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.

Vertigo from Vestibular Neuritis with Iyad Salloum

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

Iyad: Good Mark. How are you today?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Iyad: Thanks Mark.

Do I Have Scoliosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wil: You're welcome Mark.

Wrist Injuries Rocking Climbing with Wil Seto

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wil: Thanks Mark.

Knee Injuries Rock Climbing wi Wil Seto

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

Wil: I'm doing good. Thanks. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wil: Thanks Mark.

Carpal Tunnel Syndrome with Iyad Salloum

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

Iyad: Good, how are you doing Mark? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mark: So diagnosis is fairly critical. Like always. 

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

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

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

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

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

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

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

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

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

Mark: And treatment time range? 

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

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

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

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

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

Iyad: Thanks Mark.

What is Carpal Tunnel Syndrome with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. And we're going to talk about specifically, what is carpal tunnel syndrome. How are you doing Iyad? 

Iyad: Good, Mark. How are you today? 

Mark: Good. So, what is it? 

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

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

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

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

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

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

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

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

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

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

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

Iyad: Thanks, Mark.

Shoulder Instability with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum he is the clinical director of Insync Physio in North Burnaby. And we're going to talk about shoulder instability, something that I know quite a bit about just from not, well, I don't nothing about it, but I have experienced a lot of it. How are you doing Iyad? 

Iyad: Good, good Mark. How are you doing? Hopefully your shoulder's not unstable. 

Mark: Well, it's gotten a lot better, but what's sort of the typical cause of that sort of instability that people can have and the pain that comes with it. 

Iyad: Yeah, so broadly speaking, you're going to split them up into two categories. You're going to have somebody who falls into the traumatic category. So like, think of anywhere from a baseball player, diving in with their arms stretched or a mountain biker falling or you know, any kind of impact that causes this. So you have that in some of the contact sports like rugby. So there's a lot of different mechanisms that could cause a shoulder dislocations and then give you, what, basically presents like a loose shoulder where people feel like they can't control it. And it doesn't sit well, the ball, sits in the socket kind of thing. 

And then you have another group where it's a little more interesting. Where are they have a loose shoulder kind of congenitally in a way. So the ligaments and the things that holds the shoulder together passively are just a bit more mobile than you'd want them to be.

And then in that group, you'll get basically what we'd call a multi-directional instability. So it's not going to be just the movement is not going to be excessive in one direction. It tends to be excessive in all directions. Meanwhile, on the traumatic side, for the most part, people tend to acquire this looseness, let's call it, and they would tend to be more one or two directions.

So not necessarily in all planes with the movement, for the ball moving in the socket. So those are the two kind of broadly speaking, those are the two groups that get this. Obviously the treatment for each one will be a bit different. 

So for example, the traumatic people, we will not be the ones usually doing the relocations. It tends to be done by a physician. Most people will go to the ER when they dislocate their shoulder and then have it relocated there. And we're involved after they get it relocated. The care off of that is all ours. And we can talk about their treatment plan from there.

Now, the other group, the rehab tends to be a bit different. We will try to identify, I guess, that they are just that multi-directional instability. And then we would kind of deal with accordingly by a mix of strengthening and proprioception training, which is kind of like your joint position sense.

So help their body identify and figure out where the shoulder is in space to allow their muscles to react in an adequate way. So it's a mix of sensory training and motor training, which is kind of like the typical resisted based program. 

Mark: So weight training of some or resistance training of some kind basically is a big part of that.

Iyad: Of course, we would want to make sure that they're able to handle the forces that they need to put on their shoulder day-to-day. So that's going to be a part of it, but then it's not enough just to kind of do blind strengthening. Sometimes we'd need to also do some kind of coordination training. And this is where the proprioception exercises come in.

Mark: So that's sort of the, what do they call it where you're feeling things in a certain way. What do you call that kind of training? 

Iyad: So here's an example. So the easiest one that most of us are familiar with is how do you stand on one foot with your eyes closed, for example? And the way we do that is we get tons of signals from what we call Somato sensory fibres. So those are things like our skin. Our muscles, inside the muscle there's a thing called the spindle. We also have little organs in our tendons. So all of those things will feed back into our brain. Our brain kind of puts it all together and it responds according to changes in those signals. 

So in doing the training, for example, after an ankle sprain, we would do tons of balance training to help boost that system. And this is kind of, you could think of it, I guess, in loose terms like balance training for your shoulder, in a way.

So we would do you know anything from weight bearing to different kind of more, I call it kind of like when we get you to do a math problem with your shoulder, or we give you a task that involves you needing to balance or coordinate changes in weight and your shoulder just has to kind of learn to balance and stabilize itself.

And we can progress that sometimes by adding a little more complexity like weight-bearing, or like maybe removing some of the visual stimulus, like closing the eyes and things like that to help kind of boost that system a bit more. But that's just kind of broadly speaking in each person's going to come in at a different level. Some people are able to do a lot. They run and, some people are going to be moving a lot slower.

Mark: When these kind of things happen, is it possible for instance, to have like, the way it worked with me was I got throwing injuries without warming up properly, starting too young. And my shoulder was always stiff. Like I lost range of motion in my shoulder. And then doing martial arts, doing jujitsu, got arm barred a few times. And then finally a really good one, I heard a pop in my shoulder and then suddenly the range of motion is back, but it's unstable. Is that fairly typical or possible, obviously it's possible. Is that a typical? 

Iyad: Yeah, so what sometimes you can have is a shoulder that is not fully relocated, so it's kind of sitting slightly out of place. And that depends on if it actually was relocated or not. You could have had, for example, a different kind of stiffness. The stiffness could be protective. It could also be that you just stopped moving in that way to protect yourself. Could be there's a lot of reasons why that could happen.

Now, in your case with the arm bar, you said, yeah, you felt a bit looser, but then it became a bit more unstable. I mean, that would fall into the traumatic kind of thing. And you probably ended up moving the ball the too far forward in the socket. And that's what did that.

We want mobility sometimes, but sometimes too much mobility could be a detriment. Especially if you think about mobility with no end, it could be a bit detrimental sometimes, especially if your muscles and your ligaments are moving past their natural end. So I think that could happen.

But the most typical one would be if somebody's really, really stiff after an episode, it will tend to be because either that the shoulder was not relocated, then they think it's fine. It's just a bit stiff. Or sometimes it could be due to protective stiffness. And in some cases we do ask people to go get to the hospital and get it checked because a dislocation can impact a structure called the axillary nerve.

So usually people with axillary nerve issues will present with a slightly different set of symptoms. And we always are vigilant for that in clinic, just to make sure that there's no nerve involvement because the nerves tends to wrap around kind of the neck of the humerus, which is kind of your shoulder bone.

So yeah, there's lots of things that we'd want to keep an eye out for. And again, each person is different. Some people just have a dislocation, get it relocated and then do very well in rehab. And some people never really cope well with it and might have to consider a surgical route. I guess it depends for the most part on your age, your level of competitive involvement in sports and things like that and how you respond to rehab really. People do really well, but there's still a subset of people who will need a surgical intervention. And we would work really closely with an orthopedic surgeon on the management there. 

Mark: So with all the range of motion that's involved in the shoulder joint, what's kind of the process of diagnosis to try and determine what's going on?

Iyad: Yeah. So the story's a big one, of course. Like you have people coming in they're like I can just feel extra movement, extra clicking. I don't want to really pull my arm up. There's a lot of apprehension that comes with this and the apprehension is actually quite a good sign. Where people feel like their shoulder's, just a bit different and a bit looser.

And there are some clinical tests that we do to test for that, that potentially can strain or stress the capsule, which is, think of the white stuff that you'd see on a drawing. Not the red stuff that are the muscles, but more like the ligamentous tissue. So we would stress those in different planes.

Obviously we do it in a controlled way that we're not just yanking the shoulder really fast and that can help us identify the direction of potential injury. And then from there, we would try to also figure out the baseline for strength and function and then go from there. But yeah, we would want to do some testing to figure out if there has been movement, excessive movement in there, or if it's just apprehension, because sometimes you can create a bit of a fear response. So I've had lots of clients who have tested very normally on the tests, but have a ton of apprehension and they don't let you go there. But the second you rest your hand on their shoulder, they can move really well because the apprehension kind of eases up a bit.

So there are people who we need to train for confidence almost as much as, and kind of to help that nervous system attenuate that response just as much as we need to fix the structures sometimes, you know what I mean? So it's not always a structural damage issue or a structural stretch to the ligaments.

Sometimes people just come so protective of themselves, and this is something that happens, not at a conscious level always because the nervous system is pretty complicated that way. And that's your body's response to excessive movement. You just try to put the kibosh on everything and just pump the brakes.

Mark: So clearly there's no typical course of treatment, but what would, you've mentioned some of the things that are, can you give us some examples of what the people would look at in terms of treatment? 

Iyad: Yeah. So let's say if you come in with full range of motion to start, obviously that shaves off a bit of time. If you're not, then we'll have to look at improving your range of motion again. And then the reason we have that is well after the injury and after the reduction, there's a period sometimes for some people that are going to need to go into a sling. So the sling obviously, immobilizes the shoulder a bit, the sling will also sometimes cause a bit of stiffness. So that's going to be the first bit to start moving the shoulder. And we move it in a way that's not necessarily excessive, but we need to kind of push it a bit. 

And then we start identifying strike deficits. So we would do just kind of your typical rotator cuff strength and also scapular muscle strength. The muscles in the shoulder blade are really important, but the rotator cuff tends to be non-negotiable here again. And then we try to just see the quality of movement and coordination. But then again, this goes back to the same idea of previous things that we talked about.

So for example, if I have a high level baseball player who needs to pitch at a very high speed, their recovery is going to be so different to somebody who fell down the stairs and just needs to be able to walk. And do their own activities of daily living, like, you know, washing their hair or doing your dishes and stuff like that. Brushing their teeth. It's just things like this, that really determined the length of treatment. 

Typically the more you need from your shoulder to the longer you should expect to need to work on it. But this is why it varies because, you know, you could have somebody who just had this at the age of 50 or an 18 year old who is super involved in five sports and just needs their arms for so much more than somebody else. And that's kind of where we can tinker with it and kind of look at developing a very comprehensive program for that person.

Mark: Complicated. Shoulders are complicated. You need expert help. If you're shoulder just doesn't feel right. It's clicking, it's making noise. It hurts to do things. You don't want to reach up over your head anymore. You need to get that looked at and get it looked after. And the experts on this are at Insync Physio. They have two locations. Cambie Street in Vancouver or the North Burnaby office. You can call and book (604) 298-4878. On Cambie at (604) 566-9716. Or for convenience, book online at Both clinics are there. You can see who's available and get in to see them. Get your shoulder looked after. And get back to living your life the way you wanna live it and your sporting life, the way you want to do it. Thanks Iyad. 

Iyad: Thanks Mark.

Rotator Cuff Pain with Iyad Salloum

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mark: And recovery times? 

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

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

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

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

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

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

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

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

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

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

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

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

Iyad: Thanks Mark.

Low Back Pain Sciatica with Iyad Salloum

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thanks Mark.