January 9


Exercise Intolerance After Concussion with Iyad Salloum

By Wil Seto

January 9, 2023


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Iyad: Thank you.

Wil Seto

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