Your practitioner isn’t “fixing” you
Here’s what’s really going on When you’re in pain, it’s natural to want someone to “fix” it. A quick adjustment, a magicneedle, a release. But the truth is — pain is more complex than a tight muscle or somethingbeing “out.” Long-term recovery is about more than just hands-on treatment. At Pittwater Chiro, we often hear praise for “fixing” your pain, and while we’d love to take thecredit, it’s not us who fixed it. We were merely the people who pointed you the way.Whether you’re dealing with back pain, a flare-up in your shoulder, or a niggly hip, youdon’t need to be fixed. You need support, guidance, and the right tools to take controlof your recovery. Pain doesn’t always mean damage (especially when it’s chronic) Many people assume that pain is equal to something torn, out of place, or broken. But this isn’talways the case. The idea of something being ‘out of place’ is often wrong, because ifsomething is truly out of place, then it has been dislocated or subluxed, which would requirea visit to the hospital, not the chiro/physio/osteo. We know that it can feel like something is out of place, though, and that pain is very real. So why does it feel like that? Sometimes, it can be due to altered nerve input/output, or it can be due to increased inflammation in the joint or area of the injury, and sometimes it can be strong muscle guarding to stop you from using that joint. Your body is smart and protective — sometimes too protective. Stress, poor sleep, past injuries, or even beliefsabout your body can amplify pain, even when no structural damage is present. Chronic pain is often more about your nervous system than your tissue. That’s why passive treatments alone don’t always create long-term change. What manual therapy can do This is not to say that manual therapy has no place. Manual therapy like dry needling, cupping, chiropractic adjustments and mobilisation has real value. These modalities can: All of these benefits are pretty important, because without them doing their thing it’s going tobe pretty hard to try to do your homework – like exercise, load management, and some otherstrategies your practitioner may recommend. Manual therapy is also most powerful whencombined with education, rehab, and consistent movement. That’s where lasting changehappens — and it’s what we focus on in the clinic. The pain gate theory: why movement and manual therapy work The pain gate theory explains how the brain filters pain signals. When you experiencemovement, pressure, or non-threatening input (like massage or joint mobilisations), it canclose the gate to pain signals travelling up the spinal cord. This reduces the intensity of pain and helps rewire the brain’s pain pathways — especiallyimportant for avoiding chronic pain. In simple terms: movement and manual therapy changehow your nervous system perceives danger. Less danger equals less pain. What else can my practitioner help with? What’s the point in seeing someone ifThey’re not “fixing” me? We’re not here to fix you. We’re here to guide you. We help you understand your pain orinjury by effectively diagnosing what is going on and giving you clear expectations ofrecovery time frames. We can also guide you on what not to do and what to do at home tohelp shorten the recovery timeframe. And, as mentioned above, we can dull your pain enough to be able to comfortably do whatyou need to do. We could use hands-on treatment to reduce symptoms and improvemobility. We can build strength and capacity through tailored rehab, and we empower you tofeel confident in your body again. You’re not broken – you just need the right tools You’re more resilient than you think. With the right approach, education, and consistenteffort, most injuries and pain states can improve — without relying on someone else to do allthe work. If you’re ready to feel strong, mobile, and back in control, we’d love to support you.
The Bucket Analogy: How we can understand and prevent injuries
When aches, pains, or injuries seem to appear out of nowhere, understanding and managing stress is key. Using the bucket analogy, we can visualize our capacity for handling physical, psychological, and environmental stressors. This blog explores what fills our bucket, the risks of overflow, and practical strategies to empty it, promoting better health, performance, and injury prevention.
Medications for low back pain
Low back pain (LBP) is a prevalent condition affecting millions worldwide, often prompting individuals to seek relief through medication. Understanding the array of options available and their respective efficacies is crucial for both patients and healthcare providers. Below we will provide three recommendations based on the current evidence. Then we will delve further into the most commonly prescribed and recommended medications for low back pain. This is based on the latest evidence, highlighting how effective they are for treating LBP and the associated risks for these medications. Based on the current research you can take away three recommendations. Acute/Sub-Acute (<3 months duration) Low Back Pain Recommendation: Considering that the majority of patients experiencing acute or subacute low back pain tend to recover spontaneously irrespective of treatment, patients are advised to opt for non-pharmacologic options. These may include superficial heat therapy, massage, acupuncture, or spinal manipulation. However, if medication is preferred, clinicians and patients should choose nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants for short-term use. For more information on what to do with a new episode of back pain, read Jess’s blog – navigating-a-new-episode-of-low-back-pain. Chronic (>3 months duration) Low Back Pain Recommendation Step 1: In the case of chronic low back pain, clinicians and patients are advised to first consider nonpharmacologic interventions. This is due to the adverse side effects from most of the medications recommended for chronic low back pain. These nonpharmacologic interventions include exercise, multidisciplinary rehabilitation, acupuncture or dry needling, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioural therapy, or spinal manipulation. For more information on the benefits of maintenance care for low back pain, read Jess’s blog – maintenance-care-for-chronic-low-back-pain Step 2: If non-pharmacologic therapy fails to adequately address chronic low back pain, clinicians and patients should contemplate pharmacologic options. Nonsteroidal anti-inflammatory drugs are recommended as the first-line treatment, followed by tramadol or duloxetine as second-line choices. Opioids should be considered only as a last resort for patients who haven’t responded to previous treatments. Also, this should only happen after an open discussion between the GP and patient. For more information on the different types of medication, see below: Acetaminophen (AKA paracetamol) e.g. Panadol Despite its widespread use, recent evidence suggests that paracetamol may not be as effective as once believed for acute LBP. Studies have shown no significant differences in pain relief between paracetamol and placebo, challenging its efficacy in managing this condition. While acetaminophen carries a lower risk of adverse events compared to NSAIDs, its effectiveness in chronic or radicular LBP remains uncertain. Non-steroidal anti-inflammatory drugs (NSAIDs) e.g. Ibuprofen, Naproxen, Advil, Voltaren NSAIDs are commonly recommended as the first-stop medication for low back pain due to their anti-inflammatory properties. Studies have demonstrated greater mean improvements in pain intensity with NSAIDs compared to placebo for both acute and chronic LBP. However, NSAIDs are associated with a higher risk of adverse effects, particularly gastrointestinal issues, emphasizing the importance of cautious use. Opioids e.g. Oxycodone, Morphine, Tramadol and Tapentadol Opioids are often prescribed for severe or chronic low back pain when other treatments have failed. While some trials suggest short-term relief with opioids, there is low quality and limited evidence to suggest long-term relief from pain. Furthermore, there are concerns regarding their safety and potential for addiction, overdose, or drug abuse. This highlighting the need for judicious prescribing and close monitoring. Systematic reviews also found short short-term use of opioids had an increased risk of nausea, dizziness, constipation, vomiting, drowsiness, and dry mouth. Skeletal muscle relaxants e.g. Methocarbamol, Cyclobenzaprine Skeletal muscle relaxants are sometimes recommended for short-term relief of acute LBP, albeit with a caveat of increased risk for adverse effects involving the central nervous system, particularly sedation. Studies have shown superior pain relief with skeletal muscle relaxants compared to placebo in the short termevidence for their efficacy in chronic LBP is lacking. Benzodiazepines e.g. Valium Benzodiazepines are occasionally prescribed for low back pain, although evidence supporting their effectiveness is limited, low quality and inconsistent. Research also suggests a greater risk for central nervous system adverse events, including drowsiness, fatigue, and lightheadedness. There are no clinical trials designed to evaluate the risk for addiction, abuse, or overdose, again suggesting against their use and prescription for back pain. Antidepressants e.g. Endep Low-dose tricyclic antidepressants, e.g. amitriptyline (Endep), and selective serotonin reuptake inhibitors (Lexapro), have limited evidence to suggest a difference in pain levels in individuals with chronic back pain. However, some studies found that the serotonin-norepinephrine reuptake inhibitor, duloxetine, has shown promise in providing modest relief for chronic low back pain. Recent trials suggest that duloxetine may be more effective than placebo in improving pain and function, albeit with increased risk of adverse events such as nausea and withdrawal symptoms once ceasing the drug’s use. Due to conflicting findings and the associated adverse effects, further research is needed to elucidate the role of antidepressants in managing low back pain and to explore their comparative effectiveness with other medications. Anti-seizure medications e.g. Pregabalin, Gabapentin Anti-seizure medications, such as pregabalin and gabapentin, have been evaluated for their efficacy in low back pain, particularly in cases of radiculopathy. However, evidence for their effectiveness remains inconclusive, with some studies reporting inconsistent results and methodological shortcomings. Overall evidence suggests no effect on pain levels and functions for both acute and chronic low back pain. Additional research is warranted to determine the optimal use of antiseizure medications in the management of low back pain. Systemic corticosteroids e.g. Prednisone Systemic corticosteroids do not appear to be effective for treating acute non-radicular low back pain or spinal stenosis. There is insufficient evidence to support their use for chronic non-radicular pain. For radicular low back pain which is back pain that refers to one or both legs, several trials consistently found no significant differences in pain relief between systemic corticosteroids and placebo, although one large trial suggested a small improvement in function with corticosteroids at 52 weeks. However, corticosteroid use was associated with an increased risk
Exploring the Interconnectedness of Chronic Pain and Mental Health Disorders
Both chronic pain and mental health disorders are extremely common conditions within the general population. Up to 80% of Australians will experience back pain in their life, and it is the leading cause of loss of work and income poverty in Australia. It’s estimated that 43.7% of Australians have experienced a mental health disorder in their lifetime. Epidemiological studies suggest a bidirectional relationship is present between mental health disorders and chronic pain. Observations from these studies even suggest shared neural mechanisms for these conditions. These neural mechanisms are referred to as the pain matrix. There are many reasons an individual may suffer from chronic pain, however, in this blog post, we will mainly discuss the impact of musculoskeletal causes of chronic pain. Chronic pain is defined as a persistent discomfort that lasts longer than 3 months, creating interference with activities of daily living, due to fear avoidance behaviour. Additionally changes to an individual’s mood, relationships, sleep and overall quality of life are often negatively impacted when suffering from a chronic pain condition. An individual suffering from chronic pain is at an increased risk of depression, anxiety, substance abuse disorders, and suicide. For more information on how to manage chronic low back pain effectively, read Jess’s blog on maintenance care for low back pain. What is the pain matrix? The “pain matrix” refers to a network of brain regions involved in the perception and processing of pain. It’s a term used in neuroscience to describe the complex system that coordinates the experience of pain within the brain. The pain matrix involves various regions of the brain that work together to process and interpret pain signals. Regions of the brain Somatosensory Cortex: Responsible for processing sensory information, including pain, and identifying the location and intensity of the pain. Thalamus: Acts as a relay station for sensory information, directing signals from the spinal cord to the different areas of the brain involved in processing pain. Insular Cortex: Plays a role in integrating sensory information, emotions, and cognitive processes related to pain perception. Anterior Cingulate Cortex (ACC): Involved in the emotional aspects of pain, such as the unpleasantness or distress associated with it. It also helps regulate attention and decision-making related to pain. Prefrontal Cortex: Responsible for higher cognitive functions, including decision-making, memory, and emotional regulation related to pain perception. It’s important to note that as the interpretation of pain occurs along different levels of our nervous system, and within these levels are various synapses and pathways, these are essentially the delivery system of the pain message to the next region of our brain or nervous system. This is important because we have the potential to alter the message that is sent to the next level of the pain matrix. We can amplify it, or attempt to stop it in its tracks, meaning pain can be either intensified or softened by our emotional and behavioral states. The pain matrix operates dynamically and can be influenced by various factors, including emotions, past experiences, expectations, and individual differences. For example, factors like anxiety, stress, or attention can modulate the perception and experience of pain by affecting how the pain matrix functions. The link between chronic pain and mental health disorders – a vicious cycle Research shows a clear link between individuals suffering from a chronic pain condition and the presence of depressive symptoms and major mood disorders. For example, an individual suffering from fibromyalgia, chronic back pain, temporomandibular joint disorders, or chronic abdominal pain is 50% more likely to suffer from a high-level depressive disorder. There is an estimated prevalence of depression exceeding 20% in those suffering from painful arthritic conditions, migraine headaches, and pelvic pain. A population-based study involving 845 adults who had mild or disabling neck or lower back pain found that these individuals were 2.0 – 2.5 times more likely to experience a depressive episode at 6 – 12 month follow-ups when compared to individuals without back pain. On the flip side, pain-free individuals who suffered extremely elevated levels of depressive symptoms were 4 times more likely to develop lower back or neck pain at the 6 – 12 month follow-up when compared to individuals with lower levels of depressive symptoms. Similar studies also concluded that the rate of depression increased with greater pain severity. These findings suggest a bidirectional relationship between chronic pain and depression, in which one condition can worsen the other. They also suggest the severity of depression can be heightened by the intensity of the pain, and vice versa. Not only that, but imaging of the brain also displays alterations in regions of the brain responsible for the processing of emotional stimuli and pain stimuli in those suffering from chronic pain and depressive disorders. So how do we address this connection? Addressing the link between mental health disorders and chronic pain is a very important first step to managing these conditions. It is important to understand that pain is extremely multi-faceted, and the more research that is done on pain the more we understand there is a lot more than biomechanical causes of pain. When managing a chronic pain condition it is important to implement the following approaches into your care plan: Holistic Approach to Treatment Treating chronic pain should involve a holistic approach that considers both physical and mental well-being. Integrated therapies that address both aspects can be more effective. This could mean seeing a chiropractor alongside seeing a psychologist. It also means addressing your well-being as a whole; look at what you’re eating, and drinking, how you spend your day, your social support systems, how you’re sleeping, etc. Mental Health Support Patients with chronic pain should have access to mental health support services like counselling or therapy to cope with emotional distress. As discussed, there is a bidirectional relationship between chronic pain and depressive symptoms, and while you might not think therapy or psychology is for you, cognitive behavioural therapy has very favourable results in managing chronic pain and depressive disorders. Cognitive behavioural therapy should only
Shockwave
In the realm of modern medicine, shockwave therapy has emerged as a groundbreaking treatment option for various musculoskeletal conditions and injuries. This non-invasive and highly effective technique utilises acoustic waves to promote healing, alleviate pain, and restore functionality. In this blog post, we will delve into shockwave therapy’s benefits, how it works, and the wide range of conditions it can treat. What is Shockwave Therapy? Shockwave therapy, also known as extracorporeal shockwave therapy (ESWT), is a procedure that involves the application of high-energy acoustic waves to affected areas of the body. These acoustic waves are generated by a device and directed towards specific anatomical regions, stimulating the body’s natural healing processes. How Does it Work? The mechanism behind shockwave therapy is fascinating yet straightforward. Here’s how it works: Stimulating Cellular Response: When the acoustic waves reach the targeted tissue, they create microtrauma at the cellular level. This microtrauma triggers a series of biological responses within the body. Blood Flow and Neovascularisation: One of the primary effects of shockwave therapy is the promotion of blood circulation. This increased blood flow accelerates the body’s healing capabilities by supplying essential nutrients and oxygen to the damaged tissue. Release of Growth Factors: Shockwave therapy stimulates the release of growth factors, which are essential for tissue regeneration and repair. This, in turn, aids in reducing inflammation and pain. Dissolution of Calcifications: Shockwaves can break down calcifications or calcium deposits within tendons and other soft tissues. This is particularly useful for conditions like plantar fasciitis and calcific shoulder tendinitis. Pain Reduction: The therapy also has a pain-relieving effect by inhibiting pain signals and reducing muscle tension around the affected area. What are Shockwave Therapy’s Benefits? Shockwave therapy has gained recognition and popularity for its versatility in treating various musculoskeletal conditions and injuries. Here are some of shockwave therapy’s benefits for some common issues: Plantar Fasciitis: Shockwave therapy is a proven treatment for the painful foot condition known as plantar fasciitis, which affects the sole. Tendinopathies: It is highly effective in treating tendinopathies such as achilles tendonitis, tennis elbow, and rotator cuff tendinitis. For more information on rotator cuff injuries, read our blog. Calcific Tendinitis: For conditions involving calcium deposits within tendons, shockwave therapy can help dissolve the deposits, promoting healing. Bone Healing: Some studies suggest that shockwave therapy can accelerate the healing process for certain bone fractures. Myofascial Pain Syndrome: Patients suffering from myofascial pain syndrome, characterized by trigger points in muscles, can benefit from shockwave therapy. Shockwave therapies non-invasive nature and versatility make it a valuable tool in the world of musculoskeletal medicine and rehabilitation. If you’re experiencing pain or discomfort related to any of the conditions mentioned above, consider discussing shockwave therapy with your chiropractor as a potential treatment option to get you back to doing what you love. By Dr Jess Milsom (B.Chiro Sc, M.Chiropractic)
Rest is not always the answer
Instinctively most of us want to rest after injuring ourselves. While this seems logical, it’s not always the best decision. The acronym taught to us by all first aid courses is RICER. Rest, ice, compression, and elevation (and referral) will help to reduce inflammation in the first 24 – 48 hours of injury. However, once the inflammatory process begins to settle returning to some modified activity will help to reduce the likelihood that this pain will become long-term. Active Recovery vs. Rest Prolonged rest – around two to three weeks following the initial injury – may have little effect on pain levels or worsen your pain. This is especially true for low back pain and soft tissue injuries. When we rest for too long, our muscles, parts of the nervous system, and the cardiovascular system begin to decondition. This means you can’t tolerate activities in the same way you used to. Think about how you feel going back to the gym after a long holiday, or after being sick, it’s never as easy as you remember. There’s a growing body of research that points to exercise as an effective form of pain relief, in fact, progressive movement and load should be prescribed for most injuries. This is why instead of the acronym RICER, there is a move towards a new acronym: PEACE and LOVE. PEACE and LOVE Protection – Avoid activities and movements that increase pain within the first few days after injury. Elevation – Elevate the injured limb higher than the heart (if possible). Avoid anti-inflammatories – These can reduce tissue healing. For more information on medications to take with pain, read our blog. Compression – Use an elastic bandage or tape over the injured site. Education – Understand the best treatment methods and the benefits of being active during recovery. & Load – Let pain guide your gradual return to activity. Optimism – Condition your brain for the best recovery. Vascularisation – Choose pain-free activities that increase the blood flow to the repairing injury. Exercise – Restore strength, mobility and proprioception by including exercise in your recovery. Current Research Research suggests that exercise can help to reduce pain intensity and frequency and improve mood. In fact, some research points to exercise being as effective as painkillers through the release of endogenous opioids i.e., endorphins. These are molecules are produced naturally by the body from our brain. It’s thought that these endorphins create an ‘exercise-induced euphoria’ and reduce our pain perception. The great thing is that it doesn’t come with the negative side effects which can be associated with painkillers. The best type of exercise will be dependent on what you enjoy most and what you’re most likely to do. Working alongside a health practitioner will ensure you return to exercise activities safely and gradually. Returning to exercise at pre-injury levels may aggravate the injury and a graded response will always be the best approach.
Welcome Our New Chiropractor: Dr Braeden Melmer
We are thrilled to introduce our newest team member at Pittwater Chiro, Dr Braeden Melmer. With a deep passion for chiropractic and a wealth of experience, Dr Braeden Melmer is eager to start treating the patients in the Balgowlah and Mona Vale community. Personal Background Dr. Braeden Melmer was inspired to pursue chiropractic by his own experiences with injuries growing up in Canada. As an avid ice hockey player, he frequently found himself in need of treatment. His chiropractor, Dr. Leonard Jay, was instrumental in helping him recover and return to the sport that he loved. This early exposure to the benefits of chiropractic sparked a fascination, he recalls thinking, “How great would it be to have this kind of knowledge to help people get back to what they love doing?” His educational journey began with a degree in Biomechanics from Guelph University, completed in 2010. He then attended the Canadian Memorial Chiropractic College (CMCC) in Toronto, where he earned his Doctor of Chiropractic degree in 2014. Dr. Braeden Melmer didn’t stop there; he furthered his expertise by obtaining a diploma in acupuncture from McMaster University. Outside of his professional life, Dr Braeden Melmer enjoys spending time with his girlfriend, Kim and Labrador, Lando. He keeps active by playing ice hockey, strength training, golf, and surfing. These hobbies keep him connected to the sports world and cement his passion for health and fitness. Professional Experience With a decade of experience as a chiropractor, Dr. Braeden Melmer specialises in treating sports and postural work injuries. His holistic and individualised approach to patient care ensures that each patient receives a tailored treatment plan. “No one-size-fits-all solution exists,” he emphasises. One of the standout moments of his career was being invited to speak at the annual Massage and Myotherapy Sports Conference in Brisbane, highlighting his expertise and dedication to his field. Philosophy and Approach Dr Braeden Melmer’s philosophy centres on a unique and holistic approach to patient care individualised for each person. He stays updated with the latest advancements in chiropractic techniques through research databases, podcasts, and collaborations with colleagues. Patients meeting Dr Braeden Melmer for the first time can expect a welcoming and relaxed environment. The initial visit involves getting to know each other, conducting a thorough history, and performing an individualised assessment to determine a diagnosis and a tailored management plan. At Pittwater Chiro Joining the team at Pittwater Chiro excites Dr Braeden Melmer because of the shared ideals and philosophies on patient care. He looks forward to being part of a prestigious clinic, well-established as the “go-to” within the local community. Dr. Braeden Melmer is particularly enthusiastic about treating sports injuries, especially those affecting the shoulders, hips, knees, ankles, and elbows. Additionally, he aims to offer services in concussion management and nutritional support. Patient Engagement Dr. Braeden Melmer advises bringing any previous medical files and imaging, as they can help diagnose and treat your condition. He reassures new patients to “breathe,” noting that chiropractic is not solely about adjustments. Treatments are diagnosis-dependent, and there are always multiple options to ensure patients feel comfortable with their treatment plan. Community and Impact Dr Braeden Melmer plans to engage with the local community by connecting with local businesses, gyms, and studios. He also intends to participate in local fundraisers and activities that his patients are involved in, and he looks forward to meeting the avid golfers in the area. His goals for the coming year include continuing the high-quality patient care and commitment that Todd and Pittwater Chiro have established and extending their health message and vision to become a cornerstone of health for the local and surrounding communities. We are confident that Dr Braeden Melmer will be an excellent addition to our team. We encourage you to book an appointment with him to experience his expert care. If you want to know more about him, click the links for his Instagram and website.
