10 Things I learnt From 10 Days With Diane Jacobs

Across the end of March and the start of April I spent 10 days straight with Canadian physiotherapist Diane Jacobs, who was in Australia to teach her DermoNeuroModulating (DNM) workshop, which I attended.

Twice.

The first event was held in Noosa, Queensland. It was hosted by Robin Kerr at her recently sold practice, Alchemy in Motion.

The second event was held in Melbourne, Victoria. It was hosted by me at the lovely Parkville hotel The Larwill Studio.

Each event started with a 3 hour lecture by Diane, which covered the theoretical foundation of her work, and was then followed by 3 full days of teaching the manual techniques and clinical reasoning outlined in her book.

I also spent a few days before and after the Melbourne workshop hosting Diane – we went to the zoo, some local pubs and restaurants as well as the Shrine of Rememberance and the National Gallery of Victoria. She even got to have lunch with my mum!

I thought the course was fantastic, overall one of the best courses I have attended, and definitely the best manual therapy course I have attended.

50 Years Is A Long Time

Diane is the same age as my mum. I won’t say what that is exactly (not that I think she’d mind), but she has been in practice for almost 50 years.

Her first years were spent in a hospital setting, which almost turned her off the profession. In fact, she did leave for a short while, but she found her groove, and has never looked back (mostly).

I think anyone who has lived a life, worked thoughtfully and experienced many interactions with people is worth listening to and learning from, and Diane proved me right.

Not David Letterman

In 2013, I took a visceral manipulation course. It was interesting, but implausible. I’d say that Diane’s explanations make more conceptual sense.

One of the benefits of the course was the location – it was in New York City, and while I was there I went to a recording of The Late Show With David Letterman.

His Top 10 lists were great.

I’m not sure I’m of that calibre, but here goes.

NEW YORK – APRIL 24: Dave reads the “Top Ten List” on the Late Show with David Letterman, Friday April 24, 2015 on the CBS Television Network. (Photo by Jeffrey R. Staab/CBS via Getty Images)

On Life

Life mostly works itself out over time. We worry about things we can’t control very much (like outcomes in manual therapy) and cause ourselves a lot of bother, but it mostly works itself out.

On Work

Being a manual therapist is a peaceful way to make a living.

On Not Knowing

It’s okay to not know something, and it’s okay to have a story that may be somewhat, or even entirely inaccurate, as long as you acknowledge it.

The first principle is that you must not fool yourself – and you are the easiest person to fool.


Richard Phillips Feynman 

On Listening

At the Noosa workshop, Diane asked the group if anyone had neck pain, as she was about to demonstrate techniques targeting the occipital nerves.

A man in his sixties volunteered, and she asked him about his pain.

What followed was a 40 minute implicit demonstration of how to listen to someone (not just a patient). Diane seemingly made him feel as they were the only 2 people in the room with her facial expressions, body language and most importantly, her quiet attention.

I really think we need to start considering listening as an intervention itself

Alison Sim

On Manual Therapy

It’s non-specific and n=1 and that’s completely okay.

Additionally, manual therapy can be optimal when it is used for certain presentations (and not very good at all when used for others).

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“For the treatment of pain, manual therapy is always OPTIONAL, but it can be OPTIMAL” – Diane Jacobs ~ So when is manual therapy likely to be optimal? According to Diane, when pain is: ~ ▪ Localised/discrete ▪ Changes with movement/position (ie mechanical) ▪ Changes with distraction ~ Manual therapy is not likely to help (resolve the condition) when: ▪ There are multiple sites of pain that are likely to be the result of central sensitisation ▪ Conditions like fibromyalgia and hyperpathia (basically anything which is highly centralised) ▪ Most (but not all) neuropathic pain ~ I think there is a dearth of research looking at indications and dosage for manual therapy, and as a result (and due to the non specific nature of manual therapy), a lot of research into effectiveness is poor and doesnt help clinical practice. ~ What are your indications for manual therapy? (if you don’t use it, don’t comment, as I know the arguments against, I’m interested in arguments for) ~ #integrativeosteopathy #osteopathy #physiotherapy #massage #manualtherapy #myotherapy #chiropractic #clinicalreasoning

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On Interoception

Often Diane would ask someone if they had pain in the region she was about to demonstrate techniques for.

One thing that really stood out was how she always wanted to get people aware and thinking about how their body felt, rather than the labels and diagnoses they’d been given.

“Does anyone have a sore back”

“I do”

“Tell me about your sore back”

“I had a disc injury”

“How does that feel?

On Beer

Dark beers are her favourite, but The Damned Pilsener by HopNation in Footscray was pretty nice as well.

On Lifespan

It’s mostly genetic.

People try all kinds of things to live longer, but it’s mostly down to genes, and maybe stress.

On Asymmetry

Asymmetrical structure is normal, common and completely okay.

Habitual asymmetrical use of our body is possibly a predisposing factor for mechanical pain.

  • Sleeping on the same side every night
  • Curling up in the same position on the couch all the time
  • Crossing arms/legs the same way all the time
  • Standing with your weight on one leg
  • Carrying bags/children on one side

Her rationale is that such sustained postures/positions/movements relatively tension and shorten the same neural tissues in the same way over time, impacting their fluid dynamics.

Better awareness leads to better use of our body, which leads to feeling better in our body.

On Diagnostic Errors

Everything is a type 1 error (when it comes to musculoskeletal pain diagnoses).

Most of the pain problems we see in clinical practice have been given structural or biomechanical labels.

Yet, often neither changes when the pain resolves.

Or on the other hand, many people walk around with these structural or biomechanical changes and experience no pain.

She is very comfortable with simply calling something “pain”, treating it conservatively and if it improves, not pursuing it further (she will refer for investigations if it doesn’t and she suspects pathology).

DNM: Just Another Acronym?

Manual therapy is full of acronyms and techniques.

Does DNM bring anything different to the table?

Yes.

DNM isn’t about the techniques, which are lovely, but often just rebadged osteopathic techniques.

DNM is about the clinical reasoning process in manual therapy.

It is about considering the role of the nervous system in pain.

It is about understanding what we can affect with manual therapy (nerves, the most excitable tissue in the body), and what we can’t (muscles, fascia and joints – at least not directly).

DNM was the first approach to manual therapy I came across that not only considered the skin (the only thing we can touch), but the physiology and potential therapeutic effects of treating the skin.

There are no rules for DNM techniques – it’s jazz, not classical music.

It’s not copyrighted.

It’s not a business.

It’s simply one woman’s interpretation of the literature on pain, physiology and manual therapy.

4 Simple Rehab Program Templates

Single leg opposite arm row, an upper body “pulling” exercise which demands stance leg and trunk stability and control.

[Note: This is an expanded form of an excerpt from the manual from my workshop Introduction to Kettlebells for Rehabilitation, which I developed and teach with exercise sciencist and personal trainer James Ross. As a brief background, we categorised the exercises into either push/pull for the upper/lower/core. The concepts below can be applied however you categorise movement for programming purposes.]

It’s easy to find exercises online.

Whether you search by joint, muscle group, movement pattern, you will find hundreds, if not thousands of examples.

This alone should tell you something: there is no one way to exercise.

In fact, the only two rules for exercise that are anything close to written in concrete are:

  1. On adaptation: start where you are (i.e. your current ability), do what you can (i.e. don’t push too hard too soon) and progress over time (without progress you stop adapting).
  2. On specificity: you have to practice what you want to get better at (i.e. if you want to run faster, you have to practice running faster).

With that said, there are definitely better and worse ways to exercise, regardless of your goals.

Better ways are more efficient, more effective, safer and more enjoyable. Worse ways are the opposite.

When it comes to clinic rehabilitation for musculoskeletal pain, exercise is an important intervention. Increasing evidence is mounting showing that for many orthopaedic/musculoskeletal conditions, a well structured rehabilitation program yields similar outcomes to surgery over the long term.

Please don’t confuse this with me saying exercise is the only intervention required for clinical rehabilitation.

It stands to reason that structuring an exercise program optimally will yield better results.

With that in mind, the following are examples of templates I commonly use when designing exercise rehabilitation programs for clients in practice.

Bare Minimum

This is simply a single movement exercise “program”, which I often utilise when there are many barriers to adherence. It can also serve as a “gateway” to a more comprehensive program in early stage rehab.

I would typically advise 1-3 sets performed to fatigue as a minimal dosage. With a set/rep based approach we can manipulate intensity via the rep range. This can be a good way to develop strength, strength endurance or even speed/power.

Otherwise a time based approach (i.e. try and do as many sets of 5 in 10 minutes as you can). With a time based approach, we are using sub maximal loads and accumulating volume. This can be a good way to develop strength endurance and work capacity.

There are 2 main ways to design this single movement program.

  • Load the painful movement:
    • Pain management via local tissue effects and central inhibitory effects
    • Develop functional capacity in local tissues
    • Enhance physiological buffer zone
  • Load the non-painful movement:
    • Pain management via central inhibitory effects
    • Develop functional capacity systemically
    • Address weakness/limitations
    • Enhance physiological buffer zone

The bare minimum approach can also be used with multiple movements – i.e. one movement each day, performed for the prescribed sets/reps/time. These are then cycled through.

An example of a 3 day cycle might be:

  1. Squat
  2. Push up
  3. Inverted row

Each of which is performed for as many sets of 10 reps as possible in a 10 minute window on consecutive days. After the third day, start the cycle again.

Whichever approach you take, with bare minimum programming, you typically want to use compound movements, as they maximise efficiency. So for lower body, things like squats, lunges, step ups and hip hinge variations reign supreme.

Minimalist

Using two exercises allows as to train the whole body or agonist/antagonist movements across a joint. This is a great compromise between time efficiency and effectiveness.

Again, these can be prescribed for sets/reps or time periods (I wouldn’t go less than 10 minutes for two exercises, as the volume ends up being too low).

Some common ways to pair movements include:

  • Upper/Lower pairing
    • Use either complementary pairing i.e. upper push/lower pull or similar pairing i.e. upper push/lower pull or vice versa
    • Pain management via both local tissue effects and/or central inhibitory effects
    • Develop whole body functional capacity
    • Enhance physiological buffer zone
  • Agonist/Antagonist pairing
    • Upper or lower push/pull (e.g. push up and row or squat and kettlebell swing/leg curl)
    • Ideal when local tissue factors are the dominant clinical feature
    • Pain management via both local tissue effects and/or central inhibitory effects
    • Develops local tissue capacity which can enhance the physiological buffer zone

Whole Body

I use Chad Waterbury’s definition of a whole body workout: each workout consists of at least one lower body exercise, along with an upper body push and pull.

(you can have two or more workouts as part of the program, to ensure you develop a variety of movements)

The benefits of a whole body workout start shifting towards central pain inhibitory mechanisms and developing the physiological buffer zone.

Again, you can program this based on sets/reps or time. With more exercises you have the option to perform straight sets, a combination or straight and alternating sets or a circuit format.

As a general rule, straight sets will bias local tissue factors slightly more, while alternating and circuit formats will bias work capacity/central factors slightly more.

I like whole body rehabilitation programs as they allow for work on both strengths and limitations simultaneously, which is good for compliance. We all like to succeed and do what we are good at.

They are also great options for in-season maintenance for athletes. Training 2-3 times per week allows the use of 6-9 key exercises, while other areas can be prioritised – i.e. tactics, skills, recovery (and work, family, social life etc).

Comprehensive

The comprehensive program, using the principles outlined in this manual [referring to our rehab manual] simply means taking one exercise from each category: upper body push and pull, lower body push and pull and core.

You can perform these in a circuit form, paired sets or straight sets depending on the desired outcomes.

This type of program trends more towards maintenance of capacity and physiological buffer zone, as well as ensuring central pain inhibitory mechanisms continue to function optimally.

Comprehensive programs are fantastic for the following scenarios:

  • End-stage rehabiliation of athletes before the return to play
  • Mid-to-end stage rehabilitation of non-athletes who are not otherwise active
  • Health-promoting effects of older people, who may be suffering from age related sarco and ostepenia, as well as reduced cardiac capacity
  • Simple preventative home exercise programs for sufferers of chronic low back pain
  • A way to engage sufferers of conditions like fibromyalgia in strength training (you can minimise the dosage and spread the loading across the whole body)

Conclusions

Rehabilitation is complex, but it doesn’t have to be complicated.

By having a set of different templates you can draw on for different scenarios, you can make your exercise prescription more systematic and efficient, leaving more time and brain power to think about and discuss the more human variables surrounding rehabilitation.

Things like goals, interests, barriers and facilitators to adherence and everything else that is important in holistic pain management.

Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

Clinical Reasoning In Manual Therapy

Touch is an important part of human interaction.

Pain is an unpleasant human experience.

Touch conveys meaning that words often cannot.

Pain is often hard, if not impossible to put into words.

It is not surprising that touching people in pain is a common ritual, and it has likely been performed for thousands of years of humanity.

Touching people in pain has now evolved into specialised forms of physical therapy, from massage to manipulation and everything in between. However, what it all boils down to is touch and narrative.

Many therapists, and particularly those who define themselves by what they do (like osteopaths), will be upset to hear that I don’t think manual therapy has to (or can be) very specific to be effective for pain relief.

Manual Therapy is Applied Force

In his excellent book The Science and Practice of Manual Therapy, osteopath and researcher, Dr Eyal Lederman describes the 2 types of force you can apply to a body with your hands, instruments or body:

  1. Tension forces
  2. Compression forces

He elaborates that combinations of these two forces can also be applied, yielding resultant forces such as:

  • Torsional forces
  • Shearing forces
  • Bending forces

When you consider the other variables relating to applied force:

  • Direction
  • Speed (technically velocity)
  • Duration
  • Rhythm/frequency
  • No of cycles

You can then begin to develop different techniques.

Techniques have historically been name in anatomical terms (myofascial release, joint articulation) or by descriptors of what the technique involves or a proposed mechanism (high velocity-low amplitude – HVLA, counterstrain, muscle-energy technique/proprioceptive neuromuscular facilitation).

Clinically, most therapists will say that different techniques (aka different applications of forces) result in different clinical effects and outcomes.

While there is some research to suggest there are different descending modulation pathways that are stimulated with different manual therapy techniques, overall, our current body of knowledge suggests that the effects are non-specific.

The (Non-Specific) Effects of Manual Therapy

Referring back to Lederman’s book, we can describe the effects of manual therapy in 3 main areas:

  1. Tissue effects, which are primarily local
  2. Neurological effects (yes, the nervous system is tissue, but this relates to function of the nervous system)
  3. Psychological effects

You Can’t Change Tissues, Directly

One of the big misnomers surrounding manual therapy is that it directly changes tissues like muscles, ligaments and fascia.

This is not the case – and it doesn’t make biological sense for it to be.

Imagine, if a pair of hands touching you for a few minutes could stretch out your muscles. What would happen to your muscles as you sit down, or sleep?

Manual therapy can possibly stimulate some cellular responses via mechanotransduction.

  • Mechanotransduction is the physiological process where cells sense and respond to mechanical loads. It is independent of the nervous system.
  • Mechanotherapy is the therapeutic application of force/load, used to differentitate between homeostatic mechanotransduction.

A 2012 study, Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage, demonstrated this.

While it was quite a small study, with only 11 participants, it shed light on some cellular effects as a result of massage.

The researchers induced muscle fatigue/damage via exercise (stationary cycling) and then massaged one thigh and used the other as a control.

They found that massage activated the mechanotransduction signaling pathways:

  • Focal adhesion kinase (FAK)
  • Extracellular signal-related kinase 1/2 (ERK1/2)
  • Potentiated mitochondiral biogenesis signaling [nuclear peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α)
  • Mitgated the rise in nuclear factor κB (NFκB) nuclear accumulation

However, whether at all this is clinically relevant remains to be seen. It is one small study, and most other studies demonstrate a very small effect as well.

What is relevant, is that there is a benefit to tissue repair, particularly in the first 2 weeks after injury from harmonic articulation. This is outlined further in Lederman’s text, but considering that pain often leads to decreased use of tissues, this should be considered as a potential therapeutic option.

So it is fair to say that tissue effects, via mechanotransduction are not relevant to the clinical outcomes resulting from manual therapy.

In part, this is because of the way force is distributed by the body.

The Frictionless Skin-Fascia Interface

Between the skin/subcutaneous fascia exists a frictionless interface. That is, the skin will slide over the fascia below it. Think about this, if this didn’t happen, you could pull your subcutaneous tissues around (this would not be good).

As a result, only force applied perpendicular to bone affects bone – tangential force is dissipated.

This knowledge has implications for manual therapy: can you really shear a fibula or radius? What about a vertebrae?

It’s not possible.

Again, thank goodness.

NeuroModulation?

The most likely effect of manual therapy on pain seems to be facilitating “the drug cabinet in the brain” by descending modulation.

Descending modulation is an important biological process that is protective of us in times of threat, but also helpful in managing pain.

It is known that manual therapy, and even touch can cause the brain to release inhibitory neurotransmitters that modulate pain, most likely at the spinal cord level.

As mentioned above, different types of manual therapy seem to evoke slightly different modulation responses.

Psycho(social) Effects of Touch

Touch is the most important sense we have. Without it, we cannot entirely feel pleasure or pain – we are less than human. – David J. Linden

Psychological effects have some crossover with neurological effects, and tend to evoke:

  • Descending modulation
  • ANS changes
  • Pleasant feelings (positive affect)

People can discern meaning from touch – thus can create therapeutic context with touch.

Think about this, if you caress a loved one, versus firmly grab them around the forearm, does the evoke different thoughts and feelings?

In their paper, The Skin As A Social Organ, the authors argue

However, because the skin is the site of events and processes crucial to the way we think about, feel about, and interact with one another, touch can mediate social perceptions in various ways.

The authors cite 3 mechanisms by which the skin can convey social meaning:

  1. Through affiliative behavior and communication
  2. Via affective processing in skin-brain pathways
  3. As a basis for intersubjective representation

I have never heard this described in any manual therapy course, or through my years of university study, yet it is arguably a bigger factor than mobilising joints or stretching muscles.

The Devil Is In The Dosage

There is scant (read: no) good research on dosage for manual therapy.

Practically, dosage is often constrained by patient/practitioner availability and resources (time, money etc).

Within a session, we can do more manual therapy or less. That much is obvious. However, it is hard to prescribe a dosage for intensity, unlike say, exercise.

That is because, as discussed above, the effects of manual therapy do not rely on mechanical stimulation, but rather contextual facilitation, affective change and possibly (probably) expectation.

So a simple way to gauge the response to manual therapy for dosage reasons is:

In other words, if you can gauge a response (within session changes) and measure the adaptation (between session changes) you can reverse engineer the dosage.

Within Session Changes: What to Look For

The responses we are looking for are often subtle, and if missed, can easily lead to overstimulus.

These are (tanks to Barrett Dorko for a couple of these):

  • Softening: a subjective feeling from either patient or practitioner of the tissues softening
  • Warmth: a noticeable increase in superficial warmth, typically explained as an increase in cutaneous blood flow
  • Movement: this is often spontaneous and effortless (think of a person “adjusting” themselves on the treatment table), but it can also be improved movement based on pre/post clinical assessment.

It is important to realise that within session improvements do not suggest resolution, only that there as been a response to the implied stimulus.

Is It Effective Though?

None of this matters if manual therapy isn’t clinically effective.

Here’s the rub (pun not intended): there is low quality evidence to suggest manual therapy can help certain conditions, while there is high(er) quality evidence that shows a smaller effect.

There is evidence (of varying quality) to suggest manual therapy can also influence the following processes:

  • Affects ANS
  • Affects tissue tone and ROM
  • Affects lymphatic system
  • Affects immune system
  • Affects haemodynamics
  • Descending modulation

Hence I favour a process based approach over a condition based approach to clinical reasoning.

This means that you aim to influence processes that are involved in the patient’s presenting complaint.

Putting It Altogether

In order for manual therapy to have a positive clinical effect, we have to apply the right dosage. In practice, underdosing is preferable to overdosing, as you can always do more, but you cannot take away work that has been performed.

We also know that manual therapy is non-specific, but different techniques potentially effect different descending modulation pathways. With this in mind, using a variety of forces (tension, compression, twisting etc) with a variety of variables (direction, duration, magnitude, frequency etc) will provide a hedge of sorts when an individual’s response and preferences are not fully known or understood. This can be modified over time as the practitioner-patient relationship develops.

Finally, we know that we can’t affect tissues, but we can affect processes, so again, as a hedge of sorts, it is preferable to treat a large proportion of the physical body over a localised approach. The exception to this is harmonic style techniques in the early stages of injury to enhance repair.

Conclusions

Two governing quotes govern my thinking around manual therapy for the treatment of pain:

When pain is the primary complaint, treatment of pain should be primary. – Barrett Dorko, PT

And the second:

Manual therapy is optional, but it can be optimal (for the treatment of pain). – Diane Jacobs, physiotherapist

If we understand the likely processes involved in manual therapy, and we acknowledge what we don’t know, along with what we know with a high degree of certainty is unlikely, then I can see well explained and well executed manual therapy continuing to play a role in therapy for many years to come.

If we continue to “treat anatomy” in relation to pain, then over time, funding from health systems and insurers will dry up, as the link between anatomy and pain is tenuous at best.

Finally, we have to give patients a voice. If patients determine they receive a benefit that is meaningful to them, we cannot discount that, as long as they understand the nature of the benefit (i.e. often transient and part of a bigger picture approach to health and pain management).

Workshop

If the topic of clinical reasoning and evidence informed practice with manual therapy interests you, come along to the 3 and a half day DermoNeuroModulation workshop in Melbourne at the end of March (presented by author and developer of the method, Diane Jacobs, who I’ve referenced throughout this post).

Details via the embedded link below.

Comments From Past Attendees:


Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

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References

A Process Model in Manual and Physical Therapies http://www.cpdo.net/Lederman_A_Process_model_in_Manual_and_Physical_Therapies.pdf

Mechanotherapy: how physical therapists prescription of exercise promotes tissue repair https://bjsm.bmj.com/content/43/4/247

Mechanotransduction: use the force(s) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491211/

The frictionless properties at the thoracic skin-fascia interface: implications in spine manipulation https://www.ncbi.nlm.nih.gov/pubmed/12034123

The relationship between the application angle of spinal manipulative therapy (SMT) and resultant accelerations in an in situ porcine model https://www.mskscienceandpractice.com/article/S1356-689X(08)00170-7/pdf

Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy http://jaoa.org/article.aspx?articleid=2093620

Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage https://www.ncbi.nlm.nih.gov/pubmed/22301554

The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/

Pain https://www.ncbi.nlm.nih.gov/pubmed/26304172

Mobilization and Manipulation of the Cervical Spine in Patients With Cervicogenic Headache: Any Scientific Evidence? https://www.ncbi.nlm.nih.gov/pubmed/27047446

Manual therapy, exercise therapy or combined treatment in the management of adult neck pain – A systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pubmed/28750310

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814665/

Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs https://bjsm.bmj.com/content/51/18/1340

Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis https://www.thespinejournalonline.com/article/S1529-9430(18)30016-0/abstract

Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial. https://www.ncbi.nlm.nih.gov/pubmed/29088393

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. https://www.ncbi.nlm.nih.gov/pubmed/29686479

Manual lymphatic drainage for lymphedema following breast cancer treatment. https://www.ncbi.nlm.nih.gov/pubmed/25994425

Manual Therapy Influences on the Autonomic Nervous System https://www.otago.ac.nz/physio/research/otago363201.html

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study. https://www.ncbi.nlm.nih.gov/pubmed/28750955

Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis https://www-sciencedirect-com.wallaby.vu.edu.au:4433/science/article/pii/S246878121730067X

Assessment of skin blood flow following spinal manual therapy: A systematic review https://www.ncbi.nlm.nih.gov/pubmed/25261088

The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695672/

Further Reading

The Science and Practice of Manual Therapy – Eyal Lederman

DermoNeuroModulating – Diane Jacobs

Clinical Neurodynamics – Michael Schacklock

Touch – David J. Linden

How To Build A Strong Back (And Why It’s Important)

Having a strong back helps improve your quality of life.

A strong back allows you to perform daily tasks with relative ease and is protective against injury.

The “back” isn’t an actual body part, but rather a descriptive term. In this article, it means the area from the base of the neck to the top of the pelvis.

Functionally, we can divide the back into two parts:

  • The lower back, which is primarily involved in lifting, carrying and supporting our upright posture
  • The upper back, which provides a foundation for the shoulder girdle and supports our head and neck

In a way, the back also encompasses the “core” and the “shoulder”, which is a good reminder that these are all labels that we give to the body – it functions as a whole, and the separation is only in the way we think about things.

So with that in mind, we can still use these concepts to help us build a strong back.

You don’t need expensive or fancy equipment. Muscles only respond to tension, which can be generated in a number of ways, with or without external weights

Barbells, dumbells, kettlebells, resistance bands, along with pull up bars and suspension trainers to leverage your own body weight are all fantastic ways to develop back strength, and of course, you have specialised machines that can help develop a strong back.

The key is to find an approach that works for your body and your situation.

Top Reasons To Build A Strong Back

  • The act of strength training is protective against back pain (1)
  • Strength training for the upper back was the best intervention for pain in desk bound office workers (2)
  • A strong back helps maintain your optimal posture (more on posture here)
  • The mid back is a common site for osteoporotic fractures – strength training prevents this (3)
  • After the legs, the back muscles are the biggest and strongest in the body, training them expends a lot of energy, helping maintain body composition and blood glucose levels (4)
  • Strong backs look good (don’t underestimate the importance of a positive self image)

Pull, Lift, Carry

There are 3 main actions you can perform with your back muscles:

  • Pulling actions, where you pull yourself towards something, or something towards you. Examples include chin ups, rows and climbing. These movements tend to develop predominantly upper back strength by working on the muscles the move the shoulder blades and arms.
  • Lifting actions, which are those actions where you pick something up (usually from the ground). Examples include deadlifts and power cleans.
  • Once you have picked something up, you can also carry the object for time or distance. Both lifting and carrying exercises develop both lower and upper back strength by working the muscles that stabilise the spine. They usually develop leg strength as well, so are very efficient exercises.

The Best Pulling Exercises

There are a variety of ways to train the pulling movement.

When you consider the freedom of movement the shoulder girdle has, it allows a high number of variations.

The Movements

The shoulder blade (scapula) has a number of ways it can move, but when it comes to pulling, the 3 we are concerned with are:

  1. Retraction: squeezing your shoulder blades together, as in when you perform a rowing action. Examples would be all the row variations in the world!
  2. Depression: pulling your shoulder blades down, as in when you pull yourself up to a bar/ledge. Examples would be chin ups and lat pulldowns.
  3. Upward rotation and elevation: when your shoulder blades turn upwards and raise, as in when you are pulling something in front of your body to your neck. Examples of these are upright rows, shrugs, high pulls, cleans and snatches.

For most people, I like body weight pulling exercises, like chin ups, inverted rows and climbs, though these are often very challenging and hard to scale down for beginners.

Where To Start

In the gym, cable rows and pulldowns, along with barbell and dumbell rows are the go to, with a large number of variation available via hand position, body angle and line of pull through the shoulder.

In practice, a $6 band from Kmart can be a great tool to enable you to perform pulling actions. Loop it around a post and pull it toward you. Loop it around your feet and pull it up. Loop it around a rafter/beam/tree branch and pull it down.

Do More Reps!

As a rule of thumb, pulling exercises are better as volume exercises, not intensity.

That is, perform a higher number of reps per set on average.

You can still load pulling exercises quite highly, but the combination of distraction force through the upper limb and ambiguous end point make it hard to do so as effectively as deadlifts, presses and squats.

Often Overlooked

One class of exercises that are often overlooked in both rehabilitation programs and fitness programs outside of the weightlifting/powerlifting world are shrugs and high pulls.

These train the upward rotation and elevation motion in the shoulder blades (shrugging), which strengthen the trapezius muscle.

A strong trapezius muscle supports healthy shoulder and neck function, but unfortunately, because many people with neck pain report a “tight” trapezius, these exercises were vilified. What was missed is that in these people, their trapezius feels “tight” because it is weak, and strengthening relieves their symptoms.

My Personal Favourites

So while my favourite pulling exercises are:

  • Chin ups (palms facing toward you) and pull ups (palms facing away from you)
  • Inverted rows (elbows high and elbows low)
  • High pull/upright row

In a perfect world, I would help all my clients develop competency and strength in these movements. But because I live and work in an imperfect world, and time, equipment and money are often limiting factors, the exercises I use most in clinical practice are:

  • Band pulldown
  • Band row
  • Band upright row

Deadlifts

The deadlift is a fantastic all-round back strength exercise. It also concurrently helps develop strong legs, particularly the posterior chain muscles, including the hamstrings and gluteals.

It involves picking up a weight implement (barbell, dumbell, kettlebell, etc) from the ground and then lowering it back down again.

There are countless deadlift variations, but my favourite is the barbell deadlift from blocks.

Rogue Metal Deadlift Blocks (https://www.roguecanada.ca/rogue-metal-pulling-blocks)

A close (equal) second is the trap bar deadlift and the kettlebell deadlift.

Why do I favour the barbell deadlift from blocks over other deadlift variations to build a strong back?

  • It allows us to infinitely and incrementally load the pattern, compared to kettlebells, which come in large jumps (usually 4 kg) and only go up to 48 kg in pro-grade style or (very large) 92 kg classic style.
  • We can control the range (rather than lifting based on the height of the weight plates) and ensure the movement is performed within a range that is safe for an individual’s mobility and strength.
  • It is better than a rack pull because the moment arm (from the centre of the bar to the load, not of the load on your spine) is larger (allows better leverage when starting the lift) and as a bonus, protects the bar.
  • Compared to the trap bar, the straight barbell requires a more bent over position, creating a large anterior shear moment on each vetebrae, which the back muscles have to resist, which develops high levels of strength in the spinal stabilisers.

The main downside to the barbell deadlift from blocks is it is more technically challenging/less intuitive than the trap bar or kettlebell deadlift. However, even though these are simpler, and some might argue more “functional” in that they require you to stand between the handle (like a wheelbarrow) or have the load between you (like lifting a heavy bag of fertiliser), I feel like they understimulate the back and posterior chain (relatively).

A second issue is equipment, while most gyms, and many clinics will have a barbell, not many have access to proper lifting blocks. A compromise is to use aerobic steps or weight plates, though they are just that, a compromise.

In reality, you can use a variety of deadlift variations, it doesn’t really matter, as long as you are developing the strength to pick things up from the ground.

Typically, deadlifts can be performed heavy for lower repetitions, or lighter for higher repetitions. They lend themselves well to both applications.

Not Quite Deadlifts

There are a number of exercises that have a similar pattern to the deadlift – the hip hinge movement – that aren’t quite the deadlift.

Think of exercises like:

  • Good mornings
  • Kettlebell swings
  • Back extensions
  • Reverse hypers

These are all great exercises.

They definitely have a place as deadlift alternatives or additions to deadlifts.

The reason I list them as a second tier, is because for most people, I seek maximum training economy, and with that in mind, deadlifts are more than enough stimulation. I would mostly use alternatives when deadlifts are not appropriate:

Loaded Carries

Loaded carries are an under utilised exercise in both performance and rehabilitation.

They are simple movements, but are definitely not simplistic.

Loaded carries can be performed in a few ways:

  • Bilateral loading
  • Unilateral loading

And with the load in different positions

  • By sides (farmer’s walks, suitcase carries)
  • In the rack position (with kettlebells or a barbell)
  • Yoke carries (across the shoulders)
  • Overhead

The most important thing to ensure with loaded carries is to retain postural integrity. The idea is to train dynamic stabilisation under load, not test your limits of how far you can carry a heavy object.

A good guideline is to work with 75% of your bodyweight for farmer’s walks. This might sound light for experienced athletes, but remember, we are trying to build strength, not test it. Building strength can be done with sub-maximal loads, and it allows for faster recovery and better movement patterns.

Conclusions

Pulls, deadlifts and carries are more than enough to build a strong back.

However, there are many other variations of exercises that can be used too.

I’m not in the business of vilifying movements, and given the low activity levels of the majority of Australians, almost any movement is good movement.

Whichever movements you choose, for most people 2-3 times per week is the optimal frequency to develop strength, while the exact amount volume of work you do is individual, the idea is to do more over time.

What I have listed here are the best back exercises for the majority of people, the majority of the time.

While in theory, structured exercise is not essential for health, when it comes to developing a strong back, the simple truth is that the majority of Australians are not physically active enough to develop and maintain adequate strength throughout their lifetime, and so need a structured program to make up for it.

Do you need a stronger back?

If you feel like you could benefit from increased back strength and a holistic exercise program, then contact me to arrange a consultation. This can be done in person or online, depending on your location.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

 


 

 

 

References

(1) Exercise for the Prevention of Low Back Pain: Systematic Review and Meta-Analysis of Controlled Trials

(2) Effects of stretching exercise training and ergonomic modifications on musculoskeletal discomforts of office workers: a randomized controlled trial

(3) Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: novel early findings from the LIFTMOR trial.

(4) Effects of Different Modes of Exercise Training on Glucose Control and Risk Factors for Complications in Type 2 Diabetic Patients

Career Advice For Osteopaths

As we approach the end of the 2018 academic year in Australia, a new cohort of student osteopaths are about to graduate and enter the next stage of their journey as an osteopath.

With this in mind I have reached out to a number of osteopaths, from new graduates to experienced practice owners, academics and entrepreneurs, to share with you some career advice in the form of a tweet (280 characters or less, although some couldn’t help themselves, and went a little longer).

The aim of this post is to help start you thinking about what you want from your career, and what you might have to do (or not do) to achieve that. I hope it will also save you some of the frustrations I (and many others) have gone through in the early stages of our careers.

A successful professional life looks different to everyone.

For some, it means making a lot of money. For others, it’s about having time flexibility. Others still want to have a big reputation and sphere of influence. Many want to be anonymous instead.

There is no one way to define success, however there are some common practices between all who have achieved success in their own way:

  • Self awareness
  • Patience
  • Flexibility
  • Discipline
  • Reflection
  • Mentorship

Whether you are a student, a recent graduate or an experienced professional, there is always potential upside in hearing from others what they believe to be important to achieving professional success.

If I have seen further it is by standing on the shoulders of giants. – Isaac Newton

Absorb What Is Useful

When it comes to receiving advice, it’s important to take what is relevant to you on board, and not get too caught up in the rest. I’ve tried to reach out to a variety of practitioners, with different professional skills and experience, to give a broad perspective on osteopathy.

Absorb what is useful. Reject what is useless. Add what is essentially your own. – Bruce Lee

So, without further ado, posted in the order I received them, the advice for new osteopaths:

Giles Gyer

Giles is an osteopath (2012 graduate of College of Osteopaths, London), medical acupuncturist and sports/remedial massage therapist and is the co-found of OMT Training, a teaching organisation for manual and physical therapists. I don’t know Giles personally, but apparently we look similar enough for a colleague to use his image (from Google Images) on a PowerPoint slide when introducing me, so he had to be part of this piece. His advice is:

“YOU are the most important person in the treatment room” the key to longevity within osteopathy is to look after your body and your hands.. Don’t use techniques that compromise your joints especially your thumbs and back.. Be opened minded to other professions, they’ve got some great skills and techniques you can steal!!

Follow Giles on Twitter and OMT Training on Instagram.

Aaron Anderson

Aaron is an Australian trained Osteopath. He completed his studies in Australia – Osteopathy with Distinction (RMIT), Sport Science (University of Ballarat). Aaron treats both adults and children. Aaron operates Movement Squared, both in Melbourne and Hong Kong locations (definitely a long commute), and additionally has been an onsite practitioner in both the corporate and sports performance world. He is currently completing a Masters in High Performance Sport through ACU. His advice is:

I recommended to my Associate try to excel in Anatomy and HVLA. These fields can easily put you in the top 10%. Be out and about in person. That’s when people will enquire directly about making an appointment. Still better than running an awesome social media campaign in my experience.

Find out more about Aaron and his business Movement Squared or follow Aaron on Twitter.

Jena Chang

Jena is an osteopath who graduated from RMIT in 2013. She works in private practice at Box Hill Osteopathy and Complete Health Osteopathy and Pilates. Her advice to new osteopaths is:

RE: job hunting
If they are interviewing you, you have a right to interview them back. Finding the right workplace is essential in your growth and development as your as your emotional well-being! Never settle for less.

Follow Jena on Instagram (side note: I love Jena’s content, it’s so positive) and Facebook.

Bruce Duncan

In over twenty five years as an Osteopath, Bruce has treated people from all walks of life. He has been Osteopath to the Australian Open Tennis Tournament since 2004, and at the Hawthorn Football Club since 2015. A graduate of RMIT, class of 1992, Bruce founded North Carlton Osteopathy in 1998. His advice is:

Interpersonal skills maketh the osteopath. Diagnostic & hands-on skills are a given, but connecting with warmth, understanding & empathy will take you next level. Build trust and take ownership of their management together.

Follow Bruce via North Carlton Osteo on Instagram and Facebook.

Alison Sim

Alison is an osteopath and pain management specialist. She graduated from Victoria University in 2001 and went on to complete her Masters in Pain Management from Sydney University Medical School and Royal North Shore Pain Management Research Institute. Alison works in private practice at Brighton Spinal and Sports Clinic and Pain Matrix in Geelong, treating people with chronic pain, and runs an education company for allied health professionals, Beyond Mechanical Pain.

Stay flexible in your thinking and humble about your role. Listen and learn from your patients. Keep a strong focus on life outside of work. Keep learning and evolving for your whole career.

Follow Alison’s work via Beyond Mechanical Pain on Twitter and Facebook.

Claire Reed

Claire is in her first year of practice as an osteopath, after graduating from RMIT with the class of 2017. Claire primarily works at Coburg Osteopathy & Health Services, and earlier this year organised the #3058Workout, a massive charity exercise day that raised over $11,000 for cancer council. She has had a great start to her career, no doubt with more to come. Her advice is:

Keep reading and asking questions. Your colleagues are your greatest resource and supporters so use them, ask them questions and observe them as often as you can.

Follow Claire on Instagram.

Nathan Kelly

Nathan, The Surfing Osteopath, a graduate of the class of 2013 from Southern Cross University, owns and operates Universal Health & Performance on the Gold Coast. He practices in an evidence informed manner, utilising traditional osteopathic techniques, dry needling and strength and conditioning principles to help people with injury management and rehab as well as performance enhancement. His advice is:

You’ve spent the last 5 years learning everyone else’s version of osteopathy, it’s now time to spend the next few years exploring how you want yours to look. Osteopathy is a framework which you can build from, and that’s the brilliant part of this job; the exterior is yours to create. The heart of osteopathy is inherently punk, it was born out of rebellion and questioning of the status quo. So keep asking questions, keep studying the human condition and keep osteopathy punk.

You can follow Nathan on his popular Instagram page.

Jacqueline Shergold

Jacquieline (Jacqui) graduated with me from Victoria University in the class of 2011, and since graduating has worked in private practice in Ireland, studied a Diploma in Paediatric Osteopathy at the Osteopathic Centre for Children (OCC) in London and now works as part of a multi-disciplinary team at a specialist baby treatment centre. Her advice is:

Listen. Listen to your instincts. Listen to your peers and mentors. Listen to your patients and listen to what their bodies need and want. Listen to podcasts and go to conferences/workshops/lectures. Take time to listen and you’ll be amazed at what you hear.

For more information, check out her practice website or connect with her on LinkedIn.

Jade Scott

Jade is a graduate of Victoria University, in the class of 2001. She is the owner and director of Western Region Health, one of Australia’s largest osteopathic practices. Jade has been involved in clinical education for a number of years and has an extensive graduate mentorship program in place in her practice and was involved in the development of the 5th year student internship program. Recently Jade has been presenting to osteopathic and allied health business owners on employment models in healthcare. Jade still practices and has a particular interest in maternal and paediatric health. Her advice is:

Don’t confuse confidence with conviction

Never underestimate the need to ‘fake it till you make it’

Social recognition is the key to filling your books

A patient’s financial situation should never cloud your ability to deliver their best treatment plan
Always go above and beyond

‘See how you go’ is not an option

‘Find, it fix it, leave it alone’ should be replaced with ‘find it, fix it, address the predisposing factors and maintain health’

Money is a wonderful byproduct of loving what you do

Core values make us the best at what we do (professionalism, integrity, respect, care and innovation)

If you surround yourself with brilliant people, remarkable things happen…

You can find out more about Jade via Western Region Health and follow them on Facebook for the latest updates.

Shane Buntman

Shane is a graduate of the Victoria University program, class of 2004. He currently operates a large practice across two locations in Melbourne’s CBD – Melbourne Osteopathy Sports Injury Centre. Shane has previously worked in the UK, and before osteopathy studied biology and genetics, as well as worked as  remedial massage therapist. Shane is passionate about developing the profession of osteopathy, and writes for Osteopathy Australia in their quarterly magazine on the topic of business in healthcare/osteopathy. Shane’s advice is:

Every time you step into the consulting room think ‘I’m representing the entire profession Osteopathy’.

It’s not about how interesting you can be, it about how interested you can be in others.

You can find out more about Shane via the MOSIC website and follow them on Facebook and Instagram.

Jon Marshall

Jon, owner of Back in Health Osteo is an osteopath and acupuncturist with clinic locations in Melbourne and Singapore, where he is currently based. Jon graduated from the program at RMIT in the class of 2008, and in 2011 he completed his Masters of Acupuncture, having previously studied a diploma prior to osteopathy. He is a master of the Japanese martial art Aikido and he founded the Melbourne Budo Academy in 2010, which teaches Aikido, Brazilian Jiu Jitsu, Shinkendo (Japanese swordsmanship),  Japanese Jujutsu, and Judo. He also teaches dry needling and cupping courses through his education company, Manual Medicine Australia. His advice is:The greatest thing that I would like to impress on you is that your learning NEVER stops.

Keep all your textbooks and don’t burn your notes. You will refer to them and keep learning from them over your entire working life; they have been written by some real giants in the Osteopathic world and we are lucky to be able to stand on their shoulders.

Don’t be overwhelmed, everything you have learnt in the course takes years to sink in, just keep learning and studying.

Be a generalist before a specialist. Be a Manual Medicine Master.

Work on yourself professionally and personally.

Don’t put down similar professions as it is unprofessional and it makes you sound like a knob. Everyone has something to teach us and never stop honing your craft.

Get together with colleagues, attend seminars and maximise your potential and be the very best Osteopath you can be.

Don’t get lazy or complacent, go out and chase your dreams.

Leaving Melbourne, while hard may be the best decision you ever make professionally…..

You have one of the best jobs for work life balance.

Keep healthy, take regular breaks and taste those sweet fruits!

The future is bright!

You can follow Jon’s clinics on Instagram and Facebook.

Tina Maio

Tina is a highly experienced osteopath who graduated from the osteopathy program at Victoria University in 1999, having also completed a Physical Education degree there previously. Tina owns and consults at Coburg Osteopathy and Health Services, where she treats people from all walks of life, but has established a reputation for her work with athletes, from the junior level all the way through to elites. Tina is particularly known for her work with golfers, with her current stable of players on the US PGA Tour, Nationwide Tour, European Tour, One Asia Tour, Japanese Tour and PGA and LPGA. Tina has presented locally and internationally in sports osteopathy and sports medicine. She is on the leadership committee for the Clinical Practice Group in Sports Osteopathy through Osteopathy Australia and is a clinical advisor for EMS Swiss Dolorclast. Her advice is:

Allocate time to professional development that excites you, it will create lightbulb 💡 moments that will fuel your passion for wanting to help others. Be committed to you career, but don’t abandon your personal life. Remember that working with people in pain is exhausting so take steps to look after yourself.

You can follow Tina through the Coburg Osteopathy Instagram and Facebook pages.

Nigel Roff

Nigel graduated from RMIT in the class of 1993. He practiced in Sydney for 6 years before establishing Willsmere Health Osteopaths in Kew, Victoria in 2000.  He practises patient-centred care with an emphasis on current evidence-based practice. He has a special interest in distance running and the treatment of injuries associated with running, and can also provide training advice. Nigel describes himself as having “No specialisations, I just treat people and their nervous systems”, but he also describes himself as a “hack runner”, so he is definitely modest (he recently competed the Chicago marathon, which is fairly far from “hack”). Nigel is an example of a practitioner who has built a successful career in osteopathy without having a high profile, except with his patients, where it counts most. His advice is:

Assume nothing, actively listen to your patients, they will tell you what’s wrong. You may not be able to help but that’s ok. And finally you are not responsible for your patients problems.

You can follow Nigel on Twitter or Facebook.

Anne Cooper

Anne is a former nurse and a 1989 graduate of the International College of Osteopaths, making her the most experienced practitioner on this list. She founded what is now Central Sydney Osteopathy in 1990 and has had a huge influence on the profession over the years. She has been president of Osteopathy Australia, and is now a life member, she is currently president of the NSW Osteopathic Council and has previously sat on the Osteopathy Board of Australia. Anne calls herself a dinosaur, but dinosaurs are extinct, while she is still overseeing a busy practice and seeing patients. Her advice is:

A new business is like any newborn; feed it when it asks to be fortified, nurture it, love it and help it grow strong and robust. That means 100% attention. Meet your patients needs, and very soon they will meet yours.

Osteopathy is medicine, not sports science. The human form, and what ails it, is not a predictable equation. Our job is simply to assist homeostasis. Treat what you find in that one unique patient, not what you’ve been told you should find.

If you think your patients should reflect your own image, then you’ll struggle. Appeal to ALL types. Old, young, fat, normal and thin, non/sporty, sick, well, straight, gay, black coffee and white, mums, overworked, unemployed.

When you graduate you don’t chat about technique at conferences and reunions. You talk business. So get it right from the start. This is a physical job, output exactly matches input, and if you get it right from the start you’ll enjoy a comfortable lifestyle and a deeply satisfying career.

You can follow Anne via the Central Sydney Osteopathy Facebook page.

 

Della Buttigieg

Della is a graduate of the Victoria University program, class of 2003. She is the founder of Melbourne Osteohealth, and a lecturer at Victoria University. She is a caring and passionate osteopath with particular interest in pain and rehabilitation for long term health and function. She firmly believes that the key to preventing many health problems from developing and recurring lies in educating our patients; arming them with an understanding of the their pain and teaching them how to reduce or eliminate it. Recently she has been involved in presenting on both the theory and application of pain science to clinical practice for allied health professionals. Her advice is:

What most patients want is someone who can help them feel good again and while better movement, more sleep and a balanced diet are a good start, humans never feel better than when they are having fun… prescribe fun!

You can follow Della via Melbourne Osteohealth on Instagram and Facebook.

Heath Williams

Heath is the founder of Principle Four Osteopathy, Corporate Work Health Australia and Ergawell. He is a graduate of Victoria University, class of 2003, and currently lectures there along with Southern Cross University, primarily in rehabilitation. Heath previously has worked in the UK and Sweden, and is currently a member of the Osteopathy Australian Clinical Practice Group for Occupational Health and Safety. Heath has a big focus on continuing education, and has undertaken numerous courses, workshops and seminars covering topics as diverse as manual therapy and exercise rehabilitation all the way through to communication. His advice is:

Be curious and open to opportunities! Learn from your own experiences, your clients and your colleagues and say yes to opportunities. Life will never be dull and work will always be fun and engaging.

You can follow Heath on his popular Instagram or Facebook pages.

Josh Lamaro

Josh is a graduate of the Victoria University osteopathy program. He owns Paleo Osteo in Bendigo and Torquay in Victoria, which is an “evolutionary medicine and nutrition clinic”. He has a special interest in the treatment of chronic conditions such as fibromyalgia, chronic fatigue syndrome, and auto-immnune diseases using the modern and traditional principles employed by Osteopaths. Certified in anti-ageing medicine through the Australasian Academy of Anti-Ageing Medicine, Josh uses functional medicine principles to help address his patients’ health in a wholistic manner. His advice is:

There is an alarming trend in osteopathic education at the moment that is tending away from what osteopathy really is.

There is a tendency to look for the “tissue causing the symptoms” and eradicate or palliate the symptoms. The ancient wisdom of the body is that it is always seeking balance, and will find it irrespective of the minds influence on what is “normal.”

A metaphor might be something like a boat sinking due to a hole in the bow of the hull. The passengers on the boat necessarily have to run to the rear of the boat to counterbalance it away from the sinking end. This could be seen as an “abnormal” distribution of human weight on a vessel (analogous to abnormal lab tests, abnormal tissue tonus etc,) but without this shift having occurred, the result would be far more disastrous. It is therefore of little use to usher the passengers back down the front (medicate/palliate/undo local “restriction,”) rather, what must be done is to seek the true reason the body is needing to find balance in this way.

Asking “why?” til one can no longer ask it anymore lands you somewhere in the realm of where to begin.

You can follow Josh on Facebook and Twitter.

Stephen King

Stephen is dual qualified as an osteopath and physiotherapist. He graduated from the Victoria University osteopathy program in the class of 2010, and the University of South Australia physiotherapy program in 2013. He is the director of Movement Assessment Technologies (MAT), which teaches allied health professionals about movement assessment and functional rehabilitation, The Injury Rehab Centre, a practice in Cheltenham, Melbourne which integrates the concepts taught through MAT and the host of the 21st Century Physio podcast, where he interviews industry leaders about the future of physiotherapy and allied health. Prior to working as a clinician he was a personal trainer and strength and conditioning coach, which is where his interest in movement started, and nowadays he spends his time helping professionals get better outcomes for their clients and patients. His advice is:

My top 3 things that I wish I knew as a new grad.

  1. Do not take everything from Uni as fact – a lot of what you learnt is out of date (it’s not 1898).
  2. Osteopathy is more than a 3x3m room. Think outside the box, set goals and work hard.
  3. Be the change you want to see.

You can follow Stephen via MAT on Facebook, Instagram and YouTube and through The Injury Rehab Centre on Facebook and Instagram.

Dr Nic Lucas, PhD

Nic is an osteopath, medical researcher, lecturer turned entrepreneur. Having completed his osteopathic studies at Victoria University in 1999, he went on to further studies at the University of Newcastle in epidemiology and pain medicine, before completing his PhD in diagnostic medicine at The University of Sydney. While at uni, Nic founded the International Journal of Osteopathic Medicine (IJOM) and served as an executive editor for 19 years and sold to Elsevier, the world’s largest medical publisher. He also started the Student Osteopathic Medicine Association (SOMA), helped develop the osteopathic course at The University of Western Sydney, where he went on to lecture for almost 9 years, and sat on numerous osteopathic committees and registration boards. After selling his two osteopathic practices, he has moved into coaching online entrepeneurs with his company X10 Entrepreneur.

Are you an Osteopath, or are you qualified as an Osteopath? Big difference. Don’t lose sight of yourself in a Title. Your identity is greater than your qualification. You can go anywhere, do anything. There’s never been more opportunity. Don’t ask for permission to go be awesome AF.

You can follow Nic on Facebook, Instagram or check out his website.

Summary

You probably started to sense a trend with the advice given.

While a few of the quotes mentioned technique, the majority talked about attitude, and the big picture.

Common themes were personal growth, education, self-care and listening/communication. This might not make sense now, but when you see such diversity in methods, all with similar results, then you have to look deeper at what is being done.

At the end of the day, this is just a milestone in your life journey. Graduating may feel like “everything” right now, but over time, you will grow and it will become “something”.

You have the opportunity to make an impact on people’s lives, which is an amazing privilege.  I wish you every success in your future, both personally and professionally, and hope that this blog helps you in some way.

Finally, start building your network. The internet makes this easier than ever before, and will strengthen your professional life immensely.

Good luck!

Class of 2011 at Victoria University (phone cameras have come a LONG way since then).

 

Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

You can follow Nick on Facebook, Instagram, Twitter and connect with him on LinkedIn and Snapchat.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.