February 27

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Young Athlete Concussions with Iyad Salloum

By Wil Seto

February 27, 2024

Concussion

Mark: Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physiotherapy in North Burnaby, BC. And we're going to talk about young athlete concussions. How you doing, Iyad?

Iyad: Good, Mark. How are you? 

Mark: Good. So, is there any difference between how you treat a young brain that's had a concussion compared to an older person? 

Iyad: Yeah, I think there's a general assumption that it might be easier for somebody who's younger in the general public to recover from an injury in general.

We see that like in the musculoskeletal world, like quite, quite well, you know, if you have a bit of low back pain when you're younger. Some people can get over it pretty fast and people say, Oh, you're young, you're resilient, or, you know, you could bounce back pretty easily. What we know about the brain and how the brain develops and how the brain actually does its thing, especially as we're growing is the brain has two different tasks.

So like the younger you are, the harder the recovery is because your brain has two different functions to do. So as part of your learning as we're developing, we have lots of like let's say a young brain, let's say at the age of three or five, we'll have much more brain cell connections that we call synapses that they have to kind of like almost clean up.

And so what are the processes of development is you are growing and strengthening new connections or even existing connections. And then you're also trimming older connections. Or maybe you're trying to suppress these older kind of developmental pathways. And what you'll see is, for example, babies have different reflexes at different phases.

And then as they get older, those things disappear. And that's basically a sign of that brain learning and nervous system adapting and growing. So, when you have somebody, like, you know, athletes 12 to 13 who get a concussion on like a ice sport, like a ringette or hockey that recovery is going to be a little different.

And then the other thing to think about is what are we trying to get back that person? Like, what are we trying to get them back to? If you are working different jobs, that's going to create different things, but most of these athletes have to come back to school. And also come back to their sport.

So that's kind of the thing that we have to kind of consider and juggle when we're trying to craft a return to play and a return to school program. And as you can see from most of these things, our priority tends to be, let's get these athletes back to school first, because that's ultimately is their kind of first priority of them and their parents, usually, and we kind of usually have a meeting about that.

And so there's differences in terms of like development. There's differences in the physical structure of the brain, but there's also differences in like the sociological piece where it's like, what's the goal here? What are we trying to get back to? What should we prioritize all of this stuff?

Mark: So does that mean it's a little bit longer recovery time? 

Iyad: It tends to be a bit longer. But again everybody is a bit different. But if we were to try to take the average, I'd say we'd have to be a little more methodical with somebody who's a bit younger because we just want to take into consideration that piece.

I think one of the main things that we're always keen to do is to afford them like a good and kind of gradual return so that they don't just do this big yo yo where they're going in and out of big symptoms spikes. And it could be for the most part, like I see some of my clients, their biggest struggle is the fact that they are scared of the second spike of symptoms or flare ups.

So then it becomes a bit of a burden. I'm just like wondering when the next flare this symptom up and that's quite challenging for many people. So that's one of the things that we will try to do a bit more. We'll try to control a bit more factors. And we'll try to really focus a lot of our time on educating them about our findings, because the assessment, it tends to be very, very comprehensive.

And we want to tell them a nice specific plan to get them back as soon as possible. And it tends to be a mix of exposure and rest. It doesn't always have to be rest. We don't always kind of pull back. We quite often want to kind of push them in, but we just want to do it in a sustainable rate, essentially. 

Mark: So, is there, what are the symptoms? Maybe if you, that's just, can you just give us a quick rundown? Is there any difference between youth and old? Or the symptoms the same? 

Iyad: Symptoms tend to be the same. I find like again, this is mostly anecdotal, but like the parents will notice differences in mood and differences in energy levels. And you can imagine how much energy the average teenager is going to have for the most part. Like, especially student athletes tend to be quite high energy as like, just by character.

So when we educate them about what to watch out for, for sudden changes, especially like, so when I do coverage on the ice, for example, and we suspect somebody got an impact or affected themselves in a concussion. We want to make sure that even if we can't make the diagnosis then and there, if the physician or myself can't, we would try to counsel the parents on what to watch out for.

And a lot of the things that tend to get overlooked are you know, things that all of us know are like, oh, everybody's going to get headaches or dizziness, those obvious symptoms. But sometimes there's other things that are kind of forgotten. Like, for example, mood disturbances, sleep disturbances, people tend to be a bit more emotional, maybe a bit more anxious.

Those are all things that usually somebody who's been around that athlete or that person more often will be able to tell you a bit more. Yes, you're a little different. You're a little off. And then the athletes themselves, sometimes they'll just notice themselves to be a second slower. Maybe experience a bit of brain fog.

Symptoms are quite varied. And so this is why we usually are on the side of caution. We just say, let's pull them out of sport, get a chance to let things settle down, assess them properly, maybe in a day or two, while we give the parents some good education and then the athlete, and then we can kind of reassess from there.

Mark: So what's an example treatment regimen that someone would go through for this, realizing that everyone is different every case? 

Iyad: Absolutely. So we assess the main systems. So essentially the first day I see somebody, if I'd never seen them before, I'd want to do a thorough detailed history. I'd want to get an idea of what their symptom baseline is. I'd want to also get an idea of what their basic function is. 

So we'll screen the major things, like we'll do a a neurological exam in the clinic. Just want to make sure that we rule out the red flags. Again, it's like how many people are going to present to a physio office or primary care, you know, you never know who's going to actually not know that they have something that needs a bit more of an urgent intervention.

So that's where we always take our extra caution and just kind of screen them. From there we will assess the following systems. We will just check different things like blood pressure, for example. Can they navigate different postural changes from lying to sitting to standing and what happens to their blood pressure in those cases?

We would do an exercise tolerance test, maybe on the second or third day that I see the athlete. We would do a detailed neck assessment because it's kind of one of those things that we're finding these days is that where there's smoke, there's fire. So whenever we see a concussion, there tends to be some involvement of the cervical spine. So we'll do a detailed assessment there. 

We would check for how the person is just coping, for example, with basic balancing tasks. And then we would also do a vestibular screen, which is your inner ear organ, which helps us figure out our equilibrium with head movement. And then there's also some screening done to the visual system.

Usually, we would do something called an oculomotor screen just to see how the eyes move and track different things. And based on that, we would kind of then craft intervention because some people might not need three of those things because those systems are quite well intact. So it's always based on we assess, we find an issue and we do that.

But often we will try to get people moving really early. Like within the first two days, we'll try to get people at least walking. And we find that really important and a really telling factor in terms of quicker return and a more kind of like timely return. And everything's based on measurements, which is really nice. It's getting better that we have enough data that we can kind of give very tailored interventions and very measurable things. 

Like we can give a prescription based on time, on heart rate, on exertion level. There's a lot of different things that we could use to kind of get that person back to whatever they need to. And then if we want to get them back to school, let's say if it's in the mid of the school year, or if it's in the summer, the intervention changes because we'll prioritize school if it's in the school year 1st over the sport, and then if it's in the summer, we'll try to do sport. 

Obviously, we don't choose what to prioritize. It's usually, you know, the family centered decision here. So we'll have a discussion with with all the stakeholders, if you want to call it that, and then kind of decide based on that which battlefront we start the attack on.

Mark: Is there any kind of generalized statement that you could make about the young athlete concussions that you've seen? 

Iyad: Yeah, I would highly recommend you don't compare. So there's two things. I work with a few teams and one of the things that I've seen, for example, one of the teams I work with, the age group is anywhere from 16 to like 40 on that group.

And so some of the younger affiliate players who are not regular starters will be on the bench and they'll see and they'll kind of observe. And one of the things that you'll see is they're like, well, so and so got back in five weeks. Why am I a little longer? Or so and so got back in two weeks. Why am I a bit longer?

I really encourage people not to compare like how they've recovered versus somebody else. Because realistically, what we do know is there's a lot of differences. Between people in this case, and if you're 16 versus 30, there are differences in your recovery. What we can't do is at this point, predict the future and tell you how long it's going to take, but we can kind of just make these functional milestone targets for us to hit and progress adequately that way.

The other general rule is get looked at early. I really recommend this. We've seen a few people now wait a month to two months before they start doing anything. And if you just visualize this as a student athlete, you're used to training anywhere from 10 hours a week to, I have some athletes in 30, 40 hours a week of activity. And you take that away from someone you're gonna see a bit of a change in lots of systems. Including their morale and you know, how they feel and their energy levels.

So I kind of look at it this way, it's nice to know what you could get away with in the early phases where you could do that safely. And you don't have to question yourself. Oh, did I go too much or did I go too little? So that's where I really recommend an early assessment, at least to get idea where you're at And then based on that, like if you need to intervene, well, the good news is we could do quite a bit of stuff at this point.

Mark: This isn't a case of toughen it out, this is a case of getting in, getting evaluated sooner, instantly, if possible. 

Iyad: Yeah, and this is a really good example of what you said, toughen it out. There's a difference between exposing people to symptoms, or just like ignoring it and just pushing your way through.

That's not what we want to do. There's a difference between poking into symptoms a bit in a gradual way, and getting somebody to do, let's say, a nice graded program versus Oh, yeah, just go do whatever you want. And if you have like a spike in symptoms, five out of 10 worse than you started before that, don't worry about it.

Again, each person is different. Some people can't tolerate a two out of 10 worsening symptom if they started at seven. But some people are able to do this more if they started at one or two. So that's where like, there's a bit of nuance here. And like, exactly like you said, it's not a case of just, like, you know suck it up and tough it out a bit and just kind of move on with your life. But we definitely try to do that in a more regimented way so that we don't, again the yo yo of doom where symptoms go up and down it tends to be quite a burden on a lot of people. So that's where we're here to help. 

Mark: If you suspect a concussion, get evaluated, whether it's at your doctors or in at Insync Physio. You can reach them online at insyncphysio.com to book an appointment. They have two locations, one in Vancouver, one in North Burnaby. The North Burnaby office is at (604) 298-4878. You have to book ahead. They're always busy. Insync Physio. Thanks so much, Iyad. 

Iyad: Thank you.

Wil Seto

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