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...

Hi Grading & Recording Your Dry Needling Treatment Following many years of implementing dry needling into different practices, two questions repeatably arise. How do I quantify the amount of needling treatment and how do I succinctly record needling treatment in my notes? First lets look at quantifying your needling treatment in this Clinical Kit. The aim of an intervention is to use the minimum amount of input to achieve your treatment goals. Whether you are a superficial needler, a fascia needler or deep muscle needler, you are using dry needling techniques that evoke chemical reactions in your client’s body. Like reactions to bee stings or drinking alcohol, the result varies from person to person and we don’t unnecessarily want to provoke...

Hi In the Advanced Lower Quadrant Course we look in detail at the involvement of the abdominal musclesand their contribution to back and pelvic pain, plus the associated viscerosomatic reflex. This article demonstrates in young women, the potential contribution of abdominal muscle trigger points to dysmenorrhoea. Titled “Wet needling of myofascial trigger points in abdominal muscles for treatment of primary dysmenorrhoea”by authors Qiang-Min Huang, Lin Liu. Reference is “Huang Q-M, et al. Acupunct Med 2014;32:346–349. doi:10.1136/acupmed-2013-010509” The authors recruited 65 participants with primary dysmenorrhoea, average age of subjects was 22 ± 2.5 years and mean VAS pain scores 7.49 ± 1.16, over a 6 year period. Patients with other diseases and conditions of the reproductive and urinary systems, as well as...

Hi This all started when someone sent me a link to a YouTube animation in an email. You will need to click on pic and have a look to understand the following discussion and I would welcome your thoughts and comments on the related blog post. See details at the end on where to put your comments. mmmm. To get involved or not…. Do you respond when poked or rise above…. Will it improve the situation or muddy the waters……. There are good physios that are also trained acupuncturists, and my thought is that they would caution against a reaction. So rather this is a clarification of some points as they rolled off my keyboard. My thoughts are they (the cartoon...

Free Online Learning Hand Hygiene Australia is providing free online learning packages on hand hygiene for a range of professional groups. The packages cover all aspects of hand hygiene including the importance of practicing excellent hand hygiene and best practice. An online test and the ability to print a certificate of completion is included. On completion of the HHA Online Learning Package, the participant will be able to: Explain what hand hygiene is and why it is importantDescribe when they should perform hand hygieneList the 5 Moments for Hand HygieneList the common products which are available for hand hygieneDescribe how to perform hand hygieneExplain the consequences of failing to perform adequate hand hygieneExplain the importance of cleaning shared equipment The HHA...

Hi We have just completed 3 dry needling courses in Perth and 2 Living Anatomy Workshops at the University of Australia. I had just driven down with family after a couple of weeks outback holiday and was really looking forward to mixing it up with some great physios, chiros and osteopaths for the week. Not disappointed, this week of courses brought out a range of great new ideas. Introductory Course The first amazing thing about this course was participants age. Apart from 2, all participants had been out for 6 months or less. Dry needling as a skill in both private practice and hospital environments is becoming a 'must have' skill as evidenced from participants comments. Quite the change around from...

Hi What do you do about latent trigger points? By definition there are active and latent trigger points. They both exist in a taut band of tissue, are hypersensitive on palpation (pressure stress), display a local twitch on needling and palpation and have spontaneous electrical activity at rest (on EMG), but only active trigger points produce symptoms that the client is familiar with. In undergraduate days the active trigger point was a holy grail in regards to the requirement of ‘thou shalt reproduce the patient’s pain'. Like other holy grails, there didn’t seem to be many around, for me at least. So if a latent trigger point isn’t producing pain, is it of clinical significance? I am guessing that some would...

Hi Frozen shoulder/Idiopathic Adhesive Capsulitis (IAC) is one of the clinical areas that has long held a fascination for me, largely because of the paradox between pain and range of motion. Whenever it is mentioned I prick up my ears, hoping for a silver bullet to use to assist my clients. While no single Lone Ranger moments have occurred, I have picked up some interesting clinical pearls that I discuss below. This recent case report is a good starting point for discussion. Abstract Available Trigger Point Dry Needling as an Adjunct Treatment for a Patient With Adhesive Capsulitis of the Shoulder My Classical Presentation Female > male, presenting with increasing degrees of shoulder pain and stiffness over several months. Can’t recall...

Hi Titled “Electroacupuncture treatment of acute low back pain: unlikely to be a placebo response” and written by Dr. Kwan Leung Chia, from the School of Medicine at Flinders University in SA, you could be forgiven for passing over the abstract if you weren’t interested in or currently using electroacupuncture, however this case report leads to broader discussion. You can read the full case report here My Comment As others treating this age group and gender will agree, this type of history and presentation is not uncommon when the pain is in the buttock or lateral thigh. Often the onset is an unremarkable single legged, sudden overload situation; like a miss step, trip or hop. Pain is initially mild and builds...

Hi For this fortnights Clinical News I am providing links to several clinical resources for you to have a look at. The first three links relate to a series of blogs on different tumors presentations that I have encountered in the past few years. Less than 5% of primary care physicians routinely examine for red flags during their initial screen (Bishop PB, Wing PC. Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial. Spine J. 2006;6:282–288) and in 160 cases, 96% physical therapists examined 64% of 11 red flag questions, but routinely didn’t ask about weight loss (Leeraret, PJ et al. Documentation of Red Flags by Physical Therapists for Patients with Low Back...

I had a client present with Horner’s syndrome that made me think it appropriate to check all their cranial nerves. That made me realise I didn’t have a good recall of each cranial nerve function and appropriate test. So back to the books and I thought that I would share with you what I have learnt. Firstly yes, there are still 12 paired cranial nerves and here are some ways to clinically test. I was looking for quick tests that could be performed in the clinic, and I may well have missed a couple of easier ones. Please let the group know of your best/easiest test for each CN via the blog. Thanks. I Olfactory Sense of smell, but don’t use...

Hi In preparation for the upcoming range of vestibular workshops and courses, I have been looking around and collating information that I have found useful and perhaps you will also. I am sure this list amounts to only a feather on the chook's back in regards to what is out there, so I would really appreciate you adding additional resource links at the end of this blog post. Much appreciated. Upcoming courses that are available include; Vestibular Introductory WorkshopVestibular Basic 5 day CourseVestibular Advanced 3 day Course and while some of these might seem awhile away, people are already enrolling such is the popularity. Currently the first Introductory Workshop in December, is 50% full. Vestibular Resources Videos Anatomy Eye Movement and...

Hi Faulty Needles & Clinical Relevance You maybe aware of the current discussion about needle quality and based upon some of the high resolution needle tip pictures , wondered how far we have advanced forward from stone needles, in this area of technology. The discussion has picked up after publication of research in the current edition of Acupuncture in Medicine, titled “Examination of surface conditions and other physical properties of commonly used stainless steel acupuncture needles” by Xie YM, Xu S, Zhang CS, et al. (Acupunct Med Published Online First: doi:10.1136/acupmed- 2013-010472). You can see the abstract here and because it is open access you can see full paper here. In this paper, needles from 2 of the ‘most commercially available’...

Hi Past readers of my blog 'Creating Clinical Success' will know about my past incursions into the realm of achilles tendinopathy. If you missed out here are the blog links; clinical-kit-30-9-2013-achilles-tendinopathyclinical-kit-5-11-2012-achilles-tendonopathy Researchers MARC STEVENS and CHEE-WEE TAN have just published a paper in Journal of Orthopaedic & Sports Physical Therapy titled "Effectiveness of the Alfredson Protocol Compared With a Lower Repetition-Volume Protocol for Midportion Achilles Tendinopathy: A Randomized Controlled Trial". The research comparison taken in this paper looked at the standard protocol of 180 eccentric heel drops cf. a Do-As-Tolerated protocol for 6 weeks. The short time frame is a bit of a weakness, as 12 weeks is standard. They used the The Victorian Institute of Sport Assessment-Achilles (VISA-A) as the...

Hi Another Possible Mechanism of Action for Dry Needling Dr. Ben Wand blogged on the Body in Mind site recently about a research project, that his team has just published in British Journal Sports Medicine. Method They looked at 25 people with chronic low back pain who were enroled in a randomised cross-over experiment. They compared the effect of acupuncture (using 14 needles in commonly agreed TCM points for back pain) delivered when sensory discrimination was optimised (by asking participant to locate on a picture where their needles were placed) to acupuncture delivered when it is not optimised (asked participant to relax and ignore the needling), on movement-related back pain immediately after each intervention. Outcome They reported that the average pain...

Hi Possibly my first presentation of Quadratus Femoris apart from the other ones that I have missed …… Clinical Presentation 51 year old male commercial painter with 2/7 Hx of pain. Not sure about cause of onset but had been painting a residential home (ladders, squatting, awkward positions) , plus moving around furniture day prior. Went to bed okay, slight sore in AM that increased as day progressed. Pain developed slowly and was described as a strong ache in R lumbar, lateral buttock with radiation to lateral thigh and hadn’t gone in the past 2/7. No PNN sensations. Over 24 Hr supine was fine, sidelying either side increased pain, walking was fine, but sit to stand or sitting increased painHad tried...

Hi Webinar cf. Course With the increasing profusion of information online plus greater demands on personal time, consideration is made about whether to attend a course or in some way gain the information via an online format. I certainly seek out a lot of information for my research online, not much shopping for IR cameras, access to research articles or experts in Esperance. When it comes to clinical education there are many reasons why I prefer to attend a course in person. The main one is that I am seeking to learn and therefore integrate or change a current clinical behavior. It maybe that I have recognized a skill set I need to develop – say occupational health or neurological treatment...

Hi Happy New Year and Welcome to 2014 Interesting Lower Quadrant Research Article Li J, Zhang J-H, Yi T, Tang W-J, Wang S-W, and Dong J-C. Acupuncture treatment of chronic low back pain reverses an abnormal brain default mode network in correlation with clinical pain relief. Acupuncture in Medicine 2013. URL: http://aim.bmj.com/content/early/2013/12/02/acupmed-2013-010423.abstract Abstract Summary Background Acupuncture is gaining in popularity as a treatment for chronic low back pain (cLBP); however, its therapeutic mechanisms remain controversial, partly because of a similar improvement in sham acupuncture control groups (but both sham and verum improve significantly more than 'usual care'). Resting-state functional MRI (rsfMRI) has demonstrated aberrant default mode network (DMN) connectivity in patients with chronic pain, and also shown that acupuncture increases DMN...

Hi I recently received this email from Tenielle Henson (with thanks), which coincided with a systematic review of the related literature, that I thought would be relevant, and of interest to a wider audience. “ I enjoy getting your news & research updates and having a read through. But I wonder if you have any info on the use of dry needling in pregnant women. As far as I was aware, all was okay as long as the patient had blood pressure managed & wasn't anywhere near the foetus & in general was asymptomatic for any vascular or neural related illness. However, I have a friend who is in the very early stages of pregnancy & who has an Achilles issue...

Hi Miracle Muscles and Neuropraxia When a client presents with noticeable weakness or other ‘hard’ neurological findings; abnormal sensation (temperature, light touch, pinprick), not just altered sensation or absent reflex, often I find clinicians jump to implicate a central nerve root involvement (dermatonal) without considering peripheral nerve compression or a somatic source. I think this just reflects the strong emphasis of our undergraduate training. This case report looks at the cubital tunnel and flexor carpi ulnaris as a source of peripheral nerve compression. No mention in this report is made of the anatomical variation anconeus epitrochularis, that would cause the same situation and as no MRI was conducted we are none the wiser as to which muscle was actually involved. You...

Hi, Over the past few months I have been in communication with the WA Health Department in an attempt to clear up the situation of what regulations dry needlers and acupuncturists need to be aware of in WA. While physiotherapists and chiropractors are registered under Australian Health Practitioners Regulation Authority (AHPRA), in WA there is also a separate "Skin Penetration Code of Practice” (the Code) written in 1998 and based upon a NH&MRC 1986 document. The base NH&MRC document has since been updated several times, most recently in 2011. The Skin Penetration Code of Practice specifies who the code covers and specifically who it excludes. It reads; "APPLICATION OF THIS CODE, This Code applies to:a) All persons who perform skin penetration...

Hi All Has Not Been Quiet On The Western Shore! Apologies, no Clinical Kit as spare time in the past few weeks have been tied up with preparation for presentations at the APA conference. Kinda newbie at this stuff, and it seems to take a fair chunk of time pulling together all required information. If you are also going to be there in October, would love to catch up. Masqueraders The hidden aspects of tumors presenting as musculoskeletal presentations has been one of my most popular blogs series (30,000 total + hits) series. I was fortunate enough to be studying Manips in Perth, 1992 at Curtin, when Mr Gregory Grieve visited. He presented a talk of the same name and raised...

Hi Background Last month the American Medical Association sparked headlines when it voted to officially classifyobesity as a disease. The question of whether obesity is a disease or not to me is pointless, there is no universally agreed definition of what constitutes a disease and solutions are way more positive. However, it importantly turns up the public discourse around the subject, especially as obesity recently overtook smoking as the leading cause of preventable death in the world. Obesity is a growing problem (excuse the pun), with an estimated 10,000 deaths per annum in Australia attributed to excess weight. “Obesity and overweight are widely prevalent in the Australian population, and this prevalence is quickly increasing.1 In 2004-05, more than half of Australian...

Strong research evidence shows that physical inactivity increases the risk of many adverse health conditions, including major non-communicable diseases such as coronary heart disease, type 2 diabetes, breast and colon cancers, and shortens life expectancy. You may have heard this music as it is often repeated and has become somewhat like elevator music, heard but not understood. So how about we crank up the bass a bit; “more people die from inactivity in the world compared to those dying from cigarette smoking”. What! Sitting on the couch is more deadly than sucking a cig? Yup. A series of papers published in the medical journal The Lancet, details the deadly impact on health of being inactive. In fact, the papers suggest that...

Hi Visitor This is the first of two eZines, that 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 is the first part of Shaun's, 10 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...

Hi We have just completed an Advanced Upper Quadrant Course in Perth and an interesting piece of information surfaced, that I felt was worth sharing with the wider clinical group. It is in relation to compression of the ulna nerve in the cubital tunnel. One of the course attendees, Ray Jongs from Sydney, works exclusively in the upper limb trauma and rehab arena and pointed out that there is a muscle present as an anomaly in approximately 20% of the population, that can cause compression to the ulna nerve (in addition to the FCU). Its called anconeus epitrochlearis. I have attached a link to a good 20 page review paper that looks at a wide variety of such anomalies in the...

One challenging aspect of being a primary contact practitioner, is being aware of red flags; fractures, infections, inflammatory conditions and tumors, which may enter your clinical door unknowingly.

Following some recent questions about trigger point treatment and associated documentation, I have developed these themes for others interested in dry needling and acupuncture.

A difficulty expressed by newly qualified clinicians when conducting their examination, is knowing what to do next. What do I mean? Well, we are told that we live in the "Information Age", but I think that we have well and truly roared through it. Basically every test, procedure or disease - our body of knowledge, can be found on the internet. All the information is out there in a variety of forms. In the same way a client is the internet - they have all the information. We are now in the "Synthesis Age." As clinicians, we need to type in the correct search parameters (know the correct questions) and be doing this in a logical sequence, thereby adding or subtracting...