AAP EDUCATION

Clinical Kit - 26/01/2014 - My First Quadratus Femoris

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...
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Clinical Kit 14/1/2014 How do you Learn?

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...
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Clinical Kit 5/1/2014 Treating cLBP

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...
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Clinical Kit 18-03-2014 Needling & Safety During Pregnancy

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...
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Clinical Kit - 15/4/2014- Miracle Muscles and Neuropraxia

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...
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Clinical Kit 28/12/2013 THR Caught between the Bedsheets

Hi Interesting Lower Quadrant Case 1 In the past 2 weeks saddling the Christmas period I have had a couple of interesting lower limb cases that highlight the usefulness of dry needling. I will outline the first now as between clients and send the other next week. He was a 70-year-old gentleman 2 months post L THR. Progress was good and he was very happy, nil pain and completing most of his pre-operation ADLs. Two weeks prior he was getting out of bed, right foot on ground and his left foot got caught in the sheets. He felt a severe left anterolateral hip pain and feared dislocation. On gentle passive movements he was largely fine but any active hip flexion, rolling...
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Clinical Kit 16/11/2013 - WA Health Department - Common Sense Prevails

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...
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Clinical Kit 2/11/2013 Acupuncture ANS & Sea Turtles

Hi ANS and Acupuncture Regardless of the types of clients you treat, the ANS will be there. Involved in the recovery from training and injury (sports & MSK), excessive daytime sleepiness (occupation health), anxiety (chronic conditions) and insomnia (20-30% population), you can see how important an understanding is. This webinar was recently presented to the October 2013 Australian Physiotherapy Association in Melbourne. As a one off special to Bronze Members this recording will only be available to you on this link for 2 weeks, then it will be added as a permanent resource for AAP Education Gold Members. Reviving Sea Turtles Jessica Seebauer sent in this photo from her friend's Australian Seabird Rescue Centre in Ballina, QLD explaining how they use...
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Clinical Kit 30-9-2013 Achilles Tendinopathy

Hi This is the second part of the Tendinopathy series. If you didn't receive the first part on the Lateral Epicondyle, you can find it in Member > Resources > eZine Archives after login. You can also view an earlier Clinical Kit on Achilles Tendinopathy and clinical interventions. Achilles Tendinopathy Toolkit This toolkit was developed by the British Columbia Tendinopathy Task Force comprised of; Dr. Alex Scott, Dr. Joseph Anthony, Diana Hughes, Michael Yates JR Justesen and Alison Ezzat. The Achilles Tendinopathy toolkit includes; A summary of the strength of evidence, key messages and recommendations for practice for an array of interventions used by physiotherapists (manual therapy, exercise, ultrasound, low level laser therapy, shock wave therapy, taping, orthotics, night splints and...
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Clinical Kit 16-9-2013 Lateral Elbow Tendinopathy

Hi September is Tendinopathy Month with Clinical Kits first looking at the up to date information and research on Lateral Elbow Tendinopathy. You can find a previous Clinical Kit about wet & dry needling of the lateral epicondyle and then later in the month we will look at Achilles Tendinopathy. Lateral Elbow Tendinopathy On our beef farm, tenderness along with flavor is the key challenge, in the clinic managing tendinous clients is usually a key challenge. A group of hard working researchers and clinicians called the BC Physiotherapy Tendinopathy Task Force, have assembled (both evidence-informed and expert-informed)and released their findings, translating research into clinical practice. I was fortunate to have worked with one of the authors for a year; Carol Kennedy,...
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Clinical Kit 30-8-2013 The Meaning of Exercise

Hi Exercise means different things to different people. Exercise & Health Benefits Every day it seems that we are hearing about another benefit from regular exercise; both physical and mental. Just as frequently, we hear how our populations are getting fatter, eating poorer quality foods, dying more from preventable disease and suffering every greater stress levels. Not sure about Australia, but between 50 million and 70 million Americans suffer from sleep disorders or sleep deprivation, according to the Institute of Medicine, and in 2008, market research from Thomson Reuters found that sleeping pill prescriptions had tripled among people younger than 45. Given exercise has been shown to enhance sleep, mood, a healthy weight, self esteem and physical longevity, it is important...
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All Has Not Been Quiet On The Western Shore!

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...
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Clinical Kit 29-7-2013 Obesity a Disease?

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...
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Clinical Kit 16-7-2013 Concussion

Hi Visitor Recently there has been a handful of genuine cases of early degenerative brain function in retired professional rugby union, league and AFL players. Overseas in the NFL there have also been legal cases on similar lines. While these cases focus on adults, my concern was with the younger cohort. It would seem logical later in life that any young concussed player will have some (small) risk of premature neurodegenerative diseases. Where is the balance point between allowing them to play, have fun, experience team involvement, physical challenges, push their personal limits and long-term safety? In the past few weeks while helping our son’s U16 football team, I have been involved in a fractured clavicle, possible ACL rupture, dislocated finger...
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Clinical Kit 28-6-2013 Safety & Needling

Hi Visitor In the past 15 years there have been a series of papers examining the issue of safety and needling. I have produced a Safety Series: Lumbar Spine & Abdomen webinar that is available to GOLD and higher members. Select Member > Resources > Resource Gateway > GOLD (or higher) > Webinar and I am finishing a Safety Series: Cervical & Thoracic Spine webinar. Starting with White A, Hayhoe S, Hart A, and Ernst E. Adverse events following acupuncture: prospective survey of 32000 consultations with doctors and physiotherapists. British Medicine Journal 323: 485–486, 2001. Seventy-eight acupuncturists, all doctors or physiotherapists, reported a total of 2178 events occurring in 31,822 consultations, an incidence of 684 per 10,000 consultations (approximately 7%). The...
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Tax Time Benefits & VideoXs

Hi Visitor June is always a good month to consider personal, capital and software investments before rolling into the next financial year. On recent courses in both Brisbane and Perth, attendees were interested in how our VideoXs app worked and how their clients would benefit. I have for this reason included a detailed description of VideoXs. In addition to the program being fully tax deductible, it would also mean your iPhone, iPad or iPod would be - but check as always with your accountant! Have you ever felt constrained by your drawing skills or the proforma program available in your clinic when prescribing a home exercises program? Have you had clients come back, demonstrating 'one of your exercises', but you had...
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Clinical Kit 24-5-2013 Outcome Measures

Hi Visitor The following is a thought journey authored by Dr. Phil Gabel, about the pros and cons of how to choose appropriate measurements to assist in arriving at qualified clinical decisions. It follows on from the Clinical Kit Needling and Chronic Low Back Pain. If you decide or believe a treatment is effective or not, then you need to consider how you have arrived at that decision. In other words, how are you measuring it; intuition? personal opinion? or the patient said so? (subjective interpretation). Perhaps you are using a VAS (Visual Analogue Scale) or NRS (Numerical Rating Scale). It has been shown that a global rating of change scale (a single dimension or construct measure e.g pain, stiffness, effort)...
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The Importance of Being Exercised!

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...
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Clinical Kit 14-5-2013 Dry Needling & Acupuncture Research - The Sham Challenge

Hi The Sham Challenge This Clinical Kit is looking at issues surrounding acupuncture and dry needling research from the perspective of sham interventions to create an effective control group. Medical researchers need to have a control group, as a basis for experimental comparison. Typically as participants are enrolled in a trial, they are randomly allocated to experimental and control groups. The control or placebo group, essentially mimics all metrics (gender, age, background) of the intervention group, thereby controlling for intervention bias or placebo effect. The control group either receives no treatment or sham treatment. In pharmaceutical trials, it is very easy to create a reliable control group intervention; have two pills, both same size, color and scour marks, with only one...
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Clinical Kit 30-4-2013 Needling and Chronic Low Back Pain

Hi In this Clinical Kit I am exploring the research related to the clinical utilisation of acupuncture & dry needling in low back pain, specifically chronic low back pain. The research papers are presented in order from older to newer and when possible I have provided links to each or an abstract for those wishing further details. This story starts with The Eur Spine J, 2006 15 (Suppl. 2): S192–S300 DOI 10.1007/s00586-006-1072-1 Chapter 4 European guidelines for the management of chronic nonspecific low back pain. The authors compiled a complete range of assessment & treatments guidelines for chronic low back pain. In their conclusions they couldn't recommend usage of acupuncture or trigger point injections as 'invasive' procedures, based upon the research...
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Clinical Kit 2-4-2013 Lateral Elbow Pain - Injection Wet & Dry + More

Lateral Epicondylitis or 'Tennis Elbow' In this eZine I am looking at some current issues relating to treatment options for lateral elbow pain. The first paper compares PRP, steroid and saline injections. Then I look at the more common options of steroid and or physiotherapy management and finally in the needling area a SR examining acupuncture solo for acute pain. Rounding out the discussion is a look at the evidence of a support, either brace or sleeve. Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline: A Randomized, Double-Blind, Placebo-Controlled Trial. Reference Link Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. BACKGROUND:Lateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy remains...
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Clinical Kit 5-3-2013 Managing Complex Necks Part 1

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...
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Clinical Kit 19-3-2013 Managing Complex Necks Part 2

Hi Visitor This is the second 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 A patient's emotional health may not only affect their neck pain experience, but may also affect their postural habits and subsequently, strain to their neck. Whilst we are not psychologists, coaching a patient to establish links with the various situations they find themselves in through the course of a day, may provide valuable information for self management. Our psychological and physical well-being is influenced by our cognitive processes. Having a healthy appreciation...
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Clinical Kit 26-2-2013 MSK US Case Study 3

Hi Visitor This is the final case study in this series of how MSK US can be used to assist in diagnosis and also in the rehabilitation phase. This case study was kindly provided by Mr Peter Esselbach course presenter of our MSK US course. Move your scroll icon over each picture for associated text. Case Study 3 Mark is a 48 yo who presented with 2 years of intermittent LBP, groin pain and lateral hip pain. He was initially diagnosed with a likely herniated lumbar disc causing his referral pattern of pain into his groin and thigh. Initial treatment was to take NSAIDʼs, pain medication and have physiotherapy for his lumbar disc complaint. This involved a series of visits for...
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Clinical Kit 7-2-2013 MSK US Case Study 1 & 2

Hi Visitor In this and the next eZine, we are exploring the clinical usefulness of musculoskeletal ultrasound or for those into acronyms, MSK US. These case studies have been kindly provided by Mr Peter Esselbach course presenter of our MSK US course. Move your scroll icon over each picture for associated text. Case Study 1 Sean is a 52 year old male who reported pain in his right upper arm after being pulled from the water abruptly while water skiing. He noticed bruising develop in his right cubital fossa and experienced pain with putting his right arm into internal rotation. He also had pain abducting his right arm above 90 degrees. His GP sent him for investigations and treatment, thinking he...
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Clinical Kit 18/1/2013 | Anconeus Epitrochlearis

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...
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Clinical Kit 10/1/2013 Red Flag Tumour 3

Here is the third in this series of Red Flags - Tumor articles. The previous ones can be accessed via links

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Clinical Kit 13/12/2012 Red Flag Tumour 2

The other case studies in this series can be access via; Red Flag Number 1 - PancoastRed Flag Number 3 - Sarcoma   Red Flag Tumor 2 23 February Physiotherapy S/E October prior year developed L lumbar pain. No recalled trauma or reason for onset. In January started getting tingling sensation in L) lateral, anterior and posterior thigh, calf and foot. Also present in R but not as bad. L) foot not able to lift off ground. Now February has constant pain 3-4/10, increase with turning or sudden movements - can take breath away. Has been seeing Chiro and OT for the past 2 months but has increased pain. Not pacing self or applying specific rest ratios. 36 yo female +...
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Clinical Kit 13/11/2012 - Red Flag Tumor 1

This is the first in a series of tumor case studies that I have been associated with while in clinical practice. This is not an area of my expertise, rather interest and I provide these case studies to alert other primary contact practitioners

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Red Flags - Cervical Fractures - NEXUS & CCR

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.

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Dry Needling Pre & Post Considerations

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

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Clinical Kit - 7 Mistakes to Avoid Part 1

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...
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Clinical Kit - 7 Mistakes to Avoid Part 2

In "Clinical Kit 12/7/2012 - 7 Mistakes to Avoid Part 1" (which can be found in the Bronze Member Resource section), I outlined our important clinical roles in the synthesis rather than collection of information and discussed in the context of client communication (client expectations & functional outcomes) the importance of red flags (I am putting together a longer article specifically on tumors which I aim to have available as a Clinical Kit article).This week I am looking at Clinical Followup, Yellow Flags, Memory Retention and Over Testing. Clinical Followup I have had the benefit of working in practices both in Australia and overseas. Many of these practices were 'cutting edge" and often leading the way clinically in their provision of...
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Clinical Kit - Acute to Chronic Pain

Subacute & Chronic pain in my mind is better described as complex pain. This is a simple acknowledgement that anyone with any pain past 6 weeks (subacute) and definitely 12 weeks (chronic) will have influences other than simple physiological pain. That means auntie with her OA knees, the electrician and his recurrent tennis elbow and the local football superstar and his popping out shoulder pain. All will have perceptions, beliefs & expectations, that to varying extents, will influence the outcome of our treatment. Perhaps "management" is a more holistic term.I just reviewed a young lady (32) referred to me having injured her lumbar spine 8 weeks prior while bending forward to look under her desk at work. She was a fly...
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