November 24, 2025 • 44 mins
A faster return isn’t always a safer one. We sit down with physiotherapist Kosta Ikonomou to unpack why musculoskeletal injuries spike two to three times after a concussion and how to build a recovery plan that restores performance, not just symptom reduction. From elite level athletes to everyday patients navigating concussion rehab, Kosta shares hard-earned lessons on testing, training, and the psychology of change.
Kosta is a clinical specialist physiotherapist with over a decade of experience in sports medicine and concussion. He has worked in acute neuro hospitals and specialized concussion clinics, treating persistent symptoms. In sports, Kosta collaborated with Chelsea Football Club Academy, Olympic GB diving, Vancouver Bandits Basketball (CEBL), CIS rugby, and ice hockey teams.
Beyond a Physiotherapy degree, Kosta holds a Master's in Sports Medicine from University College London, a FIFA Sports Medicine Diploma, and certifications in Vestibular Rehabilitation and visual-vestibular postgraduate training for concussion rehabilitation from Duke University. His research findings on the effects of fatigue on the vestibular oculomotor screen was presented at BASEM in Leeds in 2018 and the 2023 Concussion Consensus statement in Amsterdam.
We break down the modern assessment toolkit—VOMS, force plates, reaction time training, neurocognitive scores, and cervical motion mapping—and why baselines matter when pressure mounts. You’ll hear how to test under fatigue to expose hidden deficits in reaction time and visual motor speed, and why neck strength is a keystone that only works when vestibular and ocular systems are trained alongside it. We get practical about exercise timing too: relative rest for 24–48 hours, then progressive aerobic work that raises brain-derived neurtrophic factor (BDNF), stabilizes the autonomic system, and reduces fear-based immobility. For sedentary listeners, microdosing workouts and “never miss twice” habits create momentum without flare-ups.
We also zoom out to the culture of concussion care: the gap between North America and Europe in awareness and access, the role of rule changes in rugby, and how youth and grassroots programs need better education. Throughout, the theme is consistent—return to performance requires objective data, deliberate progressions, and a team approach that meets people where they are. If you’re an athlete, a parent, a clinician, or someone rebuilding life after impact, this conversation gives you clear steps and smarter standards for safer returns.
If this
Get 20% off your first order of Puori protein with code LIFEAFTERIMPACT by following this link.
Dr. Wolf's book Concussion Breakthrough: Discover the Missing Pieces of Concussion Recovery is now available on Amazon!
What topics do you want to hear more about? What questions do you have? Email us at lifeafterimpact@gmail.com
Follow us on Instagram @lifeafterimpact
Website: lifeafterimpact.com
Medical disclaimer: this video or podcast is for general informational purposes only, and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice diagnosis or treatment. Consumers of this information should seek the advice of a medical professional for any and all health related issues.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kosta Ikonomou (00:00):
Athletes' risk of injury after they get clear
to play, there's a two to threetimes risk of getting a
muscoskeletal injury.
So that means like an ankleinjury, hamstring injury, um,
you know, blown ACL or somethinglike that, put them more at
risk, and now they're out evenmore.
And depending on what level youplay, uh you're you know
(00:24):
involved in, that's hundreds ofthousands of dollars.
Every time at the end of theyear, you get this sheet that
says how many missed games we'vehad and how much that costs the
team.
So as a you as a as aclinician, you you want that to
be as low as possible.
Dr. Ayla Wolf (00:42):
Welcome to Life After Impact, the concussion
recovery podcast.
I'm Dr.
Ayla Wolf, and I will behosting today's episode where we
help you navigate the oftenconfusing, frustrating, and
overwhelming journey ofconcussion and brain injury
recovery.
This podcast is your go-toresource for actionable
information.
Whether you're dealing with arecent concussion, struggling
(01:05):
with post-concussion syndrome,or just feeling stuck in your
healing process.
In each episode, we dive deepinto the symptoms, testing,
treatments, and neurologicalinsights that can help you move
forward with clarity andconfidence.
We bring you the leadingexperts in the world of brain
health, functional neurology,and rehabilitation to share
(01:25):
their wisdom and strategies.
So if you're feeling lost,hopeless, or like no one
understands what you're goingthrough, know that you are not
alone.
This podcast can be your guideand partner in recovery, helping
you build a better life afterimpact.
Kosta Ikonomou, thank you somuch for joining me for the Life
(01:47):
After Impact podcast.
Kosta Ikonomou (01:49):
Thank you so much.
Really excited to be here.
Dr. Ayla Wolf (01:52):
Yeah, you are a physiotherapist specializing in
uh working with elite athleteswith concussions and doing a lot
of concussion rehabilitation.
Why don't you give us a littlebit of background on how you
ended up in that space?
Kosta Ikonomou (02:06):
Yeah, so I've been a physio for uh about 10
years now.
I um did uh I started onedegree, I did my kinesiology
degree in Vancouver, Canada.
And that's where it kind of gotinto just the whole space.
I ended up um going to London,England to do my physio.
(02:28):
And then upon returning, I haduh always promised my parents as
long as you return back toCanada, study for your exams,
get uh certified here, you cango anywhere else in the world,
they said.
So I was like, great, I'll comeback to Canada.
Um while I returned, I therewas it was right around 2015.
(02:49):
If you remember like theconcussion movie just came out,
there's this kind of this uptickof the kind of the media
starting to talk more about it.
So I ended up going uh to workat the British Columbia's first
uh concussion clinic.
So it was a dedicatedconcussion clinic, it was
(03:10):
modeled after uh the Pittsburghmodel.
Um, so it was kind of anopportunity.
I just got went into there, andthat was my first introduction
into concussion.
So, and um uh as a physio, Iknew how to treat the neck.
And then as the years went on,I ended up um, you know, uh
(03:32):
certifying myself in vestibularrehab.
Uh for two years, I was workingat the concussion clinic, and
then I really wanted to get intosome research.
So I ended up back to Englandand I did my master's at UCL in
sports uh sports medicine.
And my research was on in theconcussion space.
I had some of my researchpublished looking at the um the
(03:56):
effects of exercise on visualmotor speed and the volumes it
had.
So uh I just kind of morphedinto that.
Um after my master's, I startedworking again uh more in elite
sport.
I worked for a Chelsea footballclub in the academy.
Uh I worked for some Olympicathletes, and then back to
(04:17):
Vancouver I came where I thelast uh seven years I worked
clinically, uh specificallytreating concussions, but also
people with persistentconcussion symptoms.
And then one of my travels insports was been in uh
professional basketball uh inthe CEBL.
So a very a very dual kind ofum clinical presence.
(04:41):
I have my clinical work and mysports work.
Dr. Ayla Wolf (04:46):
Yeah, absolutely.
And then it are there any umdifferences that you have
noticed when you're working withmaybe these different patient
populations in terms of what youhave to do differently or
adjust differently when you'reworking with an athlete versus
kind of the general public interms of concussion rehab?
Kosta Ikonomou (05:05):
So in clinic, you know, the majority of your
concussions are gonna come fromuh car accidents, is a big
portion of that.
And now your patients who dosuffer, you know, go through
with a car accident kind ofexperience.
There's a lot of uh, you know,other factors that play into
that in the sense of one, itthey never wanted to, it's
(05:28):
something that suddenly happenedto them.
So uh emotionally, there's alot, um there's a big part of
that that uh is a toll on them.
And with that, now their lifewas can kind of completely
turned upside down.
So you weren't kind of goingout there with the sense of so
an athlete who's playing a sportknows there's a bit of a
(05:50):
relative risk to whether they'replaying a contact sport.
So they already have thatexpectation.
So emotionally, we have twovery different kinds of starting
points.
One is a um, you know, I play acertain sport, there's a
certain risk that I'm aware of,and these things happen.
(06:10):
And in the sporting world, wehave, you know, there's
protocols in place, there's, youknow, you get their care really
quickly, um, their referralsreally quickly.
So they and they already comefrom a level of their kind of
exercise and sense of fitness isalready, you know, at a certain
(06:31):
level.
So their drop of, you know,when they do sustain a
concussion, um they're able toget themselves up a little bit
quicker.
When we deal with somebody inclinic, again, so we have that
part where they weren'texpecting this, it's an
unexpected, uh unfortunate eventthat happened, whether maybe it
was a fall, uh, you know, or acar accident.
(06:52):
And now this has completelyderailed their life, right?
So now it's um and uh we'retalking about it's affecting
their work, it's affecting theirum uh their family life, their
social life.
So with this, I think, like Isaid, the starting point
expectation is a big, bigdifference.
(07:14):
The access of care is a bigdifference, the level of fitness
is is a is a difference.
You know, we have somebodywho's bat who's an athlete,
their balance system is gonna bequite high already.
Um, whereas somebody maybe umwho wasn't as physically active
and now somebody who hasn'tbeen, now our big barrier is
(07:36):
trying to get them to be active.
So it takes a little bit moreum, I think there's a bit more
steps.
And you know, clinically wehave to take in consideration
more things that are that arehappening to the patient.
Uh, but from an objectivesense, a concussion is this
almost retreat it the same,essentially.
Dr. Ayla Wolf (07:58):
Right.
Well, I think you make a verygood point where the clinician
really needs to meet the personwhere they're at, and you can't
necessarily treat a high-levelbasketball player in their 20s
the same as somebody who's 70years old and was just in a car
accident.
And so, as a clinician uh and atherapist, you have to be able
(08:19):
to kind of structure your entireneurological exam probably a
little bit differently in termsof your expectations of where
somebody's balanced system isand also kind of the level at
which you come in and try tomaybe tone the autonomic nervous
system with exercise.
Um, so I think you bring up agood point that as somebody
(08:39):
working in both of those worlds,you have to be very flexible
and adaptable to reallycompletely different
populations.
Kosta Ikonomou (08:46):
Everybody presents differently and
everyone's experience and uheverybody's uh kind of how they
they grew up and how wherethey're at in their life is
completely different.
And this all plays a role.
Dr. Ayla Wolf (09:02):
Yeah.
And can you talk a little bitmaybe about the the technology
that you use or kind of what haschanged in your examination of
people over the years from 2015to now, as far as assessing the
vestibular and ocular motorsystems?
I mean, the VOMS test is not awhole lot of technology
involved, but since then we'vewe've also got a lot of
(09:23):
additional computerized balancetesting and a lot of cool tools
that are out there these days.
Kosta Ikonomou (09:30):
Yeah.
Um so I I still use the VOMS.
I feel that it is, you know, uhthese kind of, I would call
them analog tests, give you somegood information because it's
all about the feedback you getfrom the patient.
Uh, more and more technologiesare coming out.
Uh, for example, uh just one ofthe assessments, so we do use
(09:54):
like an impact, like aneurocognitive test.
Something like this can giveyou some good information, both
on their symptom score, sleep,their visual motor speed, and
cognition.
But you have to, there's no onetest.
So that's why we have a batteryof tests that we kind of use.
Um the VOMS is a great sidelinetool to see if you are in a
(10:17):
somewhere where you're not in ain um, you know, a clinical
setting.
Um, but now there's a um, Ibelieve it's called like you
have like psychade analytics,they've just rebranded uh
neuroflex, they're called now.
Um so that is one technology wehave now, instead of you
(10:38):
balancing on foam, you know, wehave force plates, we have um
things that look at sway.
Um obviously our you know, ourjoint position test, so our head
test.
I just um chatted with uh it'snot a plug, it's uh uh neck
care, I think it's called.
Uh it's like a Bluetooth devicethat uh I know it's very big
(10:59):
there in America, um, which is avery cool product.
Gives you a great um kind of a3D visual of how well your neck
is moving.
Um so a lot of the stuff hasgone from I think 2015, where we
just had a laser taped ontosomebody's head to actual
something that is uh, you know,uh a bit more looks a little bit
(11:21):
more professional.
Um we have the uh reaction timeboards have definitely gotten
you know cheaper.
I don't remember the first cameout, they're very expensive.
Um so every the thing is I lookback at 2015, I look now, and I
the whether you how you assess,we're still gonna assess the
(11:43):
neck, we're still gonna look atthe balance system, we're still
gonna look at the visual system,and we're still gonna look at
the autonomic system.
I think what we understand nowis the interplay between all of
them, and we have it which is isbetter.
So, in a sense, has my maybe myassessment has gotten a little
more, you know, it looks morelike a new iPhone now, I guess,
(12:05):
a little bit newer, but it's itit is still the it's still the
same essentially.
Dr. Ayla Wolf (12:12):
Right, right.
You're still testing all thesame things, just um have a
little bit more refinement ofthe metrics and the objective
data.
Kosta Ikonomou (12:20):
Yeah, exactly.
Dr. Ayla Wolf (12:21):
Yeah, amazing.
And then when somebody is intheir recovery process, um, at
what point do you try to bringin exercise as a therapy?
Uh you know, is there a certainkind of like symptom threshold
that you want reduced or are youdoing that right away?
Kind of where do you seeexercise and um that kind of
(12:42):
training kind of brought in inthis in this process?
Kosta Ikonomou (12:45):
We know, and that's the work done out of
Buffalo from John Letty, that uhthe faster we get people into
you know aerobically buildingtheir aerobic capacity, uh
produces a uh hormone calledbrain drive neurotropic factor,
helps bathe the nerves, helps heincrease the brain healing
(13:06):
part, gets oxygen, blood flow tothe brain.
So all that stuff is what wewant.
Now in even in the athleticpopulation, after 24 hours to 48
hours, where we have ourrelative rest, which is one
thing that really changed from,you know, in the beginning, say
2050, where it was like darkroom, don't rest.
(13:27):
Now in the sports medicineworld, we like to call it
relative rest, which is likekind of you can putter around a
bit, you can go for a lightwalk, you you know, don't cocoon
yourself up.
But there's um really goodresearch and uh that states that
you know the quicker we geteverybody moving, the better it
(13:48):
is for their recovery.
Um now there's a big now.
Here's the two when you have anathlete, they can't wait to get
back to exercising.
Um clinically, I find, youknow, if somebody's super dizzy,
um, you know, you have to alsorespect their symptoms of where
they're at, right?
You can't just say just sorry,you have all these symptoms, and
(14:13):
I'm not gonna make you rush ona treadmill.
Um, because then that we'regonna just trigger more of a
fear, fear response to exercise.
Um, you so you have to, youknow, respect the symptoms,
respect what the patient'sexperiencing is right now, and
and really meet them wherethey're at.
But then the goal is to, ifthey were exercising, great,
(14:37):
then we know where we need toget them back to.
If they weren't as uh active,there's a bit of a challenge of
like, we're gonna have to getyou at least meeting some the
North American guidelines of 150minutes of moderate activity of
aerobic a week uh a week.
(14:57):
So there's about 30 minutes ofwalking continuous.
So the there's challengingways.
If they're, you know, you don'tyou don't need to always go in
a treadmill.
There's uh, you know, a bike isprobably really great because
we can take out the vestibularsystem a bit from there where
they're not moving.
So um that's always a goodstart.
(15:20):
So if uh I would say start thestart as moving as as as soon as
possible.
And if it's not aerobically,some form of movement is okay.
Maybe it's like really um, youknow, half a yoga, like uh
something really kind of lightbody movement.
It's always your what we don'twant is to let the body adapt or
(15:44):
kind of build this fearresponse to symptoms.
So I think that's the so thesooner we break through that,
then it always reminds me, youknow, when you say the things
like when you fell fell off yourbuck, and it's like you gotta
get back on your bicycle, right?
So there's a there's a there'sa bit of that, but we're not
pushing people to the deep end.
We are doing, we are being abit, you know, cautious.
Dr. Ayla Wolf (16:09):
Yeah.
And I do think it is uhdifficult when you have a
patient that comes in who is notused to exercising, they've
been relatively sedentary forkind of their that part of their
life, and then they get aconcussion, and then you start
to realize the importance ofgetting them moving and toning
that autonomic nervous system,but they're like, well, I've
(16:30):
never, I'm not active.
So it's like, um, what are yourkind of tools and strategies
for uh communicating withsomebody, like the importance of
movement and exercise whenmaybe that isn't um a big part
of their life even prior to theconcussion?
Kosta Ikonomou (16:45):
Yeah, I mean, a concussion is one of the hardest
injuries anybody will gothrough.
And it is especially hard forsomebody who you know hasn't had
that deactivity level in thepast, because to kind of get
your yourself out of the kind ofthe symptom rut, you almost
(17:07):
have to become the healthiestversion of yourself.
And that is, you know, it takesa bit of uh, you know, some
motivational interviewing.
There's there the patient hasto meet you, has to be ready for
it as well.
You I usually end up startingwith, okay, if exercise is kind
of like this daunting task, andand uh, and I get it, there's it
(17:30):
it can be, especially when youhaven't been exercising and you
know, walking 20 minutes, is alot, is you know, it seems like
a mountain for some individuals.
So then we're really focused onwhat are some healthy habits
and really break it down tookay, let's make better um, you
know, nutritious food choices,uh, hydrating well.
(17:53):
Do we have a regular sleeppattern?
Are we doing kind of ourlifestyle healthy habits?
And then we're kind of slowly,you know, short-term goals
bringing in that exercise piece.
Um and that's where we I stealthis from actually some of the
uh athletes I work with withthe, you know, what we do in a
(18:16):
season is we call we callmicrodosing.
So we these athletes areplaying so many games.
They're oh, we want to get themexercising, but how do you
exercise some during how do youget an athlete to exercise and
maintain fitness when they'realready playing so many games
and travel traveling so much?
So, what we do is uh we we do amicrodose.
(18:40):
So essentially it is like threeexercises, like six minutes,
but like more for every singleday.
So after a practice, you'll seea lot of professional athletes
will go in the weight room andthey'll lift weights after
practice.
And that is it's a compoundinginterest kind of thing.
(19:01):
So I I same, I use that sameprinciple to patients who are
experiencing you know persistentsymptoms or or have not gotten
into exercise is we're gonna doa little bit, and but we're
gonna do a little bit every day.
And it's gonna be it's gonnacome into a habit, and you'll
see the will slowly increase itover time.
Dr. Ayla Wolf (19:25):
Yeah, that's such a great point that you make uh
in terms of the complexity ofthe brain injury, kind of
putting people in a situationwhere they now do have to really
dig deep and say, okay, I'mgonna have to become the best
healthiest version of myself inorder to heal from this, which
might mean, you know, okay, Ididn't used to exercise, but now
I have to make that a priorityin my life, or maybe my diet
(19:48):
wasn't that great, but now Ihave to be extra careful about
how much sugar I eat, or, youknow, things like that.
And uh, you know, in in mybook, I think I made the
statement that concussionrecovery is a participation
sport.
Um, you know, it really takesit's a team sport.
It takes a lot of people tohelp people, but it also takes
that participation level ofsaying, okay, I guess it's time
(20:11):
to make some some lifestylechanges here as part of that
recovery.
It's not just uh take, youknow, put a cast on it and wait
six weeks.
Kosta Ikonomou (20:19):
And it's hard.
And because now you're doingthat with some a headache, with
some symptoms, right?
Um, but I've always also likedthe um the atomic habits book
where he talks about, I'll stealthe quote, never miss twice.
So I always tell people, uh mypatients, like, all right, you
(20:39):
didn't do your exercise one day,or you had kind of a down day.
That's okay, but we're gonnamake sure the next day you're
not gonna miss twice.
So I I really like that for mypatients as well.
Dr. Ayla Wolf (22:03):
Yeah.
So you certainly do a lot of,like you said, kind of
motivational interviewing andreally uh pay attention to just
the the mental hurdles thatpeople have to overcome as part
of the recovery and changingsome of those lifestyle habits.
Kosta Ikonomou (22:18):
Yeah, it's a big, big factor in why if you
should have a team around it.
So somebody who's really goodon the exercise front, some you
should be seeing maybe acounselor, a psychologist,
somebody who, or somebody whocan help you with that piece,
somebody who can help you withthe symptom piece of, you know,
maybe your concussion triggereda migraine, you need, you know,
(22:40):
or a good neurologist, a gooddoctor.
So, you know, like you said,you mentioned that you need a
team, so team support.
Dr. Ayla Wolf (22:48):
Yeah, yeah.
And you started off theconversation by saying that
initially in your career, you'relike, I'm really good with
necks, and then you had to learnabout vestibular rehab.
But bringing it back to theneck, I know that neck
strengthening is such animportant component, even in
concussion recovery forathletes.
But I also find that with a lotof my patient population of
(23:10):
people that were in caraccidents, that causes a lot of
whiplash injuries, uh damage tothe ligaments.
And so do you include like a alot of neck strengthening in
your program with those peopleas well?
Kosta Ikonomou (23:23):
Yeah, it gets um this is where it becomes the
the concussion recovery becomesvery complex, I feel.
I've seen a lot of individualswho will only treat the neck and
kind of miss the vestibularpart of it.
But actually, patients are havea stiff neck, have neck pain
because they haven't tackledtheir vestibular part, because
(23:46):
their neck is just constantlyguarding because they're dizzy.
So it's it is that kind of finebalance of you gotta treat the
neck and but also treat theother part are kind of like uh
the other, the other aspects,the eyes and the and the um and
the balance system.
Uh there's parts where you knowpatients early on become very
(24:09):
symptomatic.
So turning kind of uh increasestheir symptoms and makes them
dizzy.
So they end up kind of learningthis learnt behavior of not
turning their neck, not so nowin turn, now you're dealing with
neck stiffness, neck tightness.
Uh obviously everybody sayslike then the stress and anxiety
holding their shoulders, theirtraps get tighter.
(24:31):
So there is this perpetual kindof downs, downward slope.
Um, but getting the neckmoving, I think, is is really
important early on, tellingpatients that you know you're
not causing damage.
I think yes, you went throughthis whiplash um mechanism, but
(24:52):
now you know pain becomes aprotective mechanism.
Your pain is not um you're notcausing damage because you're
moving your neck, right?
So within your tolerance, uhsay that I feel it is okay, but
anything that makes you wince,you know, okay, back off a
little bit.
But you need to get into thatum comfortable moving your neck
(25:16):
because later on in your AHAB,we're gonna have to do some VOR,
which is the everyone's leastfavorite head shapes.
And in order to train thatsystem, we're gonna have to go
at 120 beats per minute.
Otherwise, you're just doingsmooth pursuits.
So it you gotta get comfortablemoving it because to tackle
(25:38):
that other part, it's gotta be abig fair.
So um definitely the neck, andthen we've, you know, it plays a
role into everything.
It's a bit of a domino effect.
Dr. Ayla Wolf (25:48):
Yeah, absolutely.
And I definitely see thosepeople when they walk in the
office, and you can tell withjust the way that they walk that
they are terrified to movetheir head.
And so, yeah, usually my firstquestion is like, let's talk
about dizziness.
Because um, you know, is thiswhy you're walking so stiffly?
Is it because you're afraidthat if you turn your head,
(26:08):
you're gonna have a moment ofvertigo or disequilibrium?
Or um, I think that so often uhpeople kind of get used, like
they might not even be awarethat they're holding their head
as stiffly as they are.
Um, they're kind of unconsciousabout those behaviors until you
can like bring that awarenessto it and then start to practice
different exercises thatinvolve kind of safely moving
(26:31):
and turning the head andwalking.
And like you said, being morecomfortable with those movements
and not afraid of causing moredamage or bringing on an episode
of dizziness.
In terms of the work that youdo with athletes, I imagine,
like you said, you know, a lotof athletes, they just want to
get back to the game.
And so if anything, I imaginethat sometimes you're having to
(26:53):
hold people back a little bitand say, uh, hey, even if your
symptoms are a lot better, westill need to maybe kind of do
this graph, like reintroducemovement and activity and sport
gradually.
So, what are your parametersaround that whole concept of
kind of getting people safelyback in a game where there may
be a potential for another headinjury, especially?
Kosta Ikonomou (27:18):
Um, yeah.
So, in the you know, theathlete population, the they
want to get back to play asquickly as possible.
And I do as well.
And I always tell the athlete,I'm not here to hold you back,
I'm here to get you back safelybecause the the worst thing that
can happen is that we haven'tgotten all those subsystems up
(27:41):
to where your baseline is, andyou get another concussion, and
now we're dealing with you know,higher symptom burden,
prolonged, you know, prolongedsymptoms, and you know, a longer
return to play the next time.
So this is where uh one of theuh things that's changed in the
sport world is we take baselinedata um as much as we can,
(28:03):
because that's the one thing asclinicians helps us.
So the more data we have oftheir preseason, better we know,
okay, this is where we need toget to because the coach is
gonna you will go, and thishappens to me all the time.
Um I want to have a meetingwith the coach to tell him this
player's you know still notwhere he needs to be.
(28:24):
He kind of beelines, ignoresme, and goes right to the player
and goes, How are you feeling?
And then then and then theplayer just goes, Yeah, I'm
good, coach.
And then he just looks at me,he's like, he's on.
But we need to have of thatobjective data uh to show.
And we know that uh athletes'risk of injury after they get
(28:44):
clear to play, there's a two tothree times risk of getting a
muscoskeletal injury.
So that that means like anankle injury, hamstring injury,
um, you know, the bike, youknow, bone ACL or something like
that, put them more at risk,and now they're out even more.
And depending on what level youplay, uh you're you know
(29:06):
involved in, that's hundreds ofthousands of dollars every time
at the end of the year, you getthis sheet that says how many
missed games we've had and howmuch that costs the team.
So as a you as a as aclinician, you you want that to
be as low as possible.
So um making sure that you havedata on their balance system,
(29:28):
their reaction time, theirneurocognitive scores, um, you
know, their neck strengths, um,which uh, you know, a lot of
that is tested in the big clubsthat use kind of these uh
isometric tests, uh, and we getlike feedback on that.
Um but also knowing yourathlete and knowing that one
(29:51):
when you clear them, you don'tclear them to to play, you
clear, you return toperformance.
So you want to be able toreturn them to a level where
they were performing hard.
And you almost have to, again,there's that like we talked
about kind of the um the ourpersistent patients where we try
(30:13):
to tell them what's thehealthiest version of yourself.
The athletes are like, we'regonna push you harder than we
did the before you were injured,um, to see, you know, and
that's kind of how um uh we kindof navigate that.
Um but there's a lot of other,you know, like I think in
(30:37):
sports, certain sports.
There's the pressure from, youknow, agents, stakeholders, you
know, fans, coaches, which makesit hard, so on certain
decisions.
We see that in the NFL a lot.
Dr. Ayla Wolf (30:53):
Right.
Yeah, absolutely.
It's like you're actually kindof seeing almost the economics
of it uh from a medicalperspective, and yet you really
just want to do what's best forthe individual in terms of
safely getting them back toperformance at the right time.
But the whole Rest of theirinfluences are kind of uh in
opposition of that.
(31:13):
That could, I imagine, be verydifficult.
Yeah.
Kosta Ikonomou (31:16):
That's what makes probably the biggest the
outside noise and the outsidepressures is the hardest part of
an athlete recovery when itcomes to concussion or any
injury.
Whereas uh what I love aboutworking clinically is I can just
go set me and the patient, andwe can just kind of take our
(31:37):
time and you know get them wherethey want to go.
And, you know, there's there'sno outside noise for it.
Dr. Ayla Wolf (31:44):
So yeah, yeah, exactly.
And so you mentioned thatthere's this increased incidence
of other types ofmusculoskeletal injuries if
people get a concussion and thengo back into performance.
And are you seeing those as aresult of maybe some residual
vestibular ocular reflex issuesor reaction time issues or
(32:06):
balance issues?
Like, do you kind of can youkind of trace that back to um
maybe some of the originalissues they were dealing with
from the concussion that thentranslated into them being more
susceptible to these otherfuture injuries?
Kosta Ikonomou (32:20):
Yeah, I was just uh referencing what what the
data shows, the research isshowing.
And I think a big part of thatis, yes, from underlining um,
you know, we our kind of our ourgoal is was to get them
asymptomatic.
Uh but now it's, you know, weknow are the proprioception and
(32:40):
kind of their coordination is ifwe don't challenge that or get
that up to speed, their bodymechanics, especially under
fatigue, is gonna be an issue.
And that's where you roll yourankle, um, you know, other
ligament injuries, things likethat.
So um that's where that comesfrom.
And we gotta think it's it'syes, we can train, you know,
(33:06):
each aspect individually, butthen we gotta do it all, you
know, put it all together andchallenge the athlete, um, kind
of, you know, in a in a gamesetting where some individuals
might not do that or might nothave the time or the pressure.
And that's when then theathlete is, you know, um goes
(33:31):
back and is at risk.
But it's also the theircapacity, depending on how long
they've been out for.
So if an athlete's been outfor, we know that their cardio
doesn't fall off, you know, tillafter two weeks.
Um, but if an athlete's alittle bit longer, we know that
we got to get them up theircardiovascular.
(33:51):
But um, from working in clinic,I'll tell you that their
reaction time, athletes'reaction times, is not trained
back to, you know, where itshould be.
It's a big thing we see fromuh, you know, one of our
clinics.
We used to get athletes to comein more for like kind of second
opinions, and they're and uhtheir reaction time was really
(34:14):
bad.
And now, if your reaction timeis off, I would assume it just
makes sense that you're gonna bemore at risk of getting another
injury.
So I think that's where theresearch is showing up for that
is their coordination reactiontime is not where it should be.
Dr. Ayla Wolf (34:29):
Yeah, and there's so many aspects involved in
reaction time from your abilityto make rapid saccade eye
movements and um to also kind ofengage the appropriate muscles,
which is often almost done atan unconscious level, those like
vestibulospinal reflexes.
And so I can imagine that ifyou're only basing somebody's
(34:50):
ability to return to performanceon a symptom level and not on
kind of a level of how are theypresenting from a neurological
exam standpoint, you could kindof miss those um deficits that
are still there and send themback out.
And then they're set up forkind of potentially these future
injuries.
Kosta Ikonomou (35:08):
Yeah.
And it's again where we shouldbe also, I think, testing.
I mean, our athletes I want tosee how they are under fatigue.
Right.
So it's it's watching them atthe end of practice, at the end
of that, and just kind of thenputting through a bit of a
battery and see how theyrespond.
Dr. Ayla Wolf (35:28):
Yeah, yeah, absolutely.
I mean, your your entire kindof nervous system can change
based on whether you are restedand energetic versus at the end
of a day when you're tired.
So that makes perfect sense.
What are you kind of are thereany projects you're currently
working on from either aresearch perspective or kind of
um sports perspective?
Kosta Ikonomou (35:48):
Yeah, so right now I've I'm in London, England.
So I'm just kind of gettingintegrated into the kind of
London system here and um reallyhoping to do a bit of research
with some of the rugby clubs.
So right now I'm more in thedevelopment stages.
Um, and especially uh justreally interested in the, you
(36:12):
know, I think how we treat inNorth America is completely
different than how we treat uhconcussions in Europe.
Uh it's almost like uh notgoing to say how we treat, I
think the um the appetite of aconcussion is a bit more aware
aware in North America.
So people are just a bit moreaware of concussions.
(36:33):
There's more concussionclinics, there's more, you know,
concussion care insurancecompanies that kind of are kind
of uh will help some individualswho are uh you know have
experience in cuss, where inEurope it's less, I would say.
So I'm really interested inseeing like kind of building bit
some services out here,building kind of edge the kind
(36:55):
of the educational stuff.
Um the I'm not sure why, butthere it is uh is definitely
different.
I'd say it reminds me just herethat things are almost five
years behind.
There's some clinicians who arereally good actually, that I've
met some who are doing greatwork and there's good research
coming out of here, especially,you know, University of Bath are
(37:17):
kind of leading in the umresearch in the sense of um the
saliva.
There's um, you know, some goodwork out of where I did my
master's out of the ICH doingsome good work.
There's just uh not as youknow, as many as it feels like
in North America I I can go,there's a lot of people doing
(37:38):
research, you know.
Um, so and I've been to a lotof conferences down in the
States, and it seems, you know,it is people want to uh you know
figure this out and and evolveit, right?
And um where I think it's Ithink it's not the the
clinicians, I think it's justthe attitude towards a
(37:59):
concussion from a populationstandpoint, like you said in
Australia.
I think that's it how it is inthe UK.
And um, you know, I've workedin football there and soccer,
and I can tell you the parents'pressure of oh my kid doesn't
have a concussion is is is therewhere it whereas I think
(38:20):
parents are more concerned, Ithink my kid has a concussion in
uh you know in in Canada wherewhere it also works.
So it's more of that sense, butthere's some really good work
happening, really goodclinicians and more and more uh
picking up here.
Dr. Ayla Wolf (38:38):
Yeah, yeah.
So that public awareness pieceis huge in terms of recognizing
the seriousness of it and theneed to actually take that time
off and treat it seriously.
And then um, in terms of thecurrent sports teams that you
work with, do you still go backto Vancouver or are you you said
you're currently working withum some of the local teams
there?
Kosta Ikonomou (38:59):
Yeah, so the CEBL, the Vancouver Bandits,
we're a summer league.
So that uh kind of kicks off inMay, May, June.
Um so see, so right now umtaking month by month right now
and uh trying to get involved abit with you know uh with some
rugby clubs out here.
Uh but so technically I'm in myoff season.
(39:21):
So this is where actually myshift focus is more towards um
treating patients.
Uh but yeah, then my sportshift is in in the summer.
Dr. Ayla Wolf (39:31):
So now I I don't know much about rugby.
Have they changed rules overthe years to try to create more
safety parameters?
Kosta Ikonomou (39:41):
Yep, they've changed the rules.
They have a now um a minimumlike uh almost like a stand down
time.
So do you experience aconcussion or you they take you
off, and there's a minimum timeframe where you have to be out
before you go back in.
Um I think there's you know thehigher leagues, uh they're
(40:06):
doing a really good job.
Um they've uh we know thatcertain contact sports, we can't
change the risk of aconcussion, but what we can
change is the rules.
So there is like some tacklingum rules that they've changed.
Uh we saw that in ice hockeywhere the band blindside hits.
(40:27):
So we they they were allowingyou know players to just come
across the ice and just hitpeople without seeing them.
So at least they said theconcussion rate was going so
high up that you know the NHLwas like, okay, no blind side
hits.
Let's make sure if you're gonnahit somebody or make contact,
it's gonna give the opportunityof somebody to to dodge it.
(40:47):
So uh even a rule change likethat uh made a big difference.
So there is, I think from uhthey are making rules to you
know decrease the amount ofconcussions.
The risk is still there,obviously.
It's a contact sort.
And then they're trying to,again, it's the you know, you
gotta have a strong, strong neckplays a role.
(41:10):
You know, you're gonna be doingyour almost your pre-hab into
the season for that.
Um, but I think really um whereit's a challenge is at the
lower levels where you knowyou're the grassroots level,
where it's you know, it's aparent who's coaching, you know,
the the kids uh rugby match.
(41:31):
Um there's no there's noaesthetic therapist, there's no
physio, you know.
So maybe Varaki one anotherparent as a doctor, and you
know, that's usually how likethe team cares.
So I think that is thechallenge that we're all that um
I'll have.
I know there's great programsin Canada and North America,
where um Southern America whereyou know there's mandatory um
(41:56):
education on concussions forcoaches if you're gonna go.
So uh I think that's comingagain.
There's some programs here aswell, but yeah.
So it's definitely the big thea struggle for them there.
Dr. Ayla Wolf (42:08):
Sure, sure.
A work in progress.
Kosta Ikonomou (42:11):
Sorry, I was gonna say this is like an
evolving injury.
The more we as the years, themore we learn more and more
about it, and I think thingsjust change.
So as we like we treated um howthings have changed in 2015
into to now, I think we're gonnacontinue to see a change.
Dr. Ayla Wolf (42:27):
Yeah, absolutely.
And so for people in the UK, umwhere can they find you in your
clinic?
Kosta Ikonomou (42:33):
Um, so right now, so I do uh a lot of my
stuff is online.
So I do a lot of onlineconsultations.
Um I do have uh in clinic, I doI'm in uh kind of the Notting
Hill area.
Um so I do have a website,people go to that.
I have a uh a newsletter that Isend kind of all about brain
(42:55):
health, uh send out monthly.
So but uh and then yeah, peopleare more than welcome to reach
out to me on social.
Um I'm happy to respond, answerquestions.
Dr. Ayla Wolf (43:08):
Excellent.
Uh well I can put all thatcontact info in the show notes,
and then what is your yourwebsite?
Kosta Ikonomou (43:15):
So my website is uh akesosportsmed uh.com.
So akasso is the where didYeah, it's the goddess of
healing.
So it's my Greek background.
So it's like, yeah.
Dr. Ayla Wolf (43:30):
Yeah, love it.
I was gonna I guess I was gonnaask you where that name came
from.
I assumed there was meaning toit.
All right, the goddess ofhealing.
I love it.
Medical disclaimer.
This video or podcast is forgeneral informational purposes
only and does not constitute thepractice of medicine or other
(43:52):
professional healthcareservices, including the giving
of medical advice.
No doctor-patient relationshipis formed.
The use of this information andmaterials included is at the
user's own risk.
The content of this video orpodcast is not intended to be a
substitute for medical advice,diagnosis, or treatment, and
consumers of this informationshould seek the advice of a
(44:15):
medical professional for any andall health related issues.
A link to our full medicaldisclaimer is available in the
notes.
Athletes' risk of injury after they get clear
to play, there's a two to threetimes risk of getting a
muscoskeletal injury.
So that means like an ankleinjury, hamstring injury, um,
you know, blown ACL or somethinglike that, put them more at
risk, and now they're out evenmore.
And depending on what level youplay, uh you're you know
(00:24):
involved in, that's hundreds ofthousands of dollars.
Every time at the end of theyear, you get this sheet that
says how many missed games we'vehad and how much that costs the
team.
So as a you as a as aclinician, you you want that to
be as low as possible.
Dr. Ayla Wolf (00:42):
Welcome to Life After Impact, the concussion
recovery podcast.
I'm Dr.
Ayla Wolf, and I will behosting today's episode where we
help you navigate the oftenconfusing, frustrating, and
overwhelming journey ofconcussion and brain injury
recovery.
This podcast is your go-toresource for actionable
information.
Whether you're dealing with arecent concussion, struggling
(01:05):
with post-concussion syndrome,or just feeling stuck in your
healing process.
In each episode, we dive deepinto the symptoms, testing,
treatments, and neurologicalinsights that can help you move
forward with clarity andconfidence.
We bring you the leadingexperts in the world of brain
health, functional neurology,and rehabilitation to share
(01:25):
their wisdom and strategies.
So if you're feeling lost,hopeless, or like no one
understands what you're goingthrough, know that you are not
alone.
This podcast can be your guideand partner in recovery, helping
you build a better life afterimpact.
Kosta Ikonomou, thank you somuch for joining me for the Life
(01:47):
After Impact podcast.
Kosta Ikonomou (01:49):
Thank you so much.
Really excited to be here.
Dr. Ayla Wolf (01:52):
Yeah, you are a physiotherapist specializing in
uh working with elite athleteswith concussions and doing a lot
of concussion rehabilitation.
Why don't you give us a littlebit of background on how you
ended up in that space?
Kosta Ikonomou (02:06):
Yeah, so I've been a physio for uh about 10
years now.
I um did uh I started onedegree, I did my kinesiology
degree in Vancouver, Canada.
And that's where it kind of gotinto just the whole space.
I ended up um going to London,England to do my physio.
(02:28):
And then upon returning, I haduh always promised my parents as
long as you return back toCanada, study for your exams,
get uh certified here, you cango anywhere else in the world,
they said.
So I was like, great, I'll comeback to Canada.
Um while I returned, I therewas it was right around 2015.
(02:49):
If you remember like theconcussion movie just came out,
there's this kind of this uptickof the kind of the media
starting to talk more about it.
So I ended up going uh to workat the British Columbia's first
uh concussion clinic.
So it was a dedicatedconcussion clinic, it was
(03:10):
modeled after uh the Pittsburghmodel.
Um, so it was kind of anopportunity.
I just got went into there, andthat was my first introduction
into concussion.
So, and um uh as a physio, Iknew how to treat the neck.
And then as the years went on,I ended up um, you know, uh
(03:32):
certifying myself in vestibularrehab.
Uh for two years, I was workingat the concussion clinic, and
then I really wanted to get intosome research.
So I ended up back to Englandand I did my master's at UCL in
sports uh sports medicine.
And my research was on in theconcussion space.
I had some of my researchpublished looking at the um the
(03:56):
effects of exercise on visualmotor speed and the volumes it
had.
So uh I just kind of morphedinto that.
Um after my master's, I startedworking again uh more in elite
sport.
I worked for a Chelsea footballclub in the academy.
Uh I worked for some Olympicathletes, and then back to
(04:17):
Vancouver I came where I thelast uh seven years I worked
clinically, uh specificallytreating concussions, but also
people with persistentconcussion symptoms.
And then one of my travels insports was been in uh
professional basketball uh inthe CEBL.
So a very a very dual kind ofum clinical presence.
(04:41):
I have my clinical work and mysports work.
Dr. Ayla Wolf (04:46):
Yeah, absolutely.
And then it are there any umdifferences that you have
noticed when you're working withmaybe these different patient
populations in terms of what youhave to do differently or
adjust differently when you'reworking with an athlete versus
kind of the general public interms of concussion rehab?
Kosta Ikonomou (05:05):
So in clinic, you know, the majority of your
concussions are gonna come fromuh car accidents, is a big
portion of that.
And now your patients who dosuffer, you know, go through
with a car accident kind ofexperience.
There's a lot of uh, you know,other factors that play into
that in the sense of one, itthey never wanted to, it's
(05:28):
something that suddenly happenedto them.
So uh emotionally, there's alot, um there's a big part of
that that uh is a toll on them.
And with that, now their lifewas can kind of completely
turned upside down.
So you weren't kind of goingout there with the sense of so
an athlete who's playing a sportknows there's a bit of a
(05:50):
relative risk to whether they'replaying a contact sport.
So they already have thatexpectation.
So emotionally, we have twovery different kinds of starting
points.
One is a um, you know, I play acertain sport, there's a
certain risk that I'm aware of,and these things happen.
(06:10):
And in the sporting world, wehave, you know, there's
protocols in place, there's, youknow, you get their care really
quickly, um, their referralsreally quickly.
So they and they already comefrom a level of their kind of
exercise and sense of fitness isalready, you know, at a certain
(06:31):
level.
So their drop of, you know,when they do sustain a
concussion, um they're able toget themselves up a little bit
quicker.
When we deal with somebody inclinic, again, so we have that
part where they weren'texpecting this, it's an
unexpected, uh unfortunate eventthat happened, whether maybe it
was a fall, uh, you know, or acar accident.
(06:52):
And now this has completelyderailed their life, right?
So now it's um and uh we'retalking about it's affecting
their work, it's affecting theirum uh their family life, their
social life.
So with this, I think, like Isaid, the starting point
expectation is a big, bigdifference.
(07:14):
The access of care is a bigdifference, the level of fitness
is is a is a difference.
You know, we have somebodywho's bat who's an athlete,
their balance system is gonna bequite high already.
Um, whereas somebody maybe umwho wasn't as physically active
and now somebody who hasn'tbeen, now our big barrier is
(07:36):
trying to get them to be active.
So it takes a little bit moreum, I think there's a bit more
steps.
And you know, clinically wehave to take in consideration
more things that are that arehappening to the patient.
Uh, but from an objectivesense, a concussion is this
almost retreat it the same,essentially.
Dr. Ayla Wolf (07:58):
Right.
Well, I think you make a verygood point where the clinician
really needs to meet the personwhere they're at, and you can't
necessarily treat a high-levelbasketball player in their 20s
the same as somebody who's 70years old and was just in a car
accident.
And so, as a clinician uh and atherapist, you have to be able
(08:19):
to kind of structure your entireneurological exam probably a
little bit differently in termsof your expectations of where
somebody's balanced system isand also kind of the level at
which you come in and try tomaybe tone the autonomic nervous
system with exercise.
Um, so I think you bring up agood point that as somebody
(08:39):
working in both of those worlds,you have to be very flexible
and adaptable to reallycompletely different
populations.
Kosta Ikonomou (08:46):
Everybody presents differently and
everyone's experience and uheverybody's uh kind of how they
they grew up and how wherethey're at in their life is
completely different.
And this all plays a role.
Dr. Ayla Wolf (09:02):
Yeah.
And can you talk a little bitmaybe about the the technology
that you use or kind of what haschanged in your examination of
people over the years from 2015to now, as far as assessing the
vestibular and ocular motorsystems?
I mean, the VOMS test is not awhole lot of technology
involved, but since then we'vewe've also got a lot of
(09:23):
additional computerized balancetesting and a lot of cool tools
that are out there these days.
Kosta Ikonomou (09:30):
Yeah.
Um so I I still use the VOMS.
I feel that it is, you know, uhthese kind of, I would call
them analog tests, give you somegood information because it's
all about the feedback you getfrom the patient.
Uh, more and more technologiesare coming out.
Uh, for example, uh just one ofthe assessments, so we do use
(09:54):
like an impact, like aneurocognitive test.
Something like this can giveyou some good information, both
on their symptom score, sleep,their visual motor speed, and
cognition.
But you have to, there's no onetest.
So that's why we have a batteryof tests that we kind of use.
Um the VOMS is a great sidelinetool to see if you are in a
(10:17):
somewhere where you're not in ain um, you know, a clinical
setting.
Um, but now there's a um, Ibelieve it's called like you
have like psychade analytics,they've just rebranded uh
neuroflex, they're called now.
Um so that is one technology wehave now, instead of you
(10:38):
balancing on foam, you know, wehave force plates, we have um
things that look at sway.
Um obviously our you know, ourjoint position test, so our head
test.
I just um chatted with uh it'snot a plug, it's uh uh neck
care, I think it's called.
Uh it's like a Bluetooth devicethat uh I know it's very big
(10:59):
there in America, um, which is avery cool product.
Gives you a great um kind of a3D visual of how well your neck
is moving.
Um so a lot of the stuff hasgone from I think 2015, where we
just had a laser taped ontosomebody's head to actual
something that is uh, you know,uh a bit more looks a little bit
(11:21):
more professional.
Um we have the uh reaction timeboards have definitely gotten
you know cheaper.
I don't remember the first cameout, they're very expensive.
Um so every the thing is I lookback at 2015, I look now, and I
the whether you how you assess,we're still gonna assess the
(11:43):
neck, we're still gonna look atthe balance system, we're still
gonna look at the visual system,and we're still gonna look at
the autonomic system.
I think what we understand nowis the interplay between all of
them, and we have it which is isbetter.
So, in a sense, has my maybe myassessment has gotten a little
more, you know, it looks morelike a new iPhone now, I guess,
(12:05):
a little bit newer, but it's itit is still the it's still the
same essentially.
Dr. Ayla Wolf (12:12):
Right, right.
You're still testing all thesame things, just um have a
little bit more refinement ofthe metrics and the objective
data.
Kosta Ikonomou (12:20):
Yeah, exactly.
Dr. Ayla Wolf (12:21):
Yeah, amazing.
And then when somebody is intheir recovery process, um, at
what point do you try to bringin exercise as a therapy?
Uh you know, is there a certainkind of like symptom threshold
that you want reduced or are youdoing that right away?
Kind of where do you seeexercise and um that kind of
(12:42):
training kind of brought in inthis in this process?
Kosta Ikonomou (12:45):
We know, and that's the work done out of
Buffalo from John Letty, that uhthe faster we get people into
you know aerobically buildingtheir aerobic capacity, uh
produces a uh hormone calledbrain drive neurotropic factor,
helps bathe the nerves, helps heincrease the brain healing
(13:06):
part, gets oxygen, blood flow tothe brain.
So all that stuff is what wewant.
Now in even in the athleticpopulation, after 24 hours to 48
hours, where we have ourrelative rest, which is one
thing that really changed from,you know, in the beginning, say
2050, where it was like darkroom, don't rest.
(13:27):
Now in the sports medicineworld, we like to call it
relative rest, which is likekind of you can putter around a
bit, you can go for a lightwalk, you you know, don't cocoon
yourself up.
But there's um really goodresearch and uh that states that
you know the quicker we geteverybody moving, the better it
(13:48):
is for their recovery.
Um now there's a big now.
Here's the two when you have anathlete, they can't wait to get
back to exercising.
Um clinically, I find, youknow, if somebody's super dizzy,
um, you know, you have to alsorespect their symptoms of where
they're at, right?
You can't just say just sorry,you have all these symptoms, and
(14:13):
I'm not gonna make you rush ona treadmill.
Um, because then that we'regonna just trigger more of a
fear, fear response to exercise.
Um, you so you have to, youknow, respect the symptoms,
respect what the patient'sexperiencing is right now, and
and really meet them wherethey're at.
But then the goal is to, ifthey were exercising, great,
(14:37):
then we know where we need toget them back to.
If they weren't as uh active,there's a bit of a challenge of
like, we're gonna have to getyou at least meeting some the
North American guidelines of 150minutes of moderate activity of
aerobic a week uh a week.
(14:57):
So there's about 30 minutes ofwalking continuous.
So the there's challengingways.
If they're, you know, you don'tyou don't need to always go in
a treadmill.
There's uh, you know, a bike isprobably really great because
we can take out the vestibularsystem a bit from there where
they're not moving.
So um that's always a goodstart.
(15:20):
So if uh I would say start thestart as moving as as as soon as
possible.
And if it's not aerobically,some form of movement is okay.
Maybe it's like really um, youknow, half a yoga, like uh
something really kind of lightbody movement.
It's always your what we don'twant is to let the body adapt or
(15:44):
kind of build this fearresponse to symptoms.
So I think that's the so thesooner we break through that,
then it always reminds me, youknow, when you say the things
like when you fell fell off yourbuck, and it's like you gotta
get back on your bicycle, right?
So there's a there's a there'sa bit of that, but we're not
pushing people to the deep end.
We are doing, we are being abit, you know, cautious.
Dr. Ayla Wolf (16:09):
Yeah.
And I do think it is uhdifficult when you have a
patient that comes in who is notused to exercising, they've
been relatively sedentary forkind of their that part of their
life, and then they get aconcussion, and then you start
to realize the importance ofgetting them moving and toning
that autonomic nervous system,but they're like, well, I've
(16:30):
never, I'm not active.
So it's like, um, what are yourkind of tools and strategies
for uh communicating withsomebody, like the importance of
movement and exercise whenmaybe that isn't um a big part
of their life even prior to theconcussion?
Kosta Ikonomou (16:45):
Yeah, I mean, a concussion is one of the hardest
injuries anybody will gothrough.
And it is especially hard forsomebody who you know hasn't had
that deactivity level in thepast, because to kind of get
your yourself out of the kind ofthe symptom rut, you almost
(17:07):
have to become the healthiestversion of yourself.
And that is, you know, it takesa bit of uh, you know, some
motivational interviewing.
There's there the patient hasto meet you, has to be ready for
it as well.
You I usually end up startingwith, okay, if exercise is kind
of like this daunting task, andand uh, and I get it, there's it
(17:30):
it can be, especially when youhaven't been exercising and you
know, walking 20 minutes, is alot, is you know, it seems like
a mountain for some individuals.
So then we're really focused onwhat are some healthy habits
and really break it down tookay, let's make better um, you
know, nutritious food choices,uh, hydrating well.
(17:53):
Do we have a regular sleeppattern?
Are we doing kind of ourlifestyle healthy habits?
And then we're kind of slowly,you know, short-term goals
bringing in that exercise piece.
Um and that's where we I stealthis from actually some of the
uh athletes I work with withthe, you know, what we do in a
(18:16):
season is we call we callmicrodosing.
So we these athletes areplaying so many games.
They're oh, we want to get themexercising, but how do you
exercise some during how do youget an athlete to exercise and
maintain fitness when they'realready playing so many games
and travel traveling so much?
So, what we do is uh we we do amicrodose.
(18:40):
So essentially it is like threeexercises, like six minutes,
but like more for every singleday.
So after a practice, you'll seea lot of professional athletes
will go in the weight room andthey'll lift weights after
practice.
And that is it's a compoundinginterest kind of thing.
(19:01):
So I I same, I use that sameprinciple to patients who are
experiencing you know persistentsymptoms or or have not gotten
into exercise is we're gonna doa little bit, and but we're
gonna do a little bit every day.
And it's gonna be it's gonnacome into a habit, and you'll
see the will slowly increase itover time.
Dr. Ayla Wolf (19:25):
Yeah, that's such a great point that you make uh
in terms of the complexity ofthe brain injury, kind of
putting people in a situationwhere they now do have to really
dig deep and say, okay, I'mgonna have to become the best
healthiest version of myself inorder to heal from this, which
might mean, you know, okay, Ididn't used to exercise, but now
I have to make that a priorityin my life, or maybe my diet
(19:48):
wasn't that great, but now Ihave to be extra careful about
how much sugar I eat, or, youknow, things like that.
And uh, you know, in in mybook, I think I made the
statement that concussionrecovery is a participation
sport.
Um, you know, it really takesit's a team sport.
It takes a lot of people tohelp people, but it also takes
that participation level ofsaying, okay, I guess it's time
(20:11):
to make some some lifestylechanges here as part of that
recovery.
It's not just uh take, youknow, put a cast on it and wait
six weeks.
Kosta Ikonomou (20:19):
And it's hard.
And because now you're doingthat with some a headache, with
some symptoms, right?
Um, but I've always also likedthe um the atomic habits book
where he talks about, I'll stealthe quote, never miss twice.
So I always tell people, uh mypatients, like, all right, you
(20:39):
didn't do your exercise one day,or you had kind of a down day.
That's okay, but we're gonnamake sure the next day you're
not gonna miss twice.
So I I really like that for mypatients as well.
Dr. Ayla Wolf (22:03):
Yeah.
So you certainly do a lot of,like you said, kind of
motivational interviewing andreally uh pay attention to just
the the mental hurdles thatpeople have to overcome as part
of the recovery and changingsome of those lifestyle habits.
Kosta Ikonomou (22:18):
Yeah, it's a big, big factor in why if you
should have a team around it.
So somebody who's really goodon the exercise front, some you
should be seeing maybe acounselor, a psychologist,
somebody who, or somebody whocan help you with that piece,
somebody who can help you withthe symptom piece of, you know,
maybe your concussion triggereda migraine, you need, you know,
(22:40):
or a good neurologist, a gooddoctor.
So, you know, like you said,you mentioned that you need a
team, so team support.
Dr. Ayla Wolf (22:48):
Yeah, yeah.
And you started off theconversation by saying that
initially in your career, you'relike, I'm really good with
necks, and then you had to learnabout vestibular rehab.
But bringing it back to theneck, I know that neck
strengthening is such animportant component, even in
concussion recovery forathletes.
But I also find that with a lotof my patient population of
(23:10):
people that were in caraccidents, that causes a lot of
whiplash injuries, uh damage tothe ligaments.
And so do you include like a alot of neck strengthening in
your program with those peopleas well?
Kosta Ikonomou (23:23):
Yeah, it gets um this is where it becomes the
the concussion recovery becomesvery complex, I feel.
I've seen a lot of individualswho will only treat the neck and
kind of miss the vestibularpart of it.
But actually, patients are havea stiff neck, have neck pain
because they haven't tackledtheir vestibular part, because
(23:46):
their neck is just constantlyguarding because they're dizzy.
So it's it is that kind of finebalance of you gotta treat the
neck and but also treat theother part are kind of like uh
the other, the other aspects,the eyes and the and the um and
the balance system.
Uh there's parts where you knowpatients early on become very
(24:09):
symptomatic.
So turning kind of uh increasestheir symptoms and makes them
dizzy.
So they end up kind of learningthis learnt behavior of not
turning their neck, not so nowin turn, now you're dealing with
neck stiffness, neck tightness.
Uh obviously everybody sayslike then the stress and anxiety
holding their shoulders, theirtraps get tighter.
(24:31):
So there is this perpetual kindof downs, downward slope.
Um, but getting the neckmoving, I think, is is really
important early on, tellingpatients that you know you're
not causing damage.
I think yes, you went throughthis whiplash um mechanism, but
(24:52):
now you know pain becomes aprotective mechanism.
Your pain is not um you're notcausing damage because you're
moving your neck, right?
So within your tolerance, uhsay that I feel it is okay, but
anything that makes you wince,you know, okay, back off a
little bit.
But you need to get into thatum comfortable moving your neck
(25:16):
because later on in your AHAB,we're gonna have to do some VOR,
which is the everyone's leastfavorite head shapes.
And in order to train thatsystem, we're gonna have to go
at 120 beats per minute.
Otherwise, you're just doingsmooth pursuits.
So it you gotta get comfortablemoving it because to tackle
(25:38):
that other part, it's gotta be abig fair.
So um definitely the neck, andthen we've, you know, it plays a
role into everything.
It's a bit of a domino effect.
Dr. Ayla Wolf (25:48):
Yeah, absolutely.
And I definitely see thosepeople when they walk in the
office, and you can tell withjust the way that they walk that
they are terrified to movetheir head.
And so, yeah, usually my firstquestion is like, let's talk
about dizziness.
Because um, you know, is thiswhy you're walking so stiffly?
Is it because you're afraidthat if you turn your head,
(26:08):
you're gonna have a moment ofvertigo or disequilibrium?
Or um, I think that so often uhpeople kind of get used, like
they might not even be awarethat they're holding their head
as stiffly as they are.
Um, they're kind of unconsciousabout those behaviors until you
can like bring that awarenessto it and then start to practice
different exercises thatinvolve kind of safely moving
(26:31):
and turning the head andwalking.
And like you said, being morecomfortable with those movements
and not afraid of causing moredamage or bringing on an episode
of dizziness.
In terms of the work that youdo with athletes, I imagine,
like you said, you know, a lotof athletes, they just want to
get back to the game.
And so if anything, I imaginethat sometimes you're having to
(26:53):
hold people back a little bitand say, uh, hey, even if your
symptoms are a lot better, westill need to maybe kind of do
this graph, like reintroducemovement and activity and sport
gradually.
So, what are your parametersaround that whole concept of
kind of getting people safelyback in a game where there may
be a potential for another headinjury, especially?
Kosta Ikonomou (27:18):
Um, yeah.
So, in the you know, theathlete population, the they
want to get back to play asquickly as possible.
And I do as well.
And I always tell the athlete,I'm not here to hold you back,
I'm here to get you back safelybecause the the worst thing that
can happen is that we haven'tgotten all those subsystems up
(27:41):
to where your baseline is, andyou get another concussion, and
now we're dealing with you know,higher symptom burden,
prolonged, you know, prolongedsymptoms, and you know, a longer
return to play the next time.
So this is where uh one of theuh things that's changed in the
sport world is we take baselinedata um as much as we can,
(28:03):
because that's the one thing asclinicians helps us.
So the more data we have oftheir preseason, better we know,
okay, this is where we need toget to because the coach is
gonna you will go, and thishappens to me all the time.
Um I want to have a meetingwith the coach to tell him this
player's you know still notwhere he needs to be.
(28:24):
He kind of beelines, ignoresme, and goes right to the player
and goes, How are you feeling?
And then then and then theplayer just goes, Yeah, I'm
good, coach.
And then he just looks at me,he's like, he's on.
But we need to have of thatobjective data uh to show.
And we know that uh athletes'risk of injury after they get
(28:44):
clear to play, there's a two tothree times risk of getting a
muscoskeletal injury.
So that that means like anankle injury, hamstring injury,
um, you know, the bike, youknow, bone ACL or something like
that, put them more at risk,and now they're out even more.
And depending on what level youplay, uh you're you know
(29:06):
involved in, that's hundreds ofthousands of dollars every time
at the end of the year, you getthis sheet that says how many
missed games we've had and howmuch that costs the team.
So as a you as a as aclinician, you you want that to
be as low as possible.
So um making sure that you havedata on their balance system,
(29:28):
their reaction time, theirneurocognitive scores, um, you
know, their neck strengths, um,which uh, you know, a lot of
that is tested in the big clubsthat use kind of these uh
isometric tests, uh, and we getlike feedback on that.
Um but also knowing yourathlete and knowing that one
(29:51):
when you clear them, you don'tclear them to to play, you
clear, you return toperformance.
So you want to be able toreturn them to a level where
they were performing hard.
And you almost have to, again,there's that like we talked
about kind of the um the ourpersistent patients where we try
(30:13):
to tell them what's thehealthiest version of yourself.
The athletes are like, we'regonna push you harder than we
did the before you were injured,um, to see, you know, and
that's kind of how um uh we kindof navigate that.
Um but there's a lot of other,you know, like I think in
(30:37):
sports, certain sports.
There's the pressure from, youknow, agents, stakeholders, you
know, fans, coaches, which makesit hard, so on certain
decisions.
We see that in the NFL a lot.
Dr. Ayla Wolf (30:53):
Right.
Yeah, absolutely.
It's like you're actually kindof seeing almost the economics
of it uh from a medicalperspective, and yet you really
just want to do what's best forthe individual in terms of
safely getting them back toperformance at the right time.
But the whole Rest of theirinfluences are kind of uh in
opposition of that.
(31:13):
That could, I imagine, be verydifficult.
Yeah.
Kosta Ikonomou (31:16):
That's what makes probably the biggest the
outside noise and the outsidepressures is the hardest part of
an athlete recovery when itcomes to concussion or any
injury.
Whereas uh what I love aboutworking clinically is I can just
go set me and the patient, andwe can just kind of take our
(31:37):
time and you know get them wherethey want to go.
And, you know, there's there'sno outside noise for it.
Dr. Ayla Wolf (31:44):
So yeah, yeah, exactly.
And so you mentioned thatthere's this increased incidence
of other types ofmusculoskeletal injuries if
people get a concussion and thengo back into performance.
And are you seeing those as aresult of maybe some residual
vestibular ocular reflex issuesor reaction time issues or
(32:06):
balance issues?
Like, do you kind of can youkind of trace that back to um
maybe some of the originalissues they were dealing with
from the concussion that thentranslated into them being more
susceptible to these otherfuture injuries?
Kosta Ikonomou (32:20):
Yeah, I was just uh referencing what what the
data shows, the research isshowing.
And I think a big part of thatis, yes, from underlining um,
you know, we our kind of our ourgoal is was to get them
asymptomatic.
Uh but now it's, you know, weknow are the proprioception and
(32:40):
kind of their coordination is ifwe don't challenge that or get
that up to speed, their bodymechanics, especially under
fatigue, is gonna be an issue.
And that's where you roll yourankle, um, you know, other
ligament injuries, things likethat.
So um that's where that comesfrom.
And we gotta think it's it'syes, we can train, you know,
(33:06):
each aspect individually, butthen we gotta do it all, you
know, put it all together andchallenge the athlete, um, kind
of, you know, in a in a gamesetting where some individuals
might not do that or might nothave the time or the pressure.
And that's when then theathlete is, you know, um goes
(33:31):
back and is at risk.
But it's also the theircapacity, depending on how long
they've been out for.
So if an athlete's been outfor, we know that their cardio
doesn't fall off, you know, tillafter two weeks.
Um, but if an athlete's alittle bit longer, we know that
we got to get them up theircardiovascular.
(33:51):
But um, from working in clinic,I'll tell you that their
reaction time, athletes'reaction times, is not trained
back to, you know, where itshould be.
It's a big thing we see fromuh, you know, one of our
clinics.
We used to get athletes to comein more for like kind of second
opinions, and they're and uhtheir reaction time was really
(34:14):
bad.
And now, if your reaction timeis off, I would assume it just
makes sense that you're gonna bemore at risk of getting another
injury.
So I think that's where theresearch is showing up for that
is their coordination reactiontime is not where it should be.
Dr. Ayla Wolf (34:29):
Yeah, and there's so many aspects involved in
reaction time from your abilityto make rapid saccade eye
movements and um to also kind ofengage the appropriate muscles,
which is often almost done atan unconscious level, those like
vestibulospinal reflexes.
And so I can imagine that ifyou're only basing somebody's
(34:50):
ability to return to performanceon a symptom level and not on
kind of a level of how are theypresenting from a neurological
exam standpoint, you could kindof miss those um deficits that
are still there and send themback out.
And then they're set up forkind of potentially these future
injuries.
Kosta Ikonomou (35:08):
Yeah.
And it's again where we shouldbe also, I think, testing.
I mean, our athletes I want tosee how they are under fatigue.
Right.
So it's it's watching them atthe end of practice, at the end
of that, and just kind of thenputting through a bit of a
battery and see how theyrespond.
Dr. Ayla Wolf (35:28):
Yeah, yeah, absolutely.
I mean, your your entire kindof nervous system can change
based on whether you are restedand energetic versus at the end
of a day when you're tired.
So that makes perfect sense.
What are you kind of are thereany projects you're currently
working on from either aresearch perspective or kind of
um sports perspective?
Kosta Ikonomou (35:48):
Yeah, so right now I've I'm in London, England.
So I'm just kind of gettingintegrated into the kind of
London system here and um reallyhoping to do a bit of research
with some of the rugby clubs.
So right now I'm more in thedevelopment stages.
Um, and especially uh justreally interested in the, you
(36:12):
know, I think how we treat inNorth America is completely
different than how we treat uhconcussions in Europe.
Uh it's almost like uh notgoing to say how we treat, I
think the um the appetite of aconcussion is a bit more aware
aware in North America.
So people are just a bit moreaware of concussions.
(36:33):
There's more concussionclinics, there's more, you know,
concussion care insurancecompanies that kind of are kind
of uh will help some individualswho are uh you know have
experience in cuss, where inEurope it's less, I would say.
So I'm really interested inseeing like kind of building bit
some services out here,building kind of edge the kind
(36:55):
of the educational stuff.
Um the I'm not sure why, butthere it is uh is definitely
different.
I'd say it reminds me just herethat things are almost five
years behind.
There's some clinicians who arereally good actually, that I've
met some who are doing greatwork and there's good research
coming out of here, especially,you know, University of Bath are
(37:17):
kind of leading in the umresearch in the sense of um the
saliva.
There's um, you know, some goodwork out of where I did my
master's out of the ICH doingsome good work.
There's just uh not as youknow, as many as it feels like
in North America I I can go,there's a lot of people doing
(37:38):
research, you know.
Um, so and I've been to a lotof conferences down in the
States, and it seems, you know,it is people want to uh you know
figure this out and and evolveit, right?
And um where I think it's Ithink it's not the the
clinicians, I think it's justthe attitude towards a
(37:59):
concussion from a populationstandpoint, like you said in
Australia.
I think that's it how it is inthe UK.
And um, you know, I've workedin football there and soccer,
and I can tell you the parents'pressure of oh my kid doesn't
have a concussion is is is therewhere it whereas I think
(38:20):
parents are more concerned, Ithink my kid has a concussion in
uh you know in in Canada wherewhere it also works.
So it's more of that sense, butthere's some really good work
happening, really goodclinicians and more and more uh
picking up here.
Dr. Ayla Wolf (38:38):
Yeah, yeah.
So that public awareness pieceis huge in terms of recognizing
the seriousness of it and theneed to actually take that time
off and treat it seriously.
And then um, in terms of thecurrent sports teams that you
work with, do you still go backto Vancouver or are you you said
you're currently working withum some of the local teams
there?
Kosta Ikonomou (38:59):
Yeah, so the CEBL, the Vancouver Bandits,
we're a summer league.
So that uh kind of kicks off inMay, May, June.
Um so see, so right now umtaking month by month right now
and uh trying to get involved abit with you know uh with some
rugby clubs out here.
Uh but so technically I'm in myoff season.
(39:21):
So this is where actually myshift focus is more towards um
treating patients.
Uh but yeah, then my sportshift is in in the summer.
Dr. Ayla Wolf (39:31):
So now I I don't know much about rugby.
Have they changed rules overthe years to try to create more
safety parameters?
Kosta Ikonomou (39:41):
Yep, they've changed the rules.
They have a now um a minimumlike uh almost like a stand down
time.
So do you experience aconcussion or you they take you
off, and there's a minimum timeframe where you have to be out
before you go back in.
Um I think there's you know thehigher leagues, uh they're
(40:06):
doing a really good job.
Um they've uh we know thatcertain contact sports, we can't
change the risk of aconcussion, but what we can
change is the rules.
So there is like some tacklingum rules that they've changed.
Uh we saw that in ice hockeywhere the band blindside hits.
(40:27):
So we they they were allowingyou know players to just come
across the ice and just hitpeople without seeing them.
So at least they said theconcussion rate was going so
high up that you know the NHLwas like, okay, no blind side
hits.
Let's make sure if you're gonnahit somebody or make contact,
it's gonna give the opportunityof somebody to to dodge it.
(40:47):
So uh even a rule change likethat uh made a big difference.
So there is, I think from uhthey are making rules to you
know decrease the amount ofconcussions.
The risk is still there,obviously.
It's a contact sort.
And then they're trying to,again, it's the you know, you
gotta have a strong, strong neckplays a role.
(41:10):
You know, you're gonna be doingyour almost your pre-hab into
the season for that.
Um, but I think really um whereit's a challenge is at the
lower levels where you knowyou're the grassroots level,
where it's you know, it's aparent who's coaching, you know,
the the kids uh rugby match.
(41:31):
Um there's no there's noaesthetic therapist, there's no
physio, you know.
So maybe Varaki one anotherparent as a doctor, and you
know, that's usually how likethe team cares.
So I think that is thechallenge that we're all that um
I'll have.
I know there's great programsin Canada and North America,
where um Southern America whereyou know there's mandatory um
(41:56):
education on concussions forcoaches if you're gonna go.
So uh I think that's comingagain.
There's some programs here aswell, but yeah.
So it's definitely the big thea struggle for them there.
Dr. Ayla Wolf (42:08):
Sure, sure.
A work in progress.
Kosta Ikonomou (42:11):
Sorry, I was gonna say this is like an
evolving injury.
The more we as the years, themore we learn more and more
about it, and I think thingsjust change.
So as we like we treated um howthings have changed in 2015
into to now, I think we're gonnacontinue to see a change.
Dr. Ayla Wolf (42:27):
Yeah, absolutely.
And so for people in the UK, umwhere can they find you in your
clinic?
Kosta Ikonomou (42:33):
Um, so right now, so I do uh a lot of my
stuff is online.
So I do a lot of onlineconsultations.
Um I do have uh in clinic, I doI'm in uh kind of the Notting
Hill area.
Um so I do have a website,people go to that.
I have a uh a newsletter that Isend kind of all about brain
(42:55):
health, uh send out monthly.
So but uh and then yeah, peopleare more than welcome to reach
out to me on social.
Um I'm happy to respond, answerquestions.
Dr. Ayla Wolf (43:08):
Excellent.
Uh well I can put all thatcontact info in the show notes,
and then what is your yourwebsite?
Kosta Ikonomou (43:15):
So my website is uh akesosportsmed uh.com.
So akasso is the where didYeah, it's the goddess of
healing.
So it's my Greek background.
So it's like, yeah.
Dr. Ayla Wolf (43:30):
Yeah, love it.
I was gonna I guess I was gonnaask you where that name came
from.
I assumed there was meaning toit.
All right, the goddess ofhealing.
I love it.
Medical disclaimer.
This video or podcast is forgeneral informational purposes
only and does not constitute thepractice of medicine or other
(43:52):
professional healthcareservices, including the giving
of medical advice.
No doctor-patient relationshipis formed.
The use of this information andmaterials included is at the
user's own risk.
The content of this video orpodcast is not intended to be a
substitute for medical advice,diagnosis, or treatment, and
consumers of this informationshould seek the advice of a
(44:15):
medical professional for any andall health related issues.
A link to our full medicaldisclaimer is available in the
notes.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.