Osteo Life Winter 2022

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

W I N T ER 2 0 2 2

Management of long COVID An evidence-based osteopathic approach

Domestic and family violence Role of osteopaths in supporting patients

Marketing during COVID and beyond Effective strategies to engage new and current patients

Retirement planning How to plan early and plan well

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WELCOME

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PRESIDENT’S MESSAGE

Get curious about data in practice!

In extending a warm welcome to Don Hunter, our newly appointed Osteopathic Director on the Osteopathy Australia Board, I’d like to thank all of the members who applied for this role.

Volunteer members are the backbone of the association so I’d encourage everyone to look at the committees that we have or the sessions that we run, such as our recent focus group on outcome measures, to get involved. Your input and voice matters, and is important in helping our profession to grow.

Don brings a new voice to the board representing osteopaths practising in rural and regional areas to provide better insights into the challenges they and their clients face. Don’s story on page 4 shines a light on his passion for research and why he thinks it’s important for clinicians to get curious about data.

For some, the word ‘data’ invokes fear and a slight sweat, while, for others, it invokes excitement! We have always wondered how we can support clinicians to get more involved in research. But, where do you start? Kathryn Refshauge, another director of Osteopathy Australia, addressed this very question in her article in the Autumn 2022 issue of Osteo Life (pages 34-35), and suggested various pathways for getting involved in research.

For many of us, the intention is not necessarily to gain an additional qualification, but we like the idea of ‘proving’ what we do and knowing that we make a positive impact on a patient’s health outcomes. Using outcome measures in your practice is in theory a great way of measuring results, but quite often, in reality, they can be hard to implement, and often we may only use them when a third-party insurer is involved.

“Your input and voice matters, and is important in helping our profession to grow” Osteopathy Australia

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

osteoaust

osteopathyaustralia

osteopathyau

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

Advancements in technology, such as Apple watches, Fitbits and myriad health apps, all gather huge amounts of health data about us, and continue to change the way we think and behave.

Even the way we collect data in practice has changed immensely – just look at the practice management systems we have in clinics now compared with our paper files 20 to 30 years ago.

What opportunities are there for osteopaths in this field? What are the data opportunities that we could mobilise to help support the evidence for osteopathy and the positive impact it has on patient outcomes? This is something that Shamona Eaves, our Senior Research and Projects Officer at Osteopathy Australia, is working on closely. If you have any bright ideas around this, we would love to hear from you. In the meantime, stay safe, well and curious!

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

In this issue...

News 4

Osteopathy Australia news

10 Domestic and family violence: how osteopaths can support patients Clinical

14 Treating long COVID patients: the potential role of osteopaths ROSALBA COURTNEY, ZOE STEELE & IMOGEN COLLYER

20 Endometriosis, chronic pelvic pain and how nutritional interventions may help

Practice Management

28 Approaches to marketing during COVID and beyond ALAN ZAIA

31 Retirement planning for osteopaths BRIAN NICHOLLS

Advertorials

33 Back pain: turning up the heat 34 Restoring health in animals with osteopathy

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.

4

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.

New Board Director for Osteopathy Australia Osteopathy Australia is delighted to welcome Don Hunter as an Osteopathic Board Director. Don brings a passion for research and an understanding of the challenges faced by practitioners and clients in regional and rural Australia, experience he hopes will be invaluable in developing the profession not just in core metropolitan hubs, but in the regions as well.

Here, Don explains why he believes that research is vital to the future of osteopathy, the need to find more pathways for osteopaths to get involved in research, and tells us about his personal mission to investigate sustainable strategies to lure more osteopaths to regional Australia!

“I

originally trained and worked as a teacher before studying osteopathy, graduating in 2003 from the University of Western Sydney.

Initially, I worked in Newcastle for over 16 years, including running my own practice in New Lambton for 10 years.

I then moved to Tamworth, regional NSW, where I have been practising for over two years. I recently submitted my PhD, which investigates the relationship between thoracic posture and shoulder impingement syndrome. As a passionate osteopathic clinician, I understand the value of research performed by osteopaths. More osteopaths doing research will enable better clinical outcomes for clients and will give osteopathy as a profession a louder voice in the healthcare landscape.

Tamworth is the largest regional town in North West NSW. However, I am the first osteopath in more than a decade to work in the region and there is only one other osteopath for the next 200km in any direction. It is common

for patients to travel more than an hour for treatment. During my time in this regional area, it has been very rewarding to find a greater collaboration between allied health professionals and the medical profession in the name of better patient outcomes.

In my view, the two issues of research and workforce distribution are, in fact, interrelated. More osteopaths in rural and regional areas can only occur with the availability of more university courses for osteopathy. However, universities are attracted to professions with great research cultures. While osteopaths are producing some research, the amount of published research is small and, as such, it has been difficult to get universities interested in osteopathy.

The more research a profession adds to the healthcare environment, the more credibility it has in the government’s eyes and the more input osteopathy can have in the allied healthcare space. This would allow Osteopathy Australia to better lobby government and have a greater say (as a profession) in conversations regarding, for example, Medicare, third-party insurance, private health and the NDIS. At an individual level, doing research, no matter how small, will improve the clinical outcome for patients, improve the individual as an osteopathic clinician, and give that practitioner greater standing within their immediate healthcare community. Osteopaths have a unique approach to healthcare and, as such, have much to offer research.”

“More osteopaths in rural and regional areas can only occur with the availability of more university courses for osteopathy”

NEWS

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Osteopathy Australia launches new consumer website whatisosteo.com

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steopathy Australia has launched a new consumer website – www.whatisosteo.com – to promote osteopathy and showcase the work of osteopaths to the general public. The site includes an interactive body map and consumer-friendly information about all the things osteopaths may be able to help with.

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

A

s another financial year clicks over and we commence a new membership year, we hopefully can focus on interesting things for the future rather than COVID. We hope COVID and its negative impact on workforce, infected osteopaths and cancelled patient attendance will gradually reduce. Certainly, it appears lockdowns are finally an obsolete strategy.

We understand, for individual osteopaths or whole businesses, readjusting and recovery from the impact of COVID has reduced energies, engagement, or willingness to risk face-to-face events. We have seen the impact across many other associations and even when trying to run our own face-to-face events. We will continue to test risk and willingness to engage in face-to-face events over the rest of this year, but it appears unlikely that we will

This is just the start!

More health and wellbeing content, with more information on conditions and healthy living using the whole-body approach, will be added over time as the website builds and grows.

be running a national conference in the next 18 months.

Luckily, Osteopathy Australia has always been innovative in ensuring our services are equitable across a nationwide cloudbased platform. That allows members, wherever you are, to access CPD, live webinars or eLearning modules. Likewise, you can access our information or advice either online or over the telephone, or access HR advice whether you are a business owner or an employee. As a membership organisation, guaranteeing safe, easy access to credible information and advice is one of our key priorities.

While we continually improve what we already do, I’m always excited about what’s new or what we are developing.

Having launched a new consumer-facing osteopathy website (see above), we are now developing a better member-facing website. This will be a great portal to access information and resources. We hope this will be live before the next edition of Osteo Life. Our aim is to streamline processes such as renewals and simplify registering for free online events, changing your details, or finding better ways to promote your business. Another key feature of the new website will be the way you can search, more like Google, to find important information you want.

After numerous delays due to COVID, we are currently conducting a member survey to better understand what are your top priorities, what you want us to develop, the services you may be missing or wanting more of, and your ideas for how to advance the profession. Find out more about how you can have your say on page 6.

As always, thank you for supporting Osteopathy Australia and we look forward to improving and doing more exciting things, for you, into the future.

Updated Graduate Guide 2022 The Osteopathy Australia Graduate Guide, updated for 2022,

is available for final-year student and graduate members to help them transition into practice. It includes a step-by-step guide on what you need to do, and where to get more information, support and help. It has everything you need to know – from the scope of practice and the business of osteopathy to working as a locum vs. an employee, understanding private health funds, and your CPD obligations.

Access the Graduate Guide at www.osteopathy. org.au/membershipbenefits/graduatemembership-1 or scan the QR code.

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NEWS

NEWS IN BRIEF Leo Di Giorgio appointed AHPA policy officer

Osteopath Leo Di Giorgio has been appointed policy officer at Allied Health Professions Australia (AHPA) to help boost visibility of allied health professionals within the healthcare system. His work will involve working with AHPA members to scope current data availability and identify what should be collected for a national minimum database to address the fact allied health is very poorly integrated into existing national data collection processes. He’ll also convene AHPA’s Mental Health Working Group, which broadly advocates for more diverse allied health service provision to help address the present mental health crisis.

Thank you and a fond farewell to Peter Lalli

After seven years as a loud and proud voice for osteopathy, Peter Lalli, Senior Policy Officer at Osteopathy Australia, is moving to pastures new. Osteopathy is in a better place today through Peter’s dedication, passion, hard work, constant policy nagging and advocacy. A big ‘thank you’ to Peter from everyone on the team – we wish him the best in his new adventure in the medical college space.

Have your say!

Take the Osteopathy Australia member survey We need your help! Tell us your opinions, desires for the profession, and what you want us to prioritise in our lobbying efforts and services.

Responses are fully confidential and anonymous. The survey findings will be shared with members and are incredibly useful for individual osteopaths and businesses on a range of issues like fees, practice, lobbying, CPD and the future of the profession. Note we do not receive and nor would we ever share individual responses.

As a token of appreciation for completing the survey, you may choose to enter your name into a draw to receive a $250 Myer gift voucher. Three winners will be chosen. Only fully completed surveys will be eligible for the draw. To access the survey, scan the QR code or visit surveymonkey.com/ r/OAMember2022

International Osteopathic Healthcare Week 2022

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steopathy Australia’s media campaign for International Osteopathic Healthcare Week 2022 was based on new market research conducted specifically for the awareness week. This research asked participants a number of health and wellbeing questions relating to work and life habits and concerns of adults aged 18 and above, including ergonomics, exercise and pain.

The awareness week, which ran from 18-24 April this year, aims to promote and raise the profile of osteopathy. The association’s campaign secured more than 134 items of coverage in broadcast, online and print media, reaching an estimated 8.8 million Australians, which represents an Advertising Value Equivalent of $291,000.

Campaign highlights included national TV coverage with 10 News First, which was syndicated to more than 20 stations, reaching over 1.6 million people. The audio news release (ANR) was picked up by 25 stations across the country and syndicated to a further 46 stations while broadcast media was syndicated to 35 stations.

In tandem with the media campaign, this year’s social media campaign, running across all of the association’s digital channels, including Instagram, Facebook, Twitter and LinkedIn, focused on promoting Osteopathy Australia’s newly launched

consumer website www.whatisosteo.com (see page 5), and specifically the association’s ‘Find an Osteo’ feature to promote members’ profiles and encourage consumers to book an appointment to see an osteopath.

As part of the social media campaign, Osteopathy Australia also created a digital kit for members to download an extensive suite of resources for sharing on their own social media channels, to help amplify the messaging throughout the awareness week and beyond.

April Falls Month

C

astle Hill Osteopathic Clinic visited Anglicare Retirement Village in Castle Hill during April Falls Month to raise awareness about the impact of falls in the older population and to promote fall prevention strategies among residents.

Luke Gillogly and Jackson Lee provided information on osteopathy and how it can help older people staying mobile and safe.

This included helping them to understand the ageing process, and how to protect and/or improve their mobility as they age to mitigate some of the effects of having

less flexibility and joint fluid, reduced muscle tissue, and stiffer or eroding cartilage between bones in joints.

NEWS

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Face-to-face at last!

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e were delighted to finally resume face-to-face events at the new Victoria University City Campus in Melbourne with our first post-COVID workshop on spinal surgery, pain intervention and exercise therapy.

During the workshop, Keat Ooi (orthopaedic and spine surgeon), Bruce Mitchell (interventional pain physician), and Paul Hermann (osteopath and exercise/sports scientist) covered: The latest evidence in spinal surgery; How to triage for spinal surgery; Pre-surgical assessment protocols; The latest on restorative neurostimulation and pain procedures; Post-surgical exercise rehabilitation protocols and ideas for function rehabilitation and exercise therapy.

Huge thanks to all our presenters for giving up their time and their speaker fees for a great cause, and for their generosity in sharing their knowledge. With 20 members attending, there was plenty of time for hands-on experience and discussions. Here is just some of the feedback we received following the event: This workshop was very engaging and thought-provoking. There were elements presented that definitely challenged my treatment style and thinking.

xtremely relevant to daily osteo practice: E 1) in medical content, current methodologies 2) practical takeaways to help patients 3) thinking outside of the box for patient problems + treatment options.

Very interactive. I found the information very important and interesting. Definitely going away with new ideas. Love how everything was connected.

It was a good balance of theory and practice.

I really enjoyed the case examples.

Kinetic Link Training

2-day workshop on 13-14 August 2022. Brisbane CBD with Wayne Rodgers, Sports and Exercise Physiotherapist.

Kinetic Link Training (KLT) is a systematic approach to full-body, functional strength training and movement restoration. $750 for Osteopathy Australia members. Book your place at bit.ly/KLTWorkshop2022

Applications open for Osteopathy Australia Research Foundation Grants 2022

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steopathy Australia is now accepting applications for its 2022 Research Foundation Grants.

This is the third year that Osteopathy Australia will be running its research grant scheme, which aims to promote, encourage, and support research that advances osteopathy and promotes the profession. We’ve funded several projects over the past couple of rounds and have seen incredibly strong applications each year. We are even more excited to see what projects are submitted this year.

Applicants should consider the following points when preparing applications:

A lignment with Osteopathy Australia’s research priorities; C apacity and credibility of the investigative team; C ollaboration; R esearch design and methodology; S ignificance, innovation and impact of the research project; P otential for future funding and budget justification; O verall feasibility.

Project and seeding grants are available valued at up to $12,500 and $5,000, respectively. Seed funding is granted for research projects that can achieve a tangible outcome within 12 months of receipt of grant funds. Project funding

is granted for research projects that can achieve a tangible outcome within 24 months of receipt of grant funds.

The number of grants awarded will depend on the quality and number of applications received.

Applications close 5pm AEST on 26 August 2022.

More information on the grants scheme, including forms and guidelines, can be found at www.osteopathy.org.au/ research/research-grants To find out more, contact Shamona Eaves, Osteopathy Australia’s Senior Research and Project Officer, on 02 9410 0099 or via email at seaves@osteopathy.org.au

8

NEWS

Global study of osteopaths reveals ambitious, adaptable workforce

While individuals clearly aspire to advance their careers, overall, the study found that people felt they were well remunerated. Employers said that they are mostly negotiating salaries well above the minimum salary – a claim backed up by employees, with people that work in these practices describing their salary as above average or excellent.

A newly released survey of allied health practitioners has found nearly all osteopathy practices have weathered the COVID-19 pandemic, embracing telehealth and savvy business strategies to support clients and keep their doors open.

T

he study was undertaken by practice management software company Cliniko, which surveyed 2,654 allied health professionals from 34 countries as part of celebrations to mark the company’s 10th anniversary.

As well as exploring people’s experiences of the pandemic, the project also scoped some of the biggest challenges facing allied health practitioners – and some of the creative ways they are supporting patients and growing their businesses.

Telehealth here to stay Cliniko founder, Joel Friedlaender, said the survey highlights some of the ways the allied health sector has stayed ahead of the curve, despite the challenges arising during COVID-19. “The pandemic has changed so much about our lives, including the way we access healthcare. A lot of people were surprised professions like osteopathy can be effective via telehealth, but the past two years have shifted these perceptions,” he said.

Almost one-third of osteopaths offered telehealth consultations during COVID restrictions, allowing a majority of staff to continue working throughout the pandemic and helping to keep businesses operating. In Australia, the use of telehealth increased by more than double (2.6 times) over the last couple of years.

Impacts of COVID The study found that less than 3% of practices shut their doors for good during the pandemic.

Despite the challenges, the allied health workforce appears settled. Overall, just 15% of respondents were looking to leave their job in the next year, with threequarters of osteopaths saying that they are satisfied with their position.

“We know that COVID-19 has placed a lot of additional pressures on healthcare workers, so it’s very positive to learn that so many practitioners have adapted and are still progressing with their work,” Mr Friedlaender said.

Day-to-day challenges The study shows that allied health workers are juggling a variety of responsibilities.

One-quarter of practices said they don’t employ any administrators and nearly half do not have a bookkeeper. Nearly twothirds said they do not outsource any roles or employ a practice manager.

Unsurprisingly, this means that time management is a commonly cited challenge. More than 11% of those surveyed said they struggle to find the time to complete administrative tasks and 6% reported feeling a general sense of not having enough time.

When it comes to treating patients, osteopaths that contributed to the survey reported that half of their patients require an average of three to four treatments to resolve physical complaints, while nearly one-quarter need five to six treatments.

Ambitious workforce Cliniko found that osteopaths have particularly ambitious goals by allied health standards, with 40% of respondents aspiring to run their own practice in the future. This figure trails behind only chiropractors and myotherapists.

Of the osteopaths surveyed, one-quarter said they aim to achieve senior practitioner status in future.

Growing businesses One unexpected finding showed that allied health practices are embracing business coaches to become more effective at the non-clinical elements of their work.

Approximately one-third of osteopaths reported engaging a coach, and cited growing their business and business mentoring as the primary motivation.

This could potentially reflect gaps in the way clinicians are prepared for their careers. Cliniko notes that, while practitioner education predominantly prepares them for the care of their patients, there is very little in their education about the business side of private practice.

The data shows that word of mouth is key to growing allied health businesses, accounting for most new referrals to many services. Patient referrals were found to be particularly valuable for osteopaths, with 40% of new clients coming through personal recommendations.

Read the full findings of the study at: Part 1. bit.ly/3lQXVqx Part 2. bit.ly/3MYDHqS

How did COVID-19 restrictions impact your staffing?

All continued to work All staff continued to work. More staff were hired once restrictions were lifted All staff continued to work with reduced hours All staff were furloughed but returned Some staff were furloughed but returned Some staff were let go Not applicable Other 0%

15%

30%

45%

60%

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Always read the label. Follow the directions for use.

If symptoms persist talk to your health professional.

For professional, in clinic dispensing only.

For more information on the Clinical range or to apply for access, please contact your practitioner consultant, call 1300 650 455 or visit www.bioceuticals.com.au

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FEATURE

Domestic and family violence: how osteopaths can support patients Whether or not they decide to disclose it to you, as osteopaths, there is a high chance some of your patients are victims of domestic and family violence (DFV), and some of them may be perpetrators. When you suspect or become aware of such situations it can be challenging on a number of levels. Knowing how to support your patient, and about the support services available, can make a huge difference for you as a practitioner and for your patients.

PREVALENCE OF DOMESTIC AND FAMILY VIOLENCE IN AUSTRALIA

Domestic and family violence (DFV) is a pervasive social and health issue that can impact a person’s physical

and mental wellbeing. In Australia, one in six women and one in 16 men have been subject to physical or sexual violence from a current or former partner since the age of 15 years.¹ One in four women and one in six

men have been subject to emotional abuse. Most frighteningly, one woman is killed every week by a current or former partner in Australia.²

WHAT IS DFV?

DFV is often mistaken to include only physical and sexual abuse, but this is only the tip of the iceberg. DFV includes psychological, emotional, financial and other controlling behaviours. ‘The central element of domestic violence is an ongoing pattern of behaviour aimed at controlling a partner through fear, for example by using behaviour which is violent and threatening’.3 It can occur among intimate partners or between other family members.

WHAT ARE THE IMPACTS OF DFV?

DFV can have a significant impact on a person’s physical and psychological wellbeing. ‘Partner violence was ranked as the third leading risk factor contributing to total disease burden for women aged 25 to 44 years’.4 It can lead to serious health issues, complex trauma, depression, anxiety and substance abuse.

Table 1 outlines various indicators a patient experiencing DFV may present

How common is family, domestic and sexual violence?

1 in 6 women 17% or 1.6 million

Have experienced physical or sexual violence by a current or previous partner since the age of 15

1 in 4 women 23% or 2.2 million

Have experienced emotional abuse by a current or previous partner since the age of 15

1 in 5 women 18% or 1.7 million

1 in 16 men 6.1% or 548,000

1 in 6 men 16% or 1.4 million

Have experienced sexual violence since the age of 15

Figure 1: Prevalence of domestic and family violence in Australia1

1 in 20 men 4.7% or 429,000

FEATURE

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with and which you are likely to come across in your practice. Note these signs may be indicative of other social or health issues.

Along with the health impacts, DFV is one of the biggest causes of homelessness in Australia.

The economic and non-economic impact of pain and suffering, and the impacts of violence on the health system, production and consumption, children, the justice and service system costs Australia an estimated $22 billion per year.5

TABLE 1: CLINICAL INDICATORS OF DOMESTIC AND FAMILY VIOLENCE7

WHY DON’T THEY JUST LEAVE?

• Abuse of a child in the family

• Multiple presentations

• Obvious injuries, especially to the head/neck or multiple areas

• Non-compliance with treatment and attendances

• Bruises in various stages of healing • Sexual assault

• Accompanying partner who is over-attentive

• Sexually transmissible infections

• Identifiable social isolation

• Chronic abdominal pain

• Chronic pelvic pain

• Recent separation or divorce

• Chronic headaches

• Past history of child abuse

• Chronic back pain

• Aged less than 40 years old

• Numbness and tingling from injuries • Lethargy

PSYCHOLOGICAL

PREGNANCY INDICATORS

• Insomnia

• Miscarriages

• Depression

• Unwanted pregnancy

• Suicidal ideation

• Antepartum haemorrhage

• Anxiety symptoms and panic disorder

• Lack of prenatal care • Low birth weight of an infant

• Somatoform disorder • Post-traumatic stress disorder • Eating disorders • Drug and alcohol abuse AL YSIC PH

VIOLENCE SEXU

AL

Using coercion and threats Making and/or carrying out threats to do something to hurt her/him • Threatening to leave her/him, to commit suicide, to report her/him to welfare • Making Using her/him drop economic charges • Making abuse her/him do Preventing her/ illegal things him from getting or keeping a job • Making her/him ask for money • Giving her/him an allowance • Taking her/his money • Not letting her/him know about or have access to family income

Using male privilege Treating partner like a servant • Making all the big decisions • Acting like the ‘master of the castle’ • Being the one to define men’s and women’s roles

Using intimidation Making her/him afraid by using looks, actions, gestures • Smashing things • Destroying her/his property • Abusing Using pets • Displaying emotional weapons abuse Putting her/him down • Making her/ him feel bad about herself/himself • Calling her/ him names, making her/him think she’s/he’s crazy, playing mind games • Humiliating her/him, making her/him feel guilty

POWER AND CONTROL

Using children Making her/ him feel guilty about the children • Using the children to relay messages • Using visitation to harass her/him • Threatening to take the children away

AL

As an osteopath, you may be the first (or only) point of contact for people experiencing DFV. The whole-person approach used by osteopaths, and the subsequent trust that is often built between osteopaths and their patients, means osteopaths are well placed to support patients in such cases.

The role of osteopaths in supporting patients experiencing DFV is sometimes described as a ‘canary in the coal mine’. While it is not the osteopath’s role to counsel the patient, an osteopath is in a unique position to recognise the signs of abuse and make referrals if the patient requires support. Osteopaths tend to have longer consultation times with patients compared with many other health professionals. The longer time allows for more in-depth conversations. Standard osteopathy treatment involves touch and visualising the affected part of the body or region, so it is often possible to see the physical signs of abuse.

Some presenting physical symptoms may relate to emotional stresses

• Delay in seeking treatment

Using isolation Controlling what she/he does, who she/he sees and talks to, what she/he reads, where she/he goes • Limiting her/his outside involvement • Using jealousy to Minimising, justify actions denying and blaming Making light of the abuse and not taking her/his concerns about it seriously • Saying the abuse didn’t happen • Shifting responsibility for abusive behaviour • Saying she/he caused it

VIOLENCE SEXU

ROLE OF AN OSTEOPATH IN SUPPORTING PATIENTS EXPERIENCING DFV

PHYSICAL

AL YSIC PH

There are many barriers preventing a person experiencing DFV from leaving an abusive relationship. For example, it can be very dangerous to leave as violence often escalates following separation. The victim/survivor may be isolated, they may have financial concerns, they may be worried about their children and/or they may feel shame. The abuse may have caused them to lose their confidence, their sense of self, and make them doubt themselves.

GENERAL

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FEATURE

Physical violence

• Slapping, hitting • Kicking, beating • Knives/guns • Threats of physical violence

Psychological and emotional abuse

• Intimidation, humiliation • Constant belittling • Harassment

Sexual abuse

• Forced intercourse • Sexual coercion • Reproductive coercion

Other coercive control tactics

• Isolation from family/friends • Monitoring movements • Deprivation of basic necessities • Mental health/substance use coercion • Financial control and/or visa abuse

In person or through the use of technology facilitated abuse

Figure 2 What is domestic and family violence?6

“An osteopath is in a unique position to recognise the signs of abuse and make referrals if the patient requires support” experienced by a patient due to abuse.

It is important to ‘connect with your patient’. When this happens and trust is developed, the patient may feel comfortable enough to share

personal details about their lives.

The combination of touch and time means that patients often develop ‘a closer relationship with their osteopath than with their GP’. This raises the

possibility of disclosing delicate or private information to their osteopath before their GP.

WHAT CAN OSTEOPATHS DO IF A PATIENT DISCLOSES DFV?

A victim survivor’s first experience of disclosure may influence whether they ever seek help in future. If they don’t feel believed, if they are blamed or if

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FEATURE

TABLE 2: THE WORLD HEALTH ORGANIZATION’S LIVES MODEL8 Listen Inquire Validate Enhance safety Support

Listen to the patient closely, with empathy and without judgement Inquire about needs and concerns, including emotional, physical, social and practical Show that you understand and believe the patient and assure them they are not to blame Discuss a plan to protect the patient and their children from further harm Help them connect to information, services and social support

Percentage (%)

they are made to feel uncomfortable, they may never reach out to others about their experience in future.

The World Health Organization has developed a helpful framework for health practitioners to support patients experiencing DFV called LIVES. It asks health professionals to listen to patients with empathy, inquire about their needs and concerns, validate their story, enhance their safety and support them by connecting them to information and services (see Table 2).

When supporting a patient experiencing DFV, it’s very important to let them lead their own journey and respect their decisions, even if you don’t agree with them. Where you have concerns for the safety of a child, you

80

Experienced current partner violence

Experienced previous partner violence

70 60 50 40 30 20 10 0

General Other health Counsellor practitioner professional or support worker

Telephone helpline

Refuge or shelter

Police

Friend or family member

Work colleague or boss

Figure 3 Who do victim survivors disclose to?1

must report this to the child protection agency in your state or territory.

As an osteopath, you don’t need to be a social worker or a counsellor, but you can make a positive impact in the

lives of your patients affected by DFV. There are a number of services available to assist you and your patients, including counselling, accommodation support, financial support and legal support.

Key considerations

References

• Statistically, it is quite likely that some of your patients are perpetrators and some of them are victims.

• Look out for ‘patterns of injuries’ as these might be an indication of DFV. • Listen to your patients. If the information doesn’t match, then listen more carefully because quite often they’ll tell you without telling you.

1 Australian Institute of Health and Welfare (2018). Family, domestic and sexual violence in Australia. Cat. no. FDV 2. Canberra 2 Australian Institute of Criminology National Homicide Monitoring Program (Cussen & Bryant, 2015) 3 The National Plan to Reduce Violence against Women and their Children 2010 – 2022 4 Australian Institute of Health and Welfare (2020) Health impacts of family, domestic and sexual violence. AIHW, Australian Government

More information about DFV and local support services available Call 1800 RESPECT (1800 737 732) or Men’s Referral Service 1300 766 491), or scan the QR codes to check out their websites.

Men’s Referral Service

1800 Respect

Read the World Health Organization’s clinical handbook on Health care for women subjected to intimate partner violence or sexual violence – scan the QR code.

Central and Eastern Sydney Primary Health Network, with funding from the Department of Health, offers a number of free services to allied health professionals to help them support patients experiencing domestic and family violence in Central and Eastern Sydney. To access these services, email dfvassist@cesphn.com.au or visit the CESPHN website by scanning the QR code.

5 KPMG (2016) The cost of violence against women and their children in Australia

WHO Handbook

CESPHN.org.au

6 The Royal Australian College of General Practitioners (2021) Abuse and violence: Working with our patients in general practice, 5th edn. Melbourne 7 Hegarty K, O’Doherty L. (2011) Intimate partner violence – identification and response in general practice. Australian Family Physician 40(11), 852-6 8 WHO (2017) Clinical Handbook: Health care for women subjected to intimate partner violence or sexual violence

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Treating long COVID patients: the potential role of osteopaths Since the very beginning of the COVID-19 pandemic it has been evident that many patients report prolonged and significant disability lasting for months after their initial infection. Despite a large amount of research internationally, much is still unknown about the pathophysiology of ‘long COVID’ or how to treat it successfully. Nevertheless, many osteopaths will see long COVID patients in their clinics and they need to keep up-to-date with the developing evidence on the best ways to advise and treat these patients. In this article, Rosalba Courtney, Zoe Steele and Imogen Collyer take a look at some of this evidence and how osteopaths may be able to help long COVID patients.

PREVALENCE OF LONG COVID

It is now well-known that many patients with post-acute COVID symptoms experience a vast array of multisystem effects that impact on their ability to work and function normally in daily life (Davis et al, 2021). The condition – most commonly known as ‘long COVID’ – is estimated to affect between 10% and 30% of people who become infected with SARS-CoV-2, with one in seven patients still symptomatic at 12 weeks (Davis et al, 2021; RiveraIzquierdo et al, 2022). In Australia it is predicted that tens of thousands of individuals with long COVID will require treatment in the coming years (Hensher & Angeles, 2022).

Long COVID seems to affect individuals across all age groups and levels of severity of initial infection, including children and those with mild disease (Yong, 2021). However, persisting symptoms are most prevalent in patients who have been hospitalised with severe COVID-19, and in those who also have comorbid diabetes, obesity and/or hypertension (Pérez-González et al, 2022).

SYMPTOMS

There are numerous potential debilitating long COVID symptoms.

Surveys of patients with post-COVID

sequelae showed that they experienced an average of 55 symptoms, which could be categorised into six broad patterns (Yelin et al, 2022): Cognitive-emotional; Pain manifestations; Pulmonary; Cardiac; Anosmia/dysgeusia; Headache.

The most frequent symptoms are fatigue, breathlessness and cognitive dysfunction presenting as brain fog and memory issues as well as mood disturbance, anxiety and depression (Davis et al, 2021).

Fatigue The fatigue of long COVID can be brought on by both physical and mental exertion and can be extremely debilitating. Clinically, there are many similarities between long COVID and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Around 50% of long COVID patients fit the criteria of ME/CFS, with symptoms such as sore throat, tender lymph nodes, headache, muscle aches, joint stiffness, unrefreshing sleep, difficulty concentrating or worsening of symptoms after mild exertion (Mancini et al, 2021).

Similar to ME/CFS, individuals with long COVID experience long-lasting

ROSALBA COURTNEY

Rosalba Courtney is an osteopath with over 45 years’ experience as a practitioner, teacher, researcher and writer. She has a deep interest in how breathing and airway function can affect health.

She is internationally recognised for her work in this field, and is widely published on this topic.

ZOE STEELE

Zoe Steele is a clinical osteopath and lecturer in the osteopathy programme at the Ara Institute of Canterbury in Christchurch, NZ, where she teaches clinical practice, manual therapy, advanced professional practice and dilemmas of patient management.

IMOGEN COLLYER

Imogen Collyer graduated in 2014 with a Masters of Health Science Osteopathy.

She has a special interest in dysfunctional breathing, long COVID, temporomandibular dysfunction and pelvic girdle pain. Imogen works in private practice in Canberra.

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‘crashes’ when their level of effort or activity goes beyond their threshold of tolerance.

Post-exertional fatigue with pronounced exercise intolerance affects around 78% of those with long COVID. The effects of the fatigue and effort intolerance on ability to work can be profound, with 20% reporting that they have not been able to return to their regular occupations (Yelin et al, 2022).

Labour shortages in the health and education sectors due to long COVID are now frequently highlighted in the media. This signals an emergent threat to economies worldwide and highlights the potential cost of disability related to the symptoms of long COVID.

PATHOPHYSIOLOGY

The pathophysiology of long COVID is still not completely understood. However some of the drivers of ongoing pathology have been established (Yong, 2021): Residual organ/tissue damage; Ongoing inflammation; Persistence of virus; Autoimmunity; Dysautonomia.

Residual organ/tissue damage Residual pathology affecting the organs or tissues can be multisystemic but predominately affects the lungs, heart and circulatory system, as well

as the brain and nervous system (Mancini et al, 2021; Yong, 2021; Xiang et al, 2022).

Pathological inflammation Long COVID patients show increased levels of cytokines and other proinflammatory markers (Yong, 2021).

This ongoing inflammation is one of the factors that contributes to organ damage.

However, it is worth noting that unresolved inflammation does not necessarily match the severity of symptoms such as fatigue and/or dyspnoea (Mehandru & Merad, 2022). Inflammation of the endothelium is one of the factors that produces hypercoagulability of blood and microclots that contribute to stroke and ongoing pathology of the lungs (Xiang et al, 2022).

Persistence of virus The persistence of inflammation long after the initial infection may be due to lingering virus, evidence of which can be found for up to six months in some patients (Yong, 2021). This might explain why even individuals with mild and asymptomatic COVID-19

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can develop long COVID. Elimination of residual virus through activation of a more robust immune response is also thought to explain why 58% of long COVID patients report reduction or cessation of their symptoms after subsequent vaccination (LongCovidSOS, 2021). The more evolved humoral/ cellular immune response produced by vaccination is associated with increased levels of a particular antigen called the nucleocapsid antigen. Increased levels of this antigen following vaccination, rather than antigen to the spike protein of SARS-CoV-2, are correlated with symptom reduction in long COVID patients (Mehandru & Merad, 2022; Varnai et al, 2022).

The risk of contracting COVID, and especially the risk of developing severe disease, is reduced in individuals who are fully vaccinated, further reducing their risk of long COVID (Antonelli et al, 2022). The severity and life impact of long COVID symptoms on patients 120 days after their initial SARS-CoV-2 infection is less in vaccinated individuals (Tran et al, 2021).

“The fatigue of long COVID can be brought on by both physical and mental exertion and can be extremely debilitating”

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Autoimmunity The presence of Epstein-Barr virus viraemia, pre-existing autoimmune disease such as diabetes, and latent viruses associated with specific autoantibodies increases the risk for long COVID (Su et al, 2022). Acute COVID infection can trigger the formation of self-tissue antigens that persist after initial infection and these are thought to contribute to lingering symptoms, particularly in patients with concurrent autoimmune conditions (Mehandru & Merad, 2022). Thus, additional measures of caution, including education about vaccination, should be taken to prevent COVID-19 infection in persons with autoimmune disease.

Dysautonomia Dysautonomia with various degrees of tachycardia, circulatory disturbances and orthostatic intolerance is common in patients with long COVID (Dani et al, 2021).

Increased sympathetic nervous system activity is part of the normal inflammatory and immune response and plays a role in helping the body to fight SARS-CoV-2 infection. The problem that occurs in long COVID is that the sympathetic nervous system remains somewhat overactive and dysregulated after the initial acute infection (Barizien et al, 2021). Also, SARS-CoV-2 appears to be neuroinvasive, bypassing the blood-brain barrier and propagating towards the central nervous system. It can directly damage areas of the brain such as the nucleus of the solitary tract involved in regulation of the autonomic nervous system as well as directly injuring the vagus and other cranial nerves (Barizien et al, 2021).

HOW OSTEOPATHS CAN HELP

Osteopaths can potentially play an important role in providing education, support and rehabilitation advice as well as manual therapy for patients with long COVID. However, the multisystem effects and complexity of long COVID symptoms mean that patients need multidisciplinary treatment and practitioners should be aware of the limitations of their scope of practice and should work with other health professionals for appropriate diagnosis and treatment. Trained mental health professionals should be consulted where indicated.

Measuring long COVID symptoms Outcome measures such as the Yorkshire Rehabilitation Scale (C19-YRS) (O’Connor et al, 2021) and the post-exertional malaise subscale questions from the DePaul Symptom Questionnaire (Cotler et al, 2018) can be useful to capture and accurately quantify the spectrum of symptoms in patients with long COVID. Where primary symptoms are related to dyspnoea or difficulty breathing, the Nijmegan Questionnaire can be used to determine the source of the symptoms (Twomey et al, 2022). In addition to the C19-YRS and the Nijmegan Questionnaire, the Self-Evaluation of Breathing Questionnaire is a validated and useful tool to measure perceptions of breathing discomfort related to breathing work or air hunger (Twomey et al, 2022). See Courtney 2022 for questionnaire templates.

Long COVID is also unpredictable, and the trajectory of the illness varies according to the extent of lingering infection, psychological factors, autoimmune and inflammatory responses, and many other factors (Décary et al, 2021). Questionnaires help practitioners track improvements or deteriorations in a patient’s condition and are useful when communicating with other health professionals (see box above). Measurement and monitoring of long COVID symptoms are necessary to provide appropriate individual treatment plans and track progress.

Safety Safety needs to be the first concern when dealing with long COVID. This means that patients should have been cleared of more serious cardiac and respiratory sequelae of COVID-19 and subsequent long COVID. It is also difficult to predict which patients will succeed in recovering their abilities to work, study and exercise, and practitioners need to be humble in promising recovery and should encourage patients to be patient (Décary et al, 2021).

Advice and education It is essential to consider post-exertional malaise (PEM) when advising patients about managing activity and rest.

Lessons learnt about the importance of pacing as a strategy in the management of patients with ME/CFS can be applied in the management of long COVID (Décary et al, 2021). The three key aspects of pacing are: Stop – before reaching a point of overexertion as this will interfere with recovery;

Rest – often and before symptoms appear; Pace – plan to space out daily physical and cognitive activities to avoid triggering symptoms.

Other triggers that can lead to ‘crashes’ include large meals, caffeine, alcohol, extremes of temperature change and psychological stress.

Symptom diaries and behavioural techniques to manage triggers and stress levels are useful tools for helping patients understand how to begin getting some control over their health and energy management.

While most patients are aware that stress management and adequate sleep are important for healing, they may not be aware of the huge role these factors play in the immune and inflammatory processes that drive physiological dysregulation and neuroinflammation in long COVID and the need to prioritise them (Brusaferri et al, 2022).

Stress is an important contributor to dysregulation of the autonomic nervous system and low vagal tone. Strategies that improve vagal tone, such as stress reduction, slow breathing and mindfulness, can reduce the inflammation and physiological dysregulation that drive dysautonomia (Puhlmann et al, 2019; Balint et al, 2021; Brusaferri et al, 2022).

A single night of partial sleep deprivation can reduce natural killer cell activity to 72% of its normal level (Irwin et al, 1994). The proinflammatory effects of sleep deprivation are also well-known. Reducing a normative eight hours of sleep by 25% and 50% will increase inflammatory cytokines in even healthy, asymptomatic

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individuals and the effects are probably greater in individuals with a propensity to inflammation (Mullington et al, 2010). Many patients have undiagnosed obstructive sleep apnoea (OSA) or some other form of sleep-disordered breathing (SDB).

OSA, and less obvious forms of SDB, such as upper airways resistance syndrome, are important causes of sleep disruption, insomnia (Broderick et al, 2014; Amdo et al, 2016), autonomic dysregulation (Harper et al, 2012), chronic stress and systemic inflammation (Gold et al, 2003; Franco et al, 2012). Patients with suspected SDB or OSA should be referred for sleep studies.

REHABILITATION STRATEGIES FOR LONG COVID Rehabilitation programs that utilise various combinations of self-regulation strategies, breathing exercises, cardiopulmonary rehabilitation and autonomic conditioning are starting to be investigated for long COVID (Besnier et al, 2022; Tabacof et al, 2022; Twomey et al, 2022). Despite the early nature of the research some are proving to be beneficial and are starting to play an increased role in the management of long COVID (Putrino et al, 2021; Twomey et al, 2022) (see box below).

Dysfunctional breathing presenting as a disordered breathing pattern, hyperventilation at rest, excessive ventilator response to exercise and breathing distress is common in long COVID patients. One study found that it was present in 88% of long COVID patients with unexplained dyspnoea (Mancini et al, 2021).

Rehabilitation primarily focused

on the cardiopulmonary system is particularly helpful in these patients (Twomey et al, 2022). Correction of dysfunctional breathing might help to reduce symptoms and psychological distress, improve exercise intolerance and support recovery (Koniukhovskaia et al, 2021; Mancini et al, 2021; Motiejunaite et al, 2021).

Osteopathic manual therapy Osteopaths working with patients who have long COVID are ideally placed to use a multifaceted approach to treatment that includes manual therapy. There is some evidence to suggest that the addition of manual therapy in the form of myofascial release of the rib cage and neck improved heart rate and subjective sense of ease of breathing after a single treatment (Fereydounnia et al, 2022).

Research is currently underway to investigate how the addition of osteopathic manual therapy (OMT) supports rehabilitation in patients with long COVID in terms of fatigue and functional capacity (Curi et al, 2022).

Previous research has shown that when used in conjunction with breathing retraining OMT improves breathing symptoms, breathing pattern and hyperventilation (Courtney et al, 2019).

A number of studies have found that OMT supports more balanced function of the autonomic nervous system (Rechberger et al, 2019) and OMT has been explored as treatment for various manifestations of dysautonomia (Cromeens & Gamber, 2010). Treatment focusing on the craniocervical area and cranium has been found to help with dysautonomia in patients with postural orthostatic tachycardia syndrome (Goodkin &

Multistep rehabilitation protocol The rehabilitation protocol used at Mount Sinai Hospitals long COVID clinic by Dr David Putrino and colleagues starts with an initial evaluation by a physician for cardiac and other organ pathologies. Patients are then given behavioural strategies for managing and controlling symptom attacks. This is followed by coaching in breathing techniques. Some patients are also referred for nutritional advice and psychological therapies. Finally, patients are referred for autonomic rehabilitation that uses breath control, isometric exercise, submaximal aerobic exercise with gentle progression and pacing while they are continually monitored for their exertional tolerance (Putrino et al, 2021).

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Bellew, 2014) and may be helpful in the dysautonomia of long COVID. The importance of cardiac and respiratory clearance in patients with long COVID cannot be overstated.

Osteopaths who employ manual therapy techniques must be mindful that after mild or severe COVID-19 infection there may be an increased risk of vascular incident (deep vein thrombosis and pulmonary embolism) in adults and in children over the age of 12, or in patients with comorbidities (Katsoularis et al, 2022).

EVIDENCE-BASED APPROACH

Emerging research will help to determine the role osteopaths can play in the management of long COVID. As this research evolves, so will the role of the osteopath, and practitioners are encouraged to be flexible in their approach and to use the best available evidence across the allied health disciplines.

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DOI: 10.3389/fimmu.2022.862522 Yelin, D., Margalit, I., Nehme, M., Bordas-Martínez, J., Pistelli, F, Yahav, D., Guessous, I., et al on behalf of the LongCov Research Group. (2022) Patterns of long COVID symptoms: a multi-center cross sectional study. Journal of Clinical Medicine 11(4), 898. DOI: 10.3390/jcm11040898 Yong, S.J. (2021) Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments. Infectious Diseases 53(10), 737–754. DOI: 10.1080/23744235.2021.1924397

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Endometriosis, chronic pelvic pain and how nutritional interventions may help Endometriosis occurs when endometrial-like tissue grows in locations outside of the uterus. It can cause chronic, and often severe, pain. The treatment of endometriosis requires a team approach, combining conventional medicine with osteopathy, nutritional interventions and psychology. This article discusses how endometriosis and associated comorbidities develop, the multiple mechanisms that generate pain, and the nutrients that may assist in providing pain relief. A second article, to be published in the Spring 2022 issue of Osteo Life, will look at the role of osteopathic care in more detail.

ENDOMETRIOSIS AND PAIN

Endometriosis is defined as the presence of endometrial-like tissue in extrauterine locations, primarily within the pelvic peritoneum, ovaries and rectovaginal septum (Leyendecker et al, 2009). It has long been considered an inflammatory, oestrogen-dependent condition causing primary symptoms of chronic pelvic pain (CPP) and infertility (Burney & Giudice, 2012). Retrograde menstruation inducing ectopic endometrial-like deposits is the most widely accepted aetiology and was first described in 1927 (Sampson, 1927) (see box on page 21). However, a definitive understanding of the aetiology and pathogenesis of endometriosisinduced pain is lacking.

Recent research recognises that the extent of pain resulting from endometriosis does not correlate to the amount or severity (grade 1–4) of disease, and other pain-inducing processes have been acknowledged, including inflammation, immune dysregulation, neurogenic inflammation, neuroangiogenesis, peripheral sensitisation and central sensitisation.

Cross-organ sensitisation, causing comorbidities such as irritable bowel syndrome (IBS), overactive bladder syndrome (OAB) and interstitial cystitis, is also becoming a recognised source of pain (Surrey et al, 2018).

It is estimated that roughly 10% of women have endometriosis and that,

on average, it takes seven years for a patient to receive a diagnosis following the onset of symptoms (Nnoaham et al, 2011). Diagnostic delay is one of the major contributors to pain development in endometriosis. Along with CPP and infertility other common features include dysmenorrhoea, menorrhagia, intermenstrual bleeding, painful ovulation, dyspareunia, dyschezia and dysuria, with or without IBS and OAB (Parasar et al, 2017).

Current biomedical treatment for endometriosis and CPP involves laparoscopic excision or ablation surgery of lesions, painkillers and hormone modulation. Some women who undergo laparoscopic excision surgery do not experience any pain relief, while others find their pain returns shortly after surgery (Sutton et al, 1994).

More extreme treatment includes hysterectomy (Donnez et al, 2010; García-Ibañez et al, 2020).

MECHANISMS OF PAIN GENERATION

Pain is very complex and lesion-specific pain is essential for pain initiation.

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.

Silent endometriosis is present without pain and is usually diagnosed following infertility or recurrent miscarriage.

Inflammation Hallmark features and effects of chronic inflammation associated with pain generation can be seen in endometriosis (Laux-Biehlmann et al, 2015). The inflammatory environment in the peritoneum arising as a result of retrograde menstruation, failed apoptosis and the immune response causes accumulation of iron, reactive oxygen species (ROS) and prostaglandins, and

“There is currently no universal ‘endometriosis diet’; instead, nutritional interventions are individualised”

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acidosis (Laux-Biehlmann et al, 2015).

This is accompanied by increased levels of inflammatory cytokines, chemokines, growth factors and neutrophils (Maddern et al, 2020). Interleukin (IL)-8, IL-1β, tumour necrosis factor-α and nerve growth factor (NGF) are found in high concentrations in the peritoneum (see Figure 1). The inflammatory response induces sensory nerve activation and altered nociception, leading to altered central nervous system (CNS) processing and crossorgan sensitisation (Morotti et al, 2017).

Neuroangiogenesis Endometrial lesions do not have a sensory nerve supply, thus neuroangiogenesis (the development of blood and neural

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Pathogenesis of endometriosis Approximately 90% of all women experience retrograde menstruation, where menstrual blood flows back through the Fallopian tubes into the peritoneal cavity. The fact that just 10% of women develop endometriosis suggests that retrograde menstruation alone cannot be responsible for its pathogenesis (Maddern et al, 2020).

For endometriosis to progress, adhesions must develop and initiate lesion formation. During normal menstruation the innate immune system initiates cyclical apoptosis and the elimination of endometrial

cells from the uterus (Critchley et al, 2001). The innate immune response also clears ectopic endometrial debris from the peritoneal cavity of those without endometriosis.

This process is characterised by the increased presence of neutrophils, macrophages, natural killer cells and dendritic cells (Dorien et al, 2017; Symons et al, 2018). It is hypothesised that endometriosis may arise as a result of immune dysfunction and an inability to effectively clear endometrial debris before lesions form (Giudice & Kao, 2004).

Figure 1: Inflammation and sensitisation in endometriosis. Reproduced from Maddern et al (2020) Pain in endometriosis. Frontiers in Cellular Neuroscience 14, 590823, used under CC.

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supplies) occurs in lesions adhering to the peritoneum. Neuroangiogenesis is regulated by oestrogen, immune cells and NGF (Asante & Taylor, 2011; Greaves et al, 2014) and alters the balance between autonomic neurons and sensory afferents, leading to increased nociceptive input with decreased parasympathetic control, amplifying pain (Hughes et al, 2013; Gebhart & Bielefeldt, 2016).

Neurogenic inflammation The build-up of degraded tissue by-products can directly sensitise sensory nerve fibres through nociceptive afferent nerves exacerbating the already pronociceptive environment (Morotti et al, 2017; Maddern et al, 2020).

Central sensitisation Painful visceral disorders increase central terminals within the spinal cord as a result of altered CNS signalling following chronic stimulation of peripheral sensory afferents. This contributes to neuron sensitisation, producing constant hyperexcitability without noxious stimuli (Latremoliere & Woolf, 2009).

Cross-organ sensitisation Cross-organ sensitisation can develop when afferents from one organ induce sensitisation of the afferents innervating another organ. This can occur because of the proximity of the afferents when they converge into similar areas of the spinal cord (Gebhart & Bielefeldt, 2016) (see Figure 2).

NUTRITIONAL INTERVENTIONS Nutritional biochemistry Several aspects of diet are implicated in the development and severity of endometriosis and numerous dietary principles and supplements used for modulating chronic inflammation, ROS, oestrogen activity, prostaglandin metabolism and the menstrual cycle may be beneficial. There is currently no universal ‘endometriosis diet’; instead nutritional interventions are individualised and dependent on current diet and nutritional status.

Diets high in saturated fats, and red and processed meat, are strongly correlated with the development and exacerbation of symptoms (Hall,

Figure 2: Schematic diagram illustrating the common nerve pathways shared by different organs and how these may lead to cross-organ sensitisation. Reproduced from Maddern et al (2020) Pain in endometriosis. Frontiers in Cellular Neuroscience 14, 590823, used under CC.

2001; García-Ibañez et al, 2020).

Animal fats are high in arachidonic acid, which increases inflammation and spasmodic activity.

Many studies report that following a plant-rich, gluten-free, anti-inflammatory diet is helpful in reducing symptom severity and inflammatory load (Missmer et al, 2010; Parazzini et al, 2013; Hopeman et al, 2015; Moore et al, 2017). The type and quality of food are also important and the presence of endocrine-disrupting chemicals used in farming, such as pesticides, needs to be considered as a trigger and cause of immune dysfunction (Hughes, 2017; García-Ibañez et al, 2020).

A primary focus of diet therapy is gut and liver support. As endometriosis is an oestrogen-dependent disease, one aspect of treatment aims to enhance oestrogen detoxification and excretion from the body. This is achieved by supporting phase 2 liver detoxification pathways (see box on page 23), boosting gut health and minimising xenoestrogen load to prevent recirculation of oestrogen back

into the blood stream. Supporting gut health and bowel movements is essential because of the likelihood of concurrent IBS, gut dysbiosis, inflammation and immune dysregulation.

Oestrogen, inflammation and immune modulation can be promoted by increasing fibre content in the diet to encourage daily bowel motions, increasing phytoestrogen intake and reducing saturated fat. Necessary nutrients include B vitamins, magnesium, calcium D-glucurate, antioxidants and omega-3 polyunsaturated fatty acids (PUFA) as well as compounds found in brassica (cruciferous) vegetables (see Table 1) (Hall, 2001; Parazzini et al, 2013; Erten et al, 2016).

Macronutrients: carbohydrates, fats and proteins Wholegrains and vegetables contain complex carbohydrates that help attenuate glycaemic and insulin responses. In contrast, excessive simple carbohydrates will spike blood glucose and insulin levels, affecting the production and action of sex hormones.

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High saturated fat intake can promote inflammation, but omega-3 fatty acids like EPA (eicosapentaenoic acid) are anti-inflammatory. Inadequate protein will lead to an overall decrease in liver function (Hall, 2001; Parazzini et al, 2013).

Fruit and vegetables have beneficial effects on health via the anti-inflammatory and antioxidant actions of their

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constituent flavonoids and polyphenols.

However, some may be detrimental to specific people. FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) are fermentable carbohydrates found in conventionally healthy foods such as dairy, wheat, rye, apples, pears, grapes, garlic, onion, almonds, etc.

They may cause gut distress and malabsorption issues in those with IBS. Thus, a FODMAP elimination diet may be required to determine exactly which foods are aggravating. As this is a very restrictive therapeutic diet it must only be followed under the guidance of a qualified practitioner for a short time.

nutrients required as cofactors necessary to drive these metabolic processes (see Figure 3) (Hall, 2001).

During P2 liver detoxification, glucuronic acid is conjugated with oestrogen (glucuronidation) to enable elimination from the body.

Some gut bacteria possess an enzyme called Beta-glucuronidase that uncouples the bond between conjugated oestrogen and glucuronic acid in the large intestine. This allows oestrogen to re-enter circulation via enterohepatic circulation, promoting excess oestrogen metabolites

throughout the body. Betaglucuronidase activity is enhanced by high-fat, low-fibre diets and can be modulated via establishing proper gut flora through diet and supplementing with probiotics, specifically Lactobacillus acidophilus and Bifidobacterium infantis. Calcium D-glucurate is a natural compound that assists glucuronidation and inhibits Beta-glucuronidase (Hall, 2001; De Preter et al, 2008).

The final excretion of oestrogen is via the urine and faeces; hence, kidney and bowel function are vital.

Metabolism of oestrogen Oestrogen metabolism is complex.

‘Oestrogen’ collectively refers to all oestrogens: the three primary forms are oestradiol, oestrone and oestriol.

These three oestrogen metabolites vary in activity, and how they are metabolised.

Metabolism occurs primarily in the liver in two phases: Phase 1 (P1) occurs via a pathway called hydroxylation; Phase 2 (P2) occurs via methylation, glucuronidation and sulfation.

Nutritional and lifestyle interventions support these pathways, with specific Fat soluble ‘toxins’ for detoxification

Phase 1

Nutrients required for P1 • Folate • Vitamin D • Vitamin A • B vitamins • Glutathione • Calcium • Zinc

Phase 2

Water soluble waste product excreted via

Nutrients required for P2 • Amino Acids • Glycine • Taurine • Methionine • Cysteine • Glutamine • Cystein • Garlic • Onion • Cruciferous vegetables • Vitamin A, C, E, Bs

Figure 3: H ormone metabolism and elimination Isoflavones, lignans and fibre increase SHBG, which transports oestrogen, making it unavailable to tissues when bound Prebiotics, probiotics, fibre, calcium-D-glucurate for gut dysbiosis, decreases B-glucuronidase and resorption of oestrogen back into the body Soy, lignans, flavonoids act as alpha and beta E receptors, triggers expression of target genes within the cell of oestrogen responsive tissue

Antioxidants that reduce ROS: vitamins A, C, E, beta-carotene, carotenoids, selenium, curucumin, NAC, green tea, lycopene, flavonoids, alpha-lipoic acid

Excretion of oestrogen and by-products occurs in bile, urine and faeces by undergoing glucuronidation, methylation, sulfation and hydroxylation pathways in the liver

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“The choice of activity can be left to the patient instead of imposing a complex exercise regime on them” Non-coeliac gluten sensitivity is also strongly correlated with endometriosis and many studies have reported better outcomes by following a gluten-free diet (Seaman et al, 2008; Shepperson Mill, 2011; Moore et al, 2017).

Dietary fibre Dietary fibre can alter the composition of intestinal bacteria, reducing the activity of β-glucuronidase, resulting in less deconjugation of oestrogen and reduced absorption, thus promoting its excretion via faeces (Hall, 2001; Casas et al, 2014). Lignans are insoluble dietary fibre-rich compounds found in foods such as flaxseeds, oil seeds, wholegrains, legumes and vegetables (Hall, 2001).

Phytoestrogens Lignans are also one of two main classes of phytoestrogens – plant compounds that have the capacity to bind to oestrogen receptors and exert an

oestrogenic or anti-oestrogenic effect.

Isoflavones are the other main class of phytoestrogens, sources of which include soy, legumes, alfalfa and clover.

Brassica vegetables Brassica vegetables (broccoli, cauliflower, cabbage, brussels sprouts, etc.) contain indole-3-carbinol and sulforaphane, which aid oestrogen metabolism and inhibit β-glucuronidase activity (Santanam et al, 2013; García-Ibañez et al, 2020).

Magnesium Magnesium optimises methylation, detoxification and oestrogen excretion.

Oestrogen levels are influenced by the menstrual cycle and ovarian hormones, which alter the calcium:magnesium ratio.

Cyclical changes can produce symptoms of premenstrual syndrome in women with calcium and magnesium deficiency and exacerbate dysmenorrhoea and CPP as a result of a reduced antispasmodic action of magnesium. Magnesium

Brassicas are a source of indole-3-carbinol and sulforaphane

dosing is dependent on the patient’s gut tolerance and high doses can cause gastrointestinal upset and diarrhoea (Bendich, 2000; Hall, 2001).

Calcium D-glucurate Calcium D-glucurate is a natural compound that increases glucuronidation and inhibits β-glucuronidase. Apples and brassica vegetables are high in glucaric acid. For high doses a supplemental form or broccoli sprout powder can be taken (Hall, 2001; De Preter et al, 2008; Dashnyam et al, 2018).

Antioxidants and vitamins Antioxidants have significant positive effects on endometriosis. Vitamins A, C and E are all high-potency antioxidants that decrease stress markers and improve antioxidant enzyme activity. Lower intakes of vitamin A, C, E and zinc have been found in endometriosis patients. Patients with CPP, dysmenorrhoea and dyspareunia reported less pain when supplemented with these nutrients, possibly due to a reduction in peritoneal fluid inflammatory markers and the antioxidant effect on lipid peroxidation (Traber & Stevens, 2011; Erten et al, 2016). Vitamin C and beta-carotene inhibit the growth and shrink the size of endometrial

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TABLE 1: EFFICACIOUS NUTRIENTS AND SUPPLEMENT DOSAGES FOR ENDOMETRIOSIS NUTRIENT

DOSAGE

ACTION

REASONING

Vitamin E

400–800 iu/day

Antioxidant

Decrease ROS activity

Beta-carotene

50,000-150,000 iu/day (avoid doses >25,000 iu in preconception and pregnancy)

Antioxidant

Inhibit endometrial growth

Vitamin C

6000–10,000 mg/day in divided doses to enhance absorption and prevent gut disturbances

Antioxidant

Pain reduction, alter lipid peroxidation sequelae, reduce the size of lesions

Inhibits aromatase activity

Oestrogen clearance, gut health, anti-inflammatory, fibre source

Flax seed

Oil: 3000 mg three times daily Seeds: 1 tbsp ground fresh daily

Magnesium

300–900 mg/day in divided doses

Antispasmodic, muscle relaxant

Support P2 liver detoxification

Calcium-D-glucurate

1000–1200 mg/day

Inhibits β-glucuronidase activity

Prevent oestrogen reconjugation and recirculation

Omega-3

1000–3000 mg/day; consume with meals, particularly fatty food sources such as avocado, for increased absorption

Anti-inflammatory, decreases prostaglandins

Decrease pain

N-acetylcysteine

1000 mg/day

Antioxidant

Pain reduction, fertility, liver metabolism

Sulforaphane, glucaric acid (found in brassica vegetables)

3–4 servings per day 2 cups salad = 1 serving ½ cup cooked vegetables = 1 serving

P2 liver detoxification, fibre, bowel movements

30 g/day via wholegrains, fruit and vegetables

Regular bowel motions, oestrogen clearance, support gut function, increase levels of sex hormone binding globulin

5–10 billion colony-forming units per day

Restore gut health, inhibit β-glucuronidase activity

Protein

~20 g/meal or 0.75–1.8 g/kg bodyweight/day, depending on body size and activity level

Adequate liver metabolism, amino acid bioavailability

Vitamin D

1000–4000 iu/day dependent on initial levels

Immune function

Fibre

Probiotics Lactobacillus acidophilus, Bifidobacterium infantis

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lesions (Santanam et al, 2013; Kobori et al, 2014; Erten et al, 2016; Carr & Maggini, 2017).

N-acetylcysteine (NAC) and vitamin E supplementation reduce pain and decrease cellular proliferation and activation caused by ROS and oxidative stress. NAC is also vital in fertility support (Porpora et al, 2013) Vitamin D Women with lowered serum vitamin D are at higher risk of endometriosis and associated symptoms. Vitamin D has significantly reduced CPP in various studies. Current literature suggests that for optimum immune function vitamin D levels should be above 75 nmol/L and ideally closer to 100 nmol/L (Aranow, 2011; Gröber et al, 2013; Grant, Al Anouti and Moukayed, 2020). However,

standard reference values currently followed by the Royal Australian College of General Practitioners do not indicate a need for supplementation until levels fall below 50 nmol/L (Lucas & Neale, 2014; Almassinokiani et al, 2016).

Omega-3 PUFA Long-chain omega-3 PUFA are primarily found in fish, nuts, seeds, leafy greens and algae. Omega-3 has a role in physiological regulation of prostaglandin and cytokines (Hall, 2001; Parazzini et al, 2013; García-Ibañez et al, 2020).

Increasing dietary intake of omega-3 affects the synthesis and activity of cytokines, and decreases prostaglandin synthesis, positively impacting dysmenorrhoea. Alpha-linolenic acid, an omega-3 PUFA, and gamma-linoleic acid, an omega-6 PUFA, decrease

TABLE 2: WHEN TO CONSIDER REFERRAL, AND WHO TO REFER TO SITUATION

Pain not remitting

REFER TO GP, gynaecologist, psychologist, pain specialist – review medications, disease progression, mental health and pain down-regulation training Nutritionist to support inflammatory processes, immune dysregulation, gut and liver health

Continued menstrual bleeding

Gynaecologist, endocrinologist – internal examination and blood tests required Clinical nutritionist to support hormone metabolism

Altered mood, depression

GP, psychologist

Fertility issues

Fertility specialist, reproductive endocrinologist, psychologist, clinical nutritionist

Ongoing IBS, interstitial cystitis/overactive bladder

GP, nutritionist/dietitian, gastroenterologist, urologist, psychologist, pelvic floor therapist (osteopath or physiotherapist)

If you feel you do not have the skills to treat the person adequately

Another osteopath or physiotherapist with experience in women’s health, pelvic floor dysfunction, visceral treatment

inflammation by affecting the type of eicosanoids produced (Wu et al, 2008).

WHEN TO REFER?

The information in this article is intended as a guide only and any patient who requires further support and specific dietary protocols with supplementation should be referred to a qualified nutritionist or dietitian.

Table 2 lists some other situations in which referral should be considered while some tips and advice that can be passed on to patients can be found in the box on the left.

SUMMARY

Used alongside conventional medicine, osteopathy and psychology, nutritional interventions can be a key component of an endometriosis patient’s toolbox. There are many nutrients that could prove beneficial to those with endometriosis but interventions must be tailored to each individual, dependent on their current nutritional status and diet. The next article will focus on osteopathy, the various pain mechanisms and how osteopathy may help endometriosis and CPP sufferers.

Tips and advice for patients Find a team of professionals that you trust; you need to be comfortable with them and feel heard – remember that no single specific approach will suit all patients Continue to engage in social activities and interactions where possible without overdoing it Find an exercise you love and keep active Eat a diet rich in antioxidants, polyphenols and fibre and work on gut health Practise meditation or mindfulness daily, particularly if you suffer from chronic pain Work on pelvic floor relaxation techniques and breathing mechanics

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Available at https://uniquenutritionsolutions.com/ wp-content/uploads/2019/05/Estrogen-MetabolismNutrients.pdf, last accessed 10 January 2022 Hopeman, M. M., Riley, J.K., Frolova, A.I. (2015) Serum polyunsaturated fatty acids and endometriosis. Reproductive Sciences. Society for Reproductive Investigation 22(9), 1083. doi: 10.1177/1933719114565030 Hughes, P.A., Zola, H., Penttila, I., Blackshaw, A.L., Andrews, J., Krumbiegel, D. (2013) Immune activation in irritable bowel syndrome: can neuroimmune interactions explain symptoms?

American Journal of Gastroenterology 108(7), 1066–1074 DOI: 10.1038/ajg.2013.120 Kobori, Y., Ota, S., Sato, R., Yagi, H., Soh, S., Arai, G., Okada, H. (2014) Antioxidant cosupplementation therapy with vitamin C, vitamin E, and coenzyme Q10 in patients with oligoasthenozoospermia.

Archivio Italiano Di Urologia E Andrologia 86(1), 1–4 DOI: 10.4081/aiua.2014.1.1 Latremoliere, A., Woolf, C.J. (2009) Central sensitization: a generator of pain hypersensitivity by central neural plasticity. Journal of Pain 10(9), 895–926 DOI: 10.1016/J.JPAIN.2009.06.012 Laux-Biehlmann, A., D’Hooghe, T., Zollner, T.M. (2015) Menstruation pulls the trigger for inflammation and pain in endometriosis. Trends in Pharmacological Sciences 36(5), 270–276 DOI: 10.1016/J.TIPS.2015.03.004 Leyendecker, G., Wildt, L., Mall, G. (2009) The pathophysiology of endometriosis and adenomyosis: tissue injury and repair. Archives of Gynecology and Obstetrics 280(4), 529–538 DOI: 10.1007/S00404009-1191-0 Lucas, R., Neale, R. (2014) What is the optimal level of vitamin D? Separating the evidence from the rhetoric. Australian Family Physician 43(3), 119–122 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 Missmer, S.A, Chavarro, J.E., Malspeis, S., BertoneJohnson, E.R., Hornstein, M.D., Spiegelman, D., Barbieri, R. L., et al. (2010) A prospective study of dietary fat consumption and endometriosis risk. Human Reproduction 25(6), 1528–1535. doi: 10.1093/HUMREP/DEQ044 Moore, J.S., Gibson, P.R., Perry, R.E., Burgell, R.E. (2017) Endometriosis in patients with irritable bowel syndrome: specific symptomatic and demographic profile, and response to the low FODMAP diet.

Australian and New Zealand Journal of Obstetrics

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and Gynaecology 57(2), 201–205 DOI: 10.1111/ AJO.12594 Morotti, M., Vincent, K., Becker, B. (2017) Mechanisms of pain in endometriosis. European Journal of Obstetrics, Gynecology, and Reproductive Biology 209, 8–13 DOI: 10.1016/J.EJOGRB.2016.07.497 Nnoaham, K.E., Hummelshoj, L., Webster, P., d’Hooghe, T., de Cicco Nardone, F., de Cicco Nardone, C., Jenkinson, C., Kennedy, S.H., Zondervan, K.T., World Endometriosis Research Foundation Global Study of Women’s Health consortium (2011) Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries.

Fertility and Sterility 96(2), 366–373 DOI: 10.1016/J. FERTNSTERT.2011.05.090 Parasar, P., Ozcan, P.,Terry, K.L. (2017) Endometriosis: epidemiology, diagnosis and clinical management.

Current Obstetrics and Gynecology Reports 6(1), 34–41 DOI: 10.1007/S13669-017-0187-1 Parazzini, F., Viganò, P., Candiani, M., Fedele, L. (2013) Diet and endometriosis risk: a literature review. Reproductive Biomedicine Online 26(4), 323–336 DOI: 10.1016/J.RBMO.2012.12.011 Porpora, M.G., Brunelli, R., Costa, G., Imperiale, L., Krasnowska, E.K., Lundeberg, T., Nofroni, I., Piccioni, M.G., Pittaluga, E., Ticino, A., Parasassi, T. (2013) A promise in the treatment of endometriosis: an observational cohort study on ovarian endometrioma reduction by N-acetylcysteine. Evidence-Based Complementary and Alternative Medicine DOI: 10.1155/2013/240702 Sampson, J.A. (1927) Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. American Journal of Obstetrics and Gynecology 14, 422–469 Santanam, N., Kavtaradze, N., Murphy, A., Dominguez, C., Parthasarathy, S. (2013) Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Translational Research 161(3), 189–195 DOI: 10.1016/J.TRSL.2012.05.001 Seaman, H.E., Ballard, K.D., Wright, J.T., De Vries, C.S. (2008) Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study – Part 2. BJOG 115(11), 1392–1396 DOI: 10.1111/J.14710528.2008.01879.X Shepperson Mill, D. (2011) A conundrum: wheat and gluten avoidance and its implication with endometriosis patients. Fertility and Sterility 96(3), S139 DOI: 10.1016/J.FERTNSTERT.2011.07.540 Surrey, E.S., Soliman, A.M., Johnson, S.J., Davis, M., Castelli-Haley, J., Snabes, M.C. (2018) Risk of developing comorbidities among women with endometriosis: a retrospective matched cohort study.

Journal of Women’s Health 27(9), 1114–1123 DOI: 10.1089/JWH.2017.6432 Sutton, C.J., Ewen, S.P., Whitelaw, N., Haines, P. (1994) Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertility and Sterility 62(4), 696–700 DOI: 10.1016/S0015-0282(16)56990-8 Symons, L.K., Miller, J.E., Kay, V.R., Marks, R.M., Liblik, K., Koti, M., Tayade, C. (2018) The immunopathophysiology of endometriosis. Trends in Molecular Medicine 24(9), 748–762 DOI: 10.1016/J. MOLMED.2018.07.004 Traber, M.G., Stevens, J.F. (2011) Vitamins C and E: beneficial effects from a mechanistic perspective. Free Radical Biology & Medicine 51(5), 1000–1013 DOI: 10.1016/J.FREERADBIOMED.2011.05.017 Wu, C-C., Huang, M-Y., Kapoor, R., Chen, C-H., Huang, Y-S. (2008) Metabolism of omega-6 polyunsaturated fatty acids in women with dysmenorrhea. Asia Pacific Journal of Clinical Nutrition 17(Suppl 1), 216–221

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Approaches to marketing during COVID and beyond

The COVID-19 pandemic has no doubt affected every osteopath in Australia. For many, it’s driven them to rethink how to promote their practices. In this article, Alan Zaia outlines some effective marketing strategies that osteopaths can introduce and implement both to bring in new patients and to engage their current patients during COVID and beyond.

DIFFERENT APPROACHES

The way we market our services to attract new patients is vastly different from reminding existing patients that we’re always here when they need us.

Therefore, when thinking about where to start marketing through COVID and beyond, we must distinguish between three approaches: Marketing to new patients; Marketing to your patient list; Keeping in contact with your patient list.

MARKETING TO NEW PATIENTS

When we think about marketing, we typically think about marketing to attract new patients. Marketing to bring new patients into the clinic hasn’t changed much since COVID and the fundamental aspects remain the same (Zaia, 2021a), namely: Strong, consistent branding; A powerful website;

An optimised Google Business Profile (formerly Google My Business); Google Ads; Community-based marketing.

These five fundamental aspects of marketing to new patients are the perfect blend of digital and physical marketing, with the ability to reach potential patients online and in the local community.

Branding Creating a brand always comes before initiating any marketing strategy, because it gives you direction, clarity and purpose.

More than just a name and logo, branding is the equivalent of taking an excellent case history. Much like how the process of taking a thorough case history tells you where and how your treatment will work best, the process of creating a strong brand tells you where and how your marketing will work best.

Both act to give you a plan immediately and into the future.

More than word of mouth While we’re diving into marketing techniques, it’s important to address the effectiveness of word of mouth, and how pairing word of mouth with additional marketing methods can boost clinic growth.

Many osteopaths would agree that word of mouth is their most effective form of marketing. However, while word of mouth is undoubtedly powerful, it’s an unreliable form of marketing because we don’t know when its powers will come into effect.

Since you can’t control when an existing patient recommends you to a friend, family member or colleague, you need to have several marketing strategies operating alongside word of mouth to help you reliably attract new patients to the clinic and encourage existing patients to return.

ALAN ZAIA

Alan Zaia is an award-winning British osteopath, a finalist in The Institute of Osteopathy Practice of the Year 2019 awards and the founder and CEO of Osteohustle (www.osteohustle.com).

Osteohustle is an international network of osteopaths who provide easy, ethical and effective business and marketing tools through coaching, courses and community.

Therefore, if you’ve tried different marketing methods in the past and didn’t get the results you wanted, it’s worth learning more about the process of branding, as a strong brand will fix your marketing forever (Zaia, 2021b).

Website, Google Business Profile and Google Ads When marketing for new patients, it’s important for your website to rank highly for geographically related Google terms like ‘osteopath near me’ and ‘osteopath [your location]’ (Zaia, 2022). There are three different ways people searching using geographically related Google terms can find your website: Organic search ranking (website search engine optimisation); Google Maps (Google Business Profile) Pay-to-be-seen adverts (Google Ads).

So, when someone searches for a term like ‘osteopath near me’, the digital trio of a website, Google Business Profile and Google Ads gives you three horses in the race instead of one.

PRACTICE MANAGEMENT

Google top tip When someone types in a geographically related Google term like ‘osteopath near me’, Google knows to display Google Maps with pins highlighting relevant businesses in the local area. The best way to have your practice listed on Google Maps is by having a Google Business Profile (Newberry, 2022). It’s free and is an excellent way for new patients to find you, so there’s no reason not to have it.

Community-based marketing Most of the fundamental aspects of marketing are digitally focused.

However, community-based marketing is a fantastic opportunity for osteopaths to grow their reputation and build trust within their community.

While COVID has had a minimal impact on our first four fundamental aspects of marketing, it has significantly affected community-based marketing.

Interestingly, COVID has encouraged small businesses to band together to support each other (Anon, 2022), and there’s no reason why osteopaths can’t be a part of that community togetherness.

One of the best bits of advice I’ve ever received when building an osteopathic clinic is to act as if the street your practice is on is a small village. Getting to know other small businesses within your local area is an easy way to build the ‘know, like and trust factor’. This is a marketing concept that suggests the more someone knows, likes and trusts you, the more likely they are to become a patient.

If you combine the five fundamentals of marketing to new patients, you can use your website as a place where both local people who hear about you and those who discover you through Google can learn more about how you help.

Now you have the steps to attract new patients easily, ethically and effectively.

MARKETING TO YOUR PATIENT LIST

Did you know there’s a 60-70% probability of selling to an existing customer vs. a 5-20% probability of selling to a new customer (Pavlovskaya,

2021)? Although this is an all-industry statistic, we can presume the percentages are similar within osteopathy.

These statistics highlight the importance of marketing to patients who already know, like and trust you. Reaching out to existing patients is a powerful strategy that helps practices grow.

As osteopaths, we all know that we can do more than help people get out of pain. We can also help people eat better, move better, sleep better and improve their overall quality of life. Therefore, you can continue reinforcing your reputation as a healthcare professional who can help with numerous lifestyle factors beyond pain management. Marketing to existing patients is a great way to educate them about this fact and improve their ability to recognise when a friend, family member or colleague would benefit from seeing an osteopath.

KEEPING IN CONTACT WITH YOUR PATIENT LIST

Keeping in contact with your patient list is simply touching base with them and sharing clinic news and updates.

We all know the expression ‘out of sight, out of mind’. Therefore, keeping patients up-to-date with clinic goings on will remind them of your existence.

Although this could be viewed as indirect marketing because the news may result in a booking, it’s not your primary intention. Instead, you are continuing to build on the know, like and trust factor.

We use the same strategies and platforms to communicate with our

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existing patients as we use when marketing to them but our intention defines whether we’re marketing or simply keeping our patients up to date with clinic news.

The main tools you can use to communicate with your existing patient list include: Email; SMS; Telephone (including virtual receptionists); Leaflets; Posters; Business cards; Social media.

MARKETING AND UPDATING: WHAT’S THE DIFFERENCE?

The key difference between marketing and keeping patients up-to-date is the action you want them to take. For example, let’s say your team recently took a COVID-safe CPD course.

Community top tip Creating genuine and authentic connections with local businesses is a fantastic, ethical way to become well-known, liked and trusted in your community.

Choosing one business close to where you work, such as a small coffee shop or hairdresser, and spending your time and money there while getting to know the owner is a good way to get started.

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Social media top tip

“By implementing the five fundamentals of osteopathy marketing we can continue to attract new patients” Here are two versions of the same email that you could send to your patient list.

Version 1 Hi [Name] All our staff have recently taken a COVID-safe course provided by Osteopathy Australia to keep our clinic and you safe during your visit.

We want to thank you for your support during this time, and we’re looking forward to your next visit.

If you have any questions about our clinic and COVID, please call us anytime on 444 123 45.

Thank you, [Your name] and the team at [Your Practice Name].

Version 2 Hi [Name], All our staff have recently taken a COVID-safe course provided by Osteopathy Australia to keep our clinic and you safe during your visit.

We understand that you may be cautious about visiting the clinic during COVID and as COVID hopefully begins to ease. So we want to do everything we can to reassure you that your health is and always will be our highest priority.

We’re ready when you are. View our online calendar here to find a time that suits you.

You can reply to this email, and I’ll gladly answer any questions you have before your visit.

Thank you, [Your name] and the team at [Your Practice Name].

As you can see in these examples, we’ve used the same topic and platform but have changed our intention depending on what action we’d like the patient to take. By pointing the patient to our online calendar in the second email, it’s clear that the action we want them to take is to book an appointment.

In comparison, the first email is an open invitation for the patient to ask your team any questions he or she may have.

Can you see how the intention is different while the information is the same? And although the first email is primarily informative, it will have a marketing undertone that may lead to a return visit.

Including a mix of intentions is an excellent way to build the know, like and trust factor with your existing patient base. Other topics you could share with your existing patient base include: New practitioners and staff; New services and products; New skills learned; Updated COVID regulations (cleaning, masks, etc.); Updated opening and closing hours, especially during holidays;

Stop selling, start sharing! Social media is a fantastic tool for osteopaths to use to share their personality and knowledge with people outside their treatment room (Zaia, 2021c). You’d be surprised how much of a better response you’ll get when you start sharing your face, voice and thoughts. Update patients with how COVID affects your clinic, but also reassure them that you’re healthcare professionals who are doing all you can to keep your clinic COVID safe.

Exercise and lifestyle tips (written, image or video-based); New blogs; Addressing a frequently asked question.

COVID AND BEYOND

By implementing the five fundamentals of osteopathy marketing we can continue to attract new patients, while we can also connect with our current patient list to build on the know, like and trust factor.

Operating a combination of strategies will help us effectively market our practices through COVID and beyond.

References Anon (2022) Local vendors to shine at Enlighten Festival. https://www.act.gov.au/our-canberra/ latest-news/2022/february/local-vendors-to-shine-atenlighten-festival, last accessed 11 May 2022 Newberry, C. (2022) How to use Google My Business to get more customers in 2022. https://blog.hootsuite.com/ google-my-business/ #Why_you_need_a_Google_My_ Business_account, last accessed 11 May 2022 Pavlovskaya, E. (2021) 70 powerful customer retention statistics you need to know in 2021. https://www. semrush.com/blog/customer-retention-stats, last accessed 11 May 2022 Zaia, A. (2022) The SEO starter toolkit. https://www. osteohustle.com/wp-content/uploads/2022/01/TheSEO- Starter-Toolkit.pdf, last accessed 11 May 2022 Zaia, A. (2021a) Osteopathy marketing: where to start. https://www.osteohustle.com/osteopathy-marketingwhere-to-start/, last accessed 11 May 2022 Zaia, A. (2021b) How branding will fix osteopaths marketing forever. https://www.osteohustle.com/howbranding-will-fix-osteopaths-marketing-forever/, last accessed 11 May 2022 Zaia, A. (2021c) Social media for osteopaths: how to get patients from social media. https://www.osteohustle. com/how-osteopaths-get-patients-social-media/, last accessed 11 May 2022

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Retirement planning for osteopaths

It’s never too early to start thinking about retirement, however far off it may seem. Achieving a comfortable retirement requires good planning and a level of financial understanding well before actually retiring. In this article, Brian Nicholls, a recently retired osteopath, offers some advice on this advanced planning based on experience from his own pathway towards retirement. Part 2, to be published in the next issue of Osteo Life, will discuss aspects to consider as retirement becomes a reality.

WHY ME?

Apart from the fact that I’m a retired osteopath of nearly two years’ standing, why am I writing an article about retirement planning? Here are a few reasons.

I used to teach a practice management module for the Victoria University osteopathy course, which included lectures on financial and retirement planning.

I’ve worked just about every way an osteopath can work. I’ve been an associate and a university academic.

I’ve run a sole practitioner practice from rented premises and also from a home I owned outright. I’ve co-owned a large practice with seven osteopaths, and I’ve sold two practices. Therefore, I have a perspective on the pros and cons of all of these in relation to retirement planning.

I’ve also made plenty of retirement planning mistakes. I never thought about retirement until I was 35; I didn’t buy a house until I was 43 and I worked overseas for seven years and saved nothing for retirement over those years. I then moved to Australia and had to start again from scratch. By dint of careful planning since then, I’ve been able to retire comfortably, but having had to play catch up for so long has given me a much clearer idea of how to do it better.

WHAT I HAVE LEARNED

How you practise is less important than learning to manage your money well It’s worth remembering that not everyone can or even wants to deal with the stresses of running their own business.

As the profession grows, we are likely to see the majority of practitioners working as employee associates. As an associate you can have a perfectly comfortable retirement if you plan well.

Also, don’t assume that owning a big practice is always the most profitable way to work. For me, the most profitable way of working was as a sole practitioner working from a home I owned outright.

Start early Time is your friend when it comes to building your savings. Accept that your savings may go down as well as up, at least for a time. Australia is one of a small group of developed countries where most workers are forced to invest part of their income in the private finance sector for retirement, so planning for ups and downs is important.

Seek advice You need to understand that the demands on your finances and savings will vary not only throughout your working life, but into retirement as well. Look for the

“It’s worth remembering that not everyone can or even wants to deal with the stresses of running your own business”

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.

best banking and investment products and get the best advice, especially on how to catch up if you didn’t start early.

Financial planners tend to divide working life into three stages, usually called: Accumulation – the stage where you build your income, but also acquire debt in the form of home loans, maybe business loans and car loans and perhaps also education fees for children. At this stage much of your income will go to servicing debt and there will be less to save.

Consolidation – the stage where you will be further growing your income (hopefully) and paying down debt as early as possible in order to grow savings and assets.

Estate planning – the stage where you are working out not only how to use your savings and assets to fund retirement, but also how to maximise the benefit to those who will inherit your remaining assets.

FINANCIAL LITERACY 1: PRODUCTS

Financial literacy is important. You need to know the differences between the various financial products out there and learn how to make the most of them with good advice. A couple of caveats here. The first is that I am not a financial adviser. The second is that many pundits are predicting an era of

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PRACTICE MANAGEMENT

Strategies to make the most of your money First, look for ‘professional’ bank account packages that offer better terms to ‘professional’ customers such as healthcare practitioners.

Also, understand how savings work.

Everyone knows about mortgage calculators, but investment calculators are available too and will show you how small changes in contributions and rates can make huge differences to your funds over time. The government’s Moneysmart website

considerable uncertainty in the finance sector as a result of factors such as geopolitical instability and the effects of climate change. Consequently, financial strategies that worked well in the past may not always work so well in the future.

However, the box above sets out some general recommendations.

There are many ways you can save for retirement. You can buy investment properties, classic cars or artworks, but of those, only investment properties provide a retirement income stream without needing to be sold. For most Australians, superannuation is considered the most tax-effective way of saving for retirement. You will need to understand the difference between: State pension – a basic safety net payment funded by tax contributions.

Industry super funds – typically managed by trade unions primarily for their members, though many are now open to anybody.

Retail super funds – for-profit funds owned by financial institutions.

Self-managed super funds – in which you control your own investments, usually with financial advice.

Choosing the right product in your 20s can make a difference of tens or even hundreds of thousands of dollars by the time you reach 65, especially if you can add extra contributions when income allows.

Employers will have a default super fund, but you can choose your own.

Historically, industry super funds have generally performed better than retail funds and had lower fees. However, some retail funds have performed well. Most funds will offer ‘conservative’ options, balancing lower growth against lower

(moneysmart.gov.au) has one, but there are many others.

Another strategy is to pay as much attention to your debts as to your income. If you play around with online mortgage calculators you will see that a cut of 0.5% in interest rates can save you tens of thousands of dollars in interest, and repaying $500 a month extra on a 30-year $500,000 loan can save you over $100,000. Repaying debt as fast as possible is vital in maximising savings.

risk, or ‘growth’ options, with potentially higher returns but more risk. Accepted wisdom is that you go for growth when you are younger, but when retired you will want to protect your assets, so will be more conservative. The important thing is to do your homework right from the start.

FINANCIAL LITERACY 2: ADVICE

Australian financial advisers must now be registered with ASIC (the Australian Securities and Investments Commission).

However, only about 50 advisers in Australia are currently listed as members on the website of the Profession of Independent Financial Advisers (pifa.org.au). These are advisers who are not receiving incentives to recommend particular investment products. That doesn’t mean you should avoid all non-independent advisers, but just make sure they disclose their incentives. Some financial advisers specialise in retirement planning.

Accountants are not usually advisers.

OTHER CONSIDERATIONS

There are a number of other matters to think about when planning for your retirement.

First, you need to understand the impact of breaks in your working life on your savings towards retirement.

Breaks occur for reasons such as starting a family, illness or working overseas.

If you can afford to continue making super contributions during breaks, or to make additional concessional contributions to your super while working, you’ll increase your retirement savings and may also save on tax.

If you work overseas you may end up paying into a state or private pension scheme where you are working. You need to check whether any pension earned overseas can be paid in Australia when you retire, or if not, whether you can cash in the payments made before returning to Australia and add them to your savings here. I spent seven years paying into the state pension fund in Japan, and essentially lost the money as I hadn’t paid enough contributions to get a Japanese pension paid here.

Also, don’t be too hopeful that the sale of your practice will fully fund your retirement. The sale price of a practice is whatever someone is prepared to pay for it, which is almost always less than what you think it should be worth. Osteopathic practices are very dependent on goodwill towards the practitioners who work there, and there’s no guarantee that goodwill will transfer to new owners. A multi-practitioner practice is worth more, and selling the property with the practice will put the value up further, but in the end it’s down to negotiation between the parties. You’ll need a proper sale contract drawn up, and if you’re simply closing your practice, check you have complied with State and Territory laws relating to practice closures.

Finally, look after your mental and physical health. You want to be able to enjoy your retirement. All the retirement savings in the world are no use if you are burned out, exhausted or barely able to walk after all those accumulated snowboarding injuries. Maintaining good health is an important part of retirement planning, as is thinking about what you actually want to do in retirement. It’s nice to just have a break for a while, but that soon gets boring. You need to plan ways to keep yourself occupied. Your partner needs to do the same. There’s a reason why the post-retirement divorce rate is surprisingly high! * 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.

Useful sources of information www.moneysmart.gov.au www.choice.com.au/money/financial-planning-andinvesting/superannuation/buying-guides/super www.calculator.net/investment-calculator.html

ADVERTORIAL

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ADVERTORIAL

Back pain: turning up the heat

T

he Royal Melbourne Hospital emergency department recently began trialling FlexEze heat wraps for back pain management.

The latest research demonstrates that using heat wraps, movement, education, reassurance and simple analgesia can significantly reduce the prescription of strong pain medication in back pain patients presenting to hospital emergency departments.

Low back pain is one of the most common conditions seen by osteopaths.

They are aware of the impact back pain can have on patients, and the disability and suffering it can cause, as well as the issues surrounding pain management.

Treatment guidelines published by the World Health Organization (WHO), American College of Physicians (ACP), and National Institute for Health and Care Excellence (NICE) all reflect a shift towards non-pharmacological interventions as a first-line treatment for low back pain.

As the evidence base supporting superficial heat use in low back pain grows, an awareness of guidelines and how to best use non-pharmacological interventions for back pain is essential to improve clinical outcomes. Superficial heat in the form of heat wraps is now recommended in multiple guidelines and widely used by osteopaths, often as an adjunct to manual therapies.

A significant advantage of heat wraps is that they enable patients to keep moving, which is a fundamental principle in osteopathy to promote recovery.

FlexEze supports Arthritis Australia to help patients with osteoarthritis.

Health professionals use its heat wraps in many major Australian hospitals, such as the Royal Prince Alfred, Austin, Cabrini, Concord and Canterbury, among many others.

FlexEze is committed to contributing to research and education and is currently engaged in three clinical research projects.

FlexEze heat wraps and hand warmers are a natural evidence-based choice for osteopaths striving for improved outcomes in low back pain patients.

A non-drug, clinically proven use of

“NDIS fully funds FlexEze’s heat wraps and the Transport Accident Commission (TAC), workers’ compensation schemes and the Department of Veterans’ Affairs (DVA) may provide funding for these products, with appropriate documentation from osteopaths.”

heat wraps keeps patients moving and promotes recovery as recommended in multiple treatment guidelines.

NDIS fully funds FlexEze’s heat wraps and the Transport Accident Commission (TAC), workers’ compensation schemes and the Department of Veterans’ Affairs (DVA) may provide funding for these products, with appropriate documentation from osteopaths.

FlexEze is Australian designed and owned, and its ingredients are ecofriendly. Contents can be disposed of in the garden to act as a soil improver.

Heat wraps activate on exposure to air and, once opened, produce heat by oxidising iron powder, which lasts for up to 12 hours. The wrap can be removed for showering or other activities and repositioned. The elastic wrap is reusable and fits most waist sizes.

Find out more For training materials, research literature, to place an order, or if you would like a FREE clinic sample pack, email your details to info@flexeze.com.au

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ADVERTORIAL

ADVERTORIAL

Restoring health in animals with osteopathy Jane Clothier, Equine Bodyworker

I

nterest in treating animals with osteopathy has grown considerably in recent years, with an unprecedented number of postgraduate and lay programs in musculoskeletal therapies emerging in online programs. As a global leader in animal osteopathic education, the London College of Animal Osteopathy (LCAO) has recently launched one of the highest levels of training currently available, providing osteopaths with the opportunity to expand their career through work with animals.

The rapid uptake of the International Diploma in Animal Osteopathy by veterinarians, osteopaths and animal bodyworkers has demonstrated that this kind of accessible learning for animal osteopathy is in high demand.

The International Diploma in Animal Osteopathy, with optional equine and canine streams, has grown from the lifelong work of the LCAO’s founder, Stuart McGregor, DO. Stuart’s interest in treating animals was already showing itself when he graduated from the UK’s European School of Osteopathy in 1984, with his dissertation The Principles of Osteopathy Applied to the Horse being

the first known work about osteopathy for horses. His long-term aim was to find a way to use osteopathic techniques to work with and benefit animals, and he achieved that sooner than expected.

On graduation, he immediately began treating horses and dogs, and it was not long before his Osteopathy Centre for Animals in Oxfordshire, England, was formed. Other osteopaths and veterinarians soon came across Stuart’s

What is osteopathic articular balancing?

Osteopathic articular balancing (OAB) is a general osteopathic treatment that is deeply rooted in classical osteopathy and the philosophies of Andrew Still.

It gently disrupts the body’s state of dysfunction and restores integration, and thereby homeostatic state of health. This is achieved through functional techniques with slow, controlled, long lever moves, with the focus on quality of movement rather than range of motion.

Stuart says, “One of the main principles in osteopathic medicine is that treatment should restore health to the local tissues. This involves the restoration of blood supply, nerve supply and lymphatic drainage. Where any of these are absent, the tissues can only be in poor health.”

In practice, OAB is a system of techniques that ease pain, remove tension and restriction, and restore full movement in every joint of the animal’s body. The therapist examines the functional anatomy of each joint and its accompanying structures, before mobilising associated bones. The direct and indirect relationships throughout the skeletal system are also considered, with posture, gait assessment and palpation forming part of the assessment.

LCAO founder, Stuart McGregor

work and were keen to learn more. It made sense to start bringing his new and evolving techniques together in the equine and canine osteopathy programs that he has now been teaching since 1998 in Europe, Australia and New Zealand. Throughout this time, he has continued to refine both the approach and his methods of instruction, leading to the osteopathic articular balancing (see box on the left) training that he practices and teaches today.

Find out more The International Diploma in Animal Osteopathy (Int’l DipAO) is available to Osteopathy Australia members www.animalosteopathycollege.com

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