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									Health
                   THE                                            Canada’s
                                                                  Source for the
                                                                  Rehabilitation
                                                                  Industry


PROFESSIONAL                                                      FALL 2010




    The Vital Role of Neurofunctional Acupuncture
      Performance Care for the Professional Athlete
          Sports Medicine and the Law
              Active Body, Healthy Mind




                                        Also inside
                                               Sport as Balance     Frank Augustyn’s
                                               Therapy              Remarkable Recovery
TheHealthProfessional.ca   PM41956516          Page 18              Page 32
contents FALL 2010                      www.TheHealthProfessional.ca




                                                                         14




                                                                         16



                                    EdiToRiAl

                                     4 Taking the Never out of Never
                                       the Twain Shall Meet
11 Active Body, Healthy Mind
                                    iSSuES in MEdicAl REHABiliTATion

25 The Vital Role of                22 Advances in the Assessment and
     Neurofunctional Acupuncture       Treatment of Concussion

                                    REgulATion MATTERS
28 Sports Medicine, Risk
     Management and the Law          8 The MIG Takes Flight
                                    16 Patient Care in an Age of
                                       Regulatory Reform
30 Performance Care
     for the Professional Athlete
                                    PRoFilES

                                    32 A Tale of Two Artists
 6 Kicking it Up a Notch
                                    liSTingS
14 And the Show Went On…
                                    34 Events Calendar
20   Sport as Balance Therapy       34 Classifieds




                                          www.thehealthprofessional.ca    3
                                                                                                             Health
FRoM THE PuBliSHER
                                                                                                                          THE




Taking the Never out of                                                                                      PROFESSIONAL

Never the Twain Shall Meet
                                                                                                             Canada’s Source For The Rehabilitation Industry




                             Rudyard Kipling’s idiom is based on the idea that peoples, regions and
                          domains can be so different that we might as well give up hope of working         The Health Professional magazine
                                                                                                                     is published by
                          with them or having them work together.
                                                                                                            Medical Professionals Media Group
                             When we planned this third issue of The Health Professional, we knew
                                                                                                                  9200 Dufferin Street
                          we had a great theme in “Lessons from the World of Sports,” but strug-                      PO Box 20010
                          gled with how to present it. The idea is that health disciplines’ specialized          Vaughan, ON L4K 0C8
                          methods and techniques applied for the recovery and enhancement of
                          performance in athletes can be applied to great effect to the rehabilitation           PHONE 416-778-1277
of persons whose lifestyles are more sedentary.                                                                TOLL-FREE 1-877-293-1277
    Three primary questions were posed. 1. Are techniques for treating athletes and sports injuries               FAx 1-877-293-4003
also applicable in the rehabilitation of non-athletes? 2. Can rehabilitation strategies offer insights
into injury prevention? 3. Does exercise contribute to rehabilitation and even mental health?               www.thehealthprofessional.ca
    In the midst of our struggle, magic started to happen. Frank Augustyn and Arto Yuzbasiyan               ___________________________
welcomed our overture to tell their stories of catastrophic injury and recovery. Members of
McMaster’s medical faculty agreed to write articles about their remarkable case studies, and a                             PuBliSHER
                                                                                                                     Maria Kelebeev
prominent law firm and an orthopaedic surgeon offered a legal perspective on return to play. Then
                                                                                                            publisher@thehealthprofessional.ca
a leading practitioner of sport and performance psychology presented some insights into exercise
and mental health, and we received a number of other thought-provoking articles about innovative
                                                                                                                              EdiToR
approaches to treating athletes. This third issue was convincingly underway!                                         Sandra Leppan
    The function of the coach is to train and challenge the athlete, and the goal of the agent is to         editor@thehealthprofessional.ca
find the best environment for the athlete to express his or her talent. However, the role of the
health professional is even more fundamental, resulting in broad responsibility and accountability                     conTRiBuToRS
for those who care for athletes.                                                                                 Alejandro Elorriaga, MD
    Health professionals must have the knowledge and expertise to treat athletes’ injuries and help          Daniel Gallucci, BSc, CSCS, D.Ac
prepare them physically and mentally for optimum performance, while also motivating, encour-                 Michael Prebeg, DC, BSc, CSCS
aging and protecting. Rehabilitation practitioners must be responsible, innovative and resourceful                  Julie Entwistle, OT
to enable recovery in those in urgent need, to help those who are disadvantaged to overcome ob-                     Sari Shatil, PT MSc
stacles and see progress, and to counsel those who should take some time off to heal.                          Kate F. Hays, Ph.D., C.Psych
                                                                                                                   G. Joseph Falconeri
    The article about “Performance Care” describes how the techniques that help professional
                                                                                                                  Leigh Harrison-Wilson
hockey players recover from injuries can also be applied to healthy athletes to help extend their
                                                                                                               Darrell J. Ogilvie-Harris, MD
careers – or, indeed, to non-athletes who want to remain fit and healthy as they age.                                  John Filo, DC
    Another article examines our growing understanding of concussion, particularly in the world                        Charles Spina
of soccer. Unfortunately, there wasn’t space in a single article for discussion of some additional in-                Michael Greco
triguing aspects of concussion: the long list of hockey players whose professional careers were                       Sandy Leppan
ended by concussion, the evidence that a head injury in early adulthood sharply increases the like-
lihood of developing major depression later in life, and the finding that any type of head injury                        AdVERTiSing
doubled veterans’ odds of developing Alzheimer’s disease and other types of dementia.                             Simon Leyderman
    There is growing interest in using dance, yoga, sports and recreational activities as therapy for         ads@thehealthprofessional.ca
stroke and other injuries, and evidence that martial arts can help the most vulnerable populations
build self-confidence, ingenuity and judgment. Regular exercise has been shown to be as effective                       ART diREcToR
as both psychotherapy and medication in alleviating clinical depression, and physical activity can                   Artur Palvanov
                                                                                                             artwork@thehealthprofessional.ca
serve a powerful preventive as well as a rehabilitative function.
                                                                                                            ___________________________
    Managing a publication of The Health Professional’s scope is not only a labour of love but is a
labour of conviction as well. Building bridges and imparting knowledge is what we are all about.
So, while we admire Kipling the novelist and adventurer, with due respect, we think he got the
twain thing wrong. ggg


                                                                       Maria Kelebeev, Publisher
                                                                       publisher@thehealthprofessional.ca




4         The Health Professional FAll 2010
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                               2011 Exhibition: November 16 & 17
                              Metro Toronto Convention Centre
                              Toronto, Ontario, Canada
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iSSuES in MEdicAl REHABiliTATion




    Kicking it
                                                                            The benefits of participating in any martial art,
                                                                        from Tai Chi to karate, are well known. Strength,
                                                                        flexibility, endurance, balance and agility are chal-
                                                                        lenged during every class. Emotionally, partici-
                                                                        pants experience improvements in mood and
    By Julie Entwistle, oT
                              Up a Notch
                                                                        mood regulation, confidence, self-discipline and
                                                                        self-esteem. Cognitively, participation in martial
                                                                        arts improves memory, coordination, concentra-
                                                                        tion, attention, focus and judgment as participants
                                                                        learn the fighting forms and make quick decisions




    A
                                                                        about how to physically react to different stimuli
              s an occupational therapist with a black belt in          and hypothetical situations. Behaviourally, martial
              karate, I have come to appreciate the benefits of         arts promote discipline, respect, impulse control
              martial arts as a rehabilitation modality for chil-       and the motivation to continue training because
                                                                        of the positive reinforcement that comes with
    dren and adults with physical, emotional, cognitive or be-          achieving the various belt levels. Spiritually, most
    havioural disabilities. Karate can also be beneficial for in-       martial artists develop an inner feeling of peace
    dividuals with developmental disorders, certain types of            and a calm ability to be one with the physical self.
                                                                        As the saying goes, in karate you wear your rank in
    autism, cerebral palsy and attention disorders. Adults with         your heart and not around your waist.
    depression or social anxieties, brain injury, stroke, early             A typical martial arts membership costs about
    Parkinson’s or Alzheimer’s can often delay the onset of             $1,000 per year, which is in line with other orga-
                                                                        nized activities such as hockey, dance, skating,
    disability or functional decline by incorporating martial           gymnastics and fitness programs (especially with
    arts into their weekly routine. With medical supervision,           a trainer). The cost of recreation and leisure pro-
    people recovering from cardiovascular conditions can also           gramming is easily justified to insurers (specifi-
                                                                        cally auto insurance, but also WSIB or LTD, de-
    engage in martial arts for cardio reconditioning.                   pending on the policies of such programs and the
                                                                        perceived benefits) when the target is physical,
                                                                        emotional, cognitive and behavioural benefit. Ka-
                                                                        rate dojos often offer free introductory classes in
                                                                        order to give clients an opportunity to try this
                                                                        form of therapy before making a commitment.
                                                                        Many facilities also have viewing areas that would




                                                                                     “  Adults with depression or
                                                                                 social anxieties, brain injury,
                                                                          stroke, early Parkinson’s or Alzheimer’s
                                                                       can often delay the onset of disability or
                                                                    functional decline by incorporating martial

                                                                                                              ”
                                                                       arts into their weekly routine.
6         The Health Professional FAll 2010
allow a health professional to observe a class and offer the
instructor suggestions on how to modify techniques or
their teaching style to suit the client’s abilities.
    Karate memberships have been successfully included
on some paediatric treatment plans. When karate was ap-
proved for a seven-year-old client with an acquired brain
injury, I went with his father to watch the first class. In
thirty minutes of karate, this child did more running,
jumping and weight bearing through his affected side than
I had been able to facilitate during many in-house OT ses-
sions. Speaking in front of the class helped with his speech
issues and confidence, and he learned part of a kata routine
(cognition) and practised how to fall forward without in-
juring himself should someone push him from behind on
the playground. Children or young adults with learning or
coordination problems might take longer to learn new
routines, but in time they are able to perform them in front
of the class to earn their next belt level.
    When a client with a hearing impairment joined an
adult class, he was unable to follow the instructor’s instruc-
tions but would do push-ups until everyone stopped be-
cause he did not hear how many to do. All the instructors
were eager to learn to assist this student, so we developed
ways to modify their teaching to provide more visual rather
than verbal instruction.
    As with any activity, participation in martial arts carries
certain risks, including risk of musculoskeletal injury when
kicking, punching or sparring. Instructors should be edu-
cated about any limits to participation (members with
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quickly and with minimal injury. For a potentially vulner-                                            Visit our website at www.kosim.ca
able child or adult with a disability who could be seen as an
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                                                                                                Fu
cape could make victimization less likely. Not being as                                            ll
                                                                                                Ma Ran
                                                                                                   s
fearful of victimization has a positive impact on socializa-
                                                                                                        g
                                                                                                Ta sag e
                                                                                                  ble e
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tion and to feeling confident enough to venture into the
community without worry. ggg
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                                                                                           www.thehealthprofessional.ca                   7
REgulATion MATTERS




The MIG Takes Flight
Be sure to reset your autopilot
By charles Spina




T
         he pun is intentional, even if the parallels are accidental.    This writer does not intend to wade into the fairness or adequacy
         The first MIG aircraft, the Model 1, was a low-wing mono-       debates. However, this article will comment on the MIG’s many
         plane of mixed construction with a taildragging undercar-       implications for patients and practitioners and it will outline how, in
riage. It underwent a number of improvements before the last one         a MIG world, practitioners can still navigate care pathways in a way
was retired in 1944.                                                     that lessens the probability of assessment and treatment disruptions
    Sixty-six years later we have the Minor Injury Guideline with its    for patients.
$3,500 benefit maximum for non-catastrophic injuries – compared              As the character who plays Robert McNamara in the movie 13
to the current limit of $100,000. Its introduction is anticlimactic, as  Days exclaimed to his trigger-happy, bow-shot-firing Navy counter-
it follows a protracted review that seemed to drag on without end,       part, his precipitous act was “language” whose expression must be
and it is receiving mixed reviews. As in the world of aeronautical       carefully considered to avoid misunderstanding of intent.
design and construction, it is also a safe bet – indeed it is the stated     The MIG is powerful language indeed, and it leaves no doubt
intention – that someday this MIG will be superseded by the next         that the regulator continues to include within its purview and pre-
best thing in the regulation and administration of auto                  rogative the dissemination of what it views as optimal clinical prac-
injury benefits.                                                         tice for the management of injuries covered under the SABS. Wit-
    The MIG first saw the light of day as Section 40 of Auto Insur-      ness the Pre-Approved Framework Guidelines Project of 2007
ance Regulation 34/10 published in Feb-                                                             during which FSCO commissioned at
ruary of this year. In June further details                                                         least one background paper and consulted
were presented as Superintendent’s Guide-
line No. 02/10. Regulation 34/10 is one of
six that resulted from the year-long review
                                                       “       The SABS could be
                                                    viewed as a public/private
                                                                                                    widely with insurers and health profes-
                                                                                                    sionals to gain a better understanding of
                                                                                                    best intervention, assessment and treat-
of Part VI of Ontario’s Insurance Act (see                                                          ment practices for WAD I and II injuries.
the articles Ontario Auto Insurance Re-
                                                     trust whose disbursements                          The MIG sets additional precedents
forms and Understanding Practice Risk in                  are for the benefit of                    that cannot be ignored, and providers and
the Spring issue of The Health Professional)                                                        insurers might justifiably interpret its lan-
                                                                 claimants.
and will be in effect for accidents occurring
September 1, 2010 and later.
    FSCO states the objectives of the MIG as:
                                                                               ”                    guage as intent to get into their respective
                                                                                                    backyards. Readers are strongly encour-
                                                                                                    aged to read the Guideline.
    1. Speeding access to rehabilitation for minor MVA injuries              In some important respects, the MIG is an extension of the PAF
    2. Improving the utilization of health care resources                model beyond WAD I and II injuries. The regulation states that a
    3. Providing certainty around costs and payments for insurers        minor injury means a sprain, strain, whiplash-associated disorder,
          and regulated health professionals                             contusion, abrasion, laceration or subluxation, and any clinically as-
    4. Providing immediate access to treatment without insurer           sociated sequelae. The term “minor injury” is intended to apply to
          approval for minor injury assessments and treatments           one or more of the following injuries.
    Within the $3,500 maximum, there is a pre-approved limit of              Sprain: An injury to one or more tendons or ligaments or to one
$2,200 for assessments, treatments, supplementary goods and ser-         or more of each, including a partial but not a complete tear
vices (maximum $400) and discharge reporting, which are supposed             Strain: An injury to one or more muscles, including a partial but
to follow a prescribed service blocking and sequencing model. The        not a complete tear
pre-approval applies provided an eligible health practitioner pre-           Subluxation: A partial dislocation of a joint
pares and signs the treatment confirmation using the new version of          Whiplash injury or whiplash-associated disorder: Accelera-
the OCF-23 form.                                                         tion-deceleration injury to the neck that does not exhibit objective,
    The MIG was controversial before it even got off the ground.         demonstrable, definable and clinically relevant neurological signs



8         The Health Professional FAll 2010
and is not accompanied by spinal fracture or dislocation
    The MIG, then, applies to the large majority of MVA injuries,
possibly as many as 80%. The regulation further states that the                “ The even got offcontroversial before it
                                                                                     MIG was
                                                                                                   the ground.
OCF-18 (treatment and assessment plan form) can continue to be
used to apply for benefits under the new $50,000 limit for serious
injuries, but it sets out a major proviso, quoted verbatim below to
                                                                                                              ”
                                                                           ultimately denied by insurers or their independent adjusters. Pro-
ensure that readers understand its definitive language.
                                                                           viders would be well advised to update their referral intake proce-


      “
                                                                           dures to determine whether or not their patients have optional auto
          Only in extremely limited instances where                        benefits coverage.
 compelling evidence provided by a health practitioner                         Providers who strongly believe that patients’ injuries fall outside
satisfactorily demonstrates that a pre-existing condition                  the MIG and who can support their contention with credible evi-
                                                                           dence should also consult with patients’ auto claims adjusters to ob-
will prevent a person from achieving maximal recovery                      tain pre-approval. Given the importance of patient service and as-
from the minor injury for the reasons described above is                   sessment/treatment continuity, pending their negotiations with
  the person’s impairment to be determined not to come                     insurers they should also ensure that their patients fully understand
 within this Guideline. Exclusion of a person from this                    what their payment obligations are for denied claims.
                                                                               The SABS could be viewed as a public/private trust whose dis-
 Guideline based on reasons or evidence falling short of                   bursements are for the benefit of claimants. Its moral, if not legal,
 this requirement is inconsistent with the intent of the                   fiduciaries are insurers, providers and Ontario’s financial services


                                                   ”
                SABS and this Guideline.                                   regulator. If standardization, consistency and equity are among the
                                                                           MIG’s stated and implied objectives, there is still work to do to en-
                                                                           sure that, for claimants whose injuries fit the same profile, a consis-
What the Mig Means for Providers                                           tent level of financial support is provided in practice as well as in
                                                                           theory.
    Providers who were adept at navigating the regulations in the
                                                                               Furthermore, though laudable, the $400 allowance for supple-
pre-MIG era in a way that brought them high adjuster approval
                                                                           mentary services and supplies included in the $2,200 pre-approved
rates and maximized fee revenue now have to reset their autopilots.
                                                                           limit could be manipulated to cover additional (i.e. high margin)
Indeed, if they want to avoid in-flight adverse events and hard land-
                                                                           services instead of the supplies needed to promote the self-rehabili-
ings, they would be wise to assume that nothing will be automatic
                                                                           tation and functional restoration aims of the Guideline. Gross
and to revert to what pilots refer to as visual flight rules in the best
                                                                           profit-taking on devices and supplies to the detriment of claimants
interests of their patients and the health of their practices.
                                                                           also remains an issue, and one that could and should be controlled.
    Some insurers may not have the tools required to effectively ad-
                                                                               Change is at hand; the MIG is airborne. All stakeholders
minister decision rules for what constitutes a serious injury and the
                                                                           have a role to play to ensure that its course leads to its desired
$50,000 limit that applies to such injuries. By the same token, in the
                                                                           destinations. ggg
absence of sophisticated internal claim adjudication rules and con-
trols, some may well take the position that except for injuries that are
obviously catastrophic in nature, the Insurer Exam mechanism
should be the final arbiter whenever an OCF-18 is submitted.               Charles Spina is a management consultant who specializes in services
    Differing definitions of “serious” are bound to complicate the         branding and brand-aligned operations design and management.
assessment/treatment flow, and will likely expose some clinical prac-      c.spina@sympatico.ca
tices to financial risk if services are performed for which payment is




                                                                                                       www.thehealthprofessional.ca             9
10   The Health Professional FAll 2010
Feature: lESSonS FRoM THE WoRld oF SPoRTS




Active Body,
By Kate F. Hays,
Ph.D., C.Psych        Healthy Mind
Whether advising our patients or in our own lives, we
are familiar with the many physical benefits of exer-
cise. We also know that during or after completing
some physical activity, our mood is usually improved.
But is exercise really so powerful that it can have im-
pact on a clinical condition such as depression?




O
           ver the past thirty years, research evidence has been accu- through the autumn foliage, chatting with a close friend. Alterna-
           mulating about the importance of exercise as a method of    tively, particularly for overburdened, over-connected women, exer-
           treatment, even in some cases                                                              cise may be a legitimate moment to have

                                                “
of severe depression. Exercise helps al-                                                              time to oneself.
leviate the immediate sense of distress –               Exercise is one of the most
an acute impact. Over time, exercise also       effective ways of regulating mood, What Works
creates a general improvement in mood
– a chronic impact.                             probably because it both increases                        What’s the best kind of exercise
                                                                                                      from a mental health perspective? Pro-
                                                    energy and reduces tension
                                                                                          ”
    Exercise has been compared to both
                                                                                                      fessor Bonnie Berger at Bowling Green
psychotherapy and medication with re-
                                                                                                      State University has developed a tax-
gard to alleviating clinical depression,
                                                                       onomy to describe types of exercise that are most effective. For
and it has been found equally effective. According to recent psycho-
                                                                       mental benefits, the crucial elements are:
logical research, evidence-based practice comprises relevant re-
search, clinical knowledge and expertise, and the patient’s contextual    •	 the activity is pleasing and enjoyable
culture, values and preferences. For any individual, the most helpful     •	 the mode is aerobic or involves rhythmical
treatment may be exercise alone or in combination with psycho-               abdominal breathing
therapy and/or medication.
                                                                          •	 the activity is predictable or spatially certain and
Exercise and Mood                                                            without interpersonal competition

    Through research and clinical experience, we have much more            •	 the exercise is of moderate intensity, lasts 20 to 30
information on the fact that exercise works than why it works. Exer-         minutes, and is part of the weekly schedule
cise is one of the most effective ways of regulating mood, probably         Do these parameters mean we shouldn’t advise a fast game of
because it both increases energy and reduces tension. One theory is     tennis, or that your favourite pickup lunchtime basketball game
that an alteration in brain chemicals affects mood – and perhaps        down at the Y is off limits? Certainly not. However, if we are ad-
these are in fact the same brain chemicals that are targeted with       vising or doing something competitive, we must also find ways to be
psychotropic medication.                                                emotionally supportive of ourselves. Being self-critical about a lousy
    Other more psychological explanations abound as well. Exercise      serve or negatively comparing oneself with teammates will improve
can provide distraction, time out from the normal preoccupations of     neither the game nor one’s mood. The distraction of that type of
everyday life. Exercise also affords a sense of mastery and accom-      activity will probably be strong, but the potential to tune out or
plishment, which in turn influences self-esteem. Additionally, exer-    contemplate will be less present. If competitive activity is enjoyable,
cise is an excellent means of regulating social distance. It may be     it certainly shouldn’t be ruled out – and it’s definitely better for one’s
taking a spinning class at the gym with some buddies or riding          mental health than not doing any activity at all.

                                                                                                     www.thehealthprofessional.ca             11
Continued from page 11                                                   suggest that exercise can have important positive effects on a number
                                                                         of mental health problems. Exercise is often recommended for the
                                                                         alleviation of stress. As with depression, it can help relieve symptoms

 “that are probably benefits, the types standard
    For the mental
                    most effective are
                                        of exercise                      of anxiety in the short term and decrease anxiety over the long haul.
                                                                         Exercise has also been associated with an increased ability to manage
                                                                         withdrawal from addictive substances. It is a key component in
     aerobic activities such as walking, running,                        weight loss, and possibly even more important, in weight loss man-
                                                                         agement.

                                                               ”
     biking, swimming or cross-country skiing
                                                                         The Body-Mind connection
    That said, for the mental benefits, the types of exercise that are       “A sound mind in a sound body” is not just a trite phrase. Phys-
probably most effective are standard aerobic activities such as          ical activity is essential for our minds as much as our bodies. From a
walking, running, biking, swimming or cross-country skiing. The          mental perspective, physical activity can serve a preventive as well as
Eastern arts, such as yoga, emphasize the value of diaphragmatic         rehabilitative function. That’s pretty powerful medicine! ggg
breathing, the integration of mind and body, mindfulness of the
present moment, and a non-judgmental attitude, all of which are
essential components for mental well-being.
                                                                         Kate F. Hays Ph.D., C.Psych. maintains a practice – The Performing Edge,
                                                                         in Toronto – specializing in sport psychology and performance psychology.
Exercise and other Emotional Problems                                    The author/editor of five books, she is past-president of the Division of
   Although the most thorough research has been conducted on             Sport and Exercise Psychology of the American Psychological Association.
exercise in relation to depression, there is considerable research to    www.theperformingedge.com.




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iSSuES in MEdicAl REHABiliTATion




     And the Show Went On...
                                                   By daniel gallucci, BSc, cScS, d.Ac




 D
               ancers at the National Ballet of Canada begin each         ability to plantar flex about 20 degrees, but other movements sur-
               day the same way. They gather for a 75-minute ballet       rounding the ankle were nonexistent. She also had an edema that
               class to develop and refine techniques they have been      reached mid-shin.
               working on since their introduction to ballet. Every
dancer has performed each movement thousands of times with a              Treatment Protocol
precision and level of conscious awareness seldom seen with other         1. Decrease excessive activity centrally and locally
athletes or performers.                                                   No matter where the injury, there will always be an acute response
    Neurofunctional acupuncture – the insertion of fine solid             with an increase in sympathetic nervous system activity. Increased
needles into innervated areas of the body for therapeutic purposes        sympathetic tone will result in a host of physiologic changes, in-
– is the perfect complement to ballet, where development of the           cluding increased heart rate and increased glucose metabolism in
nervous system in a dancer’s technical foundation is of the utmost        muscle. Central stabilization of the sympathetic nervous system was
priority.                                                                 achieved by stimulating insertion sites on the head and ear as well as
    Ten days before the start of the 2010 Winter Olympics in Van-         distal neurovascular bundles in the upper extremity. Local stabiliza-
couver, a National Ballet dancer preparing to perform at the Games        tion was achieved initially by stimulating distal neurovascular net-
landed poorly from a jump, severely rolling her right ankle. The phy-     works on the contralateral lower extremity and ankle.
sician diagnosed the injury as a second- to third-degree lateral ankle
sprain and suggested she be off work for two or three weeks. While        2. Decrease nociception from the injured area
this dancer wasn’t competing for gold medals, she had been sched-         The nociceptive information into the dorsal horn must be decreased
uled for more than a year to dance at the Olympics and the thought        in an acute situation. The dancer did much of this herself when she
of not participating was disheartening.                                   was not receiving treatment. She constantly iced and elevated her
    I first saw the dancer six hours after the injury. She was on         ankle, used a jobes pump with light compression, and took an anti-
crutches, bound with ice and in a great deal of pain. She still had the   inflammatory prescribed by the sports medicine physician.



 14
14 TheThe Health Professional FAll 2010
       Health Professional FAll 2010
3. Decrease spinal processing of nociceptive signals
Decreasing the nociceptive signalling taking place at the spinal cord          QUALITY PRODUCTS
is of the utmost importance when attempting to quickly restore
function. Initially, because the injury was acute, the strategy was to
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stimulate peripheral neurovascular bundles both proximal and distal
to the injury site. With each passing day, the goal was to get closer to
the injury while increasing the non-noxious signals being sent to the
spinal cord and while working on contralateral stimulation of the
affected tissue and corresponding area.

The day after the injury, the dancer received two treatments. One
session was devoted to stimulation of the posterior rami at spinal
levels neurologically relevant to the problem. This was done with
bilateral needle insertions into the paravertebral musculature at seg-
mental somatic as well as reflex vascular levels of the preganglionic
neurons that supplied the injured area. Electrical stimulation of 2Hz          Order toll free: 1 (877) 475-8344
for 20 minutes was also added to increase the neuromodulatory ef-              or online: www.etdinc.ca
fect.                                                                          •   Acupuncture needles
                                                                               •   Electro-therapeutic devices
                                                                               •   Books and charts
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By the fourth day the dancer was feeling much better and treatment
was becoming more local around the sinus tarsus and some of the                             ELECTRO-THERAPEUTIC DEVICES INC.
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tremity points, as well as head and ear points. 2Hz of electrical stim-                     Health Canada Quality International Assurance Standards
ulation was used to release endorphins and decrease nociception                             More than just acupuncture.
centrally.

5. Increase strength and function
Restoring strength and function is of the utmost importance. This
was done by stimulating healthy surrounding tissue, relevant local
                                                                           3 MONTH RENTALS
nerves, various myotendinous units and intra-articular insertions
within both the talocrural and talocalcaneal joints. Soft tissue work
                                                                                e       d MAGNETIC F IELD T HERAPY
was also added bilaterally to clean the peripheral nervous system and
                                                                           Puls
encourage lymphatic drainage.

Result                                                                     Chronic Pain
    The dancer flew to Vancouver three days before the show. At this       Arthritis
point she was performing barre exercises at the beginning of ballet
class, as well as propioceptive training, muscle activation and motor      Sport
pattern drills, core exercises and cardiovascular conditioning on an        Injuries
exercise bike. While in Vancouver, the same strategies were imple-
mented and she continued to regain strength, function and the con-
fidence needed to perform on stage at the Olympic Games in front                                                    Degenerative
of thousands of people. The quality of the dancer’s neuromuscular
system in combination with neurofunctional acupuncture was in-
                                                                                                                     Problems
strumental in allowing her to experience this once-in-a-lifetime op-                                                Musculoskeletal
portunity. ggg
                                                                                                                     Conditions


Daniel Gallucci BSc. CSCS D.Ac is a strength and conditioning coach, an
exercise physiologist, a contemporary medical acupuncturist and a
manual osteopath practising in the Toronto area. He can be reached via
www.physicalprep.ca.                                                                       1 800 387 8326
                                                                                          www.centurionsystem s . c o m


                                                                                                 www.thehealthprofessional.ca                         15
REgulATion MATTERS




                           Patient Care in an Age of
                              Regulatory Reform
                                                            By JoHn Filo, dc




A
         disconnect in recent years between     ance, one reason is to control exorbitant         tred care, something the mainstream model
         insurers, patients, providers and      claiming practices. It is imperative that         has neglected in recent years.
         other stakeholders has magnified to    counter measures be injected at critical              It is not an easy transition, since the
the extent that it is destabilizing the On-     stages in the cycle to encourage sustain-         gravy train was near full capacity and roaring
tario auto insurance industry. As we have       ability and equity.                               full speed ahead. To weather these changes
clearly seen in the recent round of reforms,        Every five years or so, regulatory changes    and continue to be a player in the auto insur-
the current insurance model is a fragile        are enacted to help stabilize the auto insur-     ance industry, providers must align them-
system at best. Although full of excruciat-     ance industry in order to better serve its true   selves with the new regulation and make a
ingly detailed checks and balances designed     purpose. Some are major transformational          concerted effort to change indulgent
to ensure stakeholders know the rules and                                                         claiming practices. As always in periods of


                                                 “
work within them, it has its periods of dis-                                                      transition, it is difficult to make sense of the
equilibrium. In this writer’s view, the pen-         As providers, we must compre-                intended outcome; however, an unwilling-
dulum has swung far from the centre as          hend the nature and implications of               ness to allow for transformation will inevi-
symptoms of mismanagement and abuse             the cycles and take every precaution              tably weaken our system franchise. All pro-
have compromised the integrity of the             to avoid jeopardizing the system                viders should heed the warning and start
system and undermined the confidence of                                                           thinking about the importance of main-
                                                since our livelihoods are dependent
patients.                                                                                         taining sustainability and integrity for the

                                                                                       ”
    At points of extreme stress, radical            on its existence and health.                  collective whole. Patient-centred care is
change is warranted to avoid further dete-                                                        where it starts.
rioration. Indeed, with so much change over     regulatory mandates that signal a major               In understanding the auto insurance in-
the years producing so few results, the via-    shift in direction. Regulation 34/10 and the      dustry, we should be more inclined to per-
bility of the entire Ontario auto insurance     Central Processing Agency (HCAI) are two          ceive changes in regulation not as “us versus
regime may be at risk. As providers, we must    such mandates. Through them, the industry         them” but as “the integrated symbiotic
comprehend the nature and implications of       has firmly positioned itself to effectively       mechanism at work.”
the cycles and take every precaution to avoid   counter the increasing cost momentum and              At first glance, Reg. 34/10 may seem a
jeopardizing the system since our liveli-       usher a shift back toward sustainability. The     strong counter measure on the part of regu-
hoods are dependent on its existence and        Minor Injury Guideline is intended to per-
health. Regulatory institutions exist for a     suade providers to focus on the core princi-
number of reasons. In the case of auto insur-   ples of rehabilitation, primarily patient-cen-




 16
16 TheThe Health Professional FAll 2010
       Health Professional FAll 2010
lators to rein in unconscionable profit-          mindful presence to counter the stresses of      current rehabilitation model. This need not
taking behaviour. However, a broader per-         life. The fitness training regimen of the past   require that we discard the old system, but
spective would view it as the initial step in     has also undergone a metamorphosis toward        instead carefully trim away the needless ex-
stabilizing the industry, which in time al-       functionality instead of brute strength. The     cess and redefine the synergistic role of each
lows free market forces to settle and adjust      clunky weights, pulleys and machines that        component of therapy in terms of the overall
the current valuation discrepancy. One in-                                                         outcome. Essentially, it’s using the compo-
surer is already taking the initiative to re-                                                      nents of the old model as a stepping stone
duce premiums and the rest might well
follow suit shortly.
    The new MIG is clear about its intent.
                                                    “   This need not require that we
                                                   discard the old system, but instead
                                                                                                   toward a more evolved therapeutic approach
                                                                                                   that incorporates both patient awareness
                                                                                                   and functionality.
                                                    carefully trim away the needless
Functional restoration is the essence of re-                                                           For providers, at least, the secret to suc-
habilitation and is based on the principle of      excess and redefine the synergistic             cess in the age of reform is not a secret at all:
restoring the functionality of the patient as a   role of each component of therapy in             play by the rules and make the patient better.

                                                                                         ”
whole, not treating the patient as a sum of          terms of the overall outcome.                 In doing so, we are given the rare opportu-
injured parts. This is where providers should                                                      nity to transform an old model and improve
begin to implement our tools and resources                                                         best practices. ggg
in establishing a new model of rehabilitation     were once the mainstay of fitness are being
– “conscious rehabilitation” – based on the       pushed aside as the new class of yoga mats,
awareness that the mind and body are inti-        balls, rollers and latex bands are ushered in.
                                                                                                   John Filo DC works as an independent medical
mately connected in the healing process.          Gyms are finding themselves in a scramble
                                                                                                   evaluator for auto insurance claims and runs a
    The shift in conscious awareness toward       to restructure their space and make room for
                                                                                                   private multidisciplinary practice in North York.
a healthy mind and body has been increas-         the new players on the scene.
                                                                                                   He can be reached at drjfilo@rogers.com.
ingly noticeable in recent years as millions of       As we embark on this new paradigm, we
people turned to yoga, meditation and             start by examining the shortcomings of the




                                                                                                      www.thehealthprofessional.ca              17
iSSuES in MEdicAl REHABiliTATion




S
       port and leisure activities are                                                             As a form of therapy, Therapeutic Golf
       components of a healthy life-                                                           Rehabilitation or TGR integrates golf
       style. Not only is sport-specific                                                       instruction, proper swing mechanics,
training beneficial for the rehabilita-                                                        physiotherapy and exercise to improve
tion of athletes, but it can also be an                                                        balance and other physical variables. My
important part of therapy regimes for                                                          own research has confirmed TGR’s
non-athletes. Participation in sport-                                                          effectiveness in improving balance with
specific training can add interest to the                                                      stroke survivors. (See Lauren La Rose’s
rehabilitation process.                                                                        Canadian Press article “Back in the Swing
    Just as physiotherapy helps with                                                           of Things” at www.healthzone.ca/health/
sport, so sport can help with physio-                                                          articlePrint/672562.)
therapy. Indeed, sport can be therapy.                                                             A study in 2010 comparing golfers to
Following are some examples of how                                                             control participants found that the golfers
sport is used as part of rehabilitation                                                        had significantly better static and dynamic
and specifically how golf, yoga and Tai                                                        balance. The authors hypothesized that the
Chi can help with balance.                                                                     coordinated movement and the weight
                                                                                               transfer required in the golf swing, as well
golf and Balance                                                                               as the need to walk uneven fairways are
    Golf is becoming increasingly pop-                                                         contributing factors to golfers’ superior
ular with all ages. Perhaps Tiger                                                              balance. Whatever the explanation, it is
Woods’ youthful successes and popu-                                                            apparent that golf can be used as a tool in
larity are partly responsible for the                                                          balance training. And further studies
many children’s golf camps throughout                                                          might also confirm the corollary: that bal-
Canada. Business people and profes-                                                            ance training improves golf performance.
sionals take up golf in adulthood as a
networking tool, and athletes who once                                                         yoga and Balance
participated in more demanding sports often take up golf in middle                             Yoga encompasses moral and ethical
age. Retired people have more time to spend on the golf course.      precepts, mental attitudes and physical practices. The goal of yoga is
Some of the benefits of golf are:                                    to improve the health and functioning of both body and mind. The
  •	 increased flexibility, particularly of the trunk and the hips   Hatha form, involving standing and lying postures, is most popular
                                                                     in the West.
  •	 improved core and extremity strength
                                                                         The benefits of yoga include improved strategic planning (plan-
  •	 improved balance and postural control                           ning and execution time, increased flexibility and muscle force or
  •	 increased cardiovascular fitness                                torque, increased vital capacity, oxygen uptake and aerobic capacity,
  •	 improved coordination and speed of movement                     and increased motor speed and reaction time. These benefits increase
                                                                     with motivation, frequency of practice, and time.
  •	 increased bilateral capabilities
                                                                         Yoga therapeutics is the application of yoga for health benefits
                                                                     and focuses on relaxation, meditation and modification of traditional


20         The Health Professional FAll 2010
postures. It is commonly used as a therapy adjunct for persons with       Tai Chi has been used as a tool for rehabilitation in persons with
neurological diseases.                                                traumatic brain injury, dementia and Parkinson’s disease. It has been
     Yoga has been shown to improve balance in many patient popu-     found to be beneficial in prevention of falls programs for the elderly
lations, including those with osteoporosis or rheumatoid arthritis,   and in standing balance in stroke survivors.
older adults, and individuals with post-stroke hemiparesis. Healthy
young adults practising Bikram yoga have been observed to substan-    Summary
tially improve their balance, leg strength and muscle control.            Not only is sport engaging and motivating, but it can also be used
                                                                      as a tool throughout the rehabilitation process. Participation in
Tai chi and Balance                                                   sport-specific training as part of rehabilitation is beneficial in im-
    Tai Chi emphasizes mind and body harmony, combining exer-         proving outcomes. As the experts in exercise prescription for injury
cise, meditation and self-defence. This low-impact, moderate-inten-   and disease, physiotherapists may incorporate golf, yoga or Tai Chi
sity exercise consists of rhythmic movements, trunk rotation and      activities into treatment. Given the growing evidence supporting in-
constant weight shifting. Performance of Tai Chi requires coordi-     tegration of sport and leisure into physiotherapy, funding for such
nated sequencing of body segments, awareness of trunk alignment,      physiotherapist-directed programs can be accessed through EHB,
deep breathing and mental concentration. With precise, smooth,        MVA and LTD insurers. A clear path to improved physical out-
flowing movement that uses “internal energy,” it slowly and gently    comes, citation of the literature demonstrating the same, and expres-
leads into complex postures performed with a lowered centre of        sion of the unique motivational aspect of sport will help solidify a
gravity.                                                              positive funding outcome. ggg
    The health benefits of practising Tai Chi include:
  •	 improved kinesthetic sense, muscular strength,
    balance and motor skills                                          Sari Shatil PT MSc is a physiotherapist and founder of Therapeutic Golf
  •	 increased cardiovascular and respiratory function                Rehabilitation (TGR). She is the owner of Neuphysio Rehabilitation (www.
  •	 enhanced mood, coping skills and self-esteem                     neuphysio.com), a centre of excellence in neurological and traumatic re-
                                                                      habilitation.
  •	 improved motivation through relaxation
  •	 reduced blood pressure, stress, anger, fatigue,
    depression and hyperactivity
  •	 enriched quality of life




                                                                                                  www.thehealthprofessional.ca            21
iSSuES in MEdicAl REHABiliTATion




                  Advances in the Assessment and
                    Treatment of Concussion
                                                               By Michael Greco




D
               ay 23 of the 2010 FIFA World Cup and Ghana is playing             Current studies contradict each other on the likelihood of a con-
               Uruguay in the quarter-finals at Johannesburg’s Soccer City   cussion occurring when the head comes in contact with the ball.
               Stadium. Forty minutes in, the game is tight and both         Some studies have shown no adverse effects in neuropsychological
               teams have yet to score a goal. Uruguayan player Jorge        test performance between “headers” and “non-headers” after training
Fucile is playing as if his life depends on it. Suddenly, he                                and matches. Nevertheless, in a 2004 discussion
attempts to intercept the ball by heading it. As                                                    paper, the Canadian Academy of Sport Med-
Fucile leaps up, not only does his head miss                                                            icine advocated teaching players proper
the ball, but he also crashes into Gha-                                                                      heading techniques that may de-
naian player Samuel Inkoom. The                                                                                 crease the amount of force trans-
collision causes Fucile to tumble                                                                                  mitted to the brain.
backward and his shoulder                                                                                                 When the referee reaches
and head bear the brunt of                                                                                             Fucile, he has not lost con-
the impact when he hits                                                                                                   sciousness and several
the ground. Fucile lies                                                                                                     minutes later he is able to
face down in the field                                                                                                       stand and converse
and the officials run                                                                                                         with officials. He is
over to assess his condi-                                                                                                      deemed well enough to
tion.                                                                                                                           play the rest of the
                                                                                                                                 match and Uruguay
Concussions                                                                                                                      wins in the final
in Soccer                                                                                                                        shootout.
                                                                                                                                     The next day, the
    In soccer, concus-                                                                                                          team’s medical staff
sions typically occur                                                                                                          announces that Fucile
from player-to-player                                                                                                         is still under observa-
contact, heading the                                                                                                        tion as a result of the
ball, and contact with                                                                                                     fall. “He is okay. He suf-
the ground or goalposts.                                                                                                 fered concussion after
A 1999 article in the                                                                                                  bumping his head, but he did
Journal of the American                                                                                              not lose consciousness. But we
Medical Association ( JAMA)                                                                                       have to take care of his state of
found that 59% of concussions                                                                                  health,” said team doctor Alberto
occur while heading the ball and                                                                            Pan. One week later, Fucile plays in a
30.5% occur during “non-heading”                                                                       match between Uruguay and Germany. The
player-to-player contact. However, FIFA                                                           game ends without any major incident for Fucile,
Medical Assessment and Research Centre’s study of 398 soccer                 but Germany manages to beat Uruguay 3-2.
matches found that all 14 reported concussions were caused by “non-
heading” player-to-player contact.                                           Research
    Concussion rates vary widely because of inconsistent definitions
or diagnosis of concussion and underreporting by players. While                 While past studies have reported that a history of concussion
soccer players are commonly believed to be at lower risk for concus-         poses significant risks for future concussion, the mechanism that
sion than athletes in other contact sports, some studies refute this         controls this increased risk has yet to be identified. A 2003 JAMA
idea. The NCAA reported that collegiate soccer players have the              study suggested that the mechanism of impaired glucose metabolism
highest rate of concussions in organized contact sports that do not          from a single concussion is a likely factor.
involve helmet protection. Studies have revealed that 25% to 40% of             A 2001 study in the Clinical Journal of Sport Medicine suggests
soccer athletes have suffered a concussion by the time their high            that there is enough data to anticipate finding cumulative neuro-
school career ends.


 22
22 TheThe Health Professional FAll 2010
       Health Professional FAll 2010
logical consequences in soccer not unlike the increased neurop-
athy found in the brains of boxers who had sustained chronic
head injuries.
    Computerized neuropsychological testing is playing an in-
creasing role in the assessment process. One notable provider of
this testing is the Australian company CogState. Its “Sport” ser-
vice tests the cognitive performance by taking baseline measure-
ments of the athlete pre-season to enable detection of any cogni-
tive changes should a concussion occur. CogState’s customers
include FIFA and the UK Rugby Football League. During FI-                       The Best for
FA’s 2007 survey of its 207 member associations, it counted 265
million participants. To make testing feasible with such a large
number of players, CogState developed test batteries that can be
                                                                                your Patients
administered reliably and repeatedly by non-experts.
    Additional research is being done in prevention, particularly
around the efficacy of soccer headgear. In 2008 McGill Sport and
Medicine Clinic looked at the effect of protective headgear in
adolescent female soccer players. Among the population studied
during one season, 27% who wore headgear and 53% who did not
wear headgear suffered concussions. Of the concussed athletes
who wore headgear, 50% suffered more than one concussion,
                                                                         The original K-Tape is now available
while 70% of the concussed athletes who did not wear headgear
                                                                         in “pre-cut” single applications with
experienced additional concussions. Currently, there is no na-           instructions. Developed by the
tional standard for soccer headgear in Canada, but studies like          K-Taping Academy.
this could lead to more protective headgear use among future
players.

The Future
   Diagnosis and assessment of concussions in athletes has made
great progress during the last fifteen years.
  •	 Concussions with no loss of consciousness are seldom being
     dismissed as temporary injuries
  •	 Sport guidelines are being developed that prevent secondary         In depth description of
     head injuries and complications                                     the six applications.

  •	 Medical practitioners in all fields are closer to agreeing on a
     multidisciplinary approach to evaluation and assessment
  •	 More objective testing methods such as computerized neu-
     ropsychological testing are being adopted
  •	 Research is ongoing to better understand the pathology and
     long-term effects of concussion

   There is reason to be optimistic about diagnosis, assessment          Attractive and practical display
and treatment of concussion in the athletes of tomorrow. ggg             available for clinic sales.


                                                                         More information and videos at
                                                                         www.orthocanada.com/k-tape
Michael Greco is a freelance writer with a special interest in health-
related topics. He can be reached at michael@grecomix.com.




                                                                                      www.thehealthprofessional.ca   23
                                                                                        Contemporary
                                                                                           Medical
                                                                                         Acupuncture
Contemporary Acupuncture for
     Health Professionals
  is a 300 hour University accredited course

              Spring 2011 Program
Introduction to Contemporary Acupuncture
Unit 1 • February 18-19-20, 2011
                                                                                           Program
Upper Extremity Problems • Acute Pain
Unit 2 • March 18-19-20, 2011                                                           Spring ’11/Fall ‘11
Axial Skeletal Problems • Visceral Regulation
Unit 3 • April 8-9-10, 2011
Head & Face Problems • Chronic Pain Syndromes
                                                                                          McMaster University
Unit 4 • April 29-30, May 1, 2011
Lower Extremity Problems • Integrated Mgmt.
Unit 5 • May 27-28-29, 2011

                  Fall 2011 Program
Introduction to Contemporary Acupuncture                                                         
Unit 1 • September 9-10-11, 2011
Upper Extremity Problems • Acute Pain
Unit 2 • September 30-October 1-2, 2011
                                                                                          Comprehensive
Axial Skeletal Problems • Visceral Regulation                                           Accelerated Training
Unit 3 • October 21-22-23, 2011
Head & Face Problems • Chronic Pain Syndromes
                                                                                         in Contemporary
Unit 4 • November 11-12-13, 2011                                                           Acupuncture
Lower Extremity Problems • Integrated Mgmt.
Unit 5 • December 2-3-4, 2011
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                                                                                    Feature: lESSonS FRoM THE WoRld oF SPoRTS




                             The Vital Role of
                       Neurofunctional Acupuncture
                                                   By Alejandro Elorriaga, Md




F
          rom a physiological perspective,                                                  2. Decrease excessive sympathetic ac-
          neurofunctional acupuncture                                                       tivity locally and regionally
          (the insertion of fine solid nee-                                                     Bilaterally or contralaterally stimulate
          dles into innervated areas of the                                                 distal neurovascular networks on the af-
body for therapeutic purposes) is easy to                                                   fected extremity.
understand: measurable physiological re-
sponses occur when acupuncture needles                                                      3. Decrease nociceptive signalling from
are inserted into humans or animals.                                                        the injured area
    This article outlines the best practical
                                                                                                Minimize the inflammatory response
strategies in the author’s experience for
                                                                                            in the injured tissues using ice, compres-
applying contemporary knowledge of
                                                                                            sion, elevation, ointments, etc.
acupuncture physiology to the integrated
treatment of acute and sub-acute sports                                                     4. Decrease spinal processing of noci-
injuries.                                                                                   ceptive signals
    Sports injuries produce a range of
physiological alterations in the body. At                                                       Increase the number of non-noxious
the tissue level, events follow a predict-                                                  signals from healthy tissues reaching the
able course with three characteristic                                                       spinal cord from the same dermatome,
phases: inflammation, proliferation and                                                     myotome and/or sclerotome that the in-
remodelling. Neurologically, responses                                                      jured tissue belongs to.
are more complex and include changes in
central and peripheral sympathetic tone,                                                        Strategies include:
regional motor inhibition and a miscel-                                                         a. Stimulation of peripheral neurovas-
lany of central repercussions.                                                              cular bundles or nerve trunks on the area
    Neurofunctional acupuncture has            Summary of therapeutic goals in              adjacent to the injury (proximal and
proven to be useful in modulating the in-      acute or sub-acute sports injuries           distal)
tensity and extent of many of these phys-                                                       b. Contralateral stimulation of the
iological responses. Below is a summary        1. Decrease excessive sympathetic            area corresponding to the affected tissue
of the main goals of neurofunctional acu-         activity centrally                        and/or its associated peripheral nerves
puncture treatment in response to acute                                                         c. Stimulation of posterior primary
                                               2. Decrease excessive sympathetic            rami at spinal levels neurologically rele-
or sub-acute sports injuries. A detailed
                                                  activity locally and regionally           vant to the problem, whether somatically
discussion of each point follows.
                                               3. Decrease nociceptive signalling           (at the same dermatome, myotome or
1. Decrease excessive sympathetic ac-             from injured area                         sclerotome) or vascularly (at the levels of
tivity centrally                                                                            the preganglionic sympathetic neurons
                                               4. Decrease spinal processing of             that supply the injured territory)
    Achieved by stimulating some stan-            nociceptive signals                           Needles are inserted bilaterally on the
dardized insertion sites on the head and
                                               5. Decrease central processing of            erector spine musculature in a multi-seg-
ear (with the option of adding electrical
                                                  nociceptive signals                       mental fashion, at least two needles on
stimulation to these sites) stimulating
                                                                                            each side for the somatic levels and an-
distal neurovascular bundles and arterial      6. Modulate centrally the                    other two for the segmental vascular
networks in the extremities. Electrical           experience of pain                        sympathetic levels of innervation.
stimulation of the needles at 2Hz en-
hances this central effect.                    7. Facilitate local tissue healing




                                                                                             www.thehealthprofessional.ca           25
Continued from page 25

5. Decrease central processing of nocicep-
tive signals
    Use stimulation strategies targeting su-
praspinal levels, such as needles on distal
extremity points, ear or head with the option
of adding 2Hz electrical stimulation of the
needles to produce central release of endor-
phins and contribute to the decrease of cen-
tral processing of nociceptive signals

6. Decrease central activities related to the
unpleasantness of the pain experience
    Stimulate the limbic system using well-
known strategies already presented above,
such as ear points, some head points and
distal points on the extremities
                                                discomfort, are able to resume training in       cessfully that the athlete was able to run and
7. Promote local tissue healing                 three to five weeks, and, in the experience of   qualify for the finals – where she placed
                                                the author, have been able to go back to peak    second. From not able to run to a medal in a
    Stimulate healthy tissue adjacent to the
                                                performance consistently in under six            week, thanks to the combined effects of
injury to facilitate local healing mechanisms
                                                months.                                          electroacupuncture and manual soft tissue
                                                     In 2001, one of the world’s top female      techniques. ggg
neurofunctional Acupuncture and                 sprinters attended the World Track and
the Sprinter’s injury                           Field Championship in Edmonton with a
    An acute hamstring injury during a          recent hamstring injury that prevented her
                                                                                                 Alejandro Elorriaga Claraco MD is a Sports
major world class event is usually very se-     from running, even though she had quali-
                                                                                                 Medicine Specialist and President and Founder
rious because of the maximum effort exerted     fied. At the request of her health care team
                                                                                                 of Advanced Performance Ltd. Dr. Elorriaga
by the athlete, which produces significant      the author started treatment with neuro-
                                                                                                 holds the following positions at McMaster
tissue destruction. After such an injury, it    functional acupuncture at once in order to       University: Assistant Clinical Professor,
takes a minimum of eight to 12 weeks to go      speed recovery for future events. When the       Department of Anesthesia; Director, Contempo-
back to training and six months to a year to    first treatment produced immediate remark-       rary Medical Acupuncture Program; and
return to peak performance. Athletes treated    able improvement, the athlete was allowed        Director, Functional Treatment of Sports
immediately with neurofunctional acupunc-       to train and test her injury right away, four    Injuries Program.
ture and manual soft tissue techniques, as in   days before the qualifying rounds. Daily
the photograph below, experience much less      treatment and training continued so suc-




26         The Health Professional FAll 2010
www.thehealthprofessional.ca   27
Feature: lESSonS FRoM THE WoRld oF SPoRTS




                                                      I
                                                             njuries are an inherent risk of sport.
                                                             While no action will eliminate injuries,
                                                             reasonable precautions can be taken so
                                                      that injuries are less frequent and less serious,
                                                      and exposure to liability is diminished.

                                                      RolE oF THE HEAlTH PRoFESSionAl
                                                          Many professional leagues require teams to have medical profes-
                                                      sionals available for assessment and treatment purposes. The medical
                                                      team usually includes an orthopaedic surgeon, a GP specializing in
                                                      sports medicine, physiotherapists and athletic therapists. The med-
                                                      ical team does not simply treat acute injuries but bears responsibility
                                                      for the athletes’ overall well-being.




      Sports Medicine, Risk
     Management and the Law
              By g. Joseph Falconeri, leigh Harrison-Wilson and darrell J. ogilvie-Harris, Md


                                                      duty of care
                                                          Members of the medical team are expected to have the expertise
                                                      to respond to foreseeable medical situations and thoroughly and ac-
                                                      curately assess the athletes’ fitness and abilities. Those who fail to
                                                      recognize problematic symptoms or to utilize appropriate assess-
                                                      ment modalities may be found liable. Every team must have a system
                                                      of medical checks in place before athletes are put into play, and the
                                                      medical team is crucial to the effective operation of this system.

                                                      Return to Play
                                                          The medical team is primarily responsible for clearing injured
                                                      athletes to return to competition. Because there is no global standard
                                                      applicable to granting medical clearance, the medical team will be
                                                      judged by the standard of what a reasonable practitioner would rec-
                                                      ommend and provide under the circumstances. Courts will examine
                                                      steps taken to protect athletes from injury, including the level of
                                                      monitoring that took place, recommendations for protective equip-
                                                      ment, use of such equipment by the athlete, and the foreseeable risk
                                                      of injury as evaluated by the medical team and management.
                                                          With these considerations in mind, we recommend the following
                                                      precautions for every medical team.



28      The Health Professional FAll 2010
1. Assessment and Treatment                                               insist on a forum juris clause, whereby all malpractice claims must be
                                                                          brought in a particular jurisdiction.
    Clearance recommendations must be within the bounds of ac-
cepted and reasonable medical practices as prescribed by the various
                                                                          concluSion
professional governing bodies. All members of the medical team
should be aware of current professional recommendations and prac-             Professional sports are extremely competitive and the industry is
tice guidelines.                                                          rife with potential claims. Often economics require teams to make
    Health professionals cannot be held liable for honest error. As-      decisions that will expose the team and its staff to liability. Under no
sessment and treatment need not be perfect but simply reasonable          circumstances should the medical team be placed in a position to act
according to current professional standards. Medical teams that           as catalyst for such decisions. By implementing the strategies rec-
follow and document appropriate protocols will significantly reduce       ommended above, health professionals can reduce their exposure to
the risk of a successful lawsuit by an injured athlete.                   liability while honouring their duties to athletes. ggg

2. documentation
   Findings and recommendations should be documented in                   Partners at Falconeri Munro Tucci LLP, G. Joseph Falconeri and Leigh
writing and provided to the athletes, their representatives and the       Harrison-Wilson practise exclusively in the areas of personal injury, med-
team. This practice will reduce exposure to a potential medical mal-      ical malpractice and professional sports dispute resolution. Dr. Darrell
practice claim if management chooses to ignore the medical team’s         Ogilvie-Harris is an orthopaedic surgeon and head of the University of
advice.                                                                   Toronto Sports Medicine Program at Women’s College Hospital; he cur-
                                                                          rently acts as physician to the National Ballet of Canada.
3. Provision of information
     The medical team must ensure that athletes are fully informed of
the risks of returning to play in light of their physical condition. We   This article draws on a paper originally presented by G. Joseph Falconeri
recommend disclosure to athletes of all material information neces-       and Dr. D.J. Ogilvie-Harris in 2004. The full text of the original paper can
sary to allow for an informed decision, especially the risks and ben-     be found at www.fmtlaw.ca.
efits of recommended treatment. This should be documented in de-
tail in writing.

4. Second or Third opinions
   When in doubt, referrals should be made to an independent
medical assessor. Seeking another opinion in times of uncertainty
represents good risk management and can insulate against medical
malpractice claims.

inTERAcTion WiTH MAnAgEMEnT
    Management – a sports team’s owner or organizational sponsor
(e.g. a university) – is responsible in law to place a medical team at
the service of the sports team’s athletes.
    Management may face liability in allowing injured athletes to
return to competition before they are ready, particularly in cases
where management has overruled the medical professionals’ recom-
mendations. While it is always important to document findings and
recommendations and inform all parties throughout the course of
treatment, it becomes essential when management opposes the med-
ical team’s advice.
    Several crucial provisions should be included in any contract be-
tween medical service providers and management. Medical teams
providing services to sports teams will not be covered by the usual
malpractice insurance available to those in private practice. Manage-
ment must ensure that sufficient insurance protection exists, and
medical service providers should demand that they be indemnified
by the team should a malpractice claim arise.
    Medical malpractice lawyers will often attempt to choose juris-
dictions in which favourable results are more likely. In order to avoid
this “forum shopping” should a claim arise, the medical team should


                                                                                                        www.thehealthprofessional.ca              29
Feature: lESSonS FRoM THE WoRld oF SPoRTS




A
          Formula One racing car has a specialized
          team of mechanics to keep it revving in
          peak condition. Professional athletes
should also have such a team to help them
maintain optimal performance
all year round.


This team of “body mechanics” should                    approach. Professional hockey players     triggering all sorts of adaptations, leading to
consist of individuals highly experi-                such as Steve Staios of the Calgary          less-than-optimal performance, and often
enced in the treatment of soft tissue injuries   Flames are seeing their best performances –      resulting in injuries in the long run.
and neuromuscular dysfunction – the              and their best contracts – in the maturity of        This is why athletes need coaches and
common problems plaguing athletes that go        their careers, while other players that do not   performance care providers to continually
largely unrecognized by health professionals     receive regular performance care are already     evaluate their technique and body me-
with no experience in this field.                in clear decline.                                chanics, ensure the maintenance of proper
    In the last few years, strength training                                                      form, and promptly detect any unwanted


                                                   “ Performance Care has
and conditioning for professional athletes                                                        adaptations that may have developed over
has morphed from rudimentary weight                                                               time.
training and running into highly sophisti-         been embraced not only by                          For the professional athlete, this ap-
cated, sport-specific training programs. The                                                      proach offers a distinct advantage. Mike
lessons learned have contributed to a new          professional sports but also                   Cammalleri of the Montreal Canadiens
focus on performance optimization versus             by the military, which                       said, “Performance care treatments allow me
the traditional focus on injury treatment.                                                        to train and play at intense levels consis-
This contemporary approach is now widely            currently considers and                       tently. My body feels loose and fast after
known as Performance Care, and has been              treats its elite troops as                   each treatment.”
embraced not only by professional sports                                                              Performance care is designed to find and
                                                       ‘tactical athletes.’
but also by the military, which currently
considers and treats its elite troops as “tac-
tical athletes.”
                                                                                   ”
                                                     Unfortunately, most athletes in profes-
                                                                                                  predict all possible areas of limitations of
                                                                                                  performance for athletes in their specific
                                                                                                  events. The athlete’s nervous system is as-
    Performance care is an integrated prac-      sional sports play the majority of their ca-     sessed for motor inhibition (often incor-
tice that includes training as well as nutri-    reers at much less than 100% of their capa-      rectly seen as muscle weakness, although the
tional and treatment interventions designed      bilities. This is due to the development of      two are very different), range of motion in
to 1. optimize immediate performance, 2.         gradual dysfunctions of the nervous system       the movement areas necessary for the sport,
reduce the chances of developing cumula-         and the musculoskeletal tissues that are sec-    and any lines of tension that would limit
tive trauma injuries and 3. increase the po-     ondary to the constant small and big traumas     performance during the sport.
tential length of an athlete’s career.           suffered by the athlete.                             Depending on the outcome of a perfor-
    In this lucrative age of professional            These traumas produce insidious changes      mance care assessment, some athletes will
sports, this can be a very rewarding             in the body that frequently go unrecognized,     require many interventions to address all the



30         The Health Professional FAll 2010
areas of the body involved in the loss of          •	 Joint manipulation techniques are em-         Performance care is the way of the fu-
function. Others might just need a quick             ployed to restore normal joint motion, a   ture, not only for professional athletes who
correction of one or two key dysfunctional           necessary function for optimal perfor-     wish to have longer and healthier careers,
elements, such as a weak muscle or a re-             mance.                                     but also for health-conscious individuals
stricted joint, which can be accomplished in                                                    who wish to minimize the risk of undesir-

                                                  “third of our livesin the last
two or three interventions.                                                                     able musculoskeletal adaptations as they age.
                                                     Quality of life                            Quality of life in the last third of our lives
   Each dysfunction needs to be addressed                             depends                   depends greatly on the state of our musculo-
technically in an optimal manner. For ex-                                                       skeletal system. Performance care is not just
ample:                                              greatly on the state of our                 about optimal sports performance but soon
                                                    musculoskeletal system.
                                                                                       ”
  •	 Electro-acupuncture   is used primarily                                                    will be about productive and enjoyable
    to address nervous system dysfunction                                                       “golden years” for all of us.
    such as muscle inhibitions and areas of          Based on the detailed and very special-
    poor blood supply due to abnormal            ized biomechanical assessment performed
    regulation of the arterial system.           by the performance care practitioner, these    Dr. Michael Prebeg is a Certified Chiropractic
                                                 techniques are combined in a single treat-
  •	 Soft tissue techniques are applied to as-                                                  Sports Physician. He is an instructor in the
                                                 ment session according to the needs of the     McMaster University Contemporary Acupunc-
    sist connective tissues to reorganize
                                                 athlete. Some sessions are as short as one     ture Program and a consulting chiropractor with
    their tension and to improve their rela-
                                                 hour but usually take several hours to ad-     the Toronto Blue Jays. Dr. Prebeg’s website is
    tionship with adjacent structures, thus
                                                 dress the multiple dimensions of the           drmichaelprebeg.com.
    facilitating smooth and painless mo-
                                                 problem.
    tion.




                                                                                                   www.thehealthprofessional.ca            31
PrOFILeS




A Tale of
Two Artists
By Sandy Leppan



The dancer
    Frank Augustyn clearly remembers planting his foot firmly as he
had done thousands of times before – but this jump wasn’t going to
turn out the same as all the others.
    It was the mid-80s and Augustyn was guest principal dancer with
the Boston Ballet, performing in a dress rehearsal of Le Corsaire Pas de
deux. This ballet required the use of hazers, which had leaked some oil on
the stage right where Frank would take off for the leap. His foot slipped
and wrenched his knee, although his momentum carried him up into the
jump anyway, and he landed on his back eight feet away. It turned out that
he had completely ruptured the tendon that holds the patella in place and
his patella was now mid-thigh.

The Artist
    Arto Yuzbasiyan clearly remembers setting up the winch to pull his
                                                                                                        Frank Augusytyn performing in La
vehicle out of the slushy rut – as he had done only too often that early                                Sylphide, 1975. Photo by Anthony
1980s winter – and in less time than it takes to tell it, he was looking at his                         Crickmay. Courtesy of The National
crushed right index finger hanging on by only the threads of his glove.                                 Ballet of Canada Archives.
    Two Canadian celebrities, not famous hockey players or Olympic
divers, but facing the same kind of career-threatening injuries and in the
same urgent need of rehabilitation to save their livelihoods. Fortunately
for them, they both had access to top-notch health care teams in On-
                                                                                           Recovery
tario and they were destined to dance and paint again.
                                                                                              Augustyn’s recovery was remarkably rapid
The Fixes                                                                                because of the revolutionary new surgery and Dr.
                                                                                       Jackson’s care and skill in performing it. For a full
     Frank Augustyn is grateful not to remember much about the
                                                                                      month in the hospital he worked with physiothera-
first hours after his accident, including the searing pain he must
                                                                                     pists and other health professionals, learning to bend
have felt. But he does recall being taken on a stretcher that same
                                                                                    and strengthen his knee. When he went home, he
night to the plane that would fly him to Toronto and the care of Dr.
                                                                                   continued with physio and after a few months he was
Robert Jackson, the Canadian pioneer in the field of arthroscopic
                                                                                  able to get back to the dance studio.
surgery. Jackson performed lengthy and delicate surgery to sew the
                                                                                       A short nine months after the accident, Augustyn
tendon back onto Augustyn’s kneecap and he then inserted a four-
                                                                                  was back on the stage. He invited Dr. Jackson to his
prong steel staple to attach a Dacron graft to the shin bone. To this
                                                                                  comeback appearance in Toronto, where he was
day, Augustyn still has the staple and the Dacron in his leg.
                                                                                  dancing Sleeping Beauty with the National Ballet of
     Arto Yuzbasiyan remembers feeling no pain as his wife raced him
                                                                                   Canada. Before the performance Jackson came to Au-
to the hospital and during the 90-minute wait in emergency. It was only
                                                                                    gustyn’s dressing room and there Augustyn demon-
when he was told his finger was too seriously smashed to be saved that
                                                                                     strated some of the steps he would be performing in
the pain set in with a vengeance. Surgery was recommended to tidy up
                                                                                      the ballet – steps he would never have been able to
the wound – which involved paring off more flesh and bone, so ultimately
                                                                                       aspire to again without the diligence and skill of
he lost almost all of his right index finger. A devastating blow to a right-
                                                                                         Jackson’s groundbreaking surgery.
handed painter.



 32
32 TheThe Health Professional FAll 2010
       Health Professional FAll 2010
     Augustyn retired from performing at 44,
a good age among male dancers. Most retire
by 35 because of injuries and the extreme
demands on the body of landing after ex-
tremely high leaps and of completing 200 or
more lifts in a single performance. Jackson’s
efforts had given Augustyn a full ten more
years of dancing life, for which Augustyn
will be forever grateful.
     Before the operation, the surgeon had
confidently told Yuzbasiyan that his middle
finger would quickly take over all the func-
tions of his index finger, including the most
delicate of brush strokes. So as soon as he
came back from surgery, Yuzbasiyan tested
the surgeon’s prediction by picking up a
pencil with his bandaged right hand, and
even though his arm was solidly frozen from
shoulder to finger tips, he was relieved to
find he could already manipulate the pencil
a bit.
     It took a few months to learn to cope,
adjust and compensate with his middle
finger, in many ways learning to paint all                         Karen Kain and Frank Augustyn in The Sleeping Beauty (1979).
over again. Although it was challenging at                 Photo by Andrew Oxenham. Courtesy of The National Ballet of Canada Archives.
first, Yuzbasiyan insists that now he doesn’t
even think about it. During the years that
                                                                                                  States and a number of countries in Europe.


 “ samefamous hockey players or Olympic divers,in the same
                                                                                                  His paintings continue to focus on our long
    Not                                             but facing                                    Canadian winters and how we cope with
the      kind of career-threatening injuries and                                                  and enjoy them. Not surprisingly, however,
                                                                                                  none of his work features snowbound vehi-
   urgent need of rehabilitation to save their livelihoods
                                                          ”                                       cles or anything that resembles a winch. ggg



have followed his accident and up to today,     physiotherapy as a supplementary form of          Sandy Leppan is the editor of The Health
he has painted prodigiously and continues       exercise to help fortify his joints and delay     Professional magazine and a great admirer of
to gain recognition across Canada and inter-    the inevitable onset of arthritis and de-         both Frank Augustyn and Arto Yuzbasiyan.
nationally. It turns out that by now he has     clining flexibility. He reports being amazed      Email address: sleppan@thehealthprofessional.
contributed to many more collections and        at how many professional dancers – both
participated in many more solo and group        men and women, and some as young as 18
exhibitions without his right index finger      – are having knee and hip replacements
                                                                                                  Sadly, Dr. Robert Jackson passed away in Jan-
than he had ever done with it.                  these days; he says it has become almost a        uary of this year. According to a 1994 Sports Il-
                                                fad. However, the good news is that after the     lustrated report, Dr. Jackson’s revolutionary
Today                                           surgery most of them, and especially the          approach to arthroscopic surgery was a contri-
                                                younger ones, have been able to come back         bution to sport medicine identified as changing
    Frank Augustyn is still totally involved
                                                to dance.                                         the sports world. THP would add: It was a
in ballet, although now it is as Chair of the
                                                    In this second decade of the millennium,      unique and invaluable contribution to the dance
Dance Department at Adelphi University in
                                                Arto Yuzbasiyan’s works of art appear in          world, too.
Garden City, New York. He has kept up his
                                                many collections in Canada, the United




                                                                                                      www.thehealthprofessional.ca             33
   eVeNTS CALeNdAR                                                                                                 See all events at www.TheHealthProfessional.ca/events


 Type                       date                 event                                                  Location        Organization                   Website
 Health Care                November 8-10        Health Achieve 2010                                    Toronto         Health Achieve                 healthachieve.com
 Spinal                     November 17          Product Education for Spinal Pain                      North York      Ted Seligman, HoMedics         abilityhealthcare.ca
                                                                                                                        Group Canada & Ability
 Patient Safety             November 22-24       Patient Safety Course                                  Toronto         Ontario Hospital Association   oha.com
 Occupational Therapy       December 14          Integrating Rehabilitation Principles into Chronic     Webinar         Canadian Association of        caot.ca
                                                 Disease Self-Management                                                Occupational Therapists
 Rehabilitation             January 21           Rehabilitation of Complex Patients: A Primer for       Toronto         Toronto Rehab                  torontorehab.com
                                                 Family Physicians
 Assessment and             January 28           Balance, Mobility and Fitness – Accelerating           Toronto         Toronto Rehab                  torontorehab.com
 Management                                      Research into Clinical Practice
 Rehabilitation             March 7              Best Practices Day: Infusing Principles of             Toronto         GTA Rehab Network              gtarehabnetwork.ca
                                                 Rehabilitation Across the Care Continuum
 Neurobehavioural           April 28-29          18th Annual Conference on Neurobehavioural             Hamilton        Hamilton Health Sciences       hamiltonhealthsciences.ca
                                                 Rehabilitation in Acquired Brain Injury: “Mild
                                                 Traumatic Brain Injury: Advances in Research and
                                                 Practice”
 Caregiving, Disability,    June 5-8             Festival of International Conferences on Caregiving,   Toronto         FICCDAT                        ficcdat.ca
 Aging and Technology                            Disability, Aging and Technology




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                                                              Full- or part-time RMT required! South City Physiother-
 EMPloyMEnT                                                                                                                 Hospital and Georgian Mall. For more information about
                                                              apy requires an RMT. This position could be full-time or      the space available please call or email Andrea at the
                                                              part-time. We prefer an RMT who is also a Kin, but are        clinic or visit our website, www.midhurstnaturalhealth-
Experienced administrators, receptionists, collection         open to one who is not. Must communicate well and             clinic.com.
agents required to work at rehabilitation and assess-         have great interpersonal skills. Please send your CV by
ment centres. Competitive salaries and possibility to         email to Francine to be considered for this opportunity
work close to home. Please fax your resumes to 416-           – francine@southcityphysio.com.                               Downtown Toronto wellness centre looking for a li-
800-0859 or email careers@moci.ca                                                                                           censed ND to join our established, multidisciplinary of-
                                                                                                                            fice. Acupuncture is an asset. Our clinic is located on
                                                              Looking for all positions, managers, estheticians, RN,        the north side of beautiful Allan Gardens at Jarvis and
RMT required in clinic setting south of Sudbury. Clinic       RMT, to join our new operative facility and MediSpa           Carlton. We are an integrated wellness centre offering
well established with therapeutic clients. If interested      opening in November 2010. Send CV to jobs@spasur-             chiropractic, massage therapy and naturopathy. Clinic
send resume to therapeutic17@aol.com.                         gica.com.                                                     has been established since 2003. Naturopathic room is
                                                                                                                            fully furnished and ready to go. Please contact Imelda at
Psychologist looking to conduct psychological MVA as-           SPAcE FoR REnT                                              (416) 944-2973 or dr_imelda05@yahoo.ca for details.
sessments for rehab clinics/assessment centres in the
GTA. Contact Dr. Jon Mills at 905-686-7184.                                                                                   clinicS FoR SAlE
                                                              Seeking Registered Massage Therapist to rent room
                                                              and work independently in established massage thera-
We are looking for a part-time Certified Personal Trainer     py clinic located in North Bay. Clinic currently has a sur-
                                                                                                                            High-volume, cash-, family-, wellness-, sublux-
to join our team! Hours are flexible and trainer will work    plus of clients needing treatment; this would be an ex-
as an independent contractor. Please email resume to          cellent time to grow your client base.
                                                                                                                            ation-based chiropractic office in beautiful Otta-
info@acceleratedphysio.com.                                                                                                 wa. Newly renovated office with platinum system,
                                                                                                                            subluxation station, x-ray, 4 adjusting stations,
                                                              Midhurst natural health clinic - Professional health care
Physiotherapy and Sports Clinic in Markham looking for
                                                                                                                            trained team with public relations CA, nutritionist
                                                              in a beautiful setting. Professional office space available
an RMT for P/T. Please email to mccowanphysio@bell-           within a multidisciplinary clinic. Currently there are two    and nutrition centre, and 2 RMTs included. Re-
net.ca.                                                       naturopathic doctors and a registered massage thera-          quires 2-3 DCs to purchase. $500,000. Bank
                                                              pist practising at the clinic. We are looking for other       funding is available. Doctor will hold paper on re-
Estheticians wanted. Looking for full- and part-time to       health care professionals to join our team, including a       sidual. Doctor will stay on to consult and coach.
join a new medical spa opening in fall in Waterloo. Must      holistic-minded medical doctor, chiropractor and other        Serious inquiries only please. Please call 1-800-
be experienced in all services. Laser experience is a         health care professionals. Each practitioner is a sole        781-8127 or email us at drmike@chiropractic-
plus. Email us at bessel@rogers.com.                          proprietor on a 60/40 split. Details: full-time reception-    masters.com.
                                                              ist, 2 storey restored century building, fully furnished
                                                              office space, waiting rooms, 2 bathrooms, laundry, linen
Looking for RPT. 2-3 evenings from 5:00 to 8:00. P/T          and office supplies included, free parking, high-traffic
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34             The Health Professional FAll 2010

								
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