CA News September 2019

news NEWSLETTER OF CHIROPRACTIC AUSTRALIA

SEPTEMBER 2019

VOLUME 2 NUMBER 3

National Conference Review Journal Club SpineWeek 2020 Chiropractic History

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FROM THE PRESIDENT

Professor Rod Bonello

BSC(SYD), DO, DC(SCC), MHA(UNSW), FRCC Continuing education This year’s annual conference focused on helping practitioners grow an evidence-based practice which is successful both in terms of providing patient-centred care and improved clinical outcomes, as well as ensuring that their clinics are profitable. Local and international speakers taught the framework for creating a successful evidence-based practice.

In addition to the conference we have been working for the last eighteen months on creating our new online education platform which has been developed in partnership with the European Chiropractors’ Union and the Royal College of Chiropractors in the UK. Under the guidance of Dr Peter Werth this platform, called the Global Education Network for Chiropractic (GEN-C), will bring together experts from around the globe, providing access to high quality online educational content to meet educational needs. This initiative is to be paired with an upgrade of the Chiropractic Australia Journal Club which has been the brainchild of Dr Adrian Sheridan. Dr Sheridan has worked tirelessly to pull together a vast resource of literature relating to the practice of chiropractic. He has condensed this into a monthly digest that provides an excellent source of the latest evidence to assist practicing clinicians. Later in the year we will be launching an updated resource in the form of a new Chiropractic Australia Journal Club website that will be accessible as a free member benefit to Chiropractic Australia members. I wish to publicly acknowledge Dr Sheridan and his team - Drs Andrew Shepherd, Matt Bulman and Amber Beynon.

These new initiatives will be launched to coincide with the new CPD cycle in December and will offer you a highly valuable portal to access all your CPD needs. In addition to this we will continue to provide our internationally applauded podcast the icarechirocast hosted by Professors Dave Newell (UK) and Stephen Perle (USA). This too is an excellent resource for clinicians to keep abreast of the latest developments in the profession through interviews with some of the leaders in musculoskeletal health care from around the world.

International symposium participation In mid September this year CA will participate in the Global Summit on the Effectiveness of Spinal Manipulation for the prevention and management of nonMusculoskeletal Disorders. This landmark event seeks to provide genuine guidance on the value of chiropractic intervention in this contentious area. Organised by Professors Jan Hartvigsen, Charlotte LeBoeuf-Yde and Pierre Cote, this meeting brings together formidable resources and the profession’s best minds to tackle this task.

Paediatric scope of practice Chiropractic Australia has made strong input to the review panel at Safer Care Victoria (SVC) with a submission which is publicly available. In that submission we defend parents’ choice in having their children seen by a chiropractor, emphasising (among other things) high levels of patient/parent satisfaction, an exceptionally low level of potential harm, as well as the emerging data on clinical efficacy. Safer Care Victoria will

hand down its recommendations in September which will be transmitted to the health ministers at their COAG meeting in October. Public support for paediatric chiropractic care has been overwhelming with SCV having received many thousands of survey responses which have been decisive in demanding continued access to chiropractic for children.

Research matters Our sister organisation, the Chiropractic Australia Research Foundation (CARF) continues to grow in its support of early career researchers and its funding of projects of importance to the profession. One of our goals in supporting research is to provide quality evidence to refine chiropractic practice and validate the fine work that our members provide each day in practice.

The future Over the last four years we have made great progress and continued to achieve our goals in advocating for chiropractors as musculoskeletal experts. As a reform organisation we stand for raising the profile of the profession as a vital component of the health care team. We will continue to focus on ethical, patient-centred and evidence-based care. However, we depend on our membership to ensure our ongoing impact so your continued support through membership is crucial. Encouraging your colleagues, associates and professional partners to also join will take us to the next level.

Rod Bonello BSc(Syd), DO, DC(SCC), MHA(UNSW), FRCC President

CHIROPRACTIC AUSTRALIA OFFICE Suite 2, 1 Rooks Rd, Nunawading Vic 3131 Ph: 1300 767 348 Fax: 1300 886 690

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Classifieds: Min charge: Members $40.00 - Non Members $78.00 Contact: Steve Kynoch Ph: 1300 767 348 or Email: info@chiropracticaustralia.org.au CA News is the newsletter of Chiropractic Australia and is published quarterly. CA News is fully protected by copyright and no part of this publication may be reproduced or transmitted in any form without the written permission of Chiropractic Australia , except as permitted under the Copyright Act. Advertising material is subject to review before acceptance. Chiropractic Australia reserves the right to accept or reject advertising at its discretion and without explanation. Advertising material contained within CA News in not necessarily endorsed by Chiropractic Australia. Readers should exercise their own judgement about whether the advertised service or product is likely to be of benefits prior to purchase. All requests for information regarding CA News should be made via Steve Kynoch. Chiropractic Australia, nor any of its servants or agents, will have any liability in any way arising from advice or information that is contained in CA News. The statements and opinions that are expressed in CA News reflect the views of the authors and do not necessarily represent the policy of CA unless otherwise stated, All rights reserved.

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Using Evidence as a Framework for Success. Chiropractic Australia National Conference 2019 By: Amber Beynon B.Sc. (Hons), B.Chiro

This year’s conference was held on Queensland’s Gold Coast, which proved to be a popular location to listen to some incredible presentations.

After CA President Rod Bonello formally opened the conference and welcomed delegates, Professor Simon French took the podium for the FG Roberts Address in which he posed the question; “Is opportunity knocking, or is the door closing for chiropractic?”

Reflecting on the growing recognition of the economic impact of spinal pain and that most guidelines routinely include SMT in their recommendations, Professor French noted that while on one hand this presents a “free kick at goal”, on the other there are recurrent negative media stories about chiropractic which are creating significant barriers and hurdles that appear to be closing doors. Professor French explored the journeys of the chiropractic professions in Canada and Denmark where they have achieved higher patient utilization rates through involvement in research to CA President Rod Bonello officially opens Conference 2019

bring credibility to the profession and break down interdisciplinary barriers. He mused on the need for more resources to support scholarships for PhDs and research projects, and to support career pathways for those who have gained their PhD. “Research is to improve practice. Not to prove practice.” was a noteworthy comment in his talk because in this regard there is a long journey ahead of us.

Next up was the first of our international guests, Professor Dave Newell, from the UK. His first presentation “The Psycho in the room: Is chiropractic care more psychosocial than bio?” was prefaced by him eating a lemon! Why? Well you just had to be there... He unwrapped the finding that differing technique systems in chiropractic (and also psychology) tend to produce similar results and this is due to psychosocial influences such as placebo and contextually aided factors.

Professor Newell was followed by another of our international

Professor Simon French delivers the FG Roberts address

speakers, Professor Stephen Perle who, having been a guest presenter on several occasions in the past, is no stranger to Australian shores. Professor Perle’s topic, “Technology tools

“

Professor French mused on the need for more resources to support scholarships for PhDs and research projects, and to support career pathways for those who have gained their PhD.

to make using evidence in a busy practice”, introduced us to a range of “Apps” designed to scaffold deep learning i.e., take what you know, compare retained information, be critical, and come up with new answers. Easy!

With a Master of Applied Science in Medical Imaging Dr Hazel Jenkins from Macquarie University was well qualified to present “X-ray imaging: When and when not to use it. What does the evidence say?” In presenting the evidence for taking X-rays Hazel mentioned ionizing radiation, however, most of her discussion focused on the many clinical guidelines, AHPRA legislation regarding evidence-based practice, clinical utility, poor screening

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utility, iatrogenic consequences, overdiagnosis, costs to the healthcare system, and many other areas of evidence or areas where evidence is lacking. A world class presentation. (Hazel later announced that she had just been awarded her PhD!) Immediately prior to the break for lunch Mr Christopher Daniel, the Program Lead of the Choosing Wisely Australia program, gave his presentation “Choosing Wisely and Chiropractic Australia”.

Choosing Wisely is “A national initiative which enables clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit, or in some cases, lead to harm”. Chiropractic Australia is now a member of Choosing Wisely and is asking its members to reflect on avoiding low value clinical activities in their day-to-day practice.

Immediately following lunch Associate Professor Peter Tuchin discussed “How to create and run a successful evidence-based practice” by detailing the four components for practice success; patient management, practice management, business management, and financial management.

Our third international guest, Dr Bobby Maybee from Portland, Oregon gave a very insightful presentation on embracing the future through “Gamification of Rehabilitation”. Gamification is the application of games into rehabilitation activities which are generally viewed by patients as having little to do with games or fun. The intent of gamification is to motivate patient behaviours by making the rehabilitation process more enjoyable. However, it is not only about making rehab fun but also improving patient outcomes and Dr Maybee urged the audience to adopt a creative, goal orientated, game approach to rehabilitation.

Returning to the stage for his second presentation of the day Professor Stephen Perle addressed the topic “Management of spinal conditions. Is it time for primary spine care practitioners?” in which he emphasised that while chiropractors have the necessary skill set along with a wide range of understanding of spinal care, we need to find ways to improve our public health perspective.

The final session of the day was the exploration of “Chiropractic’s role as a member of a team managing MSK conditions” by a knowledgeable panel comprising Stephen Perle, Dave Newell, Bobby Maybee, Dawn Dane and Peter Tuchin.

Formal conference proceedings on Sunday morning were preceded by the inaugural Women@CA breakfast event, organised by Dr Katie de Luca, which aims to support women in

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CONFERENCE REVIEW

chiropractic research and to establish a community of likeminded researchers with a vision to decrease gender inequity

“

Professor Stephen Perle emphasised that while chiropractors have the necessary skill set along with a wide range of understanding of spinal care, we need to find ways to improve our public health perspective.

in academia. This was followed by a presentation from the Chiropractic Board of Australia in which board member Dr Michael Badham covered the changes to CPD requirements for chiropractors which come into force on 1st December.

On the Sunday Dr Andrew Shephard continued to discuss ways to use technology in practice in his presentation “Leveraging technology in modern practice: Working smarter not harder”. He showed how much technology has changed and introduced us to a wide range of digital aids such as practice management systems, electronic health records, online accounting systems, and clinical apps such as Physitrack.

Professor Dave Newell added to this technological evolution in his presentation entitled ”Going to the Proms” in which he discussed the impact of the routine collection of patient reported outcomes in practice and encouraged us to use a PROM system (its free folks!). The PROMs allow a practitioner to assess and follow up a patient’s clinical progress. He suggested it could soon become the norm.

Dr Bobby Maybee’s second presentation “Foundations of ethical approaches to effective marketing” went through the steps needed to put you on the path to success. A fantastic presentation on how to ethically build up your presence and then importantly, maintain your presence.

While Bobby Maybee’s presentation was very much about how social media is an essential tool for chiropractors to promote their practice, the next speaker, Dr Matthew Bulman, offered a far more cautionary view during his presentation “Social media for Australian Chiropractors and Osteopaths: Friends or Foe?” He discussed the dangers surrounding social media and its powerful impact on individuals and society as a whole. He also provided evidence on how data collection and the use of algorithms is used to influence behaviours. Disconcertingly he felt social media stood at odds with our AHPRA obligations.

The final individual presentation of the conference was given

by Dr Sasha Aspinall and her topic was “Behind the crack! A modern explanation for spinal manipulation”. She reviewed the science around SMT and what that means for how we use and explain spinal manipulation in our practices.

The conference wrapped up with a panel comprising Professor Stephen Perle and Drs Bobby Maybee, Andrew Shepherd, Estee Lombard and Adrian Sheridan discussing “The business of evidence-based practice”.

Special mention should also be made that CA President Rod Bonello was awarded life member of Chiropractic Australia in part for his tireless work in establishing CA and pushing it forward. Responding to this achievement and in typically selfeffacingly style he said, “This to me is not a big deal, I feel we just need to give back”. Congratulations to Rod! Overall, an excellent weekend in an outstanding venue. A range of insights were gained from the variety of local and overseas presenters with many delegates calling it the best Chiropractic Australia conference so far. Until next time, that’s a wrap.

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Women@CA Breakfast On the Sunday morning of the Chiropractic Australia annual conference, Dr Katie de Luca opened the inaugural Women@CA – supporting women in chiropractic research networking breakfast. Katie’s purpose is to bring a together a community of like-minded researchers in a vision to decrease gender inequity in academia. She reported that whilst more than half of PhDs are awarded to females, there are fewer women holding senior scientific academic positions than men. When this happens, not only is trained scientific expertise lost but also female leaders, representation on boards, positions on organising committees, and women available for HDR supervision. Acknowledging the work of Male Champions of Change, Katie emphasized that we need men in powerful positions to step up beside women in building a gender equal academic world. After this thoughtprovoking opening, Katie then invited two keynote speakers to give their perspectives of the current landscape for women in academia.

Dr Carolyn Ee is a strong and inspirational woman with an incredible story.

In her presentation “If not me then who?” she discussed her journey as a clinician, researcher, mother, and reluctant leader. She made an important point when she said, “Maybe there isn’t going to be a right time.” In other words, sometimes you just have to give a career in research a shot. For her there were struggles in balancing the raising of her children with her research commitments. She pointed out the importance of supportive supervisors and flexible working arrangements. She reiterated that to succeed, you should keep true to your values and define your academic mission. Reflectively, she assessed life’s seasons, and to take the time you need when you need, take time with your family and take time with your research.

Carolyn also shared her experience on setting boundaries as a woman in academia and emphasised that it was important that researchers “don’t forget who you are”. In excellent advice to many people in the crowd, she shared her strategies of academic survival that included banishing unhealthy perfectionism, leaning in to new and exciting opportunities, and that sometimes you need to step up and take leadership on professional matters particularly when colleagues see you as the expert.

Carolyn intimately shared her ways to keep sane, including teamwork and collaboration, humour, taking breaks, outsourcing, psychological wellbeing, and physical exercise. “Some of these may work for you and some may not, but you need to find what works for you.” Overall it was a fabulous story from Carolyn, a GP, PhD and leader of the Jacka Foundation Integrative Medicine program at NICM Health Research Institute.

Special guest speaker Dr Carolyn Ee from NICM Health Research Institute

Women@CA Convenor Dr Katie de Luca Dr Ee was followed by Amber Beynon, a PhD student at Murdoch University and recipient of a CA Research Foundation PhD Scholarship.

Amber was candid in sharing that whilst she is supported by a team of supervisors and colleagues at work, the vast majority are men. She bravely discussed her experiences as an isolated, young female researcher, but one with strong female role models including one of her supervisors, female researchers, and other PhD students.

Currently more than half of the chiropractic profession are women so it is appropriate that representation in both academia and leadership positions should reflect this change in the demographics within our profession and one of the aims of Women@CA is to raise awareness of the imbalance that exists. In order to stay relevant, professional organisations are urged to consider gender balance across a range of positions.

The event also provided a networking opportunity for the more than 40 people who attended. The organisers would like to thank Chiropractic Australia for their support and also Foot Levelers for their generous sponsorship and also to Maria Bernard-Giglio who made a personal donation in support of the event. We look forward to building strong supportive relationships to support women in chiropractic research into the future. For more information, please contact Dr. Katie de Luca at katie. deluca@mq.edu.au

Murdoch University PhD student Dr Amber Beynon

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CA Researchers’ Day 2019 By: Amber Beynon B.Sc. (Hons), B.Chiro

This was the eighth annual CA Researchers’ Day and proved to be another fantastic day. Master of ceremonies, Michael Swain, opened proceedings by reminding us of the purpose of the researchers’ day and encouraging us to become researchers hallmarked by critical thinking.

The first speaker was the incredible Dr Hazel Jenkins. Recently awarded her PhD she talked about juggling the work-life balance and shared insights gained while completing her PhD by balancing working as a chiropractor and lecturer while also being a mother and wife.

Hazel explained it is about each person being happy with their particular balance. She mused on coming to terms with not being able to do everything and finding ways of managing the challenges. Her story involved setting limits, goal setting, prioritising realistically, good support, and taking holidays! These were some great take-home messages for those considering or currently engaged in research but also for clinical practice!

The next speaker was the inspirational Michele Sterling, a Professor in the Recover Injury Research Centre, Program Lead of the Designing Better Therapies research program, Director of the NHMRC Centre of Research Excellence in Road Traffic Injury Recovery al

at the University of Queensland. In addition, Michelle is a Musculoskeletal Physiotherapist and a Fellow of the Australian College of Physiotherapists. Her impressive resume included generating over $13M in research funding from NHMRC, ARC, and industry partners. No easy feat! She pointed out that sometimes it takes time for the research you are engaged in to become fruitful.

Often times you question the worth of it during the early stages. Michelle spoke of the positives of having a research career and these included the joy of continued learning, travel opportunities, engaging with smart and dedicated people, writing, and having a flexible schedule. On the other side, the negatives included needing to be resilient, maintaining focus, dealing with criticism, and finding a work/life balance.

After a break the morning sessions concluded with a panel comprising Professors Dave Newell and Stephen Perle, alongside Drs Bobby Maybee, Matthew Bulman, Amber Beynon and Julie Kendall discussing “What do chiropractors want from their researchers?’

As is now customary, the afternoon was dedicated to podium and poster research presentations, An excellent response to the Call for Papers meant the convenors had their work cut out to manage the peer review process to select those to present at podium, however this did result in the eight podium presentations being of a very high standard.

First place was awarded to Katie de Luca for her research “Older patients who present to chiropractors in Australia and Canada: Who are they and what conditions do they present with?”, second place went to Amber Beynon for her

“Systematic review with meta-analysis of chronic physical illnesses, mental health disorders and psychological features as potential risk factors for back pain from childhood to young adulthood” while third place was awarded to Hazel Jenkins who presented research on “Effectiveness of treatments to decrease thoracic hyperkyphosis: a systematic literature review and meta-analysis”.

A large number of posters were also on display presenting a range of research including several entries from students at Murdoch University. The Best Poster was awarded to Amber Beynon who presented her project “What happens to children who have low back pain at 14? A trajectory study until the age of 22” while the People’s Choice award went to Natalie Clohessy for her poster “Patient reported outcome measures for low back pain and utilisation amongst Chiropractors in Australia: Facilitators and barriers to clinical implementation”. Murdoch University students P. Kim, A. Bridge, J. Jessop, S. Saunders, D. Williams and their supervisor Jeff Cooley took home the prize for Best Student Poster for “Testing the feasibility of a protocol for assessing the accuracy of DEXA scans versus plain film x-rays in identifying common variations in spinal bone anatomy”.

Now firmly established as an annual event, the Researchers’ Day continues to raise the bar each year by attracting outstanding speakers and providing a platform for high quality research presentations. Those attending get to see first-hand the research that is happening within chiropractic and many leave with a renewed sense of hope for the future of research within our profession.

Winners: Dr Amber Beynon, Dr Katie de Luca, Dr Natalie Clohessy, Dr Hazel Jenkins with convenors Dr Michael Swain and Professor Simon French.

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INTERVIEW

Congratulations to Dr Lee Daffin for completing his PhD By: Amber Beynon B.Sc. (Hons), B.Chiro

Lee Daffin is a chiropractor, researcher and full-time lecturer at Murdoch University. He has successfully completed his PhD titled: “The Impact of the Cervical Lordosis on Postural Sway Parameters in Asymptomatic Participants”.

A fantastic achievement! He is also the Anatomy Lecturer at Murdoch University. He was kind enough to take time out of his busy schedule to answer a few questions about his PhD journey for our membership.

Q. Congratulations on successfully gaining your PhD! Can you tell us a bit about your PhD research?

I investigated 150 asymptomatic participants and their naturally occurring sagittal cervical alignment. We determined their curve radiographically and photographically and compared and contrasted the images in order to establish their objective upright natural cervical alignment. The participant’s alignment was then classified into one of the five accepted alignment patterns. I balanced them on a force platform which is the gold standard use to determine the neurological control of balance and then compared these parameters against their classified cervical alignment. I demonstrated a loss of lordosis detrimentally affects postural control parameter in asymptomatic people.

I wanted to establish an objective rational that could be expanded upon that may help explain the possible transitional phases that allow an asymptomatic participant to become a nonspecific neck pain sufferer.

Q. The PhD journey is not an easy one.

How did you find the experience?

Overwhelming, daunting but then at some stages exhilarating. Exhilarating when you reach the many milestones involved and finally when you find your hypothesis to be objectively sound. It was also a very time consuming (life consuming) experience. I lost of lot of time from my young family, losing many years watching my kids grow up. But it does pay off. Now my kids are older I can better support their ambitions.

Q. What would you say would be the highlight of your PhD journey?

The biggest highlight was the finish. Now I am

doing what I love, teaching anatomy and neuroanatomy to chiropractic students. I wouldn’t have been able to achieve my ideal career without obtaining a PhD. The milestones were such things as completing data collection (2 years part time), submission of the thesis for examination, and having three articles accepted for publication in some of the best journals in their respective fields. One particular highlight moment comes to mind. Being in a room with my supervisors while they were critiquing a paper for publication. It was exactly the same as the Big Bang episode with Raj and Sheldon, when they were writing on the white board with the eye of the tiger music playing.

Q. Where do you see your research going now?

I want to be able to demonstrate what I have found in young adolescents, 13-15 years of age. If we can show the same results in adolescents, then we could potentially develop a relevant biomarker that enables the identification of at-risk individuals. I would like to investigate potentially reversing their curves and re-balance them. If we can demonstrate posture control improvement, we could then potentially address structural changes prior to symptomatic presentation. It would also be great to have longitudinal data to establish if those with nonlordotic curves develop neck pain in the future, to determine a temporal understanding between structural changes in the neck and non-specific neck pain.

Q. Who are some inspiring people that you admire?

David Attenborough and Carroll Shelby. They pushed the boundaries in their fields and have both come out winners.

Q. Do you have any hobbies?

When I have the time, I enjoy building things such as houses and DIY home projects. I enjoy landscaping and yard work, working on cars and mechanical things, basically pulling things apart and putting them back together.

Q. What are your favourite films?

Mad Max and Mad Max II, Star Wars (all films), Apocalypse Now, Deadpool, and Jackass (all of them!).

Q. Do you have any advice for early career researches?

Have confidence in yourself because if you have the ability to become a chiropractor you can do a Higher Degree by Research project, if you really want to. You have to really want it!

You need dedication! Dedication like getting up a 5am for months to finish the thesis before you go to work for the day.

Q. Is there anything else you would like to add?

Overall, I feel proud to have achieved it, but it is not a solo event. You stand on the shoulders of giants. The giants are your supervisors and the literature you use as a starting point. Supervisors are without a doubt the most important aspect of a PhD, helping you to navigate through the many unknowns. One final shout out is to one of my supervisors, Dr Max Stuelcken the most genuine person I came across during my PhD journey, a legend and pure gentleman. Mate, if it wasn’t for you I could have never finished this PhD. If you want more information about my PhD you can read my thesis by following this link: http://research.usc.edu.au/vital/access/ manager/Repository/usc:29139?fbclid=IwA R2xWPG6M6aerHqPPl1sA4iHdEHessDpJuSxlnnJybZkiGspmPKYytKaFg

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RESEARCH

Back Pain in Older Adults The World Health Organisation has identified low

determine predictors of disability in this population.

surveys over the course of 12 months, answering

back pain as the major disabling condition in older

Ultimately, information collected through

questions related to healthcare use and their pain

persons. Low back pain limits their physical ability

BACE:C-A will assist chiropractic representation

experience.

and decreases social well-being. Of those older

when engaging with healthcare policymakers and

adults who experience back pain, 1 in 5 report

will place chiropractors as important stakeholders

“As a researcher, the clinics of chiropractors are the

difficulties in caring for themselves at home or

in the primary care of spinal health for older adults.

participating in family and social activities.1-4

The study was awarded a competitive research

In Australia, the prevalence of low back pain

grant by the Australian Chiropractors Association

in older adults is 24 - 27%,5 therefore, in our

in January 2019.

ageing population a substantial number of older

We need you!!

Australians regularly experience low back pain.

Low back pain in older adults is more severe than in younger adults.6 For example, people aged >80 years are three times more likely to have high intensity low back pain than those aged 50-59 years.(7)

Having recently been granted ethics approval from

in BACE:C—A. Chiropractors and their staff will be trained to recruit older chiropractic patients

patients are older Australians.8 Therefore in terms

will not be asked to provide an intervention to their

of improving patient-centred care, research that

patients. After completing the baseline survey,

is focused on establishing evidence on whether

participants will complete a further six studies

chiropractic is safe for older Australians and in

over 12 months, regardless of whether they have

understanding the risk factors of disability in this

chiropractic treatment or not.

population is extremely important.

Interested chiropractors are invited to contact

BACE:C-A

the BACE:C-A team to express their interest in

Luca from Macquarie University. The team join a European BACE:C research group, led by Dr Sidney Rubenstein who developed the chiropractic protocol from the international consortium on BAck Complaints in Elders in a primary care setting.9

practice-based research arise. These are very exciting times, and I am looking forward to working with Australian chiropractors to collect valuable

How to be a part of BACE:C-A

and recruit chiropractors interested in participating

purely observational, participating chiropractors

led by post-doctoral research fellow, Dr Katie de

will engage with researchers as opportunities for

team are now ready to engage with the profession

regularly see older adults7 and 12% of chiropractic

collaborative, prospective, longitudinal study being

its kind in Australia, and I hope that chiropractors

patient data.”

with low back pain to the study. As this study is

– Australia (BACE:C-A) study is an internationally

on chiropractic patients. This is the first study of

Macquarie University, the BACE:C-A research

In a recent study, 74% of chiropractors reported

The Back Complaints in the Elderly: Chiropractic

greatest opportunity that we have to collect data

If you wish to be a part of the BACE:C-A study, please email Katie or Lucy (Research Assistant) at bace.c@mq.edu.au or for more information visit our website at mq.edu.au/about/bacechiropractic

participating. The study is particularly interested in hearing from chiropractors who feel they have a high number of older patients, particularly older people who are new patients.

What do patients have to do?

We are looking to recruit 1,000 older adults (aged 55 years and over) who present with a NEW episode of low back pain. Eligible older patients will be provided with an information sheet and

The study will follow adults over the age of 55 who

consent form by clinic administration staff (where

see a chiropractor for a NEW episode of back pain

possible) and then asked to complete an online

for 12 months. It will collect vital information on the

survey. Study participants will then be contacted

safety and satisfaction of chiropractic care for the

via phone by the BACE:C-A team to confirm the

treatment of low back pain in older people and

details of the study. Participants will be sent six

REFERENCES: 1. Hartvigsen J, Frederiksen H and Christensen K. Back and neck pain in seniors-prevalence and impact. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2006; 15: 802-806.

2. Leveille SG, Guralnik JM, Hochberg M, et al. Low back pain and disability in older women: independent association with difficulty but not inability to perform daily activities. The journals of gerontology Series A, Biological sciences and medical sciences 1999; 54: M487-493. 1999/11/24.

3. Weiner DK, Haggerty CL, Kritchevsky SB, et al. How does low back pain impact physical function in independent, well-functioning older adults?

Evidence from the Health ABC Cohort and implications for the future. Pain medicine (Malden, Mass) 2003; 4: 311-320. 2004/01/31.

4. de Luca K, Parkinson L, Haldeman S, et al. The relationship between spinal pain and comorbidity: a cross-sectional analysis of 579 communitydwelling, older, Australian women. Journal of manipulative and physiological therapeutics 2017; 40: 459-466.

5. Walker BF, Muller R and Grant WD. Low back pain in Australian adults: prevalence and associated disability. Journal of manipulative and physiological therapeutics 2004; 27: 238-244. 2004/05/19. DOI: 10.1016/j.jmpt.2004.02.002.

6. Stewart Williams J, Ng N and Peltzer K. Risk Factors and Disability Associated with Low Back Pain in Older Adults in Low- and Middle Income Countries. Results from the WHO Study on Global AGEing and Adult Health (SAGE). . PloS One 2015; 10. DOI: 10.1371/journal.pone.0127880.

7. Moore C, de Luca K, Wong A, et al. Characteristics of chiropractors who manage people aged 65 and older: A nationally representative sample of 1903 chiropractors. Australasian Journal of Ageing 2018; In Press.

8. Charity MJ, Britt HC, Walker BF, et al. Who consults chiropractors in Victoria, Australia?: Reasons for attending, general health and lifestyle habits of chiropractic patients. Chiropractic & manual therapies 2016; 24: 28.

9. Scheele J, Luijsterburg PA, Ferreira ML, et al. Back Complaints in the Elders (BACE); design of cohort studies in primary care: an international consortium. BMC musculoskeletal disorders 2011; 12: 193. DOI: 10.1186/1471-2474-12-193.

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RESEARCH

Chiropractic Australia Journal Club By: Dr Andrew Shepherd BSC Chiro Sc, M Chiropractic This edition we will be exploring the use of technology in using patient reported outcome measures (PROMs) in clinical practice and is based on the recent paper titled “PROMs data: can it be used to make decisions for individual patients? A narrative review” by Jonathon Field, Michelle M Holmes and Dave Newell (2019).

This paper discusses the current use of PROMs and its growing importance in both health care research and private clinical practice in providing data on the patient’s perspective of their health and care. Traditionally these validated outcome measures have been used in clinical practice for predicting the course of a disease, the efficacy of treatment and care quality.

Although very useful, Field et al describe the main issue with PROMs in clinical practice being their infrequent use by clinicians as part of their interaction with their patients either due to time constraints due to the higher administrative workload involved in using PROMs or not having the necessary knowledge to implement them.

PROMs have utility to establish baselines and as a screening tool for patients along with tracking progress in care at different points in the course of their treatment. However, the authors propose that PROMs could be used for every clinical encounter as a routine assessment and tracking tool.

PROM data has become increasingly useful in providing information about aspects of a patient’s health and care that are specifically important to the actual patient. This in turn can drive the decisions clinicians can make on a

course of care and catering to all three facets of the biopsychosocial model of evidencebased practice.

By being more able to track the psychosocial aspects of patient care, PROMs can also inform the practitioner on when to refer, enhancing collaborative care with other allied health and medical practitioners. It also improves the patient-practitioner relationship by using the PROM to keep both parties on the same page as a partnership, as well as empowering the patient to engage more in their own care outside of the clinical encounter.

In the past as well as present, PROMs have been measured by pen and paper questionnaires filled out by the patient and scored and recorded by the practitioner. This can be seen as too time consuming and tedious by some patients and practitioners. However, with recent innovations in technology and the rise of the E-PROM or electronic PROM, these questionnaires are becoming more user friendly and efficient, demonstrated by the authors own E-PROM, Care Response (https://support.care-response.com/).

Given that smart phone and other electronic device ownership has risen dramatically over the past few years, the use of bespoke apps and web applications are becoming more practical for clinical practice. These E-PROMs need to be simple for both the clinician and the patient to use and clinicians need some training as well as collaboration with their patient as to what E-PROM is appropriate for the needs of the patient at the time of presentation.

In order to make E-PROMs a part of everyday practice it may be necessary to develop algorithms based on data from the patient’s initial history on intake in order to decide which E-PROMs are appropriate for initial assessment, establishment of baseline data and ongoing progress tracking.

Cloud-based web applications are useful as they can be accessed from any device that can connect to the cloud. These applications could provide ongoing PROM data by allowing both the practitioner and the patient to access it from anywhere in real time and make the process part of a clinicians ongoing clinical note taking, effectively integrating traditional SOAP notes with E-PROMs. If this method could be standardised it could mean that clinical note taking, and PROM use becomes more consistent between practitioners and professions.

In addition, if the daily use of E-PROMs integrated with clinical note taking can capture large amounts of data in the way that Care Response does then this provides a wealth of data that, if de-identified and exported safely to a university database, can be used for research.

As far as chiropractic is concerned, there is still some catching up to do in terms of research to validate our place in health care. If technology can combine efficient note taking and PROM tracking along with important data capture for research, it presents a tremendous win/win opportunity for the profession.

SpineWeek 2020 coming to Melbourne For the first time since its inception in 2004 SpineWeek will be held in Australia from 27 April to 1 May 2020 at the Melbourne Convention and Exhibition Centre.

The week brings together spine societies from across the globe serving as the prime arena for scientific collaborations between different scientists and clinicians, advancing the science of the spine.

SpineWeek began in Porto, Portugal in 2004 and has occurred once every four years since then, taking place in Geneva, Amsterdam and Singapore. As more and more participants were journeying from Asia and Oceania region, the SpineWeek committee is excited to bring the conference to Australia.

The SpineWeek 2020 conference is the first time that chiropractic organisations have been involved. “This represents a great opportunity for Australian chiropractic” says ACA Professional Services Manager Glynis Grace. “The SpineWeek conference provides ACA and Chiropractic Australia the chance to work collaboratively on a major international event”, she said.

“Given the growing evidence supporting nonpharmacological and non-surgical approaches to the management of neck and back pain, it is an opportune time for the chiropractic profession to become involved in this prestigious conference by highlighting the role chiropractors can play in the conservative management of spinal pain”, noted Chiropractic Australia’s President, Rod Bonello.

Call for Abstracts now open Don’t wait until next year to be a part of SpineWeek, submit an abstract for consideration by 15 October 2019. There are varying topics for chiropractors to get involved with SpineWeek 2020. Authors will be notified of the acceptance of their abstract by email in January 2020. Find out more about making an abstract submission at https://spineweek.org/abstracts Find our more information about SpineWeek by visiting https://spineweek.org and get excited about this big step in the future of chiropractic on a global scale.

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ARTICLE

BJ Palmer’s Sarasota house By: Dr Kenneth Young DC, DACBR, MAppSc (Medical Imaging)

There is a law in America that requires everyone living in the Northeast or Midwest of the country to retire to Florida.

Being good citizens, my parents did this, choosing Sarasota as their new home in the early 2000s. At the time, I did not realise that this was where BJ Palmer spent many of his winters, eventually retiring there as well.

I probably should have, since his main home was in Iowa, which is in the Midwest. I guess he was a good citizen, too.

There were many other things I did not realise about Sarasota. It is an artist community. The white sand at Siesta beach is like flour. There are mangroves, where manatees (sort of like dugongs) live. Jerry Springer and Stephen King have homes there. I met Jerry Springer in the Tampa airport once, but that’s another story. Sarasota was also the winter home of Ringling Brothers Barnum and Bailey Circus. And so we circle back to BJ Palmer.

BJ was a huge circus fan. He never charged circus people for treatments.

His home is owned by a not-for-profit foundation now, who maintain it much as BJ had it when he died in 1961. It is full of artefacts, and you can have a private tour if you are in the area. Since I happened to find myself in the area quite a bit visiting my parents, I have toured it a couple of times.

I thought I would share some of those photos and thoughts with you.

One of the destinations in Sarasota is St Armand’s Circle on St Armand’s Key. Key, in Florida-speak, means island. The Circle is full of shops and restaurants and is a great place to have a coffee and watch the cosmetic

Fig 1- Exterior in 2012 with BJ Palmer name plaque

Fig 3 – BJ’s signature, shoe prints and footprints

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Fig 4 – The backyard

surgeons’ work go by. BJ’s house is just a short walk off the Circle. Here is the exterior in 2012 (Fig. 1) and 2005 (Fig. 2 – pre-renovation). It certainly looks much happier since the restoration.

Like the Hollywood Walk of Fame, the house has prints memorialised in concrete. You can see BJ’s signature, shoe-prints and footprints.

(Fig. 3) Why no hand prints? That one has me baffled.

The house is on a waterway; this is the backyard. Not too bad, eh? (Fig. 4) It starts to get a little creepy now. BJ’s bedroom with his death bed and memorial sign. (Figs. 5 and 6) The living room, painted in circus colours. Notice the planters designed to look like hands. The sign to the left of the fireplace says “No opium smoking.” What kind of parties did this guy throw?

The living room furniture. (Fig. 8) Although the official website describes the living room as “vast,” I’m not so sure. But those chairs definitely look comfy.

One of the worst possible photographs of the copy of the letter from Samuel Weed to DD Palmer naming chiropractic. You’re welcome. (Fig. 9) A letter, original, from Hollywood director Cecil B DeMille to BJ, thanking him for promoting his latest picture, “The Greatest Show on Earth” on BJ’s Davenport radio station. (Fig. 10) I wonder if the movie is available for streaming?

BJ’s Sarasota house is a fascinating place and I feel very privileged to have been able to look round. I recommend a visit if you get the opportunity. You can find out more at https://www.bjph.org.

Fig 2 – Exterior in 2005, pre-renovation

ARTICLE

Fig 5 – BJ’s bedroom with his death-bed

Fig 6 – The death-bed with commemorative sign

Fig 7 – Fireplace in living room with photos

Fig 8 – Living room

Kenneth Young is the curator for the Chiropractic History Special Collection at Murdoch University. It can be seen here: https://www.murdoch. edu.au/library/resources-collections/ special-collections/chiropractichistory-collection, or search ‘special collections’ on the main university website, www.murdoch.edu.au. If you would like to comment on this article, or for further information on the Special Collection, or to discuss making a donation of time, money, or documents or other items, please contact Ken at k.young@murdoch.

Fig 9 – Copy of letter naming chiropractic

Fig 10 – Letter from Cecil B. DeMille

edu.au or on (08)93607370.

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ARTICLE

Probiotics, Prebiotics and Synbiotics – To take or not to take?

By: Mi Kyung Lee, BSc (Nutrition and Food Sc), GradDip (HSc), MA, PhD The term ‘probiotic’ means “for life” in Greek.

It is currently used to describe bacteria which are associated with beneficial effects for humans and animals. The original observation of the positive role played by some selected bacteria is attributed to Elie Metchnikoff, a Russian scientist, who worked at the Pasteur Institute at the turn of the century. He is best known for his pioneering research in immunology and was awarded a Nobel Prize in Physiology or Medicine.

At the same time, a French paediatrician, Henry Tissier, observed that children with diarrhoea had in their stools a low number of bacteria (bifida) which were found to be abundant in healthy children.

Probiotics are defined as ‘live microorganisms that confer a health benefit on the host, when administered (in a viable form and) in adequate amounts’ (FAO/WHO, 2002).

The FAO/WHO Working Group specified the following key aspects of this definition for food use (FAO/WHO, 2002): • Taxonomy (strain identification): A probiotic must be a taxonomically defined microbe or combination of microbes (genus, species and strain level) • Safety: a probiotic must be safe for its intended use • Substantiation/Scientific evidence of health benefits: A probiotic must have undergone controlled evaluation to document health benefits in the target host • A probiotic must be alive when administered Prebiotics are defined as ‘non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth and/or activity of one or a limited number of bacterial species already established in the colon, and thus in effect improve host health’ (Gibson and Roberfroid, 1995 – cited in (FAO/WHO, 2006).

Synbiotics are defined as products that contain both probiotics and prebiotics (Zhang, Ju, & Zuo, 2018).

Probiotics have been consumed by humans since time immemorial, for example as fermented milks, yogurts and kimchi. Breastmilk is an example of a synbiotic as it contains living bacteria (bifidobacter, lactobacillus) and prebiotics (oligosaccharides). This is one of the reasons why breastmilk is so superior to the artificial formula.

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Use of Probiotics in preventing or treating illness/conditions Recent systematic reviews have reported the following beneficial use of probiotics: • Prevention and treatment of Paediatric diarrhea (Guarino, Guandalini, & Lo Vecchio, 2015) • Treatment of Infant colic (Schreck Bird, Gregory, Jalloh, & Risoldi Cochrane, 2017) • Prevention of Antibiotic induced diarrhea both in children and adults and moderately reducing the duration of diarrhea (Guo, Goldenberg, Humphrey, El Dib, & Johnston, 2019) • Improvement in Abdominal pain, especially in children categorized as having irritable bowel syndrome (Mellis, 2017) • Prevention of Clostridium difficile infection (CDI) in adults (Barker, Duster, Valentine, & Hess, 2017)

Not conclusive • Prevention of traveller’s diary (McFarland & Goh, 2019); • Influence of gut bacteria on the brain: Therapeutic potential for depression, anxiety, autism and other psychological disorders (Butler, Cryan, & Dinan, 2019).

Use of Probiotics in otherwise Healthy People It is currently not clear if the regular intake of probiotics, as a supplement, has any long term benefit. The FAO/WHO Working Group stated that the use of probiotics should not replace a nutritious diet and a healthy and active lifestyle in otherwise healthy people. There are inherent biological difficulties in the administration of probiotics.

The gastrointestinal tract develops its microbiome early in life and by two years age immunological tolerance has developed for the 1000 or so types of bacteria living in a healthy gut. After that time the introduction of new bacteria is usually unsuccessful and to have any effect probiotics have to be given daily or even more often.

Thus, the use of probiotics likely confers more temporary than long-term effects, and so if long term benefits are identified, continued intake would be required.

Food Sources of Probiotics The most common bacteria included in commercial foods or added in dietary supplements or drugs are Lactobacillus and Bifidobacterium species. Food sources of probiotics (live organisms) include yogurt and some fermented food and drinks.

Not all fermented foods can be considered as probiotics, but they can have health benefits (Chilton, Burton, & Reid, 2015). Eating fermented foods could increase the number of microbes in the diet by multiple folds.

Food processing, including pasteurization, destroys microbes eliminating any probiotic function. The most abundant microbe in kimchi (fermented cabbages consumed in Korea) and sauerkraut is Lactobacillus plantarum. As a Korean-born Australian, I am happy to see kimchi on the list of beneficial food for gut health. However, one caution of the fermented products is that they are usually high in sodium content, especially when consumed in a large quantity.

Consuming sodium reduced fermented probiotic-rich products as part of a regular diet would be the best outcome.

Probiotic Supplements and Regulation Is there a regulation of probiotics used as supplements? A recent review of the current regulation of probiotics used for the dietary management of medical conditions concludes that the current regulation of probiotics is inadequate to protect consumers and doctors (de Simone, 2019).

Overall probiotic use is safe in most of the cases. However, probiotic use should be avoided in some people who are immunologically compromised.

Generally randomised controlled trials of probiotics have been disappointing. Probiotic containing foods are associated with health benefits in longitudinal studies. When probiotic bacteria are isolated and given for preventive and therapeutic purposes the results are mostly disappointed with few positive Cochrane reviews. This is similar to many other individual nutrients confirming that a healthy, balanced diet is likely to be the best treatment(Binns, Lee, & Lee, 2018).

The International Scientific Association for Probiotics and Prebiotics (ISAPP) recommends to review the following four criteria before choosing a probiotic: 1. “Probiotic strain: Not all the probiotics are the same. Match the particular strain with published scientific research.

2. Proof of efficacy: Probiotics must be tested and be shown effective in humans to determine health benefits. Look for information such as scientific evidence and what health claims on the products mean.

ARTICLE 1. Quality and quantity: Choose a quality product at the right quantity. Probiotics can be effective at varying strengths.

Scientific studies have determined health benefits from 50 million to more than 1 trillion CFUs (colony forming units, which is the measure of viable microbes in a probiotic) per day. A probiotic with higher CFUs doesn’t necessarily equal better quality or effectiveness.

2. Package information: Pick quality packaging and a trusted manufacturer” (ISAPP, 2016)

Key messages: • Gut microbiota may influence many areas of human health from innate immunity to appetite and energy metabolism, but in most areas conclusive proof is not yet available.

• Diet (and different components of food) and medication have a strong influence on gut microbiota composition • Eat healthy diet (e.g. Mediterranean diet, DASH diet) rich in fresh fruit, vegetables, fish, less meat and less fast food • nclude fibre rich food in the diet (whole grains, fruit and vegetables, etc.)

• Include fermented products in your diet e.g. yoghurt, kimchi, sour kraut, etc.

• Probiotic supplements – it is not worth taking unless you have gastro-intestinal problems where therapeutic benefit has been established.

Conclusion Probiotics may be beneficial to health, however, even more important are the dietary factors that help maintain a diverse

and healthy microbiome. Instead of looking for one component in food to boost health, eating healthy diet (and healthy dietary pattern), being physically active and leading health-conducive lifestyle should be emphasized for the prevention of lifestyleassociated non-communicable diseases.

Useful Resources • Gut Microbiota for Health (Public Information Service from European Society of Neurogastroenterology and Motility): https://www.gutmicrobiotaforhealth.com/ en/home/ • A consumer’s guide for probiotics: 10 golden rules for a correct use: https://doi. org/10.1016/j.dld.2017.07.011

Fig. 1. Overview of the interplay between food components, gut microbiota, metabolites, and host health. Dietary compounds may elicit changes in the composition and the activity of the gut microbiota resulting in the generation of secondary metabolites that modulate host responses.

Arrows indicate interaction between gut microbiota and metabolites. Ahr: Aryl: aryl hydrocarbon receptor; BCAAs: branched-chain amino acids; MAC: microbiota accessible carbohydrates; SCFAs: shortchain fatty acids; TMAO: trimethylamine oxide.

REFERENCES: 1. Barker, A. K., Duster, M., Valentine, S., & Hess, T. (2017). A randomized controlled trial of probiotics for Clostridium difficile infection in adults (PICO). Journal of antimicrobial chemotherapy, 72(11), 3177-3180. doi:10.1093/jac/dkx254 2. Binns, C. W., Lee, M. K., & Lee, A. H. (2018). Problems and Prospects: Public Health Regulation of Dietary Supplements. Annu Rev Public Health, 39, 403-420. doi:10.1146/annurev-publhealth-040617-013638 3. Butler, M. I., Cryan, J. F., & Dinan, T. G. (2019). Man and the Microbiome: A New Theory of Everything? Annual Review of Clinical Psychology, 15(1), null. doi:10.1146/annurev-clinpsy-050718-095432 4. Chilton, S. N., Burton, J. P., & Reid, G. (2015). Inclusion of Fermented Foods in Food Guides around the World. Nutrients, 7(1), 390-404.

5. Danneskiold-Samsøe, N. B., Dias de Freitas Queiroz Barros, H., Santos, R., Bicas, J. L., Cazarin, C. B. B., Madsen, L., . . . Maróstica Júnior, M. R. (2019). Interplay between food and gut microbiota in health and disease. Food Research International, 115, 23-31. doi:https://doi.org/10.1016/j.foodres.2018.07.043 6. de Simone, C. (2019). The Unregulated Probiotic Market. Clinical Gastroenterology and Hepatology, 17(5), 809-817. doi:https://doi.org/10.1016/j.cgh.2018.01.018 7. FAO/WHO. (2002). Guidelines for the Evaluation of Probiotics in Food. Retrieved from London, Ontrario, Canada: https://www.who.int/foodsafety/fs_management/ en/probiotic_guidelines.pdf 8. FAO/WHO. (2006). Probiotics in Food: Health and nutritional properties and guidelines for evaluation. Retrieved from Rome: http://www.fao.org/tempref/docrep/ fao/009/a0512e/a0512e00.pdf 9. Guarino, A., Guandalini, S., & Lo Vecchio, A. (2015). Probiotics for Prevention and Treatment of Diarrhea. Journal of clinical gastroenterology, 49, S37-S45. doi:10.1097/MCG.0000000000000349 10. Guo, Q., Goldenberg, J. Z., Humphrey, C., El Dib, R., & Johnston, B. C. (2019). Probiotics for the prevention of pediatric antibiotic‐associated diarrhea. Cochrane Database of Systematic Reviews(4). doi:10.1002/14651858.CD004827.pub5 11. ISAPP. (2016, 2015). Probiotics: Consumer guide for making smart choices Retrieved from https://isappscience.org/clinicians/consumer-guidelines-probiotic-2/ 12. McFarland, L. V., & Goh, S. (2019). Are probiotics and prebiotics effective in the prevention of travellers’ diarrhea: A systematic review and meta-analysis. Travel Med Infect Dis, 27, 11-19. doi:10.1016/j.tmaid.2018.09.007 13. Mellis, C. (2017). Probiotics for recurrent abdominal pain in childhood. Journal of paediatrics and child health, 53(7), 722-723. doi:10.1111/jpc.13623 14. Schreck Bird, A., Gregory, P. J., Jalloh, M. A., & Risoldi Cochrane, Z. (2017). Probiotics for the Treatment of Infantile Colic: A Systematic Review. Journal of pharmacy practice, 30(3), 366-374. doi:10.1177/0897190016634516 15. Zhang, N., Ju, Z., & Zuo, T. (2018). Time for food: The impact of diet on gut microbiota and human health. Nutrition, 51-52, 80-85. doi:https://doi.org/10.1016/j. nut.2017.12.005

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ALL NEW! Online evidence-based chiropractic CPD developed by leading experts in our profession

GLOBAL EDUCATION NETWORK FOR CHIROPRACTIC

Available to Australian Chiropractors December 2019

GEN-C is produced collaboratively by leading chiropractic professional bodies

ARTICLE

Taming Achilles Tendinopathies By: Dr Nicholas Shannon PGDipSEM, ICCSP Tendinopathies, including Achilles Tendinopathies (AT), are prevalent injuries that can affect anyone from a sedentary office worker to an elite athlete. AT classically present with pain, swelling of the tendon and impaired function (1). Tendinopathies are difficult cases to treat and often patients present having tried multiple treatment options without success.

There is evidence suggesting a genetic link to tendinopathies, with ABO blood typing being linked to tendon ruptures, the Tenascin C gene being linked to Achilles tendon injuries, as well as COL5A1 being linked to Achilles tendon pathology (2–4). There is also evidence associating high cholesterol with tendon pain, as well as a link between fluroquinolones (antibiotics), tendinopathies and tendon ruptures (5,6). Of more clinical importance is the link between tendon loads and tendinopathies (7,8).

The role of tendons is to capture and release energy which occurs through type I collagen fibres and a well organised tendon cell structure (9) . When excessive loads are placed on a tendon it results in cell breakdown including apoptosis, disorganisation and changes in the collagen fibre quality with an increase in type III collagen, breakdown of the cell matrix, and an increase in fatty tissue, proteoglycans (responsible for swelling in the tendon) and tenocytes (7,10–13). The breakdown and disorganisation of the tendon cell structure directly affects the tendons ability to store and release energy resulting in tissue breakdown, neovascularisation (infiltration of new blood and nerve vessels) and ultimately degeneration of the tendon (7,10–13).

This cell structure breakdown occurs on a sliding continuum which is directly related to tendon load, with a healthy tendon at one end and a degenerative tendon at the other (7). When there is continuous excessive tendon load, the mechanically compromised tendon slides down the continuum from a normal tendon, to a reactive tendon, into tendon disrepair, ending at a degenerative tendon (7,14). During this degenerative process there is no frank evidence of inflammation hence the terminology shift from tendonitis to tendinopathy (15).

Clinically the 3 stages of tendon degradation present as follows (7): Reactive tendinopathy – most commonly seen in acute overload, usually in the young population, with no prior history of tendon pain.

On MRI and ultrasound (US) the tendon will appear swollen with no signal change (MRI) and diffuse hypoechogenicity (US).

Tendon disrepair – can be seen in chronically overloaded young individuals, however it can be seen in a wide variety of ages across a spectrum of loading. The tendons are thickened with local changes in one area of the tendon.

On MRI and ultrasound, they will appear swollen, with high signal (MRI) and small areas of hypoechogenicity and possible increased vascularity (US) within the tendon.

Degenerative tendon – is usually seen in the older population but can be seen in a young person or elite athlete with a chronically overloaded tendon. The typical patient is a middle aged, recreational athlete with focal Achilles tendon pain and swelling. There is usually a history of repeated tendon pain which self-limits with tendon load changes. These tendons have a higher risk of rupturing and cannot be rehabilitated. MRI and US show an increase in tendon size, high signal (MRI) and focal hypoechogenicity along with large and numerous vessels.

The most common type of tendinopathy seen in clinic will be the patient aged 40-60 years of age, with a past history of load exacerbations and an onset of increased pain following tendon overload (8). The tendon will be degenerative with reactive aspects. The next most common is the young person 15-25 years of age, acute onset of pain, swollen tendon, associated with a rapid increase in tendon load, aggravated by exercise and slow to settle (8).

Achilles Tendinopathy Treatment Interventions Radial Extracorporal Shockwave Therapy (RESWT) – there is good quality, low level evidence to suggest RESWT is comparable to eccentrics for pain at 4 months and is superior to wait and see for pain and disability at 4 months for mid portion AT, as well as being superior to eccentrics at 4 months for pain and disability for insertional AT (16). A meta-analysis of randomized controlled trials showed RESWT had a positive effect on pain and function in AT, however the study had high heterogeneity and used the QVAS (VISA-A is the gold standard) as the primary outcome measure (17).

Exercise Therapy – exercise therapy has been advocated for AT with evidence supporting improvements in pain and function in mid portion AT (8,18). Exercise therapy for AT typically consists of differing loading programs involving isometric, eccentric and concentric exercises.

Currently there is no evidence to support one loading program over another with all programs resulting in improvements (19,20). Commonly used

protocols include the Alfredson protocol and a 4 stage tendinopathy rehabilitation program developed by Jill Cook et.al (8,21).

Platelet-Rich-Plasma (PRP) – a robust meta-analysis of randomized controlled trials looking at the use of PRP and eccentric exercises versus placebo (saline) and eccentric exercises for chronic AT, found no difference between the groups for pain and function (VISA-A score) nor changes in tendon thickness (22). This is supported by another meta-analysis that found inconclusive evidence to support the use of PRP in AT (23).

Corticosteroid injections – are associated with a high risk of adverse effects including tendon rupture, tendon atrophy, decreased tendon strength, there is also insufficient evidence to support the use of corticosteroid injections for AT (24,25).

Orthotics – there is no evidence to support the use of orthotics for the improvement in pain and function for AT (18).

NSAIDs – the use of NSAID’s in chronic AT appears redundant as there is no evidence of inflammation in the tendon. There is an argument they could be used to treat pain in the acute phase however, evidence shows they have little or no effect on the outcome of AT (1).

Surgery – there are a wide variety of invasive, minimally invasive and endoscopic techniques for treating mid portion AT. There appears to be no difference in outcomes between techniques (26,27) . However, there are no studies comparing surgery to placebo or non-surgical interventions such as exercise therapy (27). There also appears to be highly variable complications risks associated with surgery (27).

AT and tendinopathies are challenging for the clinician and patient. Tendinopathy treatment needs to be individualised and should focus on removing the “abusive” tendon load, as well as utilizing exercise therapy to strengthen any deficient areas and to manage tendon pain and improve function. Shockwave therapy should be considered for those not responding solely to exercise therapy or used in addition to exercise therapy. Clinicians also need to manage the expectations of their patients, as tendinopathies can take several months and sometimes longer to rehabilitate (28). With exercise therapy being the primary treatment modality, chiropractors are well placed to be the first-choice clinician in the management of AT tendinopathies.

References on next page.

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ARTICLE REFERENCES: 1. Li H-Y, Hua Y-H. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Res Int. 2016 Nov 3;doi:2016:6492597.

2. Magra M, Maffulli N. Genetic aspects of tendinopathy. J Sci Med Sport. 2008 Jun;11(3):243–7.

3. Mokone GG, Gajjar M, September AV, Schwellnus MP, Greenberg J, Noakes TD, et al. The guanine-thymine dinucleotide repeat polymorphism within the tenascin-C gene is associated with achilles tendon injuries. Am J Sports Med. 2005 Jul;33(7):1016–21.

4. Mokone GG, Schwellnus MP, Noakes TD, Collins M. The COL5A1 gene and Achilles tendon pathology. Scand J Med Sci Sports. 2006 Feb;16(1):19–26.

5. Tilley BJ, Cook JL, Docking SI, Gaida JE. Is higher serum cholesterol associated with altered tendon structure or tendon pain? A systematic review. Br J Sports Med. 2015 Dec;49(23):1504–9.

6. Lewis T, Cook J. Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature. J Athl Train.

2014;49(3):422–7.

7. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009 Jun 1;43(6):409–16.

8. Cook JL, Kahn K, Reiman MP. Why and How Exercise is the Best Treatment for Tendinopathy. Combined Sections Meeting of The American Physical Therapy Association 2016. 2016 Feb 17-20; Anaheim California USA. 9. Franchi M, Trirè A, Quaranta M, Orsini E, Ottani V. Collagen structure of tendon relates to function. ScientificWorldJournal. 2007 Mar 30;7:404–20.

10. Samiric T, Ilic MZ, Handley CJ. Characterisation of proteoglycans and their catabolic products in tendon and explant cultures of tendon. Matrix Biol J Int Soc Matrix Biol. 2004 May;23(2):127–40.

11. Danielson P, Alfredson H, Forsgren S. Distribution of general (PGP 9.5) and sensory (substance P/CGRP) innervations in the human patellar tendon. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2006 Feb;14(2):125–32.

12. Yu JS, Popp JE, Kaeding CC, Lucas J. Correlation of MR imaging and pathologic findings in athletes undergoing surgery for chronic patellar tendinitis. AJR Am J Roentgenol. 1995 Jul;165(1):115–8.

13. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999 Feb;81(2):259–78.

14. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc Rev. 2009 Jun;17(2):112–26.

15. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 1998 Dec;14(8):840–3.

16. 1Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018 Mar 1;52(6):387–407.

17. Liao C-D, Tsauo J-Y, Chen H-C, Liou T-H. Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials. Am J Phys Med Rehabil. 2018 Sep;97(9):605.

18. Wilson F, Walshe M, O’Dwyer T, Bennett K, Mockler D, Bleakley C. Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis. Br J Sports Med. 2018 Dec 1;52(24):1564–74.

19. Habets B, Cingel R. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: A systematic review on different protocols. Scand J Med Sci Sports.

2014 Apr 1;25.

20. Murphy M, Rio E, Chivers P, Debenham J, Docking S, Travers M, et al. The rate of improvement of pain and function in mid-portion Achilles tendinopathy with loading protocols: A Systematic Review and Meta-Analysis Protocol. Sports Med. 2018 Aug;48(8):1875-1891.

21. Plas A van der, Jonge S de, Vos RJ de, Heide HJL van der, Verhaar J a. N, Weir A, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012 Mar 1;46(3):214–8.

22. Zhang Y-J, Xu S-Z, Gu P-C, Du J-Y, Cai Y-Z, Zhang C, et al. Is Platelet-rich Plasma Injection Effective for Chronic Achilles Tendinopathy? A Meta-analysis. Clin Orthop. 2018 Aug;476(8):1633–41.

23. Hussain N, Johal H, Bhandari M. An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature. SICOT-J. 2017 Oct 9;doi: 10.1051/sicotj/2017036.

24. Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med Off J Can Acad Sport Med. 2011 Nov;21(6):540–1.

25. Kearney RS, Parsons N, Metcalfe D, Costa ML. Injection therapies for Achilles tendinopathy. Cochrane Database Syst Rev. 2015 May 26;(5):CD010960.

26. Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy - a systematic review. BMC Musculoskelet Disord. 2016 10;17:207.

27. Baltes TPA, Zwiers R, Wiegerinck JI, van Dijk CN. Surgical treatment for midportion Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(6):1817–38.

28. Lipman K, Wang C, Ting K, Soo C, Zheng Z. Tendinopathy: injury, repair, and current exploration. Drug Des Devel Ther. 2018 Mar 20;12:591–603.

DVA Changes The Treatment Cycle For Allied Health Referrals DVA’s treatment cycle changes to allied health referrals will start on 1 October 2019.

General practitioner (GP) referrals to allied health providers will be valid for up to 12 sessions or a year, whichever ends first. Clients may have as many treatment cycles as the GP determines are needed. The treatment cycle does not limit the number of clinically required services that the client needs. These new arrangements aim to improve the quality of care for DVA clients.

There is no change to referral arrangements between GPs and medical specialists (including surgeons and psychiatrists).

The new referral arrangements apply to Gold Card and White Card holders, excluding exercise physiology and physiotherapy services for Totally and Permanently Incapacitated (TPI) Gold Card holders.

Transitioning to the treatment cycle arrangements DVA understands providers need certainty about the validity of referrals made prior to 1 October 2019. When the new treatment cycle begins on 1 October 2019, the following arrangements will apply:

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• All new referrals made on or after 1 October 2019 will be subject to treatment cycle arrangements, except for exercise physiology and physiotherapy for DVA clients with a TPI marked Gold Card.

• After 1 October 2019, clients with an existing indefinite allied health referral can receive up to 12 sessions or access for one year (whichever ends first) before they need a new GP referral.

• After 1 October 2019, clients with an existing annual allied health referral can receive up to 12 sessions or treatment until their annual referral expires (if that occurs first).

DVA will send information to allied health providers, GPs and DVA clients currently receiving allied health services before the treatment cycle commences The new End of Cycle Report item As the care coordinator, the GP is key to the treatment cycle. They will ensure health care and allied health treatment is the most appropriate for their patient’s needs. The allied health provider will need to prepare a treatment plan and ask the patient about their goals.

At the end of the treatment cycle, the allied health provider will send a report back to the patient’s usual GP. The GP will use this report to review the treatment progress and assess if further treatment is clinically required or whether other treatment options are needed.

To support allied health providers, DVA is introducing a new End of Cycle Report item with a fee of $30 (excl. GST) that allied health providers can claim on completion of the report at the end of each treatment cycle. This End of Cycle Report item will be available for reports made from 1 October 2019.

Further details about the treatment cycle, including revised Notes for Providers and Fee Schedules, will be published on the DVA website in coming weeks.

More information See Improved Dental and Allied Health (provider information) for further information about the treatment cycle.

Subscribe to DVA Provider News for updates on DVA health arrangements.

RESEARCH NEWS

Abstracts THE FABQ MEASURES PATIENT EXPECTATIONS AND NOT FEAR. STUDY DESIGN: A cohort study with 12 months of follow-up.

OBJECTIVE: To assess 1) the unidimensionality of the Fear-Avoidance Beliefs Questionnaire (FABQ) and 2) whether single questions in the FABQ predict future sickness absence as well as the whole scale.

SUMMARY OF THE BACKGROUND DATA: The fear-avoidance model is a leading model in describing the link between musculoskeletal pain and chronic disability.

However, reported measurement properties have been inconsistent regarding the FABQ. METHODS: Individuals (n = 722) sick listed due to musculoskeletal, unspecified or common mental health disorders undergoing rehabilitation was included. A Rasch analysis was applied to evaluate the measurement properties of FABQ and its two subscales (physical activity and work). Linear regression was used to assess how well single items predicted future sickness absence.

RESULTS: The Rasch analysis did not support the FABQ or its two subscales representing a unidimensional construct. The 7-point scoring of the items was far too fine meshed and in the present population the data only supported a yes or no or a 3-point response option. The items were invariant to age, whereas two of the items revealed gender differences. The item “I do not think that I will be back to my normal work within 3 months” was the best predictor of future sickness absence. Adding the item “I should not do my regular work with my present pain” improved the prediction model slightly.

CONCLUSIONS: The FABQ is not a good measure of fear-avoidance beliefs about work or physical activity, and the predictive property of the FABQ questionnaire is most likely related to expectations rather than fear. Based on these results we do not recommend using the FABQ to measure fear-avoidance beliefs Lene et al. The Fear Avoidance Beliefs Questionnaire (FABQ). Does it really measure fear beliefs? Spine. 2019.

WHAT CHANGES DOES SMT BRING ABOUT IN HEALTHY INDIVIDUALS? INTRODUCTION: The effectiveness of spinal manipulative therapy (SMT) for improving athletic performance in healthy athletes is unclear. Assessing the effect of SMT on other

performance outcomes in asymptomatic populations may provide insight into the management of athletes where direct evidence may not be available. Our objective was to systematically review the literature on the effect of SMT on performance-related outcomes in asymptomatic adults.

Info Bites

METHODS: MEDLINE, CINAHL, SPORTDiscus, and Cochrane Central Register of Controlled Trials were systematically searched from 1990 to March 23, 2018.

Inclusion criteria was any study examining a performance-related outcome of SMT in asymptomatic adults. Methodological quality was assessed using the SIGN criteria. Studies with a low risk of bias were considered scientifically admissible for a best evidence synthesis. We calculated the between group mean change and 95% confidence intervals.

In this retrospective cohort analysis involving a sample of the paediatric US Medicaid population, researchers assessed the risk of developing asthma in relation to antibiotic fills in the first 2 years of life in these individuals.

Participants included children with continuous medical and pharmacy coverage from birth to 2.5 years of age. Those who received a diagnosis of asthma prior to 2.5 years of age were removed from the study. Of 79,582 children included, antibiotic prescriptions filled were 0, 1-2, or ≥ 3 for 29,931 (37.6%), 27,403 (34.4%), and 22,248 (28.0%) children, respectively. A follow-up of 89,545 personyears was performed, during which time 2,381 new cases of asthma were documented. In this Medicaid population, an increased risk of asthma diagnosis from 2.5 to 5 years of age was observed in relation to antibiotic prescriptions filled in the first 2 years of life.

RESULTS: Of 1415 articles screened, 20 studies had low risk of bias, seven were randomized crossover trials, 10 were randomized controlled trials (RCT) and three were RCT pilot trials. Four studies showed SMT had no effect on physiological parameters at rest or during exercise. There was no effect of SMT on scapular kinematics or transversus abdominus thickness. Three studies identified changes in muscle activation of the upper or lower limb, compared to two that did not. Five studies showed changes in range of motion (ROM). One study showed an increase lumbar proprioception and two identified changes in baropodometric variables after SMT. Sport-specific studies show no effect of SMT except for a small increase in basketball free-throw accuracy.

CONCLUSION: The preponderance of evidence suggests that SMT in comparison to sham or other interventions does not enhance performance-based outcomes in asymptomatic adult population. All studies are exploratory with immediate effects. In the few studies suggesting a positive immediate effect, the importance of such change is uncertain. Further high-quality performance specific studies are required to confirm these preliminary findings.

Corso et al. The effects of spinal manipulation on performance-related outcomes in healthy asymptomatic adult population: a systematic review of best evidence. Chiropractic & Manual Therapies, 2019

ASSOCIATION BETWEEN EARLYCHILDHOOD ANTIBIOTIC EXPOSURE AND SUBSEQUENT ASTHMA IN THE US MEDICAID POPULATION

Fishman E, Crawford G, DeVries A, et al.

Association between early-childhood antibiotic exposure and subsequent asthma in the US Medicaid population.

Annals of Allergy, Asthma, and Immunology | August 01, 2019 ARE WE MAXIMISING OUR USE OF ONLINE RESOURCES? Researchers examined the current practices of New Zealand (NZ) healthcare providers in recommending online resources for persistent pain management. In addition, they assessed factors that predict healthcare providers’ recommendations, and investigated common concerns. Via performing an online survey, they collected and analysed data from 213 NZ healthcare providers involved in the management of persistent pain.

Recommendation for online resources was reported to be valued by only half of the healthcare providers surveyed, suggesting limited confidence in recommending, or knowledge of, existing online resources for persistent pain management.

Recommendations for online resources was positively influenced by specialist interest in treating pain, and level of confidence. Findings suggested the necessity for ongoing education for healthcare providers on evidence-based online resources to promote online resources as a self-management support tool for people with persistent pain.

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RESEARCH NEWS Devan H, Godfrey HK, Perry MA, et al.

Current practices of health care providers in recommending online resources for chronic pain self-management. Journal of Pain Research | August 13, 2019 CONCERNS OVER OSTEOPOROTIC MEDICATION APPEAR UNFOUNDED Through a meta-analysis of 38 randomized clinical trials involving 101,642 participants that assessed drug therapies for osteoporosis, researchers determined whether randomized clinical trials showed that treatment with bisphosphonates, especially zoledronate, was correlated with decreased mortality rates. Between all drug treatments, no important relation for osteoporosis and the overall mortality rate was evident, and no meaningful relationship between clinical trials of bisphosphonate treatment and overall mortality was noted. Moreover, clinical trials of zoledronate treatment demonstrated no relationship with the overall mortality rate, though, for heterogeneity of the results, evidence existed. Thus, bisphosphonate treatment may not be related to decreased overall mortality rates in addition to reduced fracture risk and should only be suggested to reduce fracture risk.

Cummings SR, et al. Association between drug treatments for patients with osteoporosis and overall mortality rates: A meta-analysis. JAMA | August 23, 2019 HOWEVER, CONCERNS OVER NSAID’S GROW, THIS TIME FOR NEPHROTIC SYNDROME. In this matched case-control study, researchers examined the link between NSAID use and the risk of nephrotic syndrome via using the UK primary care database. Patients with a first diagnosis of nephrotic syndrome comprised cases. Patients without nephrotic syndrome served as controls. Based on cyclooxygenase enzyme selectivity and chemical groups, the investigators categorized NSAID exposure as either current, recent, or past use. According to findings, the use of conventional NSAIDs was related to a higher risk of nephrotic syndrome starting from at least 2 weeks of exposure, as well as for recent and past exposure up to 2 years prior to the diagnosis of nephrotic syndrome. Mainly acetic acid and propionic acid derivatives seemed to be responsible for this higher risk.

Bakhriansyah M, et al. Risk of nephrotic syndrome for non-steroidal antiinflammatory drug users. Clinical Journal of the American Society of Nephrology | August 19, 2019

MORE ON NSAIDS AND CARDIOVASCULAR DISEASES. The authors sought to disentangle the role of NSAIDs in the increased risk of CVD among OA patients. To this end they conducted a longitudinal study based on linked health administrative data (HAD) from British Columbia, Canada. From a population based cohort of 720,055 British Columbians, they matched on age and sex to assemble 7,743 Osteoarthritis (OA) patients and 23,229 non OA controls. They found that people with OA had a higher risk of developing CVD compared to people without OA. Approximately 41% of the total effect of OA on increased CVD risk was mediated through NSAID. Among the secondary outcomes, the proportion mediated through NSAID was 23%, 56% and 64% for CHF, IHD and stroke, respectively.

Atiquazzaman et al. Role of Non Steroidal Anti Inflammatory Drugs (NSAIDs) in the Association between Osteoarthritis and Cardiovascular Diseases: A Longitudinal Study. Arthritis & Rheum. 2019.

TIME TO RETHINK LASLETT’S CRITERIA FOR DETECTING SIJ PROBLEMS...

Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg.

Patients’ pain was assessed via 0–10 NRS pre-injection and immediately post-injection to determine positive anaesthetic response to the injection. Six physical exam manoeuvres (thigh thrust, Geanslen’s test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes post-injection. The results of these SIJ physical exam manoeuvres were evaluated singly and in combinations for diagnostic power in relation to a positive anaesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam manoeuvre or combination of manoeuvres and anaesthetic response to the injection.

The authors concluded that in this cohort, patient physical exam manoeuvres to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anaesthetic block.

And Furthermore...

LIFESTYLE AND CANCER INCIDENCE AND MORTALITY RISK In this prospective study using two Swedish cohorts— the Malmö Diet and Cancer Study (N=25,604) and the Malmö Preventive Project (N=16,216)— researchers assessed the magnitude of the link between a favourable lifestyle (based on non-smoking, normal-weight, absence of excessive drinking, regular physical activity, and healthy diet) and cancer incidence and mortality risk by using Cox regression stratified by family history of cancer (all types). A 22% and 40% lower risk of cancer incidence and mortality, respectively, was observed in relation to a favourable lifestyle vs an unfavourable lifestyle. Family history did not significantly modify these links, but subjects with ≥ 2 affected first-degree relatives exhibited a null link between lifestyle and cancer incidence. Overall, attenuated cancer incidence and mortality risk in the general population may be achieved by improving adherence to cancer prevention recommendations.

Drake I, et al. Lifestyle and cancer incidence and mortality risk depending on family history of cancer in two prospective cohorts. International Journal of Cancer | May 15, 2019.

TAX A SUGAR-SWEETENED BEVERAGE AND WATCH THE SALES FALL . . . .

Researchers examined how beverage prices and volume of sales were influenced by the implementation of a beverage excise tax on sugar-sweetened and artificially sweetened beverages, which took effect in Philadelphia in 2017.

According to findings, the beverage excise tax on sugar-sweetened and artificially sweetened beverages led to a significant rise in beverage prices and a significant decrease in volume sales of

Schneider et al. Validity of Physical Exam Manoeuvres in the Diagnosis of Sacroiliac

taxed beverages, although purchases in

Joint Pathology. Pain Medicine, 2019.

changes in sales volume.

neighbouring areas partially offset the Roberto CA, et al. Association of a beverage tax on sugar-sweetened and artificially sweetened beverages with changes in beverage prices and sales at chain retailers in a large urban setting.

JAMA | May 16, 2019

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CLASSIFIEDS THOSE AT A HIGH RISK OF MS MAY BENEFIT FROM THE ADDITION OF UNPROCESSED RED MEAT TO A MEDITERRANEAN DIET. Using data from an Australian multicenter, case-control study, researchers examined the links between Mediterranean diet adherence and the risk of a first clinical diagnosis of central nervous system demyelination (FCD), a common precursor to multiple sclerosis (MS). Study participants were matched on age, sex, and study region (282 cases, 558 controls; aged 18–59 years; 78% female). Using data from a food-frequency questionnaire, calculation of the alternate Mediterranean diet score was done. According to findings, reduced risk of FCD was evident in relation to adherence to a Mediterranean diet in this Australian adult population.

Subjects at high risk of MS may benefit from the addition of unprocessed red meat to a Mediterranean diet.

Black LJ, et al. A higher Mediterranean diet score, including unprocessed red meat, is associated with reduced risk of central nervous system demyelination in a casecontrol study of Australian adults. The Journal of Nutrition | May 30, 2019

Classifieds ASSOCIATES REQUIRED VIC – Caroline Springs: Chiropractor wanted, to join our busy Wellness Studio; comprising of Chiropractic, Remedial Massage, Yoga, Reformer Pilates and Psychology services. You will be taking over an existing client base as well as new referrals. Our senior Chiropractor is going on maternity leave. We’re looking for a candidate who is friendly, highly motivated who possess great communication skills and has strong manual adjusting skills. Our practitioners use a wide range of techniques such as dry needling, cupping therapy, massage & manual manipulation techniques within their treatments. So if you see yourself practicing this way, we’d love to hear from you. Please send your CV to info@chiroease. com.au SA – Adelaide Northern Suburbs: An enthusiastic, energetic chiropractor, with a passion for family focused, wellness care, wanted to join a like minded team in an Adelaide Northern Suburbs practice. With one long term practitioner leaving due to injury, we have 2-3 half day shifts available

immediately. The successful applicant will have the opportunity to increase those hours if desired, as you build your own patient base. Terms and conditions are negotiable, and mentoring is available, with both male and female chiropractors on staff offering a combined experience of over 50 years to draw from. Please direct your enquiries to info@sachiropractic.com.au NSW – ChiroRelief: based in Enmore, Sydney is looking for a part time chiropractor to join our team. The successful candidate will have to be proficient at manual adjusting full spine, have a maintenance/wellness philosophy with the ability to keep patients engaged in their health journey. We use spinal decompression / automated flexion distraction, manual adjustive techniques plus mobilisation techniques, dependent on the case, with the addition of dry needling and cupping and soft tissue techniques.

Training will be provided however some background knowledge in these areas will be useful. We are looking for a long term addition to our clinic, who shares our love for chiropractic and an ability to think outside the box. A female associate would be preferable. Superstar new Grads are welcome to apply. Please send resume to chiroshiyab@gmail.com QLD – Kingaroy: We are looking for the right person to share and hone their skills delivering awesome chiropractic, to uplift the health and wellbeing of our clients. You must be energetic, enthusiastic and a great communicator.

Founded in 2007, our client base has seen continuous growth. We offer mentorship, a place to practice your art of Chiropractic and earn with generous remuneration. We encourage you to further your professional knowledge and skills within a supportive team.

Located in Kingaroy, QLD, we boast a strong community with a population of 30,000 in the region and are only a short drive to the Sunny Coast, Brisbane and Toowoomba. Kingaroy has a variety of major retail chains plus awesome local retailers and wineries, clubs, pubs and cafes. Our community is bursting with vitality with a wide selection of sporting clubs, community groups and fun regional events involving food, wine and music.

Kingaroy caters for the family with multiple community kindy’s, day care centres as well as public, independent and private schools throughout the region. If this Full-Time position is for you, contact us at the e-mail below with attention to Karissa Stallwood and attach your CV. Experienced and New Grads both welcome. We will consider assisting someone to relocate. reception@ intouchchiro.net.au or 0429 621 320

ACT – Quenbeyan: Growth, Contribution and Fun! We’re looking for an energetic, vitalistic chiropractor to join our successful wellness practice of 23 years. There are 2 things we care about most at Provolution Health – our clients and each other! Our practice has a beautiful, positive energy and culture! This means you’ll have excellent people skills, are warm and genuine in your interest and concern for others. Our team is like a second family. We’re hardworking, but our practice never goes a minute without laughter and fun. Personal and professional development is extremely important to us, so you’ll be excited at the idea of growth and developing additional skills! Whether you’ve recently completed your training or have years of experience, what’s important is that you love chiropractic and want to make a difference in people’s lives. If you’re seeking to grow as a practitioner, be supported and valued – all while having fun and receiving above industry average remuneration, we want to hear from you! Please e-mail your resume to melinda@ provolutionhealth.com.au with a cover letter and brief introduction of who you are and why this opportunity excites you.

ACT – Canberra and VIC – Maryborough: Graduate chiropractor positions in Canberra and Maryborough VIC. Lots of new patients.

Work alongside and be mentored by experienced chiropractors with Australia wide and international experience. Work across two clinics in the ACT or single clinic in Victoria with less competition than Melbourne or Sydney. Strong manual adjusting skills, chiropractic philosophy and x-ray licence a must. Established company to start your career in a nurturing and productive environment. Contact Dr Jeremy with your details and why you would like to join GHC chiropractic. 0487 001 462 drjeremy@ ghcchiro.com QLD – Milton: Chiropractix is seeking a dedicated and compassionate associate chiropractor to join our motivated and patientfocused team in Milton. We offer attractive remuneration, existing patient base, constant influx of patients and training opportunities only 3km from Brisbane CBD. Please email your CV to chiropractix@gmail.com QLD – Redland: Locum for 6.5 weeks (Oct 23rd – Dec 7th) with the opportunity to become Associate – Redland City – 20 km east of the Brisbane CBD. This is an opportunity to join an outcome driven, patient centred, multimodal practice. Our philosophy: From pain to flexibility and stability to peak performance. We let the diagnosis determine the choice of therapeutic protocols. Passive modalities include: Diversified manipulation, impulse instruments, dry needling, fascia manipulation (skin rolling / Graston

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CLASSIFIEDS technique), Hill Spinal Decompression Traction, laser, microcurrent therapy, ultrasound, kinesio-taping, and mirror image traction (Chiropractic Biophysics). Active therapies include: mirror image exercises, fascia fitness (foam rolling / stretching), core stabilization, spinal stenosis boot camp, and whole body vibration. Suitable for a fitness minded chiropractor who wants to be a doctor of musculoskeletal medicine without the use of drugs or surgery. Great remuneration. For more information contact chiro@bytesite.com.au NSW – Jervis Bay: Retainer $400/day.

Looking for the right associate to join our rapidly expanding Chiropractic & Podiatry clinic in beautiful Jervis Bay only 2 hours south of Sydney. Mainly utilising manual therapy & soft tissue / rehab focused.

Welcome to introduce your own techniques.

Beautiful location, great facilities. Medical Doctors also at hand within the clinic & supportive of chiropractic. Mentoring is also available from the Principal. Days & Rates negotiable & flexible. Attractive retainer. Call Ned on 0412494013 or info@ backandfootclinics.com.au

BUSINESSES FOR SALE VIC – Wantirna: Natural Therapy Centre (established 1978) incorporating Remedial Massage/Structure Alignment/Acupuncture/ Naturopathy in a busy shopping precinct has become available. Current owner (sole practitioner) wishes to retire and has priced the opportunity accordingly. Presently sharing with a Naturopath, who works independently, the Centre has two treatment rooms (could be made into more), air conditioner, mini kitchen, waiting room & bathroom. Currently operating 4 days a week so there is opportunity to expand and/or share with a fellow practitioner to reduce costs. Suit newly qualified person or somebody who wishes to establish their own practice. Price is very negotiable. For more information please email Leo – Lmgrona026@ yahoo.com.au or mobile 0418 580 960 WA – Mandurah: Solo practitioner clinic located in city centre, with generous reception area & disabled access. Gross (2017/18) = $169,680.98; (2016/17) = $159,929.00.

Lease, outgoings, utilities = only $1300 p/m + GST. To enquire, contact Ben: waterschiro@icloud.com or 0404 683 143

FOR SALE Australia Wide: New chiropractic tables and supplies for all your practice needs.

Australia’s largest supplier of treatable tables allows Everfit to provide the lowest prices.

FREE shipping Australia Wide. Visit us today: http://www.everfithealthcare.com.au/ or call 1800 908 903

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LOCUMS AVAILABLE Dr Marcus Drenslaw - Associateship/locum position desired. In busy private practice 20+ years, practicing almost entirely activator and SOT. Call Marcus 0434 238 359 Dr Darren Riordan - Proficient in Diversified, Drop piece, Activator, basic AK and Dural Release techniques. 30 years experience working as an associate, locum and in solo practice 0413 065 386, driordan12@gmail.com NSW Brendan King - Macquarie graduate with 3 years locum experience. Happy to observe you to emulate your treating style in the clinic. Proficient in Diversified manual adjusting, Activator, Drop piece, DNS (dynamic neural stabilisation), SOT and soft tissue techniques. I focus on my communication and leaving the practice with a healthy load for when you return.

Comfortable with different treatment lengths and practice settings. Ph: 0434 867 294 Email: brendankingchiropractor@gmail.com VIC Dr Athol Morris - Many years experience in solo practice and with associates. Exp. diversified, drop piece, Thompson, Pierce Stillwagon, Derefield, some Activator and TRT and exercises.

Wellness and maintenance care. Palmer Gonstead marking. Will support your practice type /team. Happy to observe prior and to adapt to your regime and to do school holiday locums. Also Animal Biomech.Med./ domestic animals, as an aside. Contact 0412 594 004 or dr.atholmorris@gmail.com SA Dr Ben Buttfield - 2009 Macquarie grad. Available for locum/associate position in Adelaide (S.A) from December 2015. Diversified, drop piece, soft tissue techniques, movement pattern appraisal/ corrective exercise. 8 years experience as an occupational therapist. Strong commitment to E.B.H. Excellent interpersonal skills.

0412 041 296 SA Dr Claire Chittleborough - I have 22 years experience that includes locum work and owning my own business and will observe prior so I can adapt to your methods to maintain continuity for your patients. Excellent manual adjusting skills, Activator, Impulse, dry needling, rehab and well being advice.

Available in Adelaide from November – March.

0413 895 150 or clairey@adam.com.au WA Dr Benjamin King - Chiropractor with 5 + years of experience as a locum.

Proficient in full spine manual diversified techniques and experienced with activator and drop piece; Derrefield, Thompson and other techniques if required. Available in WA metro/country. Adaptable and willing to observe. References available upon request. Contact via 0438 311 089 or kingorb@gmail.com

Dr Scott Palmer - 97 RMIT Graduate.

Experienced Locum with over 60 Locums covered. Excellent references. Proficient in SOT, Diversified, Drop piece, Activator Methods, NSA, TRT. Ph: 0405 445 722 or spinalscotty@gmail.com Dr Louise Fisher - I have 13 years clinical experience in Diversified, Activator, Drop-Piece, basic AK, Cranio-Sacral, Dural release and soft tissue therapy techniques. Proficient in both locum and associate positions i have worked on many major international sporting teams as well as completing a Post Graduate Diploma in Paediatric Neurology with the CCNP. I am based in Perth but happy to travel nationally and observe prior to if needed. If interested please contact at loulabell27@hotmail.com or phone: 0415 251 493 Scott Fargie - Available for Australia wide immediate locum positions. 20+ years experience. Traditional manual care: skilled spinal manipulation with soft-tissue work. No fuss approach to registration for your location & management. References. 0468 313 744, scottfargie@gmail.com VIC Dr Sean McKenna - RMIT 2003 graduate. Available for part-time locum work in Melbourne. Proficient in Diversified, Thompson, SOT, Activator. Capable of tailoring care to best suit your patients and practice. Will observe prior. Call 0401 350 537 or email: drseanmckenna@hotmail.com Dr Ashka Mehta - 2011 Murdoch graduate with previous locum experience.

Available to work in Perth, Brisbane, Sydney and Melbourne metropolitan areas. I predominantly use diversified technique but am able to adapt to your practice style.

Phone 0423 163 367 or email: ashka316@ yahoo.com.au QLD Paul Mellish - RMIT grad ’83.

Excellent manual adjusting skills. Available immediately for short or long term, Gold Coast and/or Brisbane. Consider position in Nth NSW or Southern QLD to Hervey Bay in the near future. Will also consider elsewhere in Queensland. Open plan clinics are OK. X-ray licence and insurance both current.

Call 0411 804 055

CLASSIFIEDS