From Sidelines To Success: Concussion Rehab That Reduces Reinjury Risk | E42

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.

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Chapters

• 0:00 Why Post-Concussion Injuries Spike
• 0:42 Welcome And Show Purpose
• 1:43 Guest Background And Career Path
• 4:46 Athletes Vs General Public: Different Needs
• 9:03 Tools And Tests: From VOMS To Force Plates
• 12:22 When To Start Exercise After Concussion
• 16:09 Motivating Sedentary Patients And Microdosing
• 20:11 Neck, Vestibular System, And Guarding
• 25:22 Safe Return To Performance And Baselines
• 29:27 Reaction Time, Fatigue, And Hidden Deficits
• 32:32 Research Plans And UK–North America Gap
• 35:17 Rugby Rule Changes And Youth Safety
• 38:25 Where To Find The Guest And Disclaimer

Transcript

Kosta Ikonomou: 0:00

Athletes' risk of injury after they get clear to play, there's a two to three times risk of getting a muscoskeletal injury. So that means like an ankle injury, hamstring injury, um, you know, blown ACL or something like that, put them more at risk, and now they're out even more. And depending on what level you play, uh you're you know involved in, that's hundreds of thousands of dollars. Every time at the end of the year, you get this sheet that says how many missed games we've had and how much that costs the team. So as a you as a as a clinician, you you want that to be as low as possible.

Dr. Ayla Wolf: 0:42

Welcome to Life After Impact, the concussion recovery podcast. I'm Dr. Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating, and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information. Whether you're dealing with a recent concussion, struggling with post-concussion syndrome, or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing, treatments, and neurological insights that can help you move forward with clarity and confidence. We bring you the leading experts in the world of brain health, functional neurology, and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless, or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. Kosta Ikonomou, thank you so much for joining me for the Life After Impact podcast.

Kosta Ikonomou: 1:49

Thank you so much. Really excited to be here.

Dr. Ayla Wolf: 1:52

Yeah, you are a physiotherapist specializing in uh working with elite athletes with concussions and doing a lot of concussion rehabilitation. Why don't you give us a little bit of background on how you ended up in that space?

Kosta Ikonomou: 2:06

Yeah, so I've been a physio for uh about 10 years now. I um did uh I started one degree, I did my kinesiology degree in Vancouver, Canada. And that's where it kind of got into just the whole space. I ended up um going to London, England to do my physio. And then upon returning, I had uh always promised my parents as long as you return back to Canada, study for your exams, get uh certified here, you can go anywhere else in the world, they said. So I was like, great, I'll come back to Canada. Um while I returned, I there was it was right around 2015. If you remember like the concussion movie just came out, there's this kind of this uptick of the kind of the media starting to talk more about it. So I ended up going uh to work at the British Columbia's first uh concussion clinic. So it was a dedicated concussion clinic, it was modeled after uh the Pittsburgh model. Um, so it was kind of an opportunity. I just got went into there, and that was my first introduction into concussion. So, and um uh as a physio, I knew how to treat the neck. And then as the years went on, I ended up um, you know, uh certifying myself in vestibular rehab. Uh for two years, I was working at the concussion clinic, and then I really wanted to get into some research. So I ended up back to England and I did my master's at UCL in sports uh sports medicine. And my research was on in the concussion space. I had some of my research published looking at the um the effects of exercise on visual motor speed and the volumes it had. So uh I just kind of morphed into that. Um after my master's, I started working again uh more in elite sport. I worked for a Chelsea football club in the academy. Uh I worked for some Olympic athletes, and then back to Vancouver I came where I the last uh seven years I worked clinically, uh specifically treating concussions, but also people with persistent concussion symptoms. And then one of my travels in sports was been in uh professional basketball uh in the CEBL. So a very a very dual kind of um clinical presence. I have my clinical work and my sports work.

Dr. Ayla Wolf: 4:46

Yeah, absolutely. And then it are there any um differences that you have noticed when you're working with maybe these different patient populations in terms of what you have to do differently or adjust differently when you're working with an athlete versus kind of the general public in terms of concussion rehab?

Kosta Ikonomou: 5:05

So in clinic, you know, the majority of your concussions are gonna come from uh car accidents, is a big portion of that. And now your patients who do suffer, you know, go through with a car accident kind of experience. There's a lot of uh, you know, other factors that play into that in the sense of one, it they never wanted to, it's something that suddenly happened to them. So uh emotionally, there's a lot, um there's a big part of that that uh is a toll on them. And with that, now their life was can kind of completely turned upside down. So you weren't kind of going out there with the sense of so an athlete who's playing a sport knows there's a bit of a relative risk to whether they're playing a contact sport. So they already have that expectation. So emotionally, we have two very different kinds of starting points. One is a um, you know, I play a certain sport, there's a certain risk that I'm aware of, and these things happen. And in the sporting world, we have, you know, there's protocols in place, there's, you know, you get their care really quickly, um, their referrals really quickly. So they and they already come from a level of their kind of exercise and sense of fitness is already, you know, at a certain level. So their drop of, you know, when they do sustain a concussion, um they're able to get themselves up a little bit quicker. When we deal with somebody in clinic, again, so we have that part where they weren't expecting this, it's an unexpected, uh unfortunate event that happened, whether maybe it was a fall, uh, you know, or a car accident. And now this has completely derailed their life, right? So now it's um and uh we're talking about it's affecting their work, it's affecting their um uh their family life, their social life. So with this, I think, like I said, the starting point expectation is a big, big difference. The access of care is a big difference, the level of fitness is is a is a difference. You know, we have somebody who's bat who's an athlete, their balance system is gonna be quite high already. Um, whereas somebody maybe um who wasn't as physically active and now somebody who hasn't been, now our big barrier is trying to get them to be active. So it takes a little bit more um, I think there's a bit more steps. And you know, clinically we have to take in consideration more things that are that are happening to the patient. Uh, but from an objective sense, a concussion is this almost retreat it the same, essentially.

Dr. Ayla Wolf: 7:58

Right. Well, I think you make a very good point where the clinician really needs to meet the person where they're at, and you can't necessarily treat a high-level basketball player in their 20s the same as somebody who's 70 years old and was just in a car accident. And so, as a clinician uh and a therapist, you have to be able to kind of structure your entire neurological exam probably a little bit differently in terms of your expectations of where somebody's balanced system is and also kind of the level at which you come in and try to maybe tone the autonomic nervous system with exercise. Um, so I think you bring up a good point that as somebody working in both of those worlds, you have to be very flexible and adaptable to really completely different populations.

Kosta Ikonomou: 8:46

Everybody presents differently and everyone's experience and uh everybody's uh kind of how they they grew up and how where they're at in their life is completely different. And this all plays a role.

Dr. Ayla Wolf: 9:02

Yeah. And can you talk a little bit maybe about the the technology that you use or kind of what has changed in your examination of people over the years from 2015 to now, as far as assessing the vestibular and ocular motor systems? I mean, the VOMS test is not a whole lot of technology involved, but since then we've we've also got a lot of additional computerized balance testing and a lot of cool tools that are out there these days.

Kosta Ikonomou: 9:30

Yeah. Um so I I still use the VOMS. I feel that it is, you know, uh these kind of, I would call them analog tests, give you some good information because it's all about the feedback you get from the patient. Uh, more and more technologies are coming out. Uh, for example, uh just one of the assessments, so we do use like an impact, like a neurocognitive test. Something like this can give you some good information, both on their symptom score, sleep, their visual motor speed, and cognition. But you have to, there's no one test. So that's why we have a battery of tests that we kind of use. Um the VOMS is a great sideline tool to see if you are in a somewhere where you're not in a in um, you know, a clinical setting. Um, but now there's a um, I believe 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 we have now, instead of you balancing on foam, you know, we have force plates, we have um things that look at sway. Um obviously our you know, our joint position test, so our head test. I just um chatted with uh it's not a plug, it's uh uh neck care, I think it's called. Uh it's like a Bluetooth device that uh I know it's very big there in America, um, which is a very cool product. Gives you a great um kind of a 3D visual of how well your neck is moving. Um so a lot of the stuff has gone from I think 2015, where we just had a laser taped onto somebody's head to actual something that is uh, you know, uh a bit more looks a little bit more professional. Um we have the uh reaction time boards have definitely gotten you know cheaper. I don't remember the first came out, they're very expensive. Um so every the thing is I look back at 2015, I look now, and I the whether you how you assess, we're still gonna assess the neck, we're still gonna look at the 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 now is the interplay between all of them, and we have it which is is better. So, in a sense, has my maybe my assessment has gotten a little more, you know, it looks more like a new iPhone now, I guess, a little bit newer, but it's it it is still the it's still the same essentially.

Dr. Ayla Wolf: 12:12

Right, right. You're still testing all the same things, just um have a little bit more refinement of the metrics and the objective data.

Kosta Ikonomou: 12:20

Yeah, exactly.

Dr. Ayla Wolf: 12:21

Yeah, amazing. And then when somebody is in their recovery process, um, at what point do you try to bring in exercise as a therapy? Uh you know, is there a certain kind of like symptom threshold that you want reduced or are you doing that right away? Kind of where do you see exercise and um that kind of training kind of brought in in this in this process?

Kosta Ikonomou: 12:45

We know, and that's the work done out of Buffalo from John Letty, that uh the faster we get people into you know aerobically building their aerobic capacity, uh produces a uh hormone called brain drive neurotropic factor, helps bathe the nerves, helps he increase the brain healing part, gets oxygen, blood flow to the brain. So all that stuff is what we want. Now in even in the athletic population, after 24 hours to 48 hours, where we have our relative rest, which is one thing that really changed from, you know, in the beginning, say 2050, where it was like dark room, don't rest. Now in the sports medicine world, we like to call it relative rest, which is like kind of you can putter around a bit, you can go for a light walk, you you know, don't cocoon yourself up. But there's um really good research and uh that states that you know the quicker we get everybody moving, the better it is for their recovery. Um now there's a big now. Here's the two when you have an athlete, they can't wait to get back to exercising. Um clinically, I find, you know, if somebody's super dizzy, um, you know, you have to also respect their symptoms of where they're at, right? You can't just say just sorry, you have all these symptoms, and I'm not gonna make you rush on a treadmill. Um, because then that we're gonna just trigger more of a fear, fear response to exercise. Um, you so you have to, you know, respect the symptoms, respect what the patient's experiencing is right now, and and really meet them where they're at. But then the goal is to, if they were exercising, great, then we know where we need to get them back to. If they weren't as uh active, there's a bit of a challenge of like, we're gonna have to get you at least meeting some the North American guidelines of 150 minutes of moderate activity of aerobic a week uh a week. So there's about 30 minutes of walking continuous. So the there's challenging ways. If they're, you know, you don't you don't need to always go in a treadmill. There's uh, you know, a bike is probably really great because we can take out the vestibular system a bit from there where they're not moving. So um that's always a good start. So if uh I would say start the start 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, you know, half a yoga, like uh something really kind of light body movement. It's always your what we don't want is to let the body adapt or kind of build this fear response to symptoms. So I think that's the so the sooner we break through that, then it always reminds me, you know, when you say the things like when you fell fell off your buck, and it's like you gotta get back on your bicycle, right? So there's a there's a there's a bit of that, but we're not pushing people to the deep end. We are doing, we are being a bit, you know, cautious.

Dr. Ayla Wolf: 16:09

Yeah. And I do think it is uh difficult when you have a patient that comes in who is not used to exercising, they've been relatively sedentary for kind of their that part of their life, and then they get a concussion, and then you start to realize the importance of getting them moving and toning that autonomic nervous system, but they're like, well, I've never, I'm not active. So it's like, um, what are your kind of tools and strategies for uh communicating with somebody, like the importance of movement and exercise when maybe that isn't um a big part of their life even prior to the concussion?

Kosta Ikonomou: 16:45

Yeah, I mean, a concussion is one of the hardest injuries anybody will go through. And it is especially hard for somebody who you know hasn't had that deactivity level in the past, because to kind of get your yourself out of the kind of the symptom rut, you almost have to become the healthiest version of yourself. And that is, you know, it takes a bit of uh, you know, some motivational interviewing. There's there the patient has to meet you, has to be ready for it as well. You I usually end up starting with, okay, if exercise is kind of like this daunting task, and and uh, and I get it, there's it it can be, especially when you haven't been exercising and you know, walking 20 minutes, is a lot, is you know, it seems like a mountain for some individuals. So then we're really focused on what are some healthy habits and really break it down to okay, let's make better um, you know, nutritious food choices, uh, hydrating well. Do we have a regular sleep pattern? Are we doing kind of our lifestyle 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 steal this from actually some of the uh athletes I work with with the, you know, what we do in a season is we call we call microdosing. So we these athletes are playing so many games. They're oh, we want to get them exercising, but how do you exercise some during how do you get an athlete to exercise and maintain fitness when they're already playing so many games and travel traveling so much? So, what we do is uh we we do a microdose. So essentially it is like three exercises, like six minutes, but like more for every single day. So after a practice, you'll see a lot of professional athletes will go in the weight room and they'll lift weights after practice. And that is it's a compounding interest kind of thing. So I I same, I use that same principle to patients who are experiencing you know persistent symptoms or or have not gotten into exercise is we're gonna do a little bit, and but we're gonna do a little bit every day. And it's gonna be it's gonna come into a habit, and you'll see the will slowly increase it over time.

Dr. Ayla Wolf: 19:25

Yeah, that's such a great point that you make uh in terms of the complexity of the brain injury, kind of putting people in a situation where they now do have to really dig deep and say, okay, I'm gonna have to become the best healthiest version of myself in order to heal from this, which might mean, you know, okay, I didn't used to exercise, but now I have to make that a priority in my life, or maybe my diet wasn't that great, but now I have to be extra careful about how much sugar I eat, or, you know, things like that. And uh, you know, in in my book, I think I made the statement that concussion recovery is a participation sport. Um, you know, it really takes it's a team sport. It takes a lot of people to help people, but it also takes that participation level of saying, okay, I guess it's time to make some some lifestyle changes here as part of that recovery. It's not just uh take, you know, put a cast on it and wait six weeks.

Kosta Ikonomou: 20:19

And it's hard. And because now you're doing that with some a headache, with some symptoms, right? Um, but I've always also liked the um the atomic habits book where he talks about, I'll steal the quote, never miss twice. So I always tell people, uh my patients, like, all right, you didn't do your exercise one day, or you had kind of a down day. That's okay, but we're gonna make sure the next day you're not gonna miss twice. So I I really like that for my patients as well.

Dr. Ayla Wolf: 22:03

Yeah. So you certainly do a lot of, like you said, kind of motivational interviewing and really uh pay attention to just the the mental hurdles that people have to overcome as part of the recovery and changing some 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 good on the exercise front, some you should be seeing maybe a counselor, a psychologist, somebody who, or somebody who can help you with that piece, somebody who can help you with the symptom piece of, you know, maybe your concussion triggered a migraine, you need, you know, or a good neurologist, a good doctor. 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 the conversation by saying that initially in your career, you're like, I'm really good with necks, and then you had to learn about vestibular rehab. But bringing it back to the neck, I know that neck strengthening is such an important component, even in concussion recovery for athletes. But I also find that with a lot of my patient population of people that were in car accidents, that causes a lot of whiplash injuries, uh damage to the ligaments. And so do you include like a a lot of neck strengthening in your program with those people as well?

Kosta Ikonomou: 23:23

Yeah, it gets um this is where it becomes the the concussion recovery becomes very complex, I feel. I've seen a lot of individuals who will only treat the neck and kind of miss the vestibular part of it. But actually, patients are have a stiff neck, have neck pain because they haven't tackled their vestibular part, because their neck is just constantly guarding because they're dizzy. So it's it is that kind of fine balance of you gotta treat the neck and but also treat the other 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 know patients early on become very symptomatic. So turning kind of uh increases their symptoms and makes them dizzy. So they end up kind of learning this learnt behavior of not turning their neck, not so now in turn, now you're dealing with neck stiffness, neck tightness. Uh obviously everybody says like then the stress and anxiety holding their shoulders, their traps get tighter. So there is this perpetual kind of downs, downward slope. Um, but getting the neck moving, I think, is is really important early on, telling patients that you know you're not causing damage. I think yes, you went through this whiplash um mechanism, but now you know pain becomes a protective mechanism. Your pain is not um you're not causing damage because you're moving your neck, right? So within your tolerance, uh say 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 that um comfortable moving your neck because later on in your AHAB, we're gonna have to do some VOR, which is the everyone's least favorite head shapes. And in order to train that system, we're gonna have to go at 120 beats per minute. Otherwise, you're just doing smooth pursuits. So it you gotta get comfortable moving it because to tackle that other part, it's gotta be a big fair. So um definitely the neck, and then 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 those people when they walk in the office, and you can tell with just the way that they walk that they are terrified to move their head. And so, yeah, usually my first question is like, let's talk about dizziness. Because um, you know, is this why you're walking so stiffly? Is it because you're afraid that if you turn your head, you're gonna have a moment of vertigo or disequilibrium? Or um, I think that so often uh people kind of get used, like they might not even be aware that they're holding their head as stiffly as they are. Um, they're kind of unconscious about those behaviors until you can like bring that awareness to it and then start to practice different exercises that involve kind of safely moving and turning the head and walking. And like you said, being more comfortable with those movements and not afraid of causing more damage or bringing on an episode of dizziness. In terms of the work that you do with athletes, I imagine, like you said, you know, a lot of athletes, they just want to get back to the game. And so if anything, I imagine that sometimes you're having to hold people back a little bit and say, uh, hey, even if your symptoms are a lot better, we still need to maybe kind of do this graph, like reintroduce movement and activity and sport gradually. So, what are your parameters around that whole concept of kind of getting people safely back in a game where there may be a potential for another head injury, especially?

Kosta Ikonomou: 27:18

Um, yeah. So, in the you know, the athlete population, the they want to get back to play as quickly 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 safely because the the worst thing that can happen is that we haven't gotten all those subsystems up to where your baseline is, and you get another concussion, and now we're dealing with you know, higher symptom burden, prolonged, you know, prolonged symptoms, and you know, a longer return to play the next time. So this is where uh one of the uh things that's changed in the sport world is we take baseline data um as much as we can, because that's the one thing as clinicians helps us. So the more data we have of their preseason, better we know, okay, this is where we need to get to because the coach is gonna you will go, and this happens to me all the time. Um I want to have a meeting with the coach to tell him this player's you know still not where he needs to be. He kind of beelines, ignores me, and goes right to the player and goes, How are you feeling? And then then and then the player 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 that objective data uh to show. And we know that uh athletes' risk of injury after they get clear to play, there's a two to three times risk of getting a muscoskeletal injury. So that that means like an ankle injury, hamstring injury, um, you know, the bike, you know, bone ACL or something like that, put them more at risk, and now they're out even more. And depending on what level you play, uh you're you know involved in, that's hundreds of thousands of dollars every time at the end of the year, you get this sheet that says how many missed games we've had and how much that costs the team. So as a you as a as a clinician, you you want that to be as low as possible. So um making sure that you have data on their balance system, their reaction time, their neurocognitive scores, um, you know, their neck strengths, um, which uh, you know, a lot of that is tested in the big clubs that use kind of these uh isometric tests, uh, and we get like feedback on that. Um but also knowing your athlete and knowing that one when you clear them, you don't clear them to to play, you clear, you return to performance. So you want to be able to return 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 our persistent patients where we try to tell them what's the healthiest version of yourself. The athletes are like, we're gonna 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 kind of navigate that. Um but there's a lot of other, you know, like I think in sports, certain sports. There's the pressure from, you know, agents, stakeholders, you know, fans, coaches, which makes it 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 kind of seeing almost the economics of it uh from a medical perspective, and yet you really just want to do what's best for the individual in terms of safely getting them back to performance at the right time. But the whole Rest of their influences are kind of uh in opposition of that. That could, I imagine, be very difficult. Yeah.

Kosta Ikonomou: 31:16

That's what makes probably the biggest the outside noise and the outside pressures is the hardest part of an athlete recovery when it comes to concussion or any injury. Whereas uh what I love about working clinically is I can just go set me and the patient, and we can just kind of take our time and you know get them where they want to go. And, you know, there's there's no outside noise for it.

Dr. Ayla Wolf: 31:44

So yeah, yeah, exactly. And so you mentioned that there's this increased incidence of other types of musculoskeletal injuries if people get a concussion and then go back into performance. And are you seeing those as a result of maybe some residual vestibular ocular reflex issues or reaction time issues or balance issues? Like, do you kind of can you kind of trace that back to um maybe some of the original issues they were dealing with from the concussion that then translated into them being more susceptible to these other future injuries?

Kosta Ikonomou: 32:20

Yeah, I was just uh referencing what what the data shows, the research is showing. And I think a big part of that is, yes, from underlining um, you know, we our kind of our our goal is was to get them asymptomatic. Uh but now it's, you know, we know are the proprioception and kind of their coordination is if we don't challenge that or get that up to speed, their body mechanics, especially under fatigue, is gonna be an issue. And that's where you roll your ankle, um, you know, other ligament injuries, things like that. So um that's where that comes from. And we gotta think it's it's yes, we can train, you know, each aspect individually, but then we gotta do it all, you know, put it all together and challenge the athlete, um, kind of, you know, in a in a game setting where some individuals might not do that or might not have the time or the pressure. And that's when then the athlete is, you know, um goes back and is at risk. But it's also the their capacity, depending on how long they've been out for. So if an athlete's been out for, we know that their cardio doesn't fall off, you know, till after two weeks. Um, but if an athlete's a little bit longer, we know that we got to get them up their cardiovascular. 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 it should be. It's a big thing we see from uh, you know, one of our clinics. We used to get athletes to come in more for like kind of second opinions, and they're and uh their reaction time was really bad. And now, if your reaction time is off, I would assume it just makes sense that you're gonna be more at risk of getting another injury. So I think that's where the research is showing up for that is their coordination reaction time is not where it should be.

Dr. Ayla Wolf: 34:29

Yeah, and there's so many aspects involved in reaction time from your ability to make rapid saccade eye movements and um to also kind of engage the appropriate muscles, which is often almost done at an unconscious level, those like vestibulospinal reflexes. And so I can imagine that if you're only basing somebody's ability to return to performance on a symptom level and not on kind of a level of how are they presenting from a neurological exam standpoint, you could kind of miss those um deficits that are still there and send them back out. And then they're set up for kind of potentially these future injuries.

Kosta Ikonomou: 35:08

Yeah. And it's again where we should be also, I think, testing. I mean, our athletes I want to see how they are under fatigue. Right. So it's it's watching them at the end of practice, at the end of that, and just kind of then putting through a bit of a battery and see how they respond.

Dr. Ayla Wolf: 35:28

Yeah, yeah, absolutely. I mean, your your entire kind of nervous system can change based on whether you are rested and energetic versus at the end of a day when you're tired. So that makes perfect sense. What are you kind of are there any projects you're currently working on from either a research 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 getting integrated into the kind of London system here and um really hoping to do a bit of research with some of the rugby clubs. So right now I'm more in the development stages. Um, and especially uh just really interested in the, you know, I think how we treat in North America is completely different than how we treat uh concussions in Europe. Uh it's almost like uh not going to say how we treat, I think the um the appetite of a concussion is a bit more aware aware in North America. So people are just a bit more aware of concussions. There's more concussion clinics, there's more, you know, concussion care insurance companies that kind of are kind of uh will help some individuals who are uh you know have experience in cuss, where in Europe it's less, I would say. So I'm really interested in seeing like kind of building bit some services out here, building kind of edge the kind of the educational stuff. Um the I'm not sure why, but there it is uh is definitely different. I'd say it reminds me just here that things are almost five years behind. There's some clinicians who are really good actually, that I've met some who are doing great work and there's good research coming out of here, especially, you know, University of Bath are kind of leading in the um research in the sense of um the saliva. There's um, you know, some good work out of where I did my master's out of the ICH doing some good work. There's just uh not as you know, as many as it feels like in North America I I can go, there's a lot of people doing research, you know. Um, so and I've been to a lot of conferences down in the States, and it seems, you know, it is people want to uh you know figure this out and and evolve it, right? And um where I think it's I think it's not the the clinicians, I think it's just the attitude towards a concussion from a population standpoint, like you said in Australia. I think that's it how it is in the UK. And um, you know, I've worked in football there and soccer, and I can tell you the parents' pressure of oh my kid doesn't have a concussion is is is there where it whereas I think parents are more concerned, I think my kid has a concussion in uh you know in in Canada where where it also works. So it's more of that sense, but there's some really good work happening, really good clinicians and more and more uh picking up here.

Dr. Ayla Wolf: 38:38

Yeah, yeah. So that public awareness piece is huge in terms of recognizing the seriousness of it and the need to actually take that time off and treat it seriously. And then um, in terms of the current sports teams that you work with, do you still go back to Vancouver or are you you said you're currently working with um 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 in May, May, June. Um so see, so right now um taking month by month right now and uh trying to get involved a bit with you know uh with some rugby clubs out here. Uh but so technically I'm in my off season. So this is where actually my shift focus is more towards um treating patients. Uh but yeah, then my sport shift is in in the summer.

Dr. Ayla Wolf: 39:31

So now I I don't know much about rugby. Have they changed rules over the years to try to create more safety parameters?

Kosta Ikonomou: 39:41

Yep, they've changed the rules. They have a now um a minimum like uh almost like a stand down time. So do you experience a concussion or you they take you off, and there's a minimum time frame where you have to be out before you go back in. Um I think there's you know the higher leagues, uh they're doing a really good job. Um they've uh we know that certain contact sports, we can't change the risk of a concussion, but what we can change is the rules. So there is like some tackling um rules that they've changed. Uh we saw that in ice hockey where the band blindside hits. So we they they were allowing you know players to just come across the ice and just hit people without seeing them. So at least they said the concussion rate was going so high up that you know the NHL was like, okay, no blind side hits. Let's make sure if you're gonna hit somebody or make contact, it's gonna give the opportunity of somebody to to dodge it. So uh even a rule change like that uh made a big difference. So there is, I think from uh they are making rules to you know decrease the amount of concussions. 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 neck plays a role. You know, you're gonna be doing your almost your pre-hab into the season for that. Um, but I think really um where it's a challenge is at the lower levels where you know you're the grassroots level, where it's you know, it's a parent who's coaching, you know, the the kids uh rugby match. Um there's no there's no aesthetic therapist, there's no physio, you know. So maybe Varaki one another parent as a doctor, and you know, that's usually how like the team cares. So I think that is the challenge that we're all that um I'll have. I know there's great programs in Canada and North America, where um Southern America where you know there's mandatory um education on concussions for coaches if you're gonna go. So uh I think that's coming again. There's some programs here as well, but yeah. So it's definitely the big the a 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, the more we learn more and more about it, and I think things just change. So as we like we treated um how things have changed in 2015 into to now, I think we're gonna continue to see a change.

Dr. Ayla Wolf: 42:27

Yeah, absolutely. And so for people in the UK, um where 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 online consultations. Um I do have uh in clinic, I do I'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 I send kind of all about brain health, uh send out monthly. So but uh and then yeah, people are more than welcome to reach out to me on social. Um I'm happy to respond, answer questions.

Dr. Ayla Wolf: 43:08

Excellent. Uh well I can put all that contact info in the show notes, and then what is your your website?

Kosta Ikonomou: 43:15

So my website is uh akesosportsmed uh.com. So akasso is the where did Yeah, 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 gonna ask you where that name came from. I assumed there was meaning to it. All right, the goddess of healing. I love it. 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, and consumers of this information should seek the advice of a medical professional for any and all health related issues. A link to our full medical disclaimer is available in the notes.