Concussion Management: Exercise, Dizziness and the Neck

This is what happens to the cells in your brain. This is what happens after that injury occurs. And this is why it's important that you follow these protocols. And this is why you feel the way you feel. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. I am going to have an interview today with somebody.

And you heard a little snippet of that. That was Dr. Cameron Marshall out of Toronto. He is the owner and creator of Complete Concussion. And he was actually recommended to be on the show by one of the listeners. Thanks for recommending. By the way, if you guys have someone you want to listen to, you just hit me up. Actually, Instagram is probably the quickest way. That's at performancehb. Or just email me. That's sub at p2sportscare.com. Anyways, this is going to be a great interview. Actually, one surprising thing that I thought with Dr. Marshall was when I was listening to his other podcast with other people, he was amazing at storytelling and just presenting very complex ideas, especially surrounding concussion and neurology and making it very simple.

So, I think it's a really big part of working with people. As you can tell, we go through that in the podcast today. A couple things, too, just to make sure that you're on the right place, is that if you're a clinician who likes to manage concussions or is looking to start managing concussions, this is a really amazing place to start. I personally don't manage concussions, so it was a lot of new stuff for me. I did go through and learn some stuff as of about three years ago on concussions, but I haven't really updated stuff, so there's a lot of new things. A lot of new things. A lot of new things changed since three years ago.

Also, too, if you're a patient who's been suffering from a concussion or know someone who has had a concussion, this is something that's going to interest you as well. We do get a little bit techie in there, but for the most part, there are some very simple points. There's a lot of simple points, and it's good conversation. We talk about jackalopes and pickle lake and all that kind of good stuff, so you'll dig it there. So, before we get in the interview, let me just remind you guys that you're going to learn a little bit more about me and my nuances today through a tiny, tiny story, and then we're going to get right into the interview.

Here we go. Now, one thing that really grinds my gears about Costco, and I love Costco. Costco, you're my boy. I love all of the meat. I love all of the crabs. I love the toilet paper, churros, everything about it except for one thing, and that thing is when you get up to that front door, they want you to take your card out and show your membership card. And by the way, I know they have the membership card, then they have a credit card. Did you know you can interchange them? You can actually take your credit card, and that works. For membership status. I had no idea. For a very long time, I was carrying two cards.

I'm a minimalist. I don't like that. So, anyways, getting into the door there, there's always someone that asks you to stop you. Hey, man, can I see your card? And I'm like, come on, man. Like, you know, going through here and getting all my stuff, I can't buy anything. I can't get through the register unless I have the card anyways. So, I mean, you've got to be kind of silly to get into Costco and not actually understand this. So, I tend to not show it. And I wait until they actually really bother me. And there's actually one guy at ours where he doesn't ask. And I love it. And I recognize him.

He recognizes me, I think. Maybe he just doesn't ask me. But I love going when he's there because I don't like getting in. It reminds me of airport security. It's like you go through. You've got to unpackage all your shit. You've got to show them your stuff. You've got to put it back in. And then there's that clog right at the front of the Costco entrance right there. So, maybe if someone works at Costco or worked at Costco, can you enlighten me on this? Because it drives me a little nuts. I know you can get pharmacy products, I think, without a card. I think you can get alcohol and then something else.

I think there was a couple exclusions, which I thought was kind of odd. I don't really understand about that either. But I think we can improve Costco if we do like a turnstile gate, maybe. That card, since you can't get through without having it anyways, leave it in your pocket. Maybe it dings you in. It just knows that you're there. And it opens this door. And that way, you don't have to deal. You don't have to pay the greeters anymore. You just have this automatic turnstile gate. Maybe those greeters can do other jobs in Costco. But we're going to be more efficient. So, anyways, let's improve Costco on this.

So, it's just one thing that drives me a little nuts every time I go. I go weekly and I keep thinking, I hope it's that guy there. I don't want to show my card. If someone else is with me, they can show their card. I don't want to show my card. I'm off the grid, man. All right. Now into the content. All right, everyone. Welcome on Dr. Cameron Marshall. Hey. Say, hey, what's going on? Hey, what's going on, everybody? Good. You're right on point. You're just exactly what I wanted you to say right there. So, I wanted to have you on, actually. So, you were actually suggested. You were suggested to be an entertainer on the show.

Good. I see you're in and blinking out a little bit. So, it was Mike Murdoch. Yeah, yeah. Hopefully, it's going to hold up. Mike Murdoch, I think you did a webinar for, is it a Cairo one at Western States, I think? Yeah, it was Western States Cairo College, I believe. It was the Rehab to Performance club that they have there. And so, I did a webinar for all the students. Oh, nice. How did they actually find you to do it? I don't even know. I think he got recommended to me in some way and then sent me an email or maybe reached out to me on Instagram. I'm not quite sure, but he asked and I said, yeah, sure.

That'd be great. Oh, cool. Well, I thought I'd try to frame things to make sure that we both know who the audience is. When we go through stuff, I might ask you a couple of secondary follow-up questions just to clarify. And I'm assuming that the listeners of this one are going to be more of like advanced-based patients, not just like standard patient, but also to younger clinicians or people like me who actually don't manage concussions. Sound good? Sounds good. Okay. I'll try to keep it not too medical sounding, I guess. Well, I think you did a good job on, was it George Tate? He interviewed you on the PT?

You guys did it. He did a good job interviewing you, I think. So whatever you did on that, we're going to do that again, but better. Okay. We're going to recreate it. So what's the deal? Like, why do you like concussions? Like, why do you like messing with concussions anyways? I don't even, I think it's, it's, it's one of those things. I think it's really the unknown. It's, um, there's so much that we don't know and there's so much untapped stuff. And, and now we're starting to learn more and more and we're kind of on the forefront of this kind of wave that I think we're starting to realize more and more that concussions are actually treatable, which they've never been in the past.

Um, and it kind of just fell in my lap, to be honest. I was, um, I'm, I'm a chiropractor. I did my sports, um, chiropractic fellowship at, at, uh, CMCC here in Toronto. And kind of, as I was going through that program, we're supposed to pick a topic in research and it was right around the time of Sidney Crosby's injury. And for, for those hockey fans out there, I mean, he's one of the best players in the NHL and was at the time and still is. And his concussion, he was out, he ended up being out for, for about a year or so. And then I kind of caught wind that he was seeing a chiropractor for some treatment.

And then I thought like, what, what the hell's going on here? You know, how is a chiropractor helping with concussion? I mean, concussion is a brain injury. And so started kind of digging into that and learning all about the pathophysiology and things that happen within the brain and, you know, why, uh, really got interested in why some people were taking so long to recover and others were recovering, you know, fairly quickly and getting back into the game within a week or so. And so once I started digging into that, I realized that like, there's actually some evidence coming out, looking at, you know, vision rehab and vestibular rehab and treatment of the neck that can resolve a lot of the symptoms that people have following concussion.

And so there's a huge overlap between, you know, what we do as, as therapists, um, and what the symptoms of concussion actually are and how we can help these patients. And so, um, I just got really, really into it. Um, obviously. And, um, uh, that, that became my entire research focus and I just haven't looked back really. It just, and it just keeps, it keeps being interesting for me, which I think is why we kind of keep, keep going on this road. It's just, it's, it's, there's always new things coming out. And once you kind of get into it and you learn about the research, it just, you end up with more questions and, and then you just kind of go down that rabbit hole of, of questions and, and learn more about it.

And so, yeah, I don't know. I just kind of fell into it, but I think the, the vastness and the, you know, kind of the cutting edge of, of where we're at is just a super, super interesting to me. So what was the other injury or the other condition that you thought that you had to put off the side? Cause it was, it was your second choice. I mean, I mean, I was doing sports medicine, so it's, you know, any type of sporting injury, it was, was, was interesting, um, to me and concussion was obviously the most interesting once it, once I kind of started digging more into it. Um, I mean, I, I assume like everyone else, I mean, back, you know, you know, five, six years ago, everyone just assumed, well, concussion is concussion.

You just got to do, you just got to wait it out and do nothing for it. And so, um, it was the realization that we actually could do something for it that interested, interested me in it. But before that, my research topic, uh, was actually, I can't wait. Yeah. It was actually going to be looking at, um, balance training for hockey players to improve, um, skating, uh, speed and kind of efficiency. So there was, there was this study that came out looking at kind of correlates of, of skating speed. And they found that the best correlates of, of skating speed and amateur hockey players was, um, was their balance measure kind of single leg standing balance and also their, their 40 yard time, which obviously makes sense, right?

The faster you can sprint, probably the faster you can skate and the better you can balance on your blades, probably the more power you can generate. And so, um, my idea was actually to do, um, kind of an interventional study where we would, we would do a balance training program, uh, and see, you know, pre versus post balance training program. Um, what, you know, what that did to their skating speed. Cause I think it's something that's not really trained a lot. I mean, people, people will look at power, people will look at, you know, uh, explosiveness, people will look at, you know, trying to improve speed, you know, in running and that, but I don't think many people are looking at something like balance.

And so I just found that kind of interesting as well. But nonetheless, I threw that, threw that to the wayside and, uh, and actually I did my thesis with, um, John Letty at the university of Buffalo, um, who, for those that are in the concussion space is a, it's a pretty big name, uh, in the field. So I was fortunate enough to be able to learn from him. I'm going to talk long enough to get, for you to get that coffee down. Um, you know, there's still a potential that you can take to finally figure out if there's a correlation between balance and concussions, because if you can skate faster and you balance better, can't you get away from the, the impact or acceleration injury a little bit better?

Yeah. I mean, possibly, I mean, there's all sorts of, and that's that again, more questions, right? More questions come out, but there's, um, I mean, I'm going to, I'm going to tie that question back into kind of some of the ideas behind why concussions are more prevalent in, in female players than male players for a sport like hockey, which is very, very, very interesting. And this is actually, yeah, like at, at, at the Canadian kind of university level, um, they find that women hockey players are actually more likely to get concussions than male hockey players. But yet women's hockey is a non-contact sport and male obviously is, is a contact sport.

So some of the theories behind that there's, there's kind of three main ones. And then one that I think, um, you know, should be looked at a little bit more closely, but this kind of ties into your idea behind, you know, balance and, and, and skating speed and agility, I guess you can say. But the first kind of theory behind why women might get more concussions than men is related to, um, neck strength or, um, kind of a head to neck ratio. And so that, um, there's, there's evidence showing that, you know, the stiffer you can keep your neck, the less, the less accelerated force would be transmitted to the head if you were to receive an impact, cause you can kind of couple your head mass with your body mass and maintain one unit, which increases the moment arm and decreases the acceleration of, of the brain during impact.

And so, uh, women just generally having, um, uh, thinner, uh, necks and not as strong potentially as males, uh, any type of impact might, you know, create more acceleration to their head, making them more susceptible. That's interesting. It's, it's kind of like a, the McGill co contraction model, but for the abdominal area, the wider base of support. Exactly. That's exactly what it is. It's, it's biomechanics, right? Um, and the kind of a secondary theory is based on, um, um, hormone levels and fluctuations in menstrual cycles and potentially increasing susceptibility during various times of the cycle.

Um, the other one is, um, potentially just the, the honesty bias, I'll call it where, where women just may be more likely to report their injury or tell somebody, uh, when they're not feeling quite right. Whereas men may be more likely to kind of keep quiet and try to, you know, you know, quote unquote tough it out. Um, and that's, and that's a theory. And my, my kind of theory comes down to, um, kind of a game awareness theory. And the reason behind that is because when you look at just neck strength, overall neck strength doesn't really protect you against concussions. And this has been disproven in a number of studies where people with, you know, strong necks from an isometric construction standpoint in various different angles of, of pull and everything else don't have any less high magnitude impacts throughout the season than people with weaker necks, meaning that their head is likely to accelerate just as much.

And the idea behind that is if you look at the amount of time it takes you to contract your neck, uh, it takes about 150 milliseconds to even initiate contraction of the neck muscles kind of voluntarily. It takes another, you know, 90 milliseconds or so to even get to half of the contractile strength of those muscles. So then if you think, okay, well then it maybe it takes another 90 milliseconds. So now you're up to close to 300 milliseconds, um, or slightly more to even get, you know, close to contracting and getting the full use of this, the, the muscle tension in your neck to create any type of stability in there.

The amount of time it takes for concussion to happen is, is very, very short. So they found that the, the peak kind of impulse magnitude or peak velocity of, of the head following impact happens in the first six to 20 milliseconds after impact. So if it takes you 300 milliseconds to contract your neck muscles, it really matters. Not necessarily about, um, how strong your neck is, but how fast you can contract it and how much time you had beforehand to know that the hit was coming. Just them being able to see the hit or see the impact. Exactly. If you know you're going to get hit, you're going to contract, you're going to stiffen up and you're potentially going to be able to take that hit a lot better where you're going to have less acceleration of the head.

Now, if we relate this now, if we compare male and female hockey, if, if you're playing men's hockey and it's a full contact sport, um, you're going to, you know, potentially be more aware of what's going on in your surroundings, uh, in terms of hits that may be coming. If I'm going to go into the corner, I'm going to get, you know, I'm going to tighten up. I'm going to get ready for the hit that may be coming at me. Right. Whereas in women's hockey, if I'm not expecting to get hit, I might not do this, do that same thing. And so when I do get hit, it, it then creates more head acceleration. So it's kind of this game awareness theory.

Now relay that long story back to, I'm still with you. I'm still with you back to kind of balance and agility. Well, again, that comes down to game awareness. Now, if you have 300 milliseconds to know that a hit is coming, why don't you just step out of the way? Right. So, so again, I think that balance and agility by themselves are not enough. I think you also have to pair it with the game awareness, um, to be able to, you know, shift and move and potentially dodge, dodge those impacts. So that's kind of my long drawn out. I still think you combine the two passions. There's still a chance. That was, that was my point.

Well, we, we test, we test, we test a lot of balance. Uh, we actually use force plates as part of our, um, baseline testing and return to play protocols. We put every, all our athletes on force plates and look at postural sway and things like that. So it's definitely still a part of, uh, and I actually use the same protocol that we were going to use for our hockey balance. So good. I was, I was, I was thinking that you probably would the, uh, cause I know there was a couple things that I've done in the past of just making random crap out of wood. I thought this would be good and it doesn't end up going anywhere.

And then I'm using that same thought process with something else that actually sticks. So marrying the ideas, it's just one big, one big learning circle, my friend. Right. You know, I was, I was thinking too, when you're talking about the, uh, the reaction, voluntary reaction time, remember that game that we used to do, uh, in school where like you'd drop the ruler and you'd measure how long it took you to grab it. So then can you reach, I know that's voluntary, but can you train their other receptors to maybe catch hold quicker? Is there a latency on some of those people or do we not know? Uh, I, I mean, that's a, I think that's a, that's a pretty big question.

The, um, we actually use that test as part of our, our baseline of post-injury testing. Um, so some of the cues that we try to avoid people from being able to see, um, it is like, for example, sometimes kids will put their hand out and they'll watch, they'll watch your hand as the examiner dropping, you know, said ruler. Um, but that test has actually been, been studied at, at the university of Michigan, uh, a guy by the name of Jeff Kutcher and, um, Paul Eckner, I think his name is. And, um, they kind of took that test a little bit further and they put a, basically a hockey puck on the end of a wooden dowel and put it and put a measuring tape on it and, um, and they would drop it.

So you make a C shape with your hand and the puck kind of sits at the, at the top of your hand and then you put the person's hand on the table so they can't move it up and down and then you drop it and they catch it and you measure it in, in centimeters and it actually converts through a formula into the reaction time in, in seconds. And, um, they've actually, they've actually validated this test. Believe it or not, listen to this. They validated that test with what they called a functional head protective response. Really? And what it was is they basically put like a helmet on people and they fired tennis balls at them out of a tennis ball machine.

Like American gladiators? Kind of. Yeah. And they would look at, and they would film them in high speed cameras and look at how, how quickly they were able to initiate reaction to protect themselves. And they called it a functional head protective response. And they actually correlated that dropstick reaction time showing that it actually is measuring reaction time and it's actually correlated with your ability to protect yourself. And so that's why we use it as one of our return to play tests. And so you're not only looking at is the reaction time back, but you know, how, how likely are they to be able to protect themselves in the event that somebody's coming at them?

So it's interesting. That, that is interesting. I could take that another route, but we'd probably talk the entire time about this one thing. Um, I was just curious cause you're, you're, you speak, uh, you speak well, you're a really good speaker. Um, and yeah, that's, it's, it's a hard thing to do. Um, but also too, you can get techie in there. How do you communicate this to a patient? Like, how do you communicate like, Hey, you've had a concussion or whatever. Do you even explain these nuances or is it just like, they're just going to hit that fog real quick? Um, I, I believe in a, a lot in patient education and that's actually one of the, the best ways to be able to improve outcomes following concussion is being able to educate and reassure your patients.

And so I think being able to take a complex topic and, um, you know, break it down into a simple format for patients is, is one of the most important skills as, you know, a therapist or healthcare provider. And we've done this with concussion and I have kind of a set way that I do it with my patients. We have, um, it's a drawing. I actually, I'll go get a piece of paper and I'll actually draw out. This is what happens to the cells in your brain. This is what happens after that injury occurs. And this is why it's important that you follow these protocols. And this is why you feel the way you feel.

And then I break it down from there. And I, I try to help the patient understand, like, you know, just when you start feeling better, it's not good to, you know, go back and play. And this is why, and I do the same thing for people with chronic injuries where I say, this is what happened initially. These are all the things that happen kind of at the same time and they all overlap in the same symptoms. And so if we can figure out which one of these things is causing your symptoms, we'll be able to help you. And look, we're just going to start at the top of the list and we're going to rule this one out and rule this one out and rule this one out.

And I find that the clinicians who are the best at this are the ones who are best able to convey that complex message. So I think that's an, that's an important piece, but I've always been decent at doing that. Like I've always been, I've always been the one to take a concept that was complicated and figure out a way to explain it to myself in, in kind of layman's terms so that I could teach it back to people. So we have, you know, in the university, have a study group type things. And I always wanted to be able to like take and go, okay, now step by step, I'm going to try and explain this. And then, then I feel I understand it.

Right. So did people go to you then, uh, like when you were in finishing school or in school, did everyone go to you at the last minute and say, Hey, what do I got to know for this test? Yeah, I guess sometimes, sometimes, sometimes it, sometimes it was the reverse when I was like, you know, what do I got to know for this? Uh, but, but yeah, I know I've always like in, in, in more so in university, I think in high school, I was able to do that. I think when you get into, you know, graduate school, uh, everyone's, everyone's pretty good at, uh, at figuring out concepts. So you don't, you're not teaching as much, but we had, we had a lot of people who were really good at playing ping pong throughout the week.

I was one of them. And at the last minute we'd all show up into the same, same, same room and say, Hey, what do we got to do? What do we got to know? And then all the acronyms come out. Yeah. You actually had a good analogy with the, uh, it was the jello one and I started thinking about it. That is, it is a concussion kind of like a neuropraxia, like a stinger, but inside the, was it inside the, it was inside the brain. Mm hmm. Yeah. I mean, you, you could kind of think of it that way. Um, I think a neuropraxia is probably a little bit more severe actually than, than what a concussion would be, but kind of a similar concept where you get a stretching kind of, and, and, and shearing of, of brain tissue, similar to what you'd get with a, with a, uh, with a burner or a stinger.

Um, but I don't, I don't think it's at the same severity level cause you can get degrees of burners and stingers where you're actually creating kind of damage into the microstructural components of that and you're, and you're getting kind of remodeling. I guess you could get that in, in some concussion cases, um, which may be a little bit more, more severe, but I think the concept is, is very similar where you're, you're getting a, a stretching of brain tissue, but just to the point of just almost just creating stimulation, like overstimulation of, of that, of that tissue. So then with the, with the severity of things, have you, have you ever found anyone that you thought this is a concussion case that it can't, that it really can't get better?

I've, I mean, I don't want like, I've, I found patients that of course are in my office and I'm like, I don't think this person's going to get better. And, and I don't, I never tell them that. I always want to give them, you know, the idea that they can get better because I think a lot of the patients that are in that category that I talked about where I say, I just don't think this person's going to get better. And actually, you know, I, I see those people quite frequently, most of the times I feel it's because the, just the, the deconditioning of the patient is such that, I mean, so the treatment now for, for concussion is, is active rehabilitation.

And if someone's not going to be compliant with that rehab and they're not going to put in the work, um, you know, that's going to be an uphill battle for them. Um, but I don't think that's related to concussion in my mind. I feel that concussion being what it is, a mild traumatic brain injury and having certain things that happen afterwards that are treatable and the, the pathophysiology itself of concussion being a short term thing. As far as we know, it's all the other components that go into it, such as the blood flow issues that are helped by exercise. Well, if you have a patient that, you know, smokes a pack a day is, you know, 70 pounds overweight and you know, they have blood flow issues.

And now this has compounded that. And if the treatment is exercise, good luck getting them to do anything. And even when you explain it, Oh, have you been exercising? No, no, I haven't. But yet they, they still just want you to help them, but you can't like you have to help yourself. And so that's one element. The other element is, is on the psychological side of things where, um, you know, patients have preexisting anxiety, depression and things like that, but they don't want to seek help for that. Or they, they're, they're still having that stigma. And so I feel that those patients are the ones that are going to have, you know, the most difficulty in recovering the patients who come in and say, you know what?

Yeah, you're right. I'm going to do all this stuff and I'm really going to take it seriously. Um, I'm pretty confident that they will get better, you know, the vast majority of the time. So I guess yes and no is the, is the short answer to that question. Yeah. I'm guessing then, so the nose, those, those ones that are, I guess I would consider them as, as non-compliant or, or just, uh, they're not, they're not giving themselves a chance. What do you like? Is there a conversation you got to have with them? Are they accepting of a conversation in an intervention basically, or is it just kind of, it's there, there's, it's a mixed bag, right?

I think that's a difficult conversation for people to have. And I, I'm very frank with my patients. Um, and I think that's important. Uh, but that being said, you also have to do it in the right way. You have to be able to tell a patient like, look, you know, this is something that is an issue. It's a known issue, right? This isn't just a you issue. This is, this happens is very common. This happens to a lot of people. And this, these are the things that can hold you back. And this is what I think we need to do to move forward. And I need you to be on board, right? If you're, if you're going to be here and we're going to go through this together, I will do everything I can to help you, but you got to put in the work and you've got to be able to do this too.

And so if I feel I'm not getting that buy-in after a few sessions, I have to be like, you know, kind of kickstart that back up and try to have that conversation again. And some people are a little more, you know, I guess, fragile or sensitive than others where it's a little bit more challenging to have that conversation. And, you know, people have all sorts of life stress and things going on that you have no idea about, right? So trying to, you know, do it in a way that's kind of firm but gentle at the same time, I think is, is a nuanced thing that, you know, I still haven't figured out quite, but I'm working on it.

I'm guessing that people, do people come, they pay you cash or is that insurance up there? It's, it's both. So it depends on what they have. So we go through third party payers for, for physio and chiropractic care. Our healthcare system from like a physician standpoint is covered through the government. So anytime, anytime you're seeing a physician, it's covered by OHIP. Anytime you need MRI, it's covered by OHIP, which is, which is our, our provincial insurance. And, but anytime you go to therapy, physio, chiro, massage, it's either if you don't have insurance, it's covered through cash. Or if you do have insurance, it's usually through your work provider.

So your, your, your job will provide you with the insurance most of the time. You don't, you don't, is there, you don't see any relationship between, uh, pay versus non-pay compliance or is it just a mixed bag in there? It's, it's really a mixed bag because if you're in a motor vehicle accident, for example, even if you don't have your own insurance, uh, through your work, uh, your, your car insurance pays for all of your therapy that, that you need. Right. So you'll have people that, um, you know, don't necessarily have work insurance, but they'll have motor vehicle accident insurance. Um, so yeah, I find that it's, it's, it's really a mixed bag.

Obviously people that are paying out of pocket, um, will come less frequently. They will, um, you'll have to just give them a lot of stuff they can try to do on their own. And they try to kind of self-manage, which sometimes isn't the best because just, I think the best thing about seeing somebody just a little bit more frequently, just at the start to try and get things kickstarted is just being there to answer their questions because when patients, patients will have like, you know, they might see their doctor, they won't see the doctor again for another six weeks. Well, during that six week period, you know, it might be the day or two after they saw that doctor and went, Oh shit, I didn't ask him this.

And you know, am I allowed to exercise for example, which they probably should have been doing, but now they didn't ask. So they're going to wait six weeks now to start something right. Whereas if, if they're seeing me, I'm going to see them, you know, probably once a week for the first couple of weeks to try and get them going on, on something, but they can continually ask me questions and I can continually reassure them, which I think is kind of the benefit of, of, um, of have more frequent follow-ups with patients. Well, I, um, I know we're going to full go for full circle back to exercise at some point here.

So there's a good point probably, but, um, you said something on a different interview that I heard there. There was, you figure out the things exercise wise that they can actually do successfully, not trigger their symptoms. Um, I would, I would assume, and you correct me if I'm wrong, but your first couple of times, if you're implementing exercise, you, you find some that are fail points and then you find some that are successes, but it's a trial and error process. Is that, is that right? Or? Yeah. I mean, with, with just cardiovascular exercise, I think is one of the most important things is just get people moving.

And so all, and it used to be that you would rest, rest, rest, you know, after injury and, and, you know, don't do anything, just stay on bed rest. The same type of thing we used to do with patients with low back pain and neck pain, put them in neck collars and tell them not to move. And, you know, but that's just, we found out that's the worst thing you do for somebody. And we're starting to realize that's the worst thing you do for somebody with concussion as well is to put them in this cocoon dark room therapy, which ends up making them more sensitive to light and more, you know, uh, deconditioned than anything and more depressed and more anxious and everything else, which then compounds and makes things worse.

And, um, so in the acute phases, now we're learning that exercise is actually potentially beneficial or therapeutic, even as early as the first day. Now there's only been a couple of studies on this. So we haven't gone to the point of full bore recommending patients start exercising that early, at least vigorously. So what we do in the first kind of 24 to 48 hours is we tell them to take it easy, but they can go on their computer. They can go on their phone. They can do some homework if they feel fine. And they can do anything from a cognitive standpoint that doesn't provoke their symptoms to a significant degree.

If, I mean, if you're sitting there with a headache, but you know, you want to watch TV and the headache is staying the same throughout. Well, are you really doing any harm? Well, probably not. Right. But if your symptoms start getting provoked, well, maybe shut it down. But one thing we will always tell them is to, is to not just lie on the couch and do nothing. We want them getting up, going for walks, you know, doing household chores, provided they're not too strenuous. You know, if they're a kid, you know, clean your room, do the dishes. You know, you can vacuum the carpet. Like, it's not a big deal.

You can do a little bit of kind of physical activity, keep yourself moving and occupied. It's when people sit around and do nothing that they have the chance to focus on their symptoms and things like that. When you get a little bit further out, when you get into, you know, maybe a week or so after the injury, um, we're actually getting to the point now where our, we put people on the treadmill, um, at the 10 day mark. And I think we're probably going to start doing that earlier and earlier, but we actually run them through a protocol. And that's when you get into establishing what their threshold is.

So we'll put them on a treadmill and we'll gradually ramp up their heart rate, uh, through a walking test. Uh, it's kind of a standardized test. It's called the Buffalo concussion treadmill test. We'll put them on that, you know, within the first 10 days or so, if they're still symptomatic, if they're still symptomatic at 10 days, we say, okay, what can you do? Let's, let's see what your physical capacity is. And we start working them out and then they get symptomatic, let's say at a heart rate of 155 beats a minute or whatever. We say, okay, 155 is your threshold. So we don't want you working out at 155.

We want you working out, you know, at less than that. And so generally the rule of thumb is, is 80% for non-athletes, 90% of their threshold for athletes and you want them to work out, um, at that 90% rate so that they're improving that blood flow. They're getting the blood flow going, but they're not creating, you know, symptoms for themselves. And the same, and the same thing goes for the vision and vestibular type stuff. It's like, okay, well, what can you do? Does this make you symptomatic? Okay, we'll do it, but do it, you know, at this level, not this level yet. And then we'll progress you as things, you know, improve in that way.

But I think the big thing is, is people tend to baby concussion patients. We really tend to, you know, back off on everything and well, don't do that. If that makes you feel, you know, symptomatic. And I think what we have to start doing is, is being a little bit more okay with, with symptoms. I think symptoms are, uh, you know, a loose guide in terms of what you should and shouldn't do, but you shouldn't totally avoid it, uh, completely avoid it because you end up kind of regressing in a way that I think is, is damaging. And I think that's, that was the issue with exercise is telling somebody to rest and sit in a dark room and don't do anything.

Well, now you have somebody, let's say who are an athlete, they completely deconditioned themselves. And now any type of exercise, like walking up the stairs or going outside for a walk provokes symptoms because they're so out of shape by this point that even getting their heart rate up slightly makes them feel dizzy and nauseous. Well, you know, it's, it's like if you haven't worked out in a while and you go back to the gym and you know, you have a hard workout. Well, yeah, yeah, I think I, I, I do think you're right with, uh, I know you have, we had back pain and neck pain, all that stuff where they, um, tend to rest them excessively.

And I know that the time and place for it, but, um, I've noticed that people tend to have a lot of sympathy or empathy for people in injuries and they just tell them to rest and relax, you know, and, uh, I don't know. I think it disables the people, honestly. And, uh, but there's that acute phase, which is obviously I think we're needed, but then the rest is like, just get them moving, you know, but it's funny how it kind of, kind of full, comes full circle on that. Cause, uh, I never like, I know very minimal about concussions. I know, I know enough to know that there's a scat and I know that I've done a scat a couple of times, but I don't like managing.

I wouldn't manage a concussion. Um, but it's funny that it kind of comes full circle. It's like, okay, well, you're not moving. Why don't we just move you? You know? So I don't know all their tolerances though. Yeah, I mean, that was, I think that was, I mean, kudos for the, to the guys in Buffalo for kind of going down that road because without, without them taking that chance and that idea, like it was, you couldn't even get a study like that pushed through like ethics committees because it was considered so common knowledge and best practice to just have people rest that even the idea of saying, well, why don't we try exercise was, was like a difficult thing to get pushed through ethics and they started out with like really, really chronic patients saying, well, like rest isn't working.

Let's, you know, get them exercising. And just with like an eight week exercise protocol, they had like almost a full resolution in symptoms and like 70% of their sample or something. So then all of a sudden they go, whoa, okay. That was a fluke. Rest is better. Yeah. Like rest, rest obviously isn't working, but there's something here. And then that led now to, let's say, okay, let's try these people at a month, then two months, then all the way down. And now we're getting to the point where the studies coming out showing like exercise on the same day of injury, you know, the day after is potentially beneficial.

So I think that, and this is only in the span of, you know, the past, maybe, you know, seven, eight years that this has kind of gone this direction. And so I think we're, uh, uh, we're, we're onto something. I don't, I don't think Zerk didn't have it right. Does Berlin have that in there or? Yeah, they do. Yeah. Yeah, they do. So Zerk, Zerk was, um, you know, rest until asymptomatic completely and then gradually reintroduce activity. Berlin is rest for 24 to 48 hours and then reintroduce activity. Oh, wow. That's a big change. I can be honest with you. I didn't read Berlin. So yeah, so it was, there was a lot of, uh, there's a lot of really good changes in, in Berlin and that was one of them.

And, um, the other part on the exercise front was, was displaying significant evidence for exercise for people with persistent concussion symptoms. Right. And then that gets into what I'm talking about with those patients who are deconditioned and, and, you know, they're a year or two out and they haven't done anything in two years because everyone they've gone to see has told them not to do anything. And that has completely disabled them to the point where they can't even leave the house half the time. Dude. Well, is there, is there public common knowledge whether, whether they have encountered a healthcare provider to tell them or not, uh, about rest?

Do they already, do they already consider rest as first option? Excessive rest? Yeah. And I have like all of patients come in and say, you know, we did everything right. You know, like this, these are more of the acute patients, right? Cause they've come to see me and maybe their injury happened a week ago and they've, you know, finally gotten into seeing me or whatever, you know, a week later and they go, they're like, yeah, we did, we've done everything right. We've been resting perfectly the whole time. We haven't done anything. We haven't let them watch TV. We haven't let them go on his phone.

We haven't, you know, we basically shut them down completely as, and then you have to be like, well, yeah, okay, but here's what we're going to do now. And the kid's depressed. You just can't play video games probably. Oh yeah. That's another problem. I think. Oh yeah. Let's, let's go down that route. Well, no, I think just, I think in general, I think just the lack of, the lack of physical activity of our youth and everyone, you know. Oh yeah. Are you a Dan John fan by the way? Uh, who's that? Oh, I got to send you some Dan John stuff. So he's a, he's a very like simple, like strength coach. And, um, I think it was him that said, basically we are, our kids aren't calloused enough.

They need to start carrying shit and everything. And, um, but he's very simple. I might be misquoting him, but for the most part, I believe so. Like I, whenever I have patients come in here and they're like, they're overall kind of soft and like overall deconditioned, they have problems. And, uh, I look at their hands and I'm like, you guys, you don't have any calluses. You're basically undateable as a human being, like man or woman. No one should date you right now. You're soft. So that's my thought on children. I, uh, I tend to agree. Can I, can I see your calluses? Let's just, let's compare calls.

I got to stop talking. Oh, I see them. Good. Hey, by the way, why are they in the last three fingers only? Unless you swing a bat. I don't know. I was thinking that the index is a dexterity digit. It has nothing to do with gripping. Yeah, maybe. I don't know. That's a, I've never even thought about it, but yeah, you're right. Yeah. But obviously with swinging a bat, you'll get them, uh, you'll get them on the, the side of the index because it's a pivot point, but I don't know. My, my, my ring finger seems to be the most prominent. Oh, is your, do you have a ring on it? Well, I do, but I take it off when I lift, but yeah, I'm just looking at it right now.

I see that it's most prominent on the. Hmm. I think I've ring ring too. I would never file it, file these things down. Um, so what are you experimenting with, uh, personally with concussions that, that you, you're excited about? Uh, I'm doing all sorts of, um, stuff really. Um, I think one of the things that I've been really interested in lately is, uh, is just dizziness and vertigo. Um, I think that's a, it's kind of a complex web. And, um, so I've been playing with all sorts of, all sorts of stuff clinically with that. Um, I mean, being a chiro, I'm really interested in the, the integration of the neck into the kind of vestibular picture.

And I think people don't give it enough credit. Um, and I've been really finding a lot of patients and whether or not it's, you know, the fact that, you know, my bias is a chiro that I, I keep finding this stuff or whether or not other people aren't looking hard enough for it or don't really know what to look for. I'm not sure, but, um, finding patients with dizziness after concussions, I think it's, it's really interesting because they come in with, they don't often come in with true vertigo where they don't really experience, you know, the room is spinning and things like that. And so, um, and I've even had patients where, you know, they've gone to vestibular rehab quote unquote, and they've put them through, you know, various, um, you know, vestibular tasks and tests and things, and they haven't really been able to find anything or help them in any way.

And, um, the, the way that they describe their dizziness, and I find this with a ton of concussion patients is that they don't really feel, you know, dizzy. They just feel off. And if you ask them to describe it, and I will always ask them to describe what they mean by dizziness, like does the room start spinning on you, you know, in that kind of vertigo feeling, but they'll describe it. It's kind of visual. They feel that the ground is a little bit shifted and moving a little bit. And they find that when they're in a car, they, you know, they don't, you know, the motion of everything around them makes them feel off.

And, or if they go to a shopping mall or they're walking up and down a, an aisle at a grocery store, that's when they start to feel it. And, and so a lot of people would think, okay, well, that's visual. That's an overstimulation of the visual system. And, um, which, which it can be in some instances. And, and what I've been looking at then is, is kind of running people through some tests for kind of the cervical spine, looking at, um, looking at just implications for different rotations of the head and having them walk and turn their head in different directions and ask, you know, when do they feel it?

And once I figure like, I have an idea behind this, actually, we did this with, um, with, uh, this virtual reality headset, this thing called saccade analytics. I'll plug that a little bit. It's a, it's a virtual reality headset. And so it looks at, it gets you doing all sorts of ocular things, but it also takes into account the position of your head. Cause it's full 3d, uh, you know, virtual reality. And so you can look around with it and everything and they get you to track, you know, dots and they get you to look at different patterns and it'll move the dot into certain things. Uh, it'll basically put you into like a Dick's hall pipe position, you know, to try and stimulate vestibular, um, you know, nystagmus and whatever else.

And it's filming your eyes the entire time. And it's tracking your people response to it. How, how close are you to the dot? What, you know, what are your saccades like, you know, what's your nystagmus like in different positions and things like that. So these are all reflexes. And so this is, this is like a very, very high tech tool designed to try and, you know, pick this stuff out. And we actually brought them in and I grabbed a bunch of my dizziness patients and they ran them through their kind of testing procedures, but I ran them through my clinical testing. And I said, you know, so I'd have them and we filmed all this too.

We have all this, we have all this footage. So YouTube video to come? Yeah, we have, well, I mean, we just, we gotta put it all together cause no one wants to watch an eight hour video of us like doing this. Right. So we have to like splice and find the time to do it. That's a good CE course. What are you talking about? Yeah, yeah. We had, so anyway, we haven't, we haven't done anything with it, but I would, I would bring them out and I would test them through kind of some of my clinical tests. Um, and then I'd kind of have, I'd say, okay, I know what I want to do. And then they'd do this, this machine and they would have a printout of, okay, here's what's, here's what's happened.

And then I would go in and based on what I found, I would just quick, quick, quick treatments, just doing little things, loosening off certain tissues, acupuncture needle here, a little bit of stimulation, maybe an adjustment or two here or there based on what I was picking up clinically and then bring them back out and run them through my tests again. And their dizziness is gone. And I'm talking in the span of like, you know, five minute, quick little treatment, they come out and they're at least significantly reduced, if not, if not gone. And then we put them on that system, which is again, think of that measuring reflexes in the vestibular ocular system.

And just by treating their neck, it's completely changed all these reflexes. And the, the person from saccade analytics was like, this is, this is insane that you're like, you're affecting neurology by doing this. And I know I listened to a little bit of the chiropractic neurology stuff, which I have absolutely zero training in. But I think that your vestibular system is your visual system, your, your kind of inner ear vestibular apparatus. And it's also the proprioceptive elements of your, of your joints and muscle tissue. And so people don't take that into account though. They'll sit there and work forever on the vestibular apparatus and the visual system.

But if that neck isn't working properly, you're still going to get that mismatched signal. And so the way I look at it is, you know, your eyes are saying, here I am, everything's level. Your ears are saying, here I am, everything's level. And your neck is saying, my head is like this because, and so then your brain goes like, okay, well, who do I believe here? Right. And it's that quick snap where you, you know, you're driving and you shoulder check and you go, whoa, that I feel weird with that. And then it kind of calms down. And that's a lot what people will explain. And what I find that's just, if you find out what's pulling where and how it's working and whatever, you can kind of get everything moving properly.

That just kind of goes away because now the signals are all saying the same thing. And I've been really, really playing around with that. So that's something that's really kind of exciting to me. Now, how do you design a study? How do you prove that out? You know, that's, I think, not for, that's for smarter people than myself. But there's been a few research articles that have shown that treatment of the neck can resolve, you know, dizziness complaints in patients. So. Well, I would imagine the treatment of the neck too is not a, it's not standardized. It's based upon each person, right? Whatever you find.

Um, maybe one way to, I was just thinking when you're doing that quick turn thing, um, I've always thought that like, at least with, with movement for, for mechanical stuff, the slower you go, the more potential you have to be able to, um, normalize a pattern. Let's just say, I'll keep it basic. Um, what if you just put like, almost like their head on a shelf and just let them slide because I was thinking about if they turn and they might say something kind of catches a little bit on one side and creates a, an altered hinge point. Maybe, maybe that affects the vestibular systems or the canals or the, uh, anyways, maybe standardize the turn is what I was thinking.

Yeah, possibly. But I think that I don't even know if it's an actual like tilting or anything of the head. I think it's just the proprioceptive input that goes to, you know, to the brainstem and to the cerebellum. It's, I think it's, yeah, so it may look, it, it may look absolutely normal. And there may be no actual tilt in the way that they turn their head, but people are going to compensate in certain ways and certain tissues are going to get stretched more than others and things like that. So I don't know if it would be appreciable, but, uh, it's an, it's an interesting concept. You ever, um, so you're talking about, um, what kind of, what kind of muscles are you usually working on back there or what things are you working on back there?

Yeah. I mean, I think that's it. I mean, so for what I, the, just the way I think about it and other people can try and play around with this too. If you have any dizziness patients, you want to put. One of the tests that I'll do is, uh, is yeah, exactly. Yeah. Uh, I'll, I'll have people just, it's just a base. Here's one of the tests I'll do. So I'll have a patient walk, you know, take two or three steps going forward, turn their head as far as they can to the right while still walking. So you're, and then you keep walking, take two or three steps with your head turned all the way to the right.

And then you come back to the middle and you keep walking and then you turn your head all the way to the right again. And you keep walking for two or three steps and then you kind of stop. So you're doing basically two or three steps, neutral, two or three steps with your head, turn to the right, two or three steps, neutral, two or three steps with your head, turn to the right and you stop. And then I'll ask them, how do you feel with that? Did that provoke anything? Do you feel a little bit off with that? Or do you feel okay? If they say, well, no, that feels fine. I'll just ignore that altogether and I'll have them come back the other way, but turning their head to the left this time, two or three steps straight on, two or three steps with your head, turn to the left, two or three steps straight on, two or three steps with your head, turn to the left.

And then, you know, oh yeah, that makes me feel a little bit weird. So in my mind and just what I've been playing with is whatever tissues are being stretched at that time, whatever tissues are being elongated or stretched at that time, those are the ones I'm going to focus on the most. Because just the way I think about it is if you have a muscle that has some sort of trigger point or tension point in it and you're going to turn, you're going to turn your head to the left, let's say, and I find that the SCM muscle, sternocleidomastoid, as well as kind of the deep neck flexors, things that are, you know, closer to the joint as well, that they're more proprioceptive in general, right?

So as you turn to the left, your left SCM kind of pulls around your neck. That's kind of getting stretched, right? Um, your, your splenius capitis on the right is getting stretched. The inferior oblique muscle on the right is getting stretched. The superior oblique muscle on the left is getting stretched. Um, and so I'll focus then on, let's say those like four main muscles where I'll do a little bit of suboccipital work on that side. I might put an acupuncture needle in the left SCM, stim it a little bit. I might get them to do a little bit of deep neck flexor as well, you know, just kind of active release therapy type stuff.

Uh, and then if there's any restricted joints, all, you know, potentially manipulate those joints. And, and then they have this full free range motion. Now, when they turn to the left, they don't, nothing's pulling, you know, they can get way more range of motion. And then I think just the signals that go up now through the brainstem is that everything is smooth and good. And there's none of those kind of pulling points and they don't feel dizzy anymore. And this is something that can literally take like five or 10 minutes to, to do. You just kind of have them walk, figure out what it is. The other one is looking straight up in the air.

So they tilt their head way back, look way up in the air. If that one is positive, then I'm going like both SCMs potentially. And then deep neck flexors is where I'm going to focus on a lot. Um, and I find a lot of people are just dysfunctional in this like deep neck flexor kind of spot. And so I'll get them doing things, you know, like isometric chin tucks. I'll get them doing a cervical joint reposition, you know, air stuff. And some of the rehab stuff that goes along with some of that manual treatment. But, I mean, this stuff will come back, right? I'm not saying this is a one shot. It's, you know, these patterns and probably been developed for years and an injury has probably provoked them or put them over the edge where they're, where they're, you know, causing trouble.

And, um, I might have to treat it two or three times, but at the same time you have to then, you know, have the right rehab strategy in place. So they're strengthening and kind of getting better at that from a movement perspective as well. Nice. Yeah. Actually, you, you covered what I was going to ask. Cause I'm guessing some of the R2P or DNS people would say, well, why don't we work on the phasic as well? But it sounds like you're doing, you're doing both. You're just, uh, uh, releasing the tonic and working the phasic and then the test normalizes. Mm-hmm for a period of time. Yeah. I mean, I feel that there's, um, and this is just from kind of the Instagram kind of rehab world.

I feel there's this huge push now against, against the manual side of things. You know what I mean? I feel this kind of phase shift where everyone's, everyone's really focusing on, um, you know, more of the rehab and the exercise model than, than the passive and manual. And I think that, I think there's a place, right? I think there's a place for both. And so my, I can get something done, I think a hell of a lot quicker by, you know, doing the manual stuff and then get them, get them feeling good. And then now rehab and strengthen that, right? Rather than if I just went straight into exercise and they have this dysfunctional pattern, right?

That's very subtle. Like, I don't think you're going to be able to pick it up as, as, as a clinician unless you get your hands right on it, but then I'm just going to reinforce and strengthen this kind of, you know, dysfunctional pattern, uh, at least in my mind. So I, I get things moving well and then kind of train them into that and then keep, you know, keep making my little adjustments while keep reinforcing that from a strengthening and rehabs perspective. So, yeah, I completely agree. I, I, I would practice exactly the same if I mess with concussions, but I, I do them on the other parts. Um, interesting though.

I didn't think we'd end up going down this today. I didn't think we'd end up in the, down the manual therapy, corrective exercise route. Never know where you're going to go. No. Um, but I do want to learn about fur trapping actually. I, I didn't know I was going to, I usually sneak it in like whatever, whatever you said earlier, I'll sneak it in through part of the story, but we're getting close to the end here and damn it. I want to hear about fur trapping. Uh, yeah. So we were talking just beforehand and I'll just kind of preface this. Uh, but he asked me if I had any good stories and I said, my background was kind of interesting and I know nothing about fur trapping.

I will tell you that. But, uh, my, my father, uh, was, it was a fur trapper. I grew up, uh, for those that know Canadian geography, I grew up about four hours north of Thunder Bay, um, in the Canadian shield in the bush. Um, my, when I was born, my parents lived in a one room cabin, um, with no running water, no road, uh, no power. Um, I don't know if they had a telephone out there. I would doubt it though, but, um, everything was run off a diesel generator to get water. We had to go cut holes in the ice with, uh, with an auger and kind of carry it up and boil it on the stove. And, um, yeah, my dad, my dad was a fur trapper.

He had a trap line. He trapped all sorts of animals. He was also a taxidermist. So he would be constantly, you know, making rugs and stuff. If, uh, like some tourists came up and let's say they shot a bear or something might, you know, give it to him, make a rug or some sort of, you know, mount or something for it. Has he ever made a jackalope by the way? A what? A jackalope. I don't even know what that is. Oh my God. Okay. I'm going to do a screen share while you keep talking. I need to find you a jackalope, but go ahead. Yeah. Well, I mean, this is just, this is just my upbringing. So yeah, I just grew up in the bush hunting, fishing and, um, you know, kind of living that life is, is good.

Now I live in a huge city and I just miss that part of, uh, I guess life and growing up. Did you, um, do you, do you consistently go back to, to kind of do that stuff? Oh, can you see my screen? Oh yeah. Okay. All right. Yeah. It's a mythical, mythical jackalope. It's a, it looks like a rabbit and a deer. Yeah. The, the ant's lope. I think this to put the horns on a jackrabbit or did they, is it real? We don't know. Only taxidermists can really tell us the truth. So you better ask your dad. I'll ask him. Yeah. Um, I used to go back quite a bit, I guess. Um, my parents moved from there, uh, when I was going to university.

So they moved a little bit further south. So, um, but I used to fight forest fires, um, up there. So when I was in university, so it's a, it's a, a summer job and, um, I would go up, uh, to where I'm from, which is Sioux Lookout, Ontario. And, uh, there's another town about two or three hours north of Sioux Lookout called Pickle Lake. And, uh, I used to fight forest, forest fires up in Pickle Lake. And, uh, so I spent my summers kind of riding around in helicopters and, um, you know, cutting down trees and putting fires out in the middle of the bush. And, um, so that would, that would bring me back in, in, in the summers.

Cause, um, Sioux Lookout was kind of the nearest town. So we'd drive there and stuff and visit all my friends and stuff. But now my parents are gone from there. So I haven't been back in, I don't know, years, I don't know, maybe like seven years or so, but, uh, we were planning on going up this summer, but, uh, uh, we ended up having a baby. So that kind of forwarded, forwarded that plan, but, uh, maybe, maybe sometime next few years I want to get up there. You know, there's a possibility that it sounds so desolate out there that maybe concussion basis can, can, can unplug at a nice clinic up there, maybe a tent camp.

I would love that. It's just like a fly in, fly in concussion program where, you know, come up and go fishing and, you know, just chill for a while. It'd be great. There'd be so much stimulus, but productive stimulus. Just fresh air, you know, breeze. You ever look out, you ever look outside and like, I do this cause I'm, so I'm an Eagle Scout. I used to, we used to go backpack a lot, but then I live in the city now too. But I look outside and I'll think, damn, like I, I wish I was by a lake right now or like I wish I could smell the Alpine. This is, this is my, ask my wife. This is, I keep telling her, I'm like, we just, I got, we got to move up north.

Like that's what I want. That's, uh, you know, that's my, my dream is to, you know, have a cottage somewhere, just a small little cabin somewhere and just get away, just, you know, just a way to get away from everything. And that's how I grew up. Like I grew up on the lake, like where house was, was right on the, right on the water. Um, you know, we had our, we had our own float plane until I was about probably 10 years old or so that we could just go fly wherever. And, uh, I had my own boat probably around when I was 10 years old and all my friends lived on the lake and just, you'd dress so free, just drive to their house and spend the day fishing or, you know, go wakeboarding or tubing or whatever.

And these, these were our summers. This is like, this is how we lived. It was just the best. And, uh, yeah, it just, it's, it's a shame that I can't do that anymore. Oh, I'm sure, I'm sure you can. You can, you can pull a, you can pull a McGill and just go live out in the bush and people fly out to see you. Yeah. That, that's, that's what I'm talking about. Just make a barn out there and a bunch of tree houses turn butter. Live off the land. Yeah, that would be great. I, I, I, I never actually killed animals to eat them. That would be the thing I would struggle with other than fishing. Um, but I would have, I would have no problem just, just walking down the woods for a little bit.

That'd be great. So never been to Canada though. I heard it's nice. Oh, you should come. I would like to. It's a great place. Just don't come in the winter. I heard, I've heard that too. It's a little cold. Yeah. We're getting there now. I mean, all the leaves are coming off the trees and it's been raining for about a week and a half, but, uh, at least we don't have some of the snow that some of the other parts of Canada have already. Yeah. What, what months should I be coming to Canada then? Like July? Yeah. Come in, come in July and August. That's a, that's a nice time. Come for Canada day. There's Canada day?

Yeah. It's like your July 4th. Ours is July 1st. Oh. Canada day. Yeah. Wait, what is it? What is it? What is yours? July 3rd? July 1st. Yeah. What is the, did Canada get its independence? This is going to seem very, it's probably a really bad question. I don't know Canada history. Well, we're still, we're still, we're still, you know, part of the British Commonwealth in terms of, uh, like our, you know, our stuff still comes from the crown, um, in terms of like any of our, our laws and stuff needs kind of Royal assent and, um, that type of stuff. So I wouldn't necessarily say it's, I mean, we are independent, like we're, we're our own nation, but, um, I think, I think Canada day is, is just like the birth of Canada as a country.

I think even, even if you're not independent technically, then I bet if they wanted to confine you, they couldn't, you just go hide out there. There's a lot of space. Yeah. Um, as we recap here, uh, I, I, I feel the need to ask you then since I, I struggle with this over here when I get a concussion, seemingly, seemingly, seemingly like, I'm going to say I got a concussion patient where the, how do I send them? Because I don't want to manage them nor can I, how do you find somebody? Cause I think that's a little challenging. Well, I mean, I, I think, I think you're right. I think it is a little challenging.

That's what we're trying to do, um, with, with complete concussion management, which is an organization that, um, I founded about five years ago. And, um, the idea was to, to educate people. I think because, you know, as I mentioned before, you know, according to the Berlin consensus statement, you know, there's more and more evidence coming out showing that the best treatments for concussion are more kind of therapy based, right? So it's, it's exercise. It's getting people on treadmills. It's things like vestibular rehab and visual rehab and, and treatment of the neck, whether it be manual or, or rehab focus.

Um, and so I think there's a lot of elements to concussion that you really need kind of a multidisciplinary approach. Um, and oftentimes you can't necessarily find that in one clinic location. I mean, there's, there's psychological components that go into this. There's, you know, there's all sorts of mental health and chronic pain overlap sometimes. And sometimes there's neurological focus where you need a neurologist to, to look at things. And so I think it's a, it's a very multi, uh, faceted kind of thing. And so what our goal is, is to set up, uh, a network of clinics where we can train healthcare professionals because it's not something that's part of standard training, right?

It's not something you typically get in a physiotherapy program or chiropractic program. And so you have to kind of go out and learn that stuff on your own. And people are picking up pieces of it here and there, right? Like we often, you know, talk with clinics in the States and say, you know, I treat concussions. I'm a vestibular therapist or, you know, that type of thing. So that's great. That's one component, but there's, you know, about five or six more components you should be adding to that list if you really want to get into the concussion field. And so what we've been, what we've been trying to do is form a network of clinics where if people type in concussion, they can find, you know, complete concussion management certified clinics.

And these clinics have been trained and educated by us. Uh, and our training course is probably 35 hours long and we update them on a, on a monthly basis as to kind of the new evidence. So these clinics are, are getting everything, not just the vestibular side of things, but they're learning everything we know about concussion. And the idea is to have these, you know, what we call primary access clinics where you can go in and see somebody like a therapist that can get you on the right path. They can go, all right, let's, let's run a treadmill test. Let's see where you're at with that. Let's check your visual and vestibular systems.

Let's get you started on some rehab for that. Let's start seeing if there's anything going on with your neck. Let's provide you with the education and hopefully kind of lower some of that anxiety you might be having. Let's fix your diet. Let's see what you're eating and why could that potentially, you know, impact things with concussion. And then from there it's, okay, this person needs a little bit more advanced stuff or this piece of person actually does need a neurologist or this person actually does need a psychotherapist or whatever it may be that's beyond, you know, the purview of the average, you know, physical therapist or chiropractor or AT or even, you know, local family physician or GP, then trying to find those professionals within the community to then be able to refer, you know, to and kind of work together on a co-management type of thing.

So in Canada, for example, we've set up all of these complete concussion management clinics and we have probably close to 200 or so in Canada. I think in the U S now, I think in the U S we have about 30 locations that are now up and running and we're, and we're probably in talks with another 50 more or so at this point. And so we're just growing the network in the U S is the first year we've been in the United States. And so that's, that's why there's not as many, but, and then in Canada, once we had that network in place of those 200 clinics, we then brought in a network of like occupational therapists that do a lot of cognitive testing, cognitive based rehabilitation.

We're currently trying to bring in a group of vision therapists that are optometrists that specialize in neuro vision rehabilitation and then a whole network of naturopathic doctors that have advanced training in like treatment of dietary issues, you know, associated with concussion and traumatic brain injury. Now you have these people that are all linked together and these networks where you know that you're referring to somebody who's, who's got kind of advanced skills in this area and everyone's going to provide, you know, consistent messaging. And so that's our goal is to set up these collaborative multidisciplinary care networks all over the place.

And so, um, like I said, we're up to about 260 clinics now, uh, worldwide, but most are in Canada because that's where we started, but, uh, we're, you know, slowly but surely picking up some momentum in the U S uh, and, uh, and as well as Australia and the UK. Yeah. Nice. I think, um, yeah, it'd be nice to, is there one down in LA area by chance? Uh, if you go to complete concussions.com, there's a button there that says find a clinic. And, uh, I think we have some, um, I know we have one up by San Francisco and, um, I think we might have a couple in, in the LA area. Okay. If I log on, there is the password pickle Lake.

It's not, but it definitely should be. It's a combination of the word pickle, your favorite dog's name in your birthday. Yeah. Look up if you have anyone who's listening, just look, just Google pickle Lake. Oh, I thought you were going to tell me to Google complete concussion. Uh, pickle Lake is an interesting, it's an interesting place. What does it, what does it taste like? Pickle juice? Oh man, it tastes, this is fresh water. It's beautiful. Oh, pickle Lake. Yeah. So we do have one, we have one in Simi Valley, um, which would be the closest one to LA just north. Oh, cool. Oh, I thought we were on pickle Lake again.

Uh, well, I'm, I was looking at the map of, Hey, they got pike there. Oh yes, they do. You catch pike walleye. Yep. Sturgeon. Yep. Oh gosh, I'm so jealous. Yeah. You should make HQ up there for sure. I don't know if I'd want to go that far, but, uh, but we'll give you a reason to, to fly your float plane three at a time. Yeah. Right on. Well, where can everyone reach you? Uh, you can find me on Instagram at a concussion underscore doc. You can also, uh, send me an email if you want, uh, see Marshall at complete concussions.com. Uh, you can find us on the web, complete concussions.com and, uh, also our Instagram page for complete concussions is at complete concussions.

Cool. Anything else you want to add before we close out? What, um, what's, what's it going to say in your gravestone? On my gravestone? Um, ah, man, you're hitting me with the hard ones here. I got to be so reflect, I'd be so reflective. I'm just not that, uh, not that witty, I guess. Yeah. I think mine would be, uh, under promise over deliver consistently. I think, I think that's, that's more of a mantra that I need to be, you know, more catering to in my, in my current life rather than, uh, yeah, I think that's, that's, that's, that's a good one though. Right on. Um, thanks so much for being on.

It was great. Yeah. Thanks for having me. Yeah. Right on. Thanks so much, Dr. Marshall for being on. I, uh, God, there's gotta be a forgetting Sarah Marshall joke in here somewhere, somewhere, but I'm sure you've heard of them. Uh, Dr. Marshall, if you, uh, remember one, if you think of one, then just email me cause I'm, I'm dry. I'm dry on this one. If you guys are looking for the show notes on this, this is 117. Just go to p2sportscare.com and go to the search function, put 117, nothing more, nothing less, no pounds, no hashtags, nothing fancy. You don't even have to put his name in. Just put 117.

But if you do search, search his name is 2Ls and Marshall. Go on there and you'll find all the show notes and transcription to the show here in any links that we spoke about. So if you guys got information from this one, there's actually quite a few more interesting podcasts that you might want to hear. The ones that at least stick out to me that I had a good time doing and I learned a lot from is that number one, number one probably is, uh, so actually, sorry, episode 91 is pretty amazing. That's Michael Shacklock talking about clinical neurodynamics. Uh, 67 is Dr. Stu McGill. He's talking about back related conditions, especially flexion intolerant back pain.

63 was Stu McGill as well as Brian Carroll, which was amazing in regards to talking about Brian's story, how he overcame, uh, a pretty horrific injury of the low back and went on to start lifting a ton of weight again. So that's a really cool one as well. 105 is one of my personal favorites and I'll leave it right there. Me and Dr. Cody Dimak go over some syndromes of the lower extremity and how we can possibly influence them using corrective exercise. So those are ones that I would suggest that you go at least start playing with if you are new to the show and you're looking for something to really wow you and change your life.

Again, if you guys have listened to this show a bit and you like it so far, I'm going to ask you to do one thing right now and I will not stop talking until you actually do it is I want you to go on, scroll down and review it for me because information, if you like, if you like the information that I'm putting out, it really only goes as far as you promote it. Okay. You want, you are my little army of promoters. If you like it, share it, send it to a friend who is in need of this information, whether doctor or patient. And if you like it, review it. Reviews are really important for podcasts. So if you can do that, I would love to get before the end of the year, before December 31st, can you give me a birthday or a Christmas present, a Christmas present and get me up to 50 reviews, please?

I think we're at like eight right now. Come on. This is 115, 17 podcasts we've already done. Can you please do one? One. We have over a thousand people downloading per podcast. Please review. I mean that in the nicest way. Help a brother out. Lastly, if you guys have someone that you want me to interview, just, just, uh, hit me up on Instagram again. That is, uh, at performance HB, uh, or just email me. That's Seb, S-E-B at p2sportscare.com. Remember, if you are dating, date an Eagle Scout who doesn't stutter and then leave people better than how you found them. Gravestone. See you later.