Category Archives for "concussion"

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.