news NEWSLETTER OF CHIROPRACTIC AUSTRALIA
VOLUME 2 NUMBER 4
CPD: The New Standard CAâ€™s All New CPD Solution Chiro History Beware Social Media
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FROM THE PRESIDENT
Professor Rod Bonello
BSC(SYD), DO, DC(SCC), MHA(UNSW), FRCC The New Registration Standard: CPD is now in force
By the time you read this the new AHPRA Registration Standard: Continuing Professional Development concerning mandatory Continuing Professional Development will have come into force. The new Registration Standard applies to many allied health practitioners, not just chiropractors, as a requirement to maintain their registration to practice. The new Registration Standard places the responsibility for Continuing Professional Development squarely on the shoulders of the individual practitioner. Consequently, the educational activities that an individual practitioner selects will need to be very focused and carefully planned to meet their needs. In fact, the starting point will be deciding exactly what areas of practice they need to expand or brush-up on. Another significant change within the new Registration Standard is the reduction in required hours from 25 to 20 and removal the requirement for the hours to be split between formal and informal. However, in doing so this does increase the responsibility of the individual to undertake educational activities that are appropriate and, as the Standard clearly states are, “evidence based and directed towards clinical matters that contribute to minimising risk, improving patient safety and improving health outcomes for patients”.
See accompanying articles in this issue from CA’s Education Manager, Dr Peter Werth.
Furthermore, in expanding on AHPRA’s new Registration Standard the Chiropractic Board of Australia Guidelines on CPD state that activities should:
• Emphasise active participation in learning (ie. be interactive) • Be readily implementable in their day-today practise of the profession • Be interprofessional where possible • Include engagement with peers and patients / health care consumers where relevant As to be expected the Chiropractic Board of Australia will continue their practice of random audits of registrants regarding the CPD they have undertaken and, under the new Registration Standard, their reflections on how their CPD can improve or has improved their practice. So, as you can see even from this broad view, the new requirements are significantly different to prior obligations. To assist you in this new regulatory environment Chiropractic Australia has assembled an overarching solution which includes: • GEN-C - a new suite of online programs to be available on the GEN-C platform,
Advertising regulation compliance has long been a difficult area for AHPRA to maintain. At Chiropractic Australia we are proud of our membership for their diligence in ensuring that all messaging to the public is clear and truthful. However, we urge all members to review their promotional materials to ensure that it is best practice. Remember, that if you are using promotional material generated in another country that it may not comply with Australian regulations. Now is a good time to review your advertising. Just type “AHPRA advertising regulations” in your web browser for further information.
Please accept my sincere wishes for a joyful end to 2019 and a successful and fulfilling 2020. Thank you to our hard-working CA Board members, our wonderful administration staff in Head Office and the many members who have contributed to this great profession.
BSc(Syd), DO, DC(SCC), MHA(UNSW), FRCC President
• CA Journal Club – an improved websitebased version free to CA members • An App to record all your CPD activity and reflections.
Best wishes for the festive season! 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: email@example.com 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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CONTINUING PROFESSIONAL DEVELOPMENT
The New Registration Standard: CPD… By: Dr Peter Werth BAppSc (Chiropractic)
CA Education Manager
December 1st marks the start of the 2019-2020 Continuing Professional Development (CPD) Cycle and with it the changes to CPD requirements recently announced by the Chiropractic Board of Australia (CBA) will come into force. These changes include the removal of the previous requirement for practitioners to obtain their CPD from sources that have had their courses accredited by either Chiropractic Australia or the Australian Chiropractors Association. Thus, the onus is now placed squarely on the individual practitioner to ensure that they undertake CPD which meets the newly announced standard. Members can rest assured that Chiropractic Australia has been working hard to ensure that the arrival of these changes will not be onerous for our members and we have developed exciting new CPD initiatives (see accompanying article) that will assist practitioners to meet their obligations while improving their clinical skills and maintaining patient safety. The new CPD Registration Standard sets out the Board’s minimum requirements for CPD for all practising chiropractors. In order to meet the standard, you must do the following; 1. Complete at least 20 hours of CPD each year that: a. Seeks to improve patient health outcomes, safety and experiences b. Draws on the best available evidence, including well-established and accepted knowledge that is supported by research where possible, to inform good practice and decision-making c. Contributes directly to maintaining and improving your competence (performance and behaviour) and keeping you up to date in your chosen scope and setting of practice, and d. Builds on your existing knowledge 2. Maintain a first aid qualification at least equivalent to HLTAID001 Provide Cardiopulmonary Resuscitation (CPR)
CA NEWS DECEMBER 2019
3. Maintain a portfolio that documents your learning goals and records all your planned CPD activities and your reflection on how these CPD activities are expected to improve or have improved your practice. The Board’s Guidelines: Continuing Professional Development also states that CPD for chiropractors should: • Draw on the best available evidence, including well-established and accepted knowledge that is supported by research where possible, to inform good practice and decision-making • Reflect the competencies that chiropractors need to maintain and develop • Include balanced and up-to-date information that supports evidence-based patientcentred practice • Emphasise active participation in learning (be interactive) • Be readily implementable in their day-to-day practise of the profession • Be interprofessional where possible • Include engagement with peers and patients / health care consumers where relevant
an approved registration standard for the profession (sections 82, 83 and 112 of the National Law) • That a failure to undertake the CPD required by this standard is not an offence, but may be behaviour for which health, conduct or performance action may be taken by the Board (section 128 of the National Law) • That registration standards, codes or guidelines can be used in disciplinary proceedings against you as evidence of what constitutes appropriate practice or conduct for chiropractors (section 41 of the National Law). Chiropractic Australia has been actively working towards preparing for the introduction of the new CPD Standard to ensure that the CPD programs we offer to our members will comply with the Board’s requirements of CPD that is evidence-based, geared towards improving patient outcomes and assisting practitioners to practice safely. Please refer to the accompanying article on the oposite page. For further details regarding the Board’s new Registration Standards and their Guidelines on CPD please visit:
• Be relevant to their practice, and
• Be carried out on an ongoing basis throughout a chiropractor’s career.
If you register part-way through a registration period you must complete five hours of CPD for every three months of registration remaining in the registration period. As has been previously required when renewing your registration, you must declare whether you have complied with the CPD standard. The Board may undertake an audit of your CPD activities to determine whether you have complied with the standard and may also review your status if the Board receives a notification about you. You must maintain records of your CPD activities for five years, and if audited you may be required to provide our CPD portfolio, and any other information the Board may require. According to the Board if you don’t meet this standard; The Health Practitioner Regulation National Law, as in force in each state and territory (the National Law) establishes possible consequences if you don’t meet this standard. These consequences include: • That the Board can impose a condition or conditions on your registration, or can refuse an application for registration or renewal of registration, if you do not meet a requirement in
CONTINUING PROFESSIONAL DEVELOPMENT
And CAâ€™s All New CPD Solution By: Dr Peter Werth BAppSc (Chiropractic)
CA Education Manager
After nearly two years of planning and development Chiropractic Australia is proud to announce the launch of exciting initiatives to coincide with the introduction of the new AHPRA Registration Standard: Continuing Professional Development and the revised Guidelines: Continuing Professional Development released by the Chiropractic Board of Australia earlier this year, both of which came into force on 1st December 2019 (see accompanying article). It is important to note that the new Registration Standard changes the landscape of CPD for chiropractors in Australia and creates new challenges in that the responsibility to comply is firmly on the shoulders of the individual practitioner. Adding further weight to this responsibility is the likelihood that many of the CPD programs and seminars that have been accredited under the previous model may not meet the new Standard. CA determined that the best way to meet these challenges was to take a fresh approach and so the first of these new initiatives is the Global Education Network for Chiropractic (GEN-C). This is a range of brand-new online programs designed to meet the requirement of the new Registration Standard to draw on the best available evidence which, where possible, is supported by research. These programs will assist practitioners to build on their knowledge and maintain and/or improve their competencies. The second initiative is the re-launch of the Chiropractic Australia Journal Club in a new website-based format. Moving away from the
current Dropbox format and positioning the Journal Club onto the CA website will raise the profile of this valuable resource and make it more readily to accessible to all practitioners.
experts to provide a source of educational options that have cliniciansâ€™ needs at the forefront of its goals.
The third part of our solution to assist practitioners to comply with the demands of the new Registration Standard is an App to enable comprehensive recording of CPD activities regardless of whether they are online or face to face. The App will allow practitioners to track and record their all CPD activities including the number of activities they have undertaken, the hours involved, their reflections on the activities, etc. Going back thirty years and looking at the CPD that we presented firstly with COMSIG, then COCA and now with Chiropractic Australia, we have been the leader in providing evidencebased CPD to the Australian chiropractic profession. These new initiatives, along with the series of icarechirocast podcasts with hosts Professors Dave Newell and Stephen Perle, and our regular conferences will ensure that both CA members and others can be confident that their CPD needs will be well met.
What is GEN-C? GEN-C represents a partnership between Chiropractic Australia, the European Chiropractors Union (ECU) (via its educational arm the European Academy of Chiropractic), and the Royal College of Chiropractors (RCC). All three organisations have a long history of providing high quality continuing professional development to the chiropractic profession in their local regions.
Access to the GEN-C platform will be available for an annual subscription of $AUD265.00 (incl GST) including free access to the CPD App. This amounts to $5 per week to access CPD by the leaders in the field.
The new and improved Chiropractic Australia Journal Club For those of you that have been active on social media, the CA Journal Club will be very familiar to you. Spearheaded by Dr Adrian Sheridan it has become a highly useful resource to keep up to date with the latest evidence published and also a repository for journal articles in over fifty subject areas relevant to chiropractic. In recognition of this valuable resource Chiropractic Australia is now expanding this service from a Dropbox based service to an integrated part of the CA website. CA members will continue to enjoy free access to the Journal Club as a member benefit and non-members can subscribe for an annual subscription of $AUD50.00 (incl GST). CA members will have received an email outlining how to sign up for these new initiatives. If you are not a CA member, now is the time to join and gain access to this highquality evidence-based CPD. Go to: www. chiropracticaustralia.org.au/professionaldevelopment/
The precedent for working together was established with the partnership formed to produce the leading chiropractic journal Chiropractic and Manual Therapies which is published by BioMed Central Ltd via the global publisher Springer Nature. Within what is a relatively small profession it seemed logical for the three organisations to jointly contribute to the development of the journal, a move that has proven to be very successful. Because of the success of Chiropractic & Manual Therapies it was a far easier process to pool resources to create and develop GEN-C as an online CPD platform producing high-quality educational programs. The CPD offering available via the GEN-C platform has enlisted expert clinicians, researchers and academics from within the chiropractic profession as well as other musculoskeletal experts from around the globe to contribute to the development of the online modules, regular journal articles to review and interviews and discussions with recognised W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U
ALL NEW! Online evidence-based chiropractic CPD developed by leading experts in our profession
GLOBAL EDUCATION NETWORK FOR CHIROPRACTIC
Launching January 2020
GEN-C is produced collaboratively by leading chiropractic professional bodies
CA NEWS DECEMBER 2019
A Report From The Summit By: Dr Michael Swain PhD MPhil MChiroprac FRCC (Hon) On the 14th & 15th of September 60 of the world’s leading researchers in chiropractic met at the Canadian Memorial Chiropractic College (CMCC) in Toronto, Canada to participate in the Global Summit on the Effectiveness of Spinal Manipulation for the Management of Non-musculoskeletal Disorders: A Focus on Patients and the Public. The successful event was organised by Prof. Jan Hartvigsen, Prof. Pierre Côté, Prof. Charlotte Leboeuf-Yde and Dr. Iben Axén. The specific purpose of the Summit was to develop evidence-based patient-centred recommendations to inform patients, the public and decision makers about the efficacy of spinal manipulation in the prevention and treatment of non-musculoskeletal disorders. Researchers worked tirelessly throughout the weekend, reading and critically appraising journal articles that were identified in the systematic review process. On Sunday afternoon, after much robust scientific debate, recommendations were voted on by the entire research team. The event was conducted according to scientific methodology with rules of engagement, the results will be communicated soon via journal publication. In the interest of total transparency, approximately 30 external observers (chiropractic representatives from around the globe) were invited to join the event to oversee the proceedings. Observers worked on behalf of chiropractic associations, regulation and accreditation bodies, and included presidents of national and international organisations from Australia, England, France, The Netherlands, Sweden, the European Chiropractors’ Union, and the World Federation of Chiropractic.
Australia and namely Chiropractic Australia were well represented in the scientific proceedings. Eleven researchers from all the Australian universitybased chiropractic programs contributed to the scientific work. While some Australian researchers participated through university and funding body grants, most were contributing their expertise by self-funding. The Summit was a unique experience for those that attended. Seldom do a large group of chiropractic researchers meet to work so intensely on a project. On several occasions I was awestruck by the calibre of the participants, the rigour of the discussions, and the magnitude of the undertaking. I felt there was a genuine desire among the scientists to take a thorough and unbiased look at the evidence underpinning spinal manipulation in the management of non-musculoskeletal disorders. In my opinion, the chiropractic profession is mature enough to take responsibility for its knowledge base. We can ‘own it’, whatever the state, and work to develop our field for the betterment of society. Importantly, the Summit was not focused on ‘chiropractic’ [the profession] but on patients and the public. That was made clear in a letter sent from the organising committee back in January. While the focus of the Summit was on patients and the public, we as a profession should consider this event as an important activity that supports our social contract with the community. In closing I would like to acknowledge the funding support that I received to attend the Summit, specifically I was the recipient of the CA Research Foundation Travel Grant 2019.
A Session with Professor Olivier Gagey On the 20th October Professor Gagey presented “New concept on the interaction between the lumbar spine, abdomen, and respiratory function” at Murdoch University. The seminar covered the lumbar spine as a key stabiliser of the trunk, an overview of functional anatomy of the lumbar spine and trunk, how the abdominal and lumbar paravertebral musculature or “Pillars” interact to stablise the spine, the function of ‘complex muscles’ and their gripping/clamping actions
that provide a stabilising action, and treatment and rehabilitation methods for three common presentations of pain in the lumbar spine, knee and shoulder. Professor Gagey reputation as an engaging presenter resulted in a sell-out audience who were treated to a one-of-a-kind presentation with no slides, no handouts, just blank paper, coloured pens and drawing! Thank you to Chiropractic Australia for sponsoring the event.
Professor Olivier Gagey and Seminar audience
L to R: Angus Chow, Olivier Gagey, Abbey Chilcott, Paul Staerker, Peter Bryner
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Congratulations to Dr Hazel Jenkins for completing her PhD By: Dr Amber Beynon B.Sc. (Hons), B.Chiro
Dr Hazel Jenkins is a Lecturer in the Department of Chiropractic at Macquarie University. She has recently completed her doctorate through the Department of Health Professions, Macquarie University. An amazing achievement! Her research was looking at reducing the inappropriate use of imaging in the management of low back pain. She was kind enough to take some time out of her busy schedule to answer a few questions about her PhD journey.
Q. Congratulations on successfully gaining your PhD! Can you tell us a bit about your PhD research? The focus of my PhD was to reduce unnecessary imaging for low back pain. Imaging is generally considered to be overused in the management of low back pain and currently there are few strategies that are successful in reducing imaging rates. A systematic review I conducted looked at whether imaging is actually being inappropriately ordered when compared to current guidelines. I found that one third of imaging ordered is inappropriate. Strategies to help reduce this unnecessary imaging use could improve patient management and reduce associated health care costs. There are many drivers that increase the use of unnecessary imaging, including poor practitioner knowledge and beliefs, lack of available time in consults, and pressure from the patient. During my PhD I developed an intervention to try and address these drivers and reduce imaging use for low back pain. The developed intervention was trialled with GPs in Sydney. GPs reported that they thought the intervention could be useful, particularly with patients who need more reassurance, and that using the intervention would help them avoid unnecessary imaging referrals in these situations. I am now progressing this research towards a randomised controlled trial to see if using the intervention can impact imaging referral rates.
Q. The PhD journey is not an easy one. How did you find the experience? It was challenging but I also found it very enjoyable. I was at a stage in my career where I was looking for new challenges. Although I had enjoyed the 12 years I had spent as a clinician, I was really wanting to get into the research world
CA NEWS DECEMBER 2019
to start trying to work towards some of the questions that kept coming up for me in clinical practice. Being able to take a general idea, narrow it down to a specific research question and then devising a way to answer that question I have found really rewarding. I have been lucky to have a great deal of support during my PhD from my supervisors, colleagues, workplace, and family and friends. There were definitely some parts of my research journey that I didn’t love (transcribing interviews being at the top of that list!) but the satisfaction from completing a study, writing it up, and getting it published was definitely worth it.
Q. What would you say would be the highlight of your PhD journey? Well, my third son was born during my PhD so I would probably say him! But if I stick to research highlights I would have to say presenting my research to world class back pain researchers at the International Back and Neck Pain Forum in Oslo in 2017, and receiving a prize for my presentation.
Q. Where do you see your research going now you have finished? As mentioned above, I definitely want to continue research into the intervention that I developed to see if it is effective in reducing unnecessary imaging. I also plan to do more work on the use of imaging in chiropractic practice and in particular, what information do chiropractors use from x-rays and does it improve patient outcomes.
Q. Do you have any advice for early career researchers? I would encourage anyone with a drive to do research to get involved. We need more researchers as there is still so much work to be done to optimise the management of musculoskeletal pain. In saying that though, you do need to have that drive to want to do research and a good support network to get through the challenges that you will face. Therefore, I think the best advice I can give is to make sure that you know why you want to do research and what you aim to get out of it, that you are interested in your chosen research topic, and that you find a supportive research supervisor who has the same general vision for your research journey as you do.
Q. I heard your presentation at the CA National conference, “X-ray imaging: When and when not to use it. What does the evidence say?” What a
fantastic presentation! Do you have anything else to share about this message? Thank you very much. I am passionate about this topic and I enjoyed giving the presentation at the CA National conference very much. The use of x-ray in chiropractic is controversial and I find there are many common misconceptions. Importantly, x-ray can be a very useful diagnostic tool but there are many situations where there doesn’t seem to be much benefit to the patient in ordering an x-ray, and it may actually be harmful. Unfortunately, there isn’t actually much research into the use of x-ray specific to chiropractic practice, which makes providing definitive answers difficult. What we do know is that many conditions can be diagnosed on x-ray, but not all of these will be associated with patient symptoms or change the way the patient is managed. It is important that practitioners consider what their differential diagnosis is, whether knowing an exact diagnosis will change the management of the patient, and whether an x-ray is the best way to diagnose the suspected condition. For more information on this topic, I published a review in Chiropractic and Manual Therapies last year summarising the available literature on the use of x-rays in chiropractic practice. The review is open access and available at: https:// chiromt.biomedcentral.com/articles/10.1186/ s12998-018-0217-8
Congratulations to Dr Stanley Innes for completing his PhD By: Dr Amber Beynon B.Sc. (Hons), B.Chiro
Dr Stanley Innes is a lecturer in Chiropractic at Murdoch University and his PhD thesis “The accreditation role of Councils on Chiropractic Education: The educational journey from craft to profession”, was recently accepted. He completed the PhD by publication and included 12 studies! An amazing achievement. Stan has kindly given us a summary of his PhD: Economies require healthcare practitioners, such as chiropractors, to assist in providing safe, effective and economical care for lower back pain, globally the leading cause of disability-adjusted life years. A minority of
chiropractors have been shown to have highly undesirable practice behaviours that have implications for public health and patient safety. These practice patterns appear to be associated, to some extent, with the chiropractic program they were trained at. This indicates a need for scrutiny of international chiropractic educational and practice standards. For chiropractic the establishment and monitoring of educational standards is the responsibility of Councils on Chiropractic Education (CCEs). This thesis consisted of 12 studies exploring CCE accreditation standards and processes. Findings included a lack of definitions around key terms such as chiropractic, also of the commonly accepted mainstream criteria such as evidence-based practice. We also learned that CCEs have enabled a “big tent” approach that allows dichotomous “traditional” and “evidencebased” approaches to clinical care to co-exist and this has implications for public safety.
Recommendations for quality improvements in CCE standards and processes were made and arguments made that the “raison d’être” of CCEs is to take a more forthright stand and better serve the patients’ best interests. Congratulations Stan!
Save the date: SpineWeek 2020 Melbourne, 27 April – 1 May 2020 SpineWeek is a large week-long multinational conference for health-professional societies whose work focuses on disorders of the spine. A joint venture between Chiropractic Australia (CA) and the Australian Chiropractors’ Association (ACA) will see Australian Chiropractors participating as one of 23 societies, including the Spine Society of Australia. Every 4-years leading scholarly spine societies hold their annual conference in one location under the SpineWeek moniker, bringing together clinicians and researchers from around the world and fostering interdisciplinary collaboration. Prominent societies include the International Society for the Study of the Lumbar Spine (ISSLS), the North American Spine Society (NASS) and the Brasilian Spine Society. The Australian Chiropractors stream at SpineWeek 2020 is a joint-professional-society meeting that will showcase leading-edge scholarship and research from the AsiaPacific region. In 2019, Chiropractic Australia and the Australian Chiropractors Association have worked strongly together to produce their SpineWeek program entitled Frontiers in Conservative Spine Care. The program
will emphasise the important work done by conservative spine professionals in caring for people with burdensome spinal disorders. This event, which provides a tremendous opportunity for chiropractors, both in Australia and worldwide is the first time that an alliedhealth profession has participated as a scientific society at this prestigious conference. This event is also a significant step for Australian chiropractic associations as they embark on a united leadership initiative. SpineWeek 2020 will provide members and non-members with a platform to network with spine professionals and relevant MedTech industry supporters. The Chiropractic program at SpineWeek 2020 has sessions dedicated to best practice, sports and physical activity, paediatrics, geriatrics, patient management, biomechanics, knowledge translation, and research. Delivered by world-leading chiropractors (Prof. Simon French, Prof. Greg Kawchuk, Prof. Jan Hartvigsen, Prof. Michael Schneider), international experts (Prof. Rachelle Buchbinder, A.Prof Manuela Ferreira, Prof. Chris Maher, Distinguished Prof. Jon Adams, Emeritus Prof Nik Bogduk, Prof Jiří Dvořák), CARL Fellows (Dr
Hazel Jenkins, Dr Diana De Carvalho, Dr Matt Fernandez, Dr Katie Pohlman, Dr Mike Swain, Dr Andreas Eklund, Dr Martha Funabashi, Dr Katie de Luca, Dr Aron Downie, Dr Arnold Wong) and local/international industry thoughtleaders (Dr Anthony Coxon, Dr Mel Wassel, Dr Chris Colloca). The Scientific Symposium has high-profile local and international researchers. Sessions will be moderated by esteemed local and international chiropractors. This unprecedented event must not be missed. For those registering as delegates of Chiropractic Australia or the Australian Chiropractors Association a special cocktail reception will be included to celebrate the joint success of these two organisations. It is important to remember that registration to SpineWeek 2020 enables delegates to participate in all society meetings throughout the week. A preliminary program will be available on the 1st of February, 2020. Event details and registration can be found at https:// www.spineweek.org/.
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Western Australian chiropractor’s patented table By: Dr. Kenneth Young DC, DACBR, MAppSc (Medical Imaging), PhD (Medical History)
Chiropractors love their tables. Chiropractors often make their own tables, either to save money, or to have custom features not found on existing commercially available tables. In 1946, Western Australian chiropractor Richard AP Todd thought that he could augment his therapeutic regimen with mild traction.
• Anesthetics or opiates to quiet nerves and lull the patient to eternal sleep
Todd was a 1939 graduate of the Lincoln College of Chiropractic in Indianapolis, Indiana. He called his invention a Spinal Revitaliser and received Australian patent number 131,956 for it. It had a large wheel which tilted the entire table surface. Feet were fixed with leather straps to a kind of stirrup and the supine patient was inclined with the head down at any desired angle from 1 to about 30 degrees. This device is just one of a great many variations on the chiropractic table.
You can see that he really warmed up and gained momentum as he compiled his list. DD’s first table was a single-piece flat board with a leather cover tacked on and no padding. The patient was instructed to lie face down. That is, prone, with the face down. DD then applied his posterior-toanterior thrust on various parts of the back and neck. Unsurprisingly, these first crude tables came to be known as “nosebreakers.” After a few years, DD, now working with BJ, modified the table with a 45 degree downward slanting piece to allow the head to hang down a bit. Nonetheless, adjustment-induced nosebleeds continued to be an issue.
In 1910, DD Palmer included in The Chiropractor’s Adjuster a list of all the items that should be found in a chiropractor’s office (p. 490): • A bifid table That was his entire list, so I’m guessing the table was pretty important. He did have a longer list, things that should not be found in a chiropractor’s office (feel free to insert your own comments after each): • Vibrators • Orthopedical stretchers • Osteopathic tables • Instruments of torture • Microscopes to study tissue – just to kill time and put on professional airs • Pestle and Mortar to pulverize nauseating drugs • Chemical laboratories to prepare pharmaceutical remedies to treat effects
Richard AP Todd from the 1939 Lincoln Chiropractic College composite graduation photo.
CA NEWS DECEMBER 2019
• Corner cupboard used as an apothecary shop for powders, extracts, elixers, tinctures, decoctions, salts, pills or ointments • Praying to lord Jupiter to make this prescription efficacious • Antizygmotic disinfectants founded on the morbific illusion of protecting us from evil • Keen-edged scalpel smiling with an insatiable desire to remove some portion of your anatomy • Operating chairs and tables to prepare the patient for the undertaker
Padding started to be added in various places. This reduced but did not eliminate adverse events. The strong thrusts to the back carried force through to various anteriorly-placed anatomical features and so different shapes to parts of tables were invented to accommodate them. An unknown person invented a cutout for male genitalia, which had apparently been paying a toll for low back treatments. Depressions and moveable segments were created for the protuberant abdomen, whether due to obesity or pregnancy. In 1913 the Griffin Company of Davenport, Iowa created a higher-placed accommodation “for ladies with full breasts.” Head pieces were padded and modified to accommodate faces. Some changes were also a response to new techniques being developed such as Palmer’s recoil, Hole-in-One, and side posture adjusting.
Todd’s Spinal Revitaliser (front)
Todd’s Spinal Revitaliser (back)
Pretty quickly, tables became complicated pieces of machinery. The first “hy-lo” table was made for Palmer by Bert Clayton in 1910 or ‘11. It used compressed air to raise the entire surface from one end for patients who had difficulty lying down or rising. Within a couple of years a commercial version was available; it was spring-loaded, and built by the Griffin Company. (The term “spring-loaded” makes me imagine patients being hurled across treatment rooms.) Through the years these types of tables progressed in their mechanics through worm-gears and finally to hydraulics. The idea of traction came from osteopathy. Well, a modern application of traction, anyway. Apparently Hippocrates discussed traction in 400 BCE. An osteopath named O N Donahoe began producing traction tables in 1937 with a business he founded called the Spinalator Company. Rollers under the top cover moved back and forth creating intersegmental traction.
Patent for Todd’s table
In the early 1900s a man named Swofford built the first gravity inversion table. I did an internet search to try to find a picture of it but entering “Swofford gravity traction table” returned too many hits to sort through right now. There are a lot of inversion traction devices out there. Other types of traction tables were developed, including those that strapped in a patient’s feet and neck, then applied a stretching motion, and in 1909 an osteopath patented a precursor to a Cox-type flexion/distraction table. Richard Todd believed that chiropractic adjustments to the spine and the inversion effects of his table could help people with all kinds of disorders, proclaiming his successes in several newspaper articles. Conditions included exhaustion, digestive disorders, learning difficulties, pectus carinatum, rheumatism and childhood “sickliness” as well as sciatica, hip and other joint disorders. Regardless of what it really accomplishes, I’ll bet that the gentle traction in the supine position feels really good.
A different tilting traction table The connection to Todd’s table is unknown, but the photo was donated with the table.
Unfortunately, little else is known about this unique Western Australian table. Many thanks to Richard Todd’s son Robert, who donated the table to Murdoch upon his retirement in 2010.
References: 1. Dye AA. The Evolution of Chiropractic, 1939. 2. Peterson D and Wiese G. Chiropractic: An Illustrated History, 1995. 3. Wells D. “From workbench to high tech: the evolution of the adjustment table. Chiropractic History, 1987. 7(2):34-39. 4. Hynes R and Callender A. “A brief history of the adjusting table: tables throughout time. Today’s Chiropractic, 2004 Nov-Dec. 33(6):24-26, 78. Kenneth Young started the Chiropractic History Special Collection at Murdoch University, which is now curated by Christopher Hodgetts. It can be seen here: https://www.murdoch.edu.au/library/resources-collections/ special-collections/chiropractic-history-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 Chris at c.hodgetts@murdoch. edu.au or on (08)93601231.
Photo from a pamphlet for the AG (anti-gravity?) Revitalizer. The connection to Todd’s table is also unknown, but again, a copy of the pamphlet was donated with the table. W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U
Beware of Social Media By: Dr Matthew Bulman BHSc, MChiro
Social media belongs on a long continuum of technological advancements which impact and change society. With each generation since The Enlightenment, new technologies emerge to revolutionise society and tear at the social fabric. The printing press allowed Martin Luther to ignite the Protestant Reformation. The wireless radio, television, the internet and social media... each has had its advantages and advancements, improving our lives immensely. But they also created new issues which required society to adapt. Chiropractors are all too aware of the tectonic rift created by social media. We are in the midst of this adaptation now. Social media has provided a platform for anyone to provide public statements, screen shots or viral videos. Some of the content is useful; but the most memorable of these have brought our profession into disrepute. Suddenly, a click of a button can allow anyone with smart phone the chance to share content that can threaten large swathes of our scope of practice. This is like Martin Luther on amphetamines. On 11 November, 2019 The Chiropractic Board of Australia (CBA) updated its website to further clarify chiropractors’ use of social media.1 Over the past several years, the CBA has presented at national conferences, offered free education events, published updates in their newsletters and attempted to make the profession aware of both advertising guidelines and social media guidelines. The current iteration of the guidelines on its website state: This guidance is to help registered health practitioners understand and meet their obligations when using social media: • complying with confidentiality and privacy obligations • complying with your professional obligations as defined in your Board’s Code of conduct • maintaining professional boundaries • communicating professionally and respectfully with or about patients, colleagues and employers, and • not presenting information that is false, misleading or deceptive, including advertising only claims that are supported by acceptable evidence. The update offers several examples of how breaches can occur. It is worth reading. Breaches sometimes happen knowingly. But they often occur accidentally. We should all be aware that the guidelines apply to our clinical pages; however, the information shared on private accounts and in private groups can still be used against a practitioner if it violates the law and a complaint is lodged. Of concern is a recent publication, At risk advertising by Australian Chiropractors and Physiotherapists by Simpson 2, which revealed that from a sample of 359 chiropractors and 380 physiotherapists:
CA NEWS DECEMBER 2019
“Two-hundred and fifty-eight (72%) audited chiropractors and 231 (61%) audited physiotherapists had breaches of the Advertising Guidelines on their websites and linked Facebook pages. The frequency of breaches by chiropractors was higher. The type and nature of the breaches by chiropractors was potentially more harmful. Membership in a professional association influenced neither the frequency nor the severity of breaches with chiropractors.” In summary, social media breaches are very common. It’s highly probable that chiropractors are unaware of their infringements. Knowledge of the law and guidelines is only one part of the story. Another aspect also warrants consideration and this aspect is more subtle and relies on knowledge of the infrastructure of social media. Many people may not be aware of the development of social media and the well construed engineering behind it. Behemoth in size, sites like Facebook and Google have the largest data sets ever compiled. And engineers have learned how to use this data and apply it to human biases, blind spots and emotional hooks. For example, did you know that in 2014 Facebook brazenly published an article, Experimental Evidence of Massive Scale Emotional Contagion through Social Networks 3. This article demonstrated: “[E]motional states can be transferred to others via emotional contagion, leading people to experience the same emotions without their awareness. We provide experimental evidence that emotional contagion occurs without direct interaction between people (exposure to a friend expressing an emotion is sufficient), and in the complete absence of nonverbal cues.” While editors of the journal expressed concern over the lack of ethics approval, they decided to publish the article anyway.4 Some background reading about the techniques used by the architects of the social media landscape can be insightful. Jaron Lanier captures the history of these platforms in his short book, Ten Arguments for Deleting your Social Media Accounts Right Now.5 Many of the engineers of Facebook, Google, YouTube, Twitter, Snap Chat, Instagram (owned by Facebook) etc. are graduates of Stanford’s Centre for Persuasive Technology.6 Here, BJ Fogg and colleagues study how technology and computers can influence the behaviour of humans. Combining techniques from psychology and computer science, these engineers have programed into your smart phone an intricate series of persuasive strategies to change human behaviour. Rewards and punishments are packaged into the products we use every day. For example, when you write a post on Facebook and get a red #1 over the bell in your Facebook feed, this is designed for social approval and reward. Your brain gets a little dopamine hit. What Lanier points out with the mobile phone, however, is the design is built essentially on the framework of a slot machine. Have you ever found yourself unconsciously swiping down with your thumb to check your email, Facebook likes, twitter likes or other “updates” on your phone? Whether you are aware of this or not, you should know this was constructed to mimic a slot machine. The infrastructure is designed to keep your attention, which is rewarded by that social approval of a digital number. And, like a slot machine, this is based on variable rewards. This can be tailored to make you behave and react to certain stimuli.
Ding! Just like one of Pavlov’s dogs. As Sean Parker, the first president of Facebook, stated: “We need to give you a little dopamine hit every once in a while, because someone liked or commented on a photo or a post or whatever… It’s a social-validation loop... we did this consciously.”7 There are dozens of designs built into our everyday devices. Their purpose is to pursue human frailties and biases. Tristan Harris, who previously worked for Google as an ethicist, summarizes many of these hijacking methods in an article free to access, How Technology is Hijacking Your Mind — from a Magician and Google Design Ethicist8. Hijack #1: If You Control the Menu, You Control the Choices Hijack #2: Put a Slot Machine In a Billion Pockets Hijack #3: Fear of Missing Something Important (FOMSI) Hijack #4: Social Approval Hijack #5: Social Reciprocity (Tit-for-tat) Hijack #6: Bottomless bowls, Infinite Feeds, and Autoplay Hijack #7: Instant Interruption vs. “Respectful” Delivery Hijack #8: Bundling Your Reasons with Their Reasons
The above article is worth a read if only to understand some of the blind spots to which we are all susceptible. With that knowledge in mind, it may be worthwhile revisiting the social media guidelines9 and looking at the common pitfalls section. Some of these infringements are clear examples of individuals hijacked by a blind, emotional state. How many times have you personally found yourself in an online argument and unable to step away? Or have you vented about a social, political or religious belief? Have strong feelings about public health issues that run counter to best available evidence? There are dozens of examples like this which have negatively impacted the chiropractic profession in the past decade. Social media is part of the attention economy. In this economy, the platforms compete for the amount of time an individual spends on their site. This time is a metric that can then be turned into advertising revenue. The algorithms themselves are agnostic to ethical responsibilities; they just learn what keeps us on the site by analysing the data we give to it. Often, the best way to keep us on a site is to circumvent any executive function and attack our emotional centres: enraged and engaged. Facebook and Google are worth billions of dollars because they are in fact advertising brokers. It is worthwhile to remember that social media is not free; you, in fact, are the product.
Hijack #9: Inconvenient Choices Hijack #10: Forecasting Errors, “Foot in the Door” strategies
REFERENCES: 1. https://www.chiropracticboard.gov.au/Codes-guidelines/Social-media-guidance.aspx 2. Simpson, J.K. At-risk advertising by Australian chiropractors and physiotherapists. Chiropr Man Therap 27, 30 (2019) doi:10.1186/s12998-019-0247-x https:// chiromt.biomedcentral.com/articles/10.1186/s12998-019-0247-x 3. Emotional contagion through social networks. Adam D. I. Kramer, Jamie E. Guillory, Jeffrey T. Hancock. Proceedings of the National Academy of Sciences Jun 2014, 111 (24) 8788-8790; DOI: 10.1073/pnas.1320040111 https://www.pnas.org/content/111/24/8788 4. Editorial Expression of Concern: Experimental evidence of massivescale emotional contagion through social networks. Proceedings of the National Academy of Sciences Jul 2014, 111 (29) 10779; DOI: 10.1073/pnas.1412469111 https://www.pnas.org/content/111/29/10779.1 5. Lanier, Jaron. (2018) Ten Arguments for Deleting your social Media Accounts Right Now. New York, New York: Henry Holt 6. https://vimeo.com/117427520 7. https://www.axios.com/sean-parker-unloads-on-facebook-god-only-knows-what-its-doing-to-our-childrens-brains-1513306792-f855e7b4-4e99-4d60-8d512775559c2671.html 8. Harris, Tristan. How Technology is Hijacking Your Mind — from a Magician and Google Design Ethicist https://medium.com/thrive-global/how-technology-hijackspeoples-minds-from-a-magician-and-google-s-design-ethicist-56d62ef5edf3 9. https://www.chiropracticboard.gov.au/Codes-guidelines/Social-media-guidance.aspx
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Murdoch University Annual Research Day 2019 By: Dr Amber Beynon B.Sc. (Hons), B.Chiro
On the 9th of November the Chiropractic Discipline at Murdoch University hosted its annual Research Day. The day is about showcasing the research being carried out by the undergraduate, honours and doctoral students, along with the academics at Murdoch University. The research day was opened by the head of the organising committee Dr Jean Théroux. He was followed by the Head of the Chiropractic Discipline Dr Barrett Losco, who spoke about the need for strong research and encouraged us to reflect upon the knowledge and see where the gaps are. As he stated, “through research you can be a life-long learner”. This year’s theme was the temporomandibular joint, an oft-forgotten part of the body. We were very fortunate to have three outstanding speakers; Dr Robert Delcanho, Orofacial Pain Specialist, Dr Lee Daffin, Chiropractor, and Leigh Ray, Physiotherapist. Dr Delcanho gave a very informative presentation on temporomandibular joint disorders, while Dr Daffin spoke about the temporomandibular joint anatomy and relationship with cervical spine. Leigh Ray concluded the day with a presentation on the conservative management of temporomandibular joint disorders.
Dr Barrett Losco – Head of the Chiropractic Discipline
CA NEWS DECEMBER 2019
Chiropractic Australia President Professor Rod Bonello attended the Research Day. CA is a sponsor of the event and presented awards for the best research presentation and the best poster. In his speech Professor Bonello made the following remarks: “This school teaches many things and teaches them well. But perhaps the most important training at Murdoch is in critical thinking. For a health care professional the ability to assess the value of existing practice and to properly review new hypotheses is paramount. Murdoch stands for critical thinking and in this area if you don’t stand for something you’ll fall for anything. Today is a celebration of success in the application of those skills in the context of scholarly research. CA is proud to be a sponsor of the Murdoch Research Day. We congratulate all those involved in today’s achievements.” We heard a range of student presentations with Honours presentations completed by Dr Kristy Black and Dr Karin Scott, and various undergraduate research projects. Winner of the best poster was Chris Hodgett’s undergraduate group presented by Tim Mcleish and Emily Thomas, with the poster “Does Hand-eye Coordination and General Self Efficacy Influence Student’s Ability to Perform Spinal Manipulation Therapy?” Winner of the best research presentation was Emad Ardakani’s undergraduate group presented by King Yi Leung, with the presentation “Exploring First and Second Year Chiropractic Students’ Willingness and Attitudes Towards Peer Physical Examination.” Overall, a fantastic event. Thank you to all involved, and thank you Rod Bonello and Chiropractic Australia for sponsoring this event.
Professor Rod Bonello – CA President
Dr Jean Theroux â€“ Research Day Convenor
...perhaps the most important training at Murdoch is in critical thinking. For a health care professional the ability to assess the value of existing practice and to properly review new hypotheses is paramount. Honours student Dr Karin Scott
Undergraduate student Kingsley Leung
Lecturer in Human Anatomy Dr Lee Draffin
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The best aspects of being a chiropractor: A survey. Summary of results As part of an undergraduate research project at Murdoch University we set out to investigate the best aspects of being a Chiropractor. Thank you to all Chiropractic Australia members that participated in this Murdoch
University survey. The summary results show that the top 10 best aspects were as follows:
Chiropractors can reduce pain, help move or build strength, flexibility and power in patients.
Chiropractors are trained to diagnose. Because chiropractors can see people without a medical referral, they need to be able to differentially diagnose.
Chiropractors can transform peopleâ€™s lives. The ability to help people feel better and give them confidence to try something that they have not been able to do for a long time.
Chiropractors can work independently in their own businesses.
Chiropractors enjoy being able to communicate with patients on a day to day basis.
Chiropractors work with people, not just bodies. Chiropractors know that it is not enough to treat the body-as-a-machine.
Chiropractors physically touch people. This is a privilege i.e. To touch people for therapeutic reasons.
Chiropractors enjoy being first contact professionals. Few others, outside of medicine and dentistry, have this privilege.
With hard work chiropractors can earn a good income
Chiropractors are constantly changing their posture at work and not sitting, standing or bending for too long.
Only 3 statements scored below the median of 5.5 and were not agreed to as best aspects of being a chiropractor by respondents. They were as follows: Chiropractors are powerful advocates for those less fortunate; advocating for people whose voices are not being heard.
Chiropractors are highly respected by the public.
Chiropractors are highly respected by other health professionals.
Full results will occur at a later time in a publication.
CA NEWS DECEMBER 2019
Best article - Chiropractic & Manual Therapies 3rd quarter 2019 Chiropractic services in the active duty military setting: A scoping review Silvano Mior, Deborah Sutton, Daphne To, Carolina Cancelliere, Simon French, Anne Taylor-Vaisey and Pierre CĂ´tĂŠ. Chiropractic services in the active duty military setting: a scoping review. Chiropractic & Manual Therapies. (2019) 27:45 https://doi.org/10.1186/ s12998-019-0259-6 https://chiromt. biomedcentral.com/track/pdf/10.1186/s12998019-0259-6 In active duty military personnel, musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries. In some countries, chiropractic services are accessed to manage such injuries within and outside military healthcare systems. The authors searched the literature and synthesized published studies exploring the nature, models, and outcomes of chiropractic services provided to active duty military. They used scoping review methodology to systematically search relevant databases and military collections. They included peerreviewed English language studies with qualitative and quantitative designs, describing chiropractic practice and services delivered to active duty
military worldwide. After screening 497 articles, 20 met our inclusion criteria, of which 17 were from the United States (US), 2 from Canada and 1 from Australia. The authors then created evidence tables to sort and summarize key information from these articles. Chiropractic services are commonly provided on-base in the US but off-base in Canada and Australia. In the US, services are accessed by physician referral, commonly after nonresponse to other forms of care. Interestingly, the use of scope of practice is determined by the system/facility, and varies from chiropractic intervention specific to chiropractor provided comprehensive services. Back pain with and without radiculopathy accounted for most presenting problems. Treatment outcomes were primarily reported only in case reports; however, two recent randomized trials for the management of low back pain reported improved pain, disability, and satisfaction when adding chiropractic care to usual medical care compared to usual medical care alone. Specific reaction time measures in special operation forces military did not improve after chiropractic are compared to wait-list control.
Despite the observed benefits from the provision of chiropractic services, interprofessional collaboration is impeded by untimely and variable access, unavailable services and unobtained referrals. In some instances, provision of chiropractic care is related to referring clinician preference or prior experience, and perceived duplication of chiropractic services, particularly in Canada. The majority of articles described chiropractic services in the active duty military in the US setting, where its expansion is legislatively driven. Recent RCTs suggest a benefit of including chiropractic care with usual medical care in managing back pain in active duty military. Yet, despite reported benefits in many countries, the authors contend we know little about chiropractic services provided in active duty military globally. Considering the burden of musculoskeletal conditions in this population, there is a need for further qualitative, descriptive, and clinical trial data to inform the role of chiropractic services in active duty military.
SpineWeek 2020 â€“ Early Bird Registration Now Open Early Bird Registration for SpineWeek 20020 is now open offering substantial savings off the full registration fee until 15th February 2020 when a second tier of Early Bird Registration will begin. This second tier will also offer a saving off the full fee until Early Bird closes on 26th April 2020. To register, go to: https://www.spineweek.org/ registration/ SpineWeek 2020 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 2020 is notable for the inclusion of chiropractic organisations for
the first time and Chiropractic Australia and the Australian Chiropractors Association are pleased to have been invited to participate in this groundbreaking, week-long event alongside more than 20 other international spine societies from around the globe. CA and ACA are working together to present an exciting and informative series of presentations devoted to progressing chiropractic within the overall SpineWeek program. SpineWeek 2020 will be held at the Melbourne Convention and Exhibition Centre from Monday 27th April to Friday 1st May 2020.
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Systematic Reviews ANTIHYPERTENSIVE TREATMENT IS A NO GO FOR THE 130-140 MM HG RANGE? Antihypertensive treatment in coronary artery disease secondary prevention was correlated with diminished risk of all-cause mortality and major cardiovascular events, however, it doubled the risk of adverse events resulting in discontinuation. Hence, in the 130–140 mm Hg systolic blood pressure range, primary preventive blood pressure-lowering contributes no cardiovascular advantage although it raises the risk of adverse events. Moreover, in secondary prevention, advantages should be weighed in contrary to the disadvantages. Brunström M, et al. Benefits and harms of lower blood pressure treatment targets: Systematic review and meta-analysis of randomized placebo-controlled trials. BMJ Open, October 04, 2019 CHANGES IN PAIN THRESHOLDS IN PEOPLE WITH NS-LBP Six databases were looked into, for appropriate literature and 24 studies contrasting mechanical quantitative sensory testing (QST) measures including individuals with subacute and chronic low back pain (LBP) and healthy controls were involved in order to investigate whether sensory function, measured with QST, was changed in individuals with nonspecific LBP. Scores on the Newcastle-Ottawa scale ranged between one and six points. In comparison with healthy controls, individuals with nonspecific LBP, had markedly lower pressure pain thresholds (PPTs) at remote sites and raised temporal summation at the lower back. In individuals with nonspecific LBP vs healthy controls, the PPTs measured at the scapula were considerably lower. Therefore, at remote body parts, the PPT measurements were significantly lower in individuals with nonspecific LBP in comparison with healthy controls. Moreover, temporal summation and conditioned pain modulation measurements yielded mixed outcomes. den Bandt HL, et al. Pain mechanisms in low back pain: A systematic review with meta-analysis of mechanical quantitative sensory testing outcomes in people with nonspecific low back pain. Journal of Orthopaedic & Sports Physical Therapy, October 08, 2019
CA NEWS DECEMBER 2019
EFFECTS OF HEAD AND NECK POSITIONS ON BLOOD FLOW IN THE HEAD AND NECK
Mian S, et al. Reduction mammoplasty and back pain: A systematic review and meta-
In a systematic review of the 1,453 recognized studies, 31 were involved, including 2,254 individuals in order to examine the impact of craniocervical positions and movements on hemodynamic parameters (blood flow velocity and/or volume) of cervical and craniocervical arteries. During maximal rotation (n = 16), most studies discussed no important hemodynamic variations. A notable reduction in hemodynamics was recognized for the vertebral artery, along with a hemodynamic reduction in the position of maximum rotation (n = 8) and combined movement of maximum extension and maximum rotation (n = 4). For the internal carotid and intracranial arteries, a comparable pattern of reduced hemodynamics was also discovered. Three studies targeted on high-velocity thrust positioning and movement. None of the studies listed hemodynamic variations. The synthesized data propose that in the major proportion of individuals, most positions and movements of the craniocervical region do not impact blood flow. Therefore, the findings of this systematic review infer that craniocervical positioning may not change blood flow as much as formerly anticipated.
“Rik” Kranenburg HA, Tyer R, Schmitt M , et al. Effects of head and neck positions on blood flow in the vertebral, internal carotid, and intracranial arteries: A systematic review. Journal of Orthopaedic & Sports Physical Therapy, October 08, 2019 IS THERE A RELATIONSHIP BETWEEN BREAST REDUCTION AND BACK PAIN? Researchers intended to appraise whether a relationship between RM and back pain existed, via systematic review and metaanalysis. The review gave 13 articles following exclusions, eight of which were appropriate for quantitative analysis. Across all studies, the outcomes of the analysis proposed betterment in back pain after reduction mammoplasty (RM). Moreover, heterogeneity was high. However casual, the evidence obtained implies that in individuals with large breasts, RM decreases the incidence of back pain. Moreover, the shortage of studies examining whether RM is at the clinical threshold of efficiency in treating back pain was reflected. Nevertheless, for suggesting RM as an option for management aimed at treating back pain, the evidence is inadequate, this review does determine the requirement for prospective data looking at back pain metrics as a particular outcome measure prior to and after RM
analysis. European Spine Journal, October
CLASSIFYING COCCYX FRACTURES A series of 104 consecutive individuals with a fracture of the coccyx was investigated in order to define a classification of fractures of the coccyx, according to their mechanism. Three mechanisms were purposed to explain these fractures ie, flexion, compression, and extension (types 1, 2 and 3, respectively). Flexion fractures (n = 38) included the upper coccyx in 35 patients, and in three with a perineal trauma, it was the lower coccyx; compression fractures (n = 24) included the middle coccyx and occurred only when Co2 and Co3 were square or cuneiform and long and straight, therefore, a nutcracker mechanism; four were adolescents with a compression of the sacrum extremity and were marked adolescent compression fracture of S5 (type 2b); extension fractures (n = 38) were obstetrical in nature and included the lower coccyx; a gradual separation of the fragments with time was their chief peculiarity. Flexion fractures normally improved spontaneously, but a correlated intermittent luxation was possible. Moreover, in their majority, nutcracker and obstetrical fractures were unstable in nature. Hence, a classification of fractures of the coccyx was exhibited for the first time. Furthermore, each type displays distinct characteristics. This should aid the clinician in the management of these cases Maigne JY, et al. Classification of fractures of the coccyx from a series of 104 patients. European Spine Journal, October 22, 2019 IS THERE A RELATIONSHIP BETWEEN SOFT DRINK CONSUMPTION AND ASTHMA? Researchers performed a meta-analysis and systematic review investigating the correlation between consumption of soft drinks and asthma prevalence among adults and children. Searching Medline, Scopus, ISI Web of Science and the Cochrane Library up to December 2018, they included 19 publications in this systematic review, including three cohort studies and 16 cross-sectional studies. These works comprised 468,836 participants, in total, with more than 50,000 asthma cases. Findings, mostly from cross-sectional studies, indicate soft drinks consumption to be positively associated with asthma prevalence. The association endured for sugar-sweetened soft drinks in subgroup analysis for childhood
RESEARCH NEWS exposure, but not for carbonated drinks. They recommend performing more longitudinal research to establish causality Al-Zalabani AH, Elahi IN, Katib A, et al. Association between soft drinks consumption and asthma: A systematic review and meta-analysis. BMJ Open, October 28, 2019
Info Bites ON-GOING PROBLEMS WITH SUBGROUPING NS-LBP This study was undertaken to determine if NSCLBP patients presented with higher lumbar muscle fatigability and fatigability asymmetry than asymptomatic candidates. For this investigation, 30 NSCLBP patients and 23 asymptomatic candidates performed the Sorensen test. During the test, the median frequencies from the electromyographs of the right and left erector spinae longissimus (ESL) and lumbar multifidus (LMF) were measured. According to results, patients with NSCLBP showed significantly poorer back extensor muscle endurance than asymptomatic candidates. There were no differences in fatigability or fatigability asymmetry for either the ESL or LMF between NSCLBP individuals and asymptomatic participants. In both muscles, the initial median frequency was significantly lower in patients with NSCLBP. These findings may be explained by the heterogeneity of the NSCLBP population due to the absence of any specific aetiology. Rose-Dulcina K, et al. Asymmetry of lumbar muscles fatigability with non-specific chronic low back pain patients. European Spine Journal, September 18, 2019 WHAT FACTORS DETERMINE A FAVOURABLE RETURN TO WORK AFTER SURGERY? Researchers examined the factors correlated with return to work (RTW) in individuals who obtained otherwise favorable outcomes following lumbar spine surgery. At 1-year postsurgery, 10,604 of 12,435 patients had successful RTW. A total of 605 among patients who accomplished good surgical outcomes, failed to RTW. For both the overall and subgroup analysis, lower odds of RTW were noted in elderly patients. In comparison with males, females had lower odds of RTW and patients with greater back pain and baseline Oswestry disability index had lower odds of RTW. Patients with longer span of symptoms, more physically requiring occupations,
worker’s compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW sovereign of their good surgical outcomes. Therefore, this study recognizes specific risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational and henceforth, involving the patient’s employer in the treatment process and setting pragmatic expectations may aid to enhance the patients’ work-associated functionality. Khan I, Bydon M, Archer KR, et al. Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery. The Spine Journal, September 19, 2019 LONG-TERM REOPERATION RATE FOLLOWING SURGERY FOR LUMBAR HERNIATED INTERVERTEBRAL DISC DISEASE Through a retrospective cohort study of a nationwide sample database of adult patients (N = 1,856) who underwent first surgery for lumbar herniated intervertebral disc disease (HIVD) during 2005 to 2007, experts contrasted the long-term incidence of reoperation for lumbar HIVD following major surgical techniques (open discectomy [OD]; laminectomy; percutaneous endoscopic lumbar discectomy [PELD]; fusion). The overall cumulative incidences of reoperation were 4%, 6%, 8%, 11%, and 16% at 1 year, 2 years, 3 years, 5 years, and at 10 years, respectively. Following OD, laminectomy, PELD, and fusion, the cumulative incidences of reoperation were 16%, 14%, 16%, and 10%, respectively, at 10 years postoperation, with no variation between the surgical techniques. Nevertheless, the distribution of reoperation types was significantly distinctive according to the first surgical technique. In 80% of patients following OD and in 81% of patients following PELD, OD was chosen as the reoperation surgical technique. Hence, during the 10-year followup period, among OD, laminectomy, PELD, and fusion, the probability of reoperation did not vary. Nevertheless, OD was the most usually practiced technique in reoperation Kim CH, Chung CK, Choi Y, et al. The longterm reoperation rate following surgery for lumbar herniated intervertebral disc disease: A nationwide sample cohort study with a 10-year follow-up. Spine, September 24, 2019 RETURN TO WORK IN PATIENTS RECOVERING FOLLOWING LUMBAR DISC HERNIATION WAS NOT
INFLUENCED BY REFERRAL FOR UNSTANDARDIZED MUNICIPAL REHABILITATION In a single-center RCT of patients (n = 146) scheduled for primary discectomy because of lumbar disc herniation, researchers examined the impact of postoperative rehabilitation on return to work, the term of sick leave and working ability following surgery for lumbar disc herniation. Both groups had a comparable postoperative sick leave period of nearly 9 weeks. Subsequent to one year, 79% in the HOME-group vs 74% in the REHABgroup had returned to work, which was not statistically meaningful. Working ability enhanced from baseline to one year in both groups and this betterment was maintained at a two-year follow-up. Statistical analysis exhibited that preoperative duration of leg pain and working ability had a correlation with duration of postoperative sick leave. Therefore, the duration of postoperative sick leave, return to work or working ability in patients recovering following surgery for lumbar disc herniation was not influenced by referral for unstandardized municipal rehabilitation. The duration of preoperative leg pain and preoperative working ability was significantly correlated with the span of postoperative sick leave. Paulsen RT, et al. Return to work after surgery for lumbar disc herniation, secondary analyses from a randomized controlled trial comparing supervised rehabilitation vs home exercises. The Spine Journal, September 27, 2019 DO ANTIDEPRESSANT LEVELS CHANGE AFTER BEING GRANTED A DISABILITY PENSION? Experts examined whether the years leading and the years following granting of disability pension (DP) because of back pain were correlated with alterations in prescription of antidepressants in 17,368 individuals with incident DP in 2009 or 2010. Both in the analyses controlling for age and gender and in the multivariable analyses, prescription of antidepressants rose only very moderately towards DP because of back pain and following the DP the trend was also only slightly declining, irrespective of the former level of specialized healthcare. Pathways to DP because of musculoskeletal and somatic diagnoses appeared to be partially motivated by adverse mental health, which continues at a higher level following DP. The rising prescription of antidepressants former to DP implies that special consideration should be paid to mental health during the process of becoming work undermined in terms of early recognition and
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RESEARCH NEWS prevention of mental disorders or symptoms and consequently of DP. Moreover, the period following DP requires also a consideration to circumvent the deterioration of mental health. Ropponen A, et al. Changes in prescription of antidepressants and disability pension due to back pain, compared with other musculoskeletal and other somatic
to exhibit any relationship with revision. Hence, for individuals treated with well-designed and well-implanted HRA, return to sporting activities following surgery was concluded as safe.
diagnoses: A cohort study in Sweden.
Amstutz HC, et al. Effects of physical activity on long-term survivorship after metal-on-metal hip resurfacing arthroplasty: Is it safe to return to sports?.
BMJ Open, September 20, 2019
The Bone & Joint Journal, October 08, 2019
SHOWING THE START BACK SCREENING TOOL WORKS
THE INCIDENCE OF SERIOUS PATHOLOGIES AMONG PATIENTS UNDERGOING MRI FOR LBP
Through a secondary analysis of data from two former studies that involved 348 individuals with nonspecific low back pain, experts investigated the responsiveness of the Subgroups for Targeted Treatment at 6 weeks and 6 months. Most of the hypotheses were included. Examining the Subgroups for Targeted Treatment Back Screening Tool (SBST) as a consistent score, 85.7% and 87.5% of the hypotheses were taken into account at 6 weeks and 6 months, respectively. For medium- and high-risk subgroups, at 6 weeks and 6 months, 85.7% and 87.5% of the hypotheses were incorporated. The low-risk subgroup had 42.9% of the hypotheses considered at 6 weeks and 100% of the hypotheses acknowledged at 6 months. Therefore, in subgroups of individuals with a medium and high risk, high responsiveness of SBST at 6 weeks, and poor responsiveness in those with a low risk, of consistent disability was concluded. Furthermore, in all SBST subgroups at 6 months, the SBST has high responsiveness. Clinicians can assuredly utilize the SBST in terms of subgroups to estimate variations over time. Medeiros FC, et al. A responsiveness analysis of the subgroups for targeted treatment (STarT) back screening tool in patients with nonspecific low back pain. Journal of Orthopaedic & Sports Physical Therapy, October 08, 2019 HIP RESURFACING IS SAFE FOR A RETURN TO SPORT A total of 661 individuals (806 hips) representing 77% of a consecutive series of patients treated with metal-on-metal hybrid hip resurfacing arthroplasty (HRA) were enrolled in a survey in order to ascertain the impact of particular groups of sporting activities on the survivorship free of aseptic failure of a large series of HRA. No correlation between any category of activity and a reduction in survivorship was found. For aseptic failure or wear, influence and hip cycle scores also failed
CA NEWS DECEMBER 2019
In this retrospective, observational cohort study of individuals (n = 2,383) referred for lumbar MRI by a specialist in private secondary care or public tertiary care setting over a 10-month period, ascertain the predominance of severe pathologies in individuals with low back pain and to examine prevalence of these severe pathologies in the geographic region of South Auckland, New Zealand. For all pathologies examined in this study, the prevalence was considerably higher in the public tertiary care setting vs private secondary care setting. Moreover, structural abnormalities related to severe pathology were exhibited by one in every 6.5 individuals referred for MRI in tertiary care, which proposes the question of if access to MRI should be re-assessed Street KJ, et al. Clinical prevalence and population incidence of serious pathologies among patients undergoing magnetic resonance imaging for low back pain. The Spine Journal, October 16, 2019 THE USE OF STATINS IS RELATED TO REDUCED MORTALITY In this historical population-based cohort study, researchers performed a 10-year follow-up of members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention, to determine how mortality and cardiovascular morbidity among older adults are influenced in long-term by adherence to statins. They used routinely collected data from the participants (n = 19,518). The participants who had adhered to statin treatment vs those who had not exhibited 34% lower all-cause mortality rates. Fewer atherosclerotic cardiovascular disease events were reported in relation to adherence to statins. Based on the findings, a possible link was suggested between adherence to statins and reduced mortality and cardiovascular morbidity among older adults, irrespective of age and gender Eilat-Tsanani S, et al. Statin use over 65
years of age and all-cause mortality: A 10-year follow-up of 19,518 people. Journal of the American Geriatrics Society, October 23, 2019
And Furthermore... DOES CHRONIC HIGH INTENSITY TRAINING IMPROVE BLOOD MARKERS? Using databases of PubMed, Science Direct, SPORTDiscus, Google Scholar and grey literatures with Mesh and freetext search as well as manual searches, researchers analyzed the impacts of highintensity chronic endurance training on cardiovascular markers of active populations and athletes. The authors discovered that chronic high-intensity endurance training improves healthy lipid profiles ie, increase high-density lipoprotein, decreased lowdensity lipoprotein and total cholesterol. And reduced inflammatory markers (IL-6 and CRP) regardless of age and gender and cannot be related to an increased risk of developing cardiovascular disease. Tesema G, et al. Does chronic highintensity endurance training have an effect on cardiovascular markers of active populations and athletes? Systematic review and meta-analysis. BMJ Open, November 04, 2019 EFFECT OF VITAMIN D ON HELICOBACTER PYLORI INFECTION In this meta-analysis of 10 studies, researchers explored the potential connection between vitamin D and Helicobacter pylori infection, as well as vitamin D and H. pylori eradication. Finally, 10 articles have been included. They found that the average 25(OH)D level in H. pyloripositive individuals was lower than H. pylorinegative individuals. Overall, vitamin D was shown to be a protective factor to H. pylori infection. In addition, vitamin D may improve the H. pylori eradication success rate. Yang L, et al. Effect of vitamin D on Helicobacter pylori infection and eradication: A meta-analysis. Helicobacter, November 13, 2019 IS ASPIRIN WARRANTED FOR THE PREVENTION OF CARDIOVASCULAR DISEASE? Thirteen randomized, controlled trials on the
CLASSIFIEDS effect of aspirin for primary prevention of CVD vs control were included in this metaanalysis to examine the benefit-risk ratio of aspirin for primary prevention of CVD with a special focus on subgroups. Researchers found that aspirin use did not decrease all-cause or cardiovascular mortality, and offers an inadequate benefit-risk ratio for CVD primary prevention. Moreover, the greatest risk reduction of major adverse cardiovascular events across subgroups was noted in non-smokers, individuals treated with statins, and males. Gelbenegger G, Postula M, Pecen L, et al. Aspirin for primary prevention of cardiovascular disease: A meta-analysis with a particular focus on subgroups. BMC Medicine, November 14, 2019 ASSOCIATION OF DIETARY FIBRE AND YOGURT CONSUMPTION WITH LUNG CANCER RISK Researchers performed a pooled analysis involving > 1.44 million individuals from the United States, Europe, and Asia in order to determine whether habitual consumption of dietary fibre (the main source of prebiotics) or yogurt (a probiotic food) affects the risk of lung cancer. They found that high consumption of dietary fibre or yogurt were individually linked to reduced lung cancer risk, independent of known risk factors. They concluded that a synergistic association of fibre and yogurt intake with the risk of lung cancer may exist. Yang JJ, Yu D, Xiang YB, et al. Association of dietary fibre and yogurt consumption with lung cancer risk: A pooled analysis. JAMA, November 08, 2019
Classifieds ASSOCIATES REQUIRED NEW ZEALAND – Dunedin: Professional Chiropractor required for central Dunedin (NZ) clinic. We are looking for a third Chiropractor to join us. Our busy multidiscipline clinic offers chiro, massage, osteo and acupuncture. We have taken care of processes and run an efficient clinic with online bookings, digital patient management system and full time reception cover. We would like a chiropractor with confident SMT skills who can offer our patients the best in hands-on therapy and rehab advice. Flexible
working hours are available and we may be able to provide temporary accommodation and vehicle access to help you get settled. For more info please see www.knoxrehab. co.nz/vacancy or contact Clinic Director Steve Morgan firstname.lastname@example.org VIC – Beaconsfield: Beaconsfield, SE Melbourne. 40 min from CBD. Long established clinic – over 25 years. Two principal chiropractors each have over 30 years experience. Both looking to scale back commitments and help someone else gain experience. Both have long term experience in teaching and mentoring younger chiropractors. General evidence based practice focusing on, but not limited to, manual, soft tissue and some instrument based techniques. Happy to talk to new graduates or experienced practitioners. Enthusiasm for patient care is vital. Possibly suit chiro who needs to work around family commitments. Prefer a female practitioner. Initially 3 days a week – Tuesday, Thursday and Saturday morning with a view to expanding. Contact email@example.com NSW – Wollongong: Chiropractor Required (Wollongong NSW). Teaming up with experienced multi-discipline professionals working within a holistic and client focused clinical approach. Current Chiropractor retiring after ten years with our clinic. Well established client base. Contact Brett at Core Naturopathics on brett@corenaturopathics. com.au or 1300 855 008 www. corenaturopathics.com.au NSW – Blacktown: Fantastic opportunity for a Chiropractor with strong manual adjustment skills to walk into an existing client base and lots of new clients (av. 12 – 15 per week) in a clinic in Westpoint shopping centre Blacktown. Flexible hours, support staff, great opportunity to leverage off the existing database. If interested call Benny on 0433 672 317 NSW – Paramatta: We are looking for an associate in the heart of Parramatta. Successful clinic expanding, Come be part of our growth. New graduates are welcome. Student Uni fee repayment bonus available. Salary, Percentage, & Eventual Ownership! Call or email: Dr Fred Kim (02) 9890 7092 or firstname.lastname@example.org QLD – Mackay: Are you a Chiropractor wanting to work near Mackay’s famous beaches and close to the Whitsundays? Due to the Principal Chiropractor reducing hours to focus on Business Development, we are advertising for this position. With outstanding management support, a positive team and negotiable hours don’t miss this opportunity. Integrate Health anticipates becoming a multi-disciplinary Allied Health Clinic and with over twenty-nine years of Chiropractic experience we are proud to be
the foundation of furthering this journey. The Associate Chiropractor or candidate we are looking for needs to have strong communication skills, be a proficient manual adjuster and display a passion for making a difference through quality health care. Your position will be fully supported and mentored where needed. The environment within the clinic is of a high standard with exceptional working relationships between both our highly trained administration staff and practitioners. The beautiful attraction of Mackay, which is situated in Central Queensland, is the endless amount of fun activities to be had in and around the city. Mackay is just a stone throw away from the Whitsundays and the beautiful Valley. The location offers an endless amount of entertainment after working hours. • Negotiable Hours • Fully supportive Staff and Practitioners • Outstanding Clinical Environment • Mentoring Supporting Relations • Outstanding Location Please email your expressions of interest and or resume to apply for this amazing opportunity to work alongside reputable practitioners and support staff. There is prospect for immediate start or a timely matter to a negotiated date. Integrate Health welcome all serious queries and applications. Please email: email@example.com NSW – North Ryde: We are seeking an enthusiastic and highly motivated chiropractor for an associate position in North Ryde. We mainly utilise: Diversified, Drop Piece, Activator, soft tissue work and dry needling but open to other techniques. Candidate must be proficient in manual adjusting. Please phone Fiona 0421 195 503 or email Fiona@ riversidechiropractic.com.au NSW South Coast – Shoalhaven: Do you want a seachange? How does the NSW South Coast sound? Are you patient centred, enthusiastic and a great communicator? Do you have strong manual adjusting skills and like to include soft tissue therapy into your treatment? Would you like to build on an established patient base, in a supported busy practice? If you answered yes to these, then this job may be yours! We have an opening for a dedicated associate Chiropractor or Osteopath at Shoalhaven Family Chiropractic Centre for two full days and two half days. Exceptional new graduates considered! Please email firstname.lastname@example.org or call Kate on 0417 577 115 NSW – Marrickville: Sydney Allied Health Clinic, located in Marrickville, has an exciting opportunity for an enthusiastic and driven Chiropractor. Our mission is to holistically promote health and wellbeing. Techniques
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CLASSIFIEDS required are Soft tissue work, Activator, SOT, Needling, Diversified and Drop piece. NET and Applied Kinesiology practitioners are welcomed to apply. The successful candidate will be proficient in pain-based treatment as well as educating maintenance and wellness. We have a very well-established marketing campaign and a well-established data base. We are looking for a long-term addition to our team. The role will start as part time including a weekend day, relieving the principal chiropractor and will have potential to build into full time. If you’d like to join our fantastic team, please email Anne at info@ sydneyalliedhealthclinic.com.au NSW – Central Coast: We are looking for a long-term associate to join our busy,well established and growing practice. Techniques utilized include, Diversified, Drop Piece, Activator, Soft Tissue and Rehabilitation. You will be working alongside either the primary Chiropractor and/or the senior associate who are at capacity. Some guidance and mentoring will be available. Questions and applications via email: email@example.com
BUSINESS FOR SALE WA – Fremantle: Selling established (2009) musculoskeletal chiropractic business due to relocation to the UK in early 2020. Recent fit out, shop front office in the heart of South Fremantle, WA. Consists of four treatment rooms. The current lease is in partnership with a podiatrist which allows for a 50/50 spilt in all outgoings. Equipment includes two tables with drops and one with flexion-distracion and extra corporeal shockwave machine. Please email Helen at firstname.lastname@example.org www. healinghandschiro.com.au
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
LOCUMS AVAILABLE PETER DUN Chiropractor Manual diversified techniques, drop piece, soft tissue techniques, dynamic neuromuscular stabilisation, customised rehab proficiency. Combination of locum, associate, solo practice, group practice experience over 25 years. Support for your practice style/ team. Options: Short Term Vic/Nationally,
CA NEWS DECEMBER 2019
Day Sessions Melb Metro. References/CV available on request. Please contact: 0413 152 054 or email@example.com 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, firstname.lastname@example.org BRENDAN KING (NSW) 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: email@example.com Dr ATHOL MORRIS (VIC) 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 firstname.lastname@example.org Dr CLAIRE CHITTLEBOROUGH (SA) 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 email@example.com Dr BENJAMIN KING (WA) 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 firstname.lastname@example.org 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, email@example.com
Dr SEAN MCKENNA (VIC) 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: firstname.lastname@example.org 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 PAUL MELLISH (QLD) 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 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 email@example.com
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