Category Archives for "concussion"

Post Concussion Syndrome with Iyad Salloum

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Iyad: Thank you.

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, 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.

Persistent Post Concussion Syndrome with Iyad Salloum

Mark: Hi, it's Mark from Top Local, I'm here with Iyad Salloum he's the clinical director of Insync Physio in North Burnaby. And we're going to talk about persistent post-concussion syndrome. What is this Iyad? 

Iyad: Yeah, so there's the common tale of like, you have two different kinds of populations that get this potentially. So you have the athletes who, you know, is playing a contact sport like anywhere from soccer to hockey, to lacrosse. They get an impact. They suffer from a concussion and then a few weeks on they're still unresponsive. They feel like they're not improving, they're not improving in the same trajectory. You'd expect it to with just time. 

Then you have another group that we see quite commonly, which is after a motor vehicle accident. So anything that involves a sudden movement to the head, a rapid acceleration deceleration kind of will potentially lead to a concussion. And then, you know, a few weeks on these people seem to struggle specifically coping with things like screen work if they’re office workers or if they're students like reading and studying. If they're athletes going back for a job, for example. 

There's all these things. And then the interesting part about it is the symptoms are so varied. As we know about concussion, no two are the same. Heterogeneous group. So some people have an issue with a light sensitivity. Some people will get dizzy. Some people get a headache. So really it's a whole kind of gamut of symptoms that we assess and treat in clinic.

And in this group, particularly where it's really confusing for them because you know, usually you'd expect things to just get better with time as like when you roll your ankle or a few of those things. But here it seems to kind of lag a little past where they think it is and you know, the reason that is, is because A, the brain's a bit more complex and B, sometime as we kind of delve into these maybe maladaptive patterns where we try to protect ourselves a bit too much, or maybe we go a bit too hard into our return.

So there's the two extremes where you do very little or your do too much. And this is kind of where we come in to help regulate that system a bit more. 

Mark: So, is there an obvious cause as to why one particular person with a similar injury would get better quickly and another person wouldn't? Is there anything that's been defined in science before? 

Iyad: Million dollar question. So far we know there are a few risk factors. So things that make you more likely to get it. So people who have had several concussions seem to cause this. If you have involvement, for example, of a few other things like the neck and the vestibular organ, which is in our inner ear, which helps us kind of balance and kind of track objects through space.

Those are very simple things that we talk about, but they actually are quite complex neurological processes. So it all depends, I guess on the person too. So it's like sometimes if they've had several concussions, that's a factor. There's some genetic reasons that we think it is. Sometimes the severity of the initial injury and then sometimes it's just the lack of education on this area where people return to quick or don't return at all. 

Sadly, we still see some bad advice out there where people sit in dark rooms for a week, which is crazy because I don't know when the last time you had to sit in a room without your phone, without reading, without running, without walking in a dark room and just do nothing. Sounds like solitary confinement to me. So I think that's a big reason why we see persisting symptoms too is it's just outdated advice, let's call it. 

Mark: So when you're diagnosing this, does it make any difference what the symptoms are when you're going through the history of someone? Do they have a history of a lot of concussions? What actually happened? How severe was it, et cetera. I guess it's graded in terms of the injury then. Okay. Someone's really light sensitive. Is that a different course of treatment than somebody who's having balance issues? 

Iyad: Yeah, that's a great question. And yes, the answer is yes. So if your main impairments are visual in nature, we'll try to target that system a bit more. If your main kind of impairments that we pick up as the vestibular impairments, we try to target that too. I usually will consult an occupational therapist on this too, where they are really good at planning and pacing.

Like this is kind of the grand scheme of things. It's like, you need to be able to preplan things in concussion, because there's a bit of a battery life that once you exceed, it seems like the symptoms go a bit way off kilter. And doing this where you're just kind of trying to mentally track things is really, really tough.

So we have a foundation of just like people being more aware of their symptoms and planning their days out and trying to separate their activities until, let's call them mentally draining intense activities, to let's say something that's light and easy. And then the exercises or the treatments will be focused on what are the specific impairments.

If you have a primarily balanced deficit, we'll try to target that a bit more in treatment. Versus if you have a visual deficit, try to I'll start with that in treatment. It'll rarely be a solo practitioner working on this. I usually will consult several team members like even optometrists if there's a lot of visual disturbances. Or occupational therapists are pretty easy one to kind of tag in here, but then often people might have some other kind of ongoing mental health issues where we actually really need to tag in our colleagues too.

So yeah it's quite complex, but it's also what makes it kind of fun. Cause it's not really a cookie cutter thing. I'll never be able to hand a printout of here's the five exercises to get rid of your concussion. We're not there yet at least, where we can classify people like that. Based on a cookie cutter recipe or we just hand it out. 

So for now, yeah, we have to treat the impairment and it tends to be very, very different person to person. 

Mark: So clearly no typical course of treatment. What are some of the things that you would do for instance, that for light sensitivity and the vision system being impaired or impacted by the concussion as compared to say a balance issue?

Iyad: Yeah, the balances should be pretty straightforward. We've got to figure out what's causing that. So it's going to be one of three things. The three systems could be a visual impairment, so like some people will actually perform better when the visual system is a bit clear, let's say. So there's different therapies we try. For example, seeing if we can optimize their visual field, get them to focus on certain things while they balance, or even maybe get them to focus less sometimes. Sometimes we try to get a little too tunnel vision. 

There's other things for vision could be as simple as where we try different tools, like some of them are called binasal occlusion and a few other things, or even prism glasses that an optometrist would recommend sometimes.

While we train that system, we definitely want a great screen exposure. So if you had just tell somebody to go stand in front of your laptop for 12 hours, I'm expecting them to fail there. So we suggest different filters, for example, like a lot of technology nowadays has a night shift mode and that could be very helpful. So we'll do that. We'll be very specific. And then the amount of screen time that we do. 

And then obviously we'd want to pay attention to sleep hygiene because initially we'll get a lot of sleeping habits where people want to sleep more. But then as that kind of throws the entire sleep cycle off, we actually see people kind of fall down a bit of a slippery slope and then we need to address that system a bit more too.

So, yeah. Meanwhile balance, I mean, we'll figure out if it's a vestibular problem. Sometimes it could be due to BPPV, which is where you have a crystal gets out of place into one of the surrounding canals in the ear. And we can treat that very easily with an Epley maneuver or a barbecue roll. Those are just two different treatments that we use for that. 

But if it's just an impairment in the system, there's lots of exercises that we could use to target those. We actually have a lot of tools in our toolbox here and that's the good news because sometimes it feels like when people have been in this for awhile, that it's just never ending. And it is quite taxing to feel that way. So we try to help whatever way we can. 

Mark: All right. If you've got any kind of persistent post-concussion issues going on, you need expert help. And the guys to see are Insync Physio in North Burnaby, (604) 298-4878. And you can also book online at Or the Vancouver office. There's also experts at (604) 566-9716 to book. Got a book ahead. They're always busy at Insync Physio. Get some help. Get some expert team work on your concussion syndrome and get feeling better quickly. 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.

Traumatic Brain Injuries

Catastrophic traumatic brain injuries, including hematomas and cerebral edema, are the second most common cause of fatalities in football players and can occur in many other contact sports. When there is severe contact with the head, the brain swells and blood pools to increase the intracranial pressure. If treatment is delayed, displacement of the brainstem, known as a herniation, or respiratory arrest can occur. 

Types of Brain Injuries:

Diffuse cerebral edema, or second impact syndrome, primarily occurs in children when the athlete suffering post-concussive symptoms following a head injury returns to play and sustains a second head injury.
Skull fractures, although not always visible, can arise from a head impact. Skull fractures can cause swelling and tenderness, bruising around the face, and bleeding from the nose or ears. All skull fractures should be treated by a physician.
Intracranial hemorrhage is a pathological accumulation of blood within the skull activity and occur in different regions of the brain. An epidural hematoma occurs when the middle meningeal artery, located by the ear, ruptures due to a direct blow to the head. Blood then pools between the skull and the dura mater, a protective membrane that envelops the brain. The onset of symptoms are rapid and emerge within a few hours. The athlete may initially have a period of lucidity, but a decline in functioning is seen 2-3 hours later. 

Another type of hematoma known as a subdural hematoma is more commonly seen in adults over 45 years old and is associated with a tear in the bridging veins of the brain due to serious head trauma. Symptoms may include nausea, headache, or vomiting.  

Common Symptoms:

Common symptoms include: visible wounds, fractures, swelling, facial bruising, altered state of consciousness,  bleeding, stiff neck

Treatment and Prevention:

If any traumatic brain injury is suspected, then treat as a medical emergency and call 911. Refer the athlete for a CT or MRI scan to confirm bleeding.

Helmets are key in preventing catastrophic head injuries and reducing the severity of concussions. Athletes and coaching staff should be educated on the risks and symptoms of concussions or the head injuries discussed above. Proper technique in contact sports may significantly reduce the occurrence of head injuries.

Watch the video below on how to mobilize a stiff neck:

InSync Physiotherapy is a multi-award winning health clinic helping you in Sports Injuries, Physiotherapy, Exercise Rehabilitation, Massage Therapy, Acupuncture & IMS.

Neck Strength Predicts Concussion Risk, Study Says

New research shows that stronger necks may lead to safer heads.

For years, biomechanics researchers have suspected that girls had higher concussion rates than boys in sports like soccer and lacrosse because of gender differences in neck strength. The weaker your neck, the more likely your head will bob around on impact. And concussions are caused by the brain shaking inside the skull.

For the first time, new research backs up this conclusion. Before practices and games, athletes shouldn’t just be stretching and strengthening their legs and backs. They should be working out their necks as well.

At the fourth annual Youth Sports Safety Summit in early February, the findings showed that presented the findings. During the 2010-2011 and 2011-2012 academic years, athletic trainers collected measurements of head circumference, neck circumference, neck length, and four measurements of neck strength — extension, flexion, right lateral and left lateral — on 6,704 athletes nationwide across three sports; boys’ and girls’ soccer, lacrosse and basketball. These measures were taken before the start of the season; during the season, athletic trainers reported injury data — including concussion incidence — for each athlete.

And the results didn’t favor those with tiny necks: concussed athletes had smaller mean neck circumference, a smaller mean neck-circumference-to head-circumference ratio (in other words, a small neck paired with a large head), and smaller mean overall neck strength than athletes who did not suffer a concussion. After adjusting for gender and sport, overall neck strength remained a statistically significant predictor of concussion. For every one pound increase in neck strength, odds of concussion fell by 5%.

Neck strengthening exercises are easy. For example, you can use your own hands as a resistance tool — put your hands on the back of your head, and press them forward while your bend your neck backwards. They don’t require any huge investment in additional equipment; that’s important for today’s cash-strapped schools.

The takeaway is clear: don’t neglect your neck. Your head may thank you later.

InSync Physiotherapy is a multi-award winning health clinic helping you in Sports Injuries, Physiotherapy, Exercise Rehabilitation, Massage Therapy, Acupuncture & IMS.


Concussions are the most common type of traumatic brain injury (TBI). They can occur as a result of a motor vehicle accident as well as various sports. Symptoms can vary greatly from person to person and not everyone may be aware that they have experienced a concussion when in fact they have.

As mentioned above, the causes of concussion can be varied. Most often, people relate a concussion to loss of consciousness. However, this is not necessarily the case. Concussions are often the result of a direct blow to the head, but can also be caused by a violent force or shaking in the upper body. For example, whiplash of the neck may result in concussion because the excess force applied to the body. Concussions may also be experienced after a large tackle that causes an unnatural jolt of the upper body. The brain sits in a pool of cerebrospinal fluid. It can move within your skull (cool, huh?). So, basically anything that projects a strong force onto the skull or nearby structures (e.g. the spine) can cause a concussion.

What’s actually happening?
During the initial blow, the brain bumps into the bony skull. This may not sound like much, but considering how many complex and intricate structures are in your brain (and there are a lot!), damage can be done. Concussions are a hot topic for research these days, and there is still much to learn. It is believed that the bumping of the brain against the skull disrupts important neural connections (kind of like your brain is short-circuiting).

Symptoms of concussion are many and varied, ranging from complete loss of consciousness to a mild headache. Symptoms may also include: drowsiness, insomnia, difficulty concentrating or remembering, an abrupt change in personality/character, feeling more emotional, dizziness, nausea/vomiting, feeling like you’re in a fog, sensitivity to light and noise and loss of balance or coordination. These may be very mild, or very severe. The SCAT tool nicely outlines these symptoms as well as testing that can be done for concussion (read here).

I think I have a concussion, now what?
If you’ve recently experienced a force to the head or upper body and are feeling any of the above symptoms, you should go to the doctor to have these assessed and properly diagnosed. Early intervention is important so you can start the recovery process. Typically, it is recommended that you are at complete mental and physical rest for 24 hours (no exercise, no physical activity, no reading and definitely no screen time). The blue light from your phone or computer screen can aggravate your symptoms if you have a concussion. It is also recommended that you avoid caffeine and alcohol and that you have somebody check in on you every few hours while you are sleeping to make sure other more serious conditions are not present (e.g. brain bleeding). After this first 24 hours, you may introduce light activity (such as walking or slow pedaling on a stationary bike). You must experience no symptoms for another 24 hours. If symptoms are still present, you will need to return to the previous stage. Each stage is outlined below. There is a minimum of 5 days to return to play, with a doctor’s assessment required prior to returning to contact sports.

There is no specific treatment to treat a concussion. Instead, focus is on alleviating the symptoms felt by the patient, and make sure to track progress to report back to the doctor. Both physiotherapy and massage therapy are excellent options to help relax the muscles around the head and calm the body. Acupuncture may also be effective in calming the nervous system. Together, these treatments may aid in a quicker recovery. Recovery from concussion symptoms can occur within a few days or several months. Again, the span is huge as concussions will affect every person in a different way.

InSync Physiotherapy is a multi-award winning health clinic helping you in Sports Injuries, Physiotherapy, Exercise Rehabilitation, Massage Therapy, Acupuncture & IMS.