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.