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.