Are You Having Low Back Pain?


The lumbar spine, or low back, is a remarkably well-engineered structure of interconnecting bones, joints, nerves, ligaments, and muscles all working together to provide support, strength, and flexibility. However, this complex structure also leaves the low back susceptible to injury and pain.

The Low Back: What is causing the pain?

The low back supports the weight of the upper body and provides mobility for everyday motions such as bending and twisting. Muscles in the low back are responsible for flexing and rotating the hips while walking, as well as supporting the spinal column. Nerves in the low back supply sensation and power the muscles in the pelvis, legs, and feet.

There are 3 main types of Low Back Pain:

Mechanical/ Discogenic

This can be a cause of acute or chronic pain in the low back. By far the most common cause of lower back pain, mechanical pain (axial pain) is pain primarily from the muscles, ligaments, joints (facet joints, sacroiliac joints), or bones in and around the spine. This type of pain tends to be localized to the lower back, buttocks, and sometimes the top of the legs. It is usually influenced by loading the spine and may feel different based on motion (forward/backward/twisting), activity, standing, sitting, or resting. 

Herniating Disc Compressing on the Nerve Room

Herniating Disc Compressing on the Nerve Room

Discogenic pain is a common degenerative condition where the changes causes increase pressure on the disc.Typically, discogenic pain is associated with activities that increase the pressure within the intervertebral disc (called intradiscal pressure).

  • Sitting, bending forward, coughing and sneezing can increase low back discogenic pain.

  • Leg pain caused by pinching of the nerves in the low back may also accompany low back discogenic pain; especially while sitting, standing or walking.

  • Discogenic low back pain is usually a chronic disorder.

Radiculopathy (Sciatica)


Nerve root compression can lead to radiculopathy, causing distal pain and symptoms radiculated from the lower back. This type of pain can occur if a spinal nerve root becomes impinged or inflamed. Radicular pain may follow a nerve root pattern or dermatome down into the buttock and/or leg. Its specific sensation is sharp, electric, burning-type pain and can be associated with numbness or weakness. This syndrome and its associated symptoms are colloquially referred to as, "sciatica" and it is typically felt on only one side of the body.

Spinal Stenosis

Spinal stenosis is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck.

Screenshot 2018-05-29 17.25.48.png

Some people with spinal stenosis may not have symptoms. Others may experience pain, tingling, numbness and muscle weakness. Symptoms can worsen over time.

Spinal stenosis is most commonly caused by spinal wear-and-tear related to osteoarthritis. In severe cases of spinal stenosis, doctors may recommend surgery to create additional space for the spinal cord or nerves.

3 Quick Tips to Improve Low Back Pain 


Regular exercising can help with relieving of pain and stiffness. Here are a few exercises you can try at home:

Get on your hands and knees (four point position) with your knees and hand at hip and shoulders width apart, respectively. Your back is in neutral position (slightly arched) and your chin must be tucked in. Activate your lower abdominals (transverse abdominis) by bringing your belly button inward and by activating your pelvic floor muscles 20 to 30% of maximal contraction. Maintain steady abdominal breathing while you simultaneously lift one leg backwards and the opposite arm overhead, keeping your back in neutral position. Return to the initial position and repeat with the other leg and arm.

Get on your hands and knees (four point position) with your knees and hand at hip and shoulders width apart, respectively. Your back is in neutral position (slightly arched) and your chin must be tucked in. Activate your lower abdominals (transverse abdominis) by bringing your belly button inward and by activating your pelvic floor muscles 20 to 30% of maximal contraction. Maintain steady abdominal breathing while you simultaneously lift one leg backwards and the opposite arm overhead, keeping your back in neutral position. Return to the initial position and repeat with the other leg and arm.

Kneel in front of a chair, placing your elbows and forearms on the chair. Perform an abdominal brace and contract your pelvic floor. Maintain this braced position through the entire exercise.  As you push into the chair with your forearms, straighten one leg at a time, contracting your glutes and quads (thigh muscles). Hold this position as you keep pushing your elbows and forearms into the chair, keeping your body in a straight line.

Kneel in front of a chair, placing your elbows and forearms on the chair. Perform an abdominal brace and contract your pelvic floor. Maintain this braced position through the entire exercise.

As you push into the chair with your forearms, straighten one leg at a time, contracting your glutes and quads (thigh muscles). Hold this position as you keep pushing your elbows and forearms into the chair, keeping your body in a straight line.

Lie on your back with your knees bent. Activate your lower abdominals (transverse abdominis) by bringing your belly button inward and by activating your pelvic floor muscles 20 to 30% of maximal contraction. Maintain steady abdominal breathing while tilting your pelvis and flattening your back to the ground.

Lie on your back with your knees bent. Activate your lower abdominals (transverse abdominis) by bringing your belly button inward and by activating your pelvic floor muscles 20 to 30% of maximal contraction. Maintain steady abdominal breathing while tilting your pelvis and flattening your back to the ground.

Place one foot on a chair in front of you with your knee bent, toe pointing forward. Keep your stationary leg extended on the floor 2-3 feet back from chair. While keeping your trunk upright, move your hips forward.

Place one foot on a chair in front of you with your knee bent, toe pointing forward. Keep your stationary leg extended on the floor 2-3 feet back from chair. While keeping your trunk upright, move your hips forward.

Start on all fours with hands underneath the shoulders. Lift the head and chest simultaneously while letting the stomach sink and the lower back arch to perform the "cow" pose. Then, round the back and let the head and neck drop while aiming to get the head and pelvis as close as possible, performing the "cat" pose

Start on all fours with hands underneath the shoulders. Lift the head and chest simultaneously while letting the stomach sink and the lower back arch to perform the "cow" pose. Then, round the back and let the head and neck drop while aiming to get the head and pelvis as close as possible, performing the "cat" pose

Frequent Breaks:

Take a break every 15-20 minutes at work and do the following stretches/ exercises.

Sit down on a chair with a straight posture. Place your hands behind your head. Slowly flex the trunk by rounding the upper back then extend back over the backrest of the chair.

Sit down on a chair with a straight posture. Place your hands behind your head. Slowly flex the trunk by rounding the upper back then extend back over the backrest of the chair.

Stand on one foot and hold on to a stable object (wall, chair or table). Keeping your body as stable as possible, swing the elevated leg forward and backwards without bending the knee.

Stand on one foot and hold on to a stable object (wall, chair or table). Keeping your body as stable as possible, swing the elevated leg forward and backwards without bending the knee.


Eat an anti-inflammatory diet to decrease potential irritation of nerves, tendons and muscles. The easiest way to reduce inflammation through nutritional therapy is to remove refined sugar, dairy and gluten from diet.


Are You Having Shoulder Pain?

What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect pitch.

Photo Credit: NPS MedicineWise

Photo Credit: NPS MedicineWise

Mobility has a price, however. The complexity of the shoulder may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all of the time. The pain may be temporary or continued, requiring medical diagnosis and treatment.

The Shoulder Pain: What is Causing the Pain?

There are 3 common causes of shoulder pain:

Soft Tissue Injury - Muscles, Tendons Strain/ Tear/ Inflammation

These injuries can be both acute and chronic. Acute muscles and tendon strains and tears can happen from a sudden quick movement and causes both pain and dysfunction. Chronic inflammation in the shoulders can lead to tendinitis and bursitis, which can cause swelling in the shoulder joint and irritation with overhead movements.

Joint Capsule Injury - Shoulder Instability, Labral Tear, Joint Sprains

This is commonly an acute injury where there is an episode of shoulder dislocation or subluxation causing a stretch in the ligaments stabilizing the joint capsule. This could lead to chronic shoulder instability, and even labral tears depending on the initial trauma.

Scapulothoracic Rhythm Dysfunction - SICK 

The scapulothroacic joint is where the shoulder blade sits on the ribcage. A common dysfunction that is seen with poor posture is "scapular winging", where the scapula is not stabilized, causing the spine of the scapula to protrude visibly. This issue arises due to tight pectoralis muscles and inhibition of the middle and lower trapezius muscles in the back.



Why What You Do Today, Matters for Tomorrow

“Getting old, aging, growing older”… words that no one is fond of hearing, but we can age well if we just set our minds to it.

Studies have shown that staying active when younger has been linked to staying physically fit later in life.

For example, the Fit in 50 Years study found that men who led an active lifestyle in their youth had better physical activity at age 70 and also visited the doctor less across their entire lifespan. 


 ‘The health benefits of physical activity are widely established... There is strong evidence that regular, moderate-intensity physical activity reduces the risk of coronary heart disease and stroke, diabetes, hypertension, colon cancer and breast cancer. Moreover, research has shown that physical activity not only improves mental well-being, but also is effective treatment for clinical depression and anxiety.’

 Feeling like you are too old to start leading a more active lifestyle may be the very thing that’s holding you back. And having the growth mindset of “open to experience” can help people stay healthier and fit later in life and even defy the aging process for a long time. People who have exercised all their lives are more likely to have the immunity, muscle mass, and cholesterol profile of a younger person. 

 Dr. Nick Tsaggarelis, chiropractor and director of ONE80 Health - an integrative health clinic in Toronto, endorses leading a more active lifestyle and believes in the four pillars of health living which incorporates - sleep, nutrition, movement, and mindset.


 Dr. Nick shared, that in his line of work he sees both active and inactive patients on a daily basis and observed that those with a more active lifestyle can overcome their ailments a lot quicker and easier than those who lead a sedentary lifestyle. Dr Nick. states that every choice we make today will define how healthy we stay in the future.

 Getting Started on your Fitness Journey

 Getting started on your fitness journey is the hardest obstacle to overcome, taking that leap and making the change is the first hurdle. When embarking on a fitness journey you should first ask yourself;

 What can I commit to?

Don’t overwhelm yourself when first starting out as taking on too much can lead to feeling burnt out and a give you lack of motivation. So, start small by incorporating exercise into your everyday routine such as taking the stairs instead of the elevator or going for a walk after dinner.

 What are my limits?

Knowing your limits is an important part of every fitness journey, don’t jump straight into lifting the heaviest weight in the gym, as you will get demotivated when you A. can’t lift the weight or B. hurt yourself by lifting too heavy.

 What do I need to learn?


This is something that a lot of people overlook when they first embark on their fitness journey. Learning how to move your body and doing so with correct form is the most important thing to master when you are first starting out. This is to ensure that you most importantly don’t hurt yourself and to ensure that you are targeting the muscles that you set out to.

This is why hiring an exercise coach is a great way to help newbie’s break the ice into correct form and build strength for every day endeavours.

 Oksana Wankiewicz , registered kinesiologist and exercise coach at ONE80 Health, urges everyone new and experienced to book an appointment with her so she can help you stay injury free and work on strengthening your body for your life’s unique demands. Oksana will take you through a comprehensive consultation and work with you to ensure you can start exercising confidently and above all safely.


How to Overcome Your Cravings

How to overcome your cravings: Build habits that help you win the cravings game


Sure, we’ve all been there, it’s a late Monday night and you’re winding from your long day from work and suddenly you feel a sudden urge to munch on some crispy, salty (delicious-I can’t get enough-please give me more) potato chips. You think to yourself, “I’m watching my favourite show, maybe I’ll just have a handful” and before you know it, the bag is empty and you feel nothing but shame and regret.

Cravings win almost every time because we are bombarded by advertisements, TV shows and social interactions that drive us to want junk food. If it isn’t hard enough, the food itself is purposely made to make us want more and signal off our dopamine receptors leaving us feeling satisfied and excited while we snack. Once everything is over, we feel powerless and remorseful of our actions, so how do we win?

It’s not about restriction because that will only leave us unhappy, it’s not about strong willpower either because this usually ends with a bingeing episode and will only perpetuate the cycle.  
The best way to overcome your cravings is by understanding why, where and when they occur, this is a strategy to help you conquer the cravings game and plan ahead of time.

The first step is to find the root of your cravings by finding the trigger. We feel it way too often, there’s a sudden urge which is the craving, followed by wanting to fulfill said craving, then we reward ourselves by eating the food we wanted. Usually the “urge” is stimulated by a trigger, whether that’s the smell of a freshly baked cookie or just by seeing an image of a mouth-watering cheeseburger. Cravings are greatly influenced by external cues such as the smell, taste, place, and even the company you keep. A good practice is to find the trends to your cravings and a good way to do that is by asking these following questions:


What are you craving? Where are you? What is your emotional state? What is your physical state? (Are you lethargic, anxious, nauseous?) Who are you with? What are you doing?
This is an on-going practice, similar to a food journal and once you have it written down you’ll start to see a pattern, then can you find an action plan to prevent yourself from falling back in.

1. Approach your craving with curiosity

The first question, I’d ask myself is, “am I actually hungry?”, or am I just trying to find something to do? Does any food sound good to me right now? Or was I triggered by the cupcakes Susan from two desks down brought in to work?
Once you notice the snack urge, rather than giving in to it immediate, wait a while before “giving in”. This isn’t like willpower, this is an exercise to give yourself some time to let your body know that you are in control, you can then make a sound decision rather than making a quick irrational one.

It’s easy to feel like a failure if you decide “yes, I’m hungry and want a cupcake” but that doesn’t mean you’ve completely lost. Healthy habits, just like any habits, take time so we have to be patient with ourselves. Again, I don’t believe in deprivation and restriction, but I also don’t believe in overindulging, there is a happy medium and with these strategies, you can get there.

2. Keep yourself busy


A lot of times when we feel a craving, we submit to it immediately, but what would happen if we did something else for a little while before deciding on that craving? By removing ourselves from the mindset of “I need French fries right now” and perhaps doing another activity such as a five minute stretch, calling a friend or going for a walk, we start replacing one behaviour for a better one.
What we don’t realize is that our cravings are more often in our mind and not necessarily physical, we won’t die if we don’t have ice cream.
There are plenty of situations where we’ve kept ourselves so busy that we forget to eat, whether we’re having a lot of fun at an event or even working away at our desks, we’ve been there!

We want to keep our mind busy and avoid our triggers, so sitting down and watching a TV show, is probably not the best practice, however, doing something that keeps us busy and distracted will keep us from submitting to our cravings.


3. Stay nourished throughout the day


Without even knowing it, we might be depriving ourselves of necessary nutrients that help us conquer our cravings. Yes, everyone is different and have their own individual needs of course, but if we continue to nourish our body with the appropriate macro and micro nutrients, we may be able to win the cravings game because our bodies are feeling satisfied and fulfilled to begin with.

Through my practice, I’m hearing more often that my clients overindulge in to their guilt foods at night and a lot of times feel worse because their attempts to be healthy during the day was ruined by snacking. Just like with anything, consistency always wins, and if we try to eat well most of the time, and build a strong foundation throughout the day, we are less likely to falter in to eating poorly at night. Most people are not getting enough fibre in their diet which is not only important for gut health but also helps fills us up. Fibre is found vegetables and grains and is an important part of any diet. Making small adjustments to our diets such as including good quality protein and tons of nutritious fruits and vegetables will leave us feeling nourished and less likely to fall off track.

4. Don’t fight it


Okay so, you really need to have a treat? That’s fine, like mentioned above, I don’t endorse calorie restriction and believe that restriction is a form of stress. If you decide to indulge, make sure you’re getting good quality snack. Practice good food hygiene by eating slowly, enjoying the food, being in a comfortable space and most importantly, savouring it. You can even decide instead of buying these snacks, you can make them from scratch, and most people discover, that it’s not worth the time or effort.
A lot of times, if we start eating well and including more plant foods in to our diet, the “bad stuff” actually starts to taste bad. We’ll know what we feel when we’re eating well and we’ll know what we feel when we’re eating poorly, and sometimes, that is enough for our body to say “no”.

If you’re really struggling, a good way to start is finding a coach or a nutritionist that be your cheerleader and help guide you to making better decisions. It can be confusing to navigate diets, nutrients needs and recipes but with the help of a coach, you feel empowered to make good decisions for yourself.

Written by:

Nina Ballares HN

Holistic Nutritionist

Attacking Adult and Teenage Acne from the Inside Out

Acne vulgaris is a long-term skin disease that occurs when hair follicles are clogged with dead skin cells and oil from the skin. It is the most common dermatological issue seen by physicians. It most often effects adolescents but it is not uncommon to suffer from acne later in life.



Diet – Dairy and sugar elimination  

A 2012 study found that acne was completely absent in two populations; the first consumed a paleolithic diet with a low glycemic load, and the other, a dairy-free diet. A cellular mechanism clarified that high glycemic foods and dairy increase levels of IGF-1 and insulin, which result in inflammation and specifically, an acne-promoting effect. Therefore, a diet without dairy and high glycemic foods is an effective dietary strategy for reducing acne.



Healing the Gut

 There is a connection between our skin and gastrointestinal system. Irritable bowel syndrome (IBS) is a common disorder that effects the large intestine. Signs and symptoms include irregular bowel movements, abdominal pain, bloating, etc. IBS is a condition of increased intestinal permeability and studies have shown increased intestinal permeability in patients with acne vulgaris, which demonstrates the need for treating IBS and testing for other gastrointestinal conditions.


Vitamin A, Vitamin E, and Zinc

 Vitamin A is essential for normal differentiation of epithelial (cells) tissues in the skin and mucous membranes and has been studied as an effective therapy for acne vulgaris. Consultation with a healthcare practitioner should occur before starting vitamin A therapy, as there are various contraindications such as pregnancy, liver disease and other conditions.



A study in 2014 evaluated the serum levels of vitamins E and zinc according to the severity of acne vulgaris. They found a negative association between acne severity and vitamin E and zinc levels, supporting the use of these important nutrients in acne prevention and treatment. A 2001 study found a total pimple count decrease of 49.8% when acne patients took 30 mg of zinc gluconate for 3 months. 


Addressing Hormonal Imbalance

 Acne treatments target different steps in the pathogenesis of acne. Such as addressing hormonal imbalances and decreasing inflammation.  Clinical trials have shown that oral contraceptives can be helpful in reducing acne by decreasing levels of free testosterone.


A successful naturopathic approach to treating acne vulgaris will involve addressing the acne of the individual by getting to the root cause through establishing if it is cause by inflammation, poor gut health, hormone imbalance) using a multi-faceted, holistic approach including dietary strategies, supplementation and topical support.

The Human Lymphatic System & Deep Oscillation Therapy

Photo Credit: OpenStax College [CC BY 3.0 (]

Photo Credit: OpenStax College [CC BY 3.0 (]

Most are unfamiliar with the human lymphatic system and how important it is to optimal health and vitality. As pictured above, the lymphatic system looks analogous to the blood circulatory system and exists as a network of capillaries, vessels and nodes. The lymphatic system connects to and interacts with every organ in the body. Its two major roles are related to our body’s self defence from infection and its ability to collect, transport and recirculate interstitial fluid.

A healthy human adult is composed of about 60% water (a new born infant is about 80%). Two-thirds of this fluid is inside of our cells, the other one-third exists outside of the cells and is known as extra-cellular fluid. This extra-cellular fluid is an ocean that bathes all of the cells in our body and is so similar in composition to blood plasma because they directly exchange gases, nutrients, electrolytes and everything else at the molecular level needed to sustain life.

Photo Credit: OpenStax College [CC BY 3.0 (]

Photo Credit: OpenStax College [CC BY 3.0 (]

 The lymphatic capillaries are one-way, unlike blood capillaries, and allow interstitial fluid to come in, but not out. They collect and direct this sea of interstitial fluid and transport it along its many twisting pathways on its journey to be filtered and then rejoined with venous blood circulation as blood plasma. Filled with metabolites, proteins, ions, bacteria, white blood cells and at times cancer cells, the lymphatic system acts as a sewer system and filter for our body to flush out toxins and cellular waste.

The lymph nodes are glandular capsules along the lymph vessels that contain white blood cells known as lymphocytes. As lymphatic fluid flows through the lymph nodes, these defence cells play a major role in identifying and fighting infections in the body.

 It is important to keep this fluid dynamic in balance and flow because when things become stagnant, it can lead to various health problems in the body. Many people have badly congested lymphatic systems and don’t even know. Lymphatic congestion is involved in health problems like inflammation, infections, arthritis, skin conditions, heart disease, cellulite and many other pathological processes in the body. The key is to keep all the fluids flowing and avoid congestion to allow optimal movement of nutrients coming into the cells, and waste products to be disposed of properly.

Getting DEEP down to the innermost levels of lymphatic circulation with Deep Oscillation

Photo Credit: Physiomed;

Photo Credit: Physiomed;

Deep Oscillation Therapy is a unique therapeutic treatment that directly impacts lymphatic circulation and as a result optimises the movement and exchange of cellular nutrition and waste throughout the body. The treatment effect is produced by a pulsating electro-static wave combined with gentle sweeping movements along the lymphatic pathways. This oscillating attractive force pulls and pushes at tissues and which mechanically breaks up and decongests any lymphatic blockages. Incredibly, the therapeutic effects penetrate 8cm into the body targeting the deepest layers of lymphatic vessels and body tissues.

 This pleasant feeling therapy is so gentle that it can be used for acute injuries as well as day one post-operatively yet works just as effectively for chronic and fibrotic conditions. The three phases of treatment work to dissolute lymphatic waste, reduce muscle tone, and displace that congested lymph back into blood circulation to restore normal fluid dynamics in the body. The net effect is muscle relaxation, relief of pain and inflammation, and improved nutrition and waste removal in the body.


After receiving this therapy you can continue to keep your circulation and lymphatic system working optimally by staying hydrated, moving and exercising regularly, and applying occasional self-massage. So remember to Move often, and Move Well.

Peter Petropanagos BSc, MScPT, DAc, FCAMPT

Recommended Reading List

Nutrition and Physical Degeneration - Weston A Price, DDS


This book is the Opus Magnum on cultural diets and the effect of the Western diet on health and physical degeneration and disease. When Dr. Price's son died from a dental abscess, he was struck with the paradox of how an apparently healthy individual could get a simple treatable infection and then die. The result was his 30 years of world travel researching the diets of the Mauri, Masai, Aborigines and other secluded cultures and then comparing it to those of these cultures who had become westernized. His discoveries were profound. He uncovered a link between maternal diet and infant diseases, dental arch malformation and processed foods, tuberculosis and white bread consumption. His study of the bones and skulls from the indigenous peoples of Peru and Florida uncovered ancient groups averaging 6 feet in height with perfect dental arches an almost no cavities. For anyone with a deep interest in cultural diets and its effects on health, this is a must-read.

The End of Alzheimer’s


The First Program to Prevent and Reverse Cognitive Decline - Dale Bredesen, MD

Alzheimer’s incidence is quickly rising to the point of being an epidemic. Dr. Bredesen’s life research has focused on the intricacies of Alzheimer’s Disease. To date, he has discovered over 38 different pathways and five major classifications associated with this degenerative disease. This is the first and only work of its type and is a must read for anyone with memory issues, declining memory or a family member with Alzheimer’s Disease.

 Amazon link -

Audio -

The Toxin Solution

How Hidden Poisons in the Air, Water, Food, and Products We Use Are Destroying Our Health—AND WHAT WE CAN DO TO FIX IT Joseph Pizzorno, MD

How Hidden Poisons in the Air, Water, Food, and Products We Use Are Destroying Our Health—AND WHAT WE CAN DO TO FIX IT Joseph Pizzorno, MD

Dr. Pizzorno is best known for founding Bastyr University and writing the textbook of Natural Medicine. This book represents his most recent research project on the association between environmental toxins and chronic illness. This book is enlightening in its clear exposition of the association of entities from diabetes and autoimmune diseases to cancer and their close association with environmental toxin exposure. This is a great recommendation for anyone who is skeptical of the association between environmental toxins and human health.

Amazon -

Audible -

The Gut Balance Revolution

The gut Balance.jpg


Benefits of Orthotics

What are Orthotics?

Orthotics are inserts we use in shoes to correct the way our feet work. When deciding on orthotics you will have to make one of two decisions:

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1.   A pre-moulded insert that you can buy in a shop that is usually referred to as an insole. This version is often a one size fits all and can be bought at most footwear shops and drugstores. Its main function is for comfort therefore it cannot correct any biomechanical issues you have in walking and standing.

2.   A custom measured and fitted orthotic that is unique to your foot that solves a specific set of issues.

Why do we need them?

Orthotics do more than just raise and support arches, they also realign the ankles and feet for added support.

 Who should wear Orthotics?

Orthotics are beneficial for everyone as they are an effective way to give your feet added support no matter what activity you’re doing. Orthotics also provide benefits to people with certain foot problems and other health issues (arthritis, diabetes, muscle tightness, joint and bone pain, etc.)

Choosing between custom orthotics and off the shelf orthotics

Despite the cost people swear by the positive changes associated with custom orthotics. Including reduced back pain and hip pain.

 When should I choose an off the shelf option? Choosing an off the shelf option is optimal if you are just looking for some extra comfort or shock prevention while you walk.

If you have any other issues such as the issues, we discuss later in this article then custom orthotics is your best bet for correction of your problems.

OVER-PRONATING – What is it?

Over pronating.png

A different problem results if the arch flattens too much. This is known as a pes planus or flat foot (over-pronation). An excessively pronated foot may cause excessive internal rotation of the entire lower limb during weight-bearing and this increases demands on numerous structures. The increased force placed on the medial aspect of the foot contributes to abnormalities of the 1st MTP
joint, including hallux valgus (bunions). Interdigital (Morton's) neuromas may be caused by metatarsal hypermobility.

Over-pronation also causes flattening of the medial longitudinal arch and increased strain on the plantar fascia and plantar musculature (connective tissue and muscles on bottom of foot). The gastrocnemius-soleus complex and tibialis posterior may overly contract while lengthening (eccentric contraction) to decelerate the rotation of the leg and pronation of the foot. This may contribute to damage of the
achilles and tibialis posterior tendons.

Overload of the long flexors of the leg may result in medial tibial stress syndrome (shin splints) which may lead to stress fractures of the tibia. Metatarsal fractures may occur due to uneven distribution of weight and excessive movement of the metatarsals with forefoot lowering. Stress fractures of the little bones of the foot (sesamoids).

Excessive pronation leads to an increased internal rotation of the tibia, which results in the patella moving outwards (lateral displacement) and muscular imbalance of the quadriceps, all of which contribute to patellofemoral joint dysfunction. Internal rotation of the tibia contributes to a change in alignment of the patellar tendon, which may predispose to patellar tendonitis, and later patellar tendinopathy. Internal rotation of the tibia may also contribute to tightening of the Iliotibial band (ITB).



Supination occurs when the arch does not flatten at all. This typically occurs in a person with a high arch, called pes-cavus (over-supination). Because the arch does not flatten, it absorbs shock poorly. Instead of spreading it throughout the entire foot, the weight of the body falls only on the heel and the bases of the toes. This may occur as a result of weakness of the peroneal muscles (muscles at outside of leg) or as a result of spasm or tightness of the tibialis posterior and the gastrocnemius-soleus complex (muscles at back of leg). The supinated foot is often less mobile, which may result in poor shock absorption.

It is possible that this may predispose to the development of stress fractures of the tibia, fibula, calcaneus and metatarsals (especially the fourth and fifth metatarsals).

 With over-pronation or over-supination, the wrong muscles contract during gait, or they contract out of their proper sequence. These muscles and tendons eventually fatigue and break down suffering microscopic tears.

This triggers inflammation leading to swelling, pain, and scarring in these tissues. In addition, your joints may suffer excess wear leading to inflammation and possibly degeneration. Treatment for any of the above conditions should include reducing inflammation with ice or non-steroidal anti-inflammatories (NSAIDs, prescribed by a physician), strengthening and normalizing normal muscle function with Active Release Technique® (ART®) and joint mobility with manipulative techniques. In addition, custom made orthotics can play an integral role in the overall treatment of many problems caused by ankle and foot dysfunction and more importantly, to prevent their re-occurrences.

What to expect when getting fitted for custom orthotics.

The process of getting fitted for orthotics will involve several visits.

Your first initial visit will involve an overall evaluation of your body. How you walk, run and stand will all be observed and examined. This will determine what your issue is and what’s the best orthotic for your condition.

After your condition has been determined a 3d scan of your foot will then be made of your foot.

 Your orthotics will then be made and your final visit to the practice will involve a fitting of the orthotics. All orthotics require a ‘break-in’ time. If after this time, they still feel uncomfortable, you will need to visit the clinic again to be assessed.

If you have any of the above issues or think you need a custom orthotic then please email us on to book an appointment or assessment. To get fitted for custom orthotics book online by clicking -



Manual therapy

One80 - Tuan Giselle 10.jpg

Manual Therapy encompasses the diagnosis and treatment of the ailments of various etiology's through hands-on intervention.

Back pain, neck pain, and other musculoskeletal issues are very common among both young and old alike. Issues can develop from injuries or the aging process. Poor posture, accidents, birth defects, and old age are the most common causes of pain, requiring the use of manual therapy.

Who uses Manual Therapy?

Manual Therapy is practiced by people within various health care professions, including Chiropractors, Physiotherapists/Physical Therapists, Massage Therapists, Occupational Therapists, Osteopaths, Physiatrists and more.

Manual Assessment uses a variety of hands-on tests in an effort to determine which structure may be responsible for the pain being assessed. Unfortunately, there are no reliability studies demonstrating the ability of such tests to accurately determine the structure responsible for the pain. In fact, the scientific literature has shown that palpation as a manual assessment tool is unreliable and that the underlying cause of 85% of low back pain cannot be determined by any means. Several manual tests that provoke or relieve pain have been shown to be reliable.

Treatment includes all the means of hands-on work and could include, but is not limited to, soft tissue mobilization, various connective tissue techniques, myofascial release, craniosacral mobilizations (developed by cranial osteopaths, mobilization of joints or spinal segments, mobilization of neural tissue, visceral mobilization, strain and counter strain.

Is Manual Therapy Actually Effective?

Advocates of the therapy claim that these techniques, when correctly applied, often result in dramatic improvement of the patient's signs and symptoms. On the other hand, properly designed prospective studies are equivocal as to the therapeutic benefits of manual therapy.

Manual therapy involves the use of body work or massage therapy and other physical manipulation of the body for healing, such as those techniques used in osteopathy, chiropractic, and physical therapy.


A survey released in May 2004 by the National Center for Complementary and Alternative Medicine focused on who used complementary and alternative medicine (CAM), what was used, and why it was used in the United States by adults age 18 years and over during 2002. According to this recent survey, manipulative therapy was the 3rd most commonly used NCCAM classification of CAM categories (10.9%) in the United States during 2002.

Styles of manual therapy

There are many different styles of manual therapy. It is a fundamental feature of ayurvedic medicine, traditional Chinese medicine and some forms of New Age alternative medicine as well as being used by mainstream medical practitioners. In one form or another it is probably as old as human culture itself and is a feature to some degree of therapeutic interactions in traditional cultures around the world. It may rely partially upon the placebo effect and can be effective in providing both short- and long-term relief.



Joint mobilization

Joint mobilization is a type of passive movement of a skeletal joint. It is usually aimed at a 'target' synovial joint with the aim of achieving a therapeutic effect.


Mobilization is a manual therapy intervention and is classified by five 'grades' of motion, each of which describes the range of motion of the target joint during the procedure. [1]

Roman numerals are generally used in labelling the grades of motion (i.e. Grades I to V). Grade V is the same as manipulation.

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Mechanisms of action

The different grades of mobilization are believed to produce selective activation of different mechanoreceptors in the joint:

  • Grade I - Activates Type I mechanoreceptors with a low threshold and which respond to very small increments of tension. Activates cutaneous mechanoreceptors. Oscillatory motion will selectively activate the dynamic, rapidly adapting receptors, i.e. Meissner's and Pacinian Corpuscles. The former responds to the rate of skin indentation and the latter respond to the acceleration and retraction of that indentation.

  • Grade II - Similar effect as Grade I. By virtue of the large amplitude movement it will affect Type II mechanoreceptors to a greater extent.

  • Grade III - Similar to Grade II. Selectively activates more of the muscle and joint mechanoreceptors as it goes into resistance, and less of the cutaneous ones as the slack of the subcutaneous tissues is taken up.

  • Grade IV - Similar to Grade III. With its more sustained movement at the end of range will activate the static, slow adapting, Type I mechanoreceptors, whose resting discharge rises in proportion to the degree of change in joint capsule tension.

  • Grade V - This is the same as joint manipulation. Use of the term 'Grade V' is only valid if the joint is positioned near to its end range of motion during joint manipulation. Evans and Breen [2] recently contested this assumption, in fact arguing that an individual synovial joint should be positioned near to its resting, neutral position.


Myofascial Release

Myofascial Release is a form of bodywork (alternative medicine) which includes but is not limited to structural assessments (where a formal diagnosis is not necessarily given) and manual massage techniques for stretching the fascia and releasing bonds between fascia, integument, muscles, and bones are mainly applied; with the goal of eliminating pain, increasing range of motion and balancing the body. The fascia is manipulated, directly or indirectly, allowing the connective tissue fibers to reorganize themselves in a more flexible, functional fashion.

Fascia is located between the skin and the underlying structure of muscle and bone, it is a seamless web of connective tissue that covers and connects the muscles, organs, and skeletal structures in our body. Muscle and fascia are united forming the myofascial system.

Injuries, stress, inflammation, trauma, and poor posture can cause restriction to fascia. Since fascia is an interconnected web, the restriction or tightness to fascia at a place, with time can spread to other places in the body like a pull in a sweater. The goal of myofascial release is to release fascia restriction and restore its tissue health. In medical literature, the term myofascial was used by Janet G. Travell M.D. in the 1940s referring to musculoskeletal pain syndromes and trigger points. In 1976 Dr. Travell began using the term "Myofascial Trigger Point" and in 1983 published the famous reference "Myofascial Pain & Dysfunction: The Trigger Point Manual". Some practitioners use the term "Myofascial Therapy" or "Myofascial Trigger Point Therapy" referring to the treatment of trigger points, this is usually in medical- clinical sense.

There are two main schools of myofascial release: the direct and indirect method.

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Direct myofascial release

The direct Myofascial Release method works directly on the restricted fascia. The practitioners use knuckles, elbows, or other tools to slowly sink into the restricted fascia applying a few kilograms-force or tens of newtons and then stretch the fascia. This is sometimes referred to as deep tissue work. Direct Myofascial Release seeks for changes in the myofascial structures by stretching, elongation of fascia, or mobilising adhesive tissues.

There can be a misconception that the direct method is violent and painful. It is not essentially aggressive and painful, as the practitioner moves slowly through the layers of the fascia until the deep tissues are reached. Robert Ward suggested that the direct method came from the osteopathy school in the 1920s by William Neidner called Fascial Twist. Dr. Ida Rolf developed Structural Integration or Rolfing in the 1950s, a holistic system of soft tissue manipulation and movement education that with the goal of balancing the body in gravitational field. She discovered that she could remarkably change the body posture and structure by manipulating the myofascial system. Rolfing® is the nickname that many clients and practitioners gave this work. Since her death in 1979, various Structural Integration schools arose which have adapted her original idea according their own flavours, lights and remembrance.

Michael Stanborough has summarised his style of Direct Myofascial Release technique as:

  • Land on the surface of the body with the appropriate 'tool' (knuckles, or forearm etc.).

  • Sink into the soft tissue.

  • Contact the first barrier/restricted layer.

  • Put in a 'line of tension'.

  • Engage the fascia by taking up the slack in the tissue.

  • Finally, move or drag the fascia across the surface while staying in touch with the underlying layers.

  • Exit gracefully.

As Dr. Rolf said Put the tissue where it should be and then ask for movement.

Indirect myofascial release

The indirect method gentle stretch, the pressure is in few grams, the hands tend to go with the restricted fascia, hold the stretch, and allow the fascia to 'unwind' itself. The gentle traction applied to the restricted fascia will result in heat, increase blood flow in the area. The intention is to allow the body's inherent ability for self-correction returns, thus eliminating pain and restoring the optimum performance of the body. This concept was suggested, by Paul Svacina, to be analogous to pulling apart a chicken carcass- when it is pulled apart slowly, the layers peel off- too fast, and it shreds.

The indirect technique originated in osteopathy schools and also popular in physical therapy. German physiotherapist Elizabeth Dicke developed Connective Tissue Massage (Bindegewebbsmassage) in the 1920s with superficial stretching of the myofascia. According to Robert C. Ward, myofascial release originated from the concept by Andrew Taylor Still, the founder of osteopathic medicine in the late 19th century. The concepts and techniques were subsequently developed by his successor, and until 1980s they were popularised. Robert Ward further suggested that the term Myofascial Release as a technique was coined in 1981 when it was used as a course title in Michigan State University.
John F. Barnes, PT has developed a unique approach to Myofascial Release that utilizes both direct and indirect techniques. He teaches his approach to Myofascial Release to healthcare professionals across the country

Carol Manheim summarized Myofascial Release principles:

  • Fascia covers all organs of the body, muscle and fascia cannot be separated.

  • All muscle stretching is myofascial stretching.

  • Myofascial stretching in one area of the body can be felt and will affect the other body areas.

  • Release of myofascial restrictions can affect other body organs through a release of tension in the whole fascia system.

  • Myofascial release techniques work even though the exact mechanism is not yet fully understood.

The indirect myofascial release, e.g. cross hand technique according to John Barnes is as follow:

  • With relaxed hand lightly contact the fascia.

  • Slowly stretch the fascia until reaching a barrier/ restriction.

  • Maintain a light pressure to stretch the barrier and wait for approximately 3-5 minutes.

  • Prior to release, the therapist will feel a therapeutic pulse (e.g. heat).

  • As the barrier releases, the hand will feel the motion and softening of the tissue.

  • The key is sustained pressure over time.

Recognizing and Preventing Childhood Injuries

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The benefits of regular exercise are vast, especially among young athletes. Athletic programs provide opportunities to improve self-esteem, acquire leadership skills and self-discipline, and develop general fitness and motor skills. Peer socialization is another important, though sometimes overlooked, benefit. Participation, however, is not without injury risk. Any parent that has had their child participate in regular physical activity knows that their child may sustain some sort of injury. Parents have also witnessed the resilience of children and how fast they heal, however, kids are not immune to developing compensations in their musculoskeletal system that can change how they will use their bodies in sport and regular day to day activities in the future. All parents understand that the choices they make today have a strong impact on their child’s future. This is why it is especially important to properly manage childhood injury. This information session is intended to improve your understanding of the following:

  • Determining if your child has an injury

  • What to do when your child is injured

  • How to prevent injuries in and out of the pool


Injuries can be either traumatic, such as a sprain or a fracture, or due to repetitive strains that overloads the tissues and lead to disruption and even failure, a great example of this is when your back has been perfectly fine and then one day you attempt to pick up a pencil and it just locks, or you hear a pop and pain sets in.

Tissue, such as skin, muscles, tendons, ligaments, bones and other forms of connective tissue can be placed under strain, and often this strain is not painful. However, this continuous strain creates some sort of compensatory movement. When a body experiences localized pain, it will attempt to adapt in a manner that decreases that local pain but changes the way a particular movement occurs, very often in an “unnatural” manner. Repetitive strains can exhaust the body’s ability to adapt and over time can lead to painful injury. This is how pain can be experienced even when there has not been a single traumatic event, remember the pencil and back example. These programmed adaptations lead to muscle weakness, uncoordinated movements, soft tissue shrinkage or atrophy, and loss of flexibility in a region of the body. These changes are termed deconditioning, and deconditioning syndromes can cause changes to surrounding joints. When joints are not moving properly, the bones surrounding the joint can weaken and breakdown, scar tissue can develop around the joint capsule and weakening of surrounding ligaments can occur.

These changes occur in children but are much subtler. Unfortunately, pain is not always the best way of determining something is wrong. Actually, pain does not serve as a good early- warning system of something wrong; it often arises only after damage is done. Once damage occurs, such as a traumatic injury or repetitive strain, several biochemical processes ensue, and inflammation begins. This inflammation is often painful but is too late to prevent and your child is not only in pain but is often removed from the activities that did not create the problem but give them very much joy. This is why it is important to have a professional that is well versed in childhood injuries and the tissue mechanics within children to appropriately assess a possible injured state.


The more often a particular movement is repeated, the greater the likelihood of sustaining an injury. However, there are certain factors that contribute to injuries among children. The following are examples that increase the risk of injury and are not exclusive to swimming:

  • Body Alignment, i.e., poor posture, such as forward slouched shoulders

  • Prior injury

  • Inappropriate rehabilitation with previous injury

  • Inadequate conditioning

  • Returning to play too soon after injury

  • Inappropriate equipment/footwear

  • Incorrect sport technique


There is not a single way to determine if your child is injured. There are often warning signs, but children often conceal an injury for fear of being punished or removed from a particular activity. Parents may notice their child supporting or rubbing a particular body part too frequently; not moving with the same grace they once did; or actually telling you that they are hurt. Decreased performance, which is often noticed by a coach or by keen parents, can be the first warning sign. However, this is not always the case, recall the whole issue of compensatory movements.

It is very important that parents realize one thing. One particular sport does not result in more injuries than another. Any form of physical activity is accompanied with risk of injury, even something as simple as walking, or even playing video games, repetitive strain injury to the thumb is highly prevalent among children that spent too much time playing video games. Therefore, it is important to communicate with your child that they should not be afraid to tell you or their coach when they are not feeling their body is working the way it used to.

If in doubt whether your child is injured or not, you should have your child see a health care provider that understands childhood sport injuries and their appropriate management, what the proper body mechanics are for their athletic event, the correct strength of opposing muscle groups necessary for their sport, the proper nutrition required to maximize their performance and aid in healing the injured athlete and the prescription of a progressive rehabilitation program for their sport. This health care provider can be like me, Dr. Nick Tsaggarelis, BKin, DC, MEd, a sports focused chiropractor, or a sports medicine physician. If you are unaware of who to send your child to, speak to the child’s coach, their paediatrician or contact my office and I can direct you to the appropriate person depending on what the condition requires.

It is important to understand that not all conditions are treated the same. There is a specific treatment for a specific condition, occurring in a specific child. This is why it is very important that the proper assessment and diagnosis be made, and the correct treatment plan be implemented. To develop the proper diagnosis a detailed assessment is necessary. Each health professional has a different approach to evaluate a patient and I can only explain the approach I take to develop a diagnosis and subsequently implement a treatment plan. I first begin with a detailed history of the child, some of the questions I may ask the athletes I take care of, especially children are as follows:

  • Has there been a similar injury in the past, and does the patient have a history of other overuse injuries?

  • How were past injuries treated?

  • Was there a change in training intensity, frequency, or duration?

  • Was a new technique or piece of equipment introduced?

  • Is the athlete involved in other activities such as resistance training or physical education classes that could have contributed to the injury?

  • When was the last athletic shoe purchase?

These questions along with a thorough exam using orthopaedic and neurological tests allows me to evaluate the movement of joints, the muscles surrounding these joints and the nervous system. This evaluation provides me with the information needed to develop an understanding of the individual needs each patient requires in order to restore optimal health and proper function of the body.


Every parent wants the best for their child. In order to receive the best possible health care parents, need to find a health care provider they can trust. One who knows how to appropriately manage their child and has a good team of other health care providers they can rely on when they need to send your child too if further investigation is necessary. In addition, it is imperative that the health care provider has the ability to communicate the diagnosis to you and your child in easy to understand terms. This is necessary because when you and your child both understand what is going on there is increased awareness and motivation to get better and stay that way for a long time.

Once the proper diagnosis is made, the key factors resulting in the injury identified, the appropriate treatment plan is implemented in order to restore proper motion to joints and surrounding muscles and rehabilitative exercises are given in order to maintain the changes that have been made. I have had great success treating both recreational and professional athletes by using a functional approach to the management of a variety of conditions. By integrating and implementing various therapies, such as Active Release Technique® (ART®), Joint Manipulation, Medical Acupuncture, and Functional Rehabilitation Exercises, I am able to quickly re-establish proper mechanics of muscles and joints. This not only reduces the pain my patients have been experiencing from their injury, but it also restores proper function and even improves performance. However, the most important point to remember in any treatment plan is a re-evaluation of your child’s condition/injury within two weeks of treatment onset in order to determine whether it has been helping or not. My experience treating various sports and recreational injuries has been that there should be an improvement within three (3) to four (4) treatments, especially among children and adolescence. An improvement is measured as either an increased range of motion, decreased intensity or duration of pain, and/or improved performance. Therefore, not only should your health professional be providing you with an accurate diagnosis, the treatment they implement should result in noticeable improvements relatively quickly. Of course, there are some exceptions, but these too should be explained and understood by all parties involved.

The following is a brief explanation of how some of the therapies can benefit your child:

JOINT MANIPULATION/CHIROPRACTIC CARE –Joint manipulation is performed by chiropractors that also diagnose pain and dysfunction of muscles and joints. With the aid of a specific, high velocity, and short amplitude thrust applied to a joint, there is an audible release of gas, which is referred to as a joint cavitation. The audible sound is caused by the release of oxygen, nitrogen, and carbon dioxide, which releases joint pressure (cavitation). These manipulations are safe and rarely cause any discomfort. The result is not only increased range of motion, and reduced nerve irritability, but also improved function of the joint manipulated and its surrounding tissue.

ACTIVE RELEASE TECHNIQUE® (ART®) – This is a specific soft tissue therapy used to break up fibrous adhesions (scar tissue between muscles, nerves and other connective tissue) that develop during a sudden injury, a repetitive or chronic injury, or poor posture. ART® re- establishes the proper motion between muscles, tendons, ligaments, blood vessels, fascia and nerves. In many situations your condition will significantly improve within five to six treatments, with the average treatment session lasting 10-15 minutes per area treated.

MEDICAL ACUPUNCTURE – This approach used by physicians and chiropractors in North America, Europe, and parts of Asia involves the insertion of very fine needles into specific points on the body to relieve pain and improve the function of the nervous system. This enhances the energy and hormonal balance within the body, stimulating your natural healing abilities.

REHABILITATIVE EXERCISE PROGRAMS – The condition being treating will dictate the type of exercise program given. By completing a progressive and easy-to-follow program, patients experience increased strength and flexibility. This not only helps decrease pain but prevents the condition from returning in the future.


It is believed that the majority of injuries are preventable. Having your child evaluated by a qualified health professional as discussed above, prior to beginning a training program and informing you and your child if any areas need to be addressed to prevent injuries can be of great benefit.


To have your child receive faster recovery from their injury or general muscle and joint pain call one80Health on (647) 560-4495.

 Our friendly and knowledgeable staff will put you at ease and answer any of your questions.

OFFICE HOURS MON – THURS 8am -8pm FRI – 8am - 6pm SAT - 8am – 4 pm

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Trigger Points

Trigger points are described as hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers. The palpable nodules are said to be small contraction knots and a common cause of pain. Compression of a trigger point may elicit local tenderness, referred pain, or motor dysfunction.

Trigger Points jpg.jpg


Trigger points have been a subject of study by a small number of doctors for several decades although this has not become part of mainstream medicine. The existence of tender areas and zones of induration in muscles has been recognized in medicine for many years and was described as muscular rheumatism or fibrositis. However, there was little agreement about what they meant. Important work was carried out by J. H. Kellgren at University College Hospital, London, in the 1930s and, independently, by Michael Gutstein in Berlin and Michael Kelly in Australia (the latter two workers continued to publish into the 1950s and 1960s). Kellgren conducted experiments in which he injected saline into healthy volunteers and showed that this gave rise to zones of referred extremity pain.

Today, much treatment of trigger points and their pain complexes are handled by massage therapists, physical therapists, osteopaths, occupational therapists, myo-therapists, some naturopaths, chiropractors and acupuncturists [3], and other hands-on somatic practitioners who have had experience or training in the field of neuromuscular therapy (NMT).

Janet G. Travell, MD

It was, however, an American physician, Janet G. Travell, who was responsible for the most detailed and important work. Her work treating US President John F. Kennedy's back pain was so successful that she was asked to be the first female Personal Physician to the President. [3] She published more than 40 papers between 1942 and 1990 and in 1983 the first volume of The Trigger Point Manual appeared; this was followed by the second volume in 1992. In her later years Travell collaborated extensively with her colleague David Simons. A third edition is soon to be published by Simons and his wife, both of whom have survived Travell.

The trigger point concept remains unknown to most doctors and is not generally taught in medical school curricula. Other health professionals, such as physiotherapists, osteopaths, naturopaths, chiropractors, physiatrists, massage    therapists and structural integrators and some veterinarians are generally more aware of these ideas and many of them make use of trigger points in their clinical work.

Travell and Simon's seminal work on the subject, Myofascial Pain and Dysfunction: The Trigger Point Manual [1] , states the following:

  • around 75% of pain clinic patients have a trigger point as the sole source of their pain.

  • The following conditions are often diagnosed (incorrectly) when trigger points are the true cause of pain: carpal tunnel syndrome, bursitis, tendinitis, angina pectoris, sciatic symptoms, along with many other pain problems.

  • Arthritis is often cited as the cause for pain even though pain is not always concomitant with arthritis. The real culprit may be a trigger point, normally activated by a certain activity involving the muscles used in the motion, by chronically bad posture, bad mechanics, repetitive motion, structural deficiencies such as a lower limb length inequality or a small hemipelvis, or nutritional deficiencies.

Myofascial pain syndrome

The main innovation of Travel’s work was the introduction of the myofascial pain syndrome concept (myofascial referring to the combination of muscle and fascia). This is described as a focal hyperirritability in muscle that can strongly modulate central nervous system functions. Travell and followers distinguish this from fibromyalgia, which is characterized by widespread pain and tenderness and is described as a central augmentation of nociception giving rise to deep tissue tenderness that includes muscles.

Qualities of trigger points

Trigger points have a number of qualities. They may be classified as active/latent and also as key/satellites and primary/secondary.
An 'active trigger' point is one that actively refers pain either locally or to another location (most trigger points refer pain elsewhere in the body along nerve pathways). A latent trigger point is one that exists, but does not yet refer pain actively, but may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point.

A key trigger point is one that has a pain referral pattern along a nerve pathway that activates a latent trigger point on the pathway or creates it. A satellite trigger point is one which is activated by a key trigger point. Successfully treating the key trigger point often will resolve the satellite and return it from being active to latent or completing treating it too.

In contrast, a primary trigger point in many cases will biomechanically activate a secondary trigger point in another structure. Treating the primary trigger point does not treat the secondary trigger point.

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psycho-emotional disorders, homeostatic imbalances, direct trauma to the region, radiculopathy, infections and health choices such as smoking.

Trigger points can appear in many myofascial structures including muscles, tendons, ligaments, skin, joint capsule, periosteal, and scar tissue. When present in muscles there is often pain and weakness in the associated structures. These pain patterns in muscles follow specific nerve pathways and have been readily mapped to allow for identification of the causative pain factor. Many trigger points have pain patterns that overlap, and some create reciprocal cyclic relationships that need to be treated extensively to remove them.

Diagnosis of trigger points is by examining signs, symptoms, pain patterns and manual palpation. Usually there is a taut band in muscles containing trigger points, and a hard nodule can be felt. Often a twitch response can be felt in the muscle by running your finger perpendicular to the muscle's direction; this twitch response often activates the "all or nothing" response in a muscle that causes it to contract. Pressing on an affected muscle can often refer pain. Clusters of trigger points are not uncommon in some of the larger muscles, such as the Gluteus group (Gluteus Maximus, Gluteus Medius, Gluteus Minimus). Often there is a heat differential in the local area of a trigger point, and many practitioners can sense that.
In order for a medical sign to be diagnostically useful, independent examiners must be able to agree on its presence.

Misdiagnosis of Pain

The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies; but physicians, in weighing all the possible causes for a given condition, have rarely even conceived of there being a myofascial source. The study of trigger points has not historically been part of medical education. Travell and Simons hold that most of the common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain. [8]


There have been several theories about trigger points. It was once believed that trigger points were scars or inflammation in the muscle. This was disproved when biopsies showed no abnormalities. [citation needed]
More recently it has been proposed that trigger points are spasms or contractures of voluntary muscle, possibly caused by an abnormality at the neuromuscular junction where the nerves controlling muscles connect to the muscle fibers (Travell & Simon). This theory seems unlikely because no contractions of voluntary muscle have been identified by traditional EMG and because the trigger points are often not in the location of the neuromuscular junction.

The most recent theory is that trigger points are muscle spindles, made over-active by adrenalin stimulation. These very short muscle fibers, only about 1 cm in length, are called intrafusal muscle fibers to distinguish them from the voluntary muscle fibers which are called extrafusal muscle fibers. Only the intrafusal muscle fibers inside the spindle are activated by adrenalin via the sympathetic nervous system which also controls heart rate, blood pressure and other internal regulatory functions. The “sympathetic spindle spasm” theory of trigger points proposes that when spindles are over-activated by adrenalin they become painful. A clinical research trial is being conducted and should be completed by the end on 2006 by Dr. David Hubbard in San Diego, California. Paul Svacina, Engineer and bodyworker also in California, believes that this theory supports the idea that stress and decrease of moderate physical activity in modern lives has increased the occurrence of myofascial pain and trigger points.

Current theories include:

  • Travell’s Initial Trauma Theory

  • Integrated Trigger Point Hypothesis

  • Pain-Spasm-Pain Cycle

  • Muscle Spindle Hypothesis

  • Neuropathic Hypothesis

  • Fibrotic Scar Tissue Hypothesis


Prior to treatment commencement, the therapist should be sure be that the pain patterns they are treating lend themselves to Trigger point therapy. If the patient presents with swelling, discoloration, or neurological symptoms, it is always advisable to refer to another health/medical care provider regarding further examination and/or investigation. The therapist should be aware of his/ her professional limitations.

Treatment of trigger points may be by manual massage (deep pressure as in Bonnie Prudden's approach or tapotement as in Dr. Griner's approach), mechanical vibration, pulsed ultrasound, electrostimulation [9], ischemic compression, injection (see below), dry-needling, "spray-and-stretch" using a cooling (vapocoolant) spray, and stretching techniques that invoke reciprocal inhibition within the musculoskeletal system. Use of elbows, feet or various tools to direct pressure directly upon the trigger point often occurs, to save practitioner's hands.

A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscule facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for a 1-3 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS), the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in Trigger Point Therapy. Further pain after one to three treatment sessions by a Trigger Point practitioner should be referred to a medical professional. Evidence based medicine researchers have concluded evidence for the usefulness of trigger points in the diagnosis of fibromyalgia is thin.[10] Fibromyalgia patients generally have multiple, reoccurring trigger points, typically in a quadrant or more of the body.


Injections provide more immediate relief and can be effective when other methods fail. Various injections can be used including saline, local anesthetics such as procaine hydrochloride (Novocain), steroids, and Botox. Injection with a low concentration, short acting local anesthetic (Procaine 0.5%) without steroids or adrenalin is recommended. High concentrations or long acting local anesthetics as well as epinephrine cause muscle necrosis. Use of steroids can cause skin atrophy. Dry needling can be just as effective but causes more post-injection soreness. Botox is rarely indicated. [1]

Despite the concerns about long acting agents [1], a mixture of lidocaine and Marcaine is often used. [11] A mixture of 1 part 2% lidocaine with 3 parts 0.5% Marcaine provides 0.5% lidocaine and 0.375% Marcaine. This has the advantages of immediate anesthesia with lidocaine during injection to minimize injection pain while providing a longer duration of action with a lowered concentration of Marcaine. Sarapin can be used for trigger point injection.


There are a number of ways to self-treat trigger points and these methods are described in numerous texts. It should be noted that due to the controversy related to this field, as well as its relative newness, that no single guide should be taken as the sole or final truth. Underlying any attempts at self-treatment should be a working knowledge of the area to be treated, especially with regard to the musculature, nerves, glands and vessels.

Trigger points in the male or female pelvis, such as found in chronic pelvic pain syndrome (CPPS), should be treated by medical doctors or osteopaths trained in the use of intra-rectal trigger point and myofascial release techniques.
Caution: Self-treatment does have some inherent dangers of damaging soft tissue and other organs. The trigger points in the upper Quadratus Lumborum, for instance, are very close to the kidneys and poorly administered self-treatment may lead to kidney damage. Likewise, treating the masseter muscles may damage the salivary glands superficial to this muscle. Furthermore, and some experts believe trigger points may develop as a protective measure against unstable joints. A qualified professional should eliminate this cause prior to beginning a self-treatment program.


  1. ^ a b c d Travell, Janet; Simons, David; Simons, Lois (1999). Myofascial Pain and Dysfunction: The Trigger Point Manual (2 vol. set, 2nd Ed.). USA: Lippincott Williams & Williams. ISBN 0-683-08363-5.

  2. ^Simons,D.G.CardiologyandMyofascialTriggerPoints:JanetG.Travell's Contribution . Tex Heart Inst J. 2003; 30(1): 3–7.[1]

  3. ^BaggJ,(2003),ThePresident'sPhysician,TexasHeartInstitute,Houston[2]

  4. ^SwedishMedicalCenter

  5. ^AmericanAcademyofFamilyPhysicians

  6. ^DynamicChiropractic

  7. ^GerwinRD,ShannonS,HongCZ,HubbardD,GevirtzR.Interrater reliability in myofascial trigger point examination. Pain. 1997 Jan;69(1-2):65- 73.

  8. ^Davies,Clair;Davies,Amber(2004).TheTriggerPointTherapyWorkbook (2nd Ed.). USA: New Harbinger Publication, Inc., 323. ISBN 1-57224-375-9.

  9. ^TheImmediateEffectivenessofElectricalNerveStimulationandElectrical Muscle Stimulation on Myofascial Trigger Points American Journal of Physical Medicine & Rehabilitation. 76(6):471-476, November/December 1997. Hsueh, Tse-Chieh MD, MS 2; Cheng, Pao-Tsai MD, MS; Kuan, Ta-Shen MD, MS; Hong, Chang-Zern MD

    10.^ Fibromyalgia: diagnosis and treatment Bandolier Journal
    11.^ Trigger Point Injection. Non-Surgical Orthopaedic & Spine Center. Retrieved on 2007-04-07.
    12.^ Sarapin: A regional Analgesic for control of pain of neuralgic origin.. Retrieved on 2007-04-03.
    13.^ PDR entry for Sarapin. Retrieved on 2007-04-03.


Low Back Pain

Low back pain is the most common form of physical disability. An estimated 80 percent of all Americans will suffer from back pain at some point in their lives. Back pain is the second leading cause of work absenteeism. Studies show that early aggressive treatment of back injuries by a physiatrist results in quicker recovery and fewer lost work days. Treatment by physiatrist center’s around various combinations of exercise and medication.

Overview of Low Back Pain/ Developing a Program That's Right for You

Information is readily available on the way to stop back pain. The challenge is to tailor it to the particular patient. For example, it's often said that swimming is good for the back. But which stroke? And how often?

Strengthening the abdominal muscles is also commonly ordered for low back pain. But how is this done? And are you exercising the proper way for your back injury? The list goes on: cold or hot applications, rest or activity?

What Kinds of Problems Might Cause Low Back Pain?

Treatment for any back condition is recommended as soon as possible to minimize the danger of further aggravation. The following is a list of only some of the conditions that may cause low back pain and is not a substitute for a visit to your doctor:

  • Radiculopathy - A pinched nerve, also called sciatica, usually from a herniated, or slipped, disk. This can cause a shooting pain down the leg that's often described as an electrical feeling.

  • Myofascial Pain - Generally an aching pain in muscles that tends to come from poor posture, sitting at a computer, or other job-related tasks. With myofascial back pain, the patient can become sore in different parts of the body like the back and legs. Often patients report that they have difficulty sleeping or feeling restored from sleep.

  • Spinal Stenosis - A narrowing of the nerve openings either around the spinal cord or nerve roots that can cause symptoms similar to a pinched nerve. It can cause leg pain in anyone, but most often does so in older people. Patients with spinal stenosis can have trouble walking, and the difficulty is usually relieved by sitting down or bending forward. It can cause aching or heaviness in the back and legs.

  • Tendon, Ligament and Soft Tissue Pain - Localized pain when an area is stretched or its muscles are overused. This results in tenderness.

  • ·Non-Spinal Causes of Low Back - Pain Pain imitating a back injury, but from another cause. Appendicitis, kidney disease, uterine disorders and urinary tract infections are a few examples of problems that can refer pain to the back.

Treatment Options

The rehabilitation of low back problems occurs in three phases. During the first phase, called the acute phase, physiatrists treat pain and inflammation. After they make a specific diagnosis and develop a treatment plan, physiatrists may offer treatment options like ultrasound, electrical stimulation, mobilization, medication, ice and even specialized injections.

In the second, or recovery, phase of treatment, flexibility and strength are developed to get the body parts into their proper positions. The goal of this phase is to get you back to your usual work, sports and leisure activities. This goal is achieved through specially designed exercises that rebuild the body.

The main goal of the third phase of treatment, the maintenance phase, is to minimize recurrence of the problem and to prevent further injury. This often consists of a total body fitness program, designed to maintain body mechanics and increase endurance after the original symptoms have resolved.

These are very broad and general approaches to the treatment of low back pain. The physiatrist that you choose will develop an individual treatment plan for you.
Early Diagnosis and Treatment of
Back Pain Is Key to Preventing Recurrence

It is estimated that 80% of Americans will experience low back pain some time during their lives. Many of these people will choose to delay treatment hoping the pain will go away. Procrastination is not the best avenue to take when experiencing back pain say specialists in physical medicine and rehabilitation (PM&R).

It is extremely important to treat low back pain at the onset in order to avoid aggravation and compounding the problem. Untreated low back pain can cause changes in your posture, gait, and bearing that may in turn worsen the problem or cause new ones. PM&R physicians, also called physiatrists, are medical specialists dedicated to restoring or maximizing function and self-sufficiency in patients who have physical disability resulting from injury or chronic illness.

Not all back pain is caused by muscle or nerve conditions. There are many different possible causes of back pain such as appendicitis, kidney disease, or urinary tract infections. Back pain can be an early warning sign for one of these more serious conditions that can be effectively treated if caught early on. That's why it's important to see a PM&R physician soon after pain develops.

While every case of low back pain is unique, many are remedied with non-surgical treatments supported by a regime of exercises to strengthen the back and prevent recurrence of the condition.

Don't Gamble with Your Low Back Pain

If you like to play the odds, here is a sure bet. 80 percent of all adults will experience low back pain at some time in their life - so chances are pretty good that if you haven't already been sidelined by it, low back pain could be on the horizon for you. It is the second most common reason for people to visit their primary care physicians.

So, if (when!) it does happen to you, what should you do? Wait for it to go away? Maybe you've heard the statistic that 45-50 percent of patients with low back pain improve within a week? Well, that may be true. But, here's the morning line from researchers:

• Over 40 percent of all patients with low back pain will have persistent complaints of pain one and two years later.

• 62 percent of patients are likely to have one or more relapses during a one-year follow-up.

• Continued problems with low back pain are even more likely in patients who wait six to 10 weeks from the first onset of pain before seeking medical care.

Don't Take that Back Pain Lying Down

Uh oh, there it is. The first twinges of low back pain. What should you do? First, experiment a little to find which positions are more comfortable for you and decrease some of that pain. Contrary to what you may think, don't just rest. Recent studies have shown that prolonged rest may cause certain kinds of low back pain to worsen because your muscles will weaken with lack of movement or exercise. You can limit your activity, but do not stop it completely. Some PM&R physicians have reported seeing more patients for low back pain in the winter, which they sometimes attribute to our tendency to be "couch potatoes" when cold weather sets in. But remember, don't ignore your back pain. If it persists, consult with a PM&R physician.

Great Expectations: Tips for Pregnant Women to Prevent Low Back Pain

With that expanding tummy, a pregnant woman's posture will begin to shift forward, changing her balance and putting new strain on back muscles. She may not notice that she is gradually adjusting her movements with compensations that might actually cause pain. Some suggestions from Dr. Prather for expectant mothers:

  • When standing, work abdominal muscles to unload the back by pulling your belly button toward your spine. Avoid high-heeled shoes.

  • When sitting, ensure that your chair height allows knees to align parallel with hips.

  • When lifting, lower your body by bending at the knees and lift by pushing up with the thighs.

  • When sleeping, lie on your side with knees and hips flexed and a pillow between your legs and under your abdomen.

PM&R physicians advise that pregnant women may want to ask their doctors about a back brace or a special sling called a "sacroiliac belt." They can ease the tension on the spine by forcing the buttocks and hip muscles to contract in support of the pelvic joints and abdomen.

Osteopathic Manipulative Medicine

Dr.Nick Clinic-151.jpg

Osteopathic Manipulative Medicine (abbreviated as OMM) is an approach to manual therapy used to improve the impaired or altered function of the muscle-skeletal system (somatic dysfunction). With roots in ancient Greek "frictions," manual manipulation has long been a part of health care. Today's OMM was first practiced by Andrew Taylor Still, M.D., the founder of modern osteopathic medicine. In the United States, its country of origin, OMM is used by Doctor of Osteopathic Medicine (D.O.s) along with surgery and medication in treatment of patients. Outside the United States, practitioners of osteopathy (who may have the qualification of D.O. as a Diploma of Osteopathy, but do not necessarily have the same medical training as American- trained D.O.s) generally limit their scope to manual manipulation.

There are different techniques applied to the musculoskeletal system as OMM. These techniques can be applied to the joints, their surrounding soft tissues, muscles and fasciae.

Also, OMM is a treatment that is intended to be used in conjunction with mainstream treatments where it is deemed appropriate. It is rarely used as a primary treatment regimen unless the D.O. is absolutely certain that the patient's problems are a result of a musculoskeletal somatic dysfunction. Furthermore, as with other medical treatment methodologies, there are certain situations where use of OMM is strictly contraindicated (for example, cervical spine HVLA techniques may never be used on patients with Down Syndrome).

While this OMM practice is traditionally ascribed to D.O.'s, it should also be noted that there are M.D. practitioners of OMM since many Osteopathic medical schools have created training programs for their M.D. counterparts. Recently OMM training programs have likewise been extended to other medical professionals including, but not limited to: Physician Assistants, Nurse Practitioners, Nurses, etc.

Some techniques used in OMM are:

  • Balanced ligamentous tension (BLT)

  • Counter-strain

  • Cranial osteopathy

  • High Velocity Low Amplitude Thrust (HVLAT)

  • Joint mobilization - articulatory techniques

  • Lymphatic Pump

  • Muscle Energy Technique (MET)

  • Myofascial Release

  • Neuromuscular therapy, trigger point therapy

  • Soft Tissue Technique

  • Visceral manipulation

When combined as Osteopathic Manual Medicine, these forms of treatment allow the osteopathic physician to restore the normal contact within the joint and with other structures. This eliminates muscular spasms and tensions in the ligaments, thereby restoring complete mobility to the joint. It is probably the comprehensive and eclectic style of OMM that distinguishes it most from that employed by most other manual therapists. The immediate goal of musculoskeletal manipulation is to restore maximal, pain-free movement of the musculoskeletal system in postural balance.


Can Amber Glasses Help You Sleep Better?

Sleep is one of the pillars of optimum health.

We’ve all heard the recommendations to put away our phones an hour or two before bed. But realistically who is following that good advice? Anyone…hello? The temptation to check our emails, Facebook and a quick binge watch of game of thrones has left us all with blue light syndrome and a brain that doesn’t want to go to sleep anytime soon.

If this sounds all too familiar and your precious phone is keeping you from catching those zzz’s, fear not as a recent study suggests that amber glasses could be your knight in shining armour when It comes too sleep.


I can hear the silent murmurs of those who say they only get five hours sleep anyway but what is the quality of that sleep and how can amber glasses help.

So, what are amber glasses?

Amber glasses block the blue light that is emitted from our phones, television, computers and even the artificial lighting in our homes. The problem with blue light particularly at night is that it is suppressing our melatonin production and disrupting our circadian rhythm. (such as the natural sleep-wake cycle)

From Harvard:

“While light of any kind can suppress the secretion of melatonin, blue light does so more powerfully. Harvard researchers and their colleagues conducted an experiment comparing the effects of 6.5 hours of exposure to blue light to exposure to green light of comparable brightness. The blue light suppressed melatonin for about twice as long as the green light. It shifted circadian rhythms by twice as much (3 hours vs. 1.5 hours).”

The scientific research behind blue light exposure and its ability to suppress sleep is robust. 

Sleep specialist Dr. Michael Breus makes this statement in his book The Power of When:

“The most disruptive event in the history of bio time occurred on December 31, 1879 with the invention of the electric light bulb.”

In recent studies amber glasses were tested by 14 insomniacs to see if they would help them get extra sleep. Research found that those using the amber glasses three hours before bed got an extra 30minutes of sleep each night. Their mood and sleep quality improved over the course of wearing amber glasses compared to a group that wore ultraviolet light blocking glasses.

Amber glasses can be purchased online - or speak to your optician for a more in-depth look at how amber glasses work.

For more information visit -

7 Tips for a Better Sleep

How many hours of sleep did you get last night? And the night before?

If you answered less than 7 hours, then its time we had a little chat! Getting good quality shut-eye is one of the most important of The Four Pillars. We can’t live without it and we spend nearly a third of our entire lives sleeping - yet very few of us pay attention to the phenomenon of sleep.

Sleep is a vital component of a flourishing lifestyle. Sleep deprivation, like starvation, can have damaging consequences to our health and wellbeing. Learning to prioritize sleep in your life, creating healthy sleeping patterns, and effectively manage sleep-related disorders can have a powerful effect on your overall wellbeing as well as the environment within which you live and work.

Take a look at these 7 Tips and try to make a positive change in your sleep hygiene. You will truly reap the benefits.

1. Don’t eat or drink too late

Bedtime snacking can lead to disrupted sleep, so it’s best not to eat or drink too late. Avoid stimulants like caffeine and nicotine within 8 hours of bedtime, and be wary of too many nightcaps – alcohol suppresses deep sleep and reduces time spent in REM. Try to reduce your liquid intake about 2-3 hours before you hit the sheets - this will reduce the urge to be woken up to run to the bathroom.

2. Exercise for at least 30 mins a day

Regular exercise has positive impact on sleep. In fact, research shows that time spent exercising decreases sleep complaints and reported insomnia. By exercising more, you may increase the amount of time you spend in deep sleep.  However, be careful of exercising too late at night; cardiovascular exercise can be too stimulating if you work out within 2 hours of bedtime, and it can cause more frequent arousals or sleep disruptions.

3. Stay consistent with your bedtime and wake time

Photo Credit: CDC photo

Photo Credit: CDC photo

Many of us tend to stay up later or sleep in more on the weekends, but this habit can actually be disruptive rather than restorative. Going to sleep and waking up around the same time each day helps you maintain your circadian rhythm. People who go to bed and wake up around the same time each day report less insomnia and less morning sleepiness.

4. Keep your bedroom/home at around 18 degrees

Photo Credit: Corgi Home Plan

Photo Credit: Corgi Home Plan

Sleeping in a room that’s too warm or too cold will disrupt your rest. Your core body temperature peaks during mid-afternoon and dips towards the end of the day, as your body prepares for sleep. The change in temperature kickstarts melatonin production, the hormone responsible for regulating your sleep.  A small drop in room temperature reinforces this process by signalling to your body that it’s time for bed.

5. No screens 1 hour before bed

Photo Credit: 1st Combat Camera Squadron

Photo Credit: 1st Combat Camera Squadron

Blue light in particular (the kind of light given off by cell phones, TV, and tablets) downregulates the amount of melatonin produced by our bodies. Without this hormone telling us it’s time for sleep, our bodies stay awake and alert, making falling asleep really difficult. Instead of scrolling on your phone or watching television in bed, try reading or meditating.

6. Try a mind-dump


What is a mind dump? It’s a simple way to clear your mind and get everything out of your head, so that you can relax. If you find your mind starts racing with lists of to-dos while you’re laying in bed, you may find that taking pen to paper helps ease the stress on your mind.

7. Practice gratitude

Photo Credit: Elizabeth McSpiritt

Photo Credit: Elizabeth McSpiritt

A gratitude list is a wonderful, positive way to end the day. Instead of focusing on anything that went wrong, or something you’re worried about for tomorrow, focus your mind on the good things that happened. Write down a few things that you’re thankful for and fall asleep with a smile!

Series: Shoulder Injuries

Today, we’ll be starting a mini-series that covers shoulder injuries that are common in racquet sport athletes. Whether you’re a recreational squash player or a national level badminton player, these conditions can impede your on-court performance as well as your daily activities.

Over the next few weeks, we will be providing you with the knowledge for early detection of injuries and dysfunction, tools to prevent injury and/or optimize recovery, and guidance for seeking out the most appropriate healthcare professional if necessary.


We’ll begin by tackling the anatomy of the shoulder. I know. Bear with me.

The shoulder is made up of 3 bones: 1) The Humerus - the large bone in your upper arm, 2) The Clavicle - otherwise known as your collarbone, and 3) The Scapula - the shoulder blade. These 3 bones make up the 1) the glenohumeral joint (ball and socket) and 2) the acromioclavicular joint. They are suspended to the axial skeleton by the 3) sternoclavicular joint and synchronize with the 4) scapulothoracic joint to perform normal shoulder movements. Numerous ligaments (connective tissue which connects bone to bone) and muscles (contractile tissue) provide the shoulder complex with stability and the latter allows for movement to occur.

shoulder 3.png

By now, you may have heard of the notorious rotator cuff. If you are like us and geek out on the human body, you can name them off by heart. If not, what a great opportunity to learn more! This group of 4 muscles (supraspinatus, subscapularis, infraspinatus and teres minor) plays an integral role in dynamically stabilizing the humerus (ball) in the glenoid of the scapula (socket). On top of centering the “ball” in the “socket”, the supraspinatus abducts or helps to lift the arm upwards, the subscapularis internally rotates the humerus or turns it inwards, and the infraspinatus/teres minor externally rotates the humerus or turns it outwards.

If you have been struggling with a shoulder injury or want to learn more, give us a call.

William Trinh, Physiotherapist

Gilroy, A. M. et al (2008). Shoulder & Arm, Atlas of Anatomy (pp. 252-278). New York, New York: Thieme Medical Publishers Inc.

Diastasis Recti Abdominis

Diastasis Recti Abdominis (DRA) is not a term most people have heard of.  If you have, it is most likely because you currently are or have been pregnant. The truth is, you do not need to be a pregnant nor female in order to have it.  DRA is common in women and men, in fact, most of us are actually born with it.

What is it and who is at risk of getting it? 

Photo Credit:

Photo Credit:

To put it in simple terms, DRA is the stretching of connective tissue between the abdominal muscle called rectus abdominus, aka six pack.  Although the separation is in rectus abdominus, it is the weak transverse abdominus, aka the human corset, that is overstretched and weak which causes the rectus abdominus to separate.  

Many babies are born with DRA.  It is most visible when a baby tries to sit up and their belly widens and something protrudes through the middle.  As their bodies grow and the nervous system develops, DRA usually goes away.  In rare cases when it does not go away, these kids have a hard time doing a sit up and may need help strengthening the muscles.  Children and teenagers can develop DRA if they do activities that require a lot of sit-up motion or overarching of the low back, like dance and gymnastics.  As an adult, DRA is generally associated with pregnant or postpartum women.  As the uterus grows the abdomen is stretched out from the inside, and so are the abdominals, causing a separation in the linea alba.  Repeated day-to-day movements can make DRA worse if one is unaware of this condition. However, many people, both men and women, have DRA and do not even know about it. In addition to pregnancy, causes for DRA could be due to:

- Enlarged abdomen due to being overweight 

- Too many sit-ups/crunch type of motion

- Hyperextension of the low back

- Abdominal hernia or surgery

How does DRA affect the body? 

The abdominals are an integral part of our core strength.  If they are weakened, they can result in:

- Poor posture

- Chronic back pain

- Abdominal hernia

- Digestive problems

How is it diagnosed?  

Photo Credit: BabyCenter, Amy Paturel

Photo Credit: BabyCenter, Amy Paturel

The diagnosis is fairly simple: while lying down on your back with knees bent, feel the linea alba and then lift your head.  Depending on what you feel, width and depth of the separation will let you know the degree and quality of the connective tissue.  Other common indicators of DRA are bulging abdomen, tenting in the middle of your abdomen when you sit up, and an outie bellybutton.

Unfortunately, it is not common practice for medical, paramedical, or fitness professionals to assess DRA on everyone and most are not trained to do it.  

Who should be checked for DRA? 

The following populations are at higher risk of having a DRA:

- chronic back pain

- weak abdominals

- tight hip flexors

- outtie belly button

- hernia, especially umbilical

- hernia repair - the repair may not hold if the DRA is not addressed

Photo Credit: Braceability

Photo Credit: Braceability

- other abdominal surgery 

- pregnant and postpartum women

If any of the above apply to you, you should avoid sit up/crunch motion.  This means no more sit up, crunches, including sitting up to get out of bed.  Sit ups and crunches are not great functional exercises for your abdominals.

Can DRA heal?  

Yes! The good news in most cases, the diastasis can be closed with 3 exercises that strengthen your transverse abdominus, which approximate and heal the connective tissue.  Although the exercises are simple, their success depends on proper execution and frequency of they being done and if they are taught and supervised by an appropriate health care or exercises professional.

If you'd like more information, Katerina Shamliyan will be happy to answer any of your questions at

Katerina Shamliyan, BSc, MPT

Smartphone Tendonitis

Photo Credit: 1st Combat Camera Squadron

Photo Credit: 1st Combat Camera Squadron

In the span of two decades, personal hand held devices evolved from a luxury reserved primarily for entertainment purposes to an integral part of our daily existence. We look to our phones, tablets and laptops for everything from education, to work, to ordering your morning coffee and coordinating your commute. As more professions become computer based, and more of our leisure time begins to revolve around the keyboard or phone screen, we tend to take for granted the extra stress we are now placing on our bodies. 

Our Hands

Typing, mousing, swiping and even holding our devices constantly can create undo tension on the hands and arms. It always surprises me how much abuse the body can take before feeling any symptoms of overuse and tissue damage.

The Neck & Spine

Looking down to our handheld device or holding a tablet too low in your lap can place the small, interlocking bones at the top of the spine (the cervical vertebrae) and the neck muscles into an unnatural posture. This can strain muscles, nerves, tendons, ligaments, and spinal discs.

Photo Credit:

Photo Credit:


The first step is simply to become aware of your posture. If you spend a lot of time on a handheld phone or using a desktop computer, laptop, or tablet, pause occasionally to notice how your body is situated. Is your back curved? Shoulders hunched? Head bent downward? Chin jutting forward or head slumped toward one shoulder? Legs crossed, hiking one hip higher than the other?

Tips & Tricks for Corrective Ergonomics

If you use a laptop or desktop computer:

  • Choose a chair with good lumbar support, or place a pillow against the small of your back.

  • Position the top of your monitor just below eye level. That helps whether you use a desktop or a laptop

  • Sit up straight with your head level, not bent forward.

  • Keep your shoulders relaxed and your elbows close to your body.

  • Keep hands, wrists, forearms, and thighs parallel to the floor.

If you use a handheld phone:

  • As with any phone, avoid propping it between your head and shoulder.

  • Consider investing in a comfortable, hands-free headset. Depending on your needs, you can choose one equipped for Bluetooth or designed for use with cordless phones, landlines, or computers.

If you use an e-reader or tablet:

  • Buy a case that allows you to prop the device at a comfortable viewing angle, and rest it somewhere that doesn't require you to bend your neck much. Keep in mind that it's best to position the device with the top edge just below eye level. Some surfaces, such as a kitchen table, may be too low even with the case.

  • Take a break every 15 minutes. Even just changing what your hands are doing, shifting your weight, standing and walking around can go a long way.

Good ergonomics, regular posture checks, stretching, flexibility exercises and a good massage can help correct these problems. Soft tissue therapy, as used by a Massage Therapist, can alleviate and prevent small aches from becoming complete injuries and creating chronic pain.

Tuan Chau, RMT