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So far Marc Cova has created 19 blog entries.

Acute Otitis Media

Ear Infections and Paediatric Chiropractic Care: Chiropractors like myself who have a special interest in Paediatric cases commonly see patients daily who present with a variety of non-specific symptoms such as irritability, poor sleep, and poor feeding. A detailed history and close physical examination of these cases can help to evaluate whether these symptoms are indeed due to Acute Otitis Media (AOM), or if they are being caused by another condition/issue. If you would like to skip the more complex Science parts of this article below, at the end you will find a list of frequently asked questions that I receive from patients regarding Acute Otitis Media. This article aims to raise awareness of AOM and highlights the relevant anatomy, epidemiology and causes. We discuss the prevention, diagnosis and management of AOM in primary care, the recognition of complications and when to refer to secondary care. AOM is one of the most common childhood diseases, and is a main cause of medical consultations and antimicrobial prescriptions in developed countries (Venekamp et al. 2014). Even though it is a concern in first world countries like Australia, there is an even greater burden in developing countries due to complications that have a much more significant impact on health. It is estimated by the World Health Organisation (WHO) that approximately 51,000 deaths occur annually in children younger than five years, attributable to complications of AOM (Safadi & Jarovsky 2017). Even though Otitis Media (OM) is a global problem, the specific number of cases per year is difficult to determine due to the lack of reporting and different incidence across many geographical regions. What we do know is that the peak incidence of OM occurs between the ages of six and twelve months of life and declines after age five. Approximately 80% of all children will experience a case of OM during their lifetime, and between 80% and 90% of all children will have OM with an effusion before school age (Curran et al. 2018; Usonis et al. 2016). OM initially starts as an inflammatory process following a viral upper respiratory tract infection involving the mucosa of the nose, nasopharynx, and Eustachian Tube. Due to the narrowness of the middle ear, the swelling caused by the inflammatory process obstructs the narrowest part of the Eustachian Tube leading to a decrease in ventilation. This leads to a cascade of events like an increase in negative [...]

Manipulation and Mobilisation of the mid back help chronic neck pain and movement

I recently discovered a research paper from Thailand published in the Journal of Physical Therapy Science that researched the effect that spinal manipulation of the thoracic spine (mid back) has on chronic neck symptoms. After finding this article I delved a bit deeper, looking into other similar articles about this topic, mostly to give myself some background by which to write this article in a more informed context. I was surprised to see there has been a great deal of research performed over the last 20 years which has focused on the relationship between the mid back and the neck. I won’t individually reference all of these articles as the referencing will bog down the purpose of this article which is to provide the public with valid and interesting facts about their spine. Neck pain is one of the most common health problems in the general population, particularly among people of working age. The prevalence of neck pain has generally been reported to be approximately 50% for workers. There are 2 very similar studies I will be reviewing today, the first is a study conducted in Thailand and published in the journal of Physical Therapy Science in 20131. 39 patients with chronic mechanical neck pain where evaluated to see whether a manipulation in their mid-back (T6/7) decreased their neck pain and increased the range of movement of their neck. Subjects included in this study had a variety of neck pain, including pain on the left and right or both, pain in the back of the neck and shoulder region, and pain which was brought on by neck movement or fingertip pressure. These are the same types of symptoms that we see in practice every day. Each of the 39 subjects had their neck pain measured on a scale of 1-10 and their range of movement was measured. The subjects were then randomly assigned to receive a single manipulation (audible crack) at T6/7 or single mid thoracic mobilisation (no audible crack) at T6/7 or to rest in a face down position (the control group). Comparisons were then made between theses three groups. The results of the study found that the subject’s pain at rest improved and their neck range of motion in all directions after single thoracic manipulation improved significantly. Additionally, a single thoracic mobilization also significantly reduced pain levels at rest and increased neck range of motion in all directions [...]

People with chronic neck pain walk with a stiffer spine.

Recently I discovered an article online which researched a simple but important aspect of spinal health and motion. In a study entitled “People with chronic neck pain walk with a stiffer spine” the researchers studied whether people with chronic neck pain walked with less rotation of their body. Essentially when we walk our normal gait involves a certain amount of rotation of our spine, this is referred to as thorax-pelvis rotations. When we walk we also activate what is call the “cross extensor mechanism” this is the simple but important reflex that means when one of our arms move forward the opposite leg moves backwards, and vice versa. This reflex develops when we are babies learning to crawl. This is why it is important for babies not to skip the crawling step in their development, children who do so may have disruptions to their gait as they get older. This may impact on the efficiency of walking and running. As we repetitively activate this cross extension mechanism, as our arms and legs rhythmically swing back and forth, the mid back (thoracic spine) twists (rotates), this is thorax-pelvic rotation. The thoracic spine is adapted to twisting and as it does it allows efficient and balanced transmission of energy form the limbs to enable propulsion. In the study, a group of patients with chronic neck pain were assessed with motion capture technology to measure exactly how much their thoracic spine rotates during walking compared to normal controls. The examination was performed at 3 speeds, 3km/h, 5 km/h and self-selected, with the patients walking with their head in neutral and rotated to 30 degrees. The results of the study demonstrated that overall, the neck pain group showed shorter stride length compared to the control group. Moreover, the patients with neck pain showed smaller trunk rotations, regardless of their speed of walking or their head rotation. In addition the difference in the amount of trunk rotation between groups became larger for the conditions of walking with the head rotated. This lead to the researches concluding that people with chronic neck pain walk with reduced trunk rotation, especially when challenged by walking with their head positioned in further rotation, thereby further stressing their spine. Indicating that chronic neck pain not only affects the neck but also directly affects the thoracic spine and gait. This kind of research is very important to clinicians. In day to [...]

The Irritable Baby

The Irritable Baby Infantile colic is a common early childhood condition that affects approximately one in six infants and is characterised by ‘inconsolable crying and fussing in otherwise healthy thriving infants’1. There has never been agreement about how to diagnose colic due to the fact that there are many different clinical presentations. In view of these difficulties, it is preferred to use the term “Irritable Baby Syndrome” (IBS). There are numerous non-chiropractic treatments available, but most have been shown to be without effect, and most drug preparations have serious side effects. A common drug treatment still used is dicyclomine which helps reduce crying, but may have dangerous adverse effects.2 The cause of infantile colic still remains unknown, however there are several proposed theories which include: (1) gastrointestinal disorder; (2) cow’s milk protein or soy protein sensitivity; (3) infection. Babies are generally considered having “uncomplicated colic” if there is an absence of any other causative conditions. Therefore it is important that the baby has a full examination done by someone trained in paediatrics.   Cow’s milk protein sensitivity: The clinical diagnosis of cow’s milk protein intolerance is made based on the presence of the “triad” of symptoms, which are: (1) Gastrointestinal disturbance, (2) Skin rash, (3) Respiratory ‘wet’ sounds. Common symptoms that are associated with cow’s milk protein intolerance include3: Gastrointestinal - Infant draws up their knees as if in pain and is often flatulent, bloating, chronic diarrhoea, constipation, or an alternating pattern of both Neurological – Disturbed sleep pattern with frequent waking and crying at night Respiratory – Crackles/wet sounds without obvious dyspnoea. Wheezing and rhinitis = snuffly breathing Skin – Maculopapular rash which can occur anywhere on the body. Most commonly found on the face, neck, buttocks or upper arms   Research behind Chiropractic care and colic: There was a study conducted by Miller, Newell and Bolton in 20124 that looked into the efficacy of chiropractic manual therapy (CMT) for infants with unexplained crying behaviour. One hundred and four patients were randomised into two treatment groups; one that received CMT and one that received no treatment. The findings from this study demonstrated a greater decline in crying behaviour in the group that received CMT compared with the group that received no care. The researches further noticed that a majority of the participants that were placed in the group that did not receive treatment withdrew from this study as their [...]

Persistent Concussion Symptoms and Neck Problems – Part 1

Impairment to neck function Over the last few years, there appears to be a greater level of awareness and interest in concussion and the changes which occur in the body post-concussion. In this 3 part article, I would like to discuss Persistent Post-Concussion Symptoms (PPCS) and how the neck may be involved. As a member of the public, you may have noticed an increased level of concern for people who have been concussed, this may be particularly evident when you have been watching sport. The most obvious change over the last few years with concussion and sport is as soon as an individual has suffered from a concussion they are immediately removed from the sporting ground and remain off the ground for a period of time. From this point, before the individual returns to the field, they are required to pass a certain amount of medical testing. This regularly occurs in contact sports as with our football codes, but also occurred most recently in The Ashes in September 2019 when Australian Captain and number one test batsman Steve Smith was ruled out of the team for the fourth test due to a blow to the head. In clinical practice concussion and post-concussion presentations occur in both adults and children and are caused by a wide variety of traumas including sport, motor vehicle accidents, incidental collisions, and assaults. These incidences can initially appear quite mild and innocuous however closer examination can reveal more profound and developed symptoms. My discussion today isn’t particularly focused on the details of concussion, however, I would like to discuss how the neck may be affected in people who suffered from a concussion and how PPCS can manifest in people's necks. In a study conducted in America on April 2019 and published in the Internal Journal of Sports Physical Therapy, an analysis was conducted on 73 children and adolescents who received physical therapy following a concussion1. From this group, the participants were assessed and divided into 4 main categories based upon exactly what type of neck impairment they were suffering.  The main categories were: Postural impairment 99%,  Myofascial impairment (muscles and other soft tissue) 98%, Joint mobility impairment 86% Muscles strength impairment 62%  As can be seen by the categories above the majority of the 73 participants had some kind of impairment to their neck, with a high percentage having multiple impairments. In fact, 90% of the [...]

Persistent Concussion Symptoms and Neck Problems – Part 2

Reduced quality of life in children and adolescents with post-concussion symptoms As I discussed in part 1 of this article there is an increased general awareness regarding concussion and how concussion patients should be managed. We also looked at the number of children and adolescents suffering from Persistent Post-Concussion Symptoms (PPCS) and exactly what type of impairments they suffer from. The previous article drew attention to the high percentages of neck symptoms in PPCS patients. This article, on the other hand, will be about the quality of life of children and adolescents with PPCS The findings below and discussion within deriving from a journal article written by a Canadian Paediatric concussion team published in the Journal of the American Medical Association in 2019. According to the article, before this paper was published there had been no large comprehensive studies that addressed the association between PPCS and health-related quality of life (HRQoL) in children implying a lack of understanding on this topic. The objective of this study was to assess whether there is an association between the HRQoL and PPCS at 4 weeks, 8 weeks and 12 weeks after a concussion injury. In this study, 1667 children aged between 5 and 18 who had presented to the emergency department with a concussion completed a questionnaire that investigated their quality of life at 4, 8 and 12 weeks post-injury. Out of these 1667 children, 510 of them (30.6%) were suffering from PPCS at the time of enquiry. In total, the 510 PPCS children had a lower total quality of life scores on the questionnaires than those who did not suffer from PPCS. Furthermore, the children with PPCS had significantly lower physical, emotional, social and school quality of life scores for all time points at 4,8 and 12 weeks. These results indicate just how common persistent post-concussion symptoms are, meaning that roughly a third of children who are concussed experience affects that measurably reduce their quality of life throughout the entire study. These affect a wide range of the child’s life and affect their physical, emotional, social and scholastic life. Furthermore, children who had a concussion but had no persistent symptoms, essentially children that would have been considered recovered had lower HRQoL scores than children with no history of concussion at 4 and 8 weeks. At 12 weeks there was no significant difference indicating that in this research article it took the concussion [...]

Persistent Concussion Symptoms & Neck Problems – Part 3

Treatment directed towards the neck helps to reduce pain and improve function in patients with post-concussion symptoms In the first 2 articles, I have written on this topic we have learned from recent research that patients who suffer from symptoms after a concussion, commonly known as Persistent Post Concussion Syndrome (PPCS) have a lower quality of life and commonly also complain of neck-related pain and stiffness. As an extension of these articles, we would naturally presume that it may be possible to improve a patient's PPCS symptoms by treating their neck. In this third and final article on this topic, we discuss a research paper published in 2017 which studied the outcomes of treatment to the neck in patients with PPCS with manual and soft tissue therapy. A concussion is typically defined as a mild brain injury, and yet the brain is unlikely to be the only source of persistent post-concussion symptoms. Concurrent injury to the neck, in particular, is acknowledged as a potential source of common persistent symptoms such as headache, dizziness and neck pain. There is an enormous body of research online focussing on the study of concussion, how to prevent it, how to treat it and how to manage it afterward. This research is being conducted by a variety of different professions and institutions worldwide. Research conducted in 2017 in the Journal of Musculoskeletal Science and Practice studied 46 people who were referred to a Physiotherapist for care post-concussion and were assessed based upon their response to care. Out of the 46 people, 32 were reported by the Physio of having a neck component to their problem, a total of 70%. These 32 patients were treated with manual and soft tissue therapy along with a prescription of home exercises to assist eye/head coordination and were gradually encouraged to return to aerobic exercise. This treatment resulted in significant improvements in the function of the patient’s neck and also lead to a significant decrease in pain. The conclusions of this article were that these clinical findings described above give support to the idea that the neck may contribute to persistent post-concussion symptoms, and highlight the value of assessment and treatment of the neck following a concussive injury. As a practitioner who sees patients for these exact problems, it is heartening to read and discover quality research on this topic. I hope you have enjoyed my discussion about concussion and [...]

Headache and Manipulation

Recently I found a research paper conducted by a group of physiotherapists in America which compared the effectiveness of manipulation versus mobilisation and exercise for treatment of headache amongst a group of 110 people. The primary outcome measured in this study was the patient’s headache intensity. Patients were asked to complete a questionnaire to indicate the average intensity of their headache pain on a scale of 1-10 at the beginning of the study in addition to their intensity at 1-week, 1-month, and 3-months following the initial treatment session. Secondary outcome measures included a disability questionnaire, headache frequency, headache duration, and medication intake. On the initial visit patients completed all outcome measures then received the first treatment session. Patients completed 6–8 treatment sessions of either manipulation of the upper neck and upper back, or mobilization of the same areas combined with exercises over a 4 week period. The exact areas of the spine to be treated were left to the discretion of the treating therapist and it was based on the combination of patient reports and examination. The exercises given to the second group was neck flexion exercises during treatment, and 10 minutes take home resistance exercises using a resistance band within their own tolerance. This study is the first clinical trial to directly compare the effectiveness of both neck and upper back manipulation versus mobilisation and exercise in patients with headache. The results suggest 6–8 sessions of manipulation over 4 weeks, directed mainly to both the upper neck and  upper back, resulted in greater improvements in all aspects of the patients headache than the mobilisation/exercise group. This included headache intensity, disability, headache frequency, headache duration, and medication intake. Most importantly the effects of manipulation were maintained at 3 months follow-up. Additionally there were no adverse reactions to either group aside from mild discomfort either at the point of manipulation/mobilisation or post exercise, which is completely normal in clinical practice. The underlying mechanisms as to why manipulation may have resulted in greater improvements than mobilisation plus exercise is still under investigation. In addition our current thinking about how manipulation affects patients positively in clinical practice delves into neurology far more deeply than what is possible in this column. More than likely it has something to do with joint receptors being stimulated which leads to pain reduction, greater range of motion and less muscle spasm. Fortunately in clinical practice patients will vote [...]

Teens and Technology

For this month’s column I found an interesting article online about spinal pain in adolescents and its relation to computer and tablet usage. This study was performed in Brazil, a country which due to government programs has seen a great increase in computer usage throughout all schools over the last 10 years. The use of electronic devices especially in more recent years has become an important part in the lives of adolescents throughout the world, who regularly use computers to carry out academic and leisure activities. The study consisted of 961 boys and girls aged 14–19 years who answered a questionnaire regarding the use of electronic devices and painful symptoms. Specifically these questions related to pain severity, a body diagram for symptom location, and questions related to the use of computer and video games over the last 6 months. The results indicated that the presence of pain was reported by 65.1% adolescents with pain located in the following areas. Thoracolumbar spine (point between the mid and low back), 46.9%.followed by Arm 20%. Neck 18.5% Shoulder blade region (15.8%) The triggering factors for these symptoms were reported as Using a computer 31.8% Physical exercise 20.5% Electronic games 2.9% Adolescents also indicated that pain interfered with activities of daily living like Study tasks 22.8% Sleeping 18.4% Playing sports 17.6% Additionally, 29.7% of adolescents said that the presence of pain made them more nervous. Finally and most importantly 32.1% of adolescents reported that they occasionally made use of analgesics, while another 11.1% reported that they frequently used these drugs. This study is important because it indicates how computer and tablet usage affects adolescents in our modern world. This study assessed a variety of important measures regarding adolescent health. Not only did it demonstrate the percentage of adolescents in pain but also reported on important measures like pain location, triggering factors, activities of daily living and medication usage. As younger generations are exposed to more technological advancement it will be interesting to see how we as a society adapt to these changes. Even now we are realizing that we have to take measures to either assist or limit computer and tablet use in our children. Balancing how much they have to do for school and leisure and supporting them with the best ergonomics possible is a challenge we all have to deal with.   Silva GR, et al. Prevalence of musculoskeletal pain in adolescents [...]

How I Roll

  I’ve discovered over the years especially before and after a gym workout that people will commonly use a foam roller to self-massage. This apparently has benefits to the individual and seems to be a way a person will manage muscle soreness pre and post workout. I’ve always been a bit sceptical about foam rolling as I never thought it really did anything beneficial and was more akin to stretching for the lazy. So I decided to look into whether there’s been any research into foam rolling and surprisingly there was, measuring different aspects of rolling, Ill discuss a couple below. The 3 studies that I’ll focus on today studied the benefits of rolling on the range of motion of a joint. Meaning after a workout was that joint able to move more as a result of the rolling. A few things stood out. The range of motion of the joint (hip extension) immediately increased after rolling the front of the thigh (quads) however these changes were short lived. When the patient was reassessed a week later there was no observable difference. Secondly in another study when foam rolling was performed along with stretching of the quads the range of motion in the hip joint was significantly greater than both rolling and stretching alone. This wasn’t just with the hip joint, there was another study that compared ankle motion.  This study found that foam rolling of the calf alone did not produce any increase in ankle range of motion at all, where calf stretching improved the motion by 6.2%. However as with the hip example above, foam rolling plus stretching increased the range of motion by 9.1%. Studies into foam rolling are still in their early days, however there is some initial evidence that if you are going to roll, it’s important to stretch as well. The extra benefits from both stretching and rolling seem to exceed that of stretching or rolling alone. Also to make a bigger difference it’s important to roll and stretch regularly. You really should stretch and roll whenever you train even if it’s only 15 minutes and you focus on a different region each time. It’ll be more effective than rolling each muscle for 30 seconds then moving on. The long‐term benefits of these interventions are still unknown plus the physiological mechanisms responsible for these interesting findings still need more investigation. As for rolling to [...]