As many of you will know, my specialisation and clinical background are focused on MSK and sleep. Along these lines, I have taught dry needling (DN), functional foot, anatomy and clinical reasoning courses for the past 30 years. During the DN courses, one of the most 'off-topic' questions I receive relates to the effectiveness of DN for spasticity. Even though I have a rural and remote practice and treat a wide range of conditions, neuro/post-stroke is just not one of them. My answer in the past has been that I don't have any clinical experience and have directed people to Val Hopwood's book Acupuncture in Neurological Conditions, 2010. A confluence of inquiries and emails following my last ...

I have been reviewing recent clinical sleep research with an eye to how it can be incorporated into clinical practice. I hope that you find some of these summaries also of practical use.  Gestational Diabetes Mellitus Diabetes mellitus complicates 6–7% of all pregnancies with 90% representing gestational diabetes mellitus [1]. Gestational diabetes mellitus is associated with an increased risk of preeclampsia, fetal macrosomia, birth trauma (e.g., shoulder dystocia), and neonatal metabolic complications [2] Women who are objectively assessed as short sleepers have poorer glucose regulation [3] and self-reported short sleepers (i.e., < 6 hours) have a 2-10% increased risk of gestationa...

If you aren't a parent, you may consider skipping this email. However, the sleep mechanisms/science underlying these protocols are still relevant to those of other age groups. Also, you might find you can lend some helpful advice to your next adult client presenting with headaches relating to their lack of sleep, secondary to their children's sleeping habits!  Children (3-12 years) What time should I put my child to bed? This depends on their age (3 - 5yo = 10 - 13 hours, 6- 13 yo 9 - 11 hours), sleep quality and wakefulness during the day. In other words, there are guidelines, but you need to see how well your child is coping with the amount and quality of sleep they are receiving. If ...

For most of us going to bed signals the end of a busy day and the chance to slip into a blissful period of rest and recovery. For some, however, it signals a period of frustration, pain and intense discomfort because they experience restless legs syndrome.  What is it? Restless legs syndrome (RLS) is a neurological and sleep disorder characterised by uncomfortable leg sensations and an irresistible urge to move the legs. Symptoms typically occur in the evening and at night, resulting in sleep disturbances but can also happen during quiet periods during the day. It mostly occurs in the legs, but can also affect the arms. Not only is it disruptive of nighttime sleep, but results in increa...

It would be hard to miss the increasing awareness of the importance of good sleep, which is fantastic. Within a few days, I had a client email me thanking me for providing sleep treatment advice that she hadn't received from her prior 3 health practitioners, a company requested me to provide a customised 1-day workshop on how to include sleep in clinical treatments and I saw the results of the HIF WA health survey on sleep. Are you riding this new health wave for your benefit and the benefit of your clients? The HIF survey focused on three domains, Environment (where and how we sleep), Priority (knowledge and value of sleep) and Impact (personal and community). There are many nuggets to dig ...

As we head towards hibernation and the shortest day of the year, I thought to share some of the great books I have been reading over the past couple of months and some of the takeaways that struck me as interesting. Will post this as a blog. Please add your own favourite texts and why.  The Good Partner (Karen Nimmo 2022) Communication is a key driver for our profession; the better our ability to listen/communicate/educate, the more successful I think we can be. And while this book is built around improving relationships, the content I believe is very relevant to our interactions with clients. Karen is a Kiwi clinical psychologist, with an interesting sense of humour, and she drills dir...

With a shortage of health professionals trained to provide F2F assistance in the insomnia space, there has been an explosion in the provision of such services over the 'net'. What is being treated and how effective are these services? Digital CBTi to prevent mental health disorders Epidemiological estimates suggest that 10% of adults meet the diagnostic criteria for insomnia disorder, about 33 million insomnia sufferers in the US (2020) or 2.6 million in Australia (2023). Despite being the gold standard treatment for insomnia, CBTi is often unavailable to patients seeking treatment. In the past few years, two studies have reported that the provision of CBTi via telemedicine is an effective a...

Does this sounds a bit like the chicken and egg story with a medical twist?   Background A growing hot topic in the past 20 years is the association between sleep and pain; one way, bi-directional, one-way dominant? While some researchers have suggested a reciprocal relationship, others have proposed that pain could be worsened by sleep disturbance [1,2]. Recently, growing evidence has suggested that sleep disturbance predicts the onset or aggravation of pain [1,3], even in healthy individuals, regardless of age (teenager, young adult and adult). Researchers conducting a 2021 systematic review found that self-reported poor sleep quality on the prior night predicted increased lumbar...

When I completed my full-time year of postgraduate in musculoskeletal Physiotherapy at Curtin University the BioPsychoSocial (BSP) model looked like this. The year was 1992. I am not exactly sure when the changes started to occur (given I live in small remote coastal time and we only get the mail on a monthly basis), but by the mid 2000's, when I was prepping for my specialisation examination, it was definitely on my radar and informing how I approached clients with persistent pain conditions. I guess that intuitively I was aware some clients had out-of-proportion pain given their injury, listed their ailments like a French cuisine menu and described their history as clearly as if reading it...

Have you noticed on those nights of poor sleep, you are less likely to put in a good effort at training or at work the next day. Just can't seem to find top gear or put it all together? You may recall a couple of months ago I drew your attention to a couple of articles examining the relationships between poor sleep and migraine and poor sleep and LBP. If not you can catch it here. Today's article titled 'Chronic Lack of Sleep is Associated With Increased Sports Injuries in Adolescent Athletes' examines another aspect of short sleeping, that is, increased injury rates. As health professionals, we are familiar with considerations of overall training loads, rates of increased training loads and...

Sleep & Migraine Background Being a clinician I am always keen to see what the researching body is producing that I can incorporate into my clinical practice. You may also find the following information of interest. There is now a longstanding evidence-base demonstrating that headaches can be triggered by various sleep disorders, including obstructive sleep apnea [1], narcolepsy [2], insomnia [3], circadian rhythm disorders [4], and restless legs syndrome [5], as well as poor quality [6] and insufficient sleep [7] in general. Management A recent study by Vgontzas et al 2022 prospectively examined participant's sleep and migraine experiences over a 6 week period. The researchers found tha...

Never read the book, but I always thought that the title described our profession well, here's why... As allied health professionals we are generally dealing with fewer black and white clinical presentations than our medical colleagues. That is, we are evaluating presentations like Myofascial Pain Syndrome, T4 Syndrome, Non-specific low back pain, Rotator Cuff Related Shoulder Pain, and Fibromyalgia Syndrome. Because of this, we are often balancing client quality of life decisions with the degree of intervention we provide. Tied up in this are difficult to tackle topics like lifestyle factors (e.g., sleep quality, smoking, healthy weight), health literacy, physical conditioning, psychosocial...

Cliches, but powerful... A picture tells a thousand words. Seeing is believing, which in this case is very concerning. One of the most common areas in which I am asked to provide a professional opinion is in regards to needling and pneumothorax or haemopneumothorax. The cause is poor or no technique and is usually due to a lack of specific training. If you learned manipulation of the thoracic spine, you would not then assume you have the skills to manipulate the cervical spine. Different anatomy, Different precautions. Different dangers. In much the same way practitioners, that have learned to needle supraspinatus are not qualified to move an extra couple of centimet...

This article combined data in the US from 3 sources; Sleep Cycle (sleep tracking app)US CensusCentre for Disease Control in the US to evaluate relationships between sleep quality/duration/snoring and various health metrics and diseases. I am not aware of such data gathering in Australia, but it does bring together several important health considerations that we can take on board clinically. The analysis helps to show that our physical, mental, and sleep health have multi-directional effects on each other. Those cities in which participants were experiencing good sleep had some similar characteristics; higher leisure timelower diabetes scoreslower obesity scores  Higher Leisure Time...

Many of you will know of my interest in sleep and the role we as primary contact practitioners can have on influencing our clients health, wellbeing and recovery, by providing evidenced based advice on improving sleep. An article published in the August edition of Sleep by Fiese et al, titled 'Bedtimes, bedtime routines, and children's sleep across the first 2 years of life', explores the benefits of establishing a bedtime routine (and what type of routine) on sleep quality. The relevance? We have a better understanding about the relevance of what we do in the first 5 years of our life. Critical brain development, habit forming, and learning all occur in these early years, which influences t...

I have been involved in many legal cases and AHPRA reports, but recently received a request for information on a client from the Government of WA Criminal Injuries Compensation (CIC) department about a client that attended our clinic 2 years prior. I had not heard of this department before and guess many others have likewise not heard, so I did some further investigation that I thought I would share. While this is a WA department, I am guessing there exist similar ones in other states and territories. The WA Government Criminal Injuries Compensation Scheme enables victims of crime to apply for compensation for injury or loss as a result of an offence or an alleged offence. Persons are eligib...

An early 20s male recently presented with unilateral, polyneuropathy that was non-dermatonal and associated with leg weakness, foot dysfunction and pain. While peripheral, it wasn't bilateral or nocturnal, lessening the likelihood of a diabetic neuropathy. With further investigations it was determined to be a hereditary motor and sensory (HMS) neuropathy, also called Charcot-Marie-Tooth disease (it is named for the three physicians who described it in 1886). I prefer the former term, as it is clinically descriptive. Hereditary motor and sensory neuropathy Hereditary motor and sensory neuropathy is one of a group of disorders that cause damage to the peripheral nerves, affecting both sensory ...

As soon as someone finds out my interest in sleep, the next statement usually involves a flick of their wrist and something like, 'last night my XX brand smart watch told me I had 4.5 hours of deep sleep, 1.5 hours of light sleep and 2 hours of dreaming, isn't that amazing'. After them outlaying upwards of $500+ what else can I say but ....amazing.... That conversation aside, millions and millions of people are wearing and taking note of a mountain of biometric data generated by smart watches, so when it comes to sleep, is it accurate? Well, the gold standard in sleep research is polysomnography (PSG). Here is a picture of a PSG getup and you wonder how in a sleep centre, with all this gear ...

Nope, not talking about my increasing age or the AM rise men supposably have. This topic came up during our last Level 1 Dry Needling course when penetration of infraspinatus was proving difficult for some participants. I have listed a range of suggestions that depend on technique, tools and patient factors. Patient Let's start in reverse. If your patient has tight fascia (infraspinatus is a good example), through positioning and support of their arm, the fascia can be loosened and made softer before needle insertion. Also if their body is supported and they are mentally relaxed, this will make it easier.  Tool Enter your text hereIt helps to start with a high quality needle like a...

Safety Acupuncture and dry needling have received much examination on the dual fronts of safety and lack of evidence. The former has largely been answered in the past two decades, with reports noting that in the hands of an adequately trained and competent practitioner, the incident of a severe adverse event (requiring hospitalisation) is very low and that minor adverse events range between 7-10% (Haake et al., 2007; Macpherson, Scullion, Thomas, & Walters, 2004; White, 2006). Training, including a high degree of anatomical knowledge remain critical. Research The quality of acupuncture and dry needling research has continued to improve over the past 20 years. Initially reportings were do...

As a health advocate for your clients, the following might be of interest to you. It is common practice to quote that we spend a 1/3 of our lives sleeping. But do we? In the US between 6-10% of people are taking sleeping medications. I have been researching and writing a Medications section for my upcoming The Sleep Mastery Course. The findings have caused me to reconsider this global statement about sleeping and to share my findings with you. Basically, I am a 'good' sleeper, even though I am writing this at 3am and became interested in sleeping not due a lack of it, rather because clients would present to the clinic with spinal pain after a night of sleeping. But you can't interact wi...

COVID has affected us all in short and long term ways. Some still playing out. With presenters from around the world, I thought it would be a great opportunity to find out in more detail how physiotherapists in different countries and regions have been affected. Europe - Italy - Julie Day Let's start with Italy, where an early explosion of COVID showed us how fast it could spread. Julie presents the Level 1 and Level 2 Fascial Manipulation courses for AAP Education. Julie was literally on the tarmac in March, heading to Australia when the Italian government closed all airports. Bam. Here is Julie's account of current life as a physio in Italy. Well here in Italy life is very gradually return...

Monash I admit to have had little knowledge of WW1 (the so-called Great War) and stumbled into it after enjoying a fiction book authored by Roland Perry. My Dad pointed out that the same author had penned several biographies featured influential Australians from WW1. Influential was an understatement, I was soon to realise and by then I was hooked. I started with 'Horrie, the War Dog'. Horrie was a mongrel pup found in the middle eastern campaign that had the life-saving capability of hearing Stuka dive bombers several minutes before they pitched out of the sky, bombing and strafing men and vehicles. Once his antics were understood, Horrie was treated with reverence, inducted into the machin...

In these unsettling days and months, AAP Education would like to assure our members and partners that we are monitoring the COVID-19 (Coronavirus) information and advice closely. As you will be aware the situation is constantly evolving all around the world and the health and wellbeing of the AAP Education tribe is paramount and will be at the forefront of any decisions made. We had to cancel the Level 1 and Level 2 Fascial Manipulation courses due to travel departure bans in northern Italy preventing Julie from leaving. Julie is fine and was keen to come if she could have left Italy. We are tentatively planning rescheduled courses later in 2020. You can reply email to me if you are keen to ...

We all experience the odd night or two of poor sleep. For some this becomes a more regular occurrence, to the point of it being more regular than not. This is insomnia and people reach the point of dreading just thinking about going to bed, anticipating the repeated battle of tossing and turning most of the night. In discussing this with clients and other clinicians, the extent and effect of not getting a regular 8 hours sleep has clinically become apparent to me. Sure, you feel off your normal game if you miss a couple of nights, but if it is ongoing, the ramifications become much more serious. Take for example; Death/severe injury due to excessive daytime sleepinessIncreased cardiovascular...

'Stop if you feel pain.' 'Rest and give your new knee (post TKR) time to settle.' 'Be very careful when you do that movement.' 'You have the joints of an 80 year old.' These were some examples of poor communications reported by researcher Emma Karran at the 2019 physio conference in her presentation titled "Screening, scans and choosing words carefully: Optimising care for patients with low back pain". Suggested alternatives were; 'Movements will be initially painful like a sprained ankle - but will get better as you get active.' 'Your knee is strong and robust - let's take it for a test drive.' 'Our tissues heal, they respond best through loading - slowly increasing your walking is the very...

2019 Adelaide Physiotherapy Conference⁣ anatomy presentation As the invited ADNG national speaker (thank you to the ADNG for the invitation) this was first presented at the 2019 Australian Physiotherapy conference. With a tongue in cheek approach, I wanted to explore 6 muscles in 3 pairs that have similar referral patterns, but IMO one gets all the news while the other languishes in obscurity. High time to back the underdog! ⁣You can view the video here.

There are a few anatomical areas that require extra consideration and training when using invasive techniques like needling. The most obvious is when needling over the lung fields. Another area that exercises peoples' consideration is in regards to the kidneys, when conceptually needling the bladder channel or lumbar paraspinals. We discuss this safety aspect in great detail in our Level 2 Advanced Spine and Lower Quadrant Course but I would like to explore some aspects in today's blog. A 2017 article (can be accessed via Research Gate) by Chia & Haberberger examined the anatomy of the kidneys and needling in relation to the bladder meridian, which involves needling in the sagittal plane...

When you think of great leaders, who comes to mind? Are they social, political, professional, athletic or business leaders. Perhaps, Mahatma Ghandi, Margaret Thatcher, Pope Francis, Nelson Mandela, Usain Bolt, Benazir Bhutto, Stephen Covey, Martin Luther King or Rosie Batty. What are the qualities, values or attributes of leadership that you so admired in these people, that elevates them for you to being a leader? Perhaps you identified qualities like compassion, conviction, wisdom, honesty and passion. It is interesting when looking at what defines a leader that it can be as simple as someone that has followers, after all, you can't be a leader if you aren't leading someone else! What about...

Sorry about not sending out my normal July email. Tomorrow is the last day before submitting my PhD thesis and I confess to burning the candle at both ends through most of July. However, the process of writing, revising and rewriting, has made me consider the importance of reflective learning/practice. In the case of my thesis, reflective learning challenges me; to read a section of thesis material/resultsapply the pub test - does it feel right and evaluate my results within the context of the broader literature and thenput into writing how this new information does or does not change my approach. You could apply the same process to how you react to a complaining client, your teenager decide...

We have all had that client rock into the clinic with a 'spasmed' neck, that came on soon after waking. It was an amazing fact that 9 years ago when I started looking into relationships between sleep posture and waking spinal pain, I couldn't find any research to guide me. Ah I thought, now that is interesting.....plenty of anecdotal stuff, but nothing on which to base clinical advice. "Herniated lumbar disc. The preferred sleep position depends in part on the position of the disc. For a paracentral disc herniation (most common), people tend to do better lying on the stomach." Complete online article written by Dr Richard A. Staehler, MD can be found here. Really! Clinically would you tell a...

****Would $125,000 help employ your next clinician?***** That is the amount of money on the table being offered by the current government, to attract allied health professionals into rural and remote locations (well basically anywhere other than metro centres) to improve the quality and availability of services. An awesome idea, because the further you move from our capital cities the worse health outcome become, the more expensive accessing health services becomes, the shorter life expectancy becomes and all because access and diversity of health services reduces. Effectively Triple $$ Dipping So putting $$ towards employing and retaining allied health professions is a no brainer....

Following on from the Upper Limb Clinical Neurological Examination blog here are the details for my Lower Limb examination. Comments in regards to increasing neurological tone in regards to using the Jendrassick maneuver apply here also. See the Upper Limb neurological examination blog for further details. For power testing I use the following; Iliacus L2 (femoral nerve), Quadriceps L34 (femoral nerve), Tibialis Anterior L4 (deep fibular nerve | sciatic), Extensor Hallucis Longus L5 (deep fibular nerve | sciatic), Fibularis Longus/Brevis L5S1 (superficial fibular nerve | sciatic) and Triceps Surae S12 (Sciatic nerve). How weak is weak? For me it is not so much that the test is...

So what are your criteria for conducting a neurological examination and what do you include when you do complete one? Like all questions there are provisos, so rather than list them all I thought I would explain my basic neurological examination and depending on the results I build from that. When to check? Generally, if symptoms extend beyond the shoulder or hip, I would consider at least a basic examination. If the history included descriptions of pins and needles, and numbness then again I would include a neurological examination. How long should it take, around 3-5 minutes. Here is my upper quadrant examination. In my type of clinical practice, I am focusing on the hard signs of a neurol...

One of the commonest challenges mentioned by new grads is overwhelm, described as the sense of treading water and just about going under, in relation to demands on time. This is not unique to recent grads. Even experienced clinicians experience the buildup, but have learnt techniques to manage these crunch times. One such technique is the Eisenhower Matrix (EM). So why the name? Dwight D. Eisenhower was the 34th President of the United States from 1953 until 1961 but before becoming President, he served as a general in the United States Army, as the Allied Forces Supreme Commander during World War II and later NATO's first supreme commander. It can be assumed the guy experienced time pressur...

As part of our quality of client care, most allied health practitioners maintain their annual CPR. But what about your first aid skills? Q: Given our range of deadly snakes and V8 lawnmowers with fins, what animal kills the most humans each year? (answer below) As a kick off you will most likely enjoy this if you haven't already viewed - "Video Come to Australia" As part of our quality of client care, most allied health practitioners maintain their annual CPR. But what about your first aid skills? Q: Given our range of deadly snakes and V8 lawnmowers with fins, what animal kills the most humans each year? (answer below) As a kick off you will most likely enjoy this if you haven't already vie...

If you have an interest in dry needling and acupuncture, it is worth utilising the auto email Table of Contents function from AIM (you can set it up here). One of the articles that grabbed my eye in a recent eTOC list was the one reporting on dry needling of rectus abdominis to treat primary dysmenorrhoea. The viscero-somatic reflex is one of the topics that we examine in the Level 2 Spine & Lower Quadrant Course and this is a great example. As a bit of background, it would be worth having a look at an earlier 2014 study that used wet needling (lignocaine). The results were pretty amazing. Participants initial details were age, 22 ± 2.5 years and mean VAS pain scores 7.49 ± 1.16. After t...

How did you explain to them what their 'non specific low back pain' diagnosis means. I understand the 'medical' reason for this term, but hey, when you just look at the words, it is so 'No-Brand-Vanilla'. How do I respond? A good question and I recently stumbled on what seemed a good analogy and will share it with you. Firstly however, I must stress that it is important to clarify they don't have a fracture, infection, inflammatory condition or tumor. This is an important part of our primary contact practitioner role. Back of the envelop calculations indicate, that if you see on average 3 new clients per day, and have 4 weeks holiday a year, you will be seeing on average 5 people a year that...

You may have seen this picture on Instagram (https://www.instagram.com/p/BmtadOungGB/) and it does show obvious issues with pillows, however, when it comes to educating our clients about making good decisions in regards to sleep, we need to have an broader understanding of the situation on the complexity of sleep posture and symptoms. Here are some thoughts. "Hi guys nice pics, but there are some broader points worth considering for our clients' benefits. True, 57.3% of healthy people wake with cervical symptoms while sleeping on their normal pillow – so potentially not a good choice (Gordon and Grimmer-Somers 2010). True, the pillow functions to support the head and maintain a neutral cervi...

If you prescribe exercises for improving spinal mobility or strength you will find this abstract of interest, but before we get into it, you need to understand how these loads are measured. Usually due to burst lumbar fractures/tumors, participants have their VB and IVDs replaced, in this case with a vertebral body replacement e.g. Synex. Build into this replacement is a telemetry chip capable of collecting and exporting load data in vivo. This has enabled the researchers to capture load data for a huge range of ADLs and they provide all this data free. Awesome. Spinal loads during post-operative physiotherapeutic exercises Rohlmann A, Schwachmeyer V, Graichen F, Bergmann G. Abstract After s...

While driving to work along lovely country roads each morning, I take the opportunity to catch up on what the rest of Australia has been doing. ABC radio national and ABC news are my favourites and it is hard not to shake the head each morning, after hearing the latest revelations from the banking royal commission. CommBank charging $120 million for no-services or charging services to dead people for 10 years ..... There seems to be a major disconnect between fund managers, financial service advisors and those other 'professionals' providing financial advice and their clients. What has happened to professional ethics in the financial profession? Looking in from outside, it seems they have co...

Research & Your Advice For the past 3 weeks I have been conducting a systematic scoping review for my PhD on the topic of "The relationship between sleep posture and waking spinal symptoms of pain, stiffness and bothersomeness". A scoping review is similar to a systematic review, except it is better suited for new areas of research and areas in which the aim is to identify gaps in our current knowledge base. What's amazing to me, is that as a clinician I have been doling out advice about corrective sleep postures for years and yet there is basically nothing with a research base, on which to construct this education. Hence the scoping review and my PhD. There is a reasonable body of evide...

At the start of our Strive & Thrive in Private Practice course, participants write down the three biggest challenges they are experiencing as a new and recent graduate. "Time Management" perennially features highly, but so does "feeling guilty" – recently expressed by Chloe in these words; "taking on the patients' problems personally and blaming myself for being the reason why they are not responding quickly enough" Let's look at this in two parts.Take the first part; "taking on the patients' problems personally and blaming myself"Now I see this statement as coming from a clinician with a big heart, who, however, is heading towards a train wreck. Why? As clinicians, most of us got into t...

I was recently asked what in my experience were the top 4 benefits of dry needling. Tough call, but when I reflect on the clients that have been assisted, it comes down to the following mix. Neurophysiological effects There are many aspects to this component. Here are three. Firstly, It is unlikely that we are actually having a direct effect on the muscle (if that is what you are needling). In the same way, that the muscle is unlikely to be the tissue at fault. Most likely the muscle is reacting to and protecting some other irritated tissue and as a result of unaccustomed static activity became symptomatic. We know trigger points have a build up in neural sensitising metabolites and lower pH...

Here are a couple of case study vignettes. This is what gets me out of bed in the morning. I would be interested in what you thought about this aspect of your practice. Last week I was referred 2 very different people, yet both were on struggle street with their injuries and perceived futures. One was a younger person that significant foot, tibia and knee injuries due to a mechanical accident. After 18 months of surgeries (foot reconstruction, tibial fixation - internal and external, skin flaps and grafts, ACL cleanup) he presented on two crutches, not wearing a shoe, foot NWB and pretty much blue and sweaty. He had constant pain, was online gaming pretty much all day, went to bed around 2-3...

Hey! The transition from student to private practice professional can be a real jolt, what with all the new and added expectations. Actually, it is often overwhelming. So, what makes being in private practice daunting for new and recent grads? To get the ball rolling, here is a quote from one of our Strive & Thrive in Private Practice participants; "When I first started I found it difficult to combine a meaningful assessment, whilst thinking to myself the direction I was going to take with the treatment and then being able to effectively communicate with the patient without seeming like I wasn't confident. I guess it was all pretty overwhelming" Understandable when university undergradua...

With the commencement of our current cohort of students undertaking the Strive & Thrive Course in Private Practice, one of the biggest issues being raised repeatably is time, or more specifically the lack of it. Reality says we have 24 hours max, and for mental and physical well-being most of us need to sleep around 7.5 - 8.5 hours (+ extra hour if you are pregnant). We discuss many strategies on during the Strive & Thrive Course but as I see it, there are two sensible ways to immediately improve your efficiency. Maximise Productivity To do this you first need to determine when you are most effective mentally (lark or owl) and use that time for high demand activities. I am generally ...

You are probably familiar with the turn of phrase 'we walk on the shoulders of those that went before'. Which expresses a significant amount of humility in acknowledging and appreciating the work that others have prior undertaken, to enable the 'we' to achieve the new things they are achieving. Now turn that phrase around. 'Encourage those behind, to take bigger strides than those in front'. Not as eloquent I accept, but essentially, if we want individuals, organisations, profession, and humanity to achieve more positive outcomes, then the leaders of today need to challenge, encourage and support others to take aim higher than they previously considered possible. One of the ways I believe th...

I recently completed a teaching block of 6 days dry needling in Perth, split between two venues. The lovely outlook over Lake Monger was a great setting for learning and sharing of new skills. What a great mix of students! Internationals from India, Hong Kong, Brazil, Singapore, and locals from both the east coast and west coasts of Australia. With the new course structure (Level 1 Introductory, Level 2 Spine & Lower Quadrant, Level 3 Spine & Upper Quadrant and Level 4 Master Needling Course), plus the integration of new technology for teaching there were lots of positive comments about the improved learning process: ​Online prior learningPalpation skills review was greatLoved the bo...

If you missed the first part of 'MSK Medications: Alternative Opportunities' you can catch it here. When considering what medications to use, individuals need to make informed decisions, balancing the research, the pros and cons (often a long list of side effects) and also examining alternative evidence-based options. Here are some alternative measures that can be used to modify pain. Analgesic Alternatives Pain Management Education Now I must admit that a lot of people just want to pop a pill and part of our responsibility is to explain the obvious, that is, having a longer term plan (with more than one strategy) for a longer term problem. Research has shown that as load/stress (physic...

We are calving on the farm at the moment  Like anything to do with kids, it brings a stretched emotional spectrum of highs and not so highs. Yesterday (Friday) was one of those days - well evenings actually. Just on dusk, I was doing a pasture check and noticed one cow with a feeding calf, acting distracted and flicking her tail. Pretty late to be bothered by flies I thought, so I wondered over to check it out. Oh no - she couple of hoofs sticking out and judging by the activity of her other calf, it had been like that for several hours. So with the last glimmers of sunlight fading away, I set up the yards, the gates and tried to coax mum and calf towards them. Not going to happen was t...

Qualifier: I am not a pharmacist or GP, so my drug knowledge is limited. That being said, being a primary contact practitioner it is important I have an awareness of the effects and side effects certain medications my clients might be taking. Also, not being 'brought up' with a script book in my back pocket, I am comfortable looking at alternatives and providing these suggestions to my clients. They can then discuss this with the other members of their medical team or do their own research. I recently had a client present with ongoing low back pain who was consuming 4 pain modifiers (including a patch) and 1 non-steroidal anti-inflammatory (NSAID) - all prescribed. In our practice, there are...

At the start of our Strive & Thrive in Private Practice course, we ask participants to look into the future and list the three most important wishes they want to achieve from completing the course; sort of a goals list. Most of us are in different phases of live, and this means we are often seeking different outcomes. However I believe strongly that regardless of your phase is life, if you want to achieve positive change and lead a fulfilling life, then you need to consider what this means to you. No map, no direction. Here is what Ken wrote when he started the course, and I love it. Ken, through experience, has identified several 'sensitive spots' about being a private practitioner and ...

Never, ever attempt this technique One of the most common areas in which I am asked to provide a professional opinion, is in regards to needling and pneumothorax or haemopneumothorax. The cause is poor or no technique and is usually due to a lack of specific training. If you have learnt manipulation of the thoracic spine, you would not then assume you have the skills to manipulate the cervical spine. Different anatomy, Different precautions. In much the same way practitioners, that have learnt to needle supraspinatus are not qualified to move an extra couple of centimetres to needle upper trapezius or levator scapulae. Now, if this picture had occurred in just about any other publication and...

We have just finished the first Introductory Dry Needling courses in Perth using the all new format of online theory and practical preparation, followed by a day of face to face training and case studies, complemented by a 2-hour wet lab at the University of WA. "Theory and preparation work was very interesting and informative" Tim Castles "Lecture series of theory and practical prior to attending practical workshop" Greg Hearn "The pre-reading and broadening handouts were excellent" Ed Butcher "Online course reinforced with practical sessions. Good repetition" Georgina Reed A strong focus in the course remains on developing practical, hands-on skills and linking good palpation technique to ...

In this piece, we are looking at one of the more common concerns expressed by new and recent graduates. To get the ball rolling, here is a quote from one of our Strive & Thrive in Private Practice participants, answering the question "'What does it mean for you, to be working in private practice?' "Having the opportunity to grow independence and confidence in my abilities as a young new graduate. Everyday is a challenge, but I look forward to going to work and learning something new everyday". Does that sound like how you feel? If so, you probably will find you benefit from the following information. Here are some other participant's challenges and suggestions on how to overcome them. Pr...

Here is a common example of a start point for a participant on our Strive & Thrive in Private Practice, when listing the areas of their concern as a new and recent graduate: The Strive & Thrive in Private Practice 8-week course looks at all these concerns, but I wanted to focus this piece on the subject of motivation. When we interact with our clients there are two aspects of motivation to consider. One is the clinician's and the other is the client's. A motivated clinician is one who is looking forward to their day ahead, the clinical challenges, the paperwork and the chance to help their client's move forward along their pathway of optimal living. Is that you? The second aspect of ...

October is 'mowing-meditation-month' on the farm, where I get to drive round and round cutting hay. I now find myself 12 months on, considering the same situation. Approximately 12 months ago I was told that due to a 'limited amount of space' in InMotion, that APP Education (and other providers) would be unable to advertise courses to the broader membership. Strange. I had been a member for 25 years, providing PD for the past 15 years and supporting the APA through advertising and venue hire. It was a mutually beneficial relationship, a win/win in business terms. What had changed? Money or Members First? After asking the executive and in conversation with members, it became clear that the AP...

Two papers recently just published bring together important information in regards to needling effectiveness and research design. Paper 1. The first discusses a long standing issue in the area of complementary and alternative medicine (CAM) e.g. needling research - that being, are we looking at the right method of assessing these interventions by using the gold standard of a double blind randomised controlled trial (RCT). One of the biggest issues relates to blinding the practitioner - pretty difficult when performing a technical procedure like inserting a dry needle! Another issue relates to the importance of the context of the treatment. A RCT aim to isolate and standardized one 'key' fact...

Abstract A 2016 paper titled 'Acupuncture for the treatment of trigger finger in adults: a prospective case series' by Motohiro Inoue et al., reinforces what we treat in our Advanced Upper Quadrant Course in relation to managing digital stenosising tenosynovitis, or as it is commonly called 'trigger finger'. You can read the full abstract here: http://aim.bmj.com/content/early/2016/07/11/acupmed-2016-011068.abstract Background Trigger finger is a degenerative condition in which there is thickening of the restraining A1 pulley (A = annular ligamentous structure) and local inflammation (pain and swelling of synovial structures) resulting in catching of the long finger flexor tendon. This resul...

Whether  you are working within a government organisation or a private practice, a varying component of your referrals are going to be directed to you from colleagues and other medical practitioners. In the case of hospitals, there will be protocols in place about appropriate reporting content and frequency. But what about in private practice? How often do you write?What information do they want? What information do they not want?How do they want to be communicated with?How technical do they understand? Step 1.  Know Your Referrers In essence, I would suggest you do what we did. Firstly contact you main 5-10 referrers in person. For the most part this will require an appointme...

I recently had three clients present with recurring spinals symptoms, for which they had been receiving manipulative therapy for varying degrees of time. They were finding that their symptom control was becoming less and less with this form of intervention. I will often see a client with this presentation, but what was different with this group, was their young age and ease of symptom provocation. After a comprehensive examination, it was determined they had no underlying red flag pathology, not PMH or history of trauma, but they all had benign hypermobility syndrome. A hypermobile joint is one whose range of movement exceeds the norm for that individual, taking into consideration age, sex a...

So you're a manual therapist health professional. Congratulations, it is an incredibly rewarding career. There are 27543 physiotherapists and 4998 chiropractors (plus 9097 and 1894 students respectively) in Australia. The graph shows the relative number of registered physiotherapists in Australia across 5 year periods. Given the average practitioner takes about 5 years to develop reasonable competency in clinical practice, we can break down their working life into two major epochs of 20 years each, so 25-44 years and 45-65 years. What becomes startlingly obvious, is that only a small percentage of physiotherapists transition from the fir...

​A question that I am often asked about relates to what information do I follow online. Well to be truthful that varies a heap, depending upon what area of interest you are asking about. So I have cut out farming, my PhD, online education and scuba diving but the list seems still pretty long. Perhaps consider it a shopping list and look to pick and choose those bits that interest you at this point in time. Blogs Creating Clinical Success https://www.aapeducation.com.au/blog/categories/clinical-kit-newsletters.html An eclectic blog by yours truly with information pertaining to dry needling, rural physio practice, MSK, sports, business, marketing and sleep related clinical information. The Spo...

Telling someone at a dinner party you are studying a PhD, has a similar result to telling them you are an accountant (professional apologies, but true). However, when I say I watch people sleeping in their bedroom at night, the normal buzz of dinner conversation drops as others tune in. Creepy. Voyeurism. Interesting. Depends on people's perspective.  Given we sleep (or for some, attempt to sleep) approximately 1/3 of our lives, it is amazing that we don't know more about what individuals do in their own bedrooms ..... after shutting their eyes. Now, most people that are crazy enough to embark upon an 8 year plan of study, have a personal burning motivation. It seems that I am weir...

In discussions with new and recent graduates, this would have to be one of the most common questions that I am asked while on lunch breaks at courses. Options being discussed include; ContractorWage/salary employee basedCommission employee basedFacilities & Services Agreement First and foremost, This information although well intentioned is not legally definitive advice and is only provided in an educational manner. Once you have a feel for your situation, it would be then best to discuss with your employer and legal advisor if you feel your situation needs reviewing. Let us tackle the employee or contractor aspect first. Contractor or Not? The important issue(s) here is that the ATO bas...

And that's why birds do it, bees do it Even educated fleas do it..... In shallow shoals, English soles do it Goldfish in the privacy of bowls do it.... The chimpanzees in the zoo do it Some courageous kangaroos do it”                                                             Selected lyrics from “Lets Do It” by Cole Porter So exactly what are they all doing? Well the obvious answer is - breathing - Jokes aside, the importance of breathing crosses all domains in life (by definition no breath no life). As a developing swimmer of the 2.5 -3.0 km range, I marveled at the effect prolonged and regular breathing has on my own state of mental hyperdrive. After a day of clients, emails, creative writing and number crunching,...

Do you Understand What Your Client Truly Wants?   The psychology of selling   What the .......!! If you don’t like your job, then stop reading now. However if you enjoy it and want to be successful, I suggest you read on. I can hear some of you saying, “Hey Doug I didn’t sign up for your Clinical Kits to learn about selling. I am a health professional. I help people, I don’t sell them anything!” With entrenched mental pictures of used car salesperson (ranked 30th) or politicians (ranked 25th least trust worthy in an annual poll of 30 professions) this is totally understandable. Given the top three positions in this same poll are medical or allied health, it is also...

This eZine focus on assisting clients presenting with complex neck complaints, by using a system of integrated solutions recommended by our guest presenter Dr.Shaun O'Leary. Here are Shaun's 9 Handy Hints when Managing Chronic Mechanical Neck Pain. When your patient complains of a 'heavy head', it is important to remember that without muscles, the cervical spine can buckle, under a mass of less than 1/5 the weight of their head. Bearing this in mind it is important to understand the anatomy of the cervical spine. During our training we are introduced to a wide variety of muscles and yet with the cervical spine, it seems there is always another muscle someone can mention which you haven’t heard of. A challenge here...

This edition of Clinical Kit focuses on the less common but generally more troublesome 'high' ankle sprain - that involving the syndesmosis. New research looks at the correlation between MRI and palpation and finds that with a good knowledge of anatomy, your palpation skills are extremely diagnostic. Something that I am always banging the drum about. Oh - if you were wondering, you are welcome to attend one of our Living Anatomy Wet Labs to assist you in upskilling :) To start with some background information on how to conduct a comprehensive assessment. Good review article on ankle on assessment techniques and their relevance can be found here; Assessment of the Injured Ankle in the Athlete Then by way of an...

It is clearly the current position of the APA executive to make money from professional development regardless if this disenfranchises members. The new stated goal... "In my role, I am responsible to the CEO to provide a revenue stream of $3.9M in 2015 from professional development. Servicing around 93,000 hours cpd, we offer some 800 events nationally. The expectations of the CEO for the professional development division is that we will grow revenue to $5M over the coming years"James Fitzpatrick GM of Professional Development I remember the days when the APA was in the red and on the brink of complete financial collapse in the 1990s. At this stage state branches were being closed to sa...

Imagine at the upcoming Federal election, either the Liberal or Labor governments had; Control of 95% of the media (but denied any unfair dealings when preventing other parties from advertising)Control of the Australian Electoral Commission and set seat boundaries to their advantage The ability that after winning government (fancy that), to determine their own salaries and entitlement packages Worried if this happened in Australia? Sound a bit like the Zimbabwe regime? Well maybe, but actually this situation is also how our APA is fashioning itself. The APA denies any unfair dealing with members in relation to advertising. Yet their policy is "If your course competes with ours, no advertisin...

You maybe aware of the simmering debate about dry needling and acupuncture. One point of view is provided here; Dry needling versus acupuncture another here; Dry needling is acupuncture When it comes to the broad family of needling techniques the obvious common element is the use of a thin, solid, metallic needle inserted into tissue to create a desired effect. There are a few needle types but a plethora of needling techniques. Translated acupuncture means needling, needle prick or needle insertion. Dry needling is a name used to describe the insertion of a needle without injection of other substance cf. wet needling. Dry needling has occurred for thousands of years in Asia and China. Appare...

Is the APA an Association of Members or a Business to make Money? The APA needs to determine if it primarily is a membership organization providing services to members or a business, making a profit. A membership organization needs to be financially responsible, but the focus in on member services. Current APA actions indicate a process of cross subsidies within aspects of the APA, which is resulting in confusion to members who are being excluded from the APA by these cross subsidy actions. As a financial member, the InMotion publication would seem to fall under the member service banner (there is no additional fee as is with InTouch or Sports publications). In it relevant health news is dis...

APA Membership & Support Thank you so much for the countless emails, lamenting the decision the APA has taken. Members are definitely NOT happy based upon the volume of emails and blog hits/comments that we have been receiving since November. We have advised members to renew their membership for 2016. Some have chosen not to and let me know; "I will not be renewing my membership due to the proposed changes to restrict non APA courses being advertised via APA and also their restriction on using APA premises. I think it anti competitive, a backwards step and have been disappointed with the APAs response to members on this matter. I will be taking out independent insurance. I will renew mem...

Christmas Wishes It is coincidental that the 100th Edition of Clinical Kit falls at the end of this year. I have been writing these fortnightly emails for over a couple of years and have enjoyed immensely the feedback and support from AAP Education members over that time. Membership has grown to 3000 and we are continuing to offer an increased range of professional development training to clinicians around Australia (and occasionally internationally). 2016 is going to be even better, with not one but 2 international presenters touring Australia, plus more and a greater variety of local presenters. APA Member: To be or not to be? The end of this year has certainly seen a flurry of professiona...

Driving home with my son from basketball at 10.30pm last night, we caught part of ABCs LNL with Phillip Adams. He was talking with Gloria Steinen about her new book "My Life on the Road". You can hear the full interview http:/www.abc.net.au/radionational/programs/latenightlive/gloria-steinem/6998434">here Gloria highlighted an important realisation she had when it came to negotiation and mediation. To paraphrase; when discussing an issue with parties in different positions of power, it was important that if you had more power, you listened and talked less i.e. consult more, dictate less. If you were in the situation of less power, you needed to talk more and listen less i.e. speak your viewp...

APA Putting $$s Before Members' Choice Senior APA members (including myself) are concerned that the issue of our APA enacting restrictive behaviour on members access to professional development is alarming and largely unrecognized. Whether by intent or timing, this significant issue has slipped under the radar for many APA members being pre-Christmas. However, those members we have spoken to are largely gobsmacked and appalled at this behaviour. I was informed, that as a result of the APA member survey (which I also completed as a member), PD was voted hands down as one of the more important issues for members. The online webinars have been a positive new service for members. However, member...

AAP Education has been informed by the Australian Physiotherapy Association (APA), that because we provide courses that compete with courses conducted by the APA, we will no longer be able to advertise our courses in APA publications, nor will AAP Education be able to rent APA facilities, starting January 2016. This apparently will be the same for all non-APA providers. The APA is a member-based organization. We have spent many years working on different APA committees in a voluntary capacity, presented numerous talks and weekend courses, helping the APA in a small way to grow as a professional association. To us, the APA’s key role is to foster the development of its members and this decision is a very backward step in...

As part of the 2015 Vestibular Program we offered a $1000.00 scholarship to rural and remote physiotherapists wanting to attend the Melbourne Basic 5 day course. One of the successful recipients was Jono Prowse from NT. Here is a pic of the happy camper with his man sized cheque and his account of Day 1. My learning experience started day 1. Brief introductions and we hit the ground running, delving straight into the anatomy and physiology of the vestibular organs. My experience in the area was limited to observing and assisting colleagues with the Epley, or as I now know it the Canalith repositioning maneuver, and listening to inservices which never seemed long enough to get around what is clearly a...

Vestibular Rehabilitation - Part 1 I recently had the opportunity to attend a 5 day "Basic" course in vestibular rehabilitation that AAP Education was hosting in Melbourne and I must admit that I thought the commitment of 5 days was a bit over the top for the needs of a small rural and remote practice. Most of you will know that I am a MSK physiotherapist with divergent interests in feet and dry needling and that my area of PhD research is exploring the association of spinal pain and sleep postures, so where would vestibular rehabilitation fit in? Having attended, let me explain why I now believe this topic to be important. But first let me introduce the Vestibular Faculty. From...

'I hand it to you', 'He has the whole world in his hands', 'Give him a hand' .... the metaphors relating to the importance of our hands are extensive and in common use. Practically without good hand/thumb control, the elbow and shoulder are of limited use. When I was studying physiotherapy, the Australian Physiotherapy Association's logo was an icon of a stylised hand and person within (the hand being much larger than the person) and we all know about the relative sensory representation of the hand on the homunculus. Yet when studying undergraduate and postgraduate physiotherapy, bar the 10 carpal tests, we glossed from the elbow, basically right past the hand. In clinical practice (in a rural situation) we see quite...

Acupuncture Safety and Pregnancy For those of you that are dry needling or practicing acupuncture, one of the delicate clinical areas is the interplay of needling during the first 3 months when the rate of spontaneous abortion is highest (20%). Along with good clinical practice (good communication and gaining client consent before needling) research is indicating that there is probably no link between needling and spontaneous abortion, in fact possibly the opposite. This has previously been discussed in a Clinical Kit newsletter. Another area relates to the needling of traditional chinese medicine points that have been graphically termed 'forbidden points'. Just published is an open source document in Acupuncture in Medicine http://aim.bmj.com/content/33/5/413?etoc titled The safety of obstetric acupuncture: forbidden points revisited....

As a musculoskeletal therapist working in private practice, I first became aware of the positive influence we could have on clients with vestibular conditions, when preparing for my Specialisation exams in 2009. This area of clinical practice was something not covered in my undergrad nor postgraduate degree in Manipulative Physiotherapy, yet had become an area of ‘expected understanding’ within the domain of a modern musculoskeletal physiotherapist. I suspect mostly as a result of the common symptom of ‘dizziness’ and the potential of overlapping causes. So with a ton of background reading and some clinical observation (thanks Alec!) I became aware of the magical reversal of the debilitating symptoms generated by dysfunction in the peripheral vestibular apparatus. Once you have helped someone...

Todays Clinical Kit is a guest piece written by physiotherapist Diane Rowan on her experience with Fascial Manipulation. Physiotherapy is ever changing. I believe this is the direct result of the many physiotherapists and researchers who are constantly striving to improve outcomes for the individuals who trust us on a daily basis to improve their function. As with most things in life, however the deeper you explore something the more you realize there is more to explore. This continual exploration is driving physiotherapy into perhaps one of the most exciting times in its history. Physiotherapists are recognizing, researching and unlocking previously disregarded or mystifying areas of the human body which are having profound impacts on the end user – our patients....

Call it the farmer in me, but when faced by a challenge I am looking for the simple and sensible solution. There is usually more than one option, but I am guided by simple and sensible. Daisy is lead in my focus group on the farm, and will pretty well let me know when I am heading in the wrong direction.     How do cows talk? - Through their action and by my observation. Ovulating - ride other cows, in pain - hang to the back, hungry - moo when I come in eyesight, curious - lift their heads and sniff, danger - facing the direction head on. Being herd animals, I am always looking for the cow that is...

With Inactivity passing Smoking as the leading cause of mortality in Australia,  we can expect different levels of government to become involved in 'educating the nation' on this vital long term factor. But what about at the grass root level, our community? As I was driving around sewing our hay paddock a couple of months ago, along with my bones this thought was bouncing around in the tractor. What would be a fun, challenging and spectator based activity that would promote the benefits and fun of sport? I have seen Tough Mudder, Cross Fit and a few others of similar ilk. There are some great themes; teams, challenges, problem solving, participation emphasis but it needed to be simpler and more condensed...

HOME | DRY NEEDLING PROGRAM | CERVICAL SPINE | FASCIAL MANIPULATION | MULLIGANS | MSK & RT ULTRASOUND | NEURODYNAMIC SOLUTIONS | THE SHOULDER | VESTIBULAR PROGRAM | LIVING ANATOMY WET LAB WORKSHOP | . Here is the second part in the series looking at status of employment as individual or independent contractor. If you would like to follow up on the first one you can read it here. Specific Q & As Q: Is the difference in employment status based on a legal or accounting principles? A: There are many accountants who offer compliance solutions without understanding this is a legal issue. The Tax Legislation over arches the PSI legislation and the interpretation of its compliance regime has been tested...

'MoMENts In Time' - Men's Health Week June 15-21 2015 Looking at men’s health across age groups there are several challenges, important to identify, that we can choose to become involved in.     Younger Males Suicide accounts for slightly more than one-quarter of all male deaths in the 20-24 year old age group. Action: As participants in society, we all need to remain alert to the challenges facing our younger males and help them develop the necessary skills to manage a changing and complex environment.   Research shows that fathers as role models have a particularly strong influence on encouraging healthy eating patterns in children. This is the same for exercising, reading, communication and manners. Action: Develop and encourage positive...

You may have noticed or read that the ATO is currently in the process of writing to a number of taxpayers who are providing personal services, to clarify if provided as a business or individual. A bit confused about the difference then read on.. Employee or Independent Contractor - What's Your Status? In talking with lots of physios over the past 18/12, there is some degree of confusion in regards to the status of individuals either as employees or contractors. As a result of this  I have asked Workforce Advisors Group to help provide some clarity in this area. Due to the volume of the information I have divided this into 2 parts. The first part will provide background information and...

If you live in rural Australia and practice acupuncture or dry needling it won’t be long before you have someone present with ‘unusual’ symptoms asking for a magical cure. It probably happens in metropolitan environs also, but talking with colleagues it seems more common in a rural situation. Presentation In this situation it was a lady in her mid 50s and her left eye was completely closed. She proceeded to explain that in addition to her eye closing, she had developed increasing frequency and severity of headaches on the L side - frontal and temporal. This had occurred over a period of a couple of months. It culminated in a GP visit while traveling in N.S.W. and was admitted to hospital....

As you may know I have been interested in heart rate variability (HRV) for several years and first presented some concepts in relation to using acupuncture to positively influence the autonomic nervous system at the 2013 APA Conference in Melbourne. At that stage to purchase a monitor enabling HRV measurement, meant spending $10,000+; outside the range of most physiotherapy practices! Fast-forward a few years and with an appropriate Bluetooth transmitter plus smartphone app, you are setup for under $100. So what is HRV? Fluctuations in time between heartbeats, specifically the 'R' part of the QRS complex, is called heart rate variability or (HRV). Previous monitors averaged your heart rate - so it would say 60 beats per minute (bpm) and then...

  Perception, Perspective, Passion and Paradise - How do they relate? This thought started after assessing a client who had just moved to Esperance, three months post an ACL reconstruction, toe walking, having had no rehab and with a grand total of 20 - 60 degrees ROM. Being in her early 20s, unemployed and in constant pain this wasn’t turning out how she had imagined. She was bitter with the surgeon and annoyed with the system. = Perception. After examination and scoring her Hospital Anxiety and Depression (both > 11), Orebro MSK Questionnaire (> unlikely to return to work) and explaining where at 12 weeks the average person is functionally at (lots of tears), I summarized she was young, graft intact...

  Infraspinatus is one of the more common muscles needled around the shoulder blade and a good one to start on because of the relative safety of solid bone as a depth stop. But wait you say, about 8% of the normal population have defective fossa floors (see 3D CTS picture). Clinically I would also add that a defect is probably more common in those over 60 years of age, due to osteoporosis and a general deconditioning in the upper limb with resultant bone loss in the scapular floor. Remember those undergraduate boxes of bones and how many had translucent scapular fossa floors? The concern in this situation is the potential of a pneumothorax or haemopneumothorax. Yes we have to be...

Hi First up, these next two Clinical Kits are an aggregation of ideas that have been brewing for several years and brought about from clinical observation and trying to make sense of the available research in regards to trigger points and myofascial pain syndrome. Many of you will appreciate there is plenty of discussion going on about the nature and relevance of trigger points. For this reason don't take these ideas as gospel. We can’t deny the existence of trigger points, but the how and why is very much under discussion. I happily confess to have mostly looked at this from a clinical standpoint, and then gone looking for information that might explain what I see - so there is a...

I am not sure about your situation, but in our practice and small rural community, we are occasionally faced with the situation of providing professional advice on the management of acute achilles injuries, including ruptures. I have previously blogged on managing tendonopathy, you can review these; Clinical-kit-30-9-2013-Achilles Tendinopathy Clinical-kit-5-11-2012-Achilles Tendonopathy Clinical Kit 26-2-2014 - Achilles Tendinopathy while this Clinical Kit will be focusing on acute achilles rupture. Achilles Rupture Background: To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In most studies the ankle is immobilized for six to...

Hi Here is the second article on 'Trigger Points' exploring a previously unmentioned idea that not all trigger points are the same. You can review article 1 here. Novel Classification of Trigger Points (hypothesis) Rather than considering all trigger points the same, I am exploring the idea that trigger points present similarly, but potentially with different underlying mechanisms. I have divided trigger point presentations into 2 groups; Non traumatic and Traumatic. Non Traumatic In my opinion this is the much bigger of the two groups and I have divided it into 3 subgroups. These trigger points occur without any notable force, incident or direct injury and as a result I wouldn’t expect stimulation of the bradykinine/histamine system. Clinically these situations don’t...

Hi Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial. Llamas-Ramos R, et al. J Orthop Sports Phys Ther. 2014 Nov;44(11):852-61. doi: 10.2519/jospt.2014.5229. Epub 2014 Sep 30. Weblink: http://www.ncbi.nlm.nih.gov/pubmed/25269764 Abstract Objectives: To compare the effects of trigger point (TrP) dry needling (DN) and TrP manual therapy (MT) on pain, function, pressure pain sensitivity, and cervical range of motion in subjects with chronic mechanical neck pain. Background: Recent evidence suggests that TrP DN could be effective in the treatment of neck pain. However, no studies have directly compared the outcomes of TrP DN and TrP MT in this population. Methods: Ninety-four patients (mean ±...

Hi Study identifies best way to treat neck pain Johns Hopkins Medicine, 24/1/2014 (based on the study – Cohen et al. Epidural Steroid Injections, Conservative Treatment, or Combination Treatment for Cervical Radicular Pain - A Multicenter, Randomized, Comparative-effectiveness Study. Anesthesiology (2014); 121:1045-55 Clinicians need to be able to see through the sensationalism of research! Commentary by Dr. Shaun O’Leary FACP APAM It’s always useful to read a bit more in depth when claims are made in the media regarding new “best ways” of managing health conditions . If one was to quickly scan the title and content of this article summary in MDLinx Orthopaedics, they could be mistaken that a new best approach has been developed for the management of neck...

Hi Too Fit To Fracture: Exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Based upon guidelines available HERE Defining Activity and Exercise Not sure about you, but I find I regularly explain to clients the important difference between activity and exercise. Physical activity refers to “… any bodily movement produced by skeletal muscles that results in energy expenditure,” whereas exercise is defined as “… physical activity that is planned, structured, repetitive and purposive in the sense that improvement or maintenance of one or more components of physical fitness is an objective”. When looking at improving physical fitness components, the focus maybe strength, aerobic capacity, balance, flexibility or several at once. Guideline Recommendations For individuals with osteoporosis: Strongly recommend that...