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Last week we held our first Strength Training workshop. This workshop followed on from our Stretch workshop the previous week. Simon presented a comprehensive workshop full of information and practical advice. Again, it was great to see some new faces to our clinic and as always, it was lovely to see some of our current clients. A big thanks to Simon for running the event and sharing his immense knowledge and expertise. We look forward to seeing some of you again in our future workshops. Stay tuned for our bike fitness workshops coming soon.
Sport & Spinal Physiotherapy has had a long history of playing an integral part in assisting SOS Health Foundation in providing physiotherapy volunteers as well as supporting the charity financially. Our practice had been involved in 3 other health outreach missions in the past, so when the opportunity came to volunteer in North East Arnhem Land this May 2014, I grabbed the chance. As it is as always with volunteering in such situations, I gained more than I gave.
SOS Health Foundation provides allied health services to the disadvantaged in remote communities. The Foundation began in 2009 and has provided allied health services (namely physiotherapy) to the indigenous people mainly in North East Arnhem Land, Northern Territory, and on Palm Island, Queensland. As of 2014, SOS Foundation is aiming to provide missions to North East Arnhem Land every 2 months.
The team for this particular mission involved physiotherapists and non-clinician members from varied places across Australia. When describing our team, it sounds as if you were telling a joke about the patrons in a bar, but essentially we all fitted in well together and worked cohesively.
Although there were some constraints in managing such a large team and making sure we were all kept busy, SOS Manager Lynda Cunningham, did a great job in doing just that. Not only that, Lynda coordinated several sessions where we were asked to reflect on our experiences in the homelands in dealing with the indigenous Yolngu people. Although unintentional in some regards, these sessions were like personal development sessions and added to the experience as a whole.
The 8 team members were as follows:
Vanessa Alvaro – physiotherapist from Adelaide
Kane Burrow – physiotherapist from Melbourne
Lynda Cunningham – manager of SOS from Melbourne
Savio Furtado – student physiotherapist from Melbourne
Don Griffin – used car salesman from Melbourne
Craig Honeybrook – physiotherapist from Canberra
Chris Ludescher – lawyer from Melbourne
Cath Thomson – physiotherapist from Brisbane
We gathered on Sunday evening 18 May 2014 at Nhulunbuy, everyone excited about the chance to make a difference to the health of the indigenous Yolngu people on the homelands. The homelands are remote communities ranging in population from 20 to 2000 people. Most communities are very small without any shops and the housing is very basic. Some communities have a health clinic whilst others do not. Most homelands have a school but education is limited by only having a teacher 2-3 days per week.
The Yulgna people are very proud and have a strong family network. Coming to this area was an eye opener for myself in learning about the health services provided to the Yolngu people. Laynha Health, based in the nearby town of Yirrkala (about 20kms from Nhulunbuy), do a fantastic in managing the health of these people in terms of nursing and medical needs, but they are pretty much limited to just providing these services alone on a regular basis. I quickly realised that the homelands had received little to no physiotherapy services until SOS Health Foundation had come onto the scene.
On my first day and second day, I travelled with 2 medical practitioners to the communities of Dhruputjpi and Gan Gan. These homelands are about a 4 hour drive from Yirrkala and due to the distance we camped out overnight. What surprised me the most when I first arrived, was how long some injuries had been going on for. A typical conversation would go like this:
“How long have you had this injury for?” I would ask.
To which the Yolngu person in respect would reply “Long time, long time.”
I pressed for more information “When you say long time, do you mean a few weeks or a few months?”
To this I received the reply “1980!”. This literally blew me away.
Indeed, it was not unusual for some people to have musculoskeletal injuries for 20 to 30 years. If this had of been in Canberra, they would have seen 5 GPs, half a dozen physios, a couple of orthopaedic surgeons and probably a psychologist to boot, just to sort the problem out.
From my part, it was a learning experience in terms of physiotherapy in the way I managed patient care and also in the types of injuries that I treated. Some injuries I had never seen previously but had only learned from text books. This happened when I visited Birany Birany homeland on our 3rd day up in NE Arnhem Land.
Birany Birany homeland is about a 2 hour drive from Yirrkala. It is a small homeland on the Gulf coastline consisting of about 30-40 Yolngu people. They have a small school, but no health clinic. I travelled with Gerard, a nurse from Laynha Health, and Savio, the physio student from our group.
I would estimate that about 75-85% of the cases we looked at were low back pain. Nearly all these were lumbar facet joint impingements, which were quite easy to treat with some mobilisations, manipulations and massage techniques. However, there was one particular 39 year old Yolngu man called Mark that was different.
Mark complained of generalised low back pain on the left side. When I assessed Mark in standing I could tell that his alignment was all wrong. It looked to me like one leg was longer. When we continued the assessment in lying, we could see that the leg length difference was a whopping 3cm, the right leg being the short leg. Mark’s right hip also had restricted range resembling an osteoarthritic hip joint. I questioned Mark further and we established that Mark had fallen off his bicycle when he was 12 years old and had been limping around for a long time with a sore leg soon afterwards. No health worker had looked at the injury at the time.
My impression is that Mark probably sustained a slipped capital femoral epiphysis, a condition in which there is a fracture through the growth plate of the upper thigh (femur). This results in slippage of the overlying ends of the femur. This injury generally requires orthopaedic surgery to correct the problem. Unfortunately, this injury was missed at the time and has left Mark with an osteoarthritic hip and a large leg length difference. Yet he copes very well with only mild back pain. To counter the leg length difference, he bends his knee more on the longer right side. He does not experience any hip pain as yet, but I would imagine he will require a total hip replacement in time as the hip joint continues to degenerate. Mark does not wear any shoes, so it is of no use building up one shoe to correct the leg length difference. So in the end we merely just treated his lower back with some manual therapy techniques and gave him an exercise to keep his back more flexible. We organised with Gerard (nurse) for Mark to have a right hip x-ray when next he was in Nhulunbuy to at least document his osteoarthritic hip and allow one to check the progression of the degeneration into the future.
When working in the homelands, I quickly learned that I could not treat the Yolngu people the same way as I treat clients in Canberra. I guess this came down to my enthusiasm to make a difference and some assumptions I had formed about the Yolngu people.
In regards to the assumptions I had made, Lynda told a tale called “How the Monkeys saved the Fish?” that seemed pertinent:
The rainy season that year had been the strongest ever and the river had broken its banks. There were floods everywhere and the animals were all running up into the hills. The floods came so fast that many drowned except the lucky monkeys who used their proverbial agility to climb up into the treetops. They looked down on the surface of the water where the fish were swimming and gracefully jumping out of the water as if they were the only ones enjoying the devastating flood.
One of the monkeys saw the fish and shouted to his companion: “Look down, my friend, look at those poor creatures. They are going to drown. Do you see how they struggle in the water?” “Yes,” said the other monkey. “What a pity! Probably they were late in escaping to the hills because they seem to have no legs. How can we save them?” “I think we must do something. Let’s go close to the edge of the flood where the water is not deep enough to cover us, and we can help them to get out.”
So the monkeys did just that. They started catching the fish, but not without difficulty. One by one, they brought them out of the water and put them carefully on the dry land. After a short time there was a pile of fish lying on the grass motionless. One of the monkeys said, “Do you see? They were tired, but now they are just sleeping and resting. Had it not been for us, my friend, all these poor people without legs would have drowned.”
The other monkey said: “They were trying to escape from us because they could not understand our good intentions. But when they wake up they will be very grateful because we have brought them salvation.” (Traditional Tanzanian Folktale)
Since many injuries had been there so long and there had never been any physio out in the homelands, my assumptions were that they would want exercises to fix the injury particularly as we may not have physio again for some time. So I proceeded to give a few exercises with each treatment, as I do in Canberra. But I quickly realised that the number of exercises and in some cases the complexity of the exercises was frustrating some of the Yolngu people. I had to tone it down. I also started to ask if they were actually interested in an exercise that would help their pain after we had gone, some said yes and some said no. This was where my assumptions were corrected.
In essence, as more and more blue shirted SOS volunteers descend on the North East Arnhem land homelands, the Yolngu people will develop a more trusting relationship with our physios and be more accepting of our approach with exercises in helping to rehabilitate injuries.
On my fourth day, I helped with some handy-man jobs on some Mission Aviation Fellowship (MAF) houses. I felt a bit guilty here, since my wife has been pestering me for ages to do all these jobs on my own house and here I was working on someone else’s. Apparently I was not alone here as Don and Chris mentioned the same. Nonetheless, it was good to help out with MAF as they do good work up in these remote areas.
MAF are a church-based volunteer organisation spread across the globe that helps connect remote areas through aviation support. Indeed, during the wet season, aviation is sometimes the only way to reach these remote communities up in North East Arnhem Land.
In the afternoon of the fourth day, I visited Bremer Island with nurse Gerard and a medical team. This homeland was very small but set on a lovely location with ocean views. We set up a make-shift health clinic in the homeland school. Here I showed Gerard some physio techniques to continue our good work whilst SOS was away. I also met Deon, who showed me his new spear and we discussed how he made it.
On my last day, Catherine (neurological physio) and I provided an in-service to MAF pilots about safe lifting techniques and posture. Some of the physios of the group had provided physio to the MAF staff and their families during the week and in appreciation MAF put on a BBQ for our whole group. At the BBQ, I found it interesting talking to some of the MAF lads about their organisation.
On our last day, a few of us from the group also managed to duck down to the Yirrkala Arts Centre and purchase some amazing indigenous art work from the area. These are traditionally bark or log paintings.
In my downtime, I also managed to write a media release for the local Nhulunbuy newspaper “The Arafura Times”.
I would like to thank SOS Health Foundation for the opportunity to travel to North East Arnhem Land. This experience benefited myself both personally and professionally. It was lots of fun working with the team and I enjoyed getting to know the small town of Nhulunbuy and tasting its many ways of cooking Barramundi.
SOS Health Foundation are doing some great things in the homelands and I am proud to say, we are making a difference. Sport & Spinal Physiotherapy will continue to support SOS both physically and financially as our primary charity that we support as part of our charitable works program because I now know first hand how we are helping.
I believe any small business can benefit from being involved with an organisation that helps the disadvantaged in ways the business could relate to. Sport & Spinal Physio chose SOS as a health related organisation because that’s what we do, but these remote communities could use any help that any business could offer. Not only do mission volunteers gain a worthwhile experience both personally and professionally but the general public are generally interested in what one can offer up in these remote areas.
Since I have returned back to Canberra, I have recollected many times my experiences to various people of all walks of life. Australians do have empathy for the plight of the indigenous in these remote homelands and any business that contributes to helping, I believe puts that business in good standing within the community. In my opinion, people tend to trust businesses that do assist in such causes. Not only this, we have found at Sport & Spinal Physio that helping out in such programs has helped gel our team together in striving to make a significant difference to the disadvantaged.
From my own personal experiences, one always gets a personal gain from volunteering for worthwhile causes. In conclusion, I shall end this report as I began – As it is as always with volunteering, one gets more back than you give, and I can certainly vouch for that after my experience in NE Arnhem Land.
Pain at the front of the knee and under the kneecap is a frequent complaint we see at Sport & Spinal Physiotherapy in Canberra. This is commonly known as anterior knee pain. This discomfort can be due to conditions such as fat pad impingement, patellar tendinopathy (injury to the tendon under your kneecap) or more commonly Patellofemoral Pain Syndrome (PFPS). In this article we discuss this type of knee pain and how to get rid it.
The typical PFPS client presents with a history of a generalized ache at the front of the knee, placing the palm of the hand directly over the kneecap to indicate the region of pain. The pain is often aggravated by running (especially downhill), walking up or down stairs and sitting for prolonged periods with the knee bent, termed a positive “theatre sign” or “movie sign” with clients preferring to sit in the aisle seats to allow them to keep the knee straight during the performance.
The cause of PFPS is usually related to poor biomechanics. In particular, clients will have a combination of tight lateral thigh structures, poor recruitment of the inner thigh muscles (VMO or vastus medialis obliquus) and the gluteal medius muscle (the butt muscles), and excessive foot pronation (low arch or flat feet). These contributing factors combine to force a lateral translation of the kneecap leading to a stress on the surrounding structures as well as the articular cartilage underneath the kneecap.
Effective management of PFPS starts with a full physiotherapy assessment to identify the problem and outline the best course of treatment to get the client back to full training and activities as soon as possible.
The initial stage of treatment (as with most overuse injuries) is to actively control pain and inflammation – this is best achieved with a combination of ice, rest from aggravating activities, anti inflammatory medication (either prescription, over-the-counter or natural supplements) and the use of taping to reduce pressure on the injured joint. Sport & Spinal Physio has a range of natural anti-inflammatory supplements to control this inflammation, which can be particularly beneficial for those that cannot take the other forms of anti-inflammatory medication because of side effects usually related to an upset gastro-intestinal system.
It is ideal to start the rehabilitation process with a stretching program of the hamstrings, calf, ilio-tibial band (ITB) and lateral thigh structures. Stretching, taping and the use of the methods listed above to control pain and inflammartion, should mean that your symptoms are largely under control within the first one to two weeks.
Analysis of your footwear is imperative particularly if you have excessive foot pronation. In some cases, you may have the wrong type of shoes for your alignment or your shoes may simply be too old and thus no longer effective in supporting your foot structure. In either case, you will need new shoes which we can prescribe here at Sport & Spinal Physiotherapy. If you still pronate in the new shoes, then you will need to see our podiatrist for orthotics.
The next stage of the rehabilitation process is to move onto a graduated strengthening program. At the end of this period, I will encourage clients to start cycling with an emphasis on correct bike set-up and proper pedalling technique. This can help encourage activation of the VMO and gluteal muscles.
Next move to a strengthening program designed to obtain proper gluteus medius and VMO function. It is important to start with the gluteals first, because a well functioning gluteal muscle will help place your VMO muscle in a position of optimal mechanical advantage, thereby making it easier for you to strengthen this muscle when you move to this part of the program.
Hands-on work with physio in the form of deep tissue release of the ITB and mobilisation of a stiff patella is an important adjunct to the rehabilitation process for a faster result. Self-massage of the ITB in the form of rolling on one of our foam rollers can also speed things up.
If you do everything right, there is no reason why you cannot fix this problem. With the right combination of rehabilitation exercises, stretching and biomechanical correction you should be back to sport in next to no time.
If you do suffer from kneecap pain, call Sport & Spinal Physio now on 6262 4464 and we will guide you on the right path to fix the problem FAST!
Improving your core stability can vastly improve your cycling performance. Although the concept of core stability has been embraced by the majority of health professionals for some time now, it is worth pointing out its importance with different sporting and training activities. A recent study printed in the “Journal of Strength and Conditioning Research” looked at the relationship between core stability and cycling performance.
The US researchers recorded data on pedal force and hip, knee and ankle joint motion of 15 competitive cyclists during bouts on a high speed treadmill cycling. In between the treadmill cycling bouts the cyclists where taken through a 30 minute workout designed to fatigue the core stabilizers – basically the researchers where interested in the effects of CORE fatigue on cycling technique and performance.
The CORE fatigue workout involved a circuit style session of 40secs on and 20secs off with a combination of seated upper torso rotations with a medicine ball, side bends with weighted plates, standing torso rotations with pulleys (like a woodchopper) and incline sit-ups with weighted plates.
The results showed that core fatigue did affect and alter cycling mechanics – especially in regards to knee motion – in a way that may increase the risk of injury. Indeed, a particular study found that if knee excursion moved more than 2.2cm away from the midline, cyclists were 3 times more likely to experience anterior knee pain. Not only does excessive translation away from the midline predispose the cyclist to knee pain, but it will also be a less effective force production on the pedals compared to driving directly upon the pedals.This study promotes the need for improved core stability and endurance to ensure correct alignment is maintained during extended cycling sessions.
In our bike fitting assessments at Sport & Spinal Physiotherapy in Gungahlin and Canberra, we have often found that cyclists with poor core stability will have excessive pelvic rocking during the pedalling. The goal is to have sufficient core stability to have what is known as “silent hips”. This is where there is little to no movement of the pelvis during pedalling whilst maintain a neutral spine or flat back providing the cyclist an optimum platform in which to activate the gluteals and drive the pedals. The analogy we provide to Canberra cyclists to understand the concept is –“imagine running on soft sand and the higher energy output required to move forward on this unstable platform, well consider the same applies to the other end (of your leg motion) if your core is unstable. Furthermore, not only will an optimum core result in improved performance but it will also minimise the risk of injury, particularly with knee and back pain.
Although this particular study looked more so at the abdominal group, the gluteals (maximus and minimus) need to be looked at as well to make sure the cyclist is applying the optimum force to the pedals. This commonly is noted as excessive medial translation of the knee towards the top tube during long training sessions or hill work. Some cyclists even comment that their knee will actually hit the top tube.
So in summary, make sure your abdominal group, back muscles and your gluteal group are activating optimally during cycling as this will help improve performance and reduce the risk of injury. Indeed, when I was training for the 2010 World 24 hour Mountain Biking Championships in Canberra my training routine included 2-3 sessions per week of core work and gluteal strengthening. Make sure you too include some core work and gluteal strengthening into your training program.
If you have any issues with cycling in Canberra and would like to improve your cycling performance AND/OR help with any cycling related back or knee pain – CALL SPORT & SPINAL PHYSIO NOW ON 6262 4464. Our physios can help get you back on the bike FAST. A bike fitting session can also help you get the most out of your bike.