Unified Manual Healthcare

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The Potential of Biomechanical Movement Analyses In Therapy Processes

Insurance, Risk and Practice Management Issues for Manual Healthcare Professionalsin Europe (Part 1)

Societal Burden Of Musculoskeletal Conditions

Foot Function, Functional OrthosesAnd Proximal Musculoskeletal Pathology

Volume 1 - Issue 1

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Advancing European Physical & Occupational Therapy

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Contents

www.umhonline.com Journal for Unified Manual Healthcare 1

Societal Burden of Musculoskeletal Conditions - 14There is conclusive evidence that individuals’ health and wellbeing is linked to their employment status; ‘good jobs’ have positive impact on health, whilst poor quality jobs are worse for our mental health than unemployment. At the same time poor health may result in reduced work productivity. National policymakers should recognise and measure the impact of MSDs on the individuals’ lives; the financial wellbeing of individual households, economic growth and welfare state associated with lost skills, working time and productivity, in order to facilitate coordination between the stakeholders involved in management of MSDs in the clinical and employment settings. Ksenia Zheltoukhova of the Fit for Work Programme argues that a comprehensive National action plan must be put in place to counteract the disabling effect of MSDs, and optimise working lives of individuals with chronic illness.

LED Light Therapy: An effective Alternative Treatment Option - 18The world of new treatment options and modalities can sometimes be overwhelming for clinicians and therapists. New technologies and modalities have to be evidence based and scientifically proven to be incorporated in a patient’s treatment plan. Numerous authors and scientists have advocated light therapy treatment (or the generic term is phototherapy) for many conditions such as; wound healing, rheumatoid arthritis, joint and soft tissue injuries and pain relief. Marietjie Venter, a qualified Physiotherapist from the University Of Pretoria, South Africa discusses how LED Light therapy devices offer a great complementary, effective treatment option.

Insurance, Risk and Practice Management Issues for Manual Healthcare Professionals in EuropeRisk Management and Risk Transfer (Part 1) - 08Perhaps the only thing we can be sure of in life is the inevitability of change. Certainly, the natural medicine movement has been in transition, and over the last two decades in the UK and Europe, has achieved greater public credibility. As higher profile, higher standards, increasing popularity and more regulation gain momentum, it is inevitable that there will be more complaints and adverse incidents being recorded. Despite the low incidence of claims, complaints and adverse events, there still remains hostility, fixed attitudes and negativity from various sources. David Balen, Business Leader of Balens discusses how improving professionalism and managing risk are vital to create a robust and sustainable manual and natural therapy community.

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Foreword - 06

Neuromusculoskeletal

The Opinions and views expressed by the authors in this magazine are not necessarily those of the Editor or the Publisher. Please note that although care is taken in preparation of this publication, the Editor and the Publisher are not responsible for opinions, views and inaccuracies in the articles. Great care is taken with regards to artwork supplied, the publisher cannot be held responsible for any loss or damage incurred. This publication is protected by copyright.2013 Health Communication Media Volume 1 Issue 1 – May 2013

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Poor Posture and the Tweet Generation - 22Repeated studies validate what chiropractors have been seeing for the past decade or more, children at a younger and younger age are seeking relief from adult type pain and discomfort. What could be the cause of this increased frequency of young patients seeking care? Dr. Joseph Ventura, a Doctor of Chiropractic in both private and group practices, believes it is the result of sociological and technological pressures that have only developed within the past generation; the Tweet Generation.

Pulsed Magnetic Fields: A Therapy for All Seasons - 24A therapy first developed 50 years ago has recently come to prominence, offering help with pathologies in many areas of medicine. Magnetic therapy has a long history, with ancient texts reporting the use of magnetite in China around 2000 BC, and in Greece around 200 BC. Pulsed magnetic fields are very different and fairly recent. Paul Lowe, an English Energy Therapist explains that for practitioners of all kinds, PEMF (or Pulsed ElectroMagnetic Fields) is a versatile technology that expands their coverage range, can be used during other treatments, and is a powerful wellness tool for home use.

Acute, Chronic & Sport Injuries Should Neck Function Play a Bigger Role in Elite Sports? - 28Elite sports performance has been subject to massive investment and research effort over the past decade. This has led to leaner, faster, stronger athlete performance in a wide range of sporting activities. However, the emphasis on performance appears to have focused on the speed, endurance and strength aspects primarily. Recognition of serious injury potential has of course led to rule changes, which although they do not completely stop the problem, can significantly reduce it. The lesser problems associated with accumulated minor trauma to this region are, as a consequence, ignored. Prof. Peter McCarthy who has been involved in chiropractic education discusses what sort of injury does this relate to and what can be done about it?

Foot Function, Functional Orthoses, and Proximal Musculoskeletal Pathology - 32Functional foot Orthoses (FFO’s) are ubiquitous in modern healthcare, being used to manage a range of symptoms across a variety of patient groups. Their use is based on the premise that the foot makes an important contribution to gait performance; pathology may result if this contribution is compromised. This paper by Ian Mathieson considers the contribution of the foot and subtalar joint to normal gait performance, reviewing its functional interdependence with the lower limb and its influence on the mechanical integrity of the foot.

The Potential of Biomechanical Movement Analyses in Therapy Processes - 36Numerous clinical, therapeutical and research related questions demand the quantification and description of the human movement in its given complexity. “Can a patient move more stable after a given treatment?”, “Which muscles are used to control a daily life movement in a stroke patient?” and “How can improvements in an impaired movement behaviour be monitored during the therapy process?” These questions are only exemplary for the many clinical challenges involving the necessity of movement behaviour quantification. Christian Lersch & Felix Matthaei of Velamed GmbH explains the aim and benefit of the application of biomechanical movement analyses to get an insight into the load application and load distribution behaviour of the human musculoskeletal system during posture and activity.

Patient Compliance & Health OutcomesThe Evolution of Engagement - 38The highly complex and multi-factorial traits of health status are a dynamic interplay between genome and environment; that is to say, our health is an on-going dialogue between nature and nurture. Enviromics is the formal study of factors influencing organismic systems, but to a high degree, within our increasingly post-modern societal consciousness we simply intuit the biopsychosocial model. The human organism inhabits several dimensions at least, including; biochemical, biomechanical and psychosocial. Dr Adam Al-Kashi, a researcher and educator in the field of healthcare development explain that the recognition and adoption of fuller sets and depths of these dimensions within the healthcare process renders access to more complete and sustainable outcomes for the patient, practitioner and policymaker.

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The Quantified Self: Patients as Partners Through Technology - 42Amongst the many problems inherent in managing long term conditions and particularly those requiring on going patient action, the issue of compliance is a great concern. Initial approaches using simple SMS messaging have been applied in a number of long term conditions. David Newell at AECC describes how innovative approaches have been created and explored using web and mobile-based techniques and these are increasingly being touted as constituting a new emerging health paradigm for the 21st century.

Clinical Management Small Changes in the Short Term can Lead to Big Changes in the Long Term - 44When it comes to the day to day operation of your clinic, you might think that a couple of minutes to write patient notes at the end of a treatment are sufficient, but how many patients do you see each day? Each month? Each year? How many seconds or even minutes does it take to locate patient records and treatment histories? There has never been a more relevant time for clinics to strive for organizational excellence; through increasing efficiency, reducing costs, enhancing patient satisfaction and identifying areas for improvement. Kyle Lunn at Blue Zinc IT Ltd recommends freeing up time for more important aspects of business; which in reality is what keeps us going and our patients returning.

Branding in a Medical Environment - 46Savvy complimentary health practitioners are realising the need to embrace the promotion of their brand as an investment, utilising creative design both on and off-line to maximise their exposure. There are dozens of agencies and firms that offer these services, whether they are Marketing Agencies who insist they have branding experience or web designers who happen to knock up the occasional logo. It is fast becoming the buzz word du jour, but what is it? Rich With at Leonmedia looks into how and why in this design conscious environment, we have to keep it creative.

Liquid Orthotics, a Simple Step Forward in Patient Care - 50 We were designed to walk on all fours on soft ground; instead, we walk around on two feet and more often, on hard tiled or concrete surfaces. Every day an average person takes 18,000 steps, whilst sustaining thousands of pounds of pressure, all on the 26 bones in their feet. Chris Fitzpatrick at Sole-Mates describes how this constant compression can not only cause pain, but also discomfort, and fatigue. Over time serious disorders; such as, arthritis, heel spurs and Plantar Fasciitis can cripple many people.

Foreword


Modern manual healthcare is relatively new, when considering the timeline of the existence of medicine. In recent years, it has grown dramatically and with increasing speed. The manual healthcare sector has now become a valuable asset to the medical profession; it has the ability to aid

and support mainstream healthcare and to increase the health outcomes of patients.

Neuromusculoskeletal (NMS) conditions have become common, from the increasing rise of the condition; however, patients desire to seek alternative treatment, without the sole treatment plan and assistance of using pharmaceutical drugs, is similarly on the rise. Within the manual healthcare sector, The European Commission has estimated that spending is to exceed EUR 100 million per annum. Through growth and monetary investment, comes a heightened level of acceptance for the sector and therefore, the growth and regulated involvement will continue to ensure the highest standards are maintained. To ensure the development of the sector will increase our knowledge and awareness of the industry amongst the entity of those who exist within it, it is important to create a platform to increase communication amongst us all. This is the primary reason why we have launched the Journal for Unified Manual Healthcare (UMH).

“The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.” Albert Einstein.Europe consists of 45 countries and if all individuals within the manual healthcare sector communicated their information, knowledge and thoughts, imagine the progress and advancements we would see; for example, technology is one of these developments.

Treatment plans are more efficient and with the use of new developing technologies, patient can be treated less invasively and more effectively. Examples of such technology are photomedicine and 3D motion capture systems. There is an ever-growing need to have scientific support such as clinical trials and Product testing. This supports the manual healthcare sector enabling growth, making it stronger and gain further regulatory empowerment.Although technology has bettered the way patients have been

treated, there is still the alarming debate on patient compliance and engagement. This is a topic that all aspects of medicine share together. Treatment plans are always being altered, due to missed appointments or patients not following treatments outside of clinical settings. To keep the patients engaged, tools are available that enable the practitioner to contact patients automatically straight to mobile devices, remind patients of appointments, etc. This can reduce DNA’s and keep the patient engaged with their treatments. In this present financial climate over 2% of the GDP for the European economy is lost, due to NMS condition. The manual healthcare sector can play a vital role in reducing this burden.

In this issue of UMH we have brought you an array of fascinating articles, which will guide you through the best methodologies to enhance your treatment regimes, and to efficiently manage your practice. We have a splendid article from David Balen on Insurance, a risk and practice management article, followed by an article on societal burdens of MSDs from the Fit for Work Europe.

In the NMS section we look into technical treatments; such as, Marietjie Venter’s insight into the efficiency of phototherapy, and PEMF therapy from Paul Lowe. We have fascinating articles from Prof. McCarthy on neck function in elite sports, and the potential of biomechanical movement analyses in therapy processes from Christian Lersch. We also look into different aspects of patient compliance & health outcomes, ways to improve your clinical efficiency and potential recommendations, which will assist in patient care.

This is an exciting time for the Manual Healthcare sector; with the increased recognition from patients, other healthcare providers and governmental bodies. It now time to unify together, sharing our knowledge, and drive healthcare forward. Journal for Unified Manual Healthcare has acquired some insightful information from the many experts in the Manual healthcare sector, and I hope that you enjoy the first, of the many issues to come.

Ross Dalley

Dr David Newell Director of Research at the AECCAECC

Jessica NelsonManaging DirectorOmega Laser Systems Ltd

Dr David ByfieldHead of WIOCWIOC

Prof. Peter McCarthyHead of the Clinical Technology and Diagnostics Research Unit

Prof. Stephen BevanDirector of the Centre for Workforce Effectiveness at The Work Foundation

David Balen Managing Director, Balens Specialist International Insurance Brokers

Adam Al-KashiHead of Research for BackCare

Joseph Ventura D.CDoctor of Chiropractic

Christian Lersch, DirectorVelamed GmbH

Paul LoweManaging DirectorLife Mat Ltd

Advisory Board

Adam Al-KashiHead of Research for BackCare

Joseph Ventura D.CDoctor of Chiropractic

Christian Lersch, DirectorVelamed GmbH

Paul LoweManaging DirectorLife Mat Ltd

Insurance, Risk and Practice Management Issues for Manual Healthcare Professionalsin Europe Risk Management and Risk Transfer (Part 1)

Perhaps the only thing we can be sure of in life is the inevitability of change. Certainly, the natural medicine movement has been in transition, and over the last two decades in the UK and the Europe, achieved greater public awareness and use. Politicians have had to take more notice of its’ popularity and credibility. There is also greater co-operation and respect from the medical mainstream many of whom now include CAM and/or wellbeing advice in their therapeutic palette. I was at two CAM Research Conferences recently at the European Parliament and also in London. It was heartening to see so much progress being made and to see that there are opinion formers in the EU government trying to bring CAM more into the provision of healthcare. Good client outcomes, together with a focus on research, and the progress with the CAMBRELLA Project have all helped to raise the status of the manual healthcare professional and CAM in general. I was however surprised that despite all the research conducted; they had not thought to explore the frequency and causes of adverse events in non biomedical medicine! This is a vital key to understanding the day to day efficiency and low risk. I offered to collaborate as we have built up a substantial body of cross-discipline data arising from hundreds of thousands of treatments since 1991. It is because of low incident rates and lower claims costs that we have been able to offer more cover for lower premiums than we had in the early 1990s! In my view, a Trials-based approach to establishing value and efficacy is only part of the picture, and there is much to commend an outcome-based approach relying on large volumes of data. I am currently collaborating on one or two projects in this area. Risk ManagementAs higher profile, higher standards, increasing popularity and more regulation gain momentum, it is inevitable that there will more complaints, and adverse incidents being recorded, even though, many adverse incidents and complaints go

Be aware of first impressions, and how you come across; you don’t need to oversell yourself or your therapy.Revisit your professional ethos and standards and your everyday culture. Be aware of how medical law operates in your country. I am sure that your intention is to provide the best advice, information and care that you can. Clients will know pretty soon if they have confidence and trust in you, with the peace of mind that they are in good hands, but it is important to know how the Law underpins your relationship. Understand and match reasonable expectations of patient with treatment outcomes. Manage those expectations throughout the process.

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unrecorded. This is because people don’t want to make a fuss, don’t want the stress of taking things further, or they simply like the practitioner and don’t want to get them into trouble. Complaints against European Manual (and CAM) Therapists historically were few and far between outside the UK and Southern Ireland. However there has been growth in claims costs and severity in the conventional medical sector across Europe, and Natural Medicine is following suit. Not only are there more cross border treatments taking place, but complaints can arise from tourists or visitor clients from other countries. In order to help you minimise the potential risk to your practice in a deteriorating climate, not helped by the economic situation in Europe I have devised a bullet point list of suggestions may help you to refresh your reflective risk management process. In compiling this list, I have drawn on 23 years of experience, where I have observed and advised a considerable number of therapists, teachers, decision makers and administrators including practitioners in many types of claims situations in the day-to-day operations of our many schemes. When lecturing on various conferences and university courses over the years, I have had to answer many questions and listen to the concerns of students and experienced practitioners.

Have good, clear information patient leaflets to help manage things pre-treatment, and reinforce your message. Record details of written information supplied to patients in your notes. Professional rigour should combine with the more intangible, intuitive, and caring qualities that often distinguish much of what is best in Private Manual Therapy and CAM delivery. There is an energetic exchange that is definitely therapeutic, but indefinable: this can be lost or substituted by too much information giving or remoteness in the therapeutic relationship. Complaints often arise when good quality communication, kindness, listening and empathy are absent.Maintain good boundaries combined with appropriate TLC. It is best not to get intimate, familiar or have relationships with your patients. It may not be helpful to them and it renders you vulnerable to complaint later on. Ensure that if they come to you for one type of therapy, that you explain and get their permission to employ another therapy that you practise. Record this in your notes.Records.Without adequate records, defending an allegation can become impossible.

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Keep legible, copious and clear patient notes for at least ten years or more. I usually recommend that therapists keep them indefinitely; Use black ink as other colours do not copy as well. If you make an error, cross it out, write the word ‘error’, and initial and date it. Make sure that a complete stranger could pick up your notes and be able to understand what you did or said, and why you did or said it, so that there is an audit trail of the therapeutic encounter and process; You need to tell the story, recording your conclusions, diagnoses and prognoses, but avoid subjective statements or opinions, making your observations factual (“the patient said, not the patient seemed” etc.).

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Make sure you get informed consent about procedures, particularly when using touch for an examination of the body and especially for erogenous zones -note this on the patient record. We have just recently learned of a client being complained about 16 years after the treatment- fortunately he had kept the notes with the clients consent form signed Best not to blame anyone or anything in the notes. Could be embarrassing if made public. Good notes = good defence in Court; inadequate notes = inadequate defence

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Take time to come to your opinion if you need it; don’t be afraid of admitting you don’t know something; clients value honestyLet patients know that they have been heard; give them time (a frequent complaint against mainstream professionals); try not to keep clients waiting by over-running with the previous one- if sustained it can provoke complaints; Be prepared to refer to/work with other disciplines, therapists or specialists for the benefit of the patient, and with respect. Be humble enough to know and accept your current limitations; Try not to allow your financial situation and need for patients or income impinge on the relationship or advice you give; Avoid criticising other therapists or the advice they have given- disagreeing is not the same as criticising;Your practice needs to be a reflective zone for people to deal with physical, emotional, mental and possibly spiritual issues — they need to be able to trust the relationship and the space it takes place in; Exploring some of the material and research on mind/body/energy medicine may be interesting and helpful here, as well as developing your understanding of psychology, counselling and how your clients learn new information;Consider risk management — how to increase quality and reduce risk. Clinical audit. Reflective practice; Continuing professional development. To be viewed as a positive way of improving delivery of care to patient/clients rather than an onerous and costly burden;If a patient is unhappy with the treatment or advice and complains, a careless or thoughtless remark previously made, even in a half-joking manner, may carry an emotional

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charge, which sticks in their memory. This may have more impact on them than the many helpful treatments you may have given. Consider how you use silence either positively or negatively, as well as inappropriate communication. Reflect on your Communication styles: listening (active) or hearing (passive)’? There is so much one could say about communication issues!

Risk Transfer- Facts you need to know about Professional Liability or Malpractice InsuranceThere are many ways you can risk manage your practice. Techniques include: being reflective about your performance, always trying to learn and improve, considering Health & Safety issues, having a robust complaints policy etc., but the main method is to transfer the risk by using Insurance. No policy will cover every situation, but it should protect you for most adverse situations you are likely to face. Choosing an insurer is not just be based on cost or the total amount of cover, but on what sorts of situations and events it will or won’t cover, and on what sort of exclusions or conditions apply. Without such research, the therapist is self-insuring and in a worst-case scenario, an uninsured practitioner would have to find their own funds for expensive legal advice and ultimately could lose all their assets if the case went against them. Malpractice Insurance is a specialised area, and it is vital that you take care to choose something robust, comprehensive and long-lasting. I will firstly explain the main heads of cover and terms:

The definition of a Health or Well-Being Professional or Business should be very wide – it could include acting as an Agent,

Teacher, and Student for work done prior to qualification, It should further extend to include any principal (e.g. someone who contracts you to work for them on a self employed basis), employer or other party with whom you have entered into a contract for the purposes of delivering services in the course of the business. Clinics, Training Schools or other health-related businesses usually need a separate corporate type of insurance. If you run a Multi Therapy clinic, you may need contingent cover in case another practitioner causes a problem and for various reasons, you get held liable. The remit of a Health and Well-Being or Lifestyle-related Professional/Business can be far-reaching and your wording should be designed to mirror that. As well as the delivery of healthcare and/or well-being sessions, treatment and advice on a multi therapy basis, it should have the flexibility to accommodate other things you may do now or in the future- for example, medico–legal work, acting as a witness, consultancy, personal development advice, coaching, plus the sale or supply of products, services, teaching, demonstrations, workshops, lectures, supervision, consultancy etc. If you teach check if your policy is extended to indemnify you for legal liability incurred in respect of teaching or running workshops as an individual tutor, where you are not personally responsible for the delivery of a certificate of competence or a qualification. These extensions usually exclude any liability arising from the management and control of a Training Establishment, Clinic or College unless specifically agreed and an appropriate premium paid.

In the UK Minors (under 16) can be treated therapeutically as long as Parents give their consent. However in the UK,

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Non Disclosure - Situations in any business change, but many claims are declined because the insurer did not know about a material fact. I would advise you to check your original proposal form and certificate of cover to ensure what you said when you took out your policy still reflects what you have now e.g. Have you missed out key areas of cover, changed your business activities or forget to declare a relevant fact such as a previous claim or conviction? Is the certificate for a new therapy a qualification or merely a CPD attendance certificate? Of course, any potential complaint or claim known about at the time of taking out the new policy would not be covered!

Retroactive or Run Off Cover- Failure to continue cover when changing insurer, and failing to retain cover after stopping a policy for late discovered claims. In order to prevent this happening you need to understand the two main types of policy mechanism. The table below will compare how these works in practice.

ConclusionThe vast majority of health professionals are caring and well-intentioned individuals. At best, they have learnt how to balance intellectual rigour with honesty and ethically- based action, and embody professionalism with heart. However practitioners should not be complacent about an unblemished record. In life we manage uncertainty and insurance is certainly about helping to do that. It protects both the insured person

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the Fraser Guidelines can override this. Following the Gillick Case and Decision some years ago, it was adjudged that a minor could make informed choices and decisions about their Health without Parental Knowledge or Consent. You should check the legal position for whichever country you practice from or follow the guidelines suggested by your School or Professional Body. You should, no matter which country you operate from, be aware of the statute of limitation that operates in your local law. Limitation is about the length of time that someone has to sue you for an adverse event. This varies from country to country, and also can vary according to the type of adverse event itself. I have included a basic but not totally comprehensive guide compiled in 2012. These may of course change so you should check the up to date position- the law is never static! Knowing this information helps you to understand how your policy will protect you from incidents arising from previous work or after you stop it for any reason, whether that be illness, disablement, sabbatical, retirement, maternity leave or simply changing to another insurer. Over the years I have seen many situations where practitioners have left themselves exposed for being inadequately insured, and I will give you two important examples of this:

The main differences are (a) flexibility of the sum insured, and (b) the length of time periods 1 and 3 explained below. I explain how explaining how each available policy type (A & B) operates for those.

and the public, as a result of any mistakes- alleged or actual. Unfortunately, despite the low incidence of claims, complaints and adverse events, hostility, fixed attitudes and negativity from various sources still remains. I fervently hope that my series of articles will help you manage risk better and demystify the technical jargon of insurance as you play your part in the growth of a resilient & sustainable European Manual Therapy Community.

Summary of Research on European Jurisdictions

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***

Summary of Research on European Jurisdictions

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David BalenDavid is the business leader one of the larg-est specialist Insurance Brokers for Health and Well-being Professionals in the UK and Europe. David lectures on a va-

riety of subjects for conferences and is a regular

guest lecturer at various Universities. He runs CPD days, and is trustee or advisor to organisations in the not for profit sector. David was a steering com-mittee member and advisor for a research project conducted by NCCOR, National Research Body for Osteopathy. He is also consulted from time to time by regulators and researchers for his views. Email: [email protected]

Societal Burden of Musculoskeletal Conditions

There is conclusive evidence that individuals’ health and wellbeing is linked to their employment status; ‘good jobs’ have positive impact on health, whilst poor quality jobs are worse for our mental health than unemployment. At the same time poor health may result in reduced work productivity.

The shrinking of the European workforce is exacerbated by workers’ poor health. Up to 3 out of every 10 Europeans live with a longstanding illness or health problem that affects their ability to work.1 In the current troubled economic times, ensuring that more people keep healthy and stay in or return to work following ill health, should be part of the European strategy for economic recovery. Now, more than ever before, health, labour and welfare policies are being framed in the context of ageing populations, diminishing social inclusion and increasing public spending cuts. Diseases associated with high mortality are rightly seen as those threatening the size of the European workforce. However, chronic diseases with low mortality but high morbidity may have an even higher impact on the individuals’ productivity at work and lead to early retirement. The example of Musculoskeletal Disorders (MSDs) is salutary. MSDs affect at least 100 million people in Europe, accounting for half of all European absences from work and for 60% of permanent work incapacity.2 In some EU countries, MSDs account for 40%of the cost of workers’ compensation, leading to a reduction of up to 1% in the gross domestic product (GDP) of individual Member States. MSDs, if not managed well, represent a significant overall economic burden on European society, estimated to be up to 2% of GDP.3 In 2012 the Fit for Work initiative has launched an EU-wide survey of individuals with a range of MSDs. This report presents the analysis of over 1500 responses collected in six European countries (Belgium, Bulgaria, Ireland, Portugal, Spain and UK). The findings show that the negative impact of MSDs surpasses the individual, affecting entire households through increased caring responsibilities and loss of income. This societal burden is poorly recognised and is not addressed sufficiently early to prevent

the accumulating cost to the national economies and the individuals living with MSDs in Europe.

Impact of MSDs on work outcomesMSDs can result in prolonged periods of sickness absence and lost productivity at work, having a dramatic impact on the individual’s ability to stay in the labour market and remain productive. For example, one of the most disabling MSDs, rheumatoid arthritis (RA) is a chronic progressive autoimmune condition that causes pain and swelling in the joints of hands, wrists and feet. It is estimated that 70 per cent of patients have irreversible joint destruction in the first year of RA being diagnosed, with 80 per cent of working age patients experiencing disabling pain and stiffness, which reduces their functional abilities.4 RA patients have significant levels of absenteeism and employment status changes, which all usually precede exit from the workforce. Within 3 years of diagnosis, 50 per cent of people with RA are registered as work disabled.5

Our survey shows that being in work – paid or unpaid – was associated with a lower degree of severity of the condition (4.52; SD = 2.12 in work vs 6.35; SD = 2.15 not in work)***. While there is ample evidence that work is therapeutic to recovery and rehabilitation, it is more likely that those with less severe forms of the condition are more likely to maintain active employment status. As such, the differences in the severity scores were reversed when we compared permanently sick and disabled with other groups: 6.85; SD = 2.10 vs 5.67; SD = 2.13 for general health state, p = .000). No significant differences were found between those retired and other groups, although over 65 per cent of the retirees said the condition played a great deal in their retirement.

It appears that the specific conditions of the labour market and the systems available to support return to work contributed to variation of concerns among countries; for example, individuals in Portugal and Bulgaria were more optimistic about their ability to continue working, but could not identify jobs that would accommodate the impact of their MSDs.

Survey findings show that individuals with MSDs experienced a significant impact of the MSDs on job opportunities and career choices. For example, 65.3 per cent said their condition affected their job satisfaction, 41.3 per cent believed it affected their choice of job, and 59.3 per cent thought it prevented them from reaching their full potential in the workplace, more so among those in full-time and non-manual jobs. Equally, it was clear that people with MSDs experienced concerns over job security because of their condition. An overwhelming 92.4 per cent agreed that they sometimes go to work despite not feeling well because of their condition. Such presenteeism is often an indicator of concerns over job security when individuals are afraid of being discriminated against, or losing their job if they miss work. An interesting link between individuals’ education level and experienced impact of the condition was observed. Those with any qualifications experienced significantly less impact of condition. This may be linked to a greater awareness about management and self-management of chronic disease among people with higher educational attainment. Managing symptoms and performance were top two concerns among those with Table 1. Extent to which MSD played a part in the decision to retire

Table 2. Workplace concerns

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MSDs with regard to their work ability. Further analysis has indicated that those with mild and moderate disease severity scores were mostly concerned about the treatment they received in the workplace (employer being flexible to their needs, fear of discrimination), whilst those with severe and most severe forms of disease were mostly concerned with their performance, and increasingly with job loss. Respondents lost an average of 4.1 hours of work per week because of their MSD, and experienced 39.5 per cent average productivity loss at work. This calls for better support of the needs of individuals with MSDs in work as their disease progresses; highlighting the importance of having early conversations with health care professionals and line managers about workplace adjustments necessary to accommodate the course of disease and retain active employment status as long as the individual is willing and capable to do so. Some countries were better than others in managing specific concerns of employees with MSDs in the workplace. It is evident that the instability of the UK labour market contributes to the fear of job loss, whilst job design may not be particularly well handled in Bulgaria.

Impact on families and householdsFinancial wellbeing, linked to the employment status, may often be a concern among those with long-term conditions. As illustrated above, the likelihood of being out of work increases with the progression of the disease, either due to the mobility limitations associated with the disease, or an inability to accommodate the chronic condition in the workplace. Once those living with chronic conditions are out of work, the longer they are inactive, the more difficult it will be for them to find another job.6 This is a concern for several reasons. First, financial problems associated with loss of income result in lower living standards, which may in turn reduce social integration and lower self-esteem. Second, unemployment can trigger distress, anxiety and depression, exacerbating the state of individuals’ health and having a spill-over impact on families and households. Third, unemployment has been linked to poor lifestyle choices, such as increased smoking and alcohol consumption and decreased physical exercise, and may lead to further or additional health problems.7 In this survey, 48.4 per cent of respondents not in employment or education indicated that they had been primary earners of their households before leaving a paid job. Equally, the majority of those with MSDs in our survey and in paid work are

the primary earners. Job loss therefore risks sudden detrimental impact on the financial impact of these households. More specifically, almost 57 per cent of those not in employment relied on social support as the main source of income for their entire household. Even amongst those with a paid job, almost 40 per cent of respondents said that having the condition has impacted their earnings. Money is only one form of support for people living with MSDs. At least 74 per cent of all respondents said they regularly received physical, emotional or financial help from their friends and family, particularly where the condition had an impact on the respondents’ mobility and functioning at work. In addition, 26.7 per cent of those employed were concerned about retaining their job status, highlighting the instability of employment associated with having an MSD. Many individuals with MSDs would prefer to stay in work and those who do stay in work report that it has had a posi-tive affect on their physical and mental health.8 As well as the financial benefits of staying in work, people with RA, for example, say that work gives them the opportunity to

Regulatory


in clinical settings, a large variation in the timing and ease of access to interventions was observed in this sample of individuals living with MSDs. It took an average of 3.54 years to diagnose MSDs correctly. Of the six countries in the survey, Bulgarian patients waited the longest to be diagnosed. Whilst in Ireland the time between onset and diagnosis is the shortest, patients still waited almost three years for a diagnosis. Even when the diagnosis is made, access to treatment can be delayed. Where early intervention is recognised as beneficial for treatment outcomes, it is often the case that the healthcare system or the welfare system (and often both) are not resourced or required to prioritise the kinds of early interventions which, in some cases, can have both clinical and work-related benefits.11 Between 62 per cent (in Spain) and 81 per cent (in Belgium) of patients with MSDs received treatment within 3 month of diagnosis. More than 11 per cent waited for over a year. In this survey only 4.7 per cent of respondents received occupational therapy. Considering the evidence on the instability

be productive and provides social interactions. This has benefited their psychologi-cal wellbeing.9 Therefore, sup-porting people with disabling MSDs to stay in work would have benefits for the individual as well as society, as there would be less pressure on welfare systems.

Support available?Early diagnosis is essential to ef-fective manage-ment of MSDs and reducing the disabling effect of these condi-tions.10 Whilst some progress is clearly being made for im-proved diagnosis and manage-ment of MSDs

Ksenia ZheltoukhovaKsenia joined The Work Foundation in 2010 to support research on the Future of HR programme. She has

since been involved in a number of people management, leadership and health and wellbeing projects at the Centre for Workforce Effectiveness. Ksenia is currently leading the Fit for Work Programme - a major international initiative, exploring early intervention, treatment and rehabilitation practices that could help people living with musculoskeletal disorders stay in or return to work.Email: [email protected]

Regulatory


References

Eurobarometer. (2007). Health in the European Union. See http://ec.europa.eu/health/ph_publication/eb_health_en.pdf

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Fit for Work? Musculoskeletal Disorders in the European Workforce (2009)Cammarota, A. (2005). The Commission’s initiative on MSDs: Recent developments in social partner consultation at the European level. Presentation to Conference on MSDs – A Challenge for the Telecommunications Industry. Lisbon, 20–21 OctoberFilipovic, I., Walker, D., Foster, F. and Curry, A.S. (2011). Quantifying the economic burden of productivity loss in rheumatoid arthritis. Rheumatology, 50(6), 1083-1090.WHO (2003).***Musculoskeletal Disorders and work: Results of a survey of individuals living with Musculoskeletal Disorders in six European countries, (March 2013), by Ksenia Zheltoukhova Programme lead Fit for Work and researcher at The Work Foundation http://www.fitforworkeurope.eu/survey.htmNolte, E. and McKee, M. (2008). Caring for people with chronic conditions. A health system perspective. Open University Press.The Marmot Review (2010). Fair society, healthy lives. London: The Marmot Review. Retrieved on 21 August 2012 from http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review Bevan et al. (2009).Gignac, M. A. M., Backman, C.L., Kaptein, S., Lacaille, D., Beaton, D.E. et al. (2012). Tension at the borders: perceptions of role overload, conflict, strain and facilitation in work, family and health roles among employed individuals with arthritis. Rheumatology, 51(2), 324-332.Bevan et al. (2009).Ibid.

Table 3. Time between symptom onset and diagnosis, by country

of employment among the individuals with MSDs, this is a concerning finding. Further exploration of management of work outcomes in the clinical settings has shown that very few health care professionals prioritised active employment status as an outcome of treatment of MSDs. For example, less than half of the respondents discussed impact of their condition on work with their doctor. Portuguese doctors appeared to be most likely to consider work as part of the treatment, with the UK lagging behind other countries. Only 26.5 per cent of respondents overall (34.1 per cent of those not in work) had a return-to-work conversation with their doctor. Patients from Portugal and the UK were much more likely to discuss return to work in the clinical settings than those from Spain and Bulgaria.

RecommendationsAlready MSDs cost Europe billions of euros in direct healthcare costs; they may have an equally vast or higher financial impact resulting from reduced work ability, and the knock-on family and social economic consequences associated with the reduced quality of life of individuals living with MSDs. We know that as the condition progresses, the chances of an individual with MSD to stay in work diminish, bringing about a higher direct and indirect burden at all stakeholder levels. Urgent action is required on behalf of the healthcare system, employers and policymakers; to help those individuals with MSDs who are wiling and able to work to remain in, or return to, the labour market. If the impact of these conditions is to be taken under control, we found that better management of work outcomes for those diagnosed with MSDs is required in both clinical and employment settings. Clear gaps in practice are evident; clinicians fail to discuss the work context when treating MSDs patients and employers do not put even reasonable adjustments in place to accommodate the impact of MSDs on an individual’s ability to remain productive in the workplace.

National policymakers should recognise and measure the impact of MSDs on the individuals’ lives; the financial wellbeing of individual households, economic growth and welfare state associated with lost skills, working time and productivity, in order to facilitate coordination between the stakeholders involved in management of MSDs in the clinical and employment settings. They should consider the evidence for joined up budgeting and make investment decisions regarding health care and employment policies that allow for greater savings to public finance in the medium and long term. A comprehensive National action plan must be put in place to counteract the disabling effect of MSDs, and optimise working lives of individuals with chronic illness. Clinicians should consider work ambitions of patients with diagnosed and undiagnosed MSDs as a realistic outcome for these individuals, and offer practical advice on staying in and returning to work. They should educate themselves on the latest standards of MSD care, occupational health issues and clinical benefits of employment to help the patient address the changes in their ability to work as the condition progresses. Clinicians should communicate the preserved abilities of the individual to the patient’s employer in an accessible manner.

The world of new treatment options and modalities can sometimes be overwhelming for clinicians and therapists. New technologies and modalities have to be evidence based and scientifically proven to be incorporated in a patient’s treatment plan.

Although light therapy was documented in medical literature as early as 1500BC, it was the Danish physician Nils Finsen, believed as the father of light therapy, who received the Nobel Prize for his work in 1903. Since then, numerous authors and scientists have advocated light therapy treatment (or the generic term is phototherapy) for many conditions such as; wound healing, rheumatoid arthritis, joint and soft tissue injuries and pain relief. The bio stimulus is dependent on the wavelength used and for an effective therapy to take place, the light needs to be absorbed by the body. Receptors identified for absorption of the wavelength energy lies inside the cell. This will be explained later. Therapists are mostly familiar with devices termed as low level laser therapy or laser based light therapy. Lasers, however, have some inherent characteristics that make their use in a clinical setting problematic; mainly limitations in beam width, heat generation, high cost, and fragility. The size of wounds and areas that can be treated is limited because of time constraint; heat production from the laser light itself can damage tissue, and the pinpoint beam of laser light can damage the eye (protective eyewear has to be used by the patient and the therapist). The modern LED based light therapy devices offer an effective alternative to lasers. These diodes can be configured to produce multiple wavelengths, which produce a more diffuse light so that larger areas can be treated at a time. The diodes are very robust, light-weight and produce virtually no heat. It is also of importance to note that LED light therapy has been deemed a no significant risk by the FDA1; thus, FDA approval for the use of LEDs in humans for light therapy has been obtained 1.

How does it work? Light therapy (laser and LED based) stimulates the basic energy processes in the mitochondria (energy compartments)

LED Light Therapy: An Effective Alternative Treatment Option

Fig 1. Hamstring injury with hematoma

Fig 3. Lymphoedema

Fig 2. 3 Treatments over 5 Days

Fig 4. 3 treatments over 5 days

Fig 5. Venous Ulcer (3 years old) Fig 6. After 10 Treatments, twice weekly(Note the regaining of pigmentation)



The depth of near-infrared light penetration into human tissue has been measured spectroscopically. Spectra taken from the wrist flexor muscles in the forearm and muscles in the calf of the leg demonstrate that most of the photons at wavelengths of 630 to 800 nm travel between 2 cm and 20 cm through the skin surface and muscle. Light therapy provides low-energy stimulation of tissues by lasers or LED-based light therapy devices2, which results in increased cellular activity during wound healing in such tissues2,3. These activities include collagen production and angiogenesis. Wound healing has three phases: first, a substrate is laid down, second, cells proliferate, and third, there is remodeling of tissue. Studies published so far suggest that light bio stimulation produces its primary effect during the cell proliferation phase of the wound healing process. It has also been demonstrated that the mitochondria are receptive to near-infrared light and that light increases respiratory metabolism of certain cells5. Processes such as fibroblast proliferation, attachment and synthesis of collagen and pro-collagen, growth factor production (including keratinocyte growth factor [KGF]), transforming growth factor [TGF], and platelet-derived growth factor [PDGF],

macrophage stimulation, lymphocyte stimulation, and greater rate of extracellular matrix production have been reported with light treatment.Light therapy can also be regarded as a complementary/extra treatment modality that will greatly enhance the effectiveness of conventional treatment modalities used in practice. The major advantage of LED

Light Therapy is that it is practical, easy to use, lightweight and portable (hospital/home visits), effective, affordable and durable. The mechanism on which light therapy works complements traditional treatment plans in acute and chronic conditions due to the following effects seen in patients: Practical Considerations in choosing a

Light Therapy Device for your PracticeClinicians and therapists working with a diverse range of patient needs are not phototherapy specialists and have great difficulty in calculating, or choosing doses for effective treatments. This could be a contributing factor in why this amazing modality has been under utilised for so long. There is, a “Therapeutic Window” of dosing, viz. 0,1 J/cm2 to 10J/cm2, that has proven bio-stimulatory effects in tissues. The treatment dose is the most important parameter in successful treatment of pathological conditions. It is also proven that the wavelength is the factor that causes the biological response in a cell, and not the way of delivering that wavelength, such as laser versus LED. Pulsed emission affects the output power and thus the average output power must be taken into consideration. When all or part of a photonic emission protocol is in the form of pulsed emission, it

Therefore, light Therapy treatment for the following pathologies will be highly effective:

ATP stimulationStimulation/regulation of DNA and RNA productionStimulation/regulation of the immune systemAnalgesic effect (acute and chronic)Strong anti-inflammatory effect Reduced scar formationCell repair if treated within 4-6 hours of injury. Regeneration of nerve, muscle, venous and bone cellsReduced muscle spasmsIncreased blood supplyIncreased lymph vessel diameter

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Fig 7. A simple graphic to show light absorption by the cell

Upper respiratory: Sinusitis, Rhinopathy, Croup, etc.Lower respiratory: Bronchospasm, Pneumonia, Pleuritis, consolidation, Asthma, Inflammatory Lung Tissue, etc.

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Respiratory Conditions

AcnePsoriasisEczemaKeloid scars Herpes simplex infections (cold sores)Cellulites

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Dermatological Conditions

Venous and arterial deficienciesVascular regenerationLymph drainage, lymph nodes

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Vascular and Lymphatic Conditions

Acute and chronic woundsPrevention of scar tissue formation (early treatment essential)Pressure points (prevention) and sores

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Wounds

of each cell, particularly when near-infrared light is used to activate the wavelength sensitive constituents inside (chromophores, cytochrome systems). Optimal light wavelengths (proven in prior studies of laser and LED light)3, 4, 5 to speed wound healing rate lie in the range between 610 and 880 nm. These wavelengths can be produced accurately by LED-based devices.

Soft tissue pathologies: muscle, tendon, fascia, ligament, menisci, etc.Arthritic Conditions: degenerative

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Orthopedics

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joint disease, RA, Gout, Spinal Column Pathology and Osteoporosis.Callus formation: fractures, stress fracturesNerve regeneration: Peripheral nerve injuries, Bell’s Palsy, Neuropathy (in diabetic patients), Postherpetic Neuralgia, Herpes Zoster infections, etc.



results in longer treatment time (compared to continuous photonic emission) in order to administer the desired dose. Numerous studies have shown there are different effects when pulsing light, as opposed to continuously emitting light25-29

Before investing in a light therapy device for your practice, a physical therapist needs to consider the following:

For devices where the treatment settings need to be programmed, make sure you know the dosage (J/cm2) formula by heart e.g. time (s) = dose X cover area (cm/2) / average output power (W)Remember:

Devices with pre-programmed dosages are available which may be a better option for therapists with little knowledge in the field of light therapy. Using a pre-programmed device emitting dosages within the ‘therapeutic window’ ensures an effective treatment dosage. When all the dose parameters are equal, laser based devices can be slightly more effective for deeper conditions (speckle formation). For superficial conditions, LEDs are equally effective.LED based devices are in most cases more practical, mainly because:

It is safe to prescribe LED based devices for home (ongoing) treatment.

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Treatment with LED based devices: + 20% higher doseMost devices’ output power is given in mW. 1W = 1000mWWALT (World Association of Laser Therapy) has published guidelines and recommended dosages (therapeutic window) for certain wavelengths.

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Wider aperture of the probes – can treat large body areas, like back, neck, etc.No need to wear eyewear (spreading beam and no risk of eye injuries).Average of 50,000 hours diode lifetime. There is no need to measure output power before treatments, as there is no lowering of output power with time (laser diodes’ output power lowers with usage).They are more robust, lightweight/portable and much cheaper that laser based devices.Diodes are not heat sensitive.

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A device that is designed with a pre-programmed effective dose is simple for the patient to apply without supervision (the same as a patient taking a prescribed dose of medication).With LED based devices, there is no risk of harmful excessive heat formation in tissuesIt is a brilliant complementary treatment modality, enhancing treatment objectivesGreat patient tolerance, especially in animal patients.

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Always treat deep areas through the shortest route to the area.Diagnose the condition, and identify the anatomical structure that needs to be treated. If structure is deep lying, treat anterior, lateral, and posterior to the area, to ensure light absorption in the desired structure. Keep in mind that light therapy has a systemic, immune-modulatory effect as well as a local effect. Treat over lung areas, where Bronchospasm and inflammation or consolidation is present.Light therapy can be safely used over growth plates, metal implants, and on patients receiving anti-clotting medication. Excellent results in treating most conditions such as: Sinusitis (penetrates bone, restores mucus membranes, relieves pain and congestion, stimulates drainage), TMJ, Bell’s Palsy (nerve regeneration, immune stimulation, anti-inflammatory), Neuropathy (especially in diabetic patients - restores sensation, with added value in balance, proprioception, etc.), sport injuries, over-use syndromes, etc.An alternative for needles in acupuncture points Use light therapy before manipulation, to relieve muscle spasms, pain, and to gain better effect.Also treat earache, sore throats and teething in pediatric patients. These are usually associated problems when treating upper respiratory conditions.Treat proximal lymph nodes to assist in reduction of swelling and local infections.Blood irradiation: treat over major blood and lymph nodes, such as armpit, groin, posterior knee, etc. This will enhance general pain relief (endorphin secretion), relaxation (serotonin

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A few practical tips:

secretion), immune response, and general wellbeing.When treating acne, tinnitus, or sinusitis, also treat over the mastoid processes.Treat fractured or cracked ribs and pleuritis. It will relieve pain and encourage deep inspiration, and effective coughing.When treating the anterior neck area, place a spoon or other light impermeable object over the Thyroid. When treating sinusitis, use a teaspoon to protect the eyes from the intense light. Treatment with light therapy before invasive procedures (directly pre-operatively or before painful/uncomfortable procedures), will result in optimum cell/tissue condition, and faster healing, less swelling, less pain and increased immune response. Treat acute conditions daily, for best results. Chronic conditions (RA, chronic pain conditions, psoriasis, and other maintenance treatments) can be treated 2-3 times weekly for 1 month, skip 1 month, repeat 2-3 times weekly. Warts, nail fungi and other longstanding viral and fungal infestations: treat daily or at least 3 times a week, for at least 15-20 treatments, to stimulate the immune response and assists in clearing the infections.Treat cold sores within 6 hours of symptoms developing. This will ensure an optimum immune response. Also treat areas where cold sores commonly appear for at least 8 treatments. This will ensure less frequent attacks. Treat the cause of conditions where possible, e.g. in venous ulcers, treat the whole extremity, and proximal lymph nodes, for an extended period. Light therapy stimulates regeneration of blood vessels, nerve and lymphatic vessels. Prevention is better than cure!

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New research is ongoing, other new advances and exciting research pave the way for a vast range of conditions effectively treatable by LED Light therapy. From Alzheimer and Dementia sufferers, eye pathologies, oral mucositis to traumatic brain injuries, the list is almost unending. LED Light therapy devices offer a great complementary, effective treatment option. Scientifically proven, non-invasive, safe and practical; Light therapy is one of the most effective treatment options for a vast array of pathologies. From newborns to geriatrics, from humans to animals: Any living cell can be treated with spectacular results.

Summary



Whelan, H.T., Buchmann, E.V., Dhokalia, A., Kane, M.P., Whelan, N.T., Wong-Riley, M.T.T., Eells, J.T., Gould, L.J., Hammamieh, R., Das, R., and Jett, M. Effect of NASA Light-Emitting Diode irradiation on molecular changes for wound healing in diabetic mice. J. Clin. Laser. Med. Surg. 2003; 32: 67-74 Enwemeka, C.S. Light is Light. Photomedicine and Laser Surg. 2005; 23: 159-160.Whelan, H.T., Houle, J.M., Whelan, N.T., et al. [2000]. The NASA light-emitting diode medical program - progress in space flight and terrestrial applications. Space Tech. Appl. Intl. Forum 504, 37–43. Whelan, H.T., Buchmann, E.V., Whelan, N.T., et al. [2001]. NASA light-emitting diode: medical applications from deep space to deep sea. Space Tech. Appl. Intl. Forum 552, 35–45. Sommer, A.P., Pinheiro, A.L.B., Mester, A.R., Franke, R.P., and Whelan, H.T. [2001]. Biostimulatory windows in low-intensity laser activation: lasers, scanners and NASA’s light-emitting diode array system. J. Clin. Laser Med. Surg. 19, 29–34.Tamura, M. Non-invasive monitoring of the redox state of cytochrome oxidase in living tissue using near-infrared laser lights. Jpn Circul J 1993;57:817–824.Whelan, H.T., Houle, J.M., Donohoe, D.L., et al. [1999]. Medical applications of space light-emitting diode technology - space station and beyond. Space Tech. Appl. Int. Forum 458, 3–15. Whelan, H.T., Houle, J.M., Whelan, N.T., et al. [2000]. The NASA light-emitting diode medical program - progress in space flight and terrestrial applications. Space Tech. Appl. Intl. Forum 504, 37–43. Whelan, H.T., Buchmann, E.V., Whelan, N.T., et al. [2001]. NASA light-emitting diode: medical applications from deep space to deep sea. Space Tech. Appl. Intl. Forum 552, 35–45.Whelan, H.T., Smits, R.L., Buchmann, E.V., et al. [2001]. Effect of NASA light-emitting diode irradiation on wound healing. J. Clin. Laser Med. Surg. 19, 305–314. Wong-Riley, M.T.T., Xuetao, B., Buchmann, E., et al. [2001]. Light-emitting diode treatment reverses the effect of TTX on cytochrome oxidase in neurons. NeuroReport 12, 3033–3037. Whelan, H.T., Houle, J.M., Whelan, N.T., et al. [2000]. The NASA light-emitting diode medical program—progress in space flight and terrestrial applications. Space Technol. Appl. Int. Forum 504, 3–15. Whelan, H.T., Buchmann, E.V., Whelan, N.T., et al. [2001]. NASA light-emitting diode medical applications: from deep space to deep sea. Space Technol. Appl. Int. Forum 552, 35–45.

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References Whelan, H.T., Smits, R.L., Buchmann, E.V., et al. [2001]. Effect of NASA light-emitting diode irradiation on wound healing. J. Clin. Laser Med. Surg. 19, 305–314.Vinck E, Cagnie B, Cambier D, Cornelissen M [2001] Does infrared light emitting diodes have a stimulatory effect on wound healing? From an in vitro trial to a patient treatment. Progress in Biomedical Optics and Imaging 3[28 Proceedings of SPIE 4903], pp 156–165.Vinck EM, Cagnie BJ, Cornelissen MJ, Declercq HA, Cambier DC [2003] Increased fibroblast proliferation induced by light emitting diode and low power laser irradiation. Laser Med Sci 18[2]:95–99.Cambier D, Blom K, Witvrouw E, Ollevier G, De Muynck M, Vanderstraeten G [2000]. The influence of low intensity infrared laser irradiation on conduction characteristics of peripheral nerve: a randomised, controlled, double blind study on the sural nerve. Laser Med Sci 15:195–200.Sinha, S., Heagerty, A.M., Shuttleworth, C.A., et al. [2002]. Expression of latent TGF-beta binding proteins and association with TGF-beta 1 and fibrillin-1 following arterial injury. Cardiovasc. Res. 53, 971–983. Sasaki, A., Naganuma, H., Satoh, E., et al. [2001]. Participation of thrombospondin-1 in the activation of latent transforming growth factor–beta in malignant glioma cells. Neurol. Med. Chir. [Tokyo] 41, 253–258.Yevdokimova, N., Wahab, N.A., and Mason, R.M. [2001]. Thrombospondin-1 is the key activator of TGF-beta1 in human mesangial cells exposed to high glucose. J. Am. Soc. Nephrol. 12, 703–712.Whelan, H.T., Buchmann, E.V., Dhokalia, A., Kane, M.P., Whelan, N.T., Wong-Riley, M.T.T., Eells, J.T., Gould, L.J., Hammamieh, R., Das, R., and Jett, M. [2003]. Effect of NASA Light-Emitting Diode Irradiation on Molecular Changes for Wound Healing in Diabetic Mice. Jnl Clin. Laser Med. Surg. 21[2] 67–74.Improved Cognitive Function After Transcranial, Light-Emitting Diode Treatments in Chronic, Traumatic Brain Injury: Two Case Reports. Naeser MA, Saltmarche A, Krengel MH, Hamblin MR, Knight JA.1 VA Boston Healthcare System , Boston, Massachusetts. Brain Res. 2010 Jan 8; 1306:100-5. Epub 2009 Oct 23.Photobiomodulation for the Treatment of Retinal Injury and Retinal Degenerative DiseasesJanis T. Eells1, Kristina D. DeSmet1, Diana K. Kirk2, Margaret Wong-Riley3, Harry T. Whelan4, James Ver Hoeve5, T. Michael Nork5, Jonathan Stone2 and Krisztina Valter2. 1. Department of Health Sciences, University of

Wisconsin-Milwaukee, Milwaukee, Wisconsin 53201. 2. CNS Stability and Degeneration Group, Research School of Biological Sciences, Australian National University Canberra, Australia 3. Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee,Wisconsin 53226. 4. Department of Pediatric Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin 5322.6. 5. Department of Ophthalmology, University of Wisconsin, Madison, Madison, Wisconsin 53792; Proceedings of Light Activated Tissue Regeneration and Therapy Conference. eds R.W. Waynant and D.B. Tata pp 39-51, Springer, New York, 2008.Treatment of Chemotherapy-Induced Oral Mucositiswith Light-Emitting Diode. luigi corti,1 vanna chiarion-sileni,2 savinaaversa,2 alberto ponzoni,3 raimondo d’arcais,3 stefano pagnutti,4 davide fiore,5 and guido sotti; Photomedicine and Laser Surgery. Volume 24, Number 2, 2006. Mary Ann Liebert, Inc.Pp. 209–216Al-Watban FA, Zhang XY. The comparison of effects between pulsed and CW lasers on wound healing. J Clin Laser Med Surg. 2004 Feb;22(1):15-8.Korolev luN, Zagorskaia NZ. The effect of infrared laser radiation of different frequencies on the healing of skin wounds. Vopr Kurortol Fizioter Lech Fiz Kult. 1996 May-Jn; (3):8-10.Ueda Y, Shimizu N. Effects of pulse frequency of low-level laser therapy (LLLT) on bone nodule formation in rat calvarial cells. J Clin Laser Med Surg. 2003 Oct;21(5):271-7.El Sayed SO, Dyson M. Effect of laser pulse repetition rate and pulse duration on mast cell number and degranulation. Lasers Surg Med. 1996;19(4):433-7.Karu (The science of Lower Power Laser Therapy, p.33, 1989)

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Marietjie VenterMarietjie qualified in 1982 as a Physiotherapist from the university of Pretoria, South Africa. She also obtained a BA

degree from UNISA, South Africa. She has been working in the clinical field since then and has a special interest in Photo Therapy that includes therapeutic Laser and LED Therapy. Marietjie is still working in physiotherapy private practice and lectures at training institutions for Somatology, Physiotherapy and other health care facilities. Email: [email protected]



Poor Posture and the Tweet Generation

Repeated studies validate what chiropractors have been seeing for the past decade or more, children at a younger and younger age are seeking relief from adult type pain and discomfort. What could be the cause of this increased frequency of young patients seeking care? The author believes it is the result of sociological and technological pressures that have only developed within the past generation; the Tweet Generation. It began in the early 90’s, when schools eliminated lockers and required children to carry their lockers in their backpacks. A couple of years later, that child began playing hand held video games. The cell phone for kids was the next evolution, with affordable family plans. The child did not use the phone to make and receive calls; they used them for texting and massive amounts of this. The author’s 11 year old daughter sent out 11,000 text messages in one month alone.

Consider the following conclusions from two recent studies:“A significant linear trend for increasing sagittal plane postural translations of the head, thorax, pelvis, and knee was found in children age from 4 years to 12 years.” 1

“Poor posture was diagnosed in 38.3% children, more frequently in boys. A significantly different occurrence of poor posture was found between 7 year old and11 year old children (33.0% and 40.8%, respectively). The most frequently detected defects were as follows: Protruding Scapulae (50% of all children), increased Lumbar Lordosis (32%), and round back (31%). Children with poor posture reported headache and pain in the Cervical and Lumbar Spine more frequently.”2

“All measures of health status showed significantly poorer scores as C7 plumb line deviation increased.” 3

“Older men and women with hyperkyphotic posture have higher mortality rates.” 4

“Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.” 5

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Next, we go back to a change made at school level. As the internet expanded, so did the reliance of schools on the internet as a method of delivering content. As a consequence, time in front of a computer within school and at home was essential. The connection between all these activities is clear; ultimately a cause of poor posture. Since the early 90’s, children from the age of nine upwards and through to young adulthood, the musculoskeletal formative years, have engaged in activities that create a Forward Head Posture environment. These activities have literally molded their bodies into an abnormal posture profile. Re-read the conclusions of the studies cited at the beginning of this article; for those readers not yet alarmed at those conclusions, consider these other studies:

scoliosis exam, a child is also examined from the side but only to observe evidence of gross kyphosis, and in most States that part of the exam is not mandatory. Studies have shown that 4.2% of the children screened for scoliosis trigger a referral for radiographs, and of those 4% only a small fraction will require advanced treatment. Nobody is educating parents and schools about the 30% of the children in that same age group that are experiencing Forward Head Posture, and it effects.

What is being done to raise adult awareness of these growing trends in children? Not much. Every State requires a school scoliosis exam. During a school



illustrated in the picture on the left. Notice how straight the black plumb line is.The most common abnormal posture profile is illustrated on the next page. The head sits forward of the shoulders, the upper back has drifted backward and the pelvis has tipped forward. This is commonly known as Forward Head Posture (FHP). Notice the straight plumb line we expect to see in good posture now has a substantial curve in FHP.It’s been estimated that 80% of the general population has varying degrees of FHP.While developing a new posture grid for school posture exams, the author

Good Posture PrimerFor the purpose of this article, the focus will be on postural alignment from the side. Normally, neutral posture is present when a plumb line passes through five anatomical landmarks: Center of the ear, center of the shoulder, greater trochanter, center of the knee and just in front of the ankle. This is

Journal for Unified Manual Healthcare 23

Joseph VenturaDr. Ventura has been involved in the healthcare profession for almost 40 years. As a U.S. Doctor of

Chiropractic in both private and group practices he specialized in sports injuries and acupuncture. Next, as an electrical engineer he designed multiple platforms for FDA cleared devices for pain control and muscle rehabilitation. These devices included TENS, interferential, microcurrent and HeNe lasers. Then he made the transition into software engineering where he developed multiple software programs for orthopedic exams and x-ray image analysis. Dr. Ventura is also recognized as a 3D anatomy artist and graphics designer. Email: [email protected]

Postural development in school children: a cross-sectional study.Chiropr Osteopat. 2007; 15:1 (ISSN: 1746-1340)

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References

placed a typical middle school youth in front of the grid and asked the youth to send out a text message. It was discovered that the head was placed in a position 4.5” in front of the shoulders and placed the shoulder joints in internal rotation. The typical youth can text up to 30 hours per month. Combined with other technology and social stressors, today’s youth is at a greater risk for “molded” forward head posture than any past generation. Considering the

important immediate and future health ramifications of poor posture, accurate posture exams and counseling with parents, children and schools should be a part of every wellness practice.


Prevalence and risk factors of poor posture in school children in the Czech Republic. J Sch Health. 2007; 77(3):131-7 (ISSN: 0022-4391)SPINE, 2005Journal of the American Geriatrics Society, 2004American Journal of Pain Management, 1994Archives of Internal Medicine 2007

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Pulsed Magnetic Fields: A Therapy for All Seasons

A therapy first developed 50 years ago has recently come to prominence, offering help with pathologies in many areas of medicine. For practitioners of all kinds, PEMF (or Pulsed ElectroMagnetic Fields) is a versatile technology that expands their coverage range, can be used during other treatments, and is a powerful wellness tool for home use.

Here’s one of my cases from one of the most researched areas of PEMF - bone and cartilage injuries:

Toby was 12 years old and a promising soccer player. A kick to the knee three months earlier left him in pain even when walking. He was diagnosed with Osteochondritis Dissecans, where a fragment of bone dislodges inside a joint. He was told to avoid exercise for a year or two. He was warned that immobilization or surgery were the most likely treatment options. After six weeks daily PEMF and weekly electro-stimulation, a new scan showed Toby’s knee to be almost normal. Two months later, he went skiing and began training for an international soccer tournament. How could a joint repair in six weeks with such a poor prognosis? The reason is that bones, cartilage and other tissues respond quickly to electrical and magnetic fields.

History and ScienceMagnetic therapy has a long history, with ancient texts reporting the use of magnetite in China around 2000 BC, and in Greece around 200 BC. Pulsed magnetic fields are very different and fairly recent. Pioneering research was done in the 1960’s, first in Japan, then the Soviet Bloc countries. By 1974, Dr. Andrew Bassett at Columbia University Medical Centre had shown that a rapidly changing sawtooth signal produced a Piezoelectric current in the bone which significantly accelerated healing of fractures.1,2

By 1982, the FDA had approved PEMF for the treatment of non-union fractures and to help with spinal fusion operations. Ten years later, the FDA approved certain types of PEMF for treating pain and edema in superficial soft tissues. In 2002 Health Canada, and in 2011 the FDA, certified

trans-cranial PEMF for the treatment of severe, drug-resistant depression. Today we have thousands of studies on the use of PEMF with a wide range of health conditions; particularly those affecting the bones, muscles, connective tissues and nervous system. This article therefore touches only on some of its most obvious uses.

Benefits for TherapistsEvery week, therapists give effective treatment but see the results overwhelmed by background health issues. Every week they see people with recent injuries where early application of an anti-inflammatory therapy would prevent them becoming chronic. Here is a technology that makes all our treatments more powerful, has rapid effects on pain and edema, improves clients’ background health, and can rapidly improve our own. I regularly see clients who have seen a succession of therapists and I wonder what the outcomes might have been, for client and therapist, if they had added on PEMF. Therapists enjoy several benefits from PEMF it helps them to differentiate their practice and expand their client lists through better client outcomes and treating a wider range of conditions. It can also generate commissions on sales of systems. Ideally it becomes a routine part of their main treatments. An added benefit is that it exposes the therapist to the same low-level PEMF field, which is energizing and gives some measure of protection against the RSI common among manipulative therapists. Some prescribe it routinely for clients to use at home, and some have made PEMF a central theme in their clinics; equipping every room with a system so that clients can drop in for regular stand-alone treatments. Let’s examine some of the extra therapy possibilities that PEMF creates.

Anti-AgeingIn anti-ageing therapies, Human Growth Hormone is a Holy Grail; it helps skin quality, muscle growth, sex drive and flexibility. Some people, especially sportsmen, have expensive HGH injections. PEMF offers a natural alternative by: a) stimulating deep, healthy sleep (during which HGH output

peaks), and b) increasing production in the liver of growth hormone co-factors, especially IGF-2 which is thought to boost the availability and effects of HGH itself.3

Leading causes of premature ageing include: stress, sleep loss, acidity, toxic skin products, sluggish lymphatic and eliminatory systems, too much sun, declining hormone levels, insufficient oxygen to the dermis, and less collagen. A nice side effect of PEMF is that it has answers to many of these issues, particularly when used with synergistic therapies and supplements. This barely touches on the range of further benefits in addressing age-related degeneration of soft tissues and nerves, especially when used in combination therapy. NASA was granted a patent in 2009 for the use of PEMF to accelerate tissue repair, and an offshoot of the NASA research was its use in stimulating stem cell growth4. PEMF fields have shown several mechanisms for regulating Prostaglandins5 and other factors involved in inflammation, oxidative stress and cellular senescence, with Arthritis being one of the most common targets6,7. Even Osteoarthritis and Osteonecrosis of the hip can be addressed, if the situation is not left too long8. Loss of bone density is increasingly common, especially in post-menopausal women. It is well documented that PEMF can stimulate Osteoblasts, Chondrocytes and Type 1 Collagen Cells responsible for building mature bone tissue, and their balance with Osteoclasts.9,10. A recent explanation of how this happens comes from In Vivo studies showing that PEMF helps to regulate genes involved in bone formation.11 Sometimes a single application is sufficient to provide lasting relief to an aching joint, while several months’ daily treatment can transform a weak, aching back. PEMF has also been seen to boost various parts of the immune system, including Interleukins and T-cells12 and to improve cognitive decline13. It has also been successfully used with many other Neurological conditions.

Injuries and SportsOne of the main aspects here is pain relief and PEMF has powerful effects in stimulating output of endorphins: our





natural opiates14. As discussed, one of PEMF's most obvious uses is accelerating the repair of fractures; get your leg plastered, apply PEMF frequently and then go back to work a month earlier than expected. It is also an excellent supportive therapy for most Soft Tissue injuries. Common examples where PEMF has been shown to have major value are; Rotator Cuff Tendinitis15, Tennis Elbow16, Sciatica17, recovery from joint surgery18, acute Ankle Sprains19, Chronic Neck Pain20, acute Whiplash injuries21, wound healing22 and Severed Nerves, where PEMF has been shown to speed up healing by up to 100%23. Regular use at a sports club or spa facility provides an excellent booster to Physiotherapy and Sports Massage, greatly improving exercise recovery and injury rehabilitation times.This has obvious benefits for those working in Sports Rehabilitation, but the treatment benefits are not confined to injuries. PEMF is used by thousands of athletes worldwide to improve performance and endurance. In addition to boosting HGH levels and tissue oxygenation, PEMF boosts cellular output of the energy molecule ATP.24 This cuts the time an athlete has to rely on energy from Phosphocreatine stored in muscles, which produces performance degrading lactic acid. Regular energising of stressed tissues is also thought to help prevent injuries; so a before and after treatment can be a great performance booster and prophylactic.

Fatigue and Sleep Loss. And the ultimate in stress management?What virtually everyone notices from using systemic PEMF is extra energy. There are many causes of fatigue, including sleep loss, nutritional deficiencies, stress, unbalanced blood sugars, and low blood oxygen levels. Using PEMF seems to affect all of these to some extent, especially through improved mitochondrial functioning, and greater oxygenation (a fact vividly demonstrated by comparing dark field microscopy before and after treatment). PEMF also increases levels of Nitric Oxide in the blood, relaxing Arterial walls and increasing blood flow.25 Most people also notice deeper, more restful sleep, especially if they use it before bed time. Constant sleep loss can damage the heart, increase weight gain, exacerbate mental instability, and be as dangerous when driving as being drunk. Up to a third of the adult population is thought to be affected. Using brainwave settings, and a sound-and-light system or just background music, systemic PEMF is also an excellent stress management tool. One study26 showed

changes in Cortisol secretion of up to 100% in patients regularly exposed to a magnetic field, and found that effects were still evident a month later. This creates a further Win-Win in that by moving into deep Parasympathetic states, the healing effects of a PEMF field are further enhanced. On some systems the client can even choose to be either deeply relaxed or alert and energized, and even make the system part of a continuous self-adjusting Heart Rate Variability loop. There is now plenty of research proving the links between chronic stress, adrenal overload, excess Cortisol, and the body’s weakening ability to deal with inflammation and disease.27 With so much at stake, some clinics and spas now offer this type of PEMF treatment as a drop-in therapy for stressed and fatigued office workers. I have developed PEMF-centred combination protocols that are quite dramatic; some clients feel more relaxed yet energized than at any time they can remember.

Cellular Messaging, Detox, NutritionOne of the most promising avenues that I have been exploring is the use of PEMF in combination therapies. In PEMF, you have a technology that re-energises the cell membranes28 which are responsible for messaging with other cells, expulsion of toxins and absorption of nutrients. The addition of certain supplements during regular PEMF use has yielded remarkable results in all three areas.

In Nature, Less is MoreAs we see with body temperature and pH balance, homeostasis exists within narrow ranges. The body runs on, and responds beneficially to, very weak energy fields and a fairly narrow range of electromagnetic frequencies. Usually the best long-term results come from the gentlest treatments within what is called the “biological window”; a concept developed by Dr. Ross Adey, a professor at UCLA School of Medicine. This was validated by the work of Goodman and Blank who found that human cells are most likely to express a cell-preserving gene (hsp70), when exposed to an electromagnetic field of only 7 to 8 microTesla, especially compared with field intensities above 70 MicroTesla (some PEMF systems use50,000 MicroTesla).29, 30. I use several energy therapies and the philosophy I apply is that less (power) is more, and copying Nature is best.

Natural Frequencies Are BestWhat we call frequency is the rate of change in waves. The time from one peak to another peak is a cycle, and the basic

unit of frequency is one cycle per second, or Hertz. With PEMF, the frequency cycle is the gap between each pulse. For long-term use, our cells respond best to a range of electromagnetic energies that match the Alpha frequencies in the human brain, and the Schumann resonances in the earth’s atmosphere (both around 8 Hz).31

Signals that fall outside the biological window have been found to have less, sometimes negative, effect. This hints at the potential for low-intensity, low-frequency PEMF to help our bodies recover from the stress they experience every day from a bewildering range of man-made frequencies (from computers at 100 Hz to cordless phones at 6 billion Hz).

Pulsed Fields Go Well Beyond Static MagnetsPEMF is based on the principle that rhythmic switching on and off of an electric current creates a pulsating electromagnetic field which produces continuous electromagnetism in the tissues, maximising the displacement of ions and preventing fatigue in the cell membranes. In other words, the cell membrane is kept constantly responsive. By contrast, the static magnets used in bracelets and mattress pads have only one field strength and one frequency, so the only way for them to have a strong continuing biological effect is through very strong fields. Even then the cells appear to become less responsive: “bored” (by the lack of signal variation) and fatigued (when an abnormally high field strength is used).

There are Many Types of PEMF to Choose fromAt one end of the PEMF spectrum are suitcase-sized devices on wheels that produce relatively strong fields of 500 gauss (50,000 MicroTesla) and higher. (Note: electromagnetic field intensity is still sometimes measured in gauss but more commonly in a unit called a Tesla, equivalent to 1 million MicroTesla). These systems generally use tubular coils that can be draped around parts of the body. They generally cost well over 10,000 euros and are primarily for in-clinic use. Worth considering, if you have the money and you want rapid analgesia and fracture repair, but do not expect long-term healing with these systems and do not see them as general wellness systems (remember the biological window). At the other end of the scale are various small pocket-sized PEMF devices that hit the market in recent years with prices as low as 100 euros. These can be useful for

C.A.Bassett, et al., "Treatment of Therapeutically Resistant Non-unions with Bone Grafts and Pulsing Electromagnetic Fields," Journal of Bone Joint Surg, 64(8), October 1982, p. 1214-1220. A.A. Goldberg: Computer Analysis of Data on More than 11,000 Cases of Un-united Fracture Submitted for Treatment with Pulsing Electromagnetic Fields, a 7-year study examining data on more than 11,000

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ReferencesFracture Healing:

temporary analgesia and a little healing, but do not expect much – for a pocket healing device, especially for First Aid use, there are much better modalities than PEMF. These days, my day-to-day preference is “Systemic PEMF” systems costing 2,000 to 3,000 euros. The best ones have a wide range of automatic and selectable frequency settings and intensities, and give users the option to over-ride the different brainwave frequencies found at different points in the circadian cycle. These typically use foldable mats that bathe the entire body in a PEMF field of as low as 8 MicroTesla, combined with smaller applicators for focusing up to 300 MicroTesla on local areas. When using a mat system, I place it on a treatment couch so that clients are bathed in the field while receiving other treatments. This can give immediate results but the strongest effects are from repeated, and if possible daily, use. Ideally, you start off with regular in-clinic treatment and eventually prescribe a system to the client as a long-term home remedy which complements their maintenance treatments.

Rising PopularityDespite the economic recession, there has been a global boom recently in awareness and demand for PEMF systems, especially in Asia. One factor was a TV endorsement in 2011 from Dr. Mehmet Oz, Professor of Surgery at Columbia University, New York. Another is the use by top sports people; but, there are other factors at work: an ageing population, and the increasing prevalence of inflammatory lifestyle diseases, particularly those affecting the skeletal and nervous systems. As an energy medicine therapist, I use many technologies: several types of Low Level Laser and Light Emitting Diodes, several types of electro-stimulation, various ultrasound and frequency systems, and several types of PEMF technology. Each therapy has different and overlapping strengths, and used in combination they become even more powerful. I use all of them on myself but PEMF is the one I use daily. The result is more energy and productivity, deeper sleep, and fewer aches and pains.



Magnetic Fields," International Journal of Neurosci, 76(3-4), June 1994, p.185-225. And R. Sandyk, et al., "Age-related Disruption of Circadian Rhythms: Possible Relationship to Memory Impairment and Implications for Therapy with Magnetic Fields," International Journal of Neurosci, 59(4), August 1991, p. 259-262.

Robertson, JA., Thomas AW., Bureau Y., Prato, PS. (2006): The Influence of Extremely Low Frequency Magnetic Fields on Cytoprotection and Repair. Bioelectromagnetics, 28 (1): 16-30.Binder, A., Parr, G., Hazelman, B., and Fitton-Jackson, S. (1984) Pulsed electromagnetic field therapy of persistent rotator cuff tendinitis: a double blind controlled assessment. Lancet 1(8379), 695-697.Uzunca, K. and Birtane, M. and Tastekin, N. [2007] Effectiveness of pulsed electromagnetic field therapy (PEMF) in lateral epicondylitis. Clinical rheumatology. 2007 Jan;26(1):69-74. Walker, J. L. and Evans, J. M. and Resig, P. and Guarnieri, S. and Meade, P. and Sisken, B. S. [1994] Enhancement of functional recovery following a crush lesion to the rat sciatic nerve by exposure to pulsed electromagnetic fields (PEMF). United States Experimental Neurology Exp Neurol. 1994 Feb;125(2):302-5. Zorzi, C. and Dall'Oca, C. and Cadossi, R. and Setti, S. [2007] Effects of pulsed electromagnetic fields (PEMF) on patients’ recovery after arthroscopic surgery: a prospective, randomized, double-blind 3-year study. Official journal of the ESSKA 2007 Jul;15(7):830-4. Pilla, A.A., D.E. Martin A.M. Schuett et al., 1996. Effect of pulsed radiofrequency therapy on edema from grades I and II ankle sprains: a placebo controlled, randomized, multi-site, double-blind clinical study. J. Athl. Train.S31:53Foley-Nolan, D., C. Barry, R.J. Coughlan, P. O’Connor and D. Roden, 1990. Pulsed high frequency (27MHz) electromagnetic therapy for persistent neck pain: a double blind placebo-controlled study of 20 patients.Orthopedics 13:445-451.Foley-Nolan, D., K. Moore, M. Codd et al., 1992. Low energy high frequency pulsed electromagnetic therapy for acute whiplash injuries: a double blind randomized controlled study. Scan. J. Rehab. Med. 24:51-59.Kloth LC, Berman JE, Sutton CH, Jeutter DC, Pilla AA, Epner ME: 1999. Effect of Pulsed Radio Frequency Stimulation on Wound Healing: A Double -Blind Pilot Clinical Study, in “Electricity and Magnetism in Biology and Medicine”, Bersani F, ed, Plenum, New York, pp. 875-878.Zhang, Y., Ding, J., et al, (2005): Influence of pulsed electromagnetic fields with different pulse duty cycles on neurite outgrowth

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Injuries and Sports: Endorphin Pain Relief, Tendinitis, Tennis Elbow, Sciatica, Post Surgical Recovery, Ankle Sprains, Neck Pain, Whiplash, Wound Healing, Nerve Repairs:

cases of non-union fractures. Bioelectrical Repair and Growth Society, Second Annual Meeting, 20-22 September 1982, Oxford, p. 61.

Fitzsimmons, R.J., Ryaby, J.T., Magee, F.P., and Baylink, D.J. (1995) IGF II receptor number is increased in TE 85 cells by low amplitude, low frequency combined magnetic field (CMF) exposure. J. Bone Min. Res. 10, 812- 819.Sun LY, Hsieh DK, Yu TC, et al (2009): Effect of Pulsed Electromagnetic Fields on the Proliferation and Differentiation Potential of Human Bone Marrow Mesenchymal Stem Cells. Bioelectromagnetics. 2009 May; 30(4):251-60. doi: 10.1002/bem.20472.Lohman, CH., Schwartz, Z., Boyan B., J: Pulsed Electromagnetic field Stimulation of MG63 Osteoblast-like Cells Affects Differentiation and Local Factor Production. Orthop Res. 2000 Jul, 18 (4), 637-46 Zizik T.M., Hoffman, K.C., Holt, P.A., Hungerford, D.S., O’Dell, J.R., Jacobs, M.A., Lewis, G.C., Deal, L.C., Caldwell, J.R., Cholewczyinski, J.G., and Free, S.M. (1995) The treatment of osteoarthritis of the knee with pulsed electrical stimulation. J. Rheumat. 22, 1757-1761.Vavken, P. and Arrich, F. and Schuhfried, O. and Dorotka, R. Effectiveness of pulsed electromagnetic field (PEMF) therapy in the management of osteoarthritis of the knee: a meta-analysis of nine randomized, controlled, double-blind trials across 483 patients. Sweden Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine J Rehabil Med. 2009 May;41(6):406-11. Ishida, M., Fujioka, M., et al. (2008): Electromagnetic Fields – A Novel Prophylaxis for Steroid-Induced Osteonecrosis. Clin Orthop Relat Res, 466 (5): 1068-1073.T.W. Bilotta. Influence of Pulsed Electromagnetic Fields on Post-Menopausal Osteoporosis, First World Congress for Electricity and Magnetism in Biology and Medicine, 14-19 June 1992, Lake Buena Vista, FL, p.78. Schnoke, M. and Midura, R. Pulsed Electromagnetic Fields Rapidly Modulate Intracellular Signaling Events in Osteoblastic Cells: Comparison to Parathyroid Hormone and Insulin. Journal of Orthopaedic Research, July 2007, Vol. 25: 933-940. Sollazo, V. and Palmieri, A. and Pezzetti, F. and Massari, L. and Carinci, F. Effects of Pulsed Electromagnetic Fields on Human Osteoblast-like Cells (MG-63): A Pilot Study. Clin Orthop Relat Res. 2010 August; 468(8): 2260–2277.Cossarizza, A., Angioni, S., et al. (1993). Exposure to low frequency pulsed electromagnetic fields increases interleukin-1 and interleukin-6 by human peripheral blood mononuclear cells. Exp Cell Res 204 (2): 385-7.R. Sandyk, "Alzheimer's Disease: Improvement of Visual Memory and Visuoconstructive Performance Treatment with Picotesla Range

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Anti-Ageing: IGF-II, Human Growth Hormone, Stem Cell Growth, Inflammation, Osteoarthritis, Osteonecrosis, Osteoporosis, Immune System, Cognitive Decline:


Paul LowePaul, MA Oxon, ITEC Dip, MBCMA, is an English energy therapist with extensive experience and training in several types

of Pulsed Magnetic Field, Scenar, Low Level Laser and other modalities. Paul began with the subtle energy therapies, Chi Gung and Reiki, before moving into technology-based therapies.

Informa Healthcare USA, Inc. ISSN: 1536-8378 print / 1536-8386 online DOI: 10.3109/15368378.2011.624662Carmody, S., Wu, X.L., Lin, H., Blank, M., Skopicki, H., and Goodman, R. 2000. Cytoprotection by Electromagnetic Field-Induced hsp70: A Model for Clinical Application. Journal of Cellular Biochemistry 79:453-459.Blank M, Goodman R (2011) DNA is a fractal antenna in electromagnetic fields (EMF). Internat. J. Radiation Biol 87: 409-15.Cohen, M., Behrenbruch, C., Cosic, I.,: Shared Frequency Components Between Schumann Resonances, EEG Spectra and Acupuncture Meridian Transfer Functions, Acupuncture and Electrotherapeutic Res., Vol 1: 92-93, 1998.

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in PC12 rat pheochromocytoma cells. Bioelectromagnetics, 26 (5): 406-11 Lednev, V., Malyshev, SL. (2001): Effects of Weak Combined Magnetic Fields on Actin-Activated ATPase Activity of Skeletalmyosin. Abstract Collection of the Bioelctromagnetics Society Annual Meeting, St.Paul, Mn, p 3-4.

McKay, JC., Thomas, AW., 2007. A Literature Review: The Effects of Magnetic Field Exposure on Blood Flow and Blood Vessels in the Microvasculature, Bioelectromagnetics 28: 81-98. Woldanska-Okonska, M., Czernicki, j=J., (2003): Influence of Pulsating Magnetic Fields Used in Magnet Therapy and Magnet Stimulation on Cortisol Secretions in Humans. Med Pr 54 (1) : 29-32.Cohen, S., Janicki-Deverts, D., Doyle, WJ., et al (2011): Chronic Stress, Glucocorticoid Receptor Resistance, Inflammation and Disease Risk, Proceedings of the National Academy of Sciences

Blank M, Goodman R (2012) Electromagnetic Fields and Health: DNA-based Dosimetry. Electromagnetic Biology and Medicine. Early Online: 1–7, 2011 Copyright Q

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Nitric Oxide and Arterial Flow, Stress and Cortisol, Inflammation and Disease:

Cell Membrane Effects, Hsp70 Protection, Natural Frequencies:


He has trained under several world leaders in these fields, and now provides international training and support to others. He runs the Life Mat company, supplying PEMF systems, and has therapy practices in Sussex, and on Harley Street, London. Email: [email protected].

Should Neck Function Play a Bigger Role in Elite Sports?

Elite sports performance has been subject to massive investment and research effort over the past decade. This has led to leaner, faster, stronger athlete performance in a wide range of sporting activities. However, the emphasis on performance appears to have focused on the speed, endurance and strength aspects primarily. Alongside this, there has been a growing awareness of the less noticeable factors which can have, on occasion, profound if not career ending consequences. Some of these are simply related to chronic stress produced by continual performance (physiological or psychological demands), whether on the field or in the gym. Sport science is now generating many assessments of immune function which can reveal subtle changes building in the background and therefore indicating when an athlete needs a break. However, there are still areas which have not been identified and where there needs to be either investigation or simply recognition of potential, if not actual, problems. These areas which need to be considered are ones which attention may be distracted away from by the sport itself, such as in rugby union, American football and ice hockey; where injury to the neck/cervical spine is only considered when

there is a noticeable or catastrophic injury. Recognition of serious injury potential has of course led to rule changes, which although they do not completely stop the problem, can significantly reduce it. The lesser problems associated with accumulated minor trauma to this region are, as a consequence, ignored; simply as a consequence of them being chronically accumulated and less traumatic in nature. So what sort of injury does this relate to and what can be done about it? Our research first looked for differences in elite sportsmen who played rugby union. Although we first considered that strength might be an important factor to assess, we soon realised that these men were all strong and changes would not necessarily be consistent across players. It was then that we fell back on a simple clinical tool, functional range of motion. There is ample evidence from x-ray studies that rugby union player’s necks are adversely affected by years of collisions. These studies show wide ranging changes indicative of Osteoarthritis, including Osteophytic change. We decided to try cervical Range of Motion (ROM); the tools we could use were for Goniometers: a reliable one for the neck being the Cervical Range of Motion Device (CROM). Our first foray in this area

indicated that there were measureable differences which relate to time in the game as well as position of play. The more we studied these groups of players, the more we realised that the changes were consistent across the players and in gross terms positions of play- be it at the club, premiership league or international level. We then wanted to determine if there were additional changes noticeable over a single game; we were helped by Bath Rugby and Northampton Saints. The data from this study showed nicely and expectedly, that players tightened up in their neck and shoulder the day after playing. We then became interested in the idea of determining how much change occurred over a season. We made the assumption based on the earlier work that the tightness after a game would be worked on and released prior to the next one. However, over a season there would be residual change, which led to the initial finding of age related reduction in active cervical ROM. This is in fact what we found. Even leaving a reasonable period after the last game of the season, but catching the players before they dispersed, we were able to show depreciation in active cervical ROM across the season. Of course, the recovery from a competitive playing season’s activity is what the off-season is all about! This is why we decided to go back to the clubs after the off season and reassess the neck function of the players. As always, there were players who stayed and those who had changed clubs causing us some hassle, but this is to be expected when working with elite teams and after all they were allowing us to access their players for which we are grateful (treat this as a symbiotic relationship and it works best). Following the re-measurement it became obvious that some recovery had occurred and players had reversed the changes accumulated over the season, to some degree. This is where it became interesting and sounded alarm bells; the changes we thought we had seen did not prove to be statistically significant, at a push it could be described as a trend (what some researchers say when the result they wanted was just not clean enough to become statistically significant). However, when we had used this number of subjects previously we had

Acute, Chronic & Sport Injuries


found significant changes. This meant that although the reversal might have started, for whatever reason, the players had not completely returned to their previous level of neck function; measured just before the seasons play had started in earnest. This left a number of conclusions and testable hypotheses. Change occurs but only incomplete restoration of function follows. This could be because of education and circumstance: players do not recognise the problem and physios/manual therapists (MTs) are often too overworked or otherwise forced to address the serious acute trauma; so, relegate the chronic minor stuff to the “on a good day” pile. We have anecdote to support this, with such as this paraphrased quote from a major club MT “we take guys who have just been in a train wreck, patch them up just in time for another train wreck”. Our next approach was to determine whether similar changes occurred in the elite women’s Rugby Union game. In a preliminary study of matched Rugby Union and Touch players, we found a significant difference between the groups. Both groups were matched for both age and the number of years of playing. The women Rugby Union players were significantly heavier, but not taller than the women Rugby Touch players. There was a significant difference between the two codes in relation to the player’s neck active cervical ROM. The significance being in that the touch group had a better active cervical ROM than the non-rugby playing controls we had been using (physically active people who trained for non-contact sports), whereas the rugby union group were sufficiently worse that the controls to be comparable to their male counterparts; more importantly also comparable to the geriatric/ whiplash patient profile.

An increase active cervical ROM is not necessarily a bad thing. There is a misconception that increased movement in the neck specifically means laxity and could lead to further injury. When found in contact rugby, this concept needs to be actively discouraged because if you cannot move your head and neck, how can you see where a ball is going to or coming from, or more importantly which direction a large bulk of muscle (other player) is going to hit

you from? There are other more pressing reasons why straining to look to the side is bad, namely neurological ones. We all talk about proprioception, but what does this mean and how can an athlete benefit (or vice versa) from awareness of this issue? In addition, there are reflex muscle facilitation and inhibition that are engaged when you look to the side; these are in direct proportion to the force needed to move your head into position. Generally, if



Lark S, McCarthy PW (2010) Active cervical range of motion recovery following the rugby off-season. Journal of Sports Medicine and Phys Fitness. 50(3):318-25Lark S., McCarthy P.W. (2007): Cervical Range of Motion and Proprioception in Rugby Players versus Non-Rugby Players, Journal of Sports Science 25(8):887-94.Lark SD, McCarthy PW (2009) The effects of a single game of rugby on active cervical range of motion. Journal of Sports Science 27(5):491-7.Lark SD, McCarthy PW (2010) The effects of a rugby playing season on cervical range of motion. Journal of Sports Science 28(6):649-55.Capuano-Pucci, D., Rheault, W., Aukai, J., Bracke, M., Day, R., & Pastrick, M. (1991). Intratester and intertester reliability of the cervical range of motion device. Archives of Physical Medicine and Rehabilitation, 72, 338 – 340Chen, J., Solinger, A.B., Poncet, J.F., Lantz, C.A. (1999) Meta-Analysis of Normative Cervical Motion. Spine 24(15): 1571-1578Reynolds, J., Marsh, D., Koller, H., Zenenr, J., Bannister, G., (2009) Cervical range of motion in relation to neck dimension. European spine journal. 18: 863- 868.Trott, P. H., Pearcy, M. J., Ruston, S. A., Fulton, I., & Brien, C. (1996). Three-dimensional analysis of active cervical motion: The effect of age and gender. Clinical Biomechanics 11: 201 – 206.Youdas, J.W., Garrett, T.R., Suman, V.J., Bogard, C.L., Carey, J.R., Hallman, H.O., Carey, J.R. (1992) Nomal Range of Motion of the Cervical Spine: An Initial Goniometric Study. Physical Therapy 72:770-780

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References

Prof. Peter McCarthy BSc, PhD, FBCA FCC FEAC MCPPPeter trained at Universities of

Manchester (BSc Jt Hons), St Andrews (PhD) and Bristol. He has been involved in chiropractic education since 1989 (AECC, then WIOC), playing an integral part in development of chiropractic education into today’s undergraduate (professional) Masters. He lectures in basic and clinical sciences and research as well as coordinating the research for the Division of Clinical Diagnostics/Clinical School and is Head of the Clinical Technology and Diagnostics Research Unit. He has published over 50 peer-reviewed articles containing original data and is on the editorial board of JACM and Clin Chiro. Email: [email protected]

you look to the side you end up running in circles! The more effort you put into turning your head, the more obvious the move to the side. It is this type of Neurological quirk that might underpin simple sporting anecdote and advice; such as, this to 100 metre runners, "keep looking forward, run to the line and ignore runners at the side of you". The issue of appreciating the role that Neurophysiological reflexes play in performance cause one to consider whether power, strength and speed are more important than finesse and flexibility? Would a ballet dancer be as graceful without the delicate balance of both the strength and the co-ordination? Within sports performance this issue needs to be raised more often, at times it can appear that the emphasis is on the strength and not on the finesse or more subtle aspects of performance. In the highly visible spectator sports, such as rugby and football, it is often very noticeable when a "strong" team faces a more coordinated team; good examples are the different approaches to play chosen by the Northern and Southern Hemisphere rugby teams. There is however one group of athletes who have to master both the skillful elements and have strength; namely

those who play Touch Rugby. Never heard of them? There is a greater appreciation of the benefits playing Touch Rugby can have if started early and played for longer. The importance is not being lost on those in the Northern Hemisphere, as this game can develop appreciation of co-ordination, balance and the more precision based fluidity that is often associated with the Southern Hemisphere clubs. This recognition is simply acknowledgment of the importance of those Neurophysiological mechanisms that have for so long been de-emphasised in the curricula and general education of sport scientists. MTs of any denomination have the training to recognise the role and importance of the nervous systems idiosyncrasies, but often do not have much opportunity to influence its fine tuning. However, the next time you consider this aspect look for names like Quade Cooper, Sonny-Bill Williams, Benji Marshall; all of these phenomenal ball players were raised playing the sport of Touch (Touch Football or Touch Rugby depending on a Hemisphere). These are exceptional athletes that ooze confidence, strength speed and especially finesse.



Foot Function, Functional Orthoses, and Proximal Musculoskeletal Pathology Functional foot Orthoses (FFO’s) are ubiquitous in modern healthcare, being used to manage a range of symptoms across a variety of patient groups. Their use is based on the premise that the foot makes an important contribution to gait performance; pathology may result if this contribution is compromised. The subtalar joint is central to this contribution due to its functional interdependency with the proximal skeletal chain. This paper considers the contribution of the foot and subtalar joint to normal gait performance, reviewing its functional interdependence with the lower limb and its influence on the mechanical integrity of the foot. Looking at the emphasis on the torque conversion mechanism of the rearfoot, the importance of neuromusculoskeletal normalcy is introduced to underpin discussion of the origin and nature of foot dysfunction. This suggests a plausible biological pathway by which proximal musculoskeletal symptoms may be associated with foot dysfunction, highlighting the potential role of functional foot Orthoses in the management of a range of symptoms.

Functional foot Orthoses (FFO’s) appear in a range of forms; from simple devices manufactured chair-side by applying pads and wedges, to flat or minimally contoured insoles, to prefabricated devices. They may be similarly customised and full custom devices manufactured to casts or using CAD/CAM techniques (Black & Mathieson 2010) and regardless of design or manufacturing process, their goal is to influence foot function to help manage symptoms in a range of locations both within the foot, and in the proximal skeletal chain. This is generally achieved by influencing the subtalar joint, which is functionally linked with both the mechanical integrity of the foot and the proximal skeletal chain. The central role of the subtalar joint means that any discussion of the role of functional foot Orthoses must consider 2 key issues:

This discussion will consider these issues to provide insight to the role that functional Orthoses may have in the management of a diverse range of pathologies.

The nature of the subtalar joint, with emphasis on its contribution to normal gait function and its interdependency with the proximal and distal skeletal chain; The origin, nature and effects of dysfunction.

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The Subtalar Joint The subtalar joint can only be understood in the context of the gait cycle, which is asserted as the entire basis for understanding the process of human walking (Gamble & Rose 2010). Comprised of alternating periods of stance and swing, Inman, Ralston & Todd (1981) suggest that a series of Determinants of Gait (table 1), first proposed by Saunders

confirmation of this functional relationship was provided by Rose (1962); who demonstrated via a rod embedded in the tibia, how internal and external limb rotation are associated with pronation and supination (figure 2). This mechanism provides a clear anatomical link between the proximal limb and subtalar joint function, and is an important mechanism by which rearfoot function may be associated with proximal pathology.

Fig 1: The subtalar joint axis & resulting torque conversion mechanismThe mitred hinge (figure 1b; right), oriented at 45º between transverse and frontal planes, approximates the average orientation of the subtalar joint axis (left, figure 1b), 42º inclined from the transverse plane and 16º medially deviated from the sagittal plane. This forms a functional coupling mechanism whereby internal and external limb rotations are interdependent with pronation and supination respectively. Diagram courtesy of Dr. Sarah Curran

Table 1: The ‘Determinants of Gait’ (Saunders, Inman & Eberhart 1953) This series of motions is suggested to be vital to the development of an energy efficient gait, through the control of the excursion of the centre of mass. Pelvic rotation results in internal and external limb rotations that are resolved at the hindfoot through the subtalar joint, via the torque conversion mechanism.

et al (1953) and including pelvic rotation, are responsible for enhancing energy conservation by minimising the vertical excursion of the centre of mass. This pelvic rotation is transferred into transverse plane femoral and tibio-fibular rotation. During swing the segments of the limb are free in space and therefore these rotations can occur without restriction. They can only occur during stance, when the foot is fixed to the floor, if there is some mechanism available for absorbing transverse motion. Whilst the ankle is capable of absorbing some motion, the subtalar joint is the structure that is principally involved (Inman, Ralston & Todd 1981). Although the validity of the determinants of gait is debated as alternative models of gait function such as the inverted pendulum emerge (Childress & Gard 2010), the role of the subtalar joint is established and accepted. Describing it as ‘crucial in most activities involving the lower extremity’ Close, Inman, Poor et al (1967); attribute the functional importance to the joint axis, which at approximately 42º inclined from the transverse plane and 16º medially deviated from the sagittal plane (figure 1a). This allows it to act as a torque convertor (figure 1b). In-vivo

Fig 2: Tibial rotation and subtalar joint motionA recreation of Rose (1962), albeit with the tibial pointer attached externally and not embedded in the tibia. Pronated (top) relaxed stance (centre) and supinated (bottom) rearfoot positions are associated with clear changes in tibial alignment.



Table 2: The Criteria for Normalcy: The development of Root et al’s criteria to more fully encompass neurological and muscular factors.

Figure 4a & 4b: Ankle EquinusIllustration of tight posterior muscles resulting in early heel lift. With the opposite limb not prepared for weight transfer, the heel lifts off the ground early (4a) and the subtalar joint is driven into pronation which unlocks the midtarsal joint which the forward motion of the centre of mass exploits to access the dorsiflexion required for forward progression (4b).

The Subtalar Joint & Gait FunctionDuring the gait cycle, a series of functional demands are encountered that are satisfied by the synchronous, closely controlled motion of numerous joints (Perry & Burnfield 2010). During the contact phase the requirement is for weight transfer and shock absorption, in mid-stance the requirement is for a stable supporting platform in varying terrain, and in propulsion stability is important for efficient leverage. Whilst these functional demands are satisfied via important mechanisms occurring in the proximal limb - for example, the knee flexion in contact to absorb impact forces - the subtalar joint also plays a key role. During the contact phase subtalar joint pronation, initiated via the normal heelstrike position on the posterior-lateral aspect of the calcaneus, couples with various mechanisms including: ankle plantarflexion, internal tibial rotation and knee flexion to decelerate the limb and control impact forces. By the end of stance the subtalar joint is in a pronated position, which increases pedal mobility to permit stable ground contact and finally, there is a reduction in the extent of pronation, as the subtalar joint supinates to increase stability for efficient propulsion. Subtalar joint motion is therefore important for normal lower limb performance in gait for the functional demands to be satisfied, influences the mechanical stability of the foot, and forms a functional couple with the proximal skeletal chain.

The Origin and Nature of Subtalar joint dysfunctionThe subtalar joint, functioning in synchrony with the lower limb, is central to normal gait function. Optimal contribution depends, however, on neuromusculoskeletal normalcy: normal skeletal alignment and function, muscle strength, flexibility and balance, and neurological control system. This concept was introduced by Root, Orien & Weed (1977) who theorised on the role of skeletal mal-alignments, and was updated by Astrom & Arvidson (1995) who re-interpreted Root et al’s criteria in a more flexible manner following examination of 50 subjects. Michaud (1997) then more fully embraced the concept of neuromusculoskeletal normalcy. Details of these different iterations of the criteria for normalcy are provided in table 2.The logical extension of these criteria is that a failure to satisfy them may result in dysfunction. This can be demonstrated by considering the examples of a skeletal mal-alignment, tibial varum, and a muscular factor, reduced

ankle dorsiflexion due to tight gastroc-soleus muscles.

Tibial varum refers to a situation in which the tibia is inverted to the vertical. As a result, it is presented to the ground at initial contact in an excessively inverted position. To attain a position of stable equilibrium it will pronate to come into contact with the supporting surface (Figure 3a & 3b). Reduced ankle dorsiflexion (ankle equinus) compromises the ability of the foot to maintain stable ground contact during the midstance phase. A tight gastroc-soleus complex inhibits the normal forward motion of the tibia during midstance, resulting in an early heel lift. Since the opposite limb is still in swing and weight transfer is not possible, the continued forward motion of the centre of mass of the body induces pronation which increases flexibility in the midfoot, to access midtarsal joint dorsiflexion for continued forward motion.

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Figures 3a & 3b: Tibial varumThe picture on the left illustrates the excessively inverted rearfoot contact position, which results in excessive pronation due to the requirement to find a stable weightbearing position.

The Effects of Subtalar joint dysfunctionThe result of these neuromusculoskeletal anomalies is that excess pronation occurs to allow a stable position of equilibrium to be achieved. However, this excess pronation will influence load transfer distally through the joints of the foot to result in a range of pathologies, predominantly related to abnormal load transmission through joints (e.g. hallux valgus, hallux limitus) but also related to the functional hypermobility (i.e. lack of dynamic stabilisation) that occurs due to the persisting pedal flexibility that occurs with excessive pronation. Since



subtalar joint pronation is coupled with internal rotation, however, there may also be proximal effects. Internal tibial rotation, unlocking and flexion of the knee, and internal rotation of the femur may also occur, although the extent of transfer of these motions up the chain is variable (Nester 2000). This will modify tissue loading, which may contribute to the development of pathology. To explore this relationship, Curran et al (2010) investigated the influence of foot posture on knee alignment by recruiting a group of 335 subjects, dividing them into pronated, neutral and supinated foot posture groups using the Foot Posture Index (Redmond et al 2006), and assessing the differences in Q angle, tibifemoral joint angle, and modified A angle. Results identified a strong relationship, suggesting that there is a clear association between foot posture and lower limb alignment (Table 3 / Figures 5a & 5b). Extension of this concept suggests that

Table 3: Curran et al (2010). The relationship between foot posture and knee alignment based on assessment of 335 subjects. SEM = standard error of measurement

Figures 5a & 5b: Foot posture and knee alignment: An illustration of the concept. The supinated (5a, left) and pronated foot (5b, right) is associated with distinct knee alignment profiles.

joint pathology may be influenced using foot orthoses, and indeed the concept is used to support the use of laterally wedged orthoses in the management of medial knee joint osteoarthritis: It is estimated that the medial tibiofemoral joint carries approximately 71-91% of total joint load, and that this can rise to 100% in diseased joints due to joint space narrowing (Maly et al 2002). Laterally wedged orthoses have been found to improve pain, function, and quality of life in medial knee osteoarthritis (Thorgaard et al 2013), possibly by reducing peak knee adduction moment and angular impulse (Hinman et al 2012).This influence on joint alignment is accompanied by changes in soft tissue loading. Musculature designed for controlling modest amounts of subtalar pronation (e.g. tibialis anterior & posterior) or supination (e.g. fibularis longus & brevis), may become symptomatic as the excess motion increases the loads placed

on them. More proximally, knee instability associated with excess internal or external rotation will increase loading on specific soft tissues (e.g. Sartorius, tensor fascia lata & iliotibial band, popliteus, short head of biceps femoris) (Draves 1986) An alternative mechanism may be that tendons are rotated out of their primary plane of function so that there are shear / torsional stresses applied to them, for example with the Achilles or patellar tendons with excessive pronation and supination. There is tacit acknowledgement of the likely role of such stresses in, for example, the inclusion of orthoses in the management algorithm for Achilles tendinopathy (Alfredson & Cook 2007).

ConclusionSaunders et al (1953) asserted that ‘Human locomotion is a phenomenon of extraordinary complexity’. This is exemplified by the interdependency of the multiple segments of the foot and ankle, lower limb, and proximal skeletal chain and by the requirement for neuromusculoskeletal normalcy for

optimal integrated function. The torque conversion mechanism of the hindfoot, which occurs by virtue of the anatomy of the subtalar joint and its obliquely oriented axis, represents an important mechanism of interdependency between the foot and proximal structures which constitutes an important, biologically plausible, pathway by which proximal pathology may be related to foot function. Whilst there are alternative theoretical mechanisms of association – including impact forces (Nigg 2001) – the functional interdependency between foot and limb via this primary mechanism is a vital link that practitioners may exploit to assist in the management of a range of proximal pathologies.

AcknowledgementsDr. Sarah Curran for figure 1 & 5Vasyli International & Canonbury Healthcare for figures 3 & 4Fraser for figure 2




Ian MathiesonIan is senior lecturer in podiatry at Cardiff Metropolitan University. He graduated with a 1st class honours

degree in Podiatry from Queen Margaret University, Edinburgh, in 1995 and was awarded his PhD in 2005. He teaches various subjects associated with lower limb biomechanics, including Human Gait and Podiatry in Sport and Exercise, is programme director for the MSc Musculoskeletal Studies (Lower Limb), retains weekly clinic sessions and has a keen interest in evidence based practice. This interest sees him teaching research at various levels from undergraduate to postgraduate levels and supervising PhD students.Email: [email protected]

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Alfredson H, Cook J (2007) A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med 41: 211-216Astrom M, Arvidson T (1995) Alignment and joint motion in the normal foot. J Orthop Sports Phys Ther 22 pp. 216-222Black J, Mathieson I (2010) Orthoses In. Frowen P, Lorimer D, O’Donnell M, et al. Neale’s Diorders of the Foot 8th Edition Edinburgh Churchill LivingstoneClose JR, Inman VT, Poor PM, Todd FN (1967) The function of the subtalar joint. Clinical Orthopaedics and Related Research 50; pp. 159-179Childress DS, Gard SA (2010) Commentary on the six determinants of gait. In Rose J, Gamble J (2010) Human Walking 3rd Edition Baltimore Lippincott Williams & WilkinsCurran SA; Upton D; Mathieson I; Learmonth ID (2010) A cross-sectional survey to formulate clinical patellofemoral joint alignment and foot posture categories Journal of Orthopaedic and Sports Physical Therapy. 101 (3) (Suppl 2) S21 – 22Draves DJ (1986) Anatomy of the lower extremity. Baltimore Williams & WilkinsGamble JG, Rose J (2010) Human Walking: Six take-home lessons. In Rose J, Gamble JG (2010) Human Walking 3rd Edition Baltimore Lippincott Williams & Wilkins


Hinman RS, Bowles KA, Metcalf BB, Wrigley TV, Bennell KL (2012) Laterally wedged insoles for medial knee osteoarthritis: Effect on lower limb frontal plane biomechanics. Clinical Biomechanics 27(1) pp. 27-33Inman VT, Ralston H, Todd F (1981) Human Locomotion In: Rose J, Gamble JG (2010) Human Walking 3rd Edition Baltimore Lippincott Williams & WilkinsMaly M, Culham E, Costigan P (2002) Static and dynamic biomechanics of foot orthoses in people with medial compartment knee osteoarthritis. Clin Biomech 17 pp. 603-610Michaud TC (1997) Foot orthoses and other forms of conservative foot care. Newton, MassNester C (2000) The relationship between transverse plane leg rotation and transverse plane motion at the knee and hip during walking Gait Posture 12 pp. 251-256Perry J, Burnfield JM (2010) Gait analysis: normal and pathological function. 2nd Edition New Jersey SLACK Inc.Redmond AC, Crosbie J, Ouvrier RA (2006) Development and validation of a novel rating system for scoring standing foot posture : the Foot Posture Index. Clinical Biomechanics 21 (1) pp. 89-98Root ML, Orien W, Weed J (1977) Normal and abnormal biomechanics of the foot. Los Angeles Clinical Biomechanics CorporationRose GK (1962) Correction of the pronated

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foot. J Bone Joint Surg 44B (3) pp. 642-647Saunders JB, Inman VT, Eberhart HD (1953) The major determinants in normal and pathological gait. J Bone Joint Surg 35A (3) pp. 543-558Thorgaard S, Hojgaard L, Simonsen OH (2013) Customized foot insoles have a positive effect on pain, function and quality of life in patients with medial knee osteoarthritis. J Am Podiatr Medical Assoc. 103(1) 50-55

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The Potential of Biomechanical Movement Analyses in Therapy Processes Numerous clinical, therapeutical and research related questions demand the quantification and description of the human movement in its given complexity. “Can a patient move more stable after a given treatment?”, “Which muscles are used to control a daily life movement in a stroke patient?” and “How can improvements in an impaired movement behavior be monitored during the therapy process?”. These questions are only exemplary for the many clinical challenges involving the necessity of movement behavior quantification. However, this quantification is not only of paramount interest for therapists themselves in order to monitor and analyze therapy progresses; there is also an increasing request for the evaluation of therapy methods by health insurances with the background of optimizing the cost-effectiveness of therapy prescriptions.

Based upon these circumstances, the classical biomechanical task of describing and analysing the different components of the human movement has got in the focus of physiotherapy, Neuro and Orthopedic rehabilitation. The classical biomechanical movement analysis is based upon three fundamental pillars: Kinematics, Kinetics and Electromyography. Kinematics involves the description of the movement itself by analysing; for example, distances, joint-angles, velocities and accelerations. Kinetics deals with the forces and torques that are necessarily involved in movements; such as, ground reaction forces during gait or running. The third pillar is electromyography (EMG), which is used to get an insight into the muscular control and coordination of a movement by analyzing the underlying myoelectrical innervation patterns. Of course, each of the three analysis methods provides valuable information regarding a studied movement on its own. However, only the combination of the analysis methods extends the access window to the mechanism underlying a given movement. The aim and benefit of the application of biomechanical movement analyses is to get an insight into the load application and load distribution behavior of the human musculoskeletal system during posture and activity. The parameters gained from the Kinematic and Kinetic analysis, does not

only allow to determine the external loading pattern applied to the human body; therefore, enabling the investigator to estimate the internal loading behavior of the biological tissue such as bones, muscles and tendons during a given movement. Within the human body muscle forces add the highest amount of load to the structures. As muscle force application and inter-muscular coordination is mainly controlled by our central nervous system; EMG contributes to the understanding of the coordination of the main actuators of our locomotor system, the muscles. While the objective of these analyses is to get a quantified insight into the loading behavior of our Musculoskeletal system, the overall purpose is to get a reliable basis for the differentiation of movement pattern that contribute to a bio-positive adaptation of the biological system from those that contribute to a bio-negative adaptation of the biological system. Apparently, this differentiation represents the most challenging part of the investigation procedure. However, the biomechanical movement analysis provides the fundamental basis to support the interpretation of movement behavior categorization. Therefore, the outcome of such analyses is important to fields like Ergonomics in order to enable and ensure for healthy workspace conditions, fields like sports and rehabilitation, in order to optimize or re-establish the performance of the athletes and patients. Especially in the area of Orthopedics, Neuro-rehabilitation and Physiotherapy, biomechanical analyses have become an integral part of the diagnostic and therapeutic procedures. The analysis can assist to quantify, document the movement and loading behavior status of a patient throughout the complete therapy process. This is done from the initial diagnostic phase in order to support the right therapy decision; during the therapeutic treatment phase in order to monitor the therapeutic progress and until the final assessment, when the therapy intervention is completed. This is completed in order to compare the biomechanical status pre and post treatment. While supporting the therapist in the choice of the right therapy decision, it can help the therapist to discuss the therapy interventions and therapy progresses with the patient, as the data of the biomechanical analysis can be visualized and therefore be explained to the patient.

Biomechanical measurement setups do not necessarily have to be complex. In order to improve the efficiency of a therapy process, the information of a biomechanical sensor; such as EMG, and a synchronized video might help to gain useful additional information to the therapy process. Traditionally, the tools for biomechanical analyses were technically complex and only accessible to research institutes with a higher budget. Due to the technical advances in hardware/ software precise and mobile measurement systems are available in different levels of complexity. Furthermore, beyond the function of documentation and decision support, modern biomechanical analysis tools allow for a real-time representation of therapy relevant parameters, in order to implement biofeedback procedures into the therapeutic process. Biofeedback can be used to visualize a biological or biomechanical parameter that is gained from the biological system of a patient in order to reflect its changes online to the patient; for instance, by displaying a given joint angle or EMG signal of a muscle of interest. The biofeedback can then help the patient to coordinate or activate the right muscles governing a given movement at the right time. This not only helps to train or develop the patient’s self-representation, it can also contribute to an intrinsic motivation to perform a given task better from one therapy session to the other. In addition to the aspect of movement quantification, this also adds a psychological momentum to the analysis procedure. Recent analysis systems for biofeedback have become more mobile, easier to set up and can be used with mobile devices; such as, smart phones or tablet PCs. Therefore, these devices allow patients to work on the therapy progress at home and during instructional sessions at the therapist’s praxis. Figure 1 displays a biofeedback supported therapy session (with permission of Gündel & Roth, Praxis für Physiotherapie, Mainz, Germany). Together with the therapist, low back pain patients performed core muscle stabilizing exercises that were recorded with a video camera. Additionally, EMG data was detected from the Mm. Erector Spinae and Obliquus Externus. The video and the mean EMG time curve were displayed to the patients during the therapy session. As every patient showed an individual range of motion and an individual muscular activation



pattern, the exercise could be adapted to the natural movement behavior of each patient. The result of this method was a customized, efficient feedback training that increased muscular activation faster and shortened the therapy process. The therapist applied that method also to patients with knee pain, neck pain and morbus Parkinson. The training process could be individualized, improved and shortened due to the supporting application of a biomechanical measurement method. Another example of biomechanically assisted therapy and training is given in figure 2. It displays a therapy circle involving

a 2D video analysis with joint angle tracking combined with EMG that focuses on hip and knee injuries. In order to support and improve the therapy interventions the relation between knee and hip joint angles and the EMG activation behavior of the joint stabilizing muscles was determined.This procedure was performed before, during and after the therapy process to quantify the progress and efficacy of the intervention. Due to the fact that the testing procedures and movement instructions were standardized, changes in EMG temporal activation pattern could be used to get an insight into the changes of Neuromuscular adaptation as a result to the intervention. As the Neuromuscular aspect of an adaptation to a therapy intervention is normally not directly accessible to the therapist, this information helped to evaluate the therapy progress and to reflect the therapy intensity level. Still, it remains to be evaluated which biomechanical measurement setup represents the optimal access to a given clinical problem. Due to the complexity of the many factors that have an influence on the locomotion of our Musculoskeletal system; the measurement setup often demands a multi-sensory or multi-device approach in order to cover at least two of the main columns of biomechanics. The necessity of the multisensory approach that is needed for a deeper biomechanical analysis drove the manufacturers of biomechanical measurement hardware to develop systems that can fulfill this multi-sensory demand. This evolution in biomechanical measurement tools led to system solutions; although they provide a detailed insight into the complex functionality of our locomotor system, they can easily be integrated into daily clinical routines. First measurement solutions implementing

virtual reality environments in combination with a multi-sensory biomechanical feedback foreshadow the future potential of the integration of biomechanics in therapy processes. This excursion to the recent and future potential of the integration of biomechanical analyses into therapeutic procedures can easily be expanded with numerous ideas to study and disclose the functionality of the human locomotor system and its patho-mechanics. However, in face of the technical progress of analysis systems, the knowledge and intuition of the therapist and his relationship to the patient still remain the key point in the therapy process.

Figure 1: Biofeedback assisted therapy session. a) Exercise performed to activate the core stabilizing muscles b) modification of first exercise that introduced higher EMG activation of deep abdominal muscles. c) Measurement display of biofeedback tool provides online video and EMG activation information d) mean EMG activation of oblique abdominal muscles during first (test 1) and second (test 2) exercise.

Figure 2: Biomechanical assessment of posture and movement tasks with 2 channel EMG and 2D kinematical joint angle analysis a) single leg stand; analysis revealed excessive subtalar pronation with internal tibial rotation and frontal plane pelvic drop as a potential result of medial gluteus muscle insufficiency. b) squat exercise; analysis revealed domination of quadriceps muscle vs. gluteus muscle contribution in knee and hip extension phase. Hip flexion showed limited contribution to squat performance.



Christian LerschChristian is a specialist in biomechanical movement analysis and in kinesiological electromyography.He graduated with a

diploma in Sport Science and worked as research associate at the Institute of Biomechanics and Orthopedics at the German Sport University Cologne for eight years. During his PhD studies he focused on the patho-mechanics of the muscles and tendons of the lower extremity, the Achilles tendon in particular. His recent position at the Velamed GmbH involves the conception of biomechanical laboratories for gait and movement analyses. Email: [email protected]

Felix MatthaeiFelix is a specialist in the field of human factor related product development in sport and working place enviroments.

He graduated with a diploma in Sport Science and worked as research associate at the Institute of Rehabilitation and Prevention at the German Sport University Cologne for 4.5 years. During this time he has been in responsibility for the R & D lab of the Center for Health of the DSHS. Since two and a half years he is the operation manager at Velamed GmbH.Email: [email protected]

The Evolution of Engagement

Including the Human in HealthcareThe highly complex and multi-factorial traits of health status are a dynamic interplay between genome and environment; that is to say, our health is an on-going dialogue between nature and nurture. Enviromics is the formal study of factors influencing organismic systems, but to a high degree, within our increasingly post-modern societal consciousness we simply intuit the biopsychosocial model. The human organism inhabits several dimensions at least, including; biochemical, biomechanical and psychosocial. The recognition and adoption of fuller sets and depths of these dimensions within the healthcare process renders access to more complete and sustainable outcomes for the patient, practitioner and policymaker.

The Patient-Centred MovementRecent decades have seen an evolution of the values animating the therapeutic alliance between patient and practitioner. We have witnessed a movement away from authoritarian modes of relation towards the increasing realisation of a patient-centred approach. The Institute of Medicine (IOM) defines the patient-centred approach as "providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions"1. Don Berwick, formerly of the Institute of Healthcare Improvement (IHI), goes a step further to forward a more highly elaborated description: "The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in healthcare".2

Balancing the Therapeutic AllianceThis dawning confers an important shift in patient engagement and compliance. Whilst the authoritarian must enforce their prescription, the truly patient-centred practitioner operates in collaboration with the patient. Since the patient is invested in co-authoring their prescription, the issues of engagement, compliance and motivation are transformed. However, whilst the patient’s own goals and values are an important inclusion in this upgrade from authoritarian healthcare, it is the

practitioner’s responsibility to balance patient needs with their own; namely the practitioner’s need to foster patient development from reactive/symptomatic towards proactive/preventative and beyond. Simply, the patient’s own preferences and judgements may be largely incompatible with health. It is important to acknowledge that failing to engage the patient’s intrinsic developmental capacity deprives them of access to increasingly sustainable versions of health, and this becomes our most insidious and epidemic contravention of the essential Hippocratic edict.

The Reconstruction of Health Before we can begin to rethink healthcare, it is important to ensure that we are clear on what we mean by the word ‘health’, and there are at least two routes we can take here. Firstly, a brief lexicographical reconnaissance of contemporary definitions yields important insights. The Oxford English Dictionary defines health in a conventional sense as “being free from illness or injury”. Merriam Webster adds to this picture with the notion of “flourishing” as well as the dimensions of “mind, body and spirit”. The Wikimedia Foundation’s Wiktionary speaks of “wellbeing, balance and overall level of function” and alludes to a spectrum of dimensions, “from the cellular level to the social level”. However, of the definitions briefly surveyed, only the World Health Organisation (WHO) makes the final emphasis, in contrast to still-prevailing convention, that; “health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity”. This definition has remained unchanged and served as a guiding principle since the organisation’s establishment in 1948. A second approach to the meaning of health is via the etymological route, delving into the origin of words. The word ‘medicine’ derives from the Latin verb ‘medeor’, meaning to ‘heal’ or bring to ‘health’, which in turn is found in the Old English ‘hælan’ (heal), to make whole, and ‘hælþ’ (health), to be whole. Unravelling this notion of becoming whole, we find the Greek ‘holos’, to become entire, complete and to bring to full development. It is important to note, that the etymological route does not lead us to an absence of disease (Old French ‘desaise’, lacking comfort or opportunity)

or pathology (Greek ‘pathos’, suffering). It is also important to be very clear that this ‘word play’ is not an exercise in pedantry. The very orientation of our medical departments and institutions, as well as societal health consciousness, hinges upon what these words actually mean to us; the medicine that seeks an absence of symptoms looks very different to the medicine that seeks full human development. As philosopher, Ludwig Wittgenstein (1889-1951) declared, “The limits of my language are the limits of my world”.

A Developmental Model of Healthcare and Engagement.Once we adopt health as a positive developmental process, it becomes essential to establish a coherent map that can guide the upbringing toward increasingly powerful models of medicine. Maps are merely abstract representations, so the emphasis here is not on dogmatic codifications but rather on a map that is conducive, operational and judged by its consequences. A suggested framework for the comparative assessment of healthcare paradigms would be to consider the following three faces3.

Natural systems and the models that describe their development, point us toward a universal toolkit of underlying processes (such as described by Systems and Complexity-type theories). Structural commonalities of developmental models include the unidirectional transition through a series of consecutive, self-consistent paradigms or stages4. A spectrum model of healthcare and patient engagement is hereby forwarded, ascending through

Individual Level: To what degree does this medicine permit and empower the individual to not only experience fulfilment but to recognise and engage their own development? Relational Level: To what degree does this relationship fulfil the shared need of both patient and practitioner for the ample provision of effective care, education and inspiration?Institutional Level: To what degree does this healthcare system facilitate effective and sufficient access to health within financial and human resource constraints?

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Patient Compliance and Health Outcomes


five vertical stages, namely: 1-Palliative, 2-Management, 3-Curative, 4-Preventative and 5-Integral.

on the understanding that quality of life is subject to multiple influences. The management approach seeks to improve quality of life despite and in the face of on-going illness; most significantly by starting to involve patient psychology. Drug and manual therapies may be employed in conjunction with nutrition, exercise and psycho-technologies (cognitive, affective, and meditative), harnessing a variety of domains that influence the expression of symptoms and quality of life. However, though this marks the beginnings of a patient-centred model, the inclusion of the mind in the management approach is fundamentally exploitative from the perspectives of higher-order healthcare models (i.e. curative and beyond). Moderating the symptoms/expressions of disease via the mind is essentially a more sophisticated version of biochemical suppression or biomechanical dissipation. In short, as long as disease is deemed incurable, the medical relationship with the human organism is suppressive (as in palliative) or manipulative (as in management) but not truly collaborative (as in curative) or beyond.

Re-Orienting Symptomatic Behaviours In keeping with the underlying structure of development, each successive stage includes and goes beyond the power/ depth of the previous. Successive models of medicine integrate more of the total human reality. New integrations marking stage transition unlock the emergent properties of new paradigms. Whilst disease management integrates multiple palliative disciplines, as well as patient psychology, curative medicine represents the first paradigm to relinquish the imposition or maintenance of limiting/disempowering beliefs (e.g. “chronic pain is incurable”) and their supporting cognitive frameworks. Many of the psychological tools in the curative toolkit may also be found in a management approach, but their power is capped by the cognitive framework into which they are situated. Unlike, palliative care where a drug can be administered in the virtual absence of psychological engagement, the curative process involves a complete reorientation of the patient’s understanding of their disease process from “I am broken” to “disease is a dynamic behaviour”. Again, in keeping with developmental dynamics, the drive toward completeness is balanced by the need for constancy. This latter need manifests in patients as well as practitioners and policymakers as an inability or unwillingness to engage

with a higher-order paradigm, to the degree that breaches their existing model. Higher-order paradigms can appear ‘soft’, untrue, uncomfortable, and bad or even offensive from preceding perspectives. Management approaches are now popular in modern national and private healthcare organisations, but curative medicine requires a depth of engagement that remains largely prohibitive for patients, practitioners and policymakers at this time.

The Embodiment of Healthy LifestyleDespite the power of the curative paradigm and its incidental consequences, the therapeutic alliance is only formed once the individual becomes symptomatic. The curative focus remains a return to health rather than a growth towards increasing health. In contrast, preventative medicine begins to integrate medicine with lifestyle, transforming the temporal dimension with respect to patient engagement. It

Diagram Of Holarchically Nested Health Paradigms

Feeling Better or Feeling Less?Palliative care (Latin 'palliare', to cloak/mask) seeks symptomatic relief through the suppression of biological processes. Whilst, palliative care may be a valuable response to acute emergency; the goal is not to feel better but, rather to feel less. The underlying implication is that the organism is broken and disease is effectively incurable; rather disempowering in all but the shortest of terms. Relationally, the therapeutic alliance is authoritarian. The patient delegates their health to the objective professional expert. Engagement with the patient’s cognitive and emotional apparatus is economised and typically sufficient only for the overarching goal of compliance. Treating the symptoms rather than the individual, means the patient can be processed rather speedily and especially with the dispensation of pharmacotherapy. However, since treatment provides only transient symptomatic relief, the patient remains an indefinitely dependent consumer, unless recovery is allowed or facilitated. Overall, palliative care is the most expensive and least effective option as a standalone medical model.

Taking Control of DiseaseDisease and pain management operates



Institute of Medicine. "Crossing the Quality Chasm: A New Health System for the 21st Century".Berwick, Don. "What Patient-Centered Should Mean: Confessions of an Extremist".The three irreducible value spheres – 1st person/subjective, 2nd person/inter-subjective and 3rd person/objective – are found in numerous works throughout history, including those of Plato, Karl Popper, Jürgen Habermas, Immanuel Kant, Gautama Buddha, and Ken Wilber.Examples of developmental models comprising discrete consecutive stages include: Jean Piaget's theory of cognitive development; Michael Commons’ model of hierarchical complexity; Jane Loevinger’s stages of ego development; and Lawrence Kohlberg's stages of moral development.As in Abraham Maslow’s ‘Heirarchy of Needs’ with the appeasement of basic, ‘deficiency’ needs as being pre-requisite to the emergence of ‘being’ needs.See the work of Søren Ventegodt. He has nine papers archived on PubMed with “life mission” in the title. Full text is available for most of these.See “Promoting Advanced Ego Development Among Adults” by John Manners, Kevin Durkin and Andrew Nesdale in the Journal of Adult Development (2004) – full text is freely available online.See “Spiral Dynamics – A Model of Human Values Development”, by Don Beck and Christopher Cowan, based on the work of Clare W. Graves.

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References

Dr Adam Al-KashiAdam is Head of Research and Education for BackCare.Immunopharmacologist by training, and with a background in industry-

funded research. Dr Al-Kashi became increasingly aware of the limitations inherent in the palliative and management models of medicine. Once applying biochemical interventions to cells and organisms, he now designs educational interventions for patients, healthcare professionals and policymakers through his role as Head of Research for BackCare, the UK’s National Back Pain Association.Email: [email protected]

is important to point out that by far the most commonplace and visible conception of ‘preventative medicine’ is merely the addition of preventative prescriptions to the palliative and management models. Fully fledged, preventative medicine is the embodiment of an entirely new orientation and outlook on living whose instillation resembles education rather than traditional healthcare. Unlike preventative prescriptions, where ‘exercise’ and ‘healthy eating’ are advised and subject to the compliance issues of an authoritarian relationship between patient and medicine, true preventative medicine is embodied by the individual for reasons that are their own, i.e. health becomes an identity rather a coerced/incentivised subscription. Nutritional and psychophysiological practices become subject to the same category of motivational mechanisms that drive and govern an individual’s pursuit and attainment of high-level proficiency in a serious hobby about which they are passionate. The role of the practitioner is transformed from remedial to educative, ensuring the individual’s health-promoting practices are effective and fully differentiated, for example; the lay “exercise” conception may be differentiated into cardiovascular, strength, calisthenic protocols and the lay “think positive/don’t stress” conception may be differentiated into cognitive, affective and meditative protocols. Whilst the focus remains the maintenance of health, effective psychophysiological practices catalyse the individual’s exposure to the experience of health as a growth process, thereby paving the way for further stage transition and emergence.

The Primacy of Purpose Individuals who truly engage with the preventative paradigm often gravitate towards the field of ‘personal development’ as they naturally search for frameworks and communities that support their evolving outlook. However, even with healthcare and lifestyle firmly integrated, there remains at least one further integration and transition to be made. Once the individual feels that their basic needs (survival, comfort, socialisation and success) have

been largely met5, a switch occurs from a sense of deficiency to abundance driving a newly predominant need for generative expression, particularly in the context of a perceived purpose or in fulfilment of a social/world need. This marks the integration of one’s life with one’s work as the primary focus shifts from material remuneration to serving a purpose beyond personal biography – the term ‘life mission’ is apt to convey the sense of primacy that accompanies this emergence6. The role of the ‘healthcare professional’ is again transformed in a move towards increasing decentralisation of the medicine, from the authoritarian doctor to preventative educator and now to the role of the mentor who inspires growth through an embodiment of growth. Intriguingly, this stage also marks a re-orientation from the ‘comfort zone’ to its boundaries and beyond where life conditions are more challenging, but also, more conducive to further growth. Disease itself is recognised as valuable feedback and part of a conscious internal dialogue on the ‘efficacy’ of one’s life path. With sickness, health, life and work all integrated into one deeply coherent stream of personal effort and experience, this stage is termed ‘Integral’.

The Engagement of EvolutionThe fundamental premise of any developmental model is a ‘vertical’ dimension/axis along which growth through stages of increasing power is realised. It cannot be over-emphasized here that the ability to grasp and embody a given stage is a consequence of actual growth rather than of being convinced or persuaded. Just as one cannot be usefully persuaded into being a concert pianist or being fluent in a foreign language, so too can one not be persuaded into embodying a stage of development that has yet to grow within. This caveat serves two purposes: firstly, to disarm the aforementioned notion that development is a matter of opinion; and, secondly, because there are profound consequences for how we apply a developmental approach to healthcare. Understanding that stage transition cannot be persuaded into patients, practitioners or policymakers alike, there is a three-fold

Summary Table of the 5 Paradigms by the 3 Value Spheres duty: to meet them where they are, facilitate best practice at their existing stage, and foster stage transition through the design of ‘educational’ initiatives. To close on a thought-point, literature on the nature of such ‘educational’ initiatives suggests that development occurs in response to experiences that are “structurally disequilibrating, personally salient, emotionally engaging, and interpersonal”7.



The Quantified Self: Patients as Partners Through Technology

Over the next 3 months, Geoff improved significantly although full recovery was taking its time. During this time period, Geoff had recorded his pain and other symptomatology on a validated low back pain (LBP) questionnaire, that was part of the app his practitioner had given him. In addition, more extensive questionnaires were automatically e-mailed out to him at 14 and 30 days after his first treatment and he had just completed his last questionnaire at three months. He had been using the smart phone app on and off, now recording his symptoms at the end of every week as opposed to every day in the first couple of weeks after he’d seen the chiropractor. There had been a couple of times where the pain had jumped up three or four points and Geoff had been delighted when a box popped up in his app from his chiropractor. His chiropractor through the app reassured him that this was normal, that he should carry on with his exercise as instructed by the app, and another visit could quickly be arranged if needed. As it happened, the pain reduced again over the next 24 hours and slowly Geoff made progress, returning to work within the first week. Geoff really liked the way the app

Geoff’s StoryGeoff is a 46-year-old self-employed builder and has had mild bouts of low back pain off and on for the last 15 years. This particular episode started two days ago when he was lifting a toolbox out of his work van and for the first eight hours he had to resort to lying flat on his back, on the lounge floor, in order to get any relief from the pain. His wife rang the local chiropractor and was told they could be seen the following morning. On the phone, the receptionist asked whether they would be willing to receive some e-mailed questions to fill in before their first visit and some follow up time points, to which they agreed, providing them with Geoff’s e mail. With the use of Paracetamol,his wife managed to get Geoff to the clinic on the morning of the next day. Geoff told the practitioner, this was the worst possible pain he had experienced and was clearly extremely worried about how he may have seriously injured his back. The chiropractor went through the answers he had given the night before he came to the clinic, on the web based questionnaire, using them as a basis for a discussion about Geoff’s low back pain episode. The practitioner was experienced, and having ruled out any red flags, considered the following treatment plan:1. Reassurance as to the benign nature of Geoff’s pain and that progress is likely to be good2. Soft tissue and massage to free up acute muscle spasm with mobilization and manipulation

“A smart phone app?” I hear you say. What has that got to do with low back pain?Well, let’s speculate about how Geoff progressed.

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reminded him to do his core exercises every morning, although he did not always have time. He had turned the alarm off a couple of times, but had mostly kept it on as the reminders did help. The activity tracking part of the app also showed just how much progress he had made in terms of his day-to-day activities; he had set it to remind him to do a 10 min walk every day after work, although he had not always stuck to it. The accumulating feedback and the ability to compete with himself, as well as other LBP patients from the same chiropractic practice on the social forum, included with the app, had spurred him on. As a result, in addition to improvements in his LBP, which had now reduced to stiffness and some pain at the end of the day, he had also lost weight and felt fitter. He reflected that he had made the sort of progress across specific areas of his health where he had struggled to do so before. He felt he had his chiropractor to thank for this and held her in high esteem, having already recommended six of his work colleagues and associates with musculoskeletal problems to the practice. He had also raved about how modern and innovative his chiropractor had been when he had visited his GP for another reason. Indeed, so much so that the GP had asked for the practices details. An ideal take perhaps of the future of health care for musculoskeletal conditions,

but surprisingly all technically possible now. Telemedicine is a term coined to describe the use of digital media in the support of health care delivery(AHRQ 2012). Web based support and latterly, even interventions(Salisbury et al. 2009) in non-life threatening longer-term conditions have been seen as potentially impacting both outcomes and cost in a favorable direction although, there is some controversy over this assumption(Steventon et al. 2013). Mobile health (mHealth) is an approach (Klasnja & Pratt 2012a), that has emerged from the increasingly ubiquitous use of mobile technology formerly using web based sites via mobile internet access and more latterly with the rise of the app, using native apps on the mobile devices themselves. Amongst the many problems inherent in managing long term conditions and particularly those requiring ongoing patient action, the issue of compliance is a great concern; for example, medication compliance can be an issue for diabetic patients. Initial approaches using simple SMS messaging have been applied in a number of long term conditions; such as, asthma and diabetes type I with encouraging results (Vervloet et al. 2011). Indeed, a small group of us here have already shown that SMS reminders can increase compliance of low back pain patients and through the exercises given by their chiropractor. (Newell & Beyer 2012). Clearly these approaches could achieve a number of positive outcomes; including, increased likelihood of improvement, but also and perhaps more importantly, an increased sense of connection between the practitioner and the patient outside of consultation times. The extra benefit of between session contact has been shown to be well received by patients trying to self manage (Cooper et al. 2009). Furthermore, the very act of recording symptomatology has been shown to increase a sense of self control (Press 2011). The recording of patient reported outcomes during healthcare, is one of the NHS’s key strategies and happens in a systematic way far less than one might think. The enduring problem with collecting these outcomes is of course the time involved for healthcare staff to distribute, collect and analyze patient data. Giving out paper forms



designed to collect regular updates on the patients progress during care, is time consuming and highly resource intensive. To this end, a system of automatic e-mailing of relevant questions has been developed within the chiropractic profession and is being utilized by an increasing number of musculoskeletal practitioners. This software is called Care Response© (https://www.care-response.com/CareResponse/home.aspx); this system requires only the date of birth and e-mail address of the patient contacting the practitioner to be entered before the first visit. The system then e-mails a link that the patient clicks on which takes them to a website; they fill in a validated musculoskeletal patient reported outcome measure (mPROM), called the Bournemouth Questionnaire (BQ) (Newell and Bolton, 2010), along with other relevant clinical data. This automatically gets sent to a server from where the clinician can review the results and have them on the screen during the initial consultation and often helping to structure a discussion around the presenting symptomatology if needed. Subsequently, and with no more input from the clinician, the system sends out e-mail links to patients for a follow up questionnaires at 14, 30 and 90 days. All this data is available to the clinician who can track the changes in the patient’s condition, which is recorded by the patient; including, a self-assessment by patients as to their recovery status. The data collected over hundreds or thousands of patients allows an entire clinic outcome performance and characteristics to be explored and if needed, disseminated to other stakeholders, providers or health care commissioners. The involvement of the patient in these approaches can be far more inclusive, and the use of such systems may have far reaching implications for documenting the care of and experience of patients across all health care sectors. Apart from the benefits of practitioner remote contact and self-monitoring, modern smart phones also holds out potential methods to collect objective data. We have, along with the University of Ulster begun the development of monitoring gait and other ambulatory activities purely by having the phone in the patients pocket. This data is automatically uploaded to the cloud and is available for clinicians and patients (Figure 1) (Yang et al. 2012). Further developments in this area are making progress in monitoring and logging all types of daily activity (Kose et al. 2012; Siirtola & Röning 2012), which has the potential to allow both patient monitoring and behavioral change in activity levels

Figure 1: Recording, uploading and monitoring of gait activity using smartphones. Chan et al, 2013

through reminders and incentives such as gaming or linking to social media (Klasnja & Pratt 2012b). Clearly this holds huge potential in the areas of public health where encouraging increased activity across the population is somewhat of a holy grail. However, this type of e-support and patient centered use of technology may not work for everyone. In addition, little research has explored the efficacy of these approaches in robust clinical designs such as RCTs, and where this has been carried out mixed results are seen; for example, a recent report concerning the use of telemedicine for remote monitoring of hypertension and diabetes found that it did not, as hoped, reduce health care seeking (Steventon et al. 2013). However, little if any research has specifically looked at appropriate targeting of this technology, both in terms of patient groups and specific conditions. It may well be as the technology matures and becomes more robust, user friendly and inclusive, significant benefits will accrue for the patient, clinician, and the wider health care system. In conclusion innovative approaches have been created and explored using web and mobile-based techniques and these are increasingly being touted as constituting a new emerging health paradigm for the 21st century. Patients with musculoskeletal problems could substantially benefit from targeted development and deployment of one or both of these approaches in supporting patient care, especially over the longer term. So, along with the musculoskeletal toolbox of treatments and rehabilitation that may vary, we welcome websites and apps? The quantified self, as it is called may increasingly become the norm.

AHRQ, 2012. Evidence Report/Technology Assessment 206: Enabling Patient-Centered Care Through Health Information Technology.pp.1–1531.Chan H, Zheng H, Wang H, Sterritt R and Newell D (2013) Tele-monitoring and assessment of gait using Smart Mobile phone for patients with Lower Back Pain. 5th Annual Translational Medicine Conference, C-TRIC, May, ChinaCooper, K., Smith, B.H. & Hancock, E., 2009. Patients’ perceptions of self-management of chronic low back pain: evidence for enhancing patient education and support. Physiotherapy, 95(1), pp.43–50.Klasnja, P. & Pratt, W., 2012a. Healthcare in the pocket: Mapping the space of mobile-

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References

David Newell, PhD, FCC (Hon), FEAC. David obtained a PhD from Molecular Biology at University of Plymouth. His career began in 1987, teaching

at Anglo European College of Chiropractic. He moved to Australia in 1997 as Research Director in a manual therapy dept. at Macquarie University, Sydney. In 2006 he returned to the UK to teach as Senior Director at McTimoney Chiropractic College, and then at AECC as a senior lecturer in Biomedicine & Research, where he was appointed Director of Research in 2012. David has published articles in the musculoskeletal field. He is presently part of an initiative to embed clinical outcome measures in chiropractic practice using aspects of mHealth, supplying PEMF systems. Email: [email protected]

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phone health interventions. Journal of Biomedical Informatics, 45(1), pp.184–198.Klasnja, P. & Pratt, W., 2012b. Healthcare in the pocket: Mapping the space of mobile-phone health interventions. Journal of Biomedical Informatics, 45(1), pp.184–198.Kose, M., Incel, O.D. &Ersoy, C., 2012.Online Human Activity Recognition on Smart Phones.research.microsoft.com.Newell D & Bolton J 2010. Responsiveness of the Bournemouth Questionnaire in determining minimal clinically important change in subgroups of low back pain patient. Spine 35(19):1801-6Newell, D. & Beyer, R.B., 2012. Increasing compliance toward home exercise in chiropractic patients using SMS texting: A pilot study. Clinical Chiropractic, 15(3-4), pp.107–111.Press, V., 2011.Patient-centered care and its effect on outcomes in the treatment of asthma.Patient Related Outcome Measures, p.81.Salisbury, C. et al., 2009. “PhysioDirect” telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial. BMC Health Services Research, 9(1), p.136.Siirtola, P. &Röning, J., 2012. Recognizing human activities user-independently on smartphones based on accelerometer data. IJIMAI.Steventon, A. et al., 2013. Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial. Age and Ageing.Vervloet, M. et al., 2011. Improving medication adherence in diabetes type 2 patients through Real Time Medication Monitoring: a Randomised Controlled Trial to evaluate the effect of monitoring patients' medication use combined with short message service (SMS) reminders. BMC Health Services Research, 11(1), p.5.Yang, M. et al., 2012. Assessing the utility of smart mobile phones in gait pattern analysis. Health and Technology, 2(1), pp.81–88.



Small Changes in the Short Term Can Lead to Big Changes in the Long Term

Save Time...and MoneyThere has never been a more relevant time for clinics to strive for organisational excellence; through increasing efficiency, reducing costs, enhancing patient satisfaction and identifying areas for improvement. When it comes to the day to day operation of your clinic, you might think that a couple of minutes to write patient notes at the end of a treatment is sufficient, but how many patients do you see each day? Each month? Each year? How many seconds or even minutes does it take to locate patient records and treatment histories? Time saving is an aspect of our businesses that we often fail to consider. Would it not be better to spend more time talking to and treating your patients rather than writing, filing and searching for records? The simple answer is, yes. Let’s free up our time for more important aspects of business; which in reality is what keeps us going and our patients returning.

Get Rid of PaperStart with the basics. Paper based medical records have been used to record patients’ medical history since the beginning of the 19th century and they are still used today. As a patient last year, when I turned up for a hospital appointment I was shocked to see a tattered old brown folder delivered to the consultant just before my appointment.I am not a regular visitor to the doctors or hospital, but the folder must have had around 40/50 pages falling out of the sides. It does not take an expert to think that surely in the 21st century there are other ways of storing my medical information? Throughout the appointment most of the time was used by the consultant flicking through barely legible notes from other doctors. If I am perfectly honest, this experience did not fill me with hope that I was receiving the best healthcare possible and was in safe hands. Paper based records may suit an individual clinician however; problems will arise when a patient is seeing more than one medical professional:

Language can be ambiguous and handwriting illegible.

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To list a few of the many disadvantages associated with these records; the actual costs of the paper, file binders and storage units can be expensive and a medium sized clinic can have 1000s of files in storage. Practitioners can learn from this; a small investment in managing electronic medical records now can save you money in the future on storage, as well as creating the right impression with clients. Turning electronic allows patients to book their own appointments and for you to be able to check your appointments/notes from any location, at the touch of a button. In essence, you will be saving both time and money. However, it is not just a matter of ditching the paper based client records, clinicians worldwide face other problematic issues such as:

No verification or validation rules – records can be incomplete or missing important information.Bulky files are not easily copied or shared between staff.Take up a lot of space.Many clinics have 3-4 filing cabinets or even an entire room for storing patient records.Paper records are easily damaged, from wear and tear, water and fire.Paper records can only be stored one way at a time either chronologically or alphabetically.Searching through records is extremely time-consuming.Paper based records can only be viewed by one clinician at a time.

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Diary management, including patient appointments.Billing and the creation and sending of invoices.Providing better patient care.Working from multiple locations with multiple practitioners.Empowering patients through better communication.Reporting on business activity.Better communication with partners and insurers. Helping your staff, from answering calls to admin duties. Greater flexibility to work and access data from anywhere.

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In my view, practice management software is the best change to make as you can improve in all of these areas in one go. It allows you to make efficient savings resulting in greater benefits to your staff and everyone associated with your clinic.

Why change?There are a vast amount of benefits to your business by using practice management software and some of these are:Flexibility – Imagine being able to work from anywhere; whether it to be to update patient notes or checking on appointments. This kind of freedom provides you more flexibility but ultimately gives you a better work / life balance as you are not constricted to your clinic 5 days a week. An additional bonus is that the information can be used by other organisations of your choice.Organisation – By improving your clinic’s organisation, you are not only saving time for you and your employees but you are also paving the way for company growth opportunities. You may have heard the phrase ‘everything you need, all under one roof’. Well, this is the same theory as all your information is not only accessible in one place by more than one person at a time, however, it is also backs the information up so you will never lose it.Simplification – By making the move to a software programme you are taking precaution by reducing the risk of human error. This software uses digitally captured information and illustrative diagrams, for your information to be easily understood by other professionals (This could be for internal or external use).Standardisation – Sharing standards across your business gives you greater control of quality and processes.Continuous support and improvement - By using a software programme you will automatically benefit from a support team. They will provide you with regular updates in line with industry developments in your area of expertise; maybe through Ezines or social media.Customer Service – In this day and age and with the rapid growth of social media, patients expect our clinics to be up to date. They are impressed by modern technologies such as touch screen note taking, digital diagrams and it is important that our clinics

Clinical Management



Clinical Management

are up to the minute. Technologies such as touch screen techniques save time for all parties.

Sharing is Knowledge.Keeping a record of patient information, this maybe medical history or even feedback from a patient is a vital tool for your business. Fundamentally, it allows you to see clearly what your patients needs are and how you can improve your service to them. If information is collated in one space and it allows you or your colleagues to make improvements to the business by analysing emerging patterns (both clinical and business patterns). The result of this will be identifying solutions for your company. Your colleagues can also all learn from each other’s experience; which can greatly assist with reviewing cases, internal training and CPD. This diagram below

should give you more of an idea about information sharing.

What does the Future Hold?The more streamlined your clinic is, the more time you will have for your patients and generally improving your business. Small changes in the short term can lead to big changes in the long term. Whether it is changing the way you deal with billing, employee welfare or simply updating the way you manage your appointments. Another way of growing your business is through improved marketing. A lot of people just do not have the time in the day to spend thinking about strategies such as ‘brand awareness’ or ‘direct marketing’. However, with fewer resources spent on recording data through the measures I have outlined above, more time can be freed up for PR and Marketing; which are essential tools for growth.

Kyle LunnKyle is a founder and Managing Director of Blue Zinc IT Ltd who develop the TM2 range of Practice Management systems.

TM2 is a leading provider of practice and patient management systems in the UK, Ireland and Australia. A graduate in Law, Kyle moved into integration consultancy before starting Blue Zinc IT in 2003. Blue Zinc IT launched the TM2 Practice Management range in 2005 and has since introduced a number of innovations to the private rehabilitation industry. Kyle has been involved in the implementation of systems in some of the largest clinic chains in the UK. Email: [email protected]

Here are some basic tips on how best to raise awareness of your clinic:

Give your clinic a brand ‘identity’ and make sure you stand out. Your look and feel should reflect your business; be it your business card, receipts or your website, these details often account for your first impression. Create a website that is simple to navigate and has your contact details on every page and links to reciprocal healthcare professionals/partners. Photos of staff can work in your favour.Engage with social media e.g. set up a Facebook page, get your employees to sign up to LinkedIn, start a twitter page (but only if you have opinions and relevant information you want to share).Update these outlets with interesting clinic news on a weekly or monthly basis.Build up relations with your local newspaper and keep them updated with any clinic news e.g. appointments and new services offered.If budget allows, advertise your business, but do it selectively and intermittently in targeted publications. Direct marketing can be one of the most successful tools.Network; build on your contacts by attending networking events and conferences.Ensure you offer good value for money and match your price to your service.Train your staff in sales techniques. It is not just healthcare that they need to be experts in; they also need to know how to sell.Make a 3 year marketing plan with a list of outgoing costs.

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Clinical Management

Branding in a Medical Environment

Savvy complimentary health practitioners are realising the need to embrace the promotion of their brand as an investment, utilising creative design both on and off-line to maximise their exposure. In this design conscious environment we have to keep it creative says Rich With. The concept of Branding is a very popular one with businesses at present. There are dozens of agencies and firms that offer these services, whether they are Marketing Agencies who insist they have branding experience or web designers who happen to knock up the occasional logo. It is fast becoming the buzz word du jour, but what is it? Sensible companies have always employed someone to produce designs for them. The days where a son/daughter/mate down the pub produced a logo because “they're good on computers” are thankfully fading away. As designers, five years ago we were asked to produce logos; it is now becoming increasingly common for businesses to demand a wholly integral identity and complete visual solution that gives them a very powerful brand. One element that many people mistake for branding is the aforementioned logo design. While a logo does indeed make up a part of your brand, it is by no means the sum of its parts. Branding is simultaneously the way that you are seen by your audience and the way in which you wish to be seen; hopefully there is congruence. It is about thinking about building a brand rather than just a business. Smart companies will utilise creativity to promote and market their services or products using the same techniques as large firms and realising that they do not need an enormous budget to achieve it. The bottom line of expansion for any business is the development of promotion using various forms to do so. Media methods such as Newspapers, setting up a Twitter account (social media) and/ or, having a nice logo will only be a limit of its own potential. The use of a wide range of other schemes, methods and ideas will help you exceed a lot further. In my mind, a Company’s Brand consists of three main factors of increased proportions. Firstly, the ubiquitous logo, that involves the wording, font, icons and shapes that make up the integral element of any business

card. Secondly, visual identity is imperative and this is an extension of the logo, compliment slips, letterhead, websites, font groups, colours, style of photography and so on. Thirdly, the remainder of appearance of the company; your house copy style, a corporate responsibility programme and even the way in which your phones are answered. Ultimately this should convey the same brand value and message you want to portray. On onset to build, rebuild or establishing a brand, the first exercise must involve recognizing their tone of voice. We initially ask three key questions to understand what sort of brand and business they would like to build:

The gut reaction for many people reading this will be thinking “Waitrose, Volkswagen, and Virgin Airlines”. There is nothing wrong with those three brands as they are upstanding and aspirational brands to many

“If you were a supermarket, what supermarket would you be?”Now ask yourself “If you were a car, what car would you be?”And finally 3. “What Airline would you be?”

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people. However, if you had asked Richard Branson 30 years ago what airline he aspired to be, it would not have been BA. Therefore, he created a different ideal that many people feel is better, fresher and ultimately different. Waitrose did not start out wanting to be a clone of Sainsbury’s and consequently they found their own way too. At a recent business event, the same question was put to the room. While many plumped for the similar to the above answers, one chap proudly announced that he would rather be a farmers market than a supermarket; rustic, wholesome, tactile and fun. If his brand was a car he would have chosen to be a Classic Ford Mustang, with the notion of effortlessly, chic and something to pass down to his son. The final question he answered was what airline he would be. He chose Fiji Airways for the reason of being full of smiles, serving a small but knowing niche and very down to earth. The answers to all his questions involved creativity and inspiration. He did not like the rules of the game, but rather than not to play he bent them to his own game. The individual took the decision to think big, be creative, to adapt, to evolve and to change elements to his advantage.

Savvy companies are striving to create powerful brands; they dare to be different and make great use of creativity. The likes of Innocent, Cath Kidston and John Lewis all have created huge engagement with their customers by utilising inspiring creative techniques. Their tools involve their websites, brochures, e-mail marketing, TV adverts and even packaging. Their creativity creates a journey that customers will be happy to go along with, because the great use of design engages them to do so. People do not buy oven gloves from Cath Kidston because she is the only one selling them. They buy the gloves because they love the designs and adore the brand. If design can be used to entice people to buy something as mundane as oven gloves, then sales of anything can be boosted with an injection of engagement and creativity. The smart companies employ creatives who can think differently, come up with strange and wonderful tweaks to really enhance the visual look of the company. This creates something that will get them noticed much before their rivals. Large, small and medium companies can afford to do this. Complimentary health and therapy firms need to embrace their creative side quickly by coming up with intriguing ideas to promote their brand. Using a website is great, but the important factor is to have returning customers. All businesses can benefit from really boosting their creativity and design. If you operate as a chiropractor in a high street setting, then you should start by looking at your shop front. Creating a clear enticing environment and forgoes crusty frosted panels for clean dramatic lines will benefit the business in the long run. Look to create a visual identity first and not just settle for what the sign-maker happened to cut the vinyl in. Service businesses are often competing within a very crowded marketplace, so their marketing material should offer something unique. Insist on your designer to come up with some creative concepts rather than just fall back on to overused and tired stock photography. Get some inspiration from the niche that you primarily service and do not be afraid to have some fun with your ideas. There are many photographers that can be employed for reasonable rates to take images of you, your staff and the environment. They will light it properly and really start to give your website visitors a feel for what your company stands for. Outside the skills and ideas that we use to entice people to our brand, it is important to consider the media tools that convey the message through a creative way. Online media tools can be enhanced to portray individuality. Social media streams can hold branded skins for YouTube, Twitter and mini website within Facebook. Think about designing different landing pages for different offers, smartphone apps and mobile websites to maximise your brand. It is worthwhile to consider Offline Media tools, by using digital printing techniques that make short-run targeted marketing relatively affordable. Similarly, look to printing techniques of the past such as Letterpress printing and an artisan technique that uses the best in paper/ink regularly. This produces beautiful work that not only looks fabulous but has a tactile quality that does not come with regular litho or digital print. Even in hi-tech and bleeding edge businesses (such as

www.umhonline.com

Clinical Management

pharma-tech) use this printing technique and therefore it is enjoying an incredible revival.

ClarityNo matter how creative the ideas to promote your brand are, you still need to bear in mind the clarity of the promotion. You should always start any marketing campaign by identifying the market you intend to exploit. Depending on the demographics; age, sex, size and interests, will then indicate the message you should use. A campaign targeting women between 18-25 will need to use a different message from women in their fifties. Consequently the media you use to push your message, whether it be print or online, should ultimately be decided by the market and message. While it may seem like a good deal to have 2,000 flyers printed for £30, if those flyers completely by-pass the market you are aiming for, then it is obviously a waste of money.

ConsistencyIf you are thinking of producing a professionally shot video for your business then it is totally unacceptable to be handing out flimsy, badly laid out business cards that you get printed for free. Furthermore, being creative with your brand is not just a one-time exercise. Each method of communication needs to inspire your customers to keep them buying from you.

Craft inspiredAs we mentioned above, digital printing can be reasonably inexpensive for small runs but by utilising skills and techniques prevalent within the Crafting or Scrap-booking community, ordinary printed material can be transformed into something unique. I recently saw a corporate invite totally elevated by the use of small gemstones readily available from a local hobby shop. The gems cost pennies and yet the overall impact was subtle, unique and inspiring. Consequently the response rate far exceeded previous events. CreativityRecently, we have been working on a brand for a new food enterprise. We could have just put together a logo, menu and t-shirt for the staff to wear, but we knew that this was not enough. We had to create a fantastic logo, and we also thought through its application to all aspects of their brand. We were constantly thinking of creative ways to make this brand stand apart, and generate fantastic word of mouth praise. This included a simple smartphone app that orders food, to renovating old taxis in their corporate colour. The creativity

Rich With Rich is a design and branding specialist based in Essex and is geared towards making YOU look better than your competitors. He

uses creativity, humour and guile to make YOU look awesome. His focus is on the creative. He will design something wonderful and special that uses techniques and skills no one else has talked to you about. He'll make sure your website not only looks good but keeps potential clients flocking to it. He'll make your brand the best it can be, and make sure you have fun doing it too. Email: [email protected]

1. Social MediaFor all its faults social media can be an excellent way of adding to your brand experience, but here is what many people forget – it is a multi-way medium. You have to engage with followers - to offer advice, help, opinion as well as broadcasting your latest offers. Use it to engage with your clients. Chiropodists could run a “Feet of the Week” competition for fun offering a small prize – it is all about engaging emotionally with your clients and enhancing their experience of your service. 2. Stick with itIf you sell a product, then packaging costs can be expensive, so perhaps invest in the cheaper option of stickers. Stickers can be applied to boxes and bags getting your brand in the marketplace, and their versatility means they have a multitude of applications. 3. Google PlacesEnsure you are on Google Places and enhance the page with photos and images. Google has a thing for local based searches so having a good presence in your vicinity can really tap into that local market. 4. BlogA blog is well worn tool to boost your brand. By utilising the RSS feed followers are automatically updated on the latest news about your brand. iPhone and Android apps such as Instagram allow you to snap, edit and upload photography instantly to your website. If that is not for you, invest in a decent camera to take regular shots of your product, your staff or yourselves in action. It all adds to enhancing the personalisation of your business. 5. Employ a professionalI am a firm believer in getting a man (or woman) in to do a job. You would not try to represent yourself in court or build your own house and therefore, you would employ a qualified professional to do it for. If you are running your own business do not spend hours of your time trying to design a website - pay a professional. For a start they will do a better job than you will, and even if you could do it, surely your time is better spent trying to get more customers than fretting over typeface intricacies?

5 Ways to get creative on a budget


does not just stop at the design. Often by thinking differently and exploring alternatives, costs can be kept down and this maybe by utilising different paper for menus or buying a second hand black cab rather than a new van. When creating beautiful designs, the influence on how people perceive your business is dramatic. Coming up with creative ideas will make your brand aspirational and attractive to the sort of clients you want. Clients who believe in what you do are prepared to spend the money you are asking for, advocate your brand to anyone who will listen, spreading the word and encouraging other people to give you their business too.


Liquid Orthotics, a Simple Step Forward in Patient Care

Feet! Love them or loath them, they are a crucial part of the body. Yet, people are more prepared to spend more money on having their hair done or having their teeth whitened than they are on looking after their feet. Shoes are chosen for how good they look, rather than for the support they offer or the comfort that provide and then they wonder why they hurt so much. We are designed to walk around on soft ground but instead, more often than not, we tend to spend our time on hard tiled or concrete surfaces. This constant pounding takes its toll on the feet, as well as the ankles, knees, hips and lower back that has to absorb the impact. Every day an average person takes 18,000 steps, whilst sustaining thousands of pounds of pressure, all on the 26 bones in their feet. This constant compression can not only cause pain, but also discomfort, and fatigue. Over time serious disorders; such as, arthritis, heel spurs and Plantar Fasciitis can cripple many people. We are not helped by our shoes; the foot has an arch to lift and support the bones in the foot, which in turn supports the spine. Most shoes have a flat inner sole that offers no support to the arch. Therefore, our feet struggle to carry the weight that is pressing down on it as we walk. This can lead to fallen arches, which in turn puts pressure on the knees and lower back as they collapse inwards. Another ever increasing occurrence is the problem of Plantar Fasciitis, (often referred to as ‘Policeman’s Heel’) which can lead to people being forced to take several weeks off work. As the arch is not being supported by shoes; this means that much of a person’s weight falls on the heel and ball of the foot, resulting in people getting hard calloused skin. This becomes painful over time and in an attempt to relieve the pressure on these points, people move their weight to the side or front of the foot. Now they are walking out of alignment and this has additional effects of putting pressure on other parts of the body; including, the knees, hips and back or even causing shin splints.

Safety boots is a requirement in all modern industrial workplace; which can often add to the problem. Whilst, they give much needed protection to the toes, the hard metal plate often found in the base can cause severe pain to people on their feet all day, as the sole of the foot presses down on it. One company in Ireland that we spoke to recently is now facing huge problems in getting their staff to wear their boots; such is the pain that many of the workers are experiencing from having to wear them. The company tried to resolve the problem by installing pressure mats at work stations; however, people move around the factory and cannot move the mats with them. Instead, an additional added risk to the working environment has been created; mats on the floor can lead to further or other types of injuries. The obvious solution is to put an insole inside the boot to absorb some of the impact on the foot. The problem is that foam or gel insoles flatten and wear out quickly. Over time insoles can be an expensive item to constantly be replacing; many of the foam insoles are flat and give little or no support to the arch, memory foam insoles suffer from amnesia after a period of time, and on the other hand gel insoles, if the moulding does not fit the foot, can put extra pressure in the wrong places causing even more discomfort. So what other options are there? You could try liquid orthotics. New to the UK, liquid orthotics was designed over twenty years ago in America as a solution to the increasing problem of plantar fasciitis. Instead of using gel or foam the designer used a bladder containing glycerine to provide support for the foot. But why use a fluid? Well, unlike foam or gel, you cannot compress a fluid so it will not flatten when you stand on it; it simply displaces across the foot. This is because it will not compress and it does not need to be bulky; meaning, it takes up very little room in the shoe. In fact, they are so thin they can be worn in any type of shoe; even high heels. Since fluid has no shape, it moulds

to the individuals foot, which provides support to the arch; as well as, the heel and the ball of the foot. The support to the arch is phenomenal; as, anyone who remembers Archimedes and his Eureka moment will tell you, when he sat in the bath and the water poured over the side, he calculated that you displace your own weight. This means, a person’s weight

Clinical Management


pressing down on the heel and the ball, will force the fluid up under the arch, with the same pressure lifting. Therefore, the arch is supported naturally without the use of a hard orthotic. This type of support usually relieves the pain caused by Plantar Fasciitis immediately; as well as, lifting and supporting fallen arches, relieving the pain and pressure on the knees that they can cause. Through lifting and supporting the arch, the fluid helps spread the weight more evenly across the whole of the foot; relieving the pressure points on the heel, the ball and making walking a lot more comfortable. The benefit of a liquid orthotics does not stop there. When the heel comes down, the pressure is exerted on the foot; rather than, pressing against something solid, it is transferred into fluid and pushed forward. In effect, it is when the ball of the foot comes down, the fluid is there to absorb the impact and be pushed back to the heel for the next step. Rather than just cushioning the impact, the insoles act like a shock absorber in the shoe and relieve the pressure on the joints. The constant movement of pushing the

fluid backwards and forwards across the foot, gently massages the muscles. If you massage a muscle it increases circulation; bringing more blood and oxygen to the legs and feet. This helps to reduce the tiredness caused by standing or walking over long periods of time. Trials in the US on liquid orthotics showed that if used for six hours a day, the average increase in circulation to the feet and lower legs was around 53%; a significant increase if you are on your feet all day. This increased blood flow helps to prevent the build-up of rubbish in the feet which, at the end of the day, when the circulation tends to slow down can lead to the build-up of sugars for diabetics and uric crystals for people who suffer from gout. Therefore, not only are liquid orthotics a lot more comfortable, they also provide other benefits that ordinary insole cannot. How durable are liquid orthotics? The fluid is sealed in the insole using radio frequency technology; therefore, it is unlikely to leak, but they contain a fluid which is susceptible to being puncture by a nail or stone in the shoe. However, such

is their durability, most liquid orthotics come with a twelve month warranty. Before you look into expensive solutions to a simple problem, look at a simple solution which may not only solve your footwear problem, but will also help improve the health of your patients, your staff and yourself.

Chris FitzpatrickChris is a qualified teacher. He has worked in the voluntary sector for a number of years, and has gained extensive experience in

setting up charities and social enterprises. Chris got involved with Sole-mates a few years ago, after having realised the incredible potential the product has to offer supporting people working on their feet, as well as delivering increased circulation to the feet and lower legs through its unique massaging system leading to increased health of the foot. Chris is spearheading a clinical research with Birmingham University to assess the benefits of Sole-Mates in people with diabetes.Email: [email protected]

Clinical Management


Exhibitions & Conferences

COPA Practice Growth 2013 is a new and one-of-a-kind large-scale exhibition tailored to help medical practice owners run their businesses better, network and share ideas with like-minded professionals while developing professional knowledge. It is the latest addition to The Business Show 2013 which is set to attract 30,000 visitors and 810 business exhibitors to London’s ExCeL conference centre on June 6-7.COPA Practice Growth is tailored to bring people together in live debates, discussions, networking, interactive workshops, and insightful seminars. It presents a singular opportunity for healthcare professionals to obtain the latest tools, techniques and advice within the ever-changing medical profession.The main aim is to enable you and your business to grow of COPA Practice Growth is to arm Chiropractors, Osteopaths, Physiotherapists and any other rehabilitation practitioners with expert advice, guidance and inspiration from experienced, successful sources. You WILL gain the knowledge you need to propel yourself and your practice to the next level through an array of informative seminars, debates, master classes.

COPA has been masterminded by PRYSM Group, the people behind the main Business Show 2013. Tom Penn, Event Director for COPA, believes that this event is needed now more than ever: “Healthcare professionals, like any other business, need help with marketing, running and growing their business. A physiotherapist knows everything about physical ailments, but they may be less sure of how to network, expand their business or find clients. That’s where COPA comes into play.”Tom Penn said: “The show welcomes professionals from all areas of healthcare, all areas of the UK and further a field, to create a dynamic event that is truly interactive. As a learning platform, COPA is fantastic. As a show, it’s simply unmissable.”At the show there'll be a host of the latest products on the market, we have seminar presentations from Ice Health Cryotherapy who will be exhibiting the UK’s only portable cryotherapy machine; to Dr Phil Harrington on the practical uses and establishing laser therapy in a clinic.Also there will be specific and cross profession networking sessions where

practioners can build their referral base, and exchange opinions, ideas and share business challenges with other practitioners from around the country and across the therapies.As well as thousands of fellow therapists, practitioners can hear about cutting edge therapies, products and business tips from the experts such as Markus Erhard, the inventor of Myofascial Taping to Celia Champion, Director of Painless Practice; from Steve Small of IDD Therapy Spinal Decompression to Oliver Hall sharing his vast knowledge of maximising websites for business growth.3,000 of the most forward thinking practitioners will be at the Show, make sure you don’t get left behind and block out 6th 7th June in your diary, head to ExCeL and give yourself a day to really improve your own knowledge, give your business a real boost and get the opportunity to rack up some vital CPD points. It's free so there is no excuse to miss it!Free tickets are available at www.copashow.co.uk. For details about visiting or exhibiting at COPA 2013, contact Tom Penn, Event Director, on 020 8834 1594 or email: [email protected].


AECC receives seal of approval from QAA The Anglo-European College of Chiropractic (AECC) is proud to announce that it has achieved an excellent outcome from the Quality Assurance Agency for Higher Education (QAA). The QAA’s mission is to safeguard quality and standards in UK universities and colleges, and all publicly funded higher education institutions in the UK subscribe to this regular and stringent review of their quality assurance policies and processes. However, as an independent provider it is unique for the AECC to be regulated in this manner.The QAA panel concluded that the public information provided by the AECC about its higher education is current, reliable, useful and accessible to students, and that the AECC manages the first year student experience carefully and effectively. AECC’s Principal, Professor Haymo Thiel, said: “Such a positive outcome from the QAA reflects a major milestone for the AECC, proving that a relatively small and independent higher education institution can punch successfully above its weight within a very challenging sector.” Source: AECC

Statutory guidance published on Joint Strategic Needs Assessments and Joint Health and Wellbeing StrategiesThe Health and Social Care Act encourages greater integration between health and care services, so that patients and the public can receive seamless care.Health and wellbeing boards are vital to that integration – local authorities, clinical commissioning groups (CCGs), local Healthwatch, public health, social care and children’s services leaders joining together to assess what health and care services local people need and agree how they can best work together to make that happen. To support health and wellbeing boards, the Department of Health has worked with stakeholders on producing statutory guidance, which explains the duties and powers of Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWSs). The Department of Health undertook a public consultation on a draft version of the

guidance which had been developed with significant input from and engagement with stakeholders across the health and social care system. The final guidance is the result of this consultation and engagement.Source: NHS – UK

Independent Advisory Service must have the right resources and incentives to be effectiveLast week (11 April) Professor Stephen Bevan, Fit for Work Europe founding president and a director at The Work Foundation, highlighted why the Government’s proposed Independent Advisory Service for helping people with health problems return to work must do more for those with long term conditions. In an interview with Radio 4’s In Business, Professor Bevan spoke of the need for a holistic service, which uses the input of occupational clinicians. He argued that tailored support for individuals would help keep people in work long term and called for the service to take a different approach to the Work Capability Assessments. He proposed that employers and employees work together to find ways for individuals to return to work.Research by Fit for Work (FfW) UK has highlighted the immense difficulties people with musculoskeletal conditions (MSDs) face trying to remain in work. FfW UK’s recent study of 809 people diagnosed with a MSD (published in December 2012) found that three quarters of survey respondents who were retired said their condition had influenced their decision to leave the labour market. While the majority retired before reaching the age of fifty-five. The findings revealed further barriers to employment. Within three years of diagnosis, half of people with rheumatoid arthritis are registered as work disabled. Inability to stay in work may have a further spill over effect into the wellbeing and financial stability of entire households which is especially worrying as, 57.4 % of respondents who were not in work had been primary income earners before leaving their job. It was also clear from the FfW findings that work needs to be introduced into the CCG (Clinical Commissioning Groups) Outcomes Indicator Set as a clinical outcome for people with MSDs as early as possible.Source: Fitforwork-europe

Chiropractic in France to a new level, says Dr. FleuriauChiropractic is at a crossroads in France. Legalized in 2002 and regulated in 2011, our colleagues have received their license between end of 2012 and early 2013. A long journey marked with pitfalls. For more than 8 years, AFC has changed its orientation of speech and presentation of our art at all levels, administrative, public and journalistic. The orientation of our pragmatic speech has evolved with the notions of indexed scientific research and high level training, but most importantly primarily through a medical language. This means avoiding the use of jargon and the philosophical part valuable for all of us, said Jean-Philippe Pialasse on behalf of the AFC President Philippe Fleuriau who was not able to be present at the WFC meeting.Without denying them, we preferred to relegate them to the philosophical historical concept of the chiropractic art. It has served us well, since in March 2013 the Academy of medicine has published a report on the CAM. Chiropractic is brought to a whole new level compared to the last report of 2006. Indeed, and thanks to a daily determination on our part, the Academy finally defined Chiropractic as different from osteopathy (1 chiropractic college for 75 osteopathic schools –19 000 osteopaths for 700 chiropractors...). As an example, they even pointed out that our discipline could avail itself of a medical study level (Of course everybody here is aware of that, but be sure it is not as well known in the medical profession). A radical change that we welcome because this old institution remains the guarantor of the medical corporatism establishment, and keeps being completely against to CAMs and other competitorsSource: UMH Staff Writer – Jaypreet Dhillon

Physios to get prescription powers in EnglandPhysiotherapists and podiatrists in England are to get the right to prescribe medicines by themselves. Ministers agreed to the change in the law after carrying out a consultation, but it will be 2014 before it is fully rolled out.



News

When physios and podiatrists do start prescribing they will become the first in the world to be given such powers. And it will mean patients do not have to go back to GPs to get drugs such as anti-inflammatories and painkillers. 'Huge improvement' the changes have still to be approved by Parliament. But the decision by ministers to press ahead marks a significant milestone in the long-running campaign to extend prescribing powers.Over the past 10 years senior nurses have been given more responsibility for prescribing and it has long been argued that other health professionals should also get the powers too. Health minister Lord Howe said: "By introducing these changes, we aim to make the best use of their skills and allow patients to benefit from a faster and more effective service."Dr Helena Johnson, of the Chartered Society of Physiotherapy, said the move would "hugely improve" the care physios could provide. "Patients will now receive a more streamlined and efficient service, meaning they get the medicines they need more immediately," she added.Source: BBC News

New Seat of the SEE Health Network Secretariat inaugurated in the former Yugoslav Republic of MacedoniaThe new Seat of the Secretariat of the South-eastern Europe Health Network (SEEHN) was inaugurated on 7 March 2013 in Skopje, the former Yugoslav Republic of Macedonia, under the auspices of Prime Minister Nikola Gruevski.The WHO Regional Director for Europe, Zsuzsanna Jakab, who attended the inauguration, said that this is a very important step to enhance cooperation among the countries in this region in the health care sector, especially in public health and prevention. The WHO Regional Office for Europe has provided continuous political, technical, managerial and financial support to the Network since its launch in 2001.Ms Jakab also met with President Ivanov Gjorgje, Prime Minister Gruevski, Minister of Health Nikola Todorov and Foreign Minister Nikola Poposki, who expressed appreciation for the crucial role played by

the WHO Country Office in the national public health reform process.Source: UMH Staff Writer – Jaypreet Dhillon

Skopje Pledge The Skopje Pledge was a cornerstone agreement for cooperation and action on health. This was the second political document on cross-border health development in the SEE region. It was signed by the ministers of health of Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Republic of Moldova, Romania, Serbia and Montenegro and The former Yugoslav Republic of Macedonia on 27 November 2005, at their Second Health Ministers Forum with special participation of ministers of finance.

Five partner countries, Belgium, Greece, Norway, Slovenia and Switzerland, and the four partner organizations, the Council of Europe, the Council of Europe Development Bank, WHO Regional Office for Europe and the Stability Pact Secretariat, co-signed the Skopje Pledge and witnessed it. Source: WHO

CEN Technical committee on Osteopathy Standards meets in Brussels Members of the CEN (European Committee for Standardisation) Project Committee leading on the development of the European Standard on Osteopathic Healthcare Provision met for the second time on 11-12 September 2012 in Brussels. Members of FORE, the European Federation of Osteopaths and elected representatives of national standardisation bodies belong to the Project Committee. While a CEN Standard will not override national law, the purpose of it is to provide a benchmark for patients and the public on the minimum standards of osteopathic care they should expect in those European countries currently without any regulatory mechanisms. This project is expected to last up to three years. The Austrian Standards Institute is providing the national secretariat function to coordinate the development of this Standard, scheduled for publication in 2015. Source: FORE Secretariat.

Yes vote for European Standard project National member organisations of the European Committee for Standardisation (CEN) have voted in favour of creating a Project Committee to develop a European Standard for services of osteopaths. Across Europe, standards of osteopathic practice care vary, and this has created a need for greater patient protection through effective regulation and high standards of treatment. Despite regulatory mechanisms existing in Finland, France, Iceland, Malta, the Netherlands, Switzerland and the UK, along with interest shown by governments in Belgium, Ireland and Portugal, it is unlikely that osteopathy will be regulated Europe-wide in the foreseeable future. For this reason, European osteopathic organisations voted to jointly fund the development of a European Standard for services of osteopaths to protect patients and members of the profession. Although the European Standard cannot override national legislation, it will be provide a benchmark of care that patients should expect from osteopaths facing opposition in their country from other professional lobbies which oppose the creation of osteopathy as an autonomous primary care profession. This project, led and paid for by members of FORE and the European Federation of Osteopaths, kicks off in early 2012 and will last up to three years at an estimated cost of 12,000 euros a year. Source: FORE Secretariat.

Role of chiropractic in managing seizures in children with autismOver a decade ago, Pistolese presented the results of a thorough chiropractic literature review that out of the 17 papers reviewed, 15 epileptic patients out of 15 reported positive outcomes resulting from subluxation-based chiropractic care. Since his paper, several studies have been published documenting similar results. Of the various theories that have been postulated to explain the apparent effectiveness subluxation-based chiropractic has in managing seizures, Amalu's work concerning cerebral penumbra applies most readily to autistic patient suffering from seizures.Source: Natural News

Drug Delivery, Drug Packaging, Labelling & Dispensing

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Unified Manual Healthcare