Running Gait Analysis with Iyad Salloum

Mark: Hi, it's Mark from TLR. I'm here with Iyad Salloum. He's the clinical director of Insync Physio in Burnaby, British Columbia, Canada. And today we're going to talk about running gait analysis. What's this all about Iyad? 

Iyad: Yeah, we see a lot of runners and some who are very into it and some who are just the weekend warriors and some people kind of want to take it to the next level. We have some very keen people who want to know how they're doing, how their form looks. So we would put them on a treadmill and take them through an assessment to see what things they could improve on from a form point of view and running economy point of view. Things like that.

And then you get also the people who are repetitively injured. Despite doing tons and tons of rehab. And they're like, well, what's going on here? And even when you try to manage how much running they're doing and the whole load management piece, they can still kind of keep cropping up with these random injuries. Like shin splint, hip pain, knee pain. And those are people who would also benefit probably from having their gait looked at or their running analyzed I guess. 

Mark: So what would be, what are some of the causes I guess of, before we get into actually talking about how you do this, what are some of the causes of somebody having kind of a not pure running style?

Iyad: I guess it's good to say that nobody, very few people have a very perfect, where we consider perfect running style. And I guess that's really important to normalize it because if you've adapted to your running form, there's really no need to change it. Now it's the people who, for example, the people I've seen mostly, have read something on a magazine, for example, that says you have to switch your running style from a hind foot strike, do a forefoot strike, where you kind of hit more with your toe than with your heel.

And that's a shock to the system, because imagine if you're running, like I think of a marathon training program and they're running between 40 to 50 kilometres a week. That's kind of on average. And then it kind of sometimes can go a bit more closer to competition time. They're trying to run up their volume. So imagine if you suddenly switch your running form. 

Well, that could change the demands on your body quite significantly. It'll change a lot of things. For example, like the length of your stride, which muscles are kind of going to hit the ground first and absorb more. Even stresses on our bones and ligaments. The average kind of like person never thinks about like, oh, I'm loading my bones when I run. And kind of also putting forces through these structures, but they are things that need to also adapt to tension and pressure. And this is kind of where having things done in a graded way is usually the best way to do it.

But then most people who like you're talking about with what happens is it tends to either be people who do too much too soon, and then they start running differently to avoid their pain, or you get the person who thinks they should run a certain way and tries to force their body to do something that maybe it hasn't been used to for 20 years plus of running.

You know, it's like since we're kids, we're just used to running a certain way and those people, if they just continue doing what they're doing, they were probably would have been okay. But now that they've kind of changed this, they got an injury and they can't seem to figure out what's the best way for them to run. So those are the people who would really benefit from kind of having that piece looked at. 

Mark: So this, if I'm to maybe, shortcut and jump through this, like the root, what we're looking at here is really the root cause of how to make your running form more efficient or less stressful and it's going to be possibly, or probably more effective than changing your running shoes or, you know, the stylish shorts you wear.

Iyad: Yeah, absolutely. So like, you know, the people we're talking about, we're not talking that like, the Eliud Kipchoge level, you know, or trying to shave off a millisecond off their marathon time. We're talking about, just you know, like recreational runners or even like serious runners who are not at the elite level.

Yeah like, definitely if you have old shoes, you should probably have that looked at. But most people do that first. Most people assume, oh my knees hurt, the shoes. Or maybe I should change something, maybe my socks are slipping. They literally change all of these things before they start to consider some of the things like, maybe it's just the way they're running.

And we tend to see these things where, it's really interesting, some people were like, well, I've been doing this all my life. How come? Well, things change depending on the stresses we put our bodies. So maybe people used to be more regularly active. And now they're going into periods where they're working all week and then trying to hit it hard on the weekend.

And those are kind of people who might benefit from having their running form maybe addressed better. Because now they're getting all of that training volume in a short period of time, and it's not leaving them with enough time to kind of cope or adjust to that. So for the most part, those are the people who would really benefit from having that looked at. But again, not every imperfect run needs to be changed because if you've adapted to it over time, you're good. 

Mark: Yeah. So before we get into the actual mechanics of what you're analyzing, you're also looking at what kind of volume they're doing? You're investigating what's their typical pattern. What's their history. How are their shoes? All of that is kind of the starting place before you get into, okay here's how the biomechanics are working. Is that right? 

Iyad: Absolutely. It's a great question Mark. The gait analysis is only a piece of this whole thing. So ultimately, even if you have the perfect running form, if I start throwing a hundred kilometres more out of you per week than you're used to, your body's going to react one way or another.

So we'd look at, we would do usually in the clinic, a good history. We'll do a training history. A specific injury history. We'll scan them, let's do a bed type exam. Or if their knees hurt, we'll check that out obviously. We'll check out how they move in like easy planes and movements like front, back and side.

And then we would want to look at them running too. Because you'll have a lot of people who have specific pains at certain distances of running. So even when that happens, we'll get people for example, to come into the clinic after they've run their 10 K and they're starting to feel soreness.

So we get to really see what they look like when they're kind of in that zone of fatigue. Maybe that's where things are starting to go poorly for them. And it really helps us identify deficits. So sometimes it's a purely strength issue. Your muscles are just not coping with with that kind of level of impact or volume. So we would kind of help them shore up up, I guess, wherever they need to strengthen. But yes, it's a total picture. It's never just a standalone piece. It has to be part of a more comprehensive exam. 

Mark: So what's involved in the actual gate analysis. Let's have a look at that. 

Iyad: Yeah, so I'll just do a quick screen share here so we can have a look. This is one of our colleagues here in the clinic when we were kind of playing around with this. So we would just kind of get somebody on the treadmill. We'd get them to run for a few minutes to kind of get used to the feel of the treadmill. And then we'd just look at basic things. 

We don't need to quantify angles and degrees to such an extent that's used in research studies primarily, but it's not going to change our clinical outcome. Because there's so much variation between people. So we look at things like how they're striking, how level they can maintain during a run.

We look at, for example, like if they're crossing over too much we tend to look at it from multiple views. So we'll do a side view. We want to see how far forward are they. For example, relative to their centre of mass. And then what we'll do from there is we will come up with a running program to kind of help supplement that and maybe help them retrain that. Sometimes it's just this small, simple cues of changing their step rate.

Sometimes it's getting their arms swinging more. And sometimes we just look at that and we're like, that looks good. It's just the volume issue. We're going to have to address that because if it ain't broke, don't fix it. 

Mark: On this idea of strengthening, how often is that a component of the analysis or the prescription that you provide?

Iyad: Prescription, almost always. And it tends to be the one area that runners don't like to really focus on. Runners love to run. We know that and they're really good at that. The way we think about this is it helps keep them running versus make them stop. Because that's the last thing I'd ever want to do is to tell them to the rest, for example.

That tends to be a bit of a last resort for us, if there's a serious issue, like a stress fracture or something like that. But yeah, strengthening tends to be a big component of this because it allows us to build capacity in some of these areas that are going to be effected or maybe need to be absorbing more of that force.

So a common example would be for example, the person who just switched their running style. Well they probably should have addressed also that maybe if I switched to my forefoot strike my calfs are going to be loaded more and my achilles tendon might need a bit more. And then their hips and quads might also need to work differently.

So those are kind of things that we want to address too. And it's always important to look at the overall picture. It doesn't need to just look pretty. It also has to be gradual. Because that's a fundamental piece where all of us get into trouble, on the non elite level at least. 

Mark: And the kind of strength training we're talking about, it's not, let's go do some curls. It's more of endurance strength training. How would you describe that? 

Iyad: It would be actually sometimes a mix of that, like where we're just getting them to just go heavy. Because sometimes they just need to get the muscles tolerant. And sometimes we will need to work on like, you know, maybe a smaller, finer movements. But there's no such thing as bad strength training. This is kind of one of the biggest myths that people think we have to do, plyometric only to get running better, actually like barbell training can be very helpful. Dumbbell training could be helpful. 

We use whatever resistance tool we think is going to help them address the deficit. So if the barbell is the best way to do it, we do a barbell. If it's the dumbbells, and it also depends on what they have access to. We get creative sometimes the equipment that they have access to.

If somebody doesn't live near a gym and doesn't want to go, especially nowadays with COVID and all that stuff. We'll try to kind of work within whatever they have at home to allow them to kind of build up that capacity that we need them to be able to run. If that's their goals around run, we kind of work with them with whatever way they have to kind of build up that program for them.

Mark: So the typical course of treatment or length of treatment to get changes so people feel a little bit better about their running. What would that be? 

Iyad: Yeah, that's a good question. So there's lots of research on this and it varies between person to person, but the average is between six to nine training sessions that they'd have to do. We give them some certain cues. Sometimes it's auditory cues. They follow a metronome with the step rate that we find works best for them. And sometimes it's to focus for a few minutes at a time on, for example, swinging their arms a bit more, being chest up a bit more. Some people's knees cave in too much when they run.

So we kind of try to give them some cues to do that. So we'll try to get them to practice that over a while. And this happens in a mix between home treatment and also in clinic treatment because we can't see them every day here. So we're aware of that and we try to give them as much to work with at home.

And yeah, it can take anywhere from six to nine training sessions for people to kind of get used to this new style of running, but it doesn't really affect their efficiency from any point of view, like in the long-term. It's a short-term dip as they get used to this new style, but as they going to work through it, people just kind of pick it up again, and it becomes a new norm for a short period of time sometimes. And yeah, most of the time it's a good way just to kind of keep people running despite the injury. That's also another use for it. So it doesn't have to be, this is going to be your new, permanent thing for life. It could just be a nice tool for us to play with their symptoms and keep them active while they're rehabbing their injuries.

Mark: If you want some expert analysis of your running gait, if you're having issues with your knees. If you're having issues with whatever you want to try something new, get expert analysis at Insync Physio. You can reach them and book at on their website. Or you can call them in Vancouver 604-566-9716 or in North Burnaby 604-298-4878. Willingdon and Hastings. Lots of parking, especially in North Burnaby. They will look after you and they're experts in this stuff. Thanks Iyad. 

Iyad: Thanks Mark.

Hidden Concussion with Iyad Salloum

Mark: Hi, it's Mark from TLR. I'm here with Iyad Salloum from Insync Physio in Burnaby. He's the clinical director. Insync in Burnaby are many time winners of best physiotherapists in Burnaby. And we're gonna talk about concussion. How you doing Iyad? 

Iyad: Good. How are you Mark? Thanks for having me.

Mark: Good. So, concussions, my brain hurts. 

Iyad: Yeah. It's I guess it's a big area. We're seeing a lot of these things happening now. And a lot of them kind of go under diagnosed actually. And mostly because people still are under the impression that you need to lose consciousness or bump your head really hard to get a concussion. So I guess I just wanted to comment on that, that it's really not necessary for you to have a direct blow to the head, to suffer.

Because what we're looking at is if there's something that causes a fast relative movement of your brain in the skull, where it moves forwards backwards to quick, you can sustain or suffer from a concussion. And you just might not lose consciousness because that's not the only, that you have a concussion.

And I think it's as we see more and more of it, I think we are seeing better awareness across everybody, but once in a while you get people coming in and they're still kind of being assessed and treated with old science. So it's just good to kind of raise that awareness out there. 

Mark: So things that like examples, if you had a fall, but you didn't actually hit your head, or if you were in a car accident, and it doesn't even have to be that hard. Just anything that, where there's that sharp movement and that your head is kind of faster than your brain, basically. That's what you're describing. 

Iyad: Yeah, absolutely. That's a great example. Or even like, sometimes let's say you're playing a game of hockey and you kind of you know, you blow a tire on the ice and you fall and your head never hits the ground, but that big jerk that your body goes through can actually be enough. Or big, quick rotations of your head can also cause that. Again, it doesn't mean if you're just swinging your head side to side, you're going to get a concussion. It's a result of something uncontrolled and quick. 

Mark: So what kind of symptoms would somebody, how would you suspect that you've had something like that? Something, a fall has happened. You've had a car accident. What would the symptoms be? 

Iyad: So, this is where it becomes really interesting. I think one of the reasons it goes so under diagnosed is because most of us are thinking, well, if my head doesn't hurt, then I probably don't have a concussion. Or something that like where it's so obvious, like a loss of consciousness, like I said earlier. 

You could have a variety of things. You can have sensitivity to light. Sensitivity to sound. Problems focusing. That's the biggest one I see. Because people just come and tell me like, yeah, been in a car accident. Just had a hard time staying focused at work. They feel like they're in a fog and just not quite kind of oriented there. Things like that. 

Like there's also issues where, sometimes you see some emotional disturbances, like somebody becomes a bit too reactive to things that normally wouldn't do much for them. And they would just kind of get, and this doesn't have to be anger. It could be just like, even a, I remember one of my clients just would tear up out of nowhere and it was completely unorthodox for them to do that. So those are just things that could happen. And I guess, just recognition of that is important. If anyone's has that probably just go see their physician or even their physio can direct them to who they could see. 

Mark: So when you're diagnosing this, what are the steps that you, what are you looking for?

Iyad: So we usually like to do a big battery of tests actually on the first session. So one of the things we would do is we would do something called, very easy thing. So it depends on where we are. So like, let's say if I'm working with a team on the sidelines, we do something called the scat five, which is the concussion recognition tool. And it has a bunch of tests that kind of assess memory, to balance, to a few other things. So that's one thing. 

Now in the clinic, when I've seen people coming in in the clinic, it tends to be after a few days, usually, no one's going to hit their head today, come in. You know, it tends to be after a few days when they've kind of been dealing with it.

And then one of the things we would do, depending on, I guess, how acute or how new the injury is, is to figure out what their exercise tolerance is. Cause exercise intolerance is very common. So people, if they go for a walk and as soon as their heart rate goes up a bit, they start to experience symptoms. So that's a very interesting one. 

We would definitely want to do a detailed assessment of their neck because a lot of the times you can have concussion like symptoms manifesting from the neck. Like as we talked earlier in previous videos, you can have headaches from your neck, dizziness that kind of originate from the neck. So those are definitely systems you'd want to assess. 

And then finally, there's also the inner ear vestibular organ, which is our kind of our balance organ where you'd want to assess that too. And we then just kind of try to take the person through a graded program from there. Which involves a bit of the treatment to the neck, if necessary, then a treatment to the vestibular organ, if necessary, and definitely trying to get them moving a bit more gradually.

Mark: So what's a typical course of treatment, I know it can be massive depending on the range of injury, but what would be something that you typically see more of? 

Iyad: So I see two distinct groups. So sometimes you'll see the very like new and recent concussion. In which case they tend to be a little more straightforward, believe it or not. Because you kind of follow their symptoms, you assess them, you figure out what their baseline is, and then get to progress them very nicely. Because you have control of it from one. And this tends to be coordinated between ourselves and their physician and potentially an occupational therapist, whoever on the team is involved for that client.

The ones that tend to be a little more, I guess different are if somebody had a head trauma, let's say six months ago and they never quite shook it. That's where you have to do a bit more detective work and figure out what else is this person missing? Cause we can get just a huge dysregulation of their nervous system and how it interacts, but also could just be a neck problem that just was never really addressed, you know. 

Most of us think if I can move my neck and all directions then I'm great, but that's really not enough sometimes. And the way your brain integrates all your senses, could also be an issue. So that's where like the rehab is focused on sometimes almost helping you process things around you a bit better. And that tends to help quite a bit.

And then obviously in some cases we would want to consult other people. For example, if the person's not sleeping well enough, we would want to address that. If the person has nutritional deficits, we'd want to address that. Usually we would work with other members of the team in that case. 

Mark: Is it fair to say that it's, people tend to not come in soon enough, that it's actually critical that they come in as soon as possible to get evaluated and find out what's going on. Not just think, oh, well, it'll go away in a couple of days. 

Iyad: We see two different groups here actually. Usually the person who will avoid it initially, and then stay in avoidance probably for a lot longer than they need to. And usually the other group where they just think, oh, this is going to be fine. And then they kind of just continually push a little further than they're ready. And then you see kind of this stagnation on both sides. One of them from avoiding too much, and one of them from doing a bit, maybe more than they're ready.

So I think it's helpful to get it recognized first. So either talk to your physician or to your therapist, or whoever's being in charge of your treatment, I think that's a very important first step. And then you can at least figure out what your baseline is. And that kind of help understand why you get dizzy, for example, when you go for a run. And it could be because your neck is sore, but it could also be because you are very intolerant to exercise. So those are very kind of important things to identify before we start calling this a concussion. So I would just say, get it assessed. And you save yourself a lot of time. If you get to looked at early. 

Mark: Don't wait, get it looked at early and get yourself back on the path to being your full self, basically without your noodle, you're kinda missing a lot. You can book there online, or you can give them a call. The Burnaby office is at 604-298-4878. Or they have a location in Vancouver on Cambie Street, 604-566-9716. Book online, it's way easier. You can get in to see Iyad. Get looked after if you have any doubts. Thanks Iyad. 

Iyad: Pleasure, thanks Mark.

Lower Back Strain with Wil Seto

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver, many time winners of best physiotherapists in Vancouver as voted by their customers. And we're talking about lower back strain today. How are you doing Wil?  

Wil: I'm doing well. Thanks. 

Mark: This is I'm sure I know in, because our business is to look at this kind of stuff that this is something that's searched for. So it happens to a lot of people, I guess, even everyone has some sort of lower back problem in their life. Is that accurate? 

Wil: You know, majority of people, for sure. I mean, I think, you know, the is a certain degree of it. It could just be like something where you feel a little bit soreness, a little bit of a mild discomfort or something like that, to something that might be a little bit more, but still on the moderate to mild side where it's hampering your function. 

Mark: I'm sure there's many kinds of strains and clauses. Can you outline some of those? 

Wil: Yeah. So one of the biggest things that most people come in and when it's more severe, you know, they think of like, oh, did I herniated a disc? Or did I do something really serious? So that's definitely a possibility when strain your back or when you hurt it. And then a big part of what you want to consider, when you think about what kind of an injury it is, is like, well, what were you doing? Like what happened? And I think a lot of what I've been seeing lately, too, just with the pandemic and lot of people working at home is more less the herniation. And people coming in and then just doing a lot more sitting and it's more postural. And they end up having more on the other end of the spectrum where it's not a disc, I don't want to downplay it, but it's a less severe than a disc. 

Disc injuries that in themselves can also be minor as well. So sometimes you might not even get back pain interestingly enough. And to say that you don't have back pain when you're getting a disc injury, it all depends on the symptoms that you're getting and other things you might have, like a lot of neurological things like gross weakness. And so those things need to be looked at and addressed. 

So with some of the clients that our physio team has been seeing lately, we've had people that have been coming in with more sort of minor back stuff where they can move and function, but it's still affecting their capacity to do things at a hundred percent. So for example, at rock climber who, you know, he had just gotten a new puppy. And basically he's been experiencing some more back pain. It could be disc, it could be maybe like a smaller joint. So the disc is basically the joint in the middle of the back, but then it could be something that's more minor, which is in the smaller joints of the back. And that's usually more common. 

So if you're over straining your back and you're not getting enough sleep, and then a lot of things where you're just utilizing your posture in ways that are basically not optimal in sitting. You know, it could be that. And with this individual, and then with another individual I'm thinking of too, that, you know, he's doing a little more shovelling, you know, it's a little joint in the back. I mean, it could be, like I said again, a disc, but then when we assessed it, it definitely looked like it was a little bit more into the little joints in the back.

So in terms of actually figuring that out, there's certain tests that we do and you touch and feel the area. And there's certain tests that actually indicate whether it's this or that. And then those are really important to also kind of determine if it's this or that, or if it's even something more serious.

So with something that's a little bit more involving the smaller joints in the back, there's certain things that we do more specific around the rehab and treatments. 

Mark: So symptoms can be just pain or weakness. In the back? Or in the legs? Is that kind of fair? 

Wil: Yeah. And even when you strain these little joints in the back called your facets, you can actually even have like a limp. And it can be from like a mild degree of it to like something more severe where you can barely walk. So that's why it gets really confusing. Where you're kind of like, oh geez, did I really hurt my back? Or what's going on? Because when you have swelling in those little joints and it becomes a little more than just a mild irritation, then it can cause compression in the nerves that come out between the vertebrae of the spine.

And so then that can cause a radiating pain or pain to shoot down or other symptoms that may mimic something more like a disc or whatnot. So you have to really get that looked at if it goes on for more than three days. 

Mark: So once you've kind of got a history, here's what the possible cause is, here we've diagnosed what we think the issues are. Then what's a typical course of treatment?

Wil: Yeah. So if it's these little joints called the facets and then the muscles all around, they're being really spasmy. The first thing that you want to do and especially like, you know, you've been suffering for this for a few days now, and it's still quite sore.

Then it's really important to actually work on pain management because you really need to get yourself moving. Because if you don't really address that pain and I'm a component of really doing things more naturally and just making sure that you don't have to take anything for it, to just do things on more of a natural basis for exercise or hands-on treatment kind of thing. But you really gotta address that pain and you definitely don't want to be going on bedrest and trying to stay bedbound definitely not more than like two days, for sure.

You get a lot of deconditioning effects. And a lot of negative things going on when you're not trying to modify your activity. And modifying your posture. And so doing those modifications initially are really helpful and then doing some active mobility things that just to just get things moving initially, is really important. 

So in terms of getting stronger is also important. Like doing a little things in those first 72 hours after the injury, because you don't want it to be totally deconditioned. That's really important. So that's huge because a lot of people think, oh, you know, like I'm just gonna need to stay in bed until this gets better. And that's really not good.

Mark: So you want to stay active, and then you're going to lay out like a course of treatment, basically. What does that look like? I know it depends on what it is, but give us a range. 

Wil: Yeah. So obviously with this type of injury, utilizing like when you come into the clinic, addressing that specific area that's been injured, and manual therapy is really, really good to open things up, get things moving, resetting some of the muscle tone around there. And also helping with the rehab process by facilitating certain muscle movements and joint movements. 

So that's our goal in the clinic is to help facilitate that. And then on a rehab perspective at a time, you know, so the initial period is to just get things moving. And get things activated in modifying the activity levels.

That way you're not totally turned off all the muscles aren't totally shut off and trying to re-engage that core. And so after you've moved beyond that stage, then you're also looking at the pain levels coming down. And things are starting to heal. And this is where you're looking at the first 72 hours, 48 to 72 hours when you have acute phase. You have a lot of that swelling and then anything after sort of that 48 to 72 hours, up to even like five days to like a week is kind of that period where now it's the second phase of the healing of the injury. Where now you want to work on getting even stronger.

And then trying to work towards more of that full range of movement that you had before. And then also one of the things that's really good to implement at this period is a little bit more cardio as well. Cause as you implement one more cardio, the blood flow really helps with the healing. 

And also there's been studies that have been shown that when you actually start to do more cardio, you get a little bit more fluid going in your spinal cord. And that helps with a certain pain modulation, which also helps with the whole rehab process. And then now you move into like, after the first week, and maybe even the like the second week, as long as you're not reaggravating it and things are kind of on this trajectory where you're healing. 

Then you really want to look at what you need to do to strengthen it because the strengthening process, which we call the remodelling phase now, which is like that final phase, can last from this period where it starts at post seven days, post 14 days up to three, four months of just rehabbing the strength and getting your full, not only your full function but preventing this from happening again. 

And then what usually happens, and it's funny because our physio team has seen this is that we've seen repeat clients that come in because things that felt great and then they kind of slacked off and oh, oh, look, it's snowing. And then they're going to shovel all that snow, and it's wet snow. But they slacked off from the rehab and they got a little weaker and then they ended up restraining something. And there's a lot of research to show that when you aren't strong and you had a pre-existing back injury and then go back to do something and then you can really increase your chance of reinjuring that same injury or doing something worse.

Mark: So on a bigger, like 10,000 foot view of prevention for back injury, specifically, what would you recommend as the steps that someone should take? 

Wil: Yeah, that's a big question. 

Mark: Well, give me three, like here's the three big ones that you need to do. 

Wil: Yeah. Well, I honestly, number one, get enough rest, get enough sleep. That's huge because your body needs that regeneration. So let's say you're doing everything else right. But you're not getting enough sleep. That is going to get you. Sleep is so important. 

 Number two is really, I think if you're looking at sleep, eating right. So those two kind of go together, sleep and eat right. And then I guess number two would be really making sure that you keep up with some kind of fitness. If you have days where you go, oh, I've got to shovel the snow and then you're not really in shape, make sure you try and keep some form of exercise, whether it's daily walks or even just some low level of fitness. And that's really, really, really important. 

And I think the third thing is just your posture. When it comes to sitting and work. And it's hard when you're working to really be cognizant of how you're sitting all the time. And to really be aware and setting timers, setting up your workstation. So that way you can change up like from sitting to standing every 45 minutes. And having a little spot where you can stretch out from like maybe five minutes after every hour is really helpful. Even myself and our physio team, we even catch ourselves having bad posture. And I think that that's one of the key things to really prevent, you know, things from going out because it's the long creep effect. 

So if you're sitting there for a long time, you don't realize it, then you know, your back takes the strain. And then you're also checked out of your awareness of how your body's feeling. So those are the big. 

Mark: If you've got some back problems the guys to see are Insync Physio. You can book your appointment at They have two locations. One in Vancouver, you can call them at (604) 566-9716 or in North Burnaby, (604) 298-4878. You got to call and book ahead. They're always busy. But they are experts in this. Like I said, they're multi time winners of best physiotherapists, both in Burnaby and Vancouver as voted by their customers. People love these guys. You need to get in there and see them get feeling better. Insync Physio. Thanks Wil. 

Wil: Thanks Mark.

Persistent Chronic Pain with Iyad Salloum

Mark: Hi, it's Mark from TLR. I'm here with Iyad Salloum of Insync Physio in Burnaby. He's the clinical director there, and we're going to talk about something that is a bit of a phantom really, persistent chronic pain. So can you actually have pain when the injuries were healed? 

Iyad: Yeah, that's a very good question, Mark. So persistent pain or chronic pain as some people call it is such an interesting and kind of broad term, right? Cause it describes like basically anybody who's had pain over a longer period of time, longer than three to six months. Depends on which definition you read. 

But I think the biggest thing I wanted to kind of clarify here is, what we know about pain now and the pain science has been growing every year, is that you don't necessarily need tissue damage to have pain. And that having tissue damage isn't enough to have pain. So those two things are quite interesting because historically we've always learned while you bumped your head, it's going to hurt.

It's because you just bumped it or you bruised the bone or you bruise the muscle or something like that. What we know now, pain is a large kind of protective response from our nervous system. And it makes sense right? So like historically speaking, if I broke my foot, I would want to rest it to the bones can heal. So that's what pain kind of access as a nice reminder for ourselves. 

But there are also cases where let's say, I don't know if you've ever broken a bone, but when you're in a cast after the first week or two, it stops hurting, but the bone is still healing. So the bone is still broken. So that's a great example of how you can have still a bit of tissue damage and it doesn't hurt anymore. Other cases are things like where you have a very minor stimulus that should hurt maybe only a little bit, but then it gets kind of magnified to such a bigger thing. And that's usually what we think of as a response, when a nervous system. 

So our nervous system is a great kind of computer in a way. It's a great processor. So every time we get a stimulus from our periphery or from anywhere, even from our internal organs, we can either choose to amplify it or kind of quiet it down. So one of the things I like to think of is that pain isn't always proportional to tissue damage. Could example paper cuts on your finger hurts so much more than somebody punching you in the shoulder.

Even though I would argue that the punch has a lot more potential to damage that. So what we see in the clinics sometimes is people who've had low back pain from a year ago. They go for a follow-up MRI or x-ray and nothing is there and it almost makes them more kind of confused and maybe sometimes angry because they're like, I swear it hurts. And then they get told a really kind of, I'd say a bad answer, which is that, oh, it's all in your head. Which is not really reasonable to kind of explain this, it's almost oversimplifying the science. You know, like all the pain is in the head cause our brain is the one thing the manufacturer's this thing.

So just saying that it's a bit kind of disrespectful and maybe a bit kind of to downplay their response. But basically what we ended up seeing there is that sometimes your nervous system learns to overprotect. So think of a car alarm, that now it goes off when the fly lands on it, instead of when you actually have a break in. So that's kind of what ends up happening in these cases.

Mark: So any ideas on possible causes other than just, Hey, you know, it's how we're wired. Some people are more wired to be sensitive to pain or in context, like some people, you know, maybe they feel it more than their teeth. 

Iyad: That's a great question. We think there's tons of causes actually. So one of them, we think definitely there's genetic components, but then some of it is learned, right. And then some of it is also centred around how our own beliefs and how our kind of expectations of things are. So for example, if you expect something to hurt. It can hurt more.

We have some interesting studies where they just flash lights a red light with warm water and the blue light with cold water. And then people get given the same kind of stimulus, which is the same temperature water with different lights and they report different stimuli. So that's a great example of how your nervous system can just modulator these things.

So some people, we don't know why specifically, this person goes down the persistent pain pathway, some people don't. But we have actually some decent data, that up to one in four can go down that way where the pain kind of lasts a little longer than you'd want it to. And when there's no more need to protect.

And the way we think of this now is based on our understanding is if you have more danger signals, in everything. And I'm talking about stress or sleep or diet, just general health lack of activity or too much activity. So this is the interesting one, where if you almost avoid too much you can actually become very sensitized to that movement or to that touch or to that whatever thing you're trying to avoid. 

Or there's the person who never really allows things to take their course and just tries to push a bit too hard. And then what happens is our nervous system goes through a response for it, they're like. I guess in layman's terms would be like, I don't think this guy's getting it. I'm going to need to crack this pain level up a bit more so that, you know, they can kind of pay a bit more attention to me and allow me to recover. But the problem is you kind of get stuck in this kind of cycle and in either way where you're either avoiding too much or you're pushing too much into it. And you're kind of none the wiser in that case. 

So treating those cases is very interesting because the, I guess the first thing we try to do and we have some excellent therapists at Burnaby, like Elizabeth, our physio has worked extensively in this area. You kind of want to take a big inventory of the person's health in a way.

You look at everything from their habits, to their diet and their sleep to their activity, to their own beliefs. And yeah, the physio is not going to be a counsellor, a dietician and a therapist at the same time. But what they ended up doing is you've identified these issues and then you can kind of get them the help they need based on working with the team.

And that's kind of what the most successful pain programs we'll do is we'll kind of integrate a good team response, but then fundamentally it seems still that movement still pretty important. You know, so we kind of help people move. Sometimes it's just move differently so that they don't do the same repeated strategy. And sometimes it's just to move. Cause some people just don't do that enough after they've been injured. And that's a cause of that kind of going down that chronic route. 

Mark: So, if you need to get moving again, you've chilled out. You've meditated your way. You've seen the therapist, you've done all the other steps and you still hurting, maybe you need to move a little more. Get a physiotherapist to help you, You can book an appointment there, or you can call them in Burnaby, 604-298-4878 or in Vancouver on Cambie, 604-566-9716. Get in and get some help and get moving again. It will help with your pain. Thanks Iyad. 

Iyad: Thanks Mark.

Neck Injury Rehab Horizontal Ball Catches

Start on your knees and lie with your belly on a balance ball while you engage your core stability muscles of your lower back to keep your posture in neutral.

Hold a lacrosse ball in your hand with your elbow up and knuckles pointing down. Open your palm releasing the ball and quickly rotate the forearm backwards and then quickly rotate it back to catch the ball with your hand without letting the ball fall to the ground. It’s important to only pivot through the elbow and not the entire arm and shoulder. Repeat this for 30 seconds doing 3 sets for each side daily.

This exercise can help rehab the functional core strength of your upper quadrant when recovering from a neck injury. If you have any pain or difficulty doing this exercise, consult your local physiotherapist before continuing. 

SacroIliac Injuries Planking Ball Crosses

Place a ball underneath you between your hands. This will be the centre position for the ball as you will be moving it out to one of four positions each time and back to centre again.

Begin in a plank position and engage your lower core by trying to make yourself skinnier below your belly button at your waist line. Supporting yourself in a plank with your right side, move the ball from centre to up above, then back to centre, then from centre out to the left and then back to centre, and then from centre to below and then back to centre again.

Finally from centre out to the far right and back to centre again. Switch and plank on the left side now and move the ball with your right hand. Do 10 reps on each side daily.

You can utilize this exercise for many different sports and activities that require strong core stability for you sacro iliac joint such as baseball, volley ball, rock climbing or ultimate frisbee. 

Herniated Disc with Wil Seto

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver, multi time, winners of best physiotherapists in Vancouver and in Burnaby. And we're going to talk about herniated disc. How are you doing Wil? 

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

Mark: Herniated discs. That horrible sounding thing. What's this all about? 

Wil: Yeah. So a herniated disc, you know, some people may even have a herniated disc and they don't even have pain. That's the thing. There's very different degrees to having a herniated disc. But what it is essentially is, when you look at your spine like the lower back is a really good example because that's where usually is most common. But you have three joints in your spine. So you have the two small ones which are called your facet joints. And then you have the one in the centre, which is basically where your disc sits. And that's the area where, you know, usually when you have a disc herniation. 

And so if you actually think about a disc herniation, kind of like a jelly donut, and if you straighten the back in a way where you bend forward too much and you strain the ligaments kind of in the back side of the back. And then what happens is like if you push the jelly donut and the jelly squeezes out, that's kind of what happens when you herniate a disc. And there's, like I said, varying degrees to severity of it too. So can we really mild where you actually don't even have back pain and that herniated disc can start to pinch up on a nerve. Or where it can be very inflamed and it could be like, basically, you know, super, super painful where you can't even like stand up or sit or move and you have to be bed bound.

Mark: So what are the symptoms other than pain? 

Wil: Yeah. Well one of the other major things that I should also mention is that if you have a herniated disc that can pinch in on your spinal cord, there's certain symptoms there that, you know, you want to make sure that you're not having issues with your bowel or bladder movements that's important.

And then any major gross motor stuff that happening as well as it pinches in. And if you lose all you know, bowel, bladder function and your motor controls all gone. So that's obviously on the extreme end. And that's when you want to definitely go to the emergency for that kind of stuff.

And there's usually a lot of pain with that as well. And so symptomology wise, like you're looking at things where even sitting is painful and standing is painful. But the worst will be like bending forward because you're putting more strain. So usually if you have like an a mechanism or a way of you can remembering how you possibly did it, where you're oh yeah, you know, it was shovelling snow for a while and it was bent over in a bad posture. And then all of a sudden, like I felt something in my left side of my lower back, but then the third hurting even more later. So that could be sort of how it happens. Or it could just be like even sitting for long periods of time. Now that we're in this kind of time and an era of like working from home and you're ergonomic setup isn't great. And maybe sitting in the bad chair. And that compression, you know, into the disc.

Speaking of compression, I've had snowboarders and skiers that have made jumps and they've landed on their tailbone and it's caused compression fractures into where the disc connects to the vertebrae. And then injuring the disc at the same time. So those are all sort of different ways that you can injure and how the pain that comes on. 

I had someone that actually just, they were already set up to have it happen. Where they had all this muscle imbalance and they went to go pick up literally a paperclip on the floor and their back just went out, so to speak. And they had super bad pain and they thought they just pulled a muscle. But it turned out to be what I thought to be a herniated disc. 

We also had another person who were at worlds. I was working with this athlete and he had flown to be with the team and to be with us. And then days to the competition, he comes up to me and say, Hey, Wil, I think I have a bit of a problem with my little toe. And I'm like, what do you mean? Oh, it just feels tingly. And then I start to ask him more questions. And oh yeah, and I don't feel strong on this whole right side. And I'm like, really? And then, so I did a thorough assessment and I suspected them afterwards that he had been playing with a herniated disc. And I said to him, I gave him the low down and I said, you can keep playing, but you might injure it more.

He kept playing. And he did have worsening symptoms. In the end, when he finally went home, I recommended him to go see a doctor and because he didn't have healthcare coverage here, and he was able to manage the symptoms while we were traveling at worlds. He didn't want to see the doctor while we were away, which I thought was silly. And then he went home, had a scan done and he had a very severe herniated disc on the right side of his L5 S1. Had surgery the next day. Wow. And then his numbness was gone and full strength back in his foot. It blew my mind away. 

So there's varying degrees of the disc issue when you have a disc herniation. And then I had someone that just had mild stuff going on that it just seemed like a back strain. Didn't even have any of the neurological, like weakness or anything like that going on. And he decided to get an MRI on his own accord and it showed that it had some disc herniation at a couple levels. But he was pretty good function. He just had some mild discomfort. 

Mark: So is it, when you're diagnosing this now, you know, as it x-rays, is it eventually, as you see more and more indications of severity, you're moving me into, okay. You got to get an x-ray, you got to get an MRI. How do you diagnose this and how what's the difference?

Wil: Yeah aside from the clinical tests that we do, this is more a medical management, where they look at, seeing the doctor and usually they do get an x-ray. But that's not what I would recommend first. You know, you want to really treat it conservatively and really work on, a lot of the times you know, really doing that rehab is the best, best way to treat it.

Like doing your physio is the best way to treat it. Doing things to really address the imbalances that are happening and the weaknesses because things get really tight when you have that disc and you want to do things to influence more decompression in there you know, and traction definitely really helps.

But you want to get things to decompress more naturally, take the load off by like really taking those muscles that are like this, and getting them to be more relaxed. And then engaging the core and then retraining that stability system. That is key. And then really working on a really good extension protocol, things that actually helped to influence that extension motion.

So there's this whole method of really being able to start to get that mobility back into the spine in a really positive way. Because you want to make sure that you do things with a herniated disc where you're addressing mobility deficits and your core stability deficits.

Mark: So when you're outlining a course of treatment, of course, it varies pretty dramatically. I'm sure. Depending on how severe the hernia is, but what can you give us kind of like a range of what the course of treatment might look like? 

Wil: Yeah. So typically for, and this is all very dependent too, on the healing process of the disc and you have to really respect that. That's the thing. It's not like a sprained ankle, or even just like a like those little joints in the back, the facet strain. It's more, you have to respect the disc injury because it's bit of a different healing process. And so when I say that, typically a disc injury can heal anywhere from four to six weeks, fully, which is great.

So then that's what you're looking at, but when it gets to be a really bad disc herniation. Those can even last up to well beyond four to six months, even up to maybe a full year, depending on what's going on. And this is where like, if it's that bad and you're looking at okay, well, there's a little bit more going on on a neurological level where, you have a lot of gross, severe stuff going on with muscle strength loss, and neurological issues.

Then that's where I definitely want to refer over to medical management, have a referral to a doctor and really get things going on that way because that's something that's a little bit more than just conservative treatment. 

Mark: And that's where you would work in concert with the doctor where the doctor's looking and checking to make sure. And then referring back to you to give, to outline the recovery process, the exercises, the treatment, basically that they're going to go through, is that how that works? 

Wil: Yeah, for sure. We definitely work with doctors on that, but usually, the most advised course of treatment is doing the rehab first. And if things aren't working out there, we're definitely all reaching out to the doctors and even, like I said, with pain management, getting some stuff to really hone down the pain because we don't want you to be bedbound for this long. That's not good. We're going to get you going. And then if it's that bad of a herniation, then let's get some more information. Let's see what's going on.

Mark: If you've got a herniated disc or suspect you have a herniated disc, or you got just back pain, the guys to see your Insync Physio in Vancouver and in North Burnaby. You can reach them and book at That's their website. Both locations are on there, or you can call and book. The Cambie location in Vancouver, it's 604-566-9716 or the North Burnaby location, 604-298-4878. Get in there, get some help. Find out what's going on. Get the heck out of bed and get moving again. Thanks Wil. 

Wil: Thanks Mark. You bet.

SacroIliac Joint Injuries Rehab Bear Walk

Start in 4 point position on your hands and the forefoot or the balls of your feet with your knees greater than 90 degrees. As you place one hand forward bring your opposite foot forward as well.

Do this while you also keep the shoulder blade muscles and the core stability muscles in your low back engaged and your mid back position in neutral. Repeat this for 45 seconds 3 sets daily. 

This is a great exercise to strengthen the core stability muscles for your sacroiliac joint after straining or injuring it. 

Low Back Injury Planking Ball Crosses

Place a ball underneath you between your hands. This will be the centre position for the ball as you will be moving it out to one of four positions each time and back to centre again.

Begin in a plank position and engage your lower core by trying to make yourself skinnier below your belly button at your waist line. Supporting yourself in a plank with your right side, move the ball from centre to up above, then back to centre, then from centre out to the left and then back to centre, and then from centre to below and then back to centre again.

Finally from centre out to the far right and back to centre again. Switch and plank on the left side now and move the ball with your right hand. Do 10 reps on each side daily. 

You can utilize this exercise for rock climbing and many other different sports that require strong core stability for you low back such as baseball, volley ball, rock climbing or ultimate frisbee. 

1 3 4 5 6 7 71