Osteo Life Spring issue 2022

OS T EO PAT H Y AU S T R A L I A M AG A ZI N E

S PR I N G 2 0 2 2

Endometriosis and chronic pelvic pain

Understanding pain mechanisms to provide osteopathic care

Cerebral palsy Early detection and diagnosis

Mergers and acquisitions

How to decide what’s right for your business

Professional development Extended and Advanced Practice Recognition

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WELCOME

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PRESIDENT’S MESSAGE

How can osteopathy empower more leaders?

Recently (perhaps a little self-indulgently), I started to think about my four-and-ahalf years on the Board of Osteopathy Australia and that my term finishes at the end of 2023. I pondered what would come next after this role, what past presidents have done, and where they are now. What will the future presidents and Board members be like? What attracts people to different leadership positions within our profession? What do people view leadership as in our profession? Do people do specific leadership training?

While I would like to be able to answer all of these questions, I’m not sure if I can at this stage. I did, however, decide to find out more about our past presidents.

In late September, we held our first Past Presidents of Osteopathy Australia meeting. This was an opportunity to

gather more information about leadership, and to discuss how people ended up in that role, where they are now, what training they have done, and also consider how we, as a profession, can empower more leaders. I’ll provide more details about our discussions in a future issue of Osteo Life.

Our Board is responsible for succession planning (this is basically all about attracting/recruiting the right people to the Osteopathy Australia Board). As part of this, we’ve decided we could be doing a better job of displaying what skills are needed to be on the Osteopathy Australia Board, and also what is involved and why you’d want to nominate for a position.

We are excited to share that as part of this strategy we will be releasing basic governance eLearning modules for our members who would like to be

“We are excited about the next generation of leaders within osteopathy and want to make sure the association can help support, empower and develop their skills” Osteopathy Australia

T (02) 9410 0099 E info@osteopathy.org.au W www.osteopathy.org.au osteopathyaustralia

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OSTEO LIFE is the quarterly magazine for Osteopathy Australia members. For enquiries, feedback, or to contribute, contact Communications on 02 9410 0099 or comms@osteopathy.org.au. For advertising enquires, email info@osteopathy.org.au.

Editorial and Education Advisory Group Toby Barker, Casey Beaumont, Amy Lawton, Melissa McDougall, Adam Nicholson, Jade Scott, Sally Tran, Heath Williams Editor Kavita Bowry Chief Executive Antony Nicholas Sub Editor Adam Scroggy Designer Stephanie Goh Advertising info@osteopathy.org.au Printed by Megacolour OSTEO LIFE is published by Citrus Media www.citrusmedia.com.au

involved in committees or the Board in the future. Georgia Ellis, another Osteopathy Australia Board director, and I will be running some webinars on ‘What you need to know if you want to be a Board member of Osteopathy Australia’ in early 2023. We hope to inspire people who are unsure of whether to nominate themselves and also help give insight into the realities of being on a Board and what that actually means.

We are excited about the next generation of leaders within osteopathy and want to make sure the association can help support, empower and develop their skills. If you are interested in leadership within osteopathy, I would love to hear from you and your thoughts on the matter. As always, feel free to email me mfunder.director@ osteopathy.org.au with any thoughts.

I hope the rest of the year is smooth sailing for you all.

Michelle Funder, President Osteopathy Australia mfunder.director@osteopathy.org.au

In this issue...

News 4

Osteopathy Australia news

10 Professional development pathways for osteopaths 12 2021 Osteopathy Australia grant recipients 14 Pain Revolution – a community-based approach to pain education

24 Early detection and diagnosis of cerebral palsy BRIAN HOARE

Practice Management

28 Mergers and acquisitions: what you need to know BRETT WIENER

32 Planning for life after retirement BRIAN NICHOLLS

Clinical

18 Endometriosis, chronic pelvic pain and the role of osteopathic care REBECCA MALON

Osteopathy Australia does not accept responsibility for any loss, damage, cost or expense incurred by reason of any person using or relying on the information contained in this magazine. The opinions expressed are those of the author and not Osteopathy Australia. All advertisements in this issue are paid advertisements. By registering with any company or affiliation mentioned in advertisements you will be sharing your personal information with the advertiser – please check their privacy policy. Osteopathy Australia takes no responsibility for the way personal information is used.

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NEWS

Osteopathy Australia news OSTEOPATHY AUSTRALIA AIMS TO SUPPORT, ENHANCE AND PROMOTE THE PROFESSION. HERE’S A QUICK RECAP OF EVERYTHING OSTEO FROM THE PAST FEW MONTHS.

Launch of the Low Back Pain Clinical Care Standard

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he Low Back Pain Clinical Care Standard was launched on 1 September 2022 by the Australian Commission on Safety and Quality in Health Care (ACSQHC).

This was produced following a consultation in March/April 2021, for which Osteopathy Australia entered a submission.

Osteopathy Australia welcomes the introduction of the Low Back Pain Clinical Care Standard and the Commission has agreed to add Osteopathy Australia’s endorsement to the Standard. The

Commission said that omission of our endorsement from the original document was an oversight for which they have apologised. The document will be updated shortly and the website amended accordingly.

Listen to the webcast of the launch at bit.ly/3UNI64k

CSQHC resources on A the national standard at bit.ly/3dOV8h5 Read Osteopathy Australia’s original submission to the Australian Commission on Safety and Quality in Healthcare at www.osteopathy.org.au

Osteopath of the Year 2022

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ongratulations to Brett Wiener, awarded Osteopath of the Year 2022 at the national Allied Health Awards this year. One of an esteemed group of finalists flying the osteo flag: Amanda Hannaford, Heath Williams, Michael Mannix, Paul Hermann and Tina Maio.

On winning the award, Brett, who is an Osteopathy Australia Board director and chairs our Early Career Advisory Group, had some sound advice for all allied health professionals: let’s work together and don’t forget to look after yourself!

The Awards bring together all allied health professions to recognise their

hard work, dedication and leadership, with the winners chosen based on five specific categories: Promotion and contribution to their profession or setting Collaboration and effective communication within allied health community Outstanding client-centred, evidence-based service delivery or health outcome Outstanding leadership and/or integrity Impact and innovation – focused over the last 12 months

NEWS

Notes from the Association ANTONY NICHOLAS, CHIEF EXECUTIVE, OSTEOPATHY AUSTRALIA

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ust as everyone starts to recover from the economic, emotional and health impacts of the COVID pandemic, we see increasing economic grey clouds. A key role and an important duty for the association is to be here for you during stormy weather.

In the coming weeks, we will be sharing the outcomes from the recent membership survey. This too captured the impact of the past two years on

osteopaths around the country. It showed that 41% of respondents only classified their mental health as fair, with a further 9% as poor, compared with good or excellent. These results were slightly worse for those under 30 years of age or those over 46 years old; and, maybe not surprisingly, particularly for those in Victoria, who were impacted by the longest lockdowns and ongoing restrictions.

To help and support our members, we introduced a free counselling service (see the box below for more details). In partnership with Converge International, this will allow you to get the confidential help you need. Converge International is known as being a market leader in providing professional counselling services for employees or members.

Seventy per cent of our members also reported a decrease in income compared with ‘normal’ years. This decrease in

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income was most significant in Victoria, Queensland and New South Wales.

Pandemic impact or not, Osteopathy Australia has always strived to minimise our costs and provide as many services, included as part of your membership, as possible.

That’s why we provide so much free CPD, advice and accessible resources online or by contacting us. Likewise, that’s why we provide free access to an employer and employee help line (it’s not just for businesses) – the HR hotline, and now the counselling service.

Our aim is to meet a lot of your professional, information, support, regulatory or policy needs, as an osteopath, within your membership fee rather than adding additional fees or forcing you to go to multiple different places, websites or companies.

I look forward to sharing more about the survey and our exciting new projects in the coming weeks. As always thank you for your support and being members.

“41% of respondents only classified their mental health as fair, with a further 9% as poor, compared with good or excellent”

New counselling service trial for Osteopathy Australia members We know it has been a tough few years. Get the help you need with Osteopathy Australia’s new, confidential counselling service provided by Converge International, a market-leading provider of professional counselling services for employees and association members.

The service is: Offered on a trial basis while Osteopathy Australia monitors uptake, quality of service and appropriateness; Free for all non-student members; Includes access to up to six consultations for your issue; Professional – counselling is provided by qualified counsellors, online or in person; Confidential – we don’t know who uses the service.

When using the Employee Assistance Program (EAP), you can speak with a qualified counsellor specifically selected to best support your issue.

The Converge International counsellors are experienced across a range of issues including: Employee assist is for personal or work stress, grief management, addiction, career issues, mental health concerns, and more.

Family assist helps you build stronger personal relationships, manage work/life balance, and cope with the demands of parenting.

Manager assist helps you lead and support people and teams, address workplace conflict, and manage change.

Legal assist can offer advice about family law, wills, tenancy, consumer disputes and more.

Specialist advice lines are also available to support LGBTQI+ and first nations. You can also access advice about domestic and family violence, aged care or disability support.

Career assist helps you with career planning and re-evaluating your work and life goals.

Money assist helps you work through financial difficulty and manage financial stress. Learn new financial skills and habits that will help you avoid problems in the future.

Call 1300 OUR EAP (1300 687 327) to arrange an appointment, or visit bit.ly/3RwdCRx to find out more and to book online.

Students can access free counselling services at their campus by calling or texting the following numbers: • Victoria University: 03 9919 5400 • RMIT University: 03 9925 5000 • Southern Cross University: 02 6626 9300 or 1300 782 676 (after hours), text 0488 884 143

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NEWS

MEMBER 2022 /2 023

Make the most of your Osteopathy Australia membership Promote your membership of Osteopathy Australia

A reminder for all Osteopathy Australia members, we have a new member lockup for you to use to promote your membership of Osteopathy Australia for 2022/23.

You will need your member login to access this page. The use of this logo is restricted to members only.

It should not be forwarded to any non-member. Note the logo should only be displayed next to the member’s name. You must not imply that your practice is a member as membership is individual.

Also, don’t forget to download your membership certificate – you can use this to get discounts and tax deductions on professional membership.

You can download the member lockup and membership certificate from your member dashboard. Visit www.osteopathy.org.au.

First Osteopathy Australia Extended Practice Osteopath

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ongratulations to Anita Biddle who has become the first recognised Extended Practice Osteopath in Australia. She has been recognised in the focus area of paediatrics.

Anita graduated from Victoria University in 2001 and is a director at Brunswick Family Osteopathy in Melbourne’s inner north.

Anita has always enjoyed working with children and babies, undertaking a postgraduate paediatrics course in her first year of practice.

On receiving Extended Practice Recognition, Anita said, “I am excited that Osteopathy Australia is offering opportunities

for extended qualifications. It is a great way for practitioners, including fellow osteopaths and other healthcare providers, to identify osteopaths with practice focus areas. Osteopathy is a very diverse profession, which is wonderful, but skills and knowledge in different areas vary a lot. Extended Practice Recognition helps clarify this. It encourages and rewards quality professional development in healthcare.

The process was really straightforward, and I enjoyed focusing professional development on my favourite topic.”

See page 10 for more information about Extended and Advanced Practice Recognition and how to apply.

Find an Osteo

Members are urged to update their Find an Osteo member profiles and clinic details to ensure you make the most of your entry in our online directory of osteopaths.

This is an important member benefit designed to help members to market themselves and promote their practice.

Go to your member dashboard at www.osteopathy.org.au to update your details.

FREE Graduate membership for final-year student members A reminder that all final-year student members can apply for FREE Graduate membership before 31 December 2022. Visit www.osteopathy.org.au to find out more.

Promoting osteopathy during National Pain Week 2022

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steopathy Australia ran a media campaign during National Pain Week at the end of July to highlight the disease burden of chronic pain in Australia and the role of allied health, such as osteopaths, in helping to manage chronic musculoskeletal conditions, such as arthritis, by busting the myths around chronic pain and pain management.

Overall, 10 items of coverage were secured, with an audience reach of more than 11.3

million Australians and an Advertising Value Equivalent (AVE) of over $157,000. This included a segment on Sunrise morning TV. Read the full media release at www.osteopathy.org.au, or: Find out more at bit.ly/3zxZIsk (or scan the first QR code) Sunrise TV segment at bit.ly/3fCetTm (or scan the second QR code)

NEWS

Hope for Health volunteering in remote and rural Australia

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hree Osteopathy Australia members, Declan Knights, Dina Culcasi and Rhonda Chen, all took the opportunity to share their osteopathy skills by volunteering for Hope for Health (hopeforhealth.com.au), a Yolngu-led preventative health program on Elcho Island in NT. During their time, they helped local artisans who were experiencing varying health concerns and pain, often due to long hours sitting on the ground bent over carrying out repetitive tasks as part of their work, such as painting, carving or weaving.

Much of their time was spent treating people for low back pain, neck/shoulder tension as well as providing exercise advice and working with other healthcare professionals to educate locals about healthy living and nutrition.

Declan, Dina and Rhonda all agree it was a special experience that provided them with a real appreciation for the challenges faced by those living in remote areas. It was, they say, a privilege to be able to give back to the community and make a difference, even if it was for just a short sojourn.

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New Advanced Practice Recognition in Sports Management Congratulations to Drew Blatchford who has become the latest Advanced Practice Osteopath in Australia. He has been recognised in the focus area of sports management.

Drew studied osteopathy at RMIT University, having previously studied sports science in the UK. He works at Wantirna Osteopathy in Victoria.

He has a long-standing interest in sports injury management and prevention, and has supported a number of elite athletes over the years, including those competing at the Tokyo 2020 Olympics and the recent Commonwealth Games 2022.

He says applying for Advanced Practice Recognition in sports management was therefore a natural progression, and he hopes this will help him to inspire others to do the same and hence achieve a greater recognition for osteopathy outside the profession.

He added, “I’m very proud to be part of such an esteemed group of osteopaths and to have had my skillsets recognised.”

Help spread the word about FREE Osteopathy Australia Student membership Encourage your ‘non-member’ friends studying osteopathy with you to join Osteopathy Australia as a Student member for FREE. For further membership enquiries, contact us on 02 9410 0099 or email membership@ osteopathy.org.au

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NEWS

Graduating soon?

Early AHPRA registration now open Osteopathy graduates due to finish their studies in the next three months are encouraged to apply for AHPRA registration early to ensure a smooth transition from study to work.

Applying before you finish study means the Board can start assessing your application while you wait for your graduate results.

Remember, registration with the Board is required before you can start working as an osteopath – and means you can work anywhere in Australia.

Find out more at bit.ly/3SjA7KF and apply at bit.ly/earlyAHPRAreg

Updated Graduate Guide 2022 If you’re a final year student or graduate member, you have free access to the Osteopathy Australia Graduate Guide, updated for 2022, to help you transition into practice. It has a step-bystep guide on what you need to do and where to get more information, support and help.

It also has everything you need to know from the scope of practice to the business of osteopathy to working as a locum vs an employee, understanding private health funds and your CPD obligations.

Access the full guide at www.osteopathy.org.au

Osteos supporting Aussie athletes to success at the Commonwealth Games 2022

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he Commonwealth Games 2022 in Birmingham saw a great result for Team Australia. Amazing athletes achieving great things, including osteopath and member, Jess Gallagher, who won two golds with her pilot, Caitlin Ward, in para-cycling.

This year’s Games highlighted the increasing role of osteopathy in preparing athletes for competition and keeping them injury free. Craig Russell, osteopath and member, working in Prahran in Melbourne, was privileged to be asked by Athletics Australia to join a training camp in St Moritz, Switzerland to help long-

distance runners and race walkers before they headed off to compete in Birmingham.

Using his experience working with track and marathon runners, Craig worked five to 10 athletes each day, including marathon runners Sinead Diver and Jess Stenson, to provide manual therapy using a structural/ biomechanical approach to management.

This involved a combination of soft tissue massage, stretching, fascial release, counterstrain, articulation and spinal and peripheral manipulation to address a variety of issues including (but not limited to) acute muscular strains, ligamentous strain/sprains, spinal and pelvic somatic dysfunctions resulting in both local and compensatory issues.

Commenting on his experience, Craig said, “It was a pleasure to work with such talented and committed athletes and to be part of a broader multidisciplinary team of health professionals to achieve the best results for the athletes. In addition, it was a great opportunity for me to promote osteopathy and, hopefully, open more doors for the profession within elite sport.”

Vale Stephen Porter and Karen Barton Osteopathy Australia was sad to hear about the passing of two members in the past few months. Our sincere and heartfelt condolences to the families of Stephen Porter and Karen Barton.

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INDUSTRY UPDATE

Professional development pathways for osteopaths

Osteopathy Australia has launched its Extended Practice Program to complement its already established Advanced Practice Program. The aim of these clinical skills recognition pathways is to offer an avenue of professional development for osteopaths, in turn cementing and lending credence to osteopaths’ place within primary healthcare while providing the association with additional scope to advocate and lobby for the profession within government and allied health networks. Here we explain the difference between Extended and Advanced Practice, and the steps involved to achieve recognition.

REQUIREMENTS AND OBLIGATIONS

Extended and Advanced recognition is only open to members of Osteopathy Australia, and you must remain a member of the association for the duration of your recognition.

FOCUS AREAS FOR EXTENDED AND ADVANCED PRACTICE

Currently, the following focus areas are covered for Extended and Advanced Practice recognition: Exercise rehabilitation Occupational health (work injury management) Paediatrics Pain management Sports management The association hopes to add further focus areas in the future.

WHAT IS EXTENDED PRACTICE?

Extended Practice recognition acknowledges that an osteopath is developing skills and reasoning in a focus practice area moving beyond the parameters of general osteopathic training at university level, to provide career opportunities within and beyond osteopathy. For the profession, Extended Practice recognition has the benefit of building understanding, connection and awareness as Osteopathy Australia can speak about the broad types of targets met by osteopaths in biopsychosocial care. Extended Practice recognition may be ideal for members working towards eventual Advanced Practice recognition.

To apply for Extended Practice recognition, you must have at least two years’ experience in practice.

How to apply for Extended Practice recognition 1. Download and read the Quality Practice Framework for your desired focus area to help you understand the broad knowledge, skills and capabilities required.

2. Download and read the application forms and templates for the focus area you have chosen.

3. Download and read the terms and conditions.

4. Pay the application fee via Osteopathy Australia’s website.

5. Lodge the complete application and all requested evidence via email to CPG@osteopathy.org.au.

6. The review process takes approximately four weeks involving a focus area multidisciplinary review panel, after which you will be notified of the outcome, which may require the submission of further evidence to qualify for recognition.

WHAT IS ADVANCED PRACTICE?

Advanced Practice recognition is a public acknowledgement and a formal professional titling to show the recipient has undergone further study and/or professional development via tertiary or vocational pathways to demonstrate advanced knowledge in a focus area.

Applications undergo transparent peer review by a multidisciplinary review panel of health practitioners. The tertiary pathway requires a further university qualification in a focus area, while the vocational pathway is for those without a further university qualification but who can demonstrate relevant work experience, professional

development, professional references and reasoned case studies. Those achieving Advanced Practice recognition are flagged as Advanced Practitioners on Osteopathy Australia’s Find an Osteo online directory. To apply for Advanced Practice recognition, you must have at least two years’ experience in practice for the tertiary pathway and four years’ experience for the vocational pathway.

How to apply for Advanced Practice recognition 1. Download and read the Quality Practice Framework for your desired focus area to help you understand the broad knowledge, skills and capabilities required.

2. Determine whether you want to undertake the tertiary or vocational pathway.

3. Download and read the application forms and templates for the focus area you have chosen.

4. Download and read the terms and conditions.

5. Pay the application fee via Osteopathy Australia’s website.

6. Lodge the complete application and all requested evidence via email to CPG@osteopathy.org.au.

7. The review process takes about six weeks involving a focus area multidisciplinary review panel, after which you’ll be notified of the outcome, which may require the submission of further evidence to qualify for recognition.

For more information, email cpd@osteopathy.org.au

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RESEARCH

2021 Osteopathy Australia grant recipients Osteopathy Australia is committed to supporting research that advances the profession. To assist researchers, the association seeks to fund osteopathic research in line with our research aims and priorities. In 2021, researchers were invited to submit applications for research funding in the form of either project or seeding grants. The following projects were successful in receiving research funding from Osteopathy Australia in the 2021-2022 financial year.

Osteopathic management of non-specific neck pain: a case series

that aims to explore the association between primitive reflex retention, motor function and executive function in a cohort of preschool children.

The same cohort will be followed up approximately 12 months later, once in kindergarten, to reassess these same factors and determine if preschool assessment is predictive of outcome in kindergarten. This clinical study examines an aspect of care that has received limited researcher attention – within and outside of the osteopathic research community – and aims to contribute to the evidence base for a practice employed by many osteopaths who have a clinical focus on paediatric development and assessment. This project seeks to answer clinical questions that osteopaths would encounter regarding the relevance and implications of motor deficit and reflex retention findings within their practice. Such research outcomes would benefit clinical decision-making and inform best practice, as well as expand market opportunities for osteopaths and the profession.

Association between primitive reflexes, motor function and executive function in preschool children

Use of respiratory and quality of life patient reported outcome measures (PROMs) for patients seeking osteopathic care: an Australian cohort study

Chief Investigator: Michael Fleischmann Institution: Victoria University Project Summary: Research shows osteopaths frequently manage neck pain. The techniques used by osteopaths are effective for pain reduction and improving neck movement. However, no research has explored why osteopaths choose to use certain treatment techniques, implement certain management strategies, and how osteopaths determine their effectiveness for the management of non-specific neck pain. This study will implement a treatment approach recommended by an expert panel of osteopaths for the management of chronic nonspecific neck pain. It will explore how osteopaths implement the therapeutic approaches described by an expert panel for the management of chronic non-specific neck pain and it will generate hypotheses that subsequently can be tested in clinical trial studies.

Chief Investigator: Kylie McWhirter Institution: University of Technology Sydney Project Summary: This project is a longitudinal observational cohort study

Chief Investigator: Lee Muddle Institution: University of Technology Sydney and Southern Cross University

Project Summary: Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow limitation, decreasing exercise capacity and deteriorating quality of life. It is common among people over the age of 40 years. A growing proportion of people over 40 see osteopaths for the management of chronic neck and/or back pain.

Given the prevalence of COPD, a proportion of these patients also have COPD. Understanding how COPD is progressing in a patient undergoing osteopathic care for neck and/or back pain provides an opportunity to improve overall management of the patient as interaction between chronic diseases affects prognosis.

Patient reported outcome measures (PROMs) are an objective measure of a patient’s condition. However, respiratory PROMs are not currently part of routine osteopathic practice.

The aim of this project is to assess the use of a respiratory PROM on osteopathic patients with COPD. Fifty osteopaths will be recruited to the study and asked to enrol four patients each with an existing diagnosis of COPD. Data will be collected from these patients on three occasions over a six-month period. The project will increase the scope of osteopaths to monitor the effectiveness of care, address a comorbidity commonly seen in osteopathic practice and promote strategies that improve patient management.

RESEARCH

Osteopaths’ Therapeutic Approaches Questionnaire (Osteo-TAQ): a crosssectional study of Australian Osteopaths

Chief Investigator: Oliver Thomson Institution: University College of Osteopathy and The University of Melbourne Project Summary: Research shows that osteopaths display different approaches to their clinical decision-making and care of their patients. Outcomes in patients experiencing common musculoskeletal problems (e.g. back pain) are influenced by different aspects such as the therapeutic

Osteopathy Australia research webinar series launched

relationship with their practitioner, the presence and impact of psychosocial factors and the biopsychosocial orientation of the practitioner. Developing knowledge of the complex, varied and distinctiveness of osteopathic approaches will facilitate more targeted delivery of treatment and measurement of patient-focused outcomes. As part of its professional maturation, osteopathy should continue to critically reflect on its traditional assumptions and generate evidence to understand the complex nature of practice. The Osteopaths’ Therapeutic Approach Questionnaire (Osteo-TAQ) is a novel tool based on

Osteopathy Australia’s research program supports and advocates for the profession through research by highlighting the research pathways open to clinicians, both in practice and in academia.

As part of this initiative, we have launched a series of research webinars that aim to inspire early

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empirical qualitative research from osteopaths and theory from healthcare sociology and psychology. The OsteoTAQ is designed to provide knowledge about the different dimensions that form the complex clinical approaches that osteopaths take with their patients and has the potential to be used with patient reported outcomes measures (PROMs).

The data from this study will highlight the role that Australian osteopaths may play in the wider healthcare landscape, identify areas to develop and support a clinician’s practice and inform future research to understand patient outcomes from osteopathic care.

career researchers and allied health clinicians to pursue health and medical research careers.

The series kicks off with two webinars discussing life as a clinician-scientist.

Visit www.osteopathy.org.au to find out more and view the webinars.

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INDUSTRY UPDATE

Pain Revolution – a community-based approach to pain education

Pain Revolution is supporting local health professionals to become pain experts to promote pain education in rural and regional communities in Australia through its Local Pain Educator (LPE) program. In this article, osteopaths and recent graduates of the program share their experience and discuss how they are using what they learned in their communities.

PAIN REVOLUTION’S LOCAL PAIN EDUCATOR PROGRAM

Pain Revolution’s Local Pain Educator (LPE) Program is a long-term strategy to build capacity in rural and regional communities by embedding knowledge and skills around best practice pain care.

Pain Revolution trains and supports LPEs. In turn, LPEs serve their community by providing public outreach and training, with a focus on evidence-based active, psychological and self-management strategies. Some LPEs go on to create collectives in their local community. Local Pain Collectives (LPCs) are communitybased interdisciplinary networks of rural and regional health professionals who meet regularly to build their skills in contemporary pain education and care.

The program highlights the importance of using a biopsychosocial framework for chronic pain management and its implications for rural and regional areas, and the role osteopathy can play in educating communities about pain.

THE PATIENT THAT HAS YOU STUMPED

Many practitioners can probably relate to that case where a client has shared their

complex pain story and you’ve sat back and thought ‘Where do I even start? What is the best approach to their management?

What does the evidence suggest? How do I meet their expectations?’. As a practitioner, there can be real pressure to be the ‘fixer’ but it is often helpful to take a balanced approach to management to achieve the best outcomes for patients.

A bird’s eye view Polarising viewpoints online can leave you feeling confused or that you need to ‘take sides’. No doubt many practitioners have questioned the place of both traditional and new tools in osteopathy at some point in their careers.

Regardless of a practitioner’s personal opinions, the reality is that the scope of osteopathy has evolved.

Some may question the place of handson therapies or newer additions, such as exercise or pain neuroscience education (PNE). Is it old versus new? Or is it more nuanced? Can we find a middle ground?

Can we start integrating both evidencebased practice and traditional osteopathy in our own unique way? Of course!

Consider the perspective of a bird (youtu.be/bG2y8dG2QIM). Some birds

“Regardless of a practitioner’s personal opinions, the reality is that the scope of osteopathy has evolved”

KATE JOHNSON

works in private practice in Albury-Wodonga and has been actively involved in Pain Revolution and the Murray Local Pain Collective for twoand-a-half years. She recently completed the Professional Certificate in Pain Sciences.

TEANO NGUYENVERDENET

is based in WA. He has a keen interest in evidence-based medicine to ensure patients get personalised solutions that combine osteopathy, nutrition and lifestyle advice, physical exercises, manual therapy, and tailored pain strategies and management plans.

CHARLOTTE BYRNES

practises in Anglesea and is passionate about educating everyone in the community on best practice care for people living with persistent pain. She completed the Professional Certificate in Pain Science and Education as part of her Pain Revolution scholarship.

MADELEINE GOODMAN graduated from RMIT University in 2014 before moving to Perth to embrace her career as an osteopath. She recently completed the Professional Certificate in Pain Science.

MADDY THORPE

is an osteopath with an interest in pain, neurological conditions, and innovative care. She is the Education and Communications Coordinator for Pain Revolution.

KEVIN JAMES

is an Osteopathy Australia Advanced Sports Osteopath. He is passionate about education and is a clinical supervisor and teacher at RMIT University. At Pain Revolution, he is working to evaluate the impact of Pain Revolution’s programs.

INDUSTRY UPDATE

Human versus bird vision

that just look black to humans appear as iridescent rainbow-coloured to other birds. A snake is a better well-known example, as they can see the infrared associated with heat. The point here being that using a different lens allows you to see a different world, and the more lenses you have, the more points of view you can challenge. So how does this approach relate to clinical practice?

Evidence-based practice Evidence-based practice comprises: Best scientific evidence; Patient values; Clinical experience.

If we view osteopathy as a gigantic, ‘all-encompassing telescope’, through which we filter many smaller lenses, we can evaluate what tool to use by looking through different lenses and weighting them accordingly.

Some examples might be: The biomechanical lens; The pathological lens; The education lens; The exercise lens The hands-on lens The market lens (yes, this is a thing!); The referral and multimodal lens; The mentor lens; Infinite more lenses.

Based on the combination of the three elements of evidence-based practice, some lenses are given more weight than others, which in clinical practice translates to your ever-changing treatment plan.

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Constituent elements of evidence-based practice (EBP)

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Putting theory into practice – an example of an individualised approach Applying a biopsychosocial approach does not mean that osteos take on the role of psychologists. Rather, it is about understanding that many factors influence pain. We need to be very mindful that our interaction, words and presence can tip the scale either way.

Take the example of a patient who presents with a 15-year history of chronic low back pain. Over this time, he may see many therapists without success. During his first consultation, he discusses how he had received many different diagnoses over the years. Some of the ‘causes’ for his low back pain included: His back and/or pelvis were ‘out of place’ or alignment; He had poor glute activation; He had no core stability; He had a twisted sacrum that was creating tension within his fascia; His paravertebral muscles needed to switch off.

The list goes on. In his initial consultation with an osteo, when asked what he thought about his body, he replied “My back is broken. I don’t know how to fix it. My pain took everything away from me.”

It was clear that his current knowledge and beliefs about his back were going to be fundamental to his recovery. This patient was worried and fearful of movement due to his pain.

It had caused him to lose his job. It had also affected his relationships. The pain had completely overtaken his life.

After a thorough assessment and examination that ruled out red flags and pathology, the working diagnosis was chronic low back pain. Management involved providing this patient with an evidence-based and accurate understanding of his back pain and manual therapy.

During lumbar and passive range of motion assessment, time was taken to create a new narrative to match the information elicited during the physical examination:

“Yes, your back muscles are really stiff but I don’t feel that your spine is actually out of place. A spine is robust and strong as there are a lot of ligaments and muscles around it.”

“Your pelvis seems to move quite well too in these positions, and you don’t have any sharp pain or jolting sensation when I move your pelvis in anterior and posterior positions.”

“It looks like you are guarding a lot and bracing yourself because of the pain.”

Osteopathic treatment was guided by assessment and consisted of muscle energy techniques, counterstrain and mobilisation. During each step, the patient and osteo were reflecting on his ability to move better and feel better.

Throughout the consultation, the use of phrases such as “motion is lotion” and “if you don’t use it, you lose it” provided further patient education.

Management of this patient also included movement rehabilitation, which aimed to provide him with increased confidence in his spine, reduce his hypervigilance and fear avoidance behaviours.

After four sessions, this patient had a significant reduction in his back pain and felt much more confident in selfmanaging his condition. He had a much more accurate understanding of chronic back pain and understood the psychosocial factors that may influence his pain experience.

He also decided to get mental health support to address his anxiety, depression and stress.

This case is an opportunity to reflect on which of the many lenses have been applied and how these interconnect with a biopsychosocial approach. By understanding how biopsychosocial elements are linked and how a patient experiences and overcomes pain, osteopaths can adjust our professional practice to find an approach that suits each individual patient.

INDUSTRY UPDATE

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Practitioner experiences of the Pain Revolution program

Teano Nguyen-Verdenet The Local Pain Educator program gave me the tools I need to understand how pain works, including tissue biology, exercise, psychosocial factors affecting pain and more. I was already aware of the research relating to pain science, which can create some disparity between osteopathic knowledge and skills. However, the more I learned about pain through the course, the more I realised that osteopathy can have a unique place within the healthcare landscape by integrating pain science and a biopsychosocial model of care within clinical practice.

The course allowed me to gain a better understanding and clarity of pain and it helped me to answer many questions around the subject.

Meeting patient expectations Some patients expect manual therapy.

Many osteopaths will have had the experience of blasting people with exercise and education, only to never see them again. This is where you may need to consider the market lens.

The market is generally a pretty good indicator of what services you need to be providing and the market demands hands-on therapy. There are so many people that get value from hands-on treatment, so the market indicates that it is of value to people.

Regardless of whatever way it becomes a value, whether it is only perception as is commonly discussed, perception is reality at the end of the day.

You might slowly start to introduce a concept or two, plant a few seeds.

Charlotte Byrnes The Local Pain Educator program is multi-faceted, comprising a University of South Australia Professional Certificate in Pain Science and Education, the Explain Pain course, and the ‘Revolutionary Immersion Weekend’.

While COVID meant content was delivered online, the sense of support was strong. The scholarship includes a year of one-on-one mentoring, which has been invaluable to my growth as an educator as I established and continue to facilitate the Local Pain Collective in the Surf Coast region, while still practising clinically. I feel privileged to be part of the national pain network. We meet quarterly for ‘cab sav’ sessions to discuss recent research and current projects, and it always leads to a great discussion.

And the opportunity to apply a new lens may present itself.

Measuring the effectiveness of patient management Should we focus on better outcomes such as, for example, pain reduction?

This can be a very reductionist approach and for many patients it may lead them on the path of searching for the ‘quick fix’, which may not be realistic in some cases. As clinicians, this focus can also lead to a dismissal or

Kate Johnson Completing the Professional Certificate in Pain Science and Education has allowed me to engage with a diverse mix of health professionals within my community and across Australia. First as a member of my Local Pain Collective, and now as a Local Pain Collective Facilitator, I have been able to build and establish relationships, and referral networks, as well as access quality up-to-date professional development locally which not only benefits my growth professionally but also client outcomes.

Find out more about Pain Revolution and the University of South Australia Professional Certificate in Pain Science and Education at www.painrevolution. org, or contact Maddy Thorpe via email maddy@painrevolution.org

misunderstanding of the patient’s actual goals and expectations.

Providing care which is patient focused, empathetic and structured on sound clinical reasoning, with predetermined objectives, is important to ensure we are engaging in optimal care. Self-reflection is integral to review our effectiveness as well as continued growth as practitioners.

This requires us to routinely step back and critically evaluate our listening, reasoning and interactions to ensure we are meeting our patients needs as best we can.

“Self-reflection is integral to review our effectiveness as well as continued growth as practitioners”

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Endometriosis, chronic pelvic pain and the role of osteopathic care One in 10 women of reproductive age will suffer from endometriosis, the major symptoms of which were discussed in an article published in the Winter 2022 issue of Osteo Life.

Osteopaths can provide pain relief to those suffering chronic pelvic pain (CPP) as a result of endometriosis. Whether practising with a direct structural approach or visceral, biodynamic or internal techniques, an osteopath’s palpatory skills, alongside their anatomical and physiological knowledge, can downregulate the sensitised nervous system and reduce the symptomatic picture. This article discusses pelvic anatomy, pain mechanisms and the care osteopaths can offer patients with CPP resulting from endometriosis.

ENDOMETRIOSIS AND CHRONIC PAIN

Chronic pain states are characterised by sensitisation, manifesting as regional allodynia and hyperalgesia. Individuals with regional pain syndromes such as endometriosis, migraine, interstitial cystitis and irritable bowel syndrome (IBS) also experience central and peripheral sensitisation (Stratton et al, 2015). A potential reason for this is neuroangiogenesis (the growth of nerves and blood vessels), which alters the

balance between autonomic neurons and sensory afferents, causing increased nociceptive input with decreased parasympathetic control, amplifying pain (Asante & Taylor, 2011; Hughes et al, 2013; Gebhart & Bielefeldt, 2016) (see box below).

Endometriosis can develop anywhere within the body but is most common in the pelvis, uterus, ovaries, Fallopian tubes, pouch of Douglas, bowel, bladder, peritoneum and uterosacral ligaments.

Three subtypes exist: superficial

The autonomic nervous system and pain The autonomic nervous system (ANS) is involved in pain physiology and maintenance. The sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) contain both afferent and efferent fibres. Activation of the SNS induces hyperexcitability and initiation of the fight or flight response, while the PNS promotes rest and digestion (Waxenbaum et al, 2021).

If the ANS’s regulatory inhibitory effect on pain is lost, a positive feedback loop is created, producing hyperexcitability of nociceptive nerve fibres, activating the SNS. Sensory

nerves relay pain signals to the central nervous system, an important component of pain processing and chronic visceral pain (Brierley & Linden, 2014; Gebhart & Bielefeldt, 2016).

Osteopaths can use their diagnostic skills to assess and treat varying spinal levels with the aim of downregulating the SNS and upregulating the PNS in chronic pain conditions (Waxenbaum et al, 2021).

The abdominal and pelvic viscera are innervated by the abdominopelvic splanchnic nerves. These nerves include the greater, lesser, least and lumbar splanchnic nerves.

REBECCA MALON

Rebecca Malon graduated from RMIT University in 2010. She provides both osteopathic and nutritional care and support in her clinic, Freya Health, where she sees primarily women’s health complaints, including chronic pelvic pain, as well as pre-conception, pregnancy and postpartum healthcare. She holds a BHSc in Nutritional Medicine.

endometriosis, ovarian endometrioma and deep infiltrating endometriosis. This last subtype is multifocal and impacts various structures of the peritoneal cavity, including the uterosacral ligaments, bladder, ureters and digestive tract (Burney & Giudice, 2012; Borghese et al, 2018).

Women can continue to experience debilitating symptoms from endometriosis even after having excision surgery and appropriate hormonal treatment. This is where osteopathy can help. The primary aims of osteopathy are to support the musculoskeletal structures – specifically the bony pelvis and its joints and ligamentous supports – ensure adequate lymphatic and venous return, and mobilise the myofascial system and

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viscera, enabling relaxation of the pelvic floor and diaphragm, while balancing the autonomic nervous system (ANS) (Maddern et al, 2020).

Pelvic Diaphragm

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PERIFORMIS

LEVATOR ANI

COCCYX

COCCYGEUS

OBTURATOR INTERNUS

PELVIC ANATOMY

Mobility and stability of the pelvis and all its joints are important for everyday wellbeing, to ensure optimal load transfer and both static and dynamic function in a controlled manner. When this is altered, dysfunction often proceeds which can impact pelvic floor and pelvic girdle function and the abdominal canister which consists of the pelvic floor, transverse abdominis, diaphragm, multifidus muscles and varying fascia.

Maintaining the mobility and stability of the sacrum, sacroiliac joints and pubic symphysis is essential. It is important to be aware of the links between the uterus, sacrum and pubic symphysis as they relate to many complex urogenital tract movements (Stone, 2007).

Ligaments of note Sacrococcygeal ligaments connect the sacrum to the coccyx. The anterior sacrococcygeal ligament is a continuation of the anterior longitudinal ligament while the posterior sacrococcygeal ligament is a continuation of the posterior longitudinal ligament and ligamentum flavum, highlighting the influence of spinal mechanics on the pelvis.

Uterosacral ligament. The uterosacral ligament contains elements of smooth muscle and is a common site for endometriosis deposits and adhesion formation. It has extensive connections with the sacrum, piriformis, ischial spine, coccygeus and sacrospinous ligaments. It also expresses hormone receptors and, as such, is influenced by the menstrual cycle (Foti et al, 2018).

Visceral pelvic fascia The bladder, urethra, vagina and uterus are attached to the pelvic walls via the endopelvic fascia, which invests each pelvic organ. Fascia allows the transmission of forces and displays the concept of biotensegrity. The endopelvic fascia is affected by forces and changes in the body; for example, a cervical flexion motion will drag the connective tissue of the pelvic floor superiorly (Herschorn, 2004; Bordoni et al, 2021).

ANAL CANAL VAGINA URETHRA UROGENITAL DIAPHRAGM SYMPHYSIS PUBIS

Levator Ani

ILIOCOCCYGEUS PUBOCOCCYGEUS

Figure 1: The muscles of the pelvic floor

The pelvic fascia and muscles of the abdominopelvic cavity work in unison with the breath, engaging, relaxing and transmitting forces from all directions.

Pelvic floor contractions and the endopelvic fascia allow dissipation of force loads from the trunk and upper limbs to the lower limbs and vice versa, while maintaining erect posture and gait.

Foot and lower limb function also impact force distribution throughout the pelvis (Bordoni et al, 2021).

The pelvic floor The pelvic diaphragm – what we know as the pelvic floor – is a wide, thin, muscular layer that forms the inferior border of the abdominopelvic cavity, extending from the pubis to the coccyx and each wall of the pelvis (Figure 1). Muscles include the levator ani – the puborectalis, pubococcygeus and iliococcygeus muscles – and the coccygeus.

The primary functions of the pelvic floor are to support the abdominopelvic viscera, counteract gravitational and inertial forces, maintain continence and sexual function, and facilitate childbirth.

These functions cannot occur effectively and pain free without adequate contraction and relaxation of the pelvic floor. Shortening and lengthening of the pelvic floor is dependent on many

factors, from the structural position of the bony pelvis and the mobility of its anchor points, to breathing mechanics and pressure gradient changes with the abdomen and respiratory diaphragm, sympathetic tone, pelvic trauma and posture (Herschorn, 2004; Bordoni et al, 2021; Waxenbaum et al, 2021).

Studies have shown that women with endometriosis and chronic pelvic pain (CPP) experience pelvic floor spasm and often have resultant widespread myofascial dysfunction. Research also shows low pressure–pain thresholds and trigger points in various body regions, along with widespread spinal segmental sensitisation throughout the thoracic, lumbosacral and cervical spine (Khachikyan et al, 2010; Phan et al, 2021).

The pelvic floor and respiratory function At rest the pelvic floor resembles the respiratory diaphragm: with contraction it ascends upwards and forwards, on relaxation it moves downwards and backwards. Sacral and coccygeal positioning and mobility are essential in this. With contraction and relaxation, the coccyx moves in a similar manner. Contraction also causes the pelvic viscera to elevate.

This rhythmic contraction creates

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pressure changes that assist the pelvic viscera in their functions, mobility and motility (Herschorn, 2004; Bordoni et al, 2021).

Many people living with CPP have ineffective breathing patterns and spend much time in a protective fetal position, especially during acute pain flares. They often suck in their stomach while holding their breath, creating unnecessary downward pressure on the pelvic floor, affecting the lymphatics, venous return and ANS. Osteopathically it is imperative to restore diaphragmatic motion, breathing mechanics and thoracic and rib mobility, and to facilitate pelvic floor relaxation (Wurn et al, 2012; Daraï et al, 2015; Goyal et al, 2017).

gluteus medius and tensor fascia latae.

It is also important to take account of any surgical scars as well as hip mobility, thoracic mobility, foot biomechanics and cervical spine and jaw function.

AT HOME SELF-CARE

ADHESIONS AND PAIN DEVELOPMENT

Pelvic floor relaxation An overactive pelvic floor is more common than an underactive one in endometriosis (Maddern et al, 2020).

Pelvic floor hypertonia may also be a result of prior trauma, compensatory patterns, chronic infections, inflammation, surgical scarring, holding patterns, hypermobile hips and lumbar spine, stress, and bowel and bladder dysfunction.

Adhesions within the abdominopelvic cavity reduce the mobility and motility of the peritoneum and visceral structures. They can give rise to pain, producing strong tensions and torsions within the cavity and often contribute to a variety of musculoskeletal problems. Caroline Stone (2007) suggests maintaining intestinal mobility in the early postoperative period to prevent adhesions developing after surgery for endometriosis.

Studies by Sillem and colleagues (2016) and Goyal and colleagues (2017) showed that osteopathic treatment may be favourable for women experiencing abnormal uterine bleeding and CPP. Treatment works within the patient’s pain response and focuses on functional, balancing and gentle mobilisation techniques. Visceral and cranial techniques were utilised in the aforementioned studies, including release of the pelvic diaphragm, sigmoid colon, gastroesophageal junction, hyoid diaphragm, atlantooccipital joint and abdominal diaphragm. Treatment improves mobility and motility of the abdominopelvic viscera and affects myometrial contractions.

Pelvic nerves The lumbosacral (Figure 2) and coccygeal plexuses are extremely important in terms of innervating pelvic structures. The nerve supply to the pelvis, particularly the pudendal nerve, can be compromised as a result of poor biomechanics, myofascial dysfunction and entrapment at various locations throughout its pathway through the pelvis.

Other muscles Other muscles to consider when treating endometriosis and CPP are the iliopsoas, piriformis, obturator internus, arcus tendinous of the levator ani, rectus abdominis, transverse abdominis, quadratus lumborum,

a Figure 2: The nerves of the (a) lumbar and (b) sacral plexuses. From Pictures, 2015.

b

Osteopaths can teach a number of easy-to-perform self-care techniques to women with CPP resulting from endometriosis.

Technique to teach L ay on back with pillows under the head and knees.

Be completely relaxed and free from distraction.

Begin by relaxing jaw, neck and shoulders and focusing on breathing deeply and rhythmically.

Try to initiate a pelvic floor contraction, feeling the pelvic floor lift upwards and forwards and the anal sphincter tighten.

On inhalation, try to fully relax and release the pelvic floor, feeling it move downwards and backwards.

Diaphragmatic breathing If the biomechanics of the diaphragm are compromised, the pelvic floor cannot relax. The benefits of teaching diaphragmatic breathing include pelvic floor relaxation, activation of the parasympathetic nervous system, reduced anxiety and rib cage mobilisation.

Technique to teach L ay on a flat surface with pillows under the head and knees.

Place one hand on the chest and the other over the belly.

Take a slow deep breath in through the nose.

Feel the belly rise while the chest should stay relatively still.

E xhale slowly through pursed lips – the hand on the belly will feel the abdominal muscles contract and fall in.

Repeat five to 10 times.

Once accustomed to doing this lying down, try it seated, keeping the neck and shoulders relaxed.

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Figure 3: Happy baby pose – if this position is not relaxing or comfortable, use a bolster or pillow under the hips, rest the feet on a wall or drop them onto a couch instead

Happy baby pose Happy baby pose can help to lengthen the pelvic floor muscles, particularly when coupled with proper breathing mechanics.

Technique to teach L ay on back and bring the knees to the chest.

Reach along each leg to grab hold of the ankle, arch of foot or big toe – whichever is accessible.

Open the feet up toward the sky while continuing to bend the knees up toward armpits (Figure 3).

Breathe into the ribs and belly and try to visualise the pelvic floor opening.

Jaw release Jaw release can be carried out by selfinhibition of the masseter and pterygoid muscles internally and/or externally. The jaw, diaphragm and pelvis are intrinsically connected through the deep frontal line.

Stress, tension and pain cause contraction of the masseter muscles, diaphragm and pelvic floor (Chen et al, 2012).

Technique to teach Locate the masseter muscle by placing hands anterior to the ear where your jaw bone meets your cheek, gently clench your jaw, you will feel muscle pop up under your hand (Figure 4).

Using your finger pads apply gentle pressure onto the masseter, slowly

Figure 4: Jaw release

open your mouth and you can apply a downward drag along the masseter to help release this. Repeat three to five times.

Alternatively, to release pterygoid internally run your thumb along your top teeth and until you reach the back of the jaw, this can be very tender, apply a lateral (toward the cheek) pressure.

Psoas muscle stretch The psoas muscle greatly impacts CPP thanks to its anatomical location and action. Psoas plays an important role in the lumbo-pelvic-hip complex due to its attachments superiorly on the lumbar vertebra and onto the lesser trochanter of the femur and its function as a hip and lumbar flexor. The psoas also works in conjunction with the

diaphragm, abdominals and pelvic floor to help transfer load and alter intraabdominal pressure.

Technique to teach Position yourself in a low lunge position with one knee on the floor, holding onto something by your side if necessary for balance and support (Figure 5).

The back foot can be flat on the floor or up on the toes. (This stretch can also be performed by placing the back foot on a couch/bench) Posteriorly rotate the pelvis or tuck the hip/imagine the pelvis is being drawn up toward the ceiling with a piece of string to create that rotation.

Increase the stretch by lunging forward through while maintaining that tucked pelvis posture.

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Figure 5: Psoas muscle stretch

Figure 6: Piriformis muscle stretch – if the full stretch (middle) is uncomfortable, lower the free foot to the floor and rest the heel of the other foot on the opposite thigh (right)

Bend one leg up to rest on top of the other creating a figure 4.

Bring your leg towards your shoulder or the shoulder on the opposite side (everyone will feel it slightly differently).

Alternatively, keep legs down and resting and use your hand to gently press your top knee away from the body as seen in the alternative photo.

Figure 7: Child’s pose – this posture can be modified by resting the arms alongside the body

To increase the stretch further, raise your arm up towards the ceiling.

Piriformis muscle stretch While the piriformis and obturator muscles do not technically make up the pelvic floor, they are situated within the pelvic cavity and have a

direct anatomical relationship with the sacrum, hip and pelvic inlet. This stretch is commonly referred to as a 'figure 4 stretch'.

Technique to teach L ay on back with the knees bent (see Figure 6).

Child pose Child pose allows the pelvic floor muscles to lengthen, and it also helps stretch the muscles around the back and hips.

Technique to teach Begin on all fours, knees wide apart and feet together.

Bring bottom down to sit back on feet.

Rest forehead on the ground or on a rolled-up towel or bolster pillow.

Reach forward with arms over the head or rest arms alongside the body (Figure 7).

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Figure 8: Enhancing thoracic mobility: (a) thread the needle; (b) thoracic rotation on all fours; and (c, d) cat-cow

Thoracic spine mobility Exercises to enhance the mobility of the thoracic spine include thoracic extension over a foam roller, thread the needle (Figure 8a), thoracic rotation on all fours (Figure 8b), cat-cow (Figure 8c, d) or sidelying thoracic rotations.

Squatty potty Defecating with the feet elevated and the knees above the hips alters the anorectal angle, enabling complete relaxation of the bowel and pelvic floor, preventing straining (Modi et al, 2019). Because many women with endometriosis will also have concurrent IBS and dyschezia, this simple measure can bring great benefit.

SUMMARY

Osteopaths have many skills that can make them an integral part of the team caring for a woman with endometriosis.

In a team environment, an osteopath can drive goal-oriented clinical outcomes to reduce pain, improve quality of life and enhance tissue health. The key to successful treatment is to actively engage with the patient, work within their pain response barriers and allow the tissues to heal.

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StatPearls Publishing. Available at: www.ncbi.nlm.nih. gov/books/NBK482200/, last accessed 25 July 2022 Borghese, B., Santuli, P., Marcellin, L., Chapron, C. (2018) [Definition, description, clinicopathological features,

pathogenesis and natural history of endometriosis: CNGOF-HAS Endometriosis Guidelines]. Gynecologie Obstétrique Fertilité Sénologie 46(3), 156–167 DOI: 10.1016/J.GOFS.2018.02.017 [in French] Brierley, S.M., Linden, D.R. (2014) Neuroplasticity and dysfunction after gastrointestinal inflammation.

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Stratton, P. (2010) CNS sensitization and myofascial dysfunction in patients with endometriosis and chronic pelvic pain. Fertility and Sterility 94(4_Suppl), S40 DOI: 10.1016/J.FERTNSTERT.2010.07.153 Loewy, A. (2020) The Autonomic Nervous System.

Britannica. Available at: www.britannica.com/science/ human-nervous-system/The-autonomic-nervoussystem, last accessed 25 July 2022 Maddern, J., Grundy, L., Castro, J., Brierley, S.M. (2020) Pain in endometriosis. Frontiers in Cellular Neuroscience 14, 590823 DOI: 10.3389/ FNCEL.2020.590823 Modi, R.M., Hinton, A., Pinkhas, D., Groce, R., Meyer, M.M., Balasubramanian, G., Levine, E., Stanich, P. (2019) Implementation of a defecation posture modification device: impact on bowel movement patterns in healthy subjects. Journal of Clinical Gastroenterology 53(3), 216–219 DOI: 10.1097/ MCG.0000000000001143 Phan, V.T., Stratton, P., Tandon, H.K., Sinai, N., Aredo, J.V., Karp, B.I. Merideth, M.A., Shah, J.P (2021) Widespread myofascial dysfunction and sensitisation in women with endometriosis-associated chronic pelvic pain: a cross-sectional study. European Journal of Pain 25(4), 831–840 DOI: 10.1002/EJP.1713 Pictures, P. (2015) Anatomy TV. Primal Pictures Ltd. Available at: www-anatomy-tv.ezproxy.endeavour.edu. au/search Sillem, M., Juhasz-Böss, I., Klausmeier, I., Mechsner, S., Siedentopf, F., Solomayer, E. (2016) Osteopathy for endometriosis and chronic pelvic pain – a pilot study.

Geburtshilfe und Frauenheilkunde 76(9), 960–963 DOI: 10.1055/s-0042-111010 Stone, C. (2007) Visceral and Obstetric Osteopathy, 1st edn. Churchill Livingstone Stratton, P., Khachikyan, I., Sinaii, N., Ortiz, R., Shah, J. (2015) Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstetrics & Gynecology 125(3), 719–728 DOI: 10.1097/AOG.0000000000000663 Waxenbaum, J.A., Reddy, V., Varacallo, M. (2021) Anatomy, Autonomic Nervous System. StatPearls [Internet]. StatPearls Publishing. Available at: www.ncbi.nlm.nih.gov/books/NBK539845/, last accessed 25 July 2022 Wurn, B.F., Wurn, L.J., Patterson, K., King, C.R., Scharf, E.S. (2012) Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: results from two independent studies. Journal of Endometriosis and Pelvic Pain Disorders 3(4), 188–196 DOI: 10.5301/ JE.2012.9088

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CLINICAL

Early detection and diagnosis of cerebral palsy The early identification of infants at risk of cerebral palsy (CP), and their prompt enrolment into appropriate intervention, can help reduce the severity and impact of the associated motor impairment as a child develops. Here, Brian Hoare describes the early signs of CP, the clinical tools that can be used to detect CP in infants as young as three months old, and when to refer to medical and allied health professionals.

WHAT IS CEREBRAL PALSY?

Cerebral palsy (CP) is defined as a disorder of movement and posture, causing activity limitation, attributed to non-progressive disturbances related to brain injury early in development (Rosenbaum et al, 2007). It is considered one of the most common causes of childhood physical disability (Oskoui et al, 2013). The motor disorders are often accompanied by disturbances of sensation, cognition, communication, perception and behaviour, and seizures.

Preterm birth is the most important risk factor for CP, although half of children with CP do not have a complicated birth history (Hubermann et al, 2016). Term births are the largest gestational age group, accounting for 59% of all children (Australian Cerebral Palsy Register [ACPR] Group, 2016).

In these children, risk factors include placental abnormalities, birth defects, low birthweight, meconium aspiration, instrumental/emergency caesarean delivery, birth asphyxia, neonatal seizures, respiratory distress syndrome, hypoglycaemia and neonatal infection (McIntyre et al, 2013).

The cause of CP is unclear in approximately 80% of cases (Nelson, 2008). In the past, CP was believed to be caused by birth asphyxia; however, this is not the case. In a populationbased study, only 6% of children with CP had a recognised birth complication capable of interrupting oxygen supply (Grether and Nelson, 1997). New evidence suggests that 14% of cases have a genetic component (McMichael et al, 2015; Novak et al, 2017).

In approximately 90% of cases, CP results from damage to healthy brain tissue rather than from abnormalities in brain development (Bax et al, 2006).

The stage of brain maturation during which the damage occurs defines the type and site of the brain lesion, as well as the specific response to injury (Graham et al, 2016).

PRESENTATION OF CP

CP is a clinical diagnosis based on a combination of clinical and neurological signs (Novak et al, 2017). It covers a wide range of clinical presentations.

The distribution of impairment can be described topographically as: Unilateral – hemiplegia, seen in 38% of cases; Bilateral – including diplegia, where the lower limbs are affected more than the upper limbs, seen in 37% of cases; and quadriplegia, with all four limbs and trunk affected, seen in 24% of cases (ACPR Group, 2016).

BRIAN HOARE

Brian Hoare is director of the Cerebral Palsy Group and CPToys, Melbourne, and adjunct associate professor at La Trobe University, Melbourne. Since 2012, he has taught over 1,800 therapists across more than 85 courses that focus on the implementation of evidence-based motorlearning models of therapy in clinical practice. His research interests include cognition and skill acquisition in young children with cerebral palsy.

In addition, four motor types exist that may emerge and change during the first two years of life. These include spasticity, dyskinesia (including dystonia and athetosis), ataxia and mixed (Rosenbaum et al, 2007).

The subjective terms ‘mild’, ‘moderate’ and ‘severe’ are no longer used to describe the severity of CP.

An improving picture Recent data from the Australian Cerebral Palsy Register, the largest CP register worldwide, indicate that the rate of CP has fallen from one in 400 to one in 700 live births, a 30% reduction (ACPR Group, 2016). The severity of CP has also become milder in the most recently reported birth years. Two out of three children living with CP can walk without assistive equipment and more than half do not have an intellectual disability (ACPR Group, 2016). There are multiple reasons for these reductions in rates and severity, including improvements in education around healthy pregnancies, maternal and neonatal care especially in high-risk pregnancies, neuroprotection, brain repair, early detection and diagnosis, and early therapy intervention.

CLINICAL

Classifying functional status A suite of classification tools has been developed to describe a child’s functioning across a range of domains, including the Gross Motor Function Classification System (Palisano et al, 1997), Manual Ability Classification System (Eliasson et al, 2006) and Communication Function Classification System (Hidecker et al, 2011). The introduction of these tools not only provides a common framework and language to describe the functional status of children with CP, but also allows evidence-based prognostication about functional progress in each domain of function, providing parents and clinicians with a means to plan interventions and to judge progress over time (Rosenbaum et al, 2002).

WHY IS EARLY DETECTION AND DIAGNOSIS OF CP IMPORTANT?

While the associated brain injury or malformation is non-progressive in children with CP, symptoms, including motor impairment, may worsen over time, leading to varying levels of disability and difficulties with skill development (Hedberg-Graff et al, 2019). As a result, there is a strong shift in current practice away from the ‘wait and see’ approach towards the early detection of infants at risk of CP and facilitating timely access to

early intervention (McIntyre et al, 2011).

When a diagnosis of CP is suspected but cannot be made with certainty, experts recommend that an interim diagnosis of high risk of CP be given (Novak et al, 2017).

Prompt referral by care providers for early occupational therapy and physiotherapy is critical (Boychuck et al, 2020) as the most rapid gains in gross motor and bimanual abilities for most children with CP have been found to occur in the first two years of development (Rosenbaum et al, 2002; Nordstrand et al, 2016). Maximising this early period of development is important as neurological pathways which remain intact can be harnessed, and enhanced through the mechanism of activity-based or experiencedependent neural plasticity (Friel et al, 2014). Early detection is also important so that parents can receive appropriate psychological and financial support (when available) following diagnosis (Novak et al, 2017).

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EARLY SIGNS OF CP AND WHEN TO REFER

It is critical to acknowledge parental concerns about an infant. Eighty-six per cent of parents of a child with CP suspect it before the diagnosis is made (Baird et al, 2000). In 2020, a group of international experts developed a list of clinical features that should prompt referral for diagnostic assessment of CP (Boychuck et al, 2020). These include: Early handedness before 12 months of age; Stiffness or tightness in the legs between six and 12 months of age (e.g., unable to bring toes to mouth); Persistent fisting of the hands beyond four months of age; Persistent head-lag beyond four months of age; Unable to sit without support beyond nine months of age; Any asymmetry in posture or movement.

“...the most rapid gains in gross motor and bimanual abilities for most children with CP have been found to occur in the first two years of development”

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CLINICAL

TOOLS FOR THE EARLY DETECTION OF CP

Advances in early detection and diagnosis Diagnosis of CP typically occurs between 12 and 24 months of age (Hubermann et al, 2016). However, recent advances in science and clinical assessment provide the opportunity to diagnose CP as early as three months corrected age (a premature baby’s chronological age minus the number of weeks or months it was born before full term), with an accuracy of more than 97%.

A recently published international clinical guideline (Novak et al, 2017) recommends the use of magnetic resonance imaging (MRI), Prechtl’s General Movements Assessment (GMA) and the Hammersmith Infant Neurological Examination (HINE) for early detection of CP (Romeo et al, 2016; Kwong et al, 2018). Each of these assessments has demonstrated high sensitivity and specificity for

detecting CP as early as three months corrected age.

The guideline presents two pathways.

The first is for infants younger than five months corrected age who have newborn-detectable risks for CP that warrant screening (such as prematurity, atypical intrauterine growth, encephalopathy, genetic abnormalities and seizures) (Novak et al, 2017). This pathway recommends the use of MRI plus the GMA or the HINE. The second pathway is for infants older than five months corrected age where the pregnancy appeared to be uneventful. Children on this pathway are typically those with unilateral CP. In this group, MRI (where possible) and the HINE are recommended (Novak et al, 2017). More recently the Hand Assessment for Infants (HAI) has been introduced to help accurately predict the risk of unilateral (hemiplegic) CP in infants aged between three and 12 months.

“...recent advances in science and clinical assessment provide the opportunity to diagnose CP as early as three months corrected age”

Prechtl’s GMA General movements (GMs) are part of the spontaneous movement repertoire that is present from early fetal stages until the end of the first six months of life (Prechtl, 1990; Kwong et al, 2018).

They involve movements of the whole body in a variable sequence of arm, leg, neck and trunk.

The General Movements Trust (general-movements-trust.info) offers training courses in Prechtl’s GMA, which allows clinicians to detect abnormalities in GMs. Two distinct movement patterns can be observed from term age: writhing movements (WMs) and fidgety movements (FMs) (Morgan et al, 2019). WMs are present from term age up to about nine weeks. FMs appear at approximately seven to eight weeks of age and can be present until about 20 weeks (Morgan et al, 2019). Following a brain injury or abnormality, GMs lose their complex and variable character and become monotonous and poor.

During the writhing period abnormal GMs are described as either poor repertoire, cramped-synchronised or chaotic (Morgan et al, 2019). Abnormal GMs at the fidgety age are classified as: Absent FMs, when normal FMs are never observed; Abnormal FMs, when FMs can be detected but their amplitude, speed and jerkiness are moderately or greatly exaggerated.

Cramped-synchronized GMs in the writhing period and an absence of fidgety GMs in the fidgety period are predictive of CP with high sensitivity and specificity (Einspieler et al, 2012; Bosanquet et al, 2013). Outcomes from the GMA can also indicate the topography of CP in infants (Novak et al, 2017).

HINE The HINE is a clinical tool designed for evaluating infants between two months and 24 months of age (Romeo et al, 2016). It includes 26 items and can be completed in five to 10 minutes. The global score can range from a minimum of 0 to a maximum of 78. Global scores are reported as optimal if they are 73 or more at nine to 12 months of age, or at least 70 and 67 at six months and three

CLINICAL

months of age, respectively. A score of 57 is recommended by the international guideline as the cutoff for predicting CP at the age of three months (Romeo et al, 2013; Novak et al, 2017). HINE scores can also indicate the topography of CP in infants (Novak et al, 2017).

HAI The recently developed HAI quantifies asymmetric hand function by measuring each hand separately as well as both hands together in infants from three to 12 months of age (Krumlinde-Sundholm et al, 2017). For infants presenting with upper limb asymmetry, the HAI can be used to help accurately predict the risk of unilateral CP as early as three months of age (Ryll et al, 2019).

EARLY DIAGNOSIS, IMPROVED OUTCOMES

There have been significant recent advances in the ability to accurately detect and diagnose infants with CP. Improved understanding of the mechanisms for activity-based or experience-dependent neural plasticity provides strong support for moving away from a ‘wait and see’ approach and warrants immediate referral to suitably qualified paediatric occupational therapists and physiotherapists to commence a range of evidence-based models of therapy as early as possible (Morgan et al, 2021). Any medical needs of the child should also be managed by a medical specialist.

References Australian Cerebral Palsy Register Group (2016) Report of the Australian Cerebral Palsy Register, Birth Years 1993–2009. www.cpregister.com/pubs/pdf/ACPRReport_Web_2016.pdf, last accessed 23 April 2022 Baird, G., McConachie, H., Scrutton, D. (2000) Parents’ perceptions of disclosure of the diagnosis of cerebral palsy. Archives of Disease in Childhood 83(6), 475–480.

DOI: 10.1136/adc.83.6.475 Bax, M., Tydeman, C., Flodmark, O. (2006) Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study. JAMA 296(13), 1602–1608. DOI: 10.1001/jama.296.13.1602 Bosanquet, M., Copeland, L., Ware, R., Boyd, R. (2013) A systematic review of tests to predict cerebral palsy in young children. Developmental Medicine & Child Neurology 55(5), 418–426. DOI: 10.1111/dmcn.12140 Boychuck, Z., Andersen, J., Bussieres, A., Fehlings, D., Kirton, A., Li, P., OskouI, M., et al (2020) International expert recommendations of clinical features to prompt referral for diagnostic assessment of cerebral palsy.

Developmental Medicine & Child Neurology 62(1), 89–96. DOI: 10.1111/dmcn.14252 Einspieler, C., Marschik, P.B., Bos, A.F., Ferrari, F., Cioni, G., Prechtl, H.F. (2012) Early markers for cerebral palsy: insights from the assessment of general movements. Future Neurology 7(6), 709–717. DOI: 10.2217/fnl.12.60 Eliasson, A.C., Krumlinde-Sundholm, L., Rösblad, B., Beckung, E., Arner, M., Ohrvall, A.M., Rosenbaum, P. (2006) The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability.

Developmental Medicine & Child Neurology 48(7), 549–554. DOI: 10.1017/S0012162206001162 Friel, K.M., Williams, P.T.J.A., Serradj, N., Chakrabarty, S., Martin, J.H. (2014) Activity-based therapies for repair of the corticospinal system injured during development. Frontiers in Neurology 5, 229. DOI: 10.3389/fneur.2014.00229 Graham, H.K., Rosenbaum, P., Paneth, N., Dan, B., Lin, J.P., Damiano, D.L., Becher, J.G., et al (2016) Cerebral palsy. Nature Review Disease Primers 2, 1–24. DOI: 10.1038/nrdp.2015.82 Grether, J.K., Nelson, K.B. (1997) Maternal infection and cerebral palsy in infants of normal birth weight.

Journal of the American Medical Association 278(3), 207–211. doi:10.1001/jama.1997.03550030047032 Hedberg-Graff, J., Granström, F., Arner, M., Krumlinde-Sundholm, L. (2019) Upper-limb contracture development in children with cerebral palsy: a population-based study. Developmental Medicine & Child Neurology 61(2), 204–211. DOI: 10.1111/dmcn.14006 Hidecker, M.J.C., Paneth, N., Rosenbaum, P.L., Kent, R.D., Lillie, J., Eulenberg, J.B., Chester Jr, K., et al (2011) Developing and validating the Communication Function Classification System for individuals with cerebral palsy. Developmental Medicine & Child Neurology 53(8), 704–710. DOI: 10.1111/j.14698749.2011.03996.x Hubermann, L., Boychuck, Z., Shevell, M., Majnemer, A. (2016) Age at referral of children for initial diagnosis of cerebral palsy and rehabilitation: current practices.

Journal of Child Neurology 31(3), 364–369. DOI: 10.1177/0883073815596610 Krumlinde-Sundholm, L., Ek, L., Sicola, E., Sjöstrand, L., Guzzetta, A., Sgandurra, G., Cioni, G., Eliasson, A-C. (2017) Development of the Hand Assessment for Infants: evidence of internal scale validity.

Developmental Medicine & Child Neurology 59(12), 1276–1283. DOI: 10.1111/dmcn.13585 Kwong, A.K.L., Fitzgerald, T.L., Doyle, L.W., Cheong, J.L.Y., Spittle, A.J. (2018) Predictive validity of spontaneous early infant movement for later cerebral palsy: a systematic review. Developmental Medicine & Child Neurology 60(5), 480–489. DOI: 10.1111/ dmcn.13697 McIntyre, S., Morgan, C., Walker, K., Novak, I. (2011) Cerebral palsy—don’t delay. Developmental Disabilities Research Reviews 17(2), 114–129. DOI: 10.1002/ ddrr.1106 McIntyre, S., Taitz, D., Keogh, J., Goldsmith, S., BadawI, N., Blair, E. (2013) A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Developmental Medicine & Child Neurology 55(6), 499–508. DOI: 10.1111/dmcn.12017 McMichael, G., Bainbridge, M.N., Haan, E., Corbett, M., Gardner, A., Thompson, S., Van Bon, B.W., et al (2015) Whole-exome sequencing points to considerable genetic heterogeneity of cerebral palsy. Molecular Psychiatry 20(2), 176–182. DOI: 10.1038/mp.2014.189

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Morgan, C., Fetters, L., Adde, L., Badawi, N., Bancale, A., Boyd, R.N., Chorna, O., et al (2021) Early intervention for children aged 0 to 2 years with or at high risk of cerebral palsy. JAMA Pediatrics 175(8), 846–858. DOI: 10.1001/ jamapediatrics.2021.0878 Morgan, C., Romeo, D.M., Chorna, O., Novak, I., Galea, C., Del Secco, S., Guzzetta, A. (2019) The pooled diagnostic accuracy of neuroimaging, general movements, and neurological examination for diagnosing cerebral palsy early in high-risk infants: a case control study. Journal of Clinical Medicine 8(11), 1879. DOI: 10.3390/jcm8111879 Nelson, K.B. (2008) Causative factors in cerebral palsy.

Clinical Obstetrics and Gynecology 51(4), 749–762.

DOI: 10.1097/GRF.0b013e318187087c Nordstrand, L., Eliasson, A.C., Holmefur, M. (2016) Longitudinal development of hand function in children with unilateral spastic cerebral palsy aged 18 months to 12 years. Developmental Medicine & Child Neurology 58(10), 1042–1048. DOI: 10.1111/ dmcn.13106 Novak, I., Morgan, C., Adde, L., Blackman, J., Boyd, R.N., Brunstrom-Hernandez, J., Cioni, G., et al (2017) Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment.

JAMA Pediatrics 171(9), 897–907. DOI: 10.1001/ jamapediatrics.2017.1689 Oskoui, M., Coutinho, F., Dykeman, J., Jetté, N., Pringsheim, T. (2013) An update on the prevalence of cerebral palsy: a systematic review and meta-analysis.

Developmental Medicine & Child Neurology 55(6), 509–519. DOI: 10.1111/dmcn.12080 Palisano, R., Rosenbaum, P., Walter, S., Russell, D.J. (1997) Gross Motor Function Classification System for cerebral palsy. Developmental Medicine & Child Neurology 39(4), 214–223. DOI: 10.1111/j.14698749.1997.tb07414.x Prechtl, H.F.R. (1990) Qualitative changes of spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction. Early Human Development 23(3), 151–158. DOI: 10.1016/03783782(90)90011-7 Romeo, D.M., Ricci, D., Brogna, C., Mercuri, E. (2016) Use of the Hammersmith Infant Neurological Examination in infants with cerebral palsy: a critical review of the literature. Developmental Medicine & Child Neurology 58(3), 240–245. DOI: 10.1111/ dmcn.12876 Romeo, D.M.M., Cioni, M., Palermo, F., Cilauro, S., Romeo, M.G. (2013) Neurological assessment in infants discharged from a neonatal intensive care unit. European Journal of Paediatric Neurology 17(2), 192–198. DOI: 10.1016/j.ejpn.2012.09.006 Rosenbaum, P., Paneth, N., Leviton, A., Goldstein, M., Bax, M., Damiano, D., Dan, B., Jacobsson, B. (2007) A report: the definition and classification of cerebral palsy April 2006. Developmental Medicine & Child Neurology Supplement 109, 8–14 Rosenbaum, P.L., Walter, S.D., Hanna, S.E., Palisano, R.J., Russell, D.J., Raina, P., Wood, E., et al (2002) Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA 288(11), 1357–1363. DOI: 10.1001/jama.288.11.1357 Ryll, U.C., Wagenaar, N., Verhage, C.H., Blennow, M., De Vries, L.S., Eliasson, A-C. (2019) Early prediction of unilateral cerebral palsy in infants with asymmetric perinatal brain injury – model development and internal validation. European Journal of Paediatric Neurology 23(4), 621–628. DOI: 10.1016/j. ejpn.2019.04.004

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PRACTICE MANAGEMENT

Mergers and acquisitions: what you need to know

Have you been approached to sell your business? If so, as an osteopathic business owner, you may be unsure how to react, what to do next, and what to prepare for should things proceed down the acquisition path. This article guides you through the process and highlights the things you need to think about before deciding what’s right for you and your business.

WHEELING AND DEALING IN ALLIED HEALTH

Healthcare mergers and acquisitions surged in 2021, growing 56% in the 12 months compared with 2020. There was particularly high growth among GP medical groups, which saw more than 400 deals, as well as managed care and rehabilitation subsectors, according to a new report from PwC. This compares with about 200 to 250 deals per year between 2017 and 2019. The growth in allied health land is rapid. Looking ahead to the rest of 2022 and beyond, the established pattern of deals surging after an economic downturn is likely to continue, with companies actively exploring potential acquisitions in the allied health industry.

STAGES OF ACQUISITION

Build your trusted, expert advisory group This is essential and the most important piece of advice you can take from this article. Experts (lawyer, accountant and a friend/family member/mentor with experience in the mergers and

acquisitions field) can be a sounding board for your decisions and a trusted resource during the rest of the acquisition process. If selected carefully, they will not only help you negotiate the best price tag but also make sure you don’t get taken advantage of by an experienced acquirer.

TOP TIP Your current accountant/lawyer may not be the right person to help with mergers and acquisitions – seek experts in the field.

Signing a non-disclosure agreement A non-disclosure agreement (NDA) is an agreement that certain information shared between parties will remain confidential. An NDA binds an individual who has signed it and prevents them from discussing information with any non-authorised party. Both the potential buyer and seller should sign this agreement. At this point in time, the potential acquirer will often ask for three to five years of basic financial reports.

“The right price for acquisition is one that recognises what you’ve built, what the acquirer will be able to do with what you’ve built and is sufficient to cause you to close the chapter on seeking your continued growth on your own”

BRETT WIENER

Brett graduated from Victoria University and completed his Masters in Applied Positive Psychology at the University of Melbourne. He has a wealth of knowledge in the science of what it means for individuals, groups and institutions to thrive. He is a director at the Sports and Spinal Group in Bayside, Melbourne.

Brett is a member of the Osteopathy Australia Board.

Back-of-the-envelope market valuation To inform owners of the estimated transaction value of their business, many companies will provide a detailed, backof-the-envelope (BOTE) market valuation.

The BOTE approach establishes the estimated transaction value of a company by comparing its financial performance with similar companies that have previously been acquired.

There is no unifying theory on a magic formula to determine the ‘right price’.

The right price for acquisition is one that recognises what you’ve built, what the acquirer will be able to do with what you’ve built and is sufficient to cause you to close the chapter on seeking your continued growth on your own.

Remember – the dollar amount isn’t all that matters – the devil is in the detail so it is important to consider the terms associated with what is being offered.

Valuation of your business Earnings before interest, taxes, depreciation and amortisation (EBITDA) is a measure of profitability. This is

PRACTICE MANAGEMENT

the ultimate measure of a company’s success in the eyes of a bank or investor. A business is much more than its profitability, but when it comes to purchase price, that price is primarily based on profitability. The adjusted EBITDA is an area where an experienced accountant can be particularly valuable in helping you as a seller. In preparation for the sale, you will want to identify all one-time expenses or those that the buyer would not incur to run the business successfully following the transaction.

Business owners often run personal or extraneous expenses through their companies that may not be necessary.

Another example is investments in more PPE brought on by the COVID-19 pandemic are not likely to be necessary in the years ahead (we hope!). These expenses are added back to EBITDA to create a more realistic adjusted EBITDA on which to base the purchase price.

Market multiples To determine valuation, most companies use a common industry standard of taking a multiple of the adjusted EBIDTA. The current, average market multiple in allied health is between 3 to 5.5 times, which means that if your adjusted EBITDA is $100,000, then we would expect offers to come in between $300,000 and $550,000. The key word here is ‘average’. Some multiples will go higher depending on the industry, size of company and demand. Recently, multiples exceeding 17 times have been seen for larger, established companies in durable medical equipment, staffing and applied behavioural analysis services while some very small providers have received offers as low as two times.

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“A business is much more than its profitability, but when it comes to purchase price, that price is primarily based on profitability” TOP TIP As there is such a substantial range of market multiples, it shows the importance of having a knowledgeable adviser who can help determine a strong adjusted EBITDA and who understands the industry and its multiples. This will lead to a fair and reasonable valuation of your business.

Letter of intent or non-binding indicative offer A letter of intent (LOI) or non-binding indicative offer (NBIO) is essentially a mergers and acquisition form of a marriage proposal from the buyer.

As the name implies, the LOI lays out the intent of both parties – that is, the seller states they are willing to sell for the proposed terms, and the buyer states what they are willing to pay.

The LOI is an important step because it lays out the basics of the final deal: the purchase price and terms, anticipated closing date, length of exclusivity (which prevents you from talking to other potential buyers – often called the ‘no shop clause’) and more. Based on what each side discovers during ‘due diligence’ (see below) and/or whether the profits of the company decline, the structure of the deal may change. The LOI is not legally binding, and either party can walk away from the deal at any time during this part of the process.

Structure of an offer Within your initial offer, the potential buyer will often take your adjusted EBITDA and attach a multiple to that number. That will provide you with

a ‘total purchase price’. They will then break this number down into a percentage of cash as an upfront payment with the rest of the total purchase price held in an agreed type of share (speak to your lawyer and accountant about these different types).

Also, there will often be an ‘escrow’ period attached to the agreement. This is how long you will be handcuffed to the business with the terms of this escrow laid out in your contract. The dollar amount of shares left in the business are often attached to what is called a maintainable EBITDA (MEBITDA) – this means you must hold or improve the business’s performance based on the agreed MEBITDA to earn out the rest of the agreed purchase price at the end of your escrow period.

Within the contract, there will be clauses that speak to your options as to when and what you can do with these shares.

There is also a formula you can use to work out what deductions will occur if the business’s performance declines. It is best to consider this percentage as ‘cream on top’, rather than a given you will receive.

TOP TIP You have the right to negotiate the initial offer (and the initial offer is never their best offer). This means not just the overall purchase multiple and price, but the breakdown of cash versus equity. Consult your team of advisers on this.

Due diligence Once an LOI is signed, the due diligence process begins. This is when the buyer conducts a complete investigation of a prospective acquisition, including gathering more intimate details of the company such as full financials, employee/associate breakdowns, customers, contracts and any skeletons

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PRACTICE MANAGEMENT

in the closet like lawsuits and potential liabilities. Most of this information is provided by the seller via the uploading of supporting documentation as requested by the buyer into a secure data room.

TOP TIP Don’t forget that the due diligence process is also for you to learn more about the potential buyer – you have full right to request all the same documentation that you are being asked for. Ask for their financials, speak to their funders, staff or other companies who have been acquired by the company.

Contract of sale and employee agreements A final contract for an acquisition will either be in the form of a:

Share sale. Where all the shares in that company are acquired; or Business sale. Where the assets of that business are acquired.

Buyers tend to prefer asset deals because it is easier to clarify what pieces of the company the buyer wants to assume, and they do not assume the

potential liabilities from years past. If the buyer acquires the stock, the liability falls on the new owner. In some cases, an asset deal may help shield a buyer from the past misdeeds of the seller, but that’s not always the case.

In addition, don’t forget that you are about to become an employee (unless you are negotiating a full and immediate exit), and this requires a new employee contract. This is where understanding where this decision is taking you on your own, personal journey and what you want to do in your professional and personal life in the future is essential.

TOP TIP This isn’t the time to get frustrated or impatient with the length of the process. Ensure that you are happy with every detail in each of the contracts – both financially and non-financially before signing.

YOU’VE SIGNED THE AGREEMENTS – NOW WHAT?

Conditions precedent are all the items that are required to occur before the confirmation of sale and settlement date.

“Buyers tend to prefer asset deals because it is easier to clarify what pieces of the company the buyer wants to assume, and they do not assume the potential liabilities from years past”

A completion checklist is commonly used to detail all the steps required through each of the final stages to settle the transaction. The business sale and transfer of funds is only complete when each step of the checklist has been executed or excused by the buyer.

Four key non-financial questions to ask You need to ask yourself four key non-financial questions. It is worth discussing these with your coach, mentor or trusted adviser. Take the time to digest, reflect and visualise what life might look like for you and your family in the future.

1. As a business owner with autonomy, are you ready to be an employee and all that comes with it?

2. Is the offer life-changing or life-helping?

3. If the acquiring company is funded by private equity, they have been proven across all industries to care about EBITDA above anything else, regardless of their philosophy and culture – are you OK to be at the mercy of this for your escrow period?

4. What does life look like for you after the escrow period?

* The information provided in this article is a personal perspective based on life lessons and not intended as formal financial advice. Always seek professional advice from qualified advisers.

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PRACTICE MANAGEMENT

Planning for life after retirement

In the last issue of Osteo Life, Brian Nicholls discussed the importance of planning early for retirement. In this article, he continues the planning theme, this time considering factors that need thinking about as retirement finally approaches.

AS RETIREMENT DRAWS NEARER

You’re approaching retirement age.

You’ve invested well and carefully.

You’ve paid off your mortgage. There’s a healthy balance in your super account.

Your multiple investment properties are bringing in good returns and the classic Ferrari in your garage is going up in value (I may be being slightly facetious here, although according to The Economist some of the bestperforming investments over the past few years have been classic cars and classic watches). Congratulations. You may now think you’ve reached the stage where you’re sitting pretty and have nothing else to do but say farewell to patients and enjoy the good life…

Not so fast! You still have a lot of things to think about and a lot of decisions to make. In no particular order these include the following.

Your assets You’ve put a lot of work into building up your assets (unless you simply won TattsLotto) and you don’t want to see them all disappear in a stock or housing market collapse. So, you need to think about how you are going to protect your assets.

Related to this is the question of what you should do with your assets. Do you

keep your money in your super fund and use it to pay a pension? Do you withdraw it and reinvest in something else? Do you keep or sell other assets?

Also, is there some way you can structure your assets and income stream so that you get even a small amount of state pension? If you can, then that pension concession card can actually save you enough money in a year to pay for a week’s holiday.

Deciding what to do with your assets is discussed in more detail below.

Your health You want to be able to enjoy retirement, but health problems catch up with us in later life. Do you want to increase your private health cover to allow for joint replacements, cataracts and the like? Do you need to put money aside for hearing aids, which can cost up to $16,000 a pair, or dental implants at $4,000 a tooth, neither of which are fully covered by health funds?

Do you take the optimistic view that you are always going to be able to live at home, or do you plan for the possibility that you may need to move into care?

Inheritance There’s an old saying that the most common cause of death is birth. All of

BRIAN NICHOLLS

Brian Nicholls became an osteopath in his 30s after living and working for seven years in Japan. He worked in the UK before moving to Australia in 1994, where he practised on the Mornington Peninsula and also taught osteopathy at Victoria University for 16 years. He retired in 2020.

us are going that way eventually, and if you want to hand your remaining assets on to your family or someone else you have to plan accordingly using things like wills or binding death benefit nominations, etc. Inheritance planning is also discussed in more detail below.

HOW MUCH MONEY WILL YOU NEED?

You may wonder how much you need for retirement. I have seen some absurd figures from banks and finance companies suggesting you need upwards of $1.5 million on top of the value your house. A more sensible figure comes from ASFA (the Association of Super Funds Australia), which suggests a figure of $640,000 for couples on top of the value of their home. This is for a comfortable retirement. ‘Comfortable’ includes things like an annual holiday, car expenses, private health cover and eating out from time to time. Check the ASFA website, www.superannuation.asn.au, for more information.

If you’re not sure how much regular income you’ll need, there are plenty of retirement calculators online, including

PRACTICE MANAGEMENT

on the government’s Moneysmart website, www.moneysmart.gov.au.

Work out your regular annual expenditure, allow for any major retirement purchases you may want to make, then plug the figures into the calculator and you should get a rough idea of what your requirements are likely to be.

THINK ABOUT THE STAGES OF RETIREMENT

Just as your working life has three stages (as explained in the previous article [Nicholls, 2022]), so too does your retirement, and each stage has different financial needs that require thought and planning. The three stages of retirement are typically called: Active – the early retirement years when retirees are most likely to travel or take up new retirement pursuits, so will need a larger retirement income or the funds to make some large capital purchases.

Sedentary – when health and energy levels start to drop. Most people at this stage will still be able to live at home but will travel less and spend less. If they are lucky, they may have sufficient income to save a little more for…

Final – when moving into care facilities may be necessary.

Considerable expense can be associated with this, and if savings are insufficient, it may involve selling the home.

The active stage of retirement is the one that requires the most thought. If your idea of the perfect retirement is pottering round the garden and looking after the grandchildren, your financial needs may not be that high. However, let’s say you plan to buy a caravan and do the grey nomad thing, or buy a boat and take up fishing, or head off on a round-theworld cruise. All of these are expensive.

You will need to take a hard look at your savings and assets several years before you retire, and if you think funds will be insufficient for the lifestyle you want, add to them if you can while you are still working and have surplus cash.

INHERITANCE PLANNING

Inheritance planning is also something you should start early. Everyone should have a will. Most people only need a simple will until they get older, and these

can be drawn up at relatively low cost.

They should be updated as and when your circumstances change. If you have money in a super fund you should also have a binding death nomination, which specifies who inherits any remaining balance in your super accounts and avoids a lot of legal faffing about that will arise if you don’t have one.

Check the rules of your super accounts. Some, though very few, defined benefit superannuation pensions still exist. These are super accounts that pay a fixed pension that is independent of stock market fluctuations, and the amount in the fund is not counted towards your assets for tax purposes.

If you have one, they’re great, but they operate very differently from other pension or accumulation super accounts in terms of what happens to the account after you pass away.

It’s very important to talk to your super fund about the best way to ensure that the maximum possible amount of inheritance can be preserved. (None of this was explained to me at the time I set up my superannuation.)

DECISIONS TO MAKE

In the run up to retirement, you should talk to a good financial adviser specialising in retirement financial planning. If you are in a super fund, they will have advisers.

You will need to make some important decisions about what happens to your investments once you finally retire.

What to do with your assets If you decide to stay invested with a super fund you will usually be offered a pension account that pays a regular amount based on a percentage of what you have saved. If you only need the minimum amount (5% a year from 2022/23 for over 65s), this may allow you to access a partial state pension.

You can also retain an accumulation account, which allows you to add to your super if you have spare cash. Many people actually find they can increase their savings during retirement.

Another strategy would be to withdraw your funds or sell your other assets and invest in something like an annuity. This will give you a fixed pension regardless of stock market fluctuations. This has some tax advantages, but once set up, you cannot

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vary the amount you draw down, and you cannot withdraw lump sums, unlike a super pension account.

The risk you wish to accept After retirement most people choose lowrisk investments to minimise the possibility of massive asset losses in stock or other market crashes. However, if your funds are marginal, you may want to accept a slightly higher risk level in the hope of growing your nest egg in the early retirement years when you will need more funds. This is a personal decision and should be based on good advice.

SOME FINAL THOUGHTS

The recommendations made in both this and the previous article (Nicholls, 2022) are typical of what has been advised for the past 20 years or so, but the world is changing. Australians now carry one of the world’s highest levels of personal debt, and it will take much longer for younger people to become debt free, which will affect their savings potential.

As always, it is important to remember that all investment strategies carry risks, and as I said in the previous article we are living in a world of great financial and geopolitical uncertainty. There is much for all working osteopaths to ponder. However, with the right choices, hopefully everyone can enjoy the good retirement they deserve.

Finally, I’ll say it again. Look after your own physical and mental health while working. Good health is a prerequisite for an enjoyable retirement. One of my tutors always used to say, ‘Yes, patients are important, but your own health comes first.’ The older I get, the more I see how right she was. * The information provided in this article is a personal perspective based on life lessons and not intended as formal financial advice. Always seek professional advice from qualified advisers.

Reference Nicholls, B. (2022) Retirement planning for osteopaths.

Osteo Life, pages 31-32.

Useful sources of information www.moneysmart.gov.au www.superannuation.asn.au

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