they're going to be engaging, like, I'll give you an example. We have a child whose father brought him in to see one of our physios, and he's trying out for a competitive soccer team. And I think he's only 12. And that's usually the typical age is 10 to 12, and it's usually more boys.

First thing is, you gotta let him rest. So you gotta, like, discontinue the running. And it's hard, you know, the kid wants to play and the dad wants to get him going in the program. It's difficult. But one of the biggest things you got to limit that activity. Discontinue the thing that's going to make it worse. And typically, like for kids, that's very important. Very important. But then it's also after we initiate that rest period for if it's like a week, to at least when they don't have any more pain. Then how do we progress them back on a program that is actually safe and is gradually getting them stronger without re aggravating this.

Mark: So what's the downstream effect? If they don't rest, what can happen? 

Wil: Yeah, that's a good question. So, there's quite a few things actually. So if you don't rest, you can actually end up getting things that can cause like a potential fracture. You know, and basically as you're looking at what's happening with this syndrome, if you're not allowing it to heal, that's huge. And that can affect, like, as the little person grows and they're going to have a sequela event. Because then if they have a fracture there, they're going to be having pain all the time. And then they're going to compensate, and their body's going to maladapt to that.

And that's huge. I mean, I can't stress how big that is. In terms of making sure that this is really diagnosed properly because there's also a lot of other things that you know, when you look at the syndrome or this disease, that you also want to rule out other things going on in there.

So when you have this and you look at the presentation of it, and you know what you can do, and like long term effects of the actual tendon integrity and also the muscle imbalances. Those are huge. But you also have to differentiate is this really a Severs or is this just like a heel spur. Or is this like just like an issue of a fat pad thing going on, or maybe it's just a bit of Achilles overuse, it could be.

We have to diagnose it properly. Usually more in boys than girls, like I was saying, so you have your kid that wants to get back into competitive sports you know, or doing something more active, rather, and be less competitive. So it's so important to be able to get that accurate diagnosis and treatment plan, because then it's just, there's the go down that rabbit hole of just really having these complications. 

And another one is Osteomyelitis, which is basically you can get an infection. I mean, that's kind of a worst case scenario, an infection of that area. And then, like I was just saying, then that would lead to just more altered gait patterns and then maybe a prolonged limp, ultimately. Prolonged pain and discomfort, which can lead to a whole series of things.

Mark: If you need to get accurate diagnosis for any injury or if your child is having some heel pain, the guys to see are Insync Physio. You can reach them on their website, insyncphysio.com to book, or you can call the Vancouver office at (604) 566-9716. Or you can call the North Burnaby office at (604) 298-4878. Thanks, Wil. 

Wil: Thanks, Mark. 

Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync Physio in Vancouver, BC, Canada. And we're going to talk about something that I think people confuse. Injury recovery versus rehab. How are you doing, Wil? 

Wil: I'm doing really well. Thanks, Mark. 

Mark: What's the difference? Is there a difference? 

Wil: Yeah. So first of all, recovery is really like an aspect of healing within a certain time frame. And it's obviously very dependent on the kind of injury that you're experiencing. So it could be like, you know, a simple ankle sprain to something a little bit more of a back strain to a disc or something like that. But ultimately the time frame, the time frames vary, but the process is the same. In the varying time frames. 

So I'll just give you a simple example, like with an ankle injury, a simple ankle injury where you tear some ligaments, maybe, and you may have a recovery time frame where it needs to heal, right, within four to six, to possibly even up to eight weeks. But it doesn't mean that you're not improving and you that you can't work on the rehab of that injury at the same time.

And so that recovery process really is looking while you're healing, addressing sort of the three main processes of that healing, where the first part of it is really when you're injured and you have the most swelling. Everything just balloons up. And sometimes it doesn't happen until the next day or up to 72 hours.

And so that's normal. That's all part of that physiological process of healing when you get injured. So there's essentially three stages to this healing. So there's that first phase that I just talked about where you get that acute swelling, and then you have the middle phase.

And so the middle phase is like the sub acute phase where you don't get any more new swelling. But then you start to go sort of in this process of the healing is now about okay, yeah, that's lay down a little bit more like groundwork here to kind of repair things. So the analogy is sort of like, let's say you got a cement building structure and that a pillar gets damaged and, you know, the concrete gets wiped out a little bit.

And now this phase, where we're pouring the concrete. We're trying to mix it, get things stabilized again to a certain extent. And so that's kind of that phase of it in the sub acute stage, like it's sort of the, your body is now trying to regenerate and reproduce cells to basically repair, right, and heal.

And so a large part of that is obviously clearing out that swelling. And then trying to get things functional again, and this is where, like, rehab is actually important in all aspects of these phases. And then in the, sort of, the third stage of that healing phase is really, and like I said, it varies. It could be, like, a shorter phase or a longer phase, depending on the type of injury, but then they call this the remodeling phase. 

So the remodeling phase is in that second phase, we talked about it being sort of like you're pouring the concrete and you're just pouring it over the broken areas or the patches that need concrete. Well, in the remodeling phase now we're trying to shape it. And then to take it a step further, we're also strengthening it a little bit more. And so we're changing the integrity of that repair aspect. 

 So to give you more concrete example, really looking at, no pun intended, so you have an ankle injury. Now you're in this third phase of healing and the swelling's come down. So you do specific strengthening to get it stronger, so it actually influences how that joint and the function of that joint will actually behave biomechanically. So how it will move in other words. So not just motion, but like a function of that motion.

So not only do I want it to move forward, backwards, left and right, and then all these other angles, but I want it to be strong in that way, and I want it to also have the reflexes to be stable. That's the remodeling and that important part of that rehab in the later stages. Now, a lot of this stuff starts to, like, happen, but if we don't, like, mold it specifically, then it may not be as nice and as specific as the way that we guide it to be.

So for example, like a lot of people that sprain their ankle and will go through the three stages of healing on their own and will do what they think they can to rehab it on their own. And it ultimately seems fine. They don't feel like they have a problem. Well, let's say they decide to like, say five years or maybe not even five, maybe two years or five years or 10 years down the road. I want to take up triathlon training. I want to do an Ironman. And then so they go through this process of or of initiating a training regimen. And then they start to increase intensity and everyone's different, some people might hit certain barriers quicker than others.

But if you're not fully rehabbed and you think you are from, like, say, this ankle injury that you had a couple of years ago or five or 10 years ago, and it will be expressed in like something that you do later on. And so what ends up happening is that then you have all these things that have happened in terms of compensation.

So in other words, your body has adapted to the slight limp that it's produced because you weren't able to fully put weight on that left ankle for the first three weeks properly or whatever, right? You weren't strong enough that left ankle and you're still compensating on the other side and your balance and your reflexes in that side weren't fully developed.

So the problem with this is that you can also come back with, you know, as you're training and you're increasing intensity, you can actually re injure that area or injure something else even worse. 

So research studies have shown that when you injure your back, and let's say you just run through that whole process of recovery and you get better. And then you do your own rehab, which is legitimately fair because there's a lot of information out there on the internet. But you don't fully rehab it properly. There is a very, very high likelihood that you can re injure your back, but even injure it worse or do something else. 

So that's pretty clear like when you extrapolate that to like other injuries and other areas of the body that get injured. And you look at this concept of recovery and rehab, they happen hand in hand. Like you do the rehab process during your recovery process, but then it continues on. 

So that last phase, which we call the remodeling phase, can be anywhere from like two weeks, three weeks from like a very simple injury, like maybe a very minorly sprained thumb and you rehab it. It only takes two weeks for that last phase in your rehab. Then like something a lot more involved, where it can take up to a full year to rehab. So like a year and a half, for example, like a total knee reconstructive ligament surgery. 

Mark: So would it be fair to say that rehab is actually, anytime you've injured yourself, there's a corresponding change in how your brain kind of operates the nervous system to compensate for that injury. And then part of the rehab is really reprogramming your brain and your nervous system so that it starts to work as you get stronger and recover properly. So that it goes back to normal or even better than what it was before it was injured?

Wil: Absolutely. And I think you hit on something that was really important. You mentioned about how you reprogram your nervous system and and you change your brain in the way it thinks about things. So that process is done through the actual physical act. 

So you set yourself up in your environment to be able to succeed. And I want to take a quote from James Clare, the author from Atomic Habits. He wrote this book that basically, I think is just amazing. He talks about how you do a whole bunch of little habits. All these little things in and of itself is not going to give you a result that you want, but you you do them every day or you accumulate them. And over time, you can get one big result. 

And I think that's amazing because in that concept is very similar to, I think what you're speaking about Mark, is that the change in your nervous system, it doesn't just happen like that. Like it takes time. And you have to it do the thing over and over again. And that's the same thing with like our bodies. In order to get strong, I can't just do the exercise once or even just three sets of 10 for even a few days. I may get a little bit stronger for a couple days, but it's not going to be sustained.

But if I do that same exercise every day for six to eight weeks, I'm going to definitely notice a difference, but I'm also going to notice a sustained difference, which is the key. And that's the thing right there and that's how your nervous system gets changed.

And I think that that's the really important key point about rehab because as you look at the kind of things that you want to do, you also want to ask yourself, well, how do I want to behave? Like, who is it that I want to be? Like, it's almost an identity around the kind of activities that you want to do.

So instead of just focusing on the goal, it's like developing habits or a system. And so James Clare very succinctly says that, "people who set goals will win once, people who set systems win repeatedly". And it's the same thing with rehab, it's got to repeat it over and over again.

Mark: If you're looking for superb recovery and rehabilitation in Vancouver, the guys to see are Insync Physio. You can book online at insyncphysio.com or you can call them at (604) 566-9716. Or if you're in North Burnaby, you can book at that office online the same or by calling (604) 298-4878. Thanks Wil. 

Wil: Thank you.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, and we're talking bodies. How you doing Iyad? 

Iyad: Doing well. Let's talk some bodies. 

Mark: So tendon pain with jumping sports. How do you deal with that?

Iyad: It's pretty common that we see people who play a lot of jumping sports in clinic and often they have aches and strains all over the place. And I mean, most athletes that we deal with are usually managing an injury or two through the season because by the time they come and see us, it's kind of been persistent and they're just kind of patching it up as they go.

So one of the things that we've been seeing more recently, especially as we get closer to kind of the nationals and the provincials where we see kinda an increase in people's schedule and their training and their volume of jumping, we start to see a little more tendon pain and tendon dysfunctions with these people.

So this isn't just necessarily one type of tendon cuz it could affect their achilles tendon or also their patellar tendon, which is the tendon at the front of the knee, under the kneecap. And we rely on those two structures very heavily when it comes to jumping. So, you know, part of the things that we would have to kind of do, and this is the challenge here, is managing mid-season versus, let's say in the off-season, where we can completely take them out of that aggressive, provocative program, build them up, and then send them back in.

Which we would never do that way anyways because we don't wanna cut off jumping entirely if they could still tolerate it. But ultimately, what we have to do in, in season is really be mindful of the total volume of things they do and their training program and kind of tinker with that. Maybe substitute some exercise and some different programming aspects, and then maybe also try to shore up some areas where they might be a bit underserved. So that we can kind of help support that sore spot. 

So a common one we'll see is in adolescent boys. We'll see this a lot. Just the the patella tendon, which is the front of the knee. We'll see a lot of people in volleyball. If you ever go to a high school volleyball game and you'll see people like knees with a little kinda strap that's just across the kneecap. They do that for relief, but those tend to be kind of like a primary demographic. Basketball, volleyball, and sometimes soccer. Anything where you're involving like repeated jumps or just like high intensity sprinting, you'll see some of that stuff happen.

Mark: So, I guess the symptoms or pain, what's causing it? Just overwork? 

Iyad: So a few things can cause this, but tendons are really funny. They're very finicky structures. They kind of like a nice consistent program. And then whenever you kind of go through a period where you disrupt that by like rapidly spiking the volume. It can happen. The funny thing about it is it doesn't just happen the next day. Basically what happens is I could ramp up all of a sudden and it could show up a few weeks later because I just don't have adequate recovery time in between that, to go back to where my baseline was. And then eventually tendon just reaches a threshold where it just becomes too sore.

And one of the things that people will complain about is, actually funny story, is we worked with a volleyball player last week, and his main complaint wasn't the pain, because he could play through pain, it was the fact that he can't jump high anymore. And he's lost some of that kind of explosiveness that is associated, like, you know, especially when he's blocking off a volleyball, where he has to jump up and create a full reach.

You know, he said, oh, I can't jump up anymore. I have to kind of really think about it and have to really, really kind of like dial in. And we were able to kind of assess him and based on what we saw, it was basically part of the process was that his pain was so significant on some days that he just can't even kind of recruit that muscle adequately in his cap.

So we had to kind of really tinker with this program and, you know, we kind of set some priorities, for example, for him to, to play in the big tournament coming up. So we kind of monitored restraining and kind of modified some of that to kind allow him to go and play in that tournament. And he ended up responding really well to the program, to the exercise program. And we just did it in a way where we just didn't only jump. And I think that's really, really important that we kinda like do the rehab along with some of the movement that we wanna do. 

Mark: So one of the things that I learned, and I don't know if this is true, it was that the muscles will increase in strength and ability to respond to hard work, far faster than tendons will. 

Iyad: That's probably accurate I would say. What I can tell you is the specifics of like, what's the dosage that you need and how much time. We just know the tendons tend to be slower in adaptation. They're quite strong structures. So what I'm trying to say here is not to freak people out and say, oh, don't ever jump, because your tendon's gonna, they're quite strong.

And they're quite resilient structures and often the fix is just more training, but just more specific training to kind of help improve, let's say, the capacity of that tissue to be able to handle all of that volume of jumping. And what we see a lot of times, especially in the adolescent population or maybe like kind of like the late teen population is, some of them absolutely love to do their jumping training and their training on the courts, but they absolutely neglect the strength side.

And that's kind of where we come in and try to like really help them on the strength and conditioning side to help, not just with the Achilles itself, but you know, when you jump it's a whole body movement. So people we've worked a lot on, kinda how their trunk, how their body stacks up over their hip, hip over the feet kinda thing.

And then also like you wanna build the areas that are potentially gonna help you put all that force into the ground so you could pop up. So yes, they are slower adapting, but the good news is they are very adaptable structures. 

Mark: So when you're diagnosing this and it could be whichever of the places that are causing an issue, how are you determining which beyond pain?

Iyad: So it's really simple actually. With tendons, there's a few rules. One of the things we see in the Achilles, for example, or in the patella tendon, is it's very localized. It tends to be about a finger width in area. Nothing more than that. So when somebody comes in and says this whole thing hurts, it might not just be the tendon.

It tends to be quite localized and pinpoint, and it also tends to be repeated because we aggravate it with repeated activity. Now most tendons will be worse upon starting the activity and kind of warm up a bit and then creep back up in the end. So that's kind of the pattern you'll see, with the runners will say, yeah, I start my run. It's kinda rough. And then it gets easier and then it gets worse later on. And then the other thing that happens with tendons is they kind of have that delayed response. So 24 hours later or so, people wake up and they're like, well, I actually feel really sore. I couldn't put too much weight, I couldn't jump as much. I couldn't kind of exert the area as much as I did before. And they often wonder if they slept upon it or anything like that. But it's really more of a product of doing too much, you know, the day or two before that. 

And then finally when we test it, it's really funny. Most people assume that the diagnosis happens by imaging and the diagnosis is a clinical one. So we do a clinical kind of cluster of exams, and what we would usually see with tendons is, if I make you do let's say a loaded activity to the tendon that's exerting it by, let's say this much and then I give you something that exerts it by this much, the more we go up and load, the more pain you're gonna have or the more discomfort you're gonna have.

So that's typically how that system works. So we kind of try to kind of do that sequencing cause we know what movements, for example, could be really, really high stress and what movements are really low stress. And based on all of those things together, we can kind of figure out, plus the pattern tell us like, oh, it hurts at 20 minutes of my run, or 30 minutes of my run. Or after intermission I usually feel it like, you know, when I'm coming back on the court. Those are kind of things that, you know, we use to put together to figure out what's that irritability level, so how much can this person handle? And that's also what's gonna dictate how aggressive we could be in their training.

Mark: In the course of treatment, was it just, I imagine it's not just laying off. If someone's in the middle of a workout or a competition season, how do you treat this? 

Iyad: So the cases where we would lay off are pretty rare, I would say. Most often we would kind of modify the program first before we lay off completely. Obviously in cases where like there are times where we lay off for a day or two. That's kind of like, what it tends to be is we would just modify that program afterwards. We would wanna look at all the things that provoke it. So sometimes it could be habitual friction or rubbing. 

So for example we had a hockey player once who developed it and you know, he just got new skates, not broken in, heels digging right into his Achilles tendon. So that got really, really sore. So we just got him to skate in his old skates while he was rehabbing. And then we actually made him do a breaking in program for the news skates where he would just wear them kind of for warmups and that's it. Just to kind of loosen them up a bit.

And then with that, we were able to train him up to the level that Achilles tendon could handle, like the pushing off. Even though hockey's not considered a high achiles tendon activity necessarily, it was still quite aggravating for him whenever he would stride out and kick his leg to the side. So that was kinda one of the things that we kinda would have to do.

And we would also really wanna exercise, like that's primarily the fix here. It's not just exercise the local area, exercise surrounding musculature, make sure they have adequate mobility in some of those areas. 

So for example, if you need to be able to squat really low or your ankle is really stiff, well that's gonna be a little more difficult to do. We tend to kind of look at the ankle underneath the hip in that case to be able to kind of carry that movement forward. But then also, I think what most people will do, is focus on that rest of the chain and forget the actual tendon itself. We really need to address the tendon. So it's a case for local intervention and also let's call it the distal and the proximal area too.

Not just the, oh yeah, just hit the knee and you'll be fine. Or not just hit the area around it and the knee will be fine. So you kinda have to like look at both. And then it's really a matter of building up tolerance from there. So we would start with managing minutes and we would never stop hundred percent, tends to be a last resort for us.

Mark: If you're having tendon pain from your jumping sport or running, sprinting, whatever, the guys to see are Insync Physio. You can book online at insyncphysio.com, or you can call the office to book. (604) 298-4878 in North Burnaby. They also have a Vancouver office at (604) 566-9716 both are available to book on the website. Thanks so much for watching and listening. Thanks Iyad. 

Iyad: Thank you.

Mark: Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physio in North Burnaby, and we're gonna talk about exercising with medical conditions. How you doing Iyad? 

Iyad: Good, Mark. Thanks for doing this.

Mark: So is there. I'm sure we're probably talking about things like heart disease or diabetes or other medical conditions. Should you exercise when you have these kind of conditions? 

Iyad: Yeah, that's primarily the topic. I've seen a huge influx of people who kind of come to see me for, let's say like a sore back. And you know, there's really often conditions that can happen from a reduction in activity versus an increase in activity. So like just aches and pains that we get just from being in prolonged positions. So just being a bit more sedentary. And then, you know when I suggest the idea of an exercise program to get them up and moving, they are often shocked or surprised by the fact that they do have options to do that and that they could be done safely.

And I think really, If we think about like the main kind of things that most people will have of a certain age. So we see a lot of people, for example, who have high blood pressure and are on medication to control that. Or some form of other kind of cardiac conditions. And then we also have like, you know, your other metabolic syndromes like your diabetes and a few other things that could really, really impact your response to exercise. And also like your energy levels and your ability to participate. 

So often we see people get kind of a bit more concerned and worried about like, well, I don't want to go too hard. What if I hurt myself? Which is completely reasonable and this is where I guess working with us could be a really helpful thing for them.

Cuz we can kind of walk them through it step by step and kind of build up kind of a tailored program to help them get back to whatever you wanna get back to. 

Mark: So a thought that occurs is what, and the exercise program could be just lifting weights, it could be going for a walk. It could be it could be stretching and yoga type things, or Pilates. I imagine that with your background, more medical training, medical oriented training, you can provide a more complete package of training for someone to be maybe safer. 

Iyad: Absolutely. So one of the things like you wanna think about is like, I'll give you an example. More recently, we worked with somebody who had had a heart transplant, and they were telling me how they had a tough go initially when they were trying to start exercise because they felt like they couldn't warm up fast enough. And that's actually something that could happen because when you have a heart transplant, you rely on a different system to get your heart rate elevated and kinda more excited.

And this is something that usually is reviewed upfront. However, imagine like you're going through a heart transplant, it could be a bit overwhelming to kind of try to absorb all that knowledge in that kind of, preoperative phase and maybe the first rehab phase that they, they have to do after surgery.

So then kind of review some of the energy systems, so they'd have to target and some of the strategies that they'd to do to go about a warmup. Also, the cool down, they said they crash after exercise. And they're following like a stock program that was given to them. So we were able to take that, look into their medication. We consulted with their physician obviously about what's appropriate, what's not. What are kind of things that they foresee being an impact. And then based on that it gave a very specific exercise program. 

We used their smartwatch that they had on their hand to help keep them in his zone of exercise that everybody's happy with both medically and also the person themselves. And then based on that, we were able to progress them. And now they have a nice exercise program. They really like cycling, so we just built it around cycling. 

Obviously we wanted to make sure that they also have enough capacity in their muscles and in their other areas that need to be engaged during that activity. So it's not just gonna be, oh yeah, here's a heart rate. I want you to stay below and have at it as much as you wanted. It was very much based on the measurements and based on where they wanna go. And then we built the program from their goals working backwards to fill in the gap. Yeah, it was quite interesting. 

And then the other thing is like, yeah, the medical training does help for sure. We monitor things like blood pressure. We're gonna monitor things like heart rate. Sometimes in certain conditions if somebody has some issues, for example, like COPD, which we don't see too often in the community, but in the hospital, we'll monitor a few things like how much is their blood oxygen saturation and things like that, because we need to be safe ultimately. 

So we don't wanna necessarily, give them something good at the expense of something else. So we try to kind of be a bit more of a reasoned approach, but also like, ultimately the goal is safety. And that's where we see a lot of those clientele and people really feel more comfortable working with somebody with more of a medical background in that case. 

Mark: So it feels like the overall message, is exercise is still important, even if you have a medical condition. In fact, that might even be extremely important. 

Iyad: Absolutely. And this is where I guess our understanding has changed over the years. It used to be that you have a condition, you don't wanna ever exercise or simulate or exert, but we've found more recently with quite a few studies that this is quite safe. But it has to be done in the right way. 

So we follow very safe, let's call them mobilization guidelines, to kinda get people up and running. And then also the other thing is we have found like one of the physicians we work with, we kind of built a program for one of their clients and we were able to really enhance how they responded to their diabetes medication just with the exercise program.

So that was quite significant. And then they felt more energetic and they felt less lethargic and all that stuff because the way diabetes works is like an uncontrolled level of blood sugar and one of the ways you control blood sugar is not just through the liver but also through your muscles. So we were able to build a specific program that addresses a little more kind of on that peripheral side, so they're able to help regulate that blood sugar.

So then even though they were still on medication, that response was much more pronounced for them. And they were happy because now they felt like, oh my God, I have had this type two diabetes and I can't do anything. And when the options kind of open up for them, it is quite a freeing thing because you start doing things that you normally wouldn't do.

So this person hadn't traveled in a while because they were worried about what would happen to them. So I think like really comes back to that independence and just being able to trust your body to handle what you want it to handle. So that's where we come in and help out with obviously our healthcare colleagues who are in the medical system as well.

Mark: If you have a medical condition and you want expert advice on an exercise program that will actually help you move and feel better about, you're not limited, you're not restricted because you have a condition. Maybe a little bit, but not as much as perhaps you've assumed. The guys to see are Insync Physio, you can reach them in North Burnaby, you can book right on the website, insyncphysio.com, or you can call them (604) 298-4878. Or in Vancouver (604) 566-9716. You can book for either office. Thanks, Iyad. 

Iyad: Thank you.

Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync Physio in Vancouver, Vancouver's favourite physiotherapist office, and we're talking bodies. How you doing Wil? 

Wil: I'm doing good. Thanks. 

Mark: So today we're talking about abdominal injuries from rock climbing. Is there something different about hurting yourself in your guts when you're rock climbing?

Wil: Yeah, so, you know, in rock climbing especially, you know, you get into like these more athletic type of climbs these days and then with the advent of indoor climbing with the bouldering and the type of routes that they're setting these days. You know, you're using a lot of your core strength now.

And then you add these movements where you're really twisting your body, and maneuvering your body in a way where you're trying to now like, get up the climb or finish the climb and it can really lead to more potential injury in the abdominal muscles, especially if you don't take care of them.

Mark: I'm gonna assume that the main symptom is it hurts, but is there something more that you look for or that people come in and tell you about? 

Wil: Yeah, so depending on how bad it is you know, you usually like, feel and hear like a popping sensation into your abdominal area. And if it's really bad, then you get this intense pain. And you know, you end up like letting go of your hold that you're climbing and you like fall to the mats. But it can range from like that kind of intense to like say you finished the climbing session and you kind of like pulled really hard and you're doing a lot of twisting motions and bending and extending or whatnot, like the motions that put you more vulnerable to that.

And then you kind of feel more sore down in your abdominal area after and it sort of persists. And you might have a little bit more of a minor strain, which is actually something that you also wanna be a little more cognizant of post climb. So sort of different degrees of it and that's what I look for.

In terms of more specific things that contribute to these strains, it's things that are involving like rotation, especially extreme rotation of trying to reach, side bending motions and then really extending in the spine. Those are the main ones. 

But then like I said, with the more dynamic nature of climbing where you're doing what's called a dynamic movement or a dino, you know, those sort of powerful moves combined now with like the twisting and bending and extending, are the main things that can lead to a strain in your abdominal area.

And most climbers that we treat, we treat quite a lot of climbers in the clinic, they are not so great at recovery and stretching and making sure that the mobility is restored. Especially in 10 sessions. That's something that we're finding a lot of.

Mark: Is there, if I'm feeling this, is there an appreciable difference between like, just, you know, I've done too many stomach exercises compared to I've actually hurt myself. Is there some kind of gauge I could say, oh, I've hurt myself. 

Wil: Yes. That's a really good question Mark. So what you're speaking of, like if you're doing a lot of sit ups and you feel that pain, like the next day is what you're alluding to, I think. Yeah.

That's a condition called delayed onset muscle soreness and so DOMS is the abbreviation or the acronym. And that's very normal. Like if you're doing a lot more than normal sit ups or if you haven't done it in a while, then DOMS is actually very prevalent. And so you'll feel sore and that soreness will last for, you know, up to 48, 72 hours and then it goes away.

And you don't feel anything happen, like when you're doing your sit ups or when you're doing your, like, you know, oblique workout or whatever you did in your workout. And you don't feel anything until the next day, to get outta bed and you're like, oh, I feel a little sore. So that's definitely some muscle damage going on through there, but it's like it's definitely excessive muscle damage. Whereas when you tear the abdominal muscle, you end up actually damaging it acutely. And you usually feel something like more immediate. So I think, point that you're trying to get at to is like how you determine the difference between that maybe versus like the more mild versions of it.

Where you don't feel it until after because obviously with the more acute strains you feel it and you feel popping and it's like a sudden pain. Right. So that's more obvious. Where it's the more mild ones, you might have felt something go, you know, like how you sometimes feel the muscle tension abnormally, so you feel something and then you're sore after.

And that's when you know you've strained something and it's more mild. Or like you have a workout, like you're climbing whatever, and you're doing all those things and you have a really hard one and you do feel sore, but then you're like, two hours later, the same day, you feel abnormally more sore.

So you shouldn't feel abnormally more sore like that, you know, like one or two hours right after. And then the key thing actually is you're looking at that timeframe of like post 48 to 72 hours. So if it's still sore after 72 hours, like where it's not going away or getting any better, that's where you know you strained something. Where it's more of a tearing of the muscle as opposed to this other micro damage that's more related to the delayed onset muscles soreness. 

Mark: So how do you diagnose this? 

Wil: Yeah, so that's a good question too. So, first of all there's different grades to the extent of injuring your abdominals. There are three different grades. Grade one being like the micro tearing and stretching of muscle fibres. And you could say that the delayed onset muscle soreness is sort of in that category, or it's a grade one. And grade two is now you actually have partial tearing of the muscle fibres. And then grade three is now like complete tearing or rupture of muscle fibres. 

And so there's different things that we test for in the clinic when we look at, you know, what you're able to do and not do, and really rule out whether or not it's something else. Is it a hernia? You know, so that's another common thing too that we gotta rule out. Because if you have like lower abdominal area, then you know, you're always suspecting hospital inguinal hernia. And some of the things can be very similar, like, you know, if you're like, oh, coughing, you know, that can hurt the abdominals, but also it could be a hernia. I won't get into that too much, but those are things that we kinda look for. We wanna rule out that it's not other things as well. 

Mark: Sure. So what's the typical course of treatment?

Wil: Well, the biggest thing we gotta unload. So we gotta basically don't do things to put force or tension into abdominals. Like even, I mean, it's it sounds kind of funny, but not. We had an individual that had a tear in their abdominal. And even laughing really hurt. So I was like, if you wanna watch movies this weekend, don't watch anything too funny. Because you just gotta rest, right? It's gotta rest. And especially from the acute injury, you gotta give it that, you know, real good time period, 72 hours to let that acute phase kinda really settle down. 

And then once we can start to like move through now. Okay. The acute phase is over. Gently start to move through mobility phase or getting more range of motion through the torso. So obviously the range of the motion that you were working through that maybe that caused an injury, if it was an overstretch, then we wanna work those last, but we wanna start getting mobility. Because it can actually then cause other issues happening where you're compensating. And then working through strength. So the strengthening of not just where you've injured, but then now the core, the inner core. 

Quite often a lot of people like mistaken your abdominal muscles for your core muscles. Well, in sense it's true, but it's your outer core. It's not your inner core. It's not your stability core. Because your abdominals actually attach onto your pubis in your pelvis, all the way up into like your chest bone, like on the tip here.

And they don't actually have any attachments on your back. So the more inner core stabilizing muscle, they actually what you wanna work on. And there's like you know, specific regimen that we can prescribe to see where you're not activating, to really say, yeah, this is what you need to work on.

And that's key because when you have an abdominal injury, then you can be prone to having a back strain after, if you don't rehab them. Because then you're not activating your core properly. Then you're gonna start doing all the outer core muscles instead of the inner core that actually attach on your spine.

So then once you get the strength going a little bit more in this coordinated fashion, then now it's looking at, well, what we call functional strength and really getting you to build final stages of movement, like the end ranges of where you really need to to get them feeling like you're back to your full mobility strength.

Mark: If you had some kind of abdominal pain, that's not going away. You can't just rest and hope it's gonna get better. Get in to see the folks at Insync Physio. You can book online at insyncphysio.com, or you can book by calling them (604) 566-9716 for the Vancouver office. Or they also have a North Burnaby office, (604) 298-4878.

Both places book online. Very easy to do, but you have to book ahead. They're always busy. Thanks so much for watching and listening. We appreciate it. Thanks, Wil. 

Wil: You bet.

Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync Physio in Vancouver, one of Vancouver's favourite physiotherapists and physiotherapist offices. And we're talking bodies. Today we're gonna talk about back of knee pain from running. How you doing Wil? 

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

Mark: Good. So, sometimes you get that back of the knee pain when I used to run. I don't run anymore. I gave up. But what's that from? What can cause that? 

Wil: Yeah. So one of the most common things and some of our physios have been treating a few runners that just ran the marathon here. And basically it's an overuse injury of a particular muscle in the back of the knee.

And so the muscle, it's called the popliteus. So just wanted to give you the name there. And basically the muscle becomes overused because it's very multifactorial. So it's not just like one thing and you look at the loading of training for something like a marathon. And you look at all the loading that happens with the training and so the popliteus muscle has a couple main functions. 

It's main function is, it flexes the knee and it helps with unlocking the knee joint. And preventing the femur, the top of the thigh bone basically dislocating over like the bottom leg. And then the secondary function of this muscle is that it acts to basically hold in place like stability, like it stabilizes the joint on a more static level. 

So how you usually injure it, like I said with an overuse, like you can also injure it traumatically but we're gonna talk about more of that overuse, kind of gradual onset. And like I said, there's multifactorial things going on and if you have over rotation of your lower leg and then you add all that load in repetition, then as you look at over time, then that can really be a big factor for that.

Mark: So why does over-training or how do you even stop this? What's the cause of this?

Wil: That's a great question. So quite often it would be someone that presented with like some previous injury or a history of an injury before. So in these specific individuals that have come in, you know two of them have actually had like reconstructive ligament repair. Reconstruction of the ACL, which is a major ligament of the knee. And so obviously when you have a surgical procedure like that, you really change the mechanics of your whole knee and your leg.

And then they rehabbed and it's been like, I don't know, maybe even like two or three years since the surgery, but their mechanics is still a little bit off. And then now they're like, Oh yeah, I wanna run a marathon now. This is my first marathon. I can, you know, test myself.

And so if they're not careful, then you can really have these compensations happen if it's weaker and you have weakness that basically occurs on the one side and you're not fully rehabbed strong enough, and you're not looking at the mechanics of your running.

And so essentially with that forced rotation and then you're getting excessive strain and pull on that popliteus when your foots in contact on the ground, and then your lower leg is essentially fixed. 

Mark: So is that the main cause? Is that someone's had reconstructive surgery or can this happen with other people?

Wil: Yeah, no, it can also happen with other type of injuries or even back pain and back stuff where essentially it's the changes in the mechanics of the leg. And when you have that extra rotation for whatever reason, whether it's like an injury or it happens to be that with something like ACL reconstructive surgery, it's a little more dramatic.

And so what happens there then, you know, you really gotta go through the rehab process to be able to have a proper normalization of the movement in that knee, in terms of mobility, but also the strength and the coordination of all the muscles around there. And so that's the main reason.

Mark: So how do you go about diagnosing it when someone comes in? 

Wil: Yeah. So there's different stages of it and we get runners that come in or even like from running sports like Ultimate, football, soccer and all that stuff, where you get pain over the sort of back outside of the knee. And it can be sometimes even just be painful like standing on it, going upstairs. And the range of motion is usually incomplete, like you're lacking range. And there could be even swelling and people usually have pain in that area. 

Mark: And so does the course of treatment include like, working on their biomechanics so they're not flexing or twisting in the wrong way that their body can't adjust to?

Wil: Yeah, 100%. And it's so crucial to be able to correct the maladaptive movement pattern. Because if we just settled down the muscle overuse aspect of it, then it doesn't necessarily fix the cause of it and how it all started. And then the other thing to really note too, like you know, when people come in with this, they're usually more concerned about like bigger things going on, and it's valid, right?

Because there could be other stuff going on that's legit. Cause it is in that area where, oh, maybe there's like a hamstring strain or like a meniscal injury, which is basically the cushiony part of the knee. Or ligament injury or something like that. And so people come in usually you know, being quite surprised when we assess their knee and one of our physios says, Well actually, you know, your ligaments are fine and you actually have an overuse in this muscle. And they never even heard of the muscle before, it's like, oh, popliteus. It's like, you know, the first time you've even heard of that word or that name of that muscle. So sort of an awareness to that too. 

Mark: What's the recovery time look like? 

Wil: Recovery time can be really good depending on how aggravated and like how bad it is, I guess. So you can have it where it's like super inflamed, then you gotta let it settle down first. So there's gonna be like a good few days where if it's swollen. So if you have pain just standing and walking and climbing stairs, then it's probably a little bit angry at you.

So you gotta let it settle down a little bit. And so that period you know, in terms of like, ok doesn't hurt with walking anymore. Then you look at, well then what's the gradual progression get back to like now doing a little bit more? And so typical timeframe is you know, we usually get runners back depending on how serious it is, but within like a couple weeks.

But the key is really unloading. So with these runners, they're doing like pretty heavy mileage per week. Or even if you're just recreationally running, like as you decrease the mileage, now you're just doing three and ones for five sets, that's significantly less than you know, 50 kilometres per week kind of thing. 

So decreasing the load is key too, in the first stage. And typically it takes about four to six weeks to fully recover to really work out that biomechanics of everything and making sure that the movement patterns are good in your hip, and also what's going on in the back, and how your core strength is activating. So that way you're not over rotating when you're making contact on the ground, when you're heel striking. And pushing through and you're not getting into that extreme range and aggravating it again. 

Mark: If you're having some back of the knee pain. The guys to see in Vancouver are Insync Physio. You can book online at insyncphysio.com, or you can call the Vancouver office, (604) 566-9716. They also have a North Burnaby office (604) 298-4878. You can book either place online at insyncphysio.com. Thanks so much for watching and listening. We appreciate it. Thanks Wil. 

Wil: Thanks, Mark.

Start by using a stool to step up to reach for grab bars or a chin up bar. Engage the core muscles of your low back and prevent it from arching. While gripping the bar above, pull the arm in towards your socket. Avoid pulling in a downward motion so you do not activate your lat muscle.

To make it easier keep both feet on the stool. To make it slightly harder leave one foot on the stool. To make it even more challenging remove both feet. Hold this for 10 seconds doing 3 sets x 10 reps daily to start.

This exercise works the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. We're talking about post-concussion syndrome. When can people actually get back to exercising Iyad? 

Iyad: Oh, hey Mark. Yeah, well that's a great question. Typically it depends when we see these people. So if I happen to be, let's say on the sidelines of the ice rink, and then I see the concussion happen live, you know, usually they're able to do quite a bit of intervention then and there it's with the education and letting people know what to do. What we've started doing more recently is once we have a confirmed diagnosis of a concussion, usually most people will see their physicians first and to get this diagnosis or their appropriate healthcare provider.

We kind of start 'em off with one or two days of rest just to kind of help things settle down a bit. Tends to be a lot of fatigue involved at first, and then, you know, soon after that we try to get people, once we kind of figure out kinda what can different impairments are at play. We design a program that helps them do that. So, but we typically get people moving within 48, 72 hours, depending obviously on the severity and what else is affected and if there's any other complications. 

So for example, for dealing with an isolated traumatic brain injury without, let's say any significant neck injury, like no fractures or anything like that, we're obviously gonna move people a lot earlier than later.

We see a lot of people who come in six months post-concussion and then who have not done anything because they're still, unfortunately feeling symptoms. And then those are the ones where we need to be a little more kind of deliberate with our programming and also figuring out a safe entryway for them to start their programming.

Mark: Having been involved in combat sports and had my bell rung more than once. Mm-hmm. It's very common. I mean, we had no idea back then. It's 40 years. Mm-hmm. 45 years ago. But what about multiple concussions? How does that affect things? 

Iyad: That's a bit of an interesting one. And it tends to be where, we know you're more prone to future concussions, for example. When you have that, and obviously like how far apart the concussions are, matter. 

Unfortunately, sometimes you see it in different sports where an athlete gets cleared or an athlete hides the fact that they potentially suffered a concussion and then they go back out in quick succession and they get a second impact pretty quick.

That could be very dangerous. Could definitely prolong the recovery. It could be even life-threatening if they do it quick enough. So that's where, you know, we really advise that people get cleared medically before they go out. And there's proper steps to take for return to play.

If you've had them more successively, like let's say consequently, but far enough away from each other. I mean, it's gonna affect the recovery, of course, but the principles won't change as much. We just try to make sure that when we get people back that they're, we don't just do one bout of clearance for example, testing. 

If let's say you've had four concussions and you know, maybe the first two were well managed. Oh yeah, you cleared one practice without symptoms, so you're good to go and just go get kicked in the head a hundred times after that. You might maybe lengthen that return to play a little longer just to make sure they're actually okay and coping with a variety of the stresses that are involved with the sport. But for the most part yeah, obviously you don't want to have a lot of concussions. That goes without saying. 

Mark: So how does the post-concussion syndrome, how do you manage that if you're having the symptoms after the fact, say a week or two later, when is it safe to start exercising again?

Iyad: So we will get people exercising again, within two to three days after the concussion, once we kind of see things settled down. We'll get people to do some form of aerobic exercise. Typically, this is done based on an assessment, so we'll assess people in our clinic, we will get 'em doing either a treadmill walking test to see their tolerance or a bike test. We could do any of those. 

There's always more than one thing in a concussion. That's kind of why it's so intriguing and interesting. And why maybe potentially so complicated. So there's that kind of exercise response that we get. 

There's also sometimes the neck involvement for which we can get headaches and dizziness contributed from that. And obviously if you walk in your head, for example, your neck is moving a little too much. You can get these symptoms and people think, oh, it's all the concussion or it could just be whiplash that's suffered as a result of the initial injury.

We will also assess the basic visual stuff and some vestibular stuff, which is in your inner ear, which helps you balance in different things. And then we can kind of identify our main target. So for example, if we have a student we're dealing with, we would probably prioritize returning to school first before we try to get them back to, let's say, high speed sprints.

So they'll be some kind of cognitive component there too. So like how much reading to do at a time and how much screen time and all those things. But yeah, exercise, we try to get people in pretty early. But then once we have that assessment of the treadmill or the bike test, like we talked about, we will be able to give them very specific parameters, for example, either based on exertion level or on time, or if they're, some people have those smart watches that can track their heart rate. So we can give 'em a heart rate prescription based on that too. 

There's a lot of different things that we could do with that and just keep people moving and start to build up their tolerance to movement and exercise gradually. And it actually could be really important at reversing some of those exercise intolerance signs. You know, so it's kind of funny cuz if you can't exercise, the fix is to not rest necessarily for too long, but maybe a gradual exercise program to schedule that within their busy schedule.

Cuz what you'll have most of the time is people have, let's say, a job or school plus some family obligations, plus some medical appointments, plus some other things that they have to kind of contend with all at the same time. And it becomes a failure of pacing. So you start seeing days where people have 10 hours of strenuous physical or cognitive activity. And then some days where it's a little less cuz they're crashing from that and maybe their sleep schedule's a little irregular and all that stuff. So that's where we figure out like, you know, where to place the exercise in the week versus just tell somebody, Hey, I need you to get me 30 minutes a week of something where they kind of have a bit less guidance there. 

So again, as I'm saying, there's a lot going on there, but it's like exercise is gonna be essential and we can do it really early. We just have to figure out where to fit it in their schedule. And then how much. That's the amount. It's not a yes or no. It's a how much potentially. That's a probably a better question to ask. 

Mark: What are your guidelines? How do you set that, the how much factor? 

Iyad: It's really easy. It's a tolerance test. We put people on a certain thing. We try to go until they either get symptoms or we keep going until they don't get symptoms.

And if they don't get symptoms, that's great. That means there's no physiological response that's, let's say that's bad to exercise. So that's great. So that clears them for a lot of different movements and exercises right away. If let's say, the heart rate starts to tick up in the 130, 140, it's just an arbitrary example and they start to get symptoms, then we would try to get them exercising maybe at a level below that. Or maybe changing if they're walking on an incline, maybe changing the level of the incline or maybe changing the speed or maybe changing a few other things. 

So that's kind of what dictates it. Again, if you have a lot of neck pain, sometimes people find walking to be sore and painful initially. So until we control neck symptoms, you can get 'em on a stationary bike and doing some of this stuff. So yeah, it's never guessed. It's always based on we assess here and this is your tolerance level and then you get the prescription to follow. 

Mark: How common is it for people to have ongoing symptoms after they've had a concussion?

Iyad: We don't have great numbers in BC but it's pretty common is what I could say. There are lots of people who, let's say, intervene with it really early on and they just kind of go 1, 2, 3, and they kind of follow the steps and within a few weeks they're back to normal. And there are some, unfortunately who maybe they start to develop more of a persistent case. But we don't have great statistics in Canada. We have some global statistics which are, you have big ranges anywhere from one in four, to one in ten. So it just varies. 

But it is common enough to be a problem. And we're seeing a lot of it in the clinic and I think it's just important for people to know. If you're failing to exercise and keep up your tolerance, it's not because the exercise is bad necessarily, it just might be that you're doing too much at once and maybe failing to pace yourself adequately.

And maybe the conversation should be, let's plan your week out in a little more a depth instead of trying to guess and see if you're gonna do well or not, and then react by sleeping through the next two days. Cause that's what we see. People go a little too hard and then they crash, and then it's like they're napping three hours in the middle of the day.

Well now your night schedule's messed up so you can't sleep so well. And then the next day is messed up and then it's like takes them till the weekend to like kind of get on level ground again. So again, it's probably just useful to start eliminating some of the noise in the program and just kind of focus in on a more of a gradual program.

Mark: If you've had a concussion. If you've got concussion syndrome or concussion symptoms after the fact, even if it's later on, you need to get in to get professional help at Insync Physio in North Burnaby. You can book online at insyncphysio.com. Or you can call them (604) 298-4878 to book your appointment. This is your brain we're talking about. You wanna look after your brain, and it really helps to have professionals helping you. Thanks, Iyad. 

Iyad: Thank you.

Start in 4 point position on your hands and knees. Engage the lower core of your low back and pull in your low abs below your belly button. Pull the arm and the ball aspect of the shoulder joint into its socket on affected side.

Then straighten out one leg and then the other leg while maintaining your spine in neutral and your shoulder socket engaged. Avoid pulling down with your lat muscle. Hold for 10 seconds doing 10 reps 3 sets in total.

This exercise works the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing.