Whether you are looking to relieve tension, relax tight muscles or take some time for yourself, many people really enjoy receiving a massage. I am often asked by patients which is the best form of massage; Swedish, Sports, Therapeutic, Remedial, Deep Tissue etc. My answer is always “if it feels good, then it is good” – because you are the only one able to know what
helps you and your body the best.
Physiotherapists often use massage as a therapeutic tool when treating patients. I have often stressed to my students, staff, and colleagues that good hands are an essential part of being a good physiotherapist. Along with good hands, physios have broad experience and knowledge working with the body: encompassing anatomy, disease, injury, sports, biomechanics, scientific rigour, and healing. This allows us to not only give a massage that is good but to give a massage that is healing.
So, what is a healing massage?
First off we assess your aches and pains to ensure that your massage is conducted in a position that will not exacerbate your pain. We like to consult with you to make sure the pressure of the massage is “just right” to follow the soft tissue pathways to relieve tension. We are confident in gently mobilising any stiff joints that would benefit from increased range once the muscle tension has been reduced. At the end of the massage, if you are interested, we might offer some exercises to continue to promote healing.
Late last year, I welcomed Brendan Luo into our practice. One of the favourable factors in Brendan’s CV was that he worked for many years as a massage therapist at a chiropractic clinic. He is a qualified physiotherapist with good hands and a good heart. If you are seeking a healing massage, I would recommend to book in to see him.
The unbelievable gift of the healing professions is that it allows one to partake in the journey of healthcare. I am once again on a journey, but this time returning to Sydney from a very brief and intense visit to Wellington, New Zealand. I have, over the last few years, had a number of patients from Wellington come to Sydney and have been meaning to see if I can conduct workshop on spine deformity in Wellington to encourage a Wellington-based physio to embark on the rigorous, exhausting, challenging but oh so agonising and somehow rewarding journey to become a competent spine deformity physio. Thank you to physiotherapists Dr. Ben Darlow and Helen McKendrey of Capital Sports Medicine for hosting the workshop.
I also took the opportunity to review some very special patients whose care I am in involved with. When we commence these treatment processes we aim for certain outcomes whilst recognising that sometimes we cannot hold these curves and they continue to progress DESPITE good bracing, good therapy, good adherence and good intentions. The surgeons want evidence of efficacy and we read scientific papers looking to support different treatment interventions. My SOSORT sponsored Harvard course taught me to critically analyse the literature, to find the holes in the research, to find gaps in the scientific method and to look at the data with a scientific and critical eye.
The problem with the literature of today is that there are no names. The patients are grouped together and described as a sample size of 50 or 100 with a mean age of 12 or 14 with a mean Cobb angle curve of 30 degrees or 50 degrees but that’s not the complete story. My patients have names, they have hopes and fears and emotions of relief and despair. They have families who commit and expend and invest and yearn and endure along the journey. And then if the curve continues to progress, they question. They question the past, they question the present and they question the future. They don’t teach you this in physio school, they don’t teach you this in Schroth school. Dr. Rigo in Barcelona once said that the principles and mechanics of spine deformity treatment can be taught but only time allows one to learn. How much time, the time it takes to establish that, despite everything, curves progress and surgery is eventually inevitable and essential.
I get it, I get the fear, concern, worry, and doubt. From profoundly devastating personal experience I get it. Alas, I offer strength and support and confidence and belief that everything works out fine. These kids, on this journey, with their families, will be fine. Katharina Schroth had a name for the typical thoracic rib hump that accompanies most scoliotics through life. She called it a “Paket” and expected her patients to call it that too. Paket in German means “package”. These kids and their families carry their package and sometimes get help from physios and sometimes get help from surgeons. And eventually…. everything works out fine.
Let’s hope a Wellington-based physio takes their first step. It’s a long journey!
The final destiny of the aged spine is to eventually succumb to the relentless force of gravity. This final position will almost always involve some form of stooping over and this “picture” seems to worry some of my Baby-Boomer patients and terrify others. I try and reassure all of them but I must admit that I do have some concerns for some. Especially those patients who are beginning to or are already exhibiting a forward-stooped posture where the trunk inclines forward over the pelvis. This forward-stooped posture, when exceeding certain thresholds, is called anterior sagittal balance and is eventually associated with increased pain, reduced function and reduced quality of life.
I recall many years ago, after presenting a spine-deformity paper in Germany, having a robust discussion with a Japanese spine surgeon who questioned whether physiotherapy treatment could alter, reverse, prevent or delay these stooping over postures. I argued that in some cases we could and I am still working on the evidence. However, without a method of accurately and reliably measuring these stooped over posture the data will always be disputed.
I am grateful to finally be able to present the first paper towards my PhD researching sagittal balance. These spinal postures are typically measured by x-ray but as this exposes our patients to radiation and increased cost, this method is unsuitable for repeated measurement and monitoring. There are other non-radiographic methods. How do I know, I searched the worlds medical literature and wish to thank my colleagues on my research team.
The take-home message is that it is possible to measure stooped over posture. Come visit us in the clinic to see how our Formetric works or come visit us to see how we use a plumb-line and ruler. If you can measure it, then maybe you can start to manage it!
Thank you to Prof Michelle Sterling who presented her work on whiplash at our weekly Sydney University Arthritis and Musculoskeletal Research Group meeting yesterday. Michelle is the associate director of the RECOVER injury research centre and is a world expert on whiplash. She presented that the prevalence of chronic disability following whiplash is possibly worse than initially suspected with 50% of sufferers not recovering and 30% experiencing ongoing moderate to severe disability. She stated that the psychological impact of whiplash can be profound and that most discomfort, whichever the level, tends to plateau around 2-3 months after the accident.
She reported that radiological investigations have not been able to identify those patients who will develop chronic severe whiplash disorder but those patients tend to have greater initial pain and disability at onset. Whiplash disorder, she advised, also seems to be clinically different from typical chronic neck pain.
So... We don’t know who will become profoundly disabled due to whiplash and we are not even sure what the pain generating structures are or how to treat it. We do know, however, that too much treatment may even be detrimental and that it requires a specialised multifactorial approach. This approach needs to incorporate bio-psycho-social and bio-medical aspects, including exercise, which she advised is better conducted by trained physiotherapists; “Even better than general practitioners”.
Michelle also responded to a question I asked which has often troubled me about injuries in compensatory environments. She stated that there is no such thing as “cure by verdict” which means that even after lump sum payments are made by insurers and compensatory authorities, the profoundly affected patients do not recover. Shame..
Since commencing my PhD a few years back and completing my Harvard Clinical Research Course last year I have had the opportunity to assist a leading European rehabilitation journal as a guest peer reviewer. The decision to agree to review a paper is not taken lightly. We reviewers are not able to see the complete submitted paper prior to accepting the offer to review (which is unpaid). We do not know the scientific rigour of research, nor the writing skill of the authors prior to committing to the potentially large amount of time required to complete the review process. The aim of scientific publication is to further the knowledge base of the field and the reviewer is tasked with upskilling to the edge of existing knowledge and then critically reviewing whether the submitted paper is worthy of adding to the body of evidence.
Last week I accepted the offer to review a paper in the field of fibromyalgia, which we see commonly in the clinic. Fibromyalgia is a chronic (long term) disorder that is associated with wide-spread pain and tenderness in the muscles and bones. It often also affects mood, sleep, general well-being, and can be debilitating. I spent considerable time over the last few days reviewing the most current literature and was relieved to find that there is a growing body of evidence supporting the efficacy of EXERCISE for the management of fibromyalgia. Interestingly, there seems be evidence demonstrating that HANDS-ON therapy is NOT efficious (effective) in the management of fibromyalgia.
The following graphic from Courtis’s et al 2015 research demonstrates the current known research on the topic. The forest plot graphic shows the pooled effectiveness of different treatment therapies and the papers that contribute to the pooling. If the back diamond at the bottom of the graph crosses the 0 midline then the pooled effect demonstrates that the particular therapy being investigated currently lacks evidence of effectiveness.
The take home message is that although massage and hands-on physiotherapy treatment for fibromyalgia might feel better in the very short term, the best short term and long term strategy is exercise. What type of exercise you might ask? A type of exercise that falls under the term of Body Awareness Intervention (BAI). Common types of body awareness intervention exercises are yoga, pilates, tai-chi, chi gong or posture and movement classes (click here to learn more about our classes). Whilst it can sometimes be hard to get moving and do exercise when you are feeling tender or in pain I would advise to just start slowly and see how you go from there.
City2Surf time is always a busy time for physiotherapists. The walking, hobbling, limping wounded “runners” start dribbling into the clinic quite a few weeks before race day. Probably a week or two after the marketing levels increase. We see all sorts of lower limb injuries with many different diagnoses, but the underlying cause is almost always the same. One or a combination of : TOO MUCH, TOO SOON, TOO FAST, TOO LONG on someone who is TOO WEAK, TOO STIFF, TOO MALALIGNED with shoes that are TOO WRONG or TOO OLD and a running technique that is TOO IMPACTING.
So, the diagnosis and treatment of the injury is relatively straightforward for a trained and experienced physiotherapist; the establishment of the cause is much more complicated but with insight and questioning, should be achievable. The management would be made easier if the ‘athlete’ was agreeable to stop all training but that is not often the case. Physiotherapists are lucky in that most of us enjoy our jobs and part of this is helping our patients succeed in their goals such as running City2Surf, EVEN WITH A LEVEL OF DISCOMFORT.
We have a rule with our patients, if they are going to do damage, or if the potential damage outweighs the potential benefit of completing the goal then we stress the need to sit out the event, recover and return. If the discomfort is tolerable and not damaging and not going to be permanent then we will try and help them through the event. I suspect that almost every athlete lining up the weekend will have some ache or pain, before, during and certainly after the event.
It’s called ‘City2Surf’ not ‘City to Beach’! If you are running the City2Surf this weekend I encourage you to consider NOT STOPPING AT THE FINISH LINE! Keep going and stand in the water (between the flags) for 5-15 minutes. (The SMH advises that the water temp will be great). The cooling effect of the water will help reduce any inflammatory processes that arise from the race. (Hopefully there is no sea-lice!)
Your physiotherapist will hopefully prefer that you DO NOT need to come in for treatment. I know we do!
Good luck this weekend if you are running!
I do write, I really do write. The prolonged silence on my blog has more to do with the my not uploading my writing than a lack of words written. I tend to only write during flights, and over the last few years I have flown, and flown. Whenever I get back to Sydney, there is often so much to do that the upload phase seems to pass away. This flight will be to a whole new continent, Welcome to South America. I am off to Brazil to complete a journey that I started in August last year when SOSORT offered its members a chance to apply for a part scholarship to undertake a course in clinical research. I remember submitting my application during a particularly difficult time in my life and not telling anyone about it; partly not expecting to be successful. Thank you SOSORT for graciously accepting my application and thank you Harvard for giving me the opportunity to participate in an educational process that has forever changed the way I consider medicine, clinical practice, clinical research, academia, industry and this thing we call…. Healing.
PPCR is a real time and online lecture, discussion forum, assignment and exam based course designed for healthcare workers hoping to become versed and skilled in the Principles and Practice of Clinical Research (PPCR). The final project of my currently ongoing PhD was always going to be a clinical research project and I was hoping to concurrently use the course to help develop the protocol. I didn’t realise that the course was going to override everything else in my life, including much of my available PhD time. But, it has provided me with a framework to become a much better clinician, researcher and healer.
In all this time, I have still been seeing my curves, teenage kids, young kids, adults and aged. I have seen kids go for surgery and have seen kids go for bracing. I have seen and felt the despair of braces not holding curves and relief of braces that have taken control of the curve for the moment. I have made late night calls to radiologists to confirm that spinal images on the x-rays I am seeing are actually as severe as they appear and not some wild radiographic artefact from poor positioning or patient movement. I have referred patients for surgery and stressed with concerned parents when a proposed 6 hour operation becomes 10 hours due to dysplastic vertabrae. I have seen experimental rods implanted and have even had some correspondence with the spine surgeons that have been so distant and silent, in the past.
Well, its now 4.5 days later and the course is over. There were 200+ young (at least younger than me) mostly medical doctors and mostly specialists. We had a geriatrician, pulmonologist, neurologist, cardiologist, plastic surgeon as well as clinical pharmacists and industry and government regulatory agency specialists in my syndicate. Oh my goodness, the intelligence, the intensity, the robust and fun debate in a beautiful setting. I am often amazed at how lucky we are to live in Sydney, but truthfully, I don’t get much time to enjoy the environment. Our PPCR course was held in a resort in the Brazilian state of Bahia. It was really beautiful and I managed to fit in a daily swim in the pool and a longer open water swim in the bay. The bay is home to a protected turtle population, whose members, I could occasionally see from the beach, but never able to locate them in the very murky, but pleasantly warm water.
The PPCR course officially ends in mid November but luckily, most of us received our graduation certificates at the end of the 5 day immersion course. The final session was a conference type session where each team presented a clinical trial protocol that we had been working on for the last few months. Our team project was presented by Dr Marlon Aliberti, a Brazilian Gerontologist who much to the surprise of many of our highly specialised team members proposed a clinical trial to evaluate the efficacy of a herb called Boswelllia in the management of hand osteoarthritis in an elderly population. We argued to the wider PPCR group that there is some preliminary evidence that Boswelia is effective in reducing pain, inflammation and increasing quality of life and that a more robust trial should be considered for hand osteoarthritis.
Dr Stefano Negrini of ISICO in Milan, often comments that there has never been a trial comparing conservative management of scoliosis with surgery. I used to think that I understood what this meant but now I really understand. Unfortunately I don’t think there will ever be a trial like this. In order to do this trial we would need to randomly assign a matching group of scoliotic kids into conservative vs surgical treatment and then follow up for a very long time. 30,40,50,60 years. Dr Manuel Rigo from Barcelona often remarks that surgical treatment today might be associated with significant complications later on in life, and that we don’t know if these complications later on in life would be worse if the scoliosis was left untreated.
This is a painfully challenging question to have to face, consider and decide. For me too!
Discs, spinal discs, those spongy, hydrated shock absorbing structures between our bony vertebrae are destined across our lifetime, to fail. Their failure often leads to pain, back pain, and nerve pain, as well as possible sensory changes such as pins and needles and tingling. Their failure can also lead to weakness and this can progress to paralysis. However, sometimes, surprisingly, their failure which can be seen on MRI has absolutely no impact on the body. NO PAIN, NO WEAKNESS AND NO REDUCTION IN FUNCTION AND QUALITY OF LIFE. Go figure….
My 16 year son says I need to be able distill my PhD research into one simple sentence. Here goes: I am researching the sideways shape of the spine. I spend hours and hours on the topic. When I am awake, when I doze off to sleep, when I run and when I swim and when I joke with my kids. I think about mechanics and load and tension and angles. Often, these thoughts are discarded, occasionally these thoughts become hunches and rarely these hunches are crystallized to become diamonds.
A few days ago, some spine specialists in Brazil turned my hunch into a diamond when they published a study in one of the worlds leading spine journals. They established that certain shapes of the spine and pelvis, when viewed from the side, are associated with increased disc degeneration. This was in a population of healthy adults aged around 27 years old with NO back pain. Time will tell if the identified group with an unhealthy spine shape (and degenerating discs) will progress to symptomatic disc back pain.
Imagine if we could predict who will get disc back pain. Imagine if we could treat the underlying cause of disc related back pain. WE CAN….