Exercise Intolerance After Concussion with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum, he's the clinical director at Insync Physiotherapy in North Burnaby. And we're gonna talk about concussions, specifically something where people can't exercise after concussion. What's going on with this Iyad? 

Iyad: Yeah, so exercise intolerance after concussion can happen quite commonly. And people don't really notice it initially, obviously because there's so much going on. So, you know, you're resting after the first couple of days of it. But then when they get the advice, the proper advice like, we need to get you moving and start walking more and doing stuff, that's where we start to see people developing certain symptoms. And one of them being we have an energy crisis in our body after a concussion, because that's kind of what happens with the pathophysiology of the disease. So you're already kind of trying to remedy.

The other thing that you are also gonna notice is there are impaired kinda changes in blood flow to the brain. And we think that could be a reason why people have really low tolerance. Especially whenever it comes to anything cardiovascular. As with concussion though, if their symptoms are headaches or dizziness or brain fog or loss of balance or anything like that. There are a lot of contributors. 

So what we would do in the clinic is try to figure out, okay, are we dealing with potentially a case of whiplash that's contributing to some of these things, tends to go hand in hand where people get a concussion, they also get whiplash. The other thing that we also look at is to see if there's any, let's say, vestibular involvement or visual disturbances that are also contributing to this.

And once we have a good idea of what's going on, would try to do an exercise tolerance test. And we monitor things like heart rate, exertion and also like how much they could do. And based on the numbers that we get, we give people a prescription to get started because it tends to actually work really well when we get them moving.

But we would just have to do it to, let's say, like a below threshold level of exercise. And I think the biggest mistake people do is sometimes doing an all or nothing approach where they go all out until they're wiped or they do absolutely nothing. And they're like, Hey, I'm not better with walking cuz I just rested for the last two weeks. Why am I not better? So, you know, that's kind of probably a common story that we've talked about with lots of other injuries, but that's how we go about things and that's how we try to figure out what are we dealing with. 

Mark: So you mentioned something interesting. Energy crisis. What did you mean specifically with that?

Iyad: So after a concussion, you don't need to hit to your head to get a concussion. But let's call it the area of the brain that's injured. Is not the only area that gets affected because we have potentially a cascade of injury where any cell talking to the cell that's affected can get also affected.

So that's kind of like a little big bombardment that happens distributedly in the brain. And luckily we have a good immune system that kind of tries to reign that in. But because of all of this that's happening, we have suddenly a release of certain neurotransmitters. And that could basically like, I guess trying to simplify the pathophysiology, but because of that, you have a sudden release of lots of stimulation focused neurotransmitters.

And you know, imagine like you're squeezing everything in your body all at once kind of thing. That's gonna cause your muscles to tire. While your brain can also get tired when it's overstimulated and it costs a lot of energy for us to try to heal from that. The brain is quite good at consuming energy.

So what we end up seeing is changes, for example, in people because the brain consumes so much glucose and energy and stuff like that. They just feel tired all the time. And that's kind of what the energy crisis term stands for. In, try to heal from the injury and try to rein it in to get a bit of that.

But then if you think about also the blood flow impairment, potentially to the brain and the disruption of the fight or flight nervous system which is what we call the sympathetic nervous system. You have all these factors coming in together that basically give you really poor regulation of your energy systems.

And then, one way we find that we could kind of get that under control is with some form of graded exercise program that's kind of tailored to that individual so that they can actually handle what we're trying to subject 'em to a bit better. 

Mark: And so the typical course of treatment might include, like walking at a slow level, even if they can't tolerate like at a quick level or walk us through that a little bit. 

Iyad: So part of the testing is we would start doing a good neurological exam, obviously right off the bat. We wanna see if there's anything serious. So if there's anything that I see that is above my pay grade, I'm gonna pass them on the appropriate services.

This obviously depends on when we see them. We're lucky if we catch somebody really early and then if somebody's been a few weeks, then it's a bit different because they've done most of the basic recovery, let's say, and now they're dealing with just this intolerance issue. Cuz they haven't done any form of exposure to any activity and movement and stuff.

And then once we're clear, let's say, the really nasty stuff, we start looking at a few other systems and then based on that, we'll give probably some kind of treatment to the neck with exercises and with other therapies, like manual therapy or whatever's appropriate.

 If we see vestibular issues, we would do that too. And then alongside of that we need to figure out what can you do comfortably and safely you know, as a stress on your overall body. Usually some form of aerobic exercise, cardiovascular exercise, like walking or biking or whatever.

And then we would find that spot that they could handle and give them prescription appropriate based on that. So if you could only walk slowly, you walk slowly, but if walking's too much for you, we can get you on a stationary bike. There's a lot of things that we could do to, to kind of let's say work with you on that because some people have really bad neck injuries that happen with it and they can't tolerate walking cuz of the bobbing of the head sometimes. And that can give them all the symptoms. 

So if you minimize that, all the shaking that can happen in their neck, cause that really throws 'em off is we get 'em on a stationary bike where there's a little less sway and impact control. So you get a bit creative sometimes according to who you have in front of you. And obviously if somebody's never really experienced in the gym and not comfortable on a stationary bike, walking still might be the best way to go. Or they like the elliptical better. We can kind of play with the preference of the person and just give them something appropriate to them. 

Mark: So bottom line, you still have to move. 

Iyad: Yeah. So gone are the days of lock yourself up in the dark room for a week or so. And I mean, we look at that now potentially as a cause of worsening symptoms. You know, if you're actually isolating yourself from all the stuff. We obviously wanna control the stimuli, let's say at the beginning, for the first two days or so, but usually we try to get people moving within the first 48 hours. You know, it's not an arbitrary move. We would look at them, make sure that it's actually safe for them to move, and then we kinda give that advice appropriately.

Usually it's coordinated between us and their physicians. And yeah, we definitely want people moving after concussion, but obviously there's a fine balance between, hey, go do whatever you want, versus here's how we do a graded exposure program to get you comfortable with things again. Get you comfortable with life.

Mark: So if you've got exercise intolerance after a concussion, this is perfectly apropos with the football World Cup. There's more undiagnosed concussions happening in soccer, football, than any other sport. Surprise. Get in to see the experts at Insync Physio. You can book online at insyncphysio.com, or you can call the Burnaby office at (604) 298-4878. Get expert help, people who are trained, how to look after you properly so you recover as quick as possible from your concussion. Thanks, Iyad. 

Iyad: Thank you.

Shoulder Injuries Instability Strengthening with Wil Seto

So I just got a five pound kettlebell. And we can also use a five pound double. And so we're gonna do an exercise to strengthen up the shoulder, I call it a straight arm rotations. 

So we're gonna just lie down at first. So if it's a heavier weight, so you want to do it in this way, so that way it's a lot easier to get into the position. So you want to be on your side. So with a five pound weight, obviously it's not too bad. So basically holding onto the weight like this. And then you're gonna roll over. And then you wanna make sure you sit the shoulder, so you engage basically the muscles into your shoulder blade. So you're gonna punch straight up and then engage.

And now from here, what I'm gonna do is I'm gonna actually turn. So keeping my arms straight, I'm gonna roll and turn this way with my arm up like this. And what I'm gonna do here is I'm just gonna rotate. And what I'm working on here is just strengthening, rotation strength, integral range of motion. That's really useful. I wanna do this for 30 seconds and do three sets. That's ideal to do both sides. Once per day. 

To get out of it, I'm gonna roll back and I'll just disengage and down.

Arm Numbness Thoracic Outlet Syndrome with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum, the clinical director of Insync Physiotherapy in North Burnaby, British Columbia. And we're gonna talk about arm numbness, a specific cause of arm numbness. How you doing Iyad? 

Iyad: Good, Mark. How are you today? 

Mark: Good. So what kind of symptoms other than your arm is numb? Like what would be the, we're gonna get into the details of this specific type, but what's kind of the clues that you look for? 

Iyad: Usually people would come in and tell you something about, I've seen this a lot with, let's say somebody who develops a shoulder injury of some sort. So they say, Hey, I'm feeling a bit of weakness in my arm. You know, like some pain in certain positions. And then we, for example, could look at that and identify, oh, you have potentially some kind of rotator cuff involvement and maybe that's contributing to the kind of the feeling of weakness and the pain with certain positions. 

And we've seen this a lot work and kind change later, for example, they'll be like, yeah, it started off with the shoulder and now when it's really bad, my arm really feels heavy and numb. And sometimes they describe things as burning. Sometimes they describe things as tingling. So it's that pins and needles down the arm. It's very vague symptoms.

They're like, I just can't put my hand on it. Nothing hurts when I squeeze it or touch it. Cuz people will try to poke, prod their arm and just doesn't do anything when I massage it. So it's just like, why is this going though? 

So, yeah, there are lots of causes for arm numbness. Obviously, we always monitor for that because it could be an indicator that a nerve is getting sensitized. And you know, right off the bat, if somebody presents into our office with this, we would do a pretty good neck examination to figure out is this potentially an issue that is manifesting itself with symptoms down the arm. 

Obviously some people can worry about am I having a heart attack? That's why I'm feeling pain down my arm. And you know, usually whenever we see people like that, I tend to be not the first person who they've seen. Tends to be they've checked who their physician, the physician clears them and they're like, no, there's nothing wrong with that. It's potentially some kind of nerve sensitization. 

So what we think is going on here is that those peripheral nerves that kind of help us do things with our hands. So either, let's say feel the world by reading the signals from our periphery to our brain, or the other way around, controlling the movement of the hands could get sensitized. Once they get repeatedly sensitized, that kind of let’s say, time to numbness gets a bit shorter cuz you're repeatedly, let's say, stimulating an area, so you can get it that, let's say smaller things now cause the arm to go numb. 

The other thing that people could think is like, oh, I might have something like carpal tunnel syndrome. Cause that's the first thing that pops up on Google. However, carpal tunnel syndrome rarely, let's say, cause your forearm and your wrist to be numb. Some people say it starts at the shoulder and goes all the way down. And the other thing that it's unlikely to do is cause numbness in the backside of your hand. So that's not usually what we'd associate with carpal tunnel syndrome. So there's that factor too. 

However, it gets confusing when you google carpal tunnel syndrome and your palm is numb and you see palm numbness as one of the main symptoms of that. So that's kind of where we'd do a good thorough exam on that and figure out what are we dealing with and where should we intervene to, let's say, help this condition.

I guess the name of it is called thoracic outlet syndrome. And there are multiple types of thoracic outlets. The ones we're talking about are not involving the vascular tissues, so there are different types of thoracic outlet syndrome. So again, we're talking about just the one affecting the peripheral nerves and that's their only symptom. It tends to be either, some kind of function disruption of that nerve caused by you know, it's usually a secondary problem. It doesn't just kind of start on its own out of the blue. So it tends to be something kind of predisposes you to get that.

Mark: So, what causes this? 

Iyad: You know, it's the million dollar question it seems to develop after people have certain types of injuries or dysfunctions. So we see it from, there are areas, let's say, that could sensitize a nerve more if they're not functioning properly. So like the neck, you know, we're talking outside of the spine, like, so the muscles here. We've seen it, for example, when somebody can have a car accident and then that car accident beyond the injury to the neck, can also cause them to have a lot of anxiety and change in their, just like the way they hold themselves and they're breathing a lot faster and briefer, so they see their neck kind of really working hard with basic things.

Well, that all of it is gonna cause sensitization from the neural tissue here and it can kind of trickle down the arm. Again we talked about shoulder injuries. Well, if you change the way your muscles behave there, well the nerves have to kind of move through a lot of muscles or tissue as they kind of move down the arm.

Well, if I just kind of sustain a bit more pressure on them, you know, over a long time, they could get sensitive. Again, there's a lot of reasons why this would happen, but typically what we see is it's like a second problem. It's not the first problem on its own. Nerves don't, unless you're dealing with a nerve condition specifically, which again, would be a different story then. We're talking here like where you have a musculoskeletal injury that could potentially spill over and cause the nerves to get sore.

Mark: So this must make it fairly difficult to diagnose. 

Iyad: It could be, but we can kind of piece it together by looking at, like, you'd have to diagnose a few things. You'd have to, let's say, assess the function of the entire limb. But then it's not just enough to just, let's say, test the nerve for conduction. Because a lot of these people can have normal nerve conduction tests, let's say like what we would do like for strength testing and sensation testing because they get it periodically. So it could be just that the nerve is getting sensitized. 

So I'll give you an example. So if you just tap your funny bone which is where your ulnar nerve is. You can get a lot of sensitization down your arm and it really hurts. However, if I was to, let's say, test you outside of that time where you're pinging your funny bone, you're probably gonna be okay. So another thing to kind of keep in mind is, usually where we're assessing is just is the nerve involved or not. Because usually people tell you, Hey, it's numb, it's tingly, it's that.

So you kind of figure, okay, we're dealing with potentially a nerve here, but maybe the more important question is, well why? Why is this happening? So we would look at the affected areas and usually the treatment would be exercises that could target, let's say sensitive nerves, but it's probably not enough just to do those on their own. So if you don't address the original complaint of why this thing got sore in the first place, it's usually again, you have to do a bit of both. It's not enough just to do, oh, I'm just gonna deal with the symptom of the nerve getting sensitized and tingly and all these kind of things. 

Mark: So, typical course of treatment looks like?

Iyad: So depends if we think the neck is the primary involvement, we would start with the neck and we would try to clear that. It would take a few weeks usually on average. But we really like right off the bat, try to get people to learn and to recognize, let's say patterns of sensitization. So there's the way they breathe potentially, that could be one of the things that we get them to kinda clue in on and then teach them different ways to do it.

You know, breathing tends to be overlooked as a thing. We think, oh, I could breathe. I could just bring air into lungs, that's fine. There might be easier ways for them to do that and slightly better ways and more optimal ways for them. The other way is if we identify some kind of shoulder dysfunction or weakness we can also address that. And that tends to help a lot.

And sometimes it's just like habitual positions that people adopt. They don't think it's, for example, pulling your shoulder blades way back excessively, which might be looked at by some people as good posture. Might not actually be helpful in this case. And it can actually make it just more sore. You're unlikely to damage things by pulling your shoulders back, but it's just kind of, you can kind of keep it sore, if that makes sense. 

So we would just teach them those patterns, teach them things that feel good or relieve those things. And then, you know, eventually the second phase of it would be trying to expose people to the things that hurt them, because you don't want any movement to be a hundred percent off limits forever. That doesn't really seem to work with a lot of people.

Mark: Unless they can't brush their teeth anymore with that hand. Yeah. So if you're having issues with arm numbness and you want expert diagnosis, as you've heard, it can be really complicated, but the causes can be found. Get the detectives at Insync Physio in North Burnaby to help you out. They're experts in diagnosing this and coming up with a treatment plan that's gonna get your numbness cured essentially, or lessened at least. So give them a call at (604) 298-4878. Get in there sooner rather than later, or you can book online at insyncphysio.com. Thanks, Iyad. 

Iyad: Thanks, Mark.

Ultimate Frisbee Knee Pain with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver, Vancouver's best physiotherapy office, many time winners of best physiotherapists in Vancouver as voted by their customers. And we're gonna talk about Ultimate Frisbee knee pain. What's different about Ultimate Frisbee and knee pain Wil?

Wil: Well there's a couple of things I want to address with that. So there's the traumatic side of things, where you can have an impact injury or something happens where you maybe not have an impact from another player or contact injury, where you might have done something to it. So the traumatic injury. You might have strained something or torn something from another ligament or a tendon or something related inside of knee joint, like a meniscus. 

So basically that traumatic injury, you know, those ones they happen definitely a lot, but the other side of things are the non-traumatic type of knee injuries and non-traumatic knee pain that also happens quite a bit. A lot of players, when they're playing Ultimate, and I've worked with a lot of different Ultimate players from different national teams, from different world championships, world games where, you know, it happens at all levels. So it's not just the beginner is starting off.

It happens even with the intermediate, more advanced veteran to like, they're competitive, like world class type of player. And so I wanna talk a little bit more about that today, the non-traumatic type of injuries. And those are the ones that are like, well, I don't know really what's going on. I didn't really do anything. Or they may not necessarily feel the pain until later on after the game or later on that night after you take a shower or waking up the next day. And then it sort of gradually builds or it may feel more sore at the beginning of a practice or warmup or when they first start playing. But then it kind of goes away, but then it it sore again after.

So those are classic symptoms that we see quite often with Ultimate Frisbee players. And so we treat a lot of Ultimate Frisbee players at our clinic. You know, we've been working with the Vancouver Ultimate Frisbee League for quite some time now in partnership. And so with these type of non-traumatic injuries, what we see a lot of is this specific type of knee issue, it's called the iliotibial band syndrome.

And it's basically a movement dysfunction issue. And so you can build up a lot of imbalance where you have this thing called the IT band. It's a connective tissue that basically connects from the outer upper part of the hip, all the way down to the outer part of the thigh, lateral thigh, the knee, and its function is to really hold the thigh muscle and then part of that lateral hamstring and all those muscles on the side that tied together. 

But like when everything starts to get really tight, you gotta ask in the history, how are you recovering from your games? How are you recovering from your workout training sessions? And that usually says a lot too. And so they're probably not doing the proper things to recover those muscles and they start to pull onto that fascia or that connective tissue to the IT band, and causing that knee pain, which is usually more on the lateral or the outside of the knee. So that's your classic symptom presentation of this type of non-traumatic knee pain, most often. 

Mark: So the possible causes really are over training and not recovering properly. Could we sum it up that way? 

Wil: Yeah, pretty much. You kinda have to dig a little bit too, history wise because, you know, there's a few Ultimate players that we're treating now that they've had some injuries in the past.

So for example, you know, if you've had an injury on the other knee, okay, so now you're compensating a little bit more on your knee that is now affected. So that compensation, you know, is why you're getting the knee pain and so there may be stuff that's going on, right, where you never fully rehabbed, or it's not fully strong enough on that knee that you originally injured and you're compensating on that knee that's now affected, that you have that gradual pain. They're like, this isn't even my injured side. I don't know what's going on. We hear that a lot. 

Mark: So you've diagnosed it, you've dug into the history, you're pretty clear on the direction, what's the course of treatment look like? 

Wil: So we wanna look at what the driving factors are to this knee pain. So what are the muscles that are really tight and pulling on it. Or is it the IT band just really super tight for whatever reason. And usually though it's a series or a few different areas pulling on it. So you gotta figure out what it is. And so once you figure that out and you start to work on increasing that mobility in those areas, then what's really important is to address the functional part of it.

So you gotta get things stronger, but then you have to help that person retrain the way they do their sprints again. The way they cut. The way they want to move on the field because if we just release it, it'll help for a little bit, but it'll most likely come back if you don't do other things to, you know, even strengthening, we can give you some strengthening release stuff. But likelihood of it coming back is pretty high, if you don't address that muscle activation pattern.

So could we sum that up even as saying like, when you've injured yourself or in the gradual process of injuring yourself, you've adopted unconsciously ways of moving that are not good. They're gonna cause the issue to come back up again. And that needs to be addressed. That needs to be, you need to relearn that basically somatically.

Yep, exactly. Yeah. You need to relearn that on a neuromuscular level. That's a big word, but it's basically trying to learn how to walk again for the first time like after you've been on crutches because you broke your leg and now you're like fresh out of the cast or whatever. But it's harder to actually relate with it because now, well I've been running and I'm playing, so I don't know what's wrong. Like why do I need to relearn that? But like, it's amazing how when we show people and we give people the exercises to do that are weak, they're like, oh my God, I can't believe how weak this is. Or, oh, I never realized. Like, I can actually play a full game, but I can't even do like one set of 10 of what you're giving me here because it's so difficult.

Mark: Expert diagnosis, expert exercise prescription so that you don't re-injure yourself. The people to see are Insync Physio. You can book online at insyncphysio.com. They have two offices in Vancouver and North Burnaby. You can call the Vancouver office, (604) 566-9716 to book your appointment. You gotta call and book ahead. They're always busy. Thanks Wil. 

Wil: Thanks Mark.

Hip Pain in Older Women with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, British Columbia. We're talking about hip pain today. This is probably even more common than I would think with older folks. Is that right? 

Iyad: Yeah, so the specific thing we wanna talk about is you know, specifically outer hip pain. When people tell you, you know, the outside of my hip feels a bit sore and it kinda tends to be quite limiting and very painful in certain cases. You'll see it favouring, let's say an older population and it tends to affect even women more than men, quite a bit more, unfortunately. 

You know, there are several causes for this that that could maybe predispose women more than men. We've actually been seeing a couple more of these, we had a really sunny October, so people were out and about moving around a lot more. And we saw this in a few hikers, you know, so we had a couple of seniors coming in actually just happened to come in the same week, same exact presentation, just went on a big hiking trip, and then suddenly started developing soreness in their outer hip.

And, you know, it feels a bit tight, feels a bit stiff, so they start stretching and then it starts to get progressively worse. To the point where they just tell you that they can't lie on it, they can't really sleep well. It kind of gets really, really bothered. 

He could walk a flat line, but that's about it. Like any kind of incline or stairs gets to really, really become bothersome. And I think the reason it's a tough one to kind of almost get at is because it could present also like an arthritic hip. So when you have arthritis in your hip, it can also give you pain in the outer hip and, you know, on excessive exertion.

But the thing we're talking about specifically affects the actual tendon of your glute muscle, your glute med muscle where it in inserts to the outer hip. Though that tendon can get affected like any other tendon, like our Achilles or our patella tendon. And it tends to get really aggravated with changes in your, let's say, loading patterns.

So if you, you know, haven't really been active that much, and you start doing a whole bunch of incline walking and stairs, well that'll do it. And then, when it flares up, it tends to get really aggravated with stretching , even though you might not be harming it just really, really gets irritated and triggered with repeated stretching. And then unfortunately it feels, you know, tight and uncomfortable, so people have the instinct to try to stretch more sometimes. 

Mark: Other than just an increase in load, are there any other causes that manifest this? 

Iyad: We do see it with impact. So if you fall flat on your outer hip, and if you're you know, if we're lucky enough not to have any like bony injuries or anything like that you can get that.

Because your glute tendon, especially glute med tendon is quite exposed on that outer hip. So we have like a big bony prominence, just the beginning of our thigh, just below the pelvis, and that's where those insert. And that really plays a huge role, that muscle, it prevents us waddling when we walk when it works, you know, normally. And so that could be a reason. And then when most people kind of end up Googling it, they find something called trochanteric bursitis, which is the most commonly viewed thing where it's classified as the inflammation of something called the bursa, which helps kind of almost like lubricate the surface between the tendon and the bone.

However, what we're finding is that bursa seems to be a victim of just the tendon at large. So if the tendon sore, the bursa could get sore. It's hard to get the bursa kind of happening on its own. You'd have to have some very specific mechanism or somebody rubbing that specific part only to get it. And it's really rare that you just get it out of the blue. 

So when we see, a lot of the times our first thing to do is actually try to identify are we actually dealing with that versus let's say an arthritic hip. And the management's really, almost a bit surprising to a lot of people cuz we will exercise it a lot. But we would just start off with also avoiding certain things like a stretch for the first week or so, just to give it a break. 

Mark: And what is the typical course of treatment? 

Iyad: So, again, you wanna identify triggers. So it's a lot of, let's say, not necessarily avoidance, I would just say, let's call it controlling the triggers. So if you can do a little less of that, that would be really good. We wanna keep people active, obviously, as much as possible. So like if somebody's used to walking a lot and we wanna keep them walking, ideally we would find a distance they're comfortable with. We would probably change them from walking big hills to more like a flat surface, a flat road, even on the treadmill, if they could tolerate that.

So that's number one. It's really important not to let people kind of decondition, you know, cause they tend to have taken quite a significant rest when they come and see us already. And it doesn't seem to kind of go away. They're like, oh, it only feels good now when I'm not doing anything.

So the second they get back to activity, it flares up. And then we will try to give specific exercises that, let's say are tolerated by that affected tendon, but also let's call it like comfortably uncomfortable, so that it kind of tends to work well without flaring them up for too long. 

And and then obviously it depends on your goals and where you want to go. So if you are trying to just get comfortable walking 30 minutes a day, obviously your treatment isn't gonna be the same as somebody who's trying to get back into running or doing some pretty intense hill work and hiking and stuff like that. So that's where you'll see a big difference between different people. And it depends a lot on their goals and where they're at already. So some people tend to be very, very affected and some people are less so. So it's not like a, a one size fits all because of the spectrum of presentation and also goals that people wanna get to. 

Mark: So is this a thing that if you just quit and didn't do anything for a year, it would go away?

Iyad: It only seems to get better at rest. That's the thing. So rest makes it better at rest. That's what we're finding with actually almost all the tendons in our body. And I mean, it makes sense, you know, we constantly think of muscles as atrophying, but tendons actually really get affected structurally when we don't put like the right amount of, let's say, stress through them. 

So yeah, like it'll probably feel better when you're not doing much. But then the second maybe you return to any form of exertion on that area, it can flare up and people think, oh my God, I thought I got rid of this. And we see it a lot. We see it with shoulders, we see it with everything. We see it with Achilles tendons, we see it with even some cases of knee pain where you know, we think rest is the way to go. But really the key thing for us tends to be about finding an activity that anybody with this can tolerate and kind of progressing them from there. And they do really well, exercise programs tend to be quite effective here. And we're having a lot more studies show that compared to other, let's say even pharmacological interventions, which is quite good. 

Mark: If you're having some hip pain get in to see the folks. Sooner is better. Always. Your recovery will probably happen quicker. The sooner you get in there, rather than you waiting around. It ain't gonna get better by itself. Go see the folks at Insync Physio in North Burnaby. You can book online at insyncphysio.com or you can call the office to book. Burnaby's office number (604) 298-4878. They also have a location in Vancouver and you can book online there as well. Thanks Iyad. 

Iyad: Thank you.

Rock Climbing Shoulder Pain with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver, one of Vancouver's best physiotherapist clinics. And we're gonna talk about rock climbing and shoulder pain. How you doing Wil? 

Wil: Yeah, I'm doing good, thanks. 

Mark: So shoulder injuries from rock climbing, I guess this is fairly common?

Wil: Yeah. So rock climbing injuries in the shoulder are quite common. I mean, they make up you know, one of the top three in terms of injuries when it comes to climbing injuries. You know, and primarily when we're looking at shoulder injuries, you can classify them as either you know, like traumatic type of injuries, acute injuries, or non-traumatic. Or I guess where you could say is chronic overuse type of injuries.

And sometimes when we get them, you know, these chronic overuse injuries, it can all of a sudden be like, Oh, that's like a sudden acute thing that never happened before. So what I'm speaking about specifically is this condition that is referred to as shoulder impingement.

So the big question is, well, what is that? It's kind of an umbrella term. Because when we think of shoulder impingement, basically the things that are kind of in the shoulders that you have, like basically certain structures like your, your tendons and, and the main structure in there, your rotator cuff tendons, that can get pinched.

And the main reasons for that is usually there's an imbalance. And with rock climbing, you tend to overemphasize a particular set of muscles. And then there's also a set of muscles that are under-emphasized. And so when you have this imbalance happening, then you can alter your mechanics in your shoulder.

And just with the nature of climbing and in terms of overhead loading repetitively. And then especially when you're looking at you know, the types of climbing, if you're doing a lot of what's called bouldering, where you're not using a rope and you're just sort of climbing up short distances. And these days when you go to the climbing gym, the bouldering gym specifically, where some of these problems that they call them root problems and bouldering problems, quite gymnastic like very parkour like and require a lot of like hanging and just with the arms. And then you do it over time and recognize like, you know, in terms of the recovery aspect of it, then you can really start to bring other problems. 

Mark: So I'm sure it's probably a painful injury. What are other symptoms that are showing up? 

Wil: Yeah, so the biggest one is that you know, it can happen during your training session or your climbing session or might not appear until the day after. And you start to get pain just with like trying to carry something, like say you go to the grocery store and you notice, Oh, I'm starting to get a little bit of a pain. And and another thing is like, you're maybe just reaching up into your cup to grab your mug for coffee or tea or your beverage for thing in the morning to even just like lowering the shoulder down without any weight.

And then you get this like sharp pinching pain. And so what ends up happening is that you have this imbalance that's already been developing there for quite some time. And so the individuals that are more prone to having this happen, you know, are usually like beginners that are just starting up climbing.

Or even more advanced climbers who have taken a bit of time off who just start back up again and now they're just like learning how to reload their body. So you have sort of this muscle memory in your head, but then your body needs to also be conditioned. Or you may be like a seasoned climber, but now you're upping your training and you're upping your game and with doing more higher intensity workouts or climbing sessions. When you're pushing the envelope a little bit more, now you really gotta look at recovery in a different way.

And part of that recovery, it isn't just about stretching, it's really looking at, well, where are you tight? Where are you imbalanced? Is the primary key to all this? Like, where are you really tight and basically always using those muscles all the time? Or weak. Where are you not like up-trained enough, where certain things can stabilize. 

So in your shoulder you have muscles that work on stabilizing the shoulder so it moves properly. So you get better movement and mechanics happening when you're doing complex movements with loading and ballistic type of movements, sometimes when you're climbing.

Mark: So how are you diagnosing this when someone comes in? 

Wil: Yeah, so obviously, after taking a history and asking questions we run them through a bunch of tests. Cause you know, the biggest concern a lot of people have is like, Oh, did I tear something? Especially if they come in and it's been like a week or two weeks because you can actually have this type of faulty mechanics and you're getting this impingement, it could be going on for like 2, 3, 4 weeks and you just haven't done anything about it because you thought that maybe you could do it on your own. It just doesn't go away. 

So yeah, we take you through a bunch of different tests and look at what's going on. Our physio team, you know we see a lot of climbers and we run you through different things to do and we look at did you tear something? Did you actually tear a ligament in there? Did you actually potentially have a tear in your rotator cuff. Which we can talk about in a different segment as well. Or is it more of a higher probability that it's just a mechanical thing going on? 

So usually if it's just a mechanical issue of what's happening under the shoulder and the rotator cuff with the impingement, then we usually get really, really excellent result in as little as like a one to two, to up to three treatment kinda thing.

Mark: And so what is the typical course of treatment for this? 

Wil: Yeah, so like I was saying, you know, this kind of stuff usually doesn't happen overnight. So we look at the impairments, like the things that are not working properly. So maybe you've developed some stiffness in your actual shoulder capsule. So then we have do some things and manually work that out. You know, maybe there's a lot of this imbalance where we gotta manually facilitate mobility to go in that area. 

So we do certain things on a manual basis after we've assessed it. And it's pretty clear, like this very clear sign if it's impingement, we do these things. It almost like instantly better. If we're talking that it's just strictly a biomechanical thing and you don't have any tearing of a rotator cuff. 

And then what's really important after you feel this instant, sort of like gains, is the reinforcement of your mobility patterns that we give to you, to mobility exercises and specific strengthening for stability and for functional strengthening. Because we wanna try and keep you climbing you know, as safely and as hard as possible.

Mark: So if you're having some shoulder pain, that suddenly come on but maybe you've up your game, rock climbing, bouldering, or you're just a beginner and suddenly you're finding, ah, it's hurting. Get in to see the folks at Insync Physio. They're experts. They're rock climbers. They're people who know what's going on. They'll be able to diagnosis and get you feeling better. You can book online at insyncphysio.com. Or you can call the Vancouver office at (604) 566-9716 or in North Burnaby, have another office, (604) 298-4878. You can book either of them online. Thanks, Wil. 

Wil: You bet.

BPPV – Vertigo with Iyad Saloum

Mark: Hi it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. Today we're talking about something that I think is, I don't know how common it is. It seems to be fairly common cuz we've talked about it a few times where the world spins all around you. What is going on with this Iyad?

Iyad: Yeah, so it's a condition called BPPV, where most of the time we get people coming in and complaining that whenever they either lie down or they turn their head to certain direction, they experience an illusion of the world spinning around them. Like the room spinning around them. I had one recently describe it as I feel like my head is spinning inside itself. 

And what tends to happen with that is inside our inner ears, we have an organ called the vestibular organ that kind of functions like an accelerometer that would be in your watch. It measures certain things and your head uses it, your brain uses it to figure out what's happening with your head, so it can kinda code for different movements of your head.

And some of these things in our ear will be gravity sensitive, and some of these things will just be rotation sensitive. So not so much sensitive to gravity. However, the things that are gravity sensitive, there's little crystals there that could get dislodged in one of those canals that usually are better at telling us about turning. And when one of those crystals can get one, or a group of those crystals can get kinda blocked in there.

And all of a sudden I get a different illusion of movement when I turn my head because I have my regular movement happening and then this crystal trickles a little further down and then I get a next kinda second bout of movement. But my brain only feels that on one side. So what happens is this kind of mismatch between left and right can cause us to feel like the world is spinning.

And it tends to be really terrifying for a lot of people when they get it because they feel like, oh my God, what's happening? Why am I spinning so much? And it just cause it tends to come out of the blue usually. Luckily it tends to be, and as for its name, benign, that's what the B stands for. It tends to not cause any serious harm beyond, you know, feeling like the world's spinning around you. And it's quite treatable, which is the good news. 

Mark: So let's talk about causes. Why would this happen? 

Iyad: The million dollar question. We don't know specifically why these things happen. They can happen spontaneously with a lot of people. In some cases we see head trauma being associated with it, but it's not really a clear definition.

So like, let's say if you were to experience any kind of impact to the head, you're not guaranteed to have it. However, we do tend to see it sometimes, like let's say there's a higher likelihood of it happening after an impact to the head. The other thing is, it tends to affect people who are a bit older, but we don't know if age could be a risk factor.

But it seems to be linked more to people who are a bit older in age. But that being said, I've treated people who are in their twenties with this, and I've also treated people in their nineties who have this. So honestly it's one of those things that the main way we distinguish it is by the pattern and the time that you stay, like in spinning, let's say. 

So the pattern tends to be associated with a head movement or any kind of change in position of the head. So people will tell you, oh, I was lying down, then I feel it for a bit. And it tends to last a short period of time. So like a couple of minutes would be as high as you would think. Most people tends to be about 30 seconds to a minute and then it settles down and they kinda tend to stop and try to brace themselves to prevent more movement. 

As far as, I guess on the biggest impact it would have is on your ability to do most things in life. You know, driving becomes a little interesting and walking up and down stairs where you have to move your head. So it tends to scare people a lot. 

And the whole reason I wanted to talk about this is, we've had a few cases in the clinic where, people go see their physicians get diagnosed adequately with the condition, and they get advised. Tends to be phone consults for the most part, to try something called the Epley Maneuver, which is the treatment that you would do, you could do it at home, it would affect about 70% of types of BPPV so it won't really capture all of them. 

And then a few of them say, they come in and see us, like Hey, I tried this thing for about a week and it hasn't really gone away. It feels horrible when I'm doing it, but it doesn't seem to kind of cause any resolution. And really the whole idea of this here is because you have three different canals and the Epley Maneuver can only really address two of those. And sometimes they do it to the wrong side.

Mark: So how do you assess that when someone comes in and they've been to see their doctor and they're still having this world spinning phenomena. 

Iyad: So we, it's a great question. We do have a very simple exam. We wanna make sure, obviously if they hadn't seen their physician, we try to make sure that there's nothing else going on. So we would want to rule out the serious, nasty stuff. And you know, again, we, once we do that, we kind of move into an assessment. We'd wanna look at a few things. If it's spinning, it tends to be related to the vestibular organ. However, if some people just say, your eyes feel dizzy or loopy, or I feel like I'm rocking on a boat, that might not necessarily be the inner ear.

So we would wanna figure out what's causing that dizziness. But if we're, let's say, diving into the inner ear part, we have certain positions and tests that we could place people in. And based on that, we could stimulate, let's say an episode of Vertigo and then based on the direction of their eye movement, and that's something called nystagmus, where your eye starts to respond as if you're actually moving, when you're stationary. We can figure out which, let's say canal is affected and we can treat it adequately. 

Mark: And what is the typical course of treatment? 

Iyad: So usually we would do something called Canalith Repositioning Maneuver, which is a fancy work for saying is we try to move those crystals that are kind of free floating in those canals, back to, we think it goes back to where they came from. But we maybe just think of it as just try to clear them out of that canal.

And what happens then is you restore the normal function of those things cause you don't have this thing that's just kind of jostling in there and maybe giving you a false perception of a movement. And Epley Maneuver is considered one of those, but again, the Epley Maneuver doesn't fix everything because it only addresses the two canals of the three. And then sometimes we have a few other things that we might do. 

The other thing that kind of tends to happen is that the Epley Maneuver only works on a certain type of BPPV. So that's where we are able to, based on the direction of the eye movement and let's say the speed at which they get the symptoms. If you lay them down and within barely any time, they start to get these different movements.

And it might indicate that they have a different type of this BPPV and we have different maneuvers that we could use to help restore that normality. And then some people will experience a small bit of kind of that residual, let's say, feeling off. And what we do with that is we give them certain exercises to help kind of habituate to that and get more comfortable with it.

So for the most part tends to be very treatable. And it's actually like one of the easier ones to deal with as a dizziness. I guess if you wanted to have something, probably would be that. But yeah, nobody wants to get dizzy at the end of the day, but that's tends to be very treatable and the treatment is quite successful.

Mark: If your world is spinning on you, the people that go see are Insync Physio in North Burnaby. You can reach them on their website, insyncphysio.com. Or you can give them a call at the clinic to book your appointment (604) 298-4878. You want physios who are trained specifically in how to treat this. This isn't just any physiotherapist. These are experts in how this works. Thanks Iyad. 

Iyad: Thanks, Mark.

Hip Pain Rehab Deadlifts by Vancouver Physio Stephen Koo

Hi. So today we're going to do a deadlift. And so this exercise is great and I really like it because it strengthens globally and it strengthens our lower back and it helps elongate the hamstrings and just helps us getting better movement globally in a functional chain. So this is what it looks like.

What we're going to do is have our hands shoulder width apart, just making sure that they're going straight down. We're hinging through our hips here. And you're not going down like a squat, but moving your hips backwards, making sure that your shoulder is nice and set, your back is straight. From here come up, hinge again at your hips and then slowly coming straight down.

And you can do this exercise, three to four sets of 10, if you're able to. If you're going at a higher weight, come down with the reps in a little bit. So about eight to 10 reps, three to four sets.

Vancouver Physio Samantha Lee

Hi, I'm Samantha and I'm a physiotherapist at Insync Physio. I enjoy being a physiotherapist because I like being able to create connections with other people and being able to help others overcome their challenges or reach their goals.

Just from my previous experiences, I know that pain and injuries, they can really affect a person's life either physically or mentally. And I find it really rewarding being able to help people and guide people through their recovery process.

So Insync is a really great place to work just because we have such an awesome team. You know, we're always talking, we're always collaborating on different cases and we're all really here to help each other out. We also do a lot of in-services, so that just helps us keep up to date with current practices and evidence.

So I like working with people of all ages and abilities, but I do focus mostly on sports and orthopedics. Outside of work, you know, I rock climb and I play bassman volleyball. So naturally I am just drawn a bit more to working with shoulders and knees.

I also really enjoy the outdoors, so outside of the clinic, I'm also camping a lot in the summer or I'll be snowboarding in the winter time. Aside for that, I'm usually looking for my next travel destination.

Heel Pain Running with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. Well, let's say they're one of the best physiotherapy clinics in Vancouver. Today we're gonna talk about a probably a pretty common thing, I would guess is heel pain from running that's due to tendinopathy. Is that what's causing this kind of pain typically? 

Wil: Yeah, yeah. Well, thanks Mark. That's exactly it. So quite often heel pain that starts to happen with running, you know, you can get what's called Achilles tendinopathy. So what it is, is basically an overuse syndrome or dysfunction. And it doesn't happen overnight.

So you can start to see the bigger picture like, when someone comes into our clinic, and I can think of someone that came in and saw one of our physios, you know he was telling me about this particular individual, and the picture was pretty clear how it all started.

And so essentially, you're looking at all the factors of like did you start running? And like where is the current fitness level at? And are they doing other types of activities that involve a lot of loading in the heel as well.

And then what are the previous injuries or past history of this person? Like, do they have a colourful history? It doesn't even have to be in the heel or the foot or leg. It could be even in the back, because that can add compensations into your mechanics with running. And then even just you know talking about this with you earlier, maybe the person is a little bit more overweight and if they're a beginner runner and you add that to the mix and then the mechanics are off, then with that actual little weight, that's also gonna, you know, basically cause more excessive, abnormal loading in the heel.

And giving you a lot more tightness into the calf, obviously. And then you're gonna overuse your calf to generate power as opposed to your glute muscles, which you really need that power with the extension of your hip. So then as a result, that tightness and that overuse of the achilles of the calf muscle specifically then causes the Achilles to be tight. And then usually the Achilles tendon is the weaker link, not the actual calf muscle itself.

Mark: So, when you're diagnosing this, what's most important? Is it history, to really dig into what's going on with somebody? Or is it testing? 

Wil: Well, history is a big thing in terms of like giving us a bigger picture of how this was caused and started. Cause that way we don't want it to come back. And we also want to address the ongoing mitigating factors that keep aggravating it. So that's huge. And then also as we assess, that's also gonna help with like, okay, yeah, this is what's contributing to it, these are the impairments and these are the actual things they can work on.

And then the other thing is looking at the, like assessing and looking at like, okay, so if it is a tendinopathy, you're gonna get soreness when you palpate around the area. So that's actually a really easy do it yourself home test. If you're feeling sore, when you're palpating yourself on that tendon, then it's most likely that. 

Because one of the other things that you could be getting, it could be like maybe a, what's called a bursitis in your Achilles. And so that's basically the fluid filled sac that protects the achilles tendon from rubbing on the bone. And so you might have a flare up of that. But if it's all along the tendon, like right on the superficial, like inside or outside or right on top, then usually it's most likely the tendon. But it could still be like some kind of bursitis or it could be something else, but most likely it's that. 

And then you look at, you know, other factors, even if you are an experienced runner, which we do treat a few experienced runners and you know, they take a break and then they start training again and they maybe do some hill training. And so that's gonna cause more stress and strain on that Achilles, just the overloading of that Achilles. Because you're always in that motion where it's more outstretched and lengthened and you're loading it more because you're going uphill. 

So that combined with intensity and frequency workouts and runs. And then just like, how long have you been running for? And then, well, what else are they doing? So maybe this person is doing other things like, you know, maybe they're doing a lot of other activities and sports that require 'em to be on their feet all day and then they go for a run. They don't do any recovery things. Those things are all important factors. 

Mark: So we've diagnosed it, we know what the symptoms are, the possible causes, the diagnosis. What's the treatment look like and how long does it typically take? 

Wil: Yeah, it varies. Depends on how long it's going on for, because when you're starting to have symptoms it's probably been going on well before you started to have symptoms. So you sort of reach a threshold until it becomes symptomatic. And you may sort of sub like you're below the threshold of having symptoms, but it's a problem. But you probably have noticed that, yeah, my calf muscles are a bit tight, you know, or I feel a little bit tight, but you don't really do anything about it until it's too late usually. So that's an important thing to look out for.

And so how we actually treat it, you can't actually address the strengthening of that Achilles. You wanna produce what's called collagen synthesis. And so basically what you're doing is you're promoting an increase of strength around the tendons where it's been effected. So you're reinforcing that tendon. So you're getting stronger all around it. And that's the key. So doing specific exercises that are based on research, also not just on clinical aspect of where we found successful, is like things that actually address and target specific and then strengthening. So starting off with what's called isometric strengthening.

You know, where you're putting constant tension force of the muscle where it's not moving. To then eccentric, which is basically constant tension force of the muscle while it's lengthening. And that's key because now you're working on getting more of that, what I described earlier as collagen synthesis are the building, the basic blocks of strengthening that tendon around that injured area, which will help with the full recovery. And we've seen some good success with this. 

Mark: If you're having some ankle heel pain from your running. Get in, get it diagnosed, get your gait checked. Is that a fair thing to say almost for any runner, get your gait checked regularly to see if there's any imbalances, cuz you can't see when you're running, you don't see what you're doing, you're just running. Is that fair assessment? 

Wil: Absolutely. 

Mark: Probably a good idea. 

Wil: Yeah, because there's many other factors to consider when you're getting your gait checked. Like how many steps you're taking per minute. And so that's your cadence and then how your form looks and whether or not your centre gravity forward enough and if you're getting enough power through your extensors. So it's a really good thing to do. 

Mark: People to call, the experts are at Insync Physio in Vancouver or in North Burnaby. They have two offices. You can book online either office at insyncphysio.com. Or you can call them. The Vancouver office is (604) 566-9716. North Burnaby is (604) 298-4878. Thank you, Wil. 

Wil: Thanks, Mark.