Search Results: acupuncture

Medical Acupuncture


Medical Acupuncture

Acupuncture treatment is insertion of single-use needle based on the points established along meridians (energy channels). Individual points are frequently targeted to treat various conditions. These points often resemble trigger points and/or motor points in the tissue. It utilizes the neurological pain control theory.

Dry Needling/Intramuscular Stimulation (IMS) Acupuncture

Dry Needling is an acupuncture-like treatment used in therapy. It is also known as intramuscular stimulation (IMS). The technique helps break down adhesions in tissues and muscles, relieving pain and tension.


Peripheral nerve stimulation for inhibited/weak muscles’ activation to increase engagement/strength and decrease pain.

Who will benefit?

Pre/post surgical conditions, acute/chronic pain, increase performance and mobility.

Service provided by:

Milad Bazaz Jazayeri, RPT, provides medical acupuncture, dry needling and electroacupuncture treatments

Igal Untershats, RMT, provides medical acupuncture, dry needling and electroacupuncture treatments

Juliette Woodruff, RMT, provides medical acupuncture

More information:

To Book an appointment call 416 925 4687 or email

Acupuncture Description


Medical acupuncture

Acupuncture treatment is insertion of single-use needle based on the points established along meridians (energy channels).  Individual points are frequently targeted to treat various conditions. These points often resemble trigger points and/or motor points in the tissue. It utilizes the neurological pain control theory.

Dry Needling/Intramuscular Stimulation (IMS) Acupuncture

Dry Needling is an acupuncture-­like treatment used in therapy. It is also known as intramuscular stimulation (IMS). The technique helps break down adhesion in tissues and muscles, relieving pain and tension.


                Peripheral nerve stimulation for inhibited/weak muscles’ activation to increase engagement/strength and decrease pain.

Who will benefit?

Pre/post surgical conditions, acute/chronic pain, increase performance and mobility.


Service provided by:

Milad Bazaz Jazayeri, RPT, provides medical acupuncture, dry needling and electroacupuncture treatments

Igal Untershats, RMT, provides medical acupuncture, dry needling and electroacupuncture treatments

Juliette Woodruff, RMT, provides medical acupuncture


More information:

More information:

Book an appt:


Hip bursitis treatment: steroid injection vs. Dry Needling & acupuncture

If you have been diagnosed with hip bursitis or tendinitis you may want to consider other options before committing to steroid injections. A new wave of research is suggesting that application of Dry Needling (DN) acupuncture, as an alternative to steroid injection for treatment of hip pain and functional limitations, is safe and just as effective1!

What is bursitis?

Bursitis refers to inflammation of the bursa. A bursa is a fluid filled sac that provides cushioning between tendons and/or bones around your joints2.

Although it is a common diagnosis, hip bursitis is an often-inaccurate term used in the medical field. The majority of cases described as hip bursitis actually have no inflammation in the bursa!  Muscle tears, tendon strains and trigger points can all cause pain in this area1.

The most common risk factor for pain in the outer hip area is overuse injuries (also referred to as repetitive stress injuries). Running and standing for long periods of time are common causes.

What are the symptoms of hip bursitis and tendonitis? 

This condition is characterized by tenderness to touch over the bony prominence on the outer aspect of the hip1. In more acute stages, pain is often described as localized and sharp. However, more chronic conditions can be felt as dull and achy.

You might also experience pain with certain movements or positions.  Your hips may hurt when you are standing and bearing weight. This pain can be more noticeable as you shift your weight to stand on the affected leg. This pain may occur when you are walking, climbing up/down the stairs, running, prolonged standing and cycling. You may also experience pain when there is simply too much pressure on your hips, like when are trying to sleep on the affected side.

How common is hip bursitis/tendinitis?

It is estimated that 10% to 25% of us will experience chronic hip pain within our lifetime1. You are more at risk for pain in this region if you have any of these issues:

  • low back pain
  • osteoarthritis
  • IT (iliotibial) band tenderness
  • excess body weight

What is Greater Trochanteric Pain Syndrome?

The term bursitis is often used as a catch-all term for pain felt in the outer aspect of the hip and thigh. We now know that pain in this body area can be caused by a number of issues. Bursitis, gluteal muscle tears, tendinopathy and trigger points in any of the muscles crossing the hip can all be a source of this discomfort1.

As we gain a deeper understanding of sensation and causes of pain, the complexity of understanding the source of the problem is leading us to prefer the term Greater Trochanteric Pain Syndrome (GTPS) over bursitis. This change reflects the fact that the bursa is not always the main source of the hip pain. It also helps us to consider more comprehensive solutions as it encompasses a wider variety of causes.

Is steroid injection beneficial?

YES! Therapeutic steroids – sometimes referred to as corticosteroids or cortisone – are helpful in treatment of a number of different conditions3 (such as hip bursitis). Therapeutic steroids are similar to the hormones your body releases to fight illnesses, injuries and help reduce inflammation in your body. Your physician or specialist will inject a small amount of steroid to control pain and inflammation in a bursa, joint, tendon or muscle. A local anesthetic is also commonly injected at the same time.

Are there any side effects to steroid injections?

Although rare, there are a number of adverse effects associated with steroid injections that should be considered. Side effects of steroid injections can include4:

  • mild allergic reactions
  • temporary increase in pain
  • swelling
  • blood sugar increase

More severe side effects may include weakening of tendons and ligaments with multiple injections in one area over a short period of time. Achieving  minimal relief after two injections is generally considered as a contraindication to having more injections4.

Are there any alternatives to steroid injection?  

Recognizing that hip bursitis is not the only cause of hip pain, other treatment options are being considered as alternatives to cortisone injections. Massage, stretching and appropriately selected exercises can all be helpful. A recent study1 shows that Dry Needling – also known as intramuscular stimulation (IMS) – is just as effective as steroid injection for treatment of GTPS (including bursitis and tendinitis)!

Dry Needling acupuncture can help!  

Dry needling (DN) is the Western approach to acupuncture. In this technique thin needles are used to stimulate local trigger points in muscles. DN treatment reduces muscular and myofascial pain, releases trigger points, and helps restore movement. (To learn more about Dry Needling technique and how it works, click here).

The key to an effective treatment is about appropriate diagnosis! By completing a detailed assessment, your physiotherapist will identify trigger points and muscles that carry excessive tone (i.e. are too tense). Once the right trigger points are identified, fine sterile needles are inserted through the skin to release these knot-like thickenings in the muscles and fascia. Muscles around the side and back of buttock region, muscles of your thighs and muscles of the lower back often respond well to dry needling for treatment of GTPS1.

When should you consider Dry Needling acupuncture for your hip pain?

Dry needling is a safe and effective alternative to corticosteroid injections for treatment of many types of hip pain.  It can be selected as an alternative when cortisone injections should not be used – such as drug allergies. Or if you prefer this type of approach, dry needling can be an appropriate substitute.

Dry Needling can benefit you if:

  • Hip pain is making your day-to-day function more difficult.
  • A steroid injection resulted in minimal or no relief.

Contact us if you are interested in learning more about alternative options to injections or would like to book a treatment for your hip pain.  Speak with Milad Bazaz-Jazayeri, Registered Physical Therapist – – to learn more about treatment options that fit your needs best.






  1. Kindyle , Brennan , Allen Bryce, and Munoz Maldonado Yolanda. “Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial.” (journal of orthopaedic & sports physical therapy) 47 (April 2017): 232-239.
  2. American Academy of Orthopaedic Surgeons. Hip Bursitis. March 2014.
  3. Labrosse, Julie, et al. “Effectiveness of Ultrasound-Guided Corticosteroid Injection for the Treatment of Gluteus Medius Tendinopathy.” American Journal of Roentgenology 194, no. 1 (January 2010): 202-206.
  4. Cardone, Dennis, Alfred Tallia, and Robert Wood Johnson. “Joint and Soft Tissue Injection.” American Family Physician 66, no. 2 (July 2002): 283-289.



Dry Needling – A Western Approach to the Eastern Art of Acupuncture

Dry Needling is an acupuncture-­like treatment used in therapy. Also known as intramuscular stimulation (IMS), this treatment is used to reduce muscular and myofascial (1) pain, release trigger points, and restore movement.

It may be used to treat a chronic condition or an acute episode particularly when there is no obvious cause of injury, i.e. repetitive strain injuries (RSI). Every muscle in your body is comprised of numerous muscle fibers, which generally line-up in the same direction. This structure helps each of your muscles produce the greatest possible amount of power. To do this, the fibers need to glide and move freely. However, through a lack of mobility the fibers within the same muscle, or between different muscles located next to each other, can stick together and form what is felt as a thickening or knot.

These adhesions can also be felt as taut and tender spots in the connective tissue or in the fascia which surrounds muscles, resulting in myofascial knots and trigger points. These adhesions  can form when your muscles are held in a shortened position for a long period of time, such as sitting at a desk with poor ergonomic support. Trigger points can also result from contusions (bruises) or repetitive stress, such as the pain you may feel in your forearms due to typing.

Eastern vs. Western Acupuncture

Dry Needling is considered to be the Western approach to acupuncture. It focuses on the biomechanics of the body, emphasizing the importance of human body’s structures and movements; rather than the energy channels used in Traditional Chinese Medicine (TCM).

The practice of dry needling began in the 70’s when North American Physicians wondered what would happen if they stimulated trigger points in the muscles using only the needles, instead of injecting local anesthetics. The term dry needling was chosen because nothing was being injected through the needles.

Ever since its introduction a number of studies have shown there is as much benefit from dry needling in the treatment of musculoskeletal pain as there is with the injection of different substances, including corticosteroids and analgesics. 

These results prompted me to study dry needling as well as acupuncture to treat muscular and myofascial pain. Although I use both techniques, in my practice I have found dry needling helps my patients recover faster and I often use it in conjunction with manual therapy and other more traditional physiotherapy modalities.

What is the difference between acupuncture and dry needling? 

In TCM, besides the points established along meridians (energy channels), individual points (2) are frequently targeted to treat myofascial conditions. These points often resemble trigger points and/or motor points in the tissue. In contrast, dry needling directly targets localized trigger points regardless of their relation to meridians. Depending on your healthcare practitioner’s approach, Dry Needling and Acupuncture points may or may not be identical. However, even when the points are identical, the two techniques can be rather different. By inserting needles through the skin, fascia, and into tense muscle fibers, dry needling directly releases knots and trigger points. These fine needles are similar to – or often the same as – acupuncture needles. However, they are not left inserted in the muscles for an extended period of time. Instead, they are moved in and out of the trigger points to elicit a contraction, twitch or “popping” sensation in the muscle fibers.

How does Dry Needling work?

Dry needling restores your muscle fibers’ natural movements and reduces restrictions that impede mobility. It helps to restore muscle efficiency through contraction and relaxation of specific fibers. This technique can also release endorphins – the body’s naturally occurring morphine which reduces pain!

By inserting a needle into a tense muscle an involuntary contraction or twitch may occur. These local twitch responses (LTR) have been shown to improve treatment outcome (3). The quick contraction causes the adhesion in between muscle fiber to break down and improves the movement of the muscle.  As the fibers shorten and pull away from the trigger point the result is a release of tension and relaxation of the muscles.

Is Dry Needling painful?

Here at the Orthopaedic Therapy Clinic we commonly believe in a  “No Pain, More Gain!” model of treatment. However, Dry Needling is one of the few techniques in which some pain can result in more gain!

When inserted into a relaxed muscle at rest, needles face minimal resistance as they move through muscle fibers and there is little to no discomfort. However, the higher the tension, the more resistance there is to the needles entering the muscle. The result is that you may experience a quick cramp-like sensation with a local twitch response when trigger points are targeted directly. For this reason, some patients may find the application of dry needling more uncomfortable than traditional acupuncture. After a treatment you may feel a localized soreness for up to 48 hours after a dry needling treatment session. It is important to allow an adequate amount of time between dry needling treatment sessions to let your body’s natural healing process to take place after each treatment.  Treatments are typically scheduled once this localized soreness has resolved.

Who benefits from dry needling?

As a practitioner, I use both acupuncture and dry needling to treat acute as well as more persistent or chronic conditions. Considering that breaking down adhesion is not the primary focus of acupuncture, I find dry needling more effective when dealing with chronic tightness and cramps in muscles and fascia; particularly when there is a plateau in recovery with other treatment techniques. Dry needling is beneficial in combination with other physiotherapy treatments (strengthening muscles, manual therapy, soft tissue release, etc.). I recommend this technique for treatment of a number of conditions; including, but not limited to:

  • Conditions associated with poor posture (i.e. Postural dysfunction),
  • Tendonitis,
  • Headaches and neck pain,
  • Back pain,
  • Repetitive strain injuries,
  • Muscle strains,
  • Concussion related symptoms

If you experience knot-like pain in your muscles that does not settle with other types of therapy, restricted range of motion or functional limitations; or if you feel that you no longer get lasting relief from other types of treatment, contact Milad Bazaz at the Orthopaedic Therapy Clinic to set up an appointment for a thorough assessment and to discuss whether dry needling is a treatment option for you.

  1. Myofascia is a dense and thin layer of tissue that covers muscles and bones in the body.
  2. Called Ah shi points
  3. APTA (American Physical Therapy Association)


What is acupuncture and how does it work?

Milad Bazaz Jazayeri, BSc (KIN.), MPT
Milad is a Registered Physical Therapist whom uses acupuncture and dry needling as part of his practice in downtown Toronto @ the Orthopaedic Therapy Clinic.

Acupuncture is a form of therapeutic modalities in Traditional Chinese Medicine – also simply referred to as TCM – that is used to treat pain and dysfunction. The TCM’s philosophy is based on the relationship between a person’s emotions and physical being with nature and having an integrative relationship between them as a whole.

What is acupuncture and how does it work?acupuncture_post
The practice of acupuncture involves insertion of thin needles through the skin and into the body. In TCM, acupuncture is used to stimulate specific points that are located on various pathways that are known as Meridians. Qi (pronounced Ch’i) is translated as “vital air” that flows in meridians, much like the oxygen that flows in blood vessels and supply the vital functions of the organs, bones, muscles, and nerves. In TCM, pain and dysfunctions arise from the blockages of Qi along the meridians. Acupuncture aims to restore the flow of Qi in order to reach physiological equilibrium, hence reducing pain
and dysfunction.
In western medicine the effect of acupuncture needles is explained as a technique to locally stimulate muscles, nerves and connective tissues below the dermis – the deepest layer of skin. In other words acupuncture stimulates the body’s natural healing response to relieve pain and restores the function of the affected region.

Does acupuncture work?
Acupuncture is most commonly used to treat local and systemic pain. Research suggests that the use of acupuncture can be beneficial for numerous conditions such as chronic low back pain, chronic neck pain, tension type headaches, chronic hip and knee osteoarthritis, shin splints, and chronic lateral elbow pain.
In western medicine the effect of acupuncture is often understood through the gate control theory. This theory indicates that an external stimulant – in this case acupuncture needles – can lead to an increased activation of neurotransmitters, which interfere with stress signals that are send to the brain. This closes the “gate” and the signal does not get through which alleviates the pain.
Acupuncture can target specific muscle pain, tightness, inflammation, and swelling via local needling traditionally but also through dry needling. Acupuncture also has global beneficial effects throughout the body. For example, points that can treat muscle soreness can also treat headache.
Acupuncture promotes circulation throughout the body (i.e. globally) which is beneficial for accelerating healing process and reducing pain. For example, patients with diabetes experience a slower rate of healing due to reduced circulation and its effects on the healing process. Hence the use of acupuncture can help facilitate this recovery process by promoting blood circulation. Increasing the circulation throughout the body can affect a person in ways other than physical well-being such as endorsing mental and emotional well-being.

Is Acupuncture painful?
In TCM, De Qi is the sensation experienced by the patient or the practitioner while administrating acupuncture. This sensation usually differs from the pain of insertion itself and is often described as distension, numbness, soreness or heaviness at the site of insertion or along meridians. The thin acupuncture needles are designed to minimize the discomfort from the insertion of the needle. However, based on the location that these needles are applied, some tenderness may be experienced, which commonly
dissipates within few seconds. Some patients may find Dry Needling technique more uncomfortable as the needle directly targets tender spots.

Is acupuncture safe?
There are a number of potential risks associated with the use of acupuncture needles, such as infection, bent or broken needles and organs puncture however these side effects are managed through proper technique and equipment. Acupuncture needles are typically made of sterilized disposable stainless steel wire to limit infection. Your healthcare provider uses their sound anatomy knowledge to minimize the risk of serious injuries to the organs, blood vessels and nerves.
As a therapist, I often choose the application of acupuncture in conjunction with other treatment methods, such as manual therapy and exercise prescription. After a thorough assessment, and based on the specific condition that is being treated – i.e. pain, swelling, muscle tension –and the individual needs of the patient, acupuncture or dry needling techniques can improve the treatment effect. I tend to integrate both western and eastern point of view on healing and physical medicine to treat the body locally and as a whole in order to ensure a comprehensive treatment.
If you wish to consider acupuncture as part of your treatment plan, consult your healthcare provider (i.e. Physical Therapist, Chiropractor, TCM acupuncturist or massage therapist) to ensure safety and efficiency of this modality for you.

Acupuncture & Cancer Treatment

Acupuncture and Cancer Treatment

OTC_acupunctureAt the Orthopaedic Therapy Clinic our Registered Massage Therapists hold a dual certification in Massage and Acupuncture. They are trained to apply acupuncture by combining an evidence-based approach with Traditional Chinese Medicine. Acupuncture may be used as a treatment on its own or in conjunction with your massage therapy.

Acupuncture is helpful in relieving pain, promoting healing and creating a general sense of well-being. It can be beneficial at many different stages of healing and is used to improve the symptoms from chemotherapy and radiation treatment. We recommend acupuncture for:

  • Cancer-related pain
  • Nausea and vomiting
  • Fatigue
  • Dry mouth
  • Restoring a general sense of wellness
  • Increasing energy levels
  • Muscle pain and dysfunction
  • Joint pain
  • Hot flashes

 How does Acupuncture work?

Western scientific research has proposed mechanisms for the effect of acupuncture on pain relief. One of the theories is based on the well-regarded gate control theory of pain originated by Melzack & Wall in 1965. This theory proposes that one type of sensory input i.e. low back pain, could be inhibited in the central nervous system by applying another type of sensory input i.e. needling. There is also evidence that acupuncture may stimulate the production of biochemicals (endorphins, serotonin, and acetylcholine) that have a pain relieving effect[1].

When should I have acupuncture treatment?

There is increasing scientific evidence to show that acupuncture is effective in treating the following conditions:

  • Low back & neck pain
  • Shoulder pain
  • Wrist & hand pain
  • Facial pain
  • Headaches

Who will I see?

When you work with any of our Registered Massage Therapist you will be treated by a highly educated professional who has extensive post-graduate experience. Each therapist is a graduate of McMasters University Acupuncture certification course and has obtained an advanced level of training.

What can I expect at my appointment?

The initial assessment is scheduled for one hour and includes a physical assessment as well as a Traditional Chinese Medicine (TCM) assessment. The TCM assessment looks at physical symptoms and includes tongue diagnosis. Once the appropriate meridians are determined sterile, single use acupuncture needles will be inserted along these ancient locations based on organs. The needles are left in for 30 minutes while you rest.

It is always important to check with your oncologist to determine if there are any concerns before starting any type of complementary or alternative treatment. Your therapist should know your full medical history including blood work, and drug history. This information should be updated at every visit, especially if something has changed.

Are there any reasons I should not have acupuncture treatment?

There are several conditions where acupuncture should not be applied or should be applied with caution.

Blood clotting disorders:

  • Blood clotting issues are common with leukaemia and other haematological concerns i.e. haemophilia
  • Before beginning treatment it is preferable that you have a platelet count of over 20,000
  • Caution needs to be exercised with anticoagulants i.e. warfarin, and the needles should not be inserted into the joints

Low white blood cells: Acupuncture should not be used if you have an increased  risk of infection

Unstable spine: Needles cannot be inserted in the local area of an unstable spine if there is a risk of spinal cord injury

Skin conditions:

  • If you have an open wound, or an infection, the needles should not be inserted into this area
  • If you have lymphedema needles should not be inserted into the affected limb

Prosthetic implants or reconstruction: Needles should not be inserted into a prosthesis i.e. breast implant or into an area of reconstruction i.e. latissimus dorsi flap

Post bone marrow transplant: Following a bone marrow transplant, a 6-12 months waiting period is recommended before starting acupuncture treatment

What should I do after my acupuncture treatment?

Following a specific protocol after treatment can help to maximize the effects of your treatment. Here’s a list of things we find are helpful to do and to avoid after acupuncture:

  • Avoid activities that require exertion for up to two hours after treatment.
  • Try to rest when you get home from your treatment.
  • If you are being treated for pain, try to avoid strenuous activity for two days after treatment. This is important even if you are pain free.
  • Take your pain pills or other medication as directed by your doctor. It is helpful to keep a record of the amount taken to determine if the acupuncture is altering your need for medication.
  • Avoid any alcohol or caffeine for two hours after treatment.

What to expect

Some people will feel immediate relief whereas others may take a few hours or even a few days to experience a benefit. You may require a few treatments before you feel the benefit. If you are not feeling some improvement after several treatments you should discuss this with your therapist.

Occasionally symptoms become worse before they improve. Typically this will last only a day or two. If your symptoms persist for more than 2 days you should contact your therapist at The Orthopaedic Therapy Clinic.

Does acupuncture have side effects?

  • Drowsiness may occur after treatment and you should not drive until it passes
  • There may be minor bleeding or bruising
  • Pain during treatment is rare
  • Occasionally symptoms get worse after treatment. When this happens it is important to let your therapist know.
  • Some people faint from needles however this is most likely at the first appointment.

How many treatments will I need?

The number of treatments will vary with each individual and with the condition being treated. For complex or long standing conditions, one or two treatments a week for several weeks may be recommended. For acute problems you may only need a few treatments to see a benefit.

[1] Chu et al., 1979; Anderson, 1993; Stux & Pmoeranz, 1998).

Acupuncture 101


Acupuncture is one of many therapeutic modalities used in Traditional Chinese Medicine to treat pain, and dysfunction. Traditional Chinese Medicine (TCM) is an ancient healing system, dating back nearly five thousand years. The Chinese philosophy in acupuncture is based on the relationship with nature, our emotions, and our bodies, and having an integrative relationship between them as a whole. It looks at different aspects of our lives such as, environment, diet, lifestyle, and emotional state. These factors all influence the body’s ability to keep in harmony creating a well-balanced system. Read more…

Winning the WAR on Low Back Pain – Managing the attack

One day it starts.  Your back hurts even though you did nothing to injure it.  The pain is intense.  You feel sharp pain shooting down your leg.  You bend forward and your muscles spasm.  It’s almost impossible to straighten up.   When you feel like this you have probably missed the warning signals and have entered the Attack stage in the WAR on low back pain. Watch the you tube video here:

man with low back pain

Signs of the Attack 

In may last blog I reviewed the stages of low back pain and gave you a guideline for recovery. Each stage has it’s own strategies and it’s important to know whether you are in the Warning, Attack or Recovery Stage (WAR).

Although it may seem obvious, the symptoms of  the Attack stage can be confused with the initial stages of Recovery.  The key characteristics that tell you that you are in a full-blown Attack are:

  • Unrelenting pain. The pain may wax and wane but you are never pain free.
  • Short term relief with changing positions however the improvement doesn’t last.
  • Symptoms present less than 3 months.

How long will the pain last?

When you are in the Attack stage you need to be prepared that your symptoms are not going to disappear overnight.  They may last for a few weeks or even a few months.  Fortunately, the odds are in your favour as you have a 95% chance that within 3 months your pain will be better.

Three months can feel like forever. I understand that no one wants to hear that they may be in pain for this long, but believe me it is comforting to know that, when the pain doesn’t immediately abate, time is truly a healer.

You can also expect your pain to progressively lessen and become more intermittent over this period.  However if you want to avoid this hiatus of life – next time pay attention to the warnings!  Right now the most important thing you can do is avoid becoming a prisoner of the pain.

Prisoner of pain

This stage is caused by your emotions.  When the pain is intense you worry that something serious is wrong or whether this will be how you will feel for the rest of your life.

The problem with these emotions is that it’s hard to heal when you are worried and it’s even harder to be logical when making decisions to manage the pain.  This can make the pain last even longer. Your job at this stage is to stay relaxed – despite the pain.

The key to avoiding becoming a prisoner is to know that most causes of low back pain are not serious and that the pain will end.  Education, medication and relaxation strategies such as breathing can all help. It is important to keep reminding yourself that you will get better with time.

Although it may take the full 90 days, many people will be much better within 2-3 weeks.  I often recommend you mark the days on a calendar as you can expect parole no later than 3 months, and it may be sooner for “good behavior”.

What have I hurt?

We all want to understand what is causing our pain. When we Google low back pain  it seems a diagnosis is critical to know how to get better.

This perspective can be problematic, as at the beginning of the Attack stage it can be difficult to determine exactly which structure is hurt.  The difficulty in getting an exact diagnosis can be unsettling.  You may interpret this as meaning you have something unusual or unknown, when the real reason we can’t tell you what you’ve injured is that the cause of the pain is somewhat generic.  Irrespective of whether you have herniated a disc, sprained a facet or pulled a back muscle, most back pain initially has the same cause.

Almost every injury starts with a stage that is variously referred to as nociceptive (pain), chemical or inflammatory.  These terms reflect that the pain you are experiencing is caused by the release of chemicals[1]. These chemicals irritate the surrounding tissues however they are not all bad as they also help you heal.  The most important thing to know is that as long as they are present you will be in pain.  Your rehab plan should include strategies to avoid prolonging this stage by limiting activities that provoke the tissues to release more chemicals.

Do I move or do I rest?

The pain makes you want to rest however the internet tells you to move.  Both are wrong!

Second only to whether to use ice or heat, the decision to move or rest can be one of the most confusing decisions in back pain recovery.  When we look online, our research tells us that core is essential to recovery however during the Attack-stage strengthening your core will not cure the pain. Too much movement or exercise can cause more irritation and prolong our recovery.

However don’t think this means you should take to your bed.  You need to move but you should also avoid substantial increases in pain from being too active before you’re ready. Movement is the key to flushing the chemicals out of your body by enhancing your circulation.

Determining the right level of activity

Start with gentle everyday movements like walking or light activities around the house i.e. dishes. As you transition out of this stage, exercise will become more valuable. Leave going to the gym until the basic movements are feeling better.

As you get moving it is normal to feel a mild increase in pain however the increase should not be intense nor last for longer than 30 minutes.  I find this guideline helps to determine whether you are doing too much or too little.

What about medication?

Medication can be helpful during the Attack stage.  It can make  the pain more manageable.  This allows you to move more easily and worry less.

Take what you need, but don’t make the mistake of thinking that intense pain needs intense medication.  Sometimes surprisingly low doses of over-the-counter medication can manage your pain.

See your family physician and discuss whether pain medication is right for you. Recognize that most medication for low back pain does not cure the problem.  The main purpose is to allow you to move more comfortably and to get more sleep.

What about Therapy?

In the Attack stage the primary focus is pain control and staying active as tolerated.  Gentle hands-on treatments and pain-relieving modalities (ice, heat, acupuncture, laser etc.) can help you to get through this stage.

If treatment doesn’t immediately relieve the pain, don’t despair.  Have your therapist help you to develop a treatment plan.  Discuss which home-based strategies are right for you i.e. heat, ice, etc.   Plan to come back for a review in a few weeks as the most value in winning the war of low back pain is to see your therapist for their guidance during the Resolution stage.

If you need more advice on managing your low back pain or preventing another WAR, contact us to book an appointment at or 416-925-4687.

[1] One of these chemicals has the self-evident name of pain substance.  Many of the other chemicals are related to inflammation.

Winning the WAR on Low Back Pain

One morning you wake up, get out of bed and find it difficult to straighten up.  Your back is stiff.  It’s hard to bend forward to put on your shoes.  You sit down and find that your leg suddenly won’t bend enough to reach your foot.  You take a hot shower and within an hour you begin to feel better and go to work.  You forget about it until the next day the same thing happens.   Whether you are 25 or 65 you may decide that this is just a sign of age when what it is telling me is that you are going to W.A.R. with your body.  These are the early signs of low back pain and unless you recognize them you may go onto a full back pain attack.

Stages of Low Back Pain

View Video, WAR on low back pain

W.A.R. is the acronym I chose to represent the struggle of the mind and body that is an integral part of this injury and because it is a helpful for understanding the 3 stages of recovery. Like with any war, there are stages of engagement.  Each stage has different characteristics and strategies.  Ultimately, winning this WAR will be determined by identifying which stage you are in and applying the treatments that work for that stage.

3 Stages of Low back pain:

  1. W- Warning
  2. A – Attack
  3. R – Resolution

Choosing your treatment

The most common mistake I see made in the recovery or prevention of low back pain is when the wrong treatment is selected for your stage of recovery.  Well-meaning friends, therapists or Dr. Google tells you about some amazing recovery from a certain type of treatment.  Maybe it’s exercise, manipulation or strong stretching techniques like ART.  Testimonials will encourage you to try it, but what is often unclear is whether it’s right for you.

While there is no doubt that each of these treatments can help reduce low back pain, if you want to win this WAR it’s critical to match the right treatment to where you are in your healing.  The wrong treatment at each stage can have a profound effect on both your speed and resilience of recovery.  The first step is to determine your stage of back pain recovery before you choose your treatment.

Stage 1 – Warning

Back pain often starts with subtle warnings. These warnings may go unrecognized or are ignored until suddenly you under Attack.  The result of missing these cues can be a full-blown episode of back pain which puts your entire life on hold for weeks or even months. To win this WAR your first goal should be to avoid the full-blown Attack.  This is best done by recognizing the Warnings and immediately making lifestyle changes.

Warning Symptoms:

Some of the most common symptoms of an impending back attack are:

  • Back stiffness in the morning
  • Back stiffness at the end of the day or after exercise
  • Back discomfort rising out of a chair
  • Back discomfort when standing. [1]
  • Muscle tightness in your hamstrings or calves when you haven’t worked-out

When you feel any of these symptoms, recognize that they are warning you that your back pain may escalate and seek some help in managing this stage.  Most people don’t need much treatment at this stage and prevention can be quite simple.  The focus of therapy should be to identify your risk factors and to understand which modifications can make a difference.

Correcting factors such as a sedentary lifestyle, tight muscles, poor core, etc. can go a long way to avoiding the Attack.  For many people preventing WAR can be as simple as reducing the length of time you are sitting and ensuring you are walking enough i.e. >8,000 steps per day. It can also be about ensuring you have a good ergonomic set-up for your computer and that you stop working on your laptop in bed or at the coffee table.


This is the stage that we all want to avoid however it is the one most people get to before they seek treatment.  It’s not surprising that this is what takes you in to your therapist, as the pain can be overwhelmingly intense.

The intensity of the pain may make this stage seem quite obvious however it is important to determine whether you are really in a full-blown Attack or already in the first stage of Resolution. Some people skip the full Attack stage or progress into the Recovery stage very quickly.  I find that these two stages are often confused and the treatment strategies are very different depending on where you are in your WAR.

Attack Symptoms:

The key characteristics of the full-blown Attack are:

  • Unrelenting pain. The pain may wax and wane but you are never pain free.
  • Short term relief may be felt from shifting positions but doesn’t last.

When you are in a full Attack the primary goal is to end it as quickly as possible.  Managing this stage is best addressed by never going to WAR in the first place, however if you find yourself in the middle of the Attack, the most important elements of treatment are management of the pain and avoidance of becoming mentally incarcerated as a prisoner of pain. This is when you should discuss medications with your physician, pain relieving strategies with your physiotherapist i.e. acupuncture, manual therapy and educate yourself on recovery strategies.

I find that the most common mistake made is over-exercising  during this stage. Knowing that core exercise is good you choose this moment to start your return to fitness.  Remember you need to move but you should also avoid substantial increases in pain.  My rule is that the pain should not increase for more than 20 minutes after movement or exercises.


Your final goal is to achieve full resolution. To do this you need a treatment plan which ensures your recovery is robust and resilient.  This is what will allow you to return to all your favourite activities and avoid future WAR’s.

The most common mistake I see at this stage is a failure to recognize the early signs of recovery. Many of us use pain as our guide, expecting to get active once the pain stops.  However pain doesn’t always shut off like a tap. The early signs of recoverycan be subtle.  There are changes in the quality, location and in what provokes the pain.  These changes tell me when you are ready to enter the final stage in the battle and really participate in therapy.

Signs of Resolution:

  1. Pain intensity lessening and/or becoming intermittent
  2. Pain localization (less leg or buttock pain)
  3. Pain improving with specific activities/directional preference i.e. walking or sitting
  4. Increasing function with no need to increase your medication

The second most frequent mistake I see is that we don’t focus enough on ensuring full resolution.  This is the stage when you should really start to exercise.  Restoring your core, re-establishing coordinated movements and strength is critical. You should be able to start weaning off medication and therapy shifts from pain relief to restoration of lifestyle.

Avoiding Future Wars

Depending on how well we manage the resolution stage determines whether we will keep going to WAR or whether our life returns to full and pain free.  Many people come out of the Attack stage only to have it replaced with constant low-grade discomfort and stiffness.  When you try to return to full activity or resume sports the Attack returns. You see numerous practitioners and no one can give you a clear answer why you can’t get rid of your pain.  MRI’s, X-rays and other tests all fail to explain your ongoing symptoms.  This reinforces the prisoner of pain.  You begin to worry that something permanent is wrong with your back – which no one can find!

If you are having repeated episodes of low back pain and all your tests are clear, this tells me that your back is structurally healthy.  If you are in the resolution stage you are ready to engage in therapy.  If there is no structural damage of significance i.e. herniated discs, stenosis, there are also no significant restrictions to recovery.  Even if you have structural changes your recovery can be good, it just takes a more thoughtful approach to planning your program.

The Recovery phase often requires the guidance of a knowledgeable spine therapist. Someone who understands which factors are challenging your recovery and can guide you into starting your exercise at the right level.  Remember if your pain has lasted longer than 3 months you are now out of shape.  You have also begun to lay down permanent motor memories which impact on your ability to recover.  A solid approach to fitness and restoring coordination are critical at this time.

Join me in the WAR on low back pain

I would like you to help win the W.A.R. on back pain.  Over the next series of articles, my goal is to help you become educated about recognizing what your body is telling you. This will help you to find the right therapist to guide you in your recovery.  It will also help you to know when it’s time to make a change in approach.  Winning this W.A.R. is also about helping you, your friends and even your children to avoid your first episode.

My next few blogs will explore each one of these stages more fully.  I will provide a more in-depth look at the symptoms and which treatments are likely to help. In the interim please contact us for more information or call 416-925-4687 to book an appointment if you need assistance in managing or preventing your own personal W.A.R. on back pain.


[1] This one is harder to recognize as may people mask this symptom by avoiding standing activities such as cocktail parties, museums, shopping or cooking

Cupping Therapy Relieves Pain

Many athletes and artists use cupping treatments to relieve pain and enhance recovery.  The awareness of this treatment increased dramatically at the Barcelona Olympics

when Michael Thorpe launched the ancient treatment of cupping into the limelight.  Many people wondered what the bruises or “hickeys” seen all over his body were and what might be the purpose of these treatments?  

Although it may seem new, the knowledge that cupping therapy relieves pain has been known for centuries in China and is commonly used as an effective part of their medical treatments.  Watch Igal Untershat’s video explaining the benefits and use of cupping- click here.

What is cupping?

Cupping is used to improve circulation.  The mechanism of effect is not fully known however theories base results on activating the body’s natural mechanisms.  The rush of circulation mimics an injury response and the tissue mobilizes a response to get “healed, renewed”.

In medicine we typically use silicone or glass cups.  They create a vacuum (negative pressure) which draws the circulation to the surface. When the cups are removed the circulation flushes creating the therapeutic effect.

Who benefits from cupping?

Cupping is recommended for many types of musculoskeletal conditions or injuries as it stimulates the fascia (coating on the muscle), increases blood flow and affects myofascial trigger points.  It is a great compliment to manual therapies, such as massage, as it enhances the effects of physical manipulation of the soft tissue.

What can you expect after a cupping treatment?

 In addition to feeling relief of tension and improvement in your pain you will also notice a change in the skin where the treatment was applied.  These changes mimic an injury and the tissue can look irritated, however this is what the treatment is supposed to do.  You will typically notice the following changes that will last a few days to a little longer than a week:

  • Redness in the tissue.  This results from extra circulation in the area/bringing blood to the surface.
  • Round bruises may appear.  These may occur in areas when cupping was done for longer than a few min.  It results from collapsed superficial blood vessels in the skin.  They will resolve on their own, typically in less than a week.
  • Increased sensitivity in the area where the tissues were treated.  You may experience more sensitivity to touch or feel a bit bruised when you lie on the area.  This increased sensitivity typically lasts for a few hours post treatment.
  • Mild irritation or itching during the treatment.  This results from the effect on the circulation and nerves.  It may last for a few hours post-treatment.

When not to use cupping:

Cupping is a safe modality when used by a trained healthcare professional.  However there are sometimes when it should not be used.  Your professional will screen you for these conditions prior to applying the treatment.  Always let the practitioner know if you

  • Bruise easily
  • Take blood thinners
  • Have sensitive or thin skin
  • Are allergic to plastic or silicone (the cups are typically comprised of these materials)
  • Have an open sore
  • Have a bruise or mark from an unknown cause
  • Have a skin disease/condition i.e. psoriasis, eczema

The research on cupping

In health care one of the most important types of studies are systematic reviews.  This is where many articles are reviewed for quality and the researchers evaluate and conclude on the overall strength of the evidence.  These types of reviews give us more confidence in ensuring our practices are based on the best evidence available.  In addition to the great results I have seen from my practice, I was pleased to find this systematic review supported it’s use in managing pain

In summary the research supports cupping is particularly effective in managing:

  • neck pain
  • low back pain
  • shingles-related nerve pain

The results were even better when combined with acupuncture and manual therapy, all of which I have found useful in my practice.   I also find it useful to manage tight muscles, particularly after work-outs or in injury management, which might be why Michael Thorpe uses it too!

If you would like to try this technique and are having back pain, neck pain or muscle tightness, please contact me at 416-925-4687 or by email at




TMJ – Temporomandibular Joint Dysfunction

 Determining the best program to relieve pain in the jaw begins with an assessment of your jaw joints, facial muscles, neck, posture and work habits. Our Registered Physiotherapists and Registered Massage Therapists work closely with your treatment team of dental professionals to find solutions to your jaw pain. In addition to direct treatment a home program of self-treatment strategies is often provided.

Who will benefit?

You may benefit from therapy if you have any of the following symptoms:

    pain with opening and closing your mouth

    pain when chewing/talking

    clicking, popping sounds

    limited range of motion of the jaw

Treatment approaches may include:

    Soft tissue release (massage therapy)  

    Joint mobilizations


    Craniosacral therapy

    Home exercises                                                           

    Correcting posture

    Coordinating treatment with your dental professional

Service provided by:

Milad Bazaz Jazayeri RPT

Juliette Woodruff RMT

More information:

To Book an appointment call 416 925 4687 or email

Jaw Discomfort With TMJ (Temporo-mandibular joint dysfunction)


Do I have TMJ?

Juliette Woodruff – Bio

Juliette WoodruffJuliette Woodruff

Registered Massage Therapist and Acupuncture Practitioner

Juliette joined The Orthopaedic Therapy Clinic Team in 2004. She is a graduate of the Sutherland-Chan College of Massage Therapy. After graduating her ongoing commitment to professional development has led her to complete advanced studies in manual lymph drainage and she is currently pursuing certification in breast cancer treatment and myofascial release therapy. In 2012 she received her certification in acupuncture from McMaster University. Juliette is committed to collaboration.

Juliette is an integral member of our treatment team working to find solutions to pain and helping to relieve the barriers limiting recovery. She has worked with a diverse range of people including athletes, expectant mothers, and business professionals. She is particularly interested in treating conditions such as scoliosis, lymphedema, and frozen shoulder. She believes in helping her clients to become an active participant in their own healing process through body awareness, postural education, and self-care exercises.

Juliette has a personal as well as clinical experience with the different stages of cancer. She works towards creating improved quality of life for her clients through education, exercise, self-bandaging, acupuncture and manual lymph drainage techniques. She believes in implementing a variety of modalities and current knowledge to improve and personalize care.

Juliette has a specific interest in the relief of pain and restoration of mobility in scoliosis. She has worked with clients following extensive reconstruction surgery as well as non-operative conditions. She has studied with Dr. Rudolph Weiss of Germany (Katerina Schroth’s grandson) and received a certification in his Scoliologic method. She has a developed an approach to the application of massage therapy in scoliosis which has been recently published by her professional alumni newsletter. SutherlandChan_FingerPrint

Juliette implements knowledge and clinical techniques from a variety of post-graduate courses such as: treatment techniques for post-operative breast cancer, cervical joint mobilizations, Structural Integration for structural alignment (Nisa), Scoliologic method, myofascial techniques, and acupuncture. She utilizes and incorporates several different treatment approaches to develop an individualized approach for each client.

Association Memberships

Juliette is registered with the College of Massage therapist of Ontario. She is a member of the Canadian Massage Therapy Association and the Canadian Academy of Medical Acupuncture. Her interest in sports and movement led her to obtaining a level II theory/practice National Coaching Certification in swimming.

Milad Bazaz Jayzayeri – Bio

MiladMilad Bazaz Jayzayeri

Registered Physical Therapist BSc. M.P.T.

Milad graduated from the University of Western Ontario in 2014 with a Master’s degree in Physical Therapy. He also holds a Bachelor of Science degree from York University’s Kinesiology and Health Science program where he graduated Summa Cum Laude in 2012.

Milad’s passion for physiotherapy led him to pursue additional courses to advance his knowledge and skills, both during and after university. He is currently completing his Level 2 manual therapy training and has completed the McKenzie training level A for treatment of spinal conditions, Mobilization with Movement (Mulligan concept) for treatment of lower quadrant conditions and Soft Tissue Release workshop. His interest in the application of acupuncture for pain management led Milad to partake in multiple courses in acupuncture and dry needling techniques through the Advanced Physical Therapy Education Institute (APTEI). He has been involved in physiotherapy research on exercise and post-concussion recovery. To further his knowledge in this field, Milad has recently completed a concussion management certification program through Shift Concussion.

Outside of the office, Milad likes to stay healthy and active. He is an avid photographer and when his time allows, he enjoys traveling and learning about different cultures as well as different perspectives on physiotherapy treatment. During his training, he completed a residency at the world famous Groote Schuur Hospital in Cape Town, South Africa; for which he was awarded the Leslie A. Bisbee Clinical Experience Bursary from Western University. During this placement Milad treated acute musculoskeletal, post-operative and trauma patients. Through necessary personalized care program and support, Milad aims to help every patient reach their best possible physical state. He is fluent in 2 languages: English and Farsi.

Temporomandibular Joint Dysfunction (TMJ)

TMJ  – Temporomandibular Joint Dysfunction

Determining the best program to relieve pain in the jaw begins with an assessment of your jaw joints, facial muscles, neck, posture and work habits. Our Registered Physiotherapists and Registered Massage Therapists work closely with your treatment team of dental professionals to find solutions to your jaw pain. In addition to direct treatment a home program of self-treatment strategies is often provided.  

Who will benefit? You may benefit from therapy if you have any of the following symptoms:

·         pain with opening and closing your mouth

·         pain when chewing/talking

·         clicking, popping sounds

·         limited range of motion of the jaw

Treatment approaches may include:

·         Soft tissue release (massage therapy)

·         Joint mobilizations

·         Acupuncture

·         Craniosacral therapy

·         Home exercises

·         Correcting posture

·         Coordinating treatment with your dental professional


Service provided by: Milad Bazaz Jazayeri RPT, Juliette Woodruff RMT

More information:


Do I have TMJ?


If you’ve ever experienced jaw pain, you may have been told, “You have TMJ!”. But do you really have that? The short answer is Yes! In fact, you and everyone you know has TMJ.


TMJ is the short form for temporomandibular joint. As it is in the name, that’s just the name of a joint in your body, to be more specific, the jaw joint. Therefore, as long as you have jaw joints, you have TMJ.

Pathology in this joint is generally referred to as Temporomandibular dysfunction (or TMD for short). Like anything else in life, this joint is all about balance! There are a lot of tiny muscles around your jaw and face that are responsible for opening and closing your mouth, one of the most important functions of the human body. You need this joint for functions like eating and speaking.

What are the symptoms of TMJ dysfunction?

If you experience any of the following symptoms, you might be dealing with TMD:

  • Pain around the jaw
  • Clicking of the joint (associated with pain)
  • Limited range of motion of the jaw (not able to fully open the mouth)
  • Morning headaches
  • Ear pain
  • Neck pain and stiffness (especially around the base of the skull)
  • Pain with chewing and/or talking
  • Pain that increases with stress

Why does my jaw click?

Your jaw clicks when the fine balance around the joint is compromised. There is a disc in the middle of your jaw joint which is responsible for smooth movements of the bones of the joint. This disc can be pushed out of the place due to a variety of reasons (like excessive muscle tension), which can lead to clicking around the joint. Pain and stiffness can be due to many factors such as excessive muscle tension, degenerative changes, tissue irritation, or joints that move too much or too little. 

What can I do to control my TMJ pain?

There are a number of self-management techniques that can help with this pain. The goal of these techniques is to reduce the tension around the joint and give it some rest. Some suggestions that you might find helpful are:

  • Avoid end range movements (e.g. taking big bites)
  • Try a softer diet for a period of time
  • Avoid habitual chewing (e.g. gum)
  • Pay attention to your posture
  • Wear your mouth guard at night (if you have one prescribed by your dentist)
  • Avoid intentional clicking of the jaw
  • consider anti-inflammatory pain medications (talk to your doctor or pharmacist if this is appropriate for you)

Who should I see for TMJ pain?

There is no one healthcare profession who is dedicated just to the treatment of TMJ pain. If you are experiencing these symptoms, you should consider discussing it with your dentist, TMJ trained physical therapist/massage therapist or your physician.

How can physiotherapy help my TMJ pain?

Your therapist assesses your jaw joints, muscles that can affect the balance around the joints, your posture and your neck. Yes, your neck! In certain cases, your neck and posture can lead to pain around the jaw.

Depending on the findings of the assessment, your therapist may consider any of the following treatment options:


If you are dealing with a jaw pain/stiffness that is not improving with self-management techniques, and/or you have seen your dentist or doctor but still have discomfort around your jaw, you may benefit from physiotherapy treatment.

Contact us if you are interested in learning more about the treatment of TMD or would like to book a treatment for your TMJ pain/stiffness.  Speak with Milad Bazaz-Jazayeri, Registered Physical Therapist – – to learn more about the treatment that fits your needs best.


Treat Yourself – The art of self-massage to relieve neck and back tension

Treat Yourself – Learn the art of self-massage to relieve neck and back tension –

Juliette Woodruff Registered Massage Therapist

June 14, 2017, 12:15-1 pm

You can’t always see your registered massage therapist when the knots in your neck give you headaches or the muscle tension builds in your back.  Self-treatment with rollers, lacrosse balls and other trigger point techniques can give you immediate relief – or make you worse.

Provided by Juliette Woodruff, Registered Massage Therapist, this 40 minute workshop will introduce you to techniques you can use to immediately reduce muscle tension and instruct you in the best applications to avoid injuries.

Format:  Participant workshop

Maximum number: Limited to 10 participants

Juliette Woodruff, Registered Massage Therapist and Certified Acupuncturist

Juliette joined The Orthopaedic Therapy Clinic Team in 2004. A graduate of the Sutherland-Chan College of Massage Therapy she has completed advanced studies in manual lymph drainage and she is currently pursuing certification in breast cancer treatment and myofascial release therapy. In 2012 she received her certification in acupuncture from McMaster University.

Stress is an Opportunity for Growth when Approached the Right Way

Stress is a fact of life. Sometimes it gets so bad we see ourselves as unfortunate, even as lost souls. But with the right understanding and resources, we can regain strength and actually grow from stressful situations. We can use stress to find our limits and boundaries—to challenge us and empower ourselves to heal.

Being stressed out is an opportunity for growth when you approach it the right way


Stress approached truthfully and intelligently can bring evolution on the highest level. I like to think of stress as an acronym, STRESS, which stands for:

  • Strain
  • Thoughts
  • Rest
  • Energy
  • Support
  • Strategy

It’s an easy way to remember the different elements that make up this force that has such great impact on our lives. A clear and strong understanding of how stress is seen intelligently can only bring an opportunity for greater confidence in healing with it.


The combination of physiological, emotional, and energetic dysfunction is the first “S” in STRESS.

  • Physiological: Chronic stress produces too much of the stress hormone, cortisol, which triggers a cascade of unhealthy changes in the body. Functional systems, such as digestion, hormone, immune, and cognition, are affected by chronically high cortisol levels and eventually become dysfunctional.
  • Emotional: When the physiological systems are not functioning well, negative emotions come up more frequently. Anxiety, depression, and nervousness are examples of chronic-stress related emotions. How we see life (with the glass half full or half empty) will affect our emotional reactions to stress, too.
  • Energetic: We exist on many different levels, energetically being one of them. (Read more about this in the Energy section further down.) When we’re healthy, our energy body is in synch with our physical body. When this dynamic is unbalanced we lose energy. A helpful analogy is to think of yourself as a computer with trillions of programs running, and how viruses in your system will slow it down or cause malfunctions.
  • Thoughts:  We are what we think about; high-vibration positive thoughts are healthier than low-vibration negative thoughts.Our thoughts affect our physical reality because we manifest what we think about, both consciously and unconsciously. From language to buildings to politics to technology to hamburgers—everything began as a thought.

We created words to articulate our thoughts and give form to our ideas. But often we don’t pay attention to the power of words. We use them indiscriminately, carelessly, angrily. Yet choosing our thoughts and words carefully, with wisdom, results in better outcomes. Positive words have a higher vibration than negative words—their energetic signature has better qualities. High vibrations are associated with positive feelings such as love, forgiveness, compassion and peace. In contrast, low vibrations are associated with harmful feelings such as hatred, fear, greed and depression.

In his book The Secret Life of Water, Masaru Emoto’s experiments with water molecules and crystallization patterns prove that the quality of thoughts and words (high vs. low vibration) influence the quality of water. In Breaking the Habit of Being Yourself, Dr. Joe Dispenza writes about the brain’s neuroplasticity and the power of words to create change—positive or negative.

  • High vibrational words: Love, Happiness, Compassion, Peace, Opportunities, Respect
  • Low vibrational words: Hate, Depression, Judgement, War, Problems, Dishonour


Strong sleep and restorative time outs are important for healing from stress. Our bodies have opportunity to heal when we sleep. This is when your functional systems and energetic systems regenerate and reboot.

Good sleep quality relies on a few factors:

  • intelligent duration ( 8-10 hours for most people )
  • a dark room to prevent disruption of your circadian biological clock
  • cool temperature
  • quiet setting
  • a comfortable, supportive bed.

Certain hormonal and physiological dysfunctions from chronic stress can disrupt sleeping patterns—seeking support from a qualified health practitioner may help. (For a well-researched, informative book on the importance of smart sleeping, pick up Lights Out by T.S Wiley with Bent Formby.)  Restorative time outs include going for walks in the park, sitting outside in the sun, deep breathing, and hugging. All these activities have been shown to reduce cortisol levels—read Cracking the Metabolic Code by Dr. James B. LaValle for more insight.


We are vibrational beings composed of many different energetic systems, including meridians, acupuncture points, chakras, and etheric fields. Vibrational Medicine by Dr. Gerber is one of the most respected and well-researched books on energy medicine. Unbalanced, stressed energy systems can affect physical biological systems (particularly the hormonal systems) and create disease.

One of the techniques I use in my practice is tapping.  It is a simple, effective way to reset and rebalance our energy systems. It’s part of a method called the Emotional Freedom Technique (EFT), which helps people deal with stress and unhealthy emotions. For more in-depth opportunities to experience energy medicine, seek out healing practitioners who use the tools I have found have found most helpful in my practice such as Reiki or Qigong. Acupuncture can also help to balance energy. These skills can introduce you to new and exciting healing methods to reduce stress.


We are all here to do two things in this world: learn and help each other out. I tell this to my patients all the time. I’m also fond of signing off my emails with “Unity and Healing”. Why? Because stress is humanity’s common denominator—we all experience it, no matter what our lives look like. With such a strong connection pulling us together, it’s natural to unite for support and healing. Friends, family, health practitioners, and support groups are all potentially blessed opportunities to heal and grow from stress.

Strategies for Stress:

We all need a well formulated and executed plan to evolve from stress. (We don’t just need it—we deserve it!) You are the only one who can control YOUR life and to be successful, strategy is pivotal.

Five Minute Living: An intelligent strategy includes having the right support (see the second-last “S” of STRESS, above), and the “Five Minute Living” concept: anyone can find five minutes a few times per day to regain a healthy state of being and happiness. Five minutes of deep breathing, stretches, tapping or other energetic practices, walking, positive affirmations, peaceful quiet sitting, hydration, supportive eating and supplements, and hugging a loved one is time well spent on powerful approaches to dealing with stress.

My patients who come to me for help managing stress may get a Reiki treatment or Qigong session. Or maybe they’ll get some bodywork to release tension. But they will also get coaching to help them adopt the practices I’ve mentioned here as part of STRESS—like exercise, better sleep habits, nutrition, positive affirmations—so they can find balance in their daily lives and learn to handle stress like a master.

If you are experiencing stress and would like to learn how to manage it or would like to learn whether Reiki, Qigong and energy balancing can help you, please contact Dr. Adonis Makris, DC at 416-925-4687 or email at

Physiotherapy for Headache and Neck Pain

Physiotherapy for Headache and Neck Pain –

Milad Bazaz Jayzayeri Registered Physiotherapist

Wednesday Feb 22nd, 2017 1-2pm

Headache is the most common pain disorder affecting both your work productivity and your quality of life!

Did you know that neck stiffness is one of the common causes of headaches?  Exercises, posture and self-treatment can be helpful strategies to prevent pain.

Milad Bazaz Jayzayeri, Registered Physiotherapist and concussion rehabilitation practitioner, will present this 40 minute workshop to help you understand the risk factors, causes, prevention and treatment of headaches caused by neck stiffness.

Milad Bazaz Jazayeri

Registered Physical Therapist

Milad completed his Master’s degree at The University of Western Ontario in 2014. With a bachelor of science in Kinesiology, he focuses on providing tailored treatment program to his patients. Milad has completed courses in acupuncture and dry needling, concussion rehab, manual therapy and myofascial release.

Format:  Participant workshop/lecture

Maximum number: Limited to 15 participants

Functional Medicine: A Proactive Approach for Long-Term Health

By Dr. Adonis Makris D.C.

About 16 years ago I discovered Functional Medicine and began studying[1] this ground-breaking method of patient care. This holistic approach to treating patients incorporates the latest genetic science, systems biology, and insights into how environmental and lifestyle factors trigger the emergence and progression of disease. As a medical professional this approach to health care is an important part of my toolkit for treating patients.

holistic medicine

What is Functional Medicine

Functional Medicine is truly holistic—it views all the components of the human biological system as a functioning whole. The body is seen as a single, integrated system rather than a bunch of organs and body parts “owned” by different medical specialties. It treats the whole person by looking at how a patient’s complete bio-system interacts dynamically with their environment to produce patterns and effects that change over time.

Bringing the practice of medicine into the 21st century

Conventional medicine today is focused on the diagnosis and treatment of trauma or acute illnesses that require urgent care—for example, pneumonia or appendicitis or a bone fracture. Physicians treat patients with drugs or surgery to try and fix the immediate problem or symptom.

This acute-care approach to medicine, however, is not designed to prevent and treat the complex, chronic diseases that are running rampant in modern Western society. This means that people who have a general sense of not feeling well and those without any confirmed disease often “fall through the cracks” in terms of conventional diagnosis, but can benefit from the principles of Functional Medicine.

The underlying causes of conditions like diabetes, heart disease, osteoporosis, reflux, mental illness, and autoimmune disorders such as fibromyalgia and Sjogren’s syndrome are often missed when the approach is limited to managing the symptoms. Most medical training does not look at preventing chronic illnesses through nutrition, diet, and exercise.  Although the research and information around managing disease is increasing, time  is needed to implement new practices in more traditional professions. Nonetheless, the changes are steadily presenting themselves in the field of medicine.

Heading off chronic disease at the pass

You don’t need to have a chronic disease to benefit from Functional Medicine. The approach addresses the underlying causes of disease even before it has a chance to take root. It engages both patient and practitioner in a therapeutic partnership to support long-term health.

Often one of the early symptoms which is addressed by Functional Medicine is a general sense of feeling unwell.  This may be the start of something that could lead to a disease. Functional Medicine can give you a chance to nip conditions in the bud before they blossom into a disease

The major influences that contribute to chronic disease include:

  • Poor nutrition
  • Sedentary lifestyles
  • Chronic stress
  • Poverty[2]
  • Environmental toxicity
  • Fragmented social networks[3]
  • Chronic infections[4]
  • Aging

How does Functional Medicine Help?

Functional Medicine integrates a patient’s signs, symptoms, and common pathways of disease with seven biological systems where core clinical imbalances are found. These core clinical imbalances bring together the mechanisms of disease with the manifestations and diagnoses of disease:

  1. Assimilation: digestion, absorption, microbiota/GI, respiration
  2. Defense and repair: immune, inflammation, infection/microbiota
  3. Energy: energy regulation, mitochondrial function
  4. Biotransformation and elimination: toxicity, detoxification
  5. Transport: cardiovascular and lymphatic systems
  6. Communication: endocrine, neurotransmitters, immune messengers
  7. Structural integrity: sub-cellular membranes to musculoskeletal integrity

In this way we can see that one disease/condition may have multiple causes (that is, multiple clinical imbalances), just as one fundamental imbalance may cause many seemingly different conditions.

For example, obesity is a condition that can result from numerous imbalances—hormones, mood disorders, diet and exercise, genetics, inflammation. But also a single imbalance, such as inflammation, can cause many conditions (diabetes, heart disease, depression, arthritis, cancer). Functional Medicine seeks to restore balance in the patient’s environmental inputs and in the body’s fundamental physiological processes because balance is the key to restoring health.

Functional medicine, nutrition and science

Scientific research around the therapeutic effects of nutrition give credibility to the Functional Medicine approach. A large and rapidly expanding evidence base about the benefits of clean eating, and the clinical use of vitamins, minerals, and other nutrients such as fish oils, support the treatment method. 

This also applies to Mother Nature’s botanicals (organic fruits, veggies, herbal medicine); exercise (aerobics, strength training, flexibility); stress management; detoxification; acupuncture; manual medicine (massage, manipulation); and mind/body techniques such as meditation. We also use guided imagery and biofeedback. All these alternative tools and practices are gaining more credibility within the medical community based on the growing body of research to support their value.

Because chronic disease is a food and lifestyle-driven, environment and genetics-influenced phenomenon, we need an approach to healthcare that integrates all these elements within the scope of each patient’s personal journey. With Functional Medicine we have a proactive approach to solving the modern epidemic of chronic disease that is creating a global health crisis.

My Approach

As a Functional Medicine practitioner I spend time with patients, listening to their histories and asking questions to uncover the interactions among genetic, environmental, and lifestyle factors. With science, clinical wisdom, and innovative tools, we can identify many of the underlying causes of chronic disease and intervene to correct the clinical imbalances, even before actual disease is present. Even for people who feel relatively healthy but may have a few complaints Functional Medicine optimizes your health and gives you strategies to prevent disease before it takes root. For example this approach can benefit you if you have any of the following concerns:

  • fatigue
  • poor sleep patterns
  • injuries
  • stress

For my patients, it begins with getting a complete history of your illnesses and injuries (about an hour-long interview), answering a series of in-depth health appraisal forms and questionnaires about food intake, plus a commitment to keeping a daily food diary to track eating habits. There’s also a physical examination that involves tests (blood pressure, pulse, respiratory rate, neurological screening) and blood work done with a chemistry lab to assess hormonal balances and metabolic function.

Ultimately, your health is your biggest asset. To get an in-depth understanding of how Functional Medicine can work for you, an initial consultation with a Functional Medicine practitioner is a great investment in preserving that asset for years to come. Contact Dr. Adonis Makris at the Orthopaedic Therapy Clinic to set up an appointment for a thorough assessment and to discuss whether Functional Medicine is a treatment option for you., 416-925-4687.

This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment options are appropriate for your condition.

[1] (Currently Dr. Adonis Makris is a post-graduate Doctorate candidate at Functional Medicine University.

[2] Fear of financial stability is the No. 1 cause of stress in today’s society; actual poverty disrupts peoples’ ability to access specialized health practitioners, and purchase quality food, supplements, and natural medicines.

[3] Society has become more individualistic; people are addicted to mobile devices and social media at the cost of personal interactions with family and friends.

[4] Candida being the most common 


Energy Work

Energy work

What is energy work. 
Energy work refers to a variety of body-work techniques used more extensively in holistic-types of treatments.  Often people with chronic diseases, low energy, intolerance of deep tissue massage and/or conditions which are not responding to traditional medical approaches find these types of treatment beneficial.
There are several schools of thought and different techniques related to Energy work.  These often consist of very light hands-on techniques or stationary placement of the therapists hands to areas which are in need of re-balancing.
Types of energy work available at The Orthopaedic Therapy Clinic
At The Orthopaedic Therapy Clinic we have 3 types of Energy-work treatments. Each type has similarities in technique and patient experience.  These similarities can sometimes allow the techniques to be interchangeable however some people respond better to one technique than another.
At our clinic each technique is associated with a different profession and depending on your benefit coverage this may make one technique more accessible than another.
Cranial-Sacral Therapy – provided by Juliette Woodruff, Registered Massage Therapist
Reiki Therapy – provided by Dr. Adonis Makris Registered Chiropractor, Reiki Master.
Who benefits from Energy Work?
Energy work may be selected when someone has a frame of reference that is more holistic.  Much like acupuncture, these techniques look to treat the entire body by improving energy flow.
These techniques can be used to help recovery after injury or disease by reducing stress and inducing a general sense of wellbeing.
What can I expect from my treatment?
Your therapist will take a history to determine your primary reasons for seeking treatment.  Treatment may be provided in a typical massage fashion using a sheet to drape the non-treatment areas or in some cases you will be fully clothed.
Treatment should induce a deep sense of relaxation and will often help to improve breathing and reduce pain.  Results are often cumulative with each session producing more substantial changes.
Insurance Coverage
All treatments are provided by registered health practitioners.  Depending on your insurance these treatments will likely be covered under your extended health benefits.

Headache and neck pain

Milad Bazaz Jazayeri, BSc (KIN.), MPT. is a Registered Physical Therapist, practicing in downtown Toronto @ the Orthopaedic Therapy Clinic.

As a physical therapist, I am often asked if physiotherapy treatment can treat headaches? In this article I have tried to briefly review and answer some of the common questions about headaches with the focus on those associated with neck pain. Neck pain is a common cause of headaches and physical therapy treatment is effective in the treatment of this condition (1).

There are a number of known factors that can cause a headache. A cervicogenic headache, also referred to as cervical headache or cervical migraine, is a headache caused by a disorder of the cervical spine and related structures. These headaches are often associated with neck pain. This condition is thought to be more prevalent in women and in the population over twenty years of age. Despite being a factor for migraines and tension type headaches, there is no known correlation between family history and cervicogenic headaches.

In the human body, the cervical region of the spine refers to the neck area. This area consists of seven vertebrae (i.e. neck bones and the surface cartilage – the smooth layer that covers the ends of bones) extending between the base of skull and the vertebrae where the ribs attach – thoracic region. The term cervicogenic means the symptoms are rooted in the cervical region (i.e. neck); hence, a cervicogenic headache comes from a problem in the neck. When a structure in your body (such as muscles or ligaments) senses potential harm, it generates stress signals and communicates them with the spinal cord through peripheral nerves. Therefore any problem in the muscles, arteries, dura matter, capsules, ligaments and joints of the upper cervical segments that are supplied by these nerves is forwarded to the brain and may result in a headache.

What are the signs and symptoms that your headache may be coming from the neck?

  • Dull, deep, achy in nature.
  • Often comes on gradually.
  • Typically these headaches are one sided and do not switch sides during or between episodes.Cervicogenic headache pattern
  • May be accompanied with pain at the base of skull, neck or shoulder.
  • Can fluctuate in frequency and intensity (generally mild to moderate).
  • Pain often begins in the neck and then spreads to other areas of the head (for example, to the top and frontal parts of the head).
  • Can last hours to weeks.
  • May be associated with limited neck movement.
  • Is made worse by moving your neck in certain directions.
  • Worsens by sustained awkward head/neck position i.e. prolonged computer use, looking down.
  • Little to no relief from pain medications.
  • Can be aggravated with stress or tension.
  • Relieved by neck treatments i.e. physiotherapy, massage.

Any limitation in movement at one joint can cause restrictions in movements of the neck as a whole.  these restrictions can potentially cause headaches. In addition, nerves that branch off the spinal cord have to pass through openings in between your neck bones. Any restrictions in these passageways can irritate the nerves and cause inflammation.  This may lead to symptoms, such as pain, numbness and tingling, radiating into other areas like shoulders, arms and hands.

The muscles around your spine and neck can also cause headaches. These muscles are loaded with sensors which act like a gauge, detecting movement and informing the brain of their position and activation pattern. This communication is crucial for the co-ordination of eyes and body movement. Postural dysfunction – i.e. forward head posture or slouching – can make these muscles shortened and tense. This increased tension is communicated with the brain and can cause headaches.

Treatment for headaches

Your registered physical therapist will use a thorough physical examination to differentiate the cause of your symptoms and to establish a program to guide you on the path to recovery. Once it is confirmed that the symptoms are coming from the neck region, your therapist may choose to use manual therapy (hands on treatment)  to restore the natural movements of the joints.  This will improve the neck’s movements and reduce the symptoms of cervicogenic headaches (2). This treatment can also help reduce the pressure on nerves and ease radiating symptoms down the arms.

As part of your assessment, your physical therapist may assess the strength and flexibility of the muscles around your neck. Strengthening programs can be beneficial for treatment of cervicogenic headaches (3). Often times, weakness of a muscle (or a muscle group) can lead to increased tension in other neighbouring muscles. In other words, in order to compensate for the weakened muscles, others have to work harder. Muscles that work harder than they should often present with increased tension. This increase in muscle tone can put them at a higher risk of injury, as they do not get adequate time to rest and recover from constant activation. When dealing with postural imbalances, it is common to note some weakness in certain muscle groups. Our body needs a proper balance between opposing muscles to maintain a healthy posture. For example, when dealing with the forward head posture, the muscles that are responsible to keep your neck in a neutral position (such as the deep neck flexor muscle group) are over-powered by the muscles that sit at the base of your skull (sub-occipitals). Strengthening the deep neck flexor muscles is like doing core exercises for you neck and can help reduce the tension and reduce intensity and frequency of cervicogenic headaches. Ensuring you have good trunk core muscles can help as well.

Releasing soft tissues can also help improve mobility and flexibility of muscles and fascia. This can reduce the tension in muscles and improve neck motion. Your therapist may assess your posture as it might play a big role in the pressure put on the structures around your neck. An individualized home exercise program designed to address your specific needs may include a focus on ergonomics and postural correction, strengthening weakened neck muscles, education on what can help or hinder healing, and improving the mobility of muscles, joints and nerves. I often consider use dry needling (also called IMS) and acupuncture as part of my patients’ treatment plan. This, in combination with other therapy approaches (such as those mentioned above), can help reduce pain and tension in muscles.

If you are experiencing headaches that present with the characteristics of a cervicogenic headache, contact us at the Orthopaedic Therapy Clinic to book an appointment or speak directly to Milad Bazaz Jazayeri, registered physiotherapist, to ensure the right diagnosis and treatment options for you. This article is not meant to replace advice from your healthcare professional.



Jaw Discomfort With TMJ (Temporo-mandibular joint dysfunction)

Jaw Discomfort With TMJ, by Juliette Woodruff R.M.T, Acupuncture Practitioner

Juliette Woodruff is a registered massage therapist practicing in downtown Toronto at The Orthopaedic Therapy Clinic. The temporomandibular joint (TMJ) is the most commonly used joint in the body.  It is estimated that most people open and close their mouth approximately 1,500 to 2,000 times a day for talking, chewing, swallowing, kissing, yawning, snoring, mouth breathing and facial expressions. It’s not surprising that this joint can get strained causing jaw discomfort.


Anatomy Of The Jaw Joint (TMJ)

 The jaw joint connects the lower jawbone called the mandible, to the bone on the side of the head called the temporal bone. These bones are where the joint gets its name – Temporomandibular or TMJ for short. When we open and close  our jaw the round part at the end of the lower jawbone (condyle) glides forward and back in the socket (fossa) located in the temporal bone.  For this gliding motion to be smooth it requires the soft disc that sits between the condyle and the temporal bone. This soft cushion-like structure separates the bones to allow the sliding effect (rotation) needed to be able to talk, chew, kiss, sing, and do a variety of other movements without pain. If you place your fingers just in front of your ears and open and close your jaw, you will feel the joint move. When there is a problem, you will feel the joint protrude out under your fingers or experience a click. TMJ – Temporomandibular joint dysfunction – YouTube

Symptoms Of Jaw Discomfort With TMJ

Jaw discomfort can cause a number of symptoms. When your jaw is a problem you may feel:

  • pain with opening and closing your mouth
  • pain when chewing gum or firm foods i.e. apples
  • clicking, popping sounds
  • limited opening of your mouth
  • locking of the jaw

Some symptoms may mimic other conditions.  TMJ issues can cause a pain in the ears similar to an earache. It can also cause a sensation of pressure, an annoying sensation of ringing in the ears (tinnitis), fuzzy sounds  and/or hearing loss. The TMJ issues can cause pain and tension around the head, neck, face, and shoulders. If muscles are involved, pain can be referred into the head causing headaches. The muscles involved in chewing (mastication) can refer pain in the forehead along eyebrows, the teeth (mimicking dental problems) and pain to the lower portion of the jaw. TMJ

Causes of Jaw Discomfort With TMJ

If the TMJ becomes damaged or misaligned, the soft disc may become compressed and torn from arthritis, trauma, or improper alignment of the jaw. Over time these bony structures, can deteriorate at an accelerating rate. The wear from the grinding on the joint, combined with the loss of the cushioning effect of the soft disc (articular), may cause difficulty in opening and closing of the mouth. The body may respond to this imbalance, by using the musculature of the face, neck, and jaw to try to realign the joint. As these muscles fatigue, additional muscles of the shoulder and back are progressively recruited into compensatory patterns.

Massage Therapy For Jaw Discomfort With TMJ

Many people clench their teeth at night without even realizing it. Once diagnosed, I wonder how many people never get a mouth guard? Perhaps you don’t want to be bothered with the annoyance of a plastic device sitting on your teeth at night and instead choose to avoid your dentist’s prescription. This avoidance may seem better at the time until your dentist finds hairline cracks in your teeth from clenching and grinding.  You may avoid it until you experience constant discomfort in the jaw, face, and other areas as the condition becomes more chronic. In addition to mouth guards, massage can be a useful therapy in the treatment of TMJ. Massage helps to lengthen the jaw muscles (treating trigger points), and reduces pain by treating the tension in the compensatory structures of the neck and shoulder region. Treatment is usually done while you are lying on your back so as to reduce pressure on the jaw area. It is often applied to the structures in and out of the mouth to achieve restorative normal motion of the jaw. The use of deep moist heat to increase blood supply to the fascia, muscles, shoulder and neck area can help loosen the tissue prior to treatment. Treatment may also involve the posture-related structures which influence the jaw position. Head forward posture or rounded shoulders create tension and excess muscle tension in the neck, and shoulders, altering the mechanics of the whole region.

Self – Treatment Strategies For Jaw Discomfort With TMJ

  • Learn how to self-massage your jaw muscles
  • Eat softer foods
  • Avoid repetitive jaw movements such as gum chewing
  • Apply heat to help relax neck and jaw muscles, but use ice when the jaw is inflamed
  • Correct your posture throughout the day (re-position head posture/watch forward head shoulder position or slouching)
  • Release tight musculature by massaging a tennis ball in your shoulders and at the base of the neck
  • Lie on a foam roller to stretch chest muscles and mobilize your mid-back
  • Learn jaw exercises to release tension
  • Avoid sleeping on your stomach to reduce strain on the neck

Other causes of Jaw Discomfort – TMJ

It’s important to get a proper diagnosis.   if symptoms persists as there are other possible causes of jaw discomfort such as:

  • Autoimmune disease
  • Infection
  • Strain from dental procedures
  • Stress

If these self-help strategies don’t work, or if the pain and discomfort in the jaw increases, then you should discuss your symptoms with your dentist, physician, and/or physiotherapist. Disclaimer-This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment are appropriate for your condition.

  3.  Canadian Dental Association
  4. Physiotherapy management of Temporomandibular Joint (TMJ) pain

What You Need to Know to Prevent and Treat Shoulder Pain Caused By Swimming

Swimmers shoulder is a soft-tissue condition caused by inflammation and is the most common injury in swimmers. If misdiagnosed or mal-treated, it can become chronic and very painful. Someone experiencing swimmer’s shoulder might ask the following questions:

  1. Why does my shoulder hurt when I swim?
  2. I train a lot and my shoulders are strong, why does swimming still hurt?
  3. What can I do to treat my shoulder so that I can return to swimming?
  4. I heard swimming injures the rotator cuff. Is swimming safe for my shoulders?

This article delves further into shoulder anatomy and the causes and resolutions of swimming-related shoulder injuries. It will answer the most important injury-related questions and provide insights to help avoid recurring injuries in swimmers and for other causes of shoulder pain.

Shoulder Anatomy

The shoulder is the most mobile joint in the human body however it’s biomechanical structure sacrifices stability for mobility. This design disadvantage can be visualized as a golf ball sitting on a tee. The large humeral head (the top of the arm) sits on a tiny scooped out glenoid cavity (part of the shoulder blade) and together, they form the shoulder joint. Unlike the golf ball which is meant to be launched from the tee, the head of the humerus must remain centered and stable yet allowing for a large range of motion.

An important muscular system called the rotator cuff stabilizes this “ball” and prevents it from sliding off the socket. The rotator cuff has the largest effect on joint stability and is comprised of four muscles; supraspinatus, infraspinatus, subscapularis and teres minor. These muscles and their tendons run around, over and under the joint and are protected from the rough surfaces of the bone by a cushioning fluid filled layer called the “bursa”. In a healthy shoulder, the tendons are protected by the bursa and glide underneath the bony structures without being harmed when the arm is moved. However, when it comes to competitive swimmers where each shoulder averages roughly 4000 strokes in a single workout, the biomechanics start to change.

1. Why does my shoulder hurt when I swim?

Swimmer’s shoulder injuries occur primarily due to excessive repetitive overhead motion. This movement narrows the subacromial space, a tunnel like opening located between the acromion (the front part of the shoulder blade) and the humerus. As this narrows, the space for the tissues becomes restricted. This results in the bone applying direct pressure to both the tendons and bursa, inflaming and irritating the soft tissues. This can lead to conditions such as impingement, bursitis or tendonitis.

2. I train a lot and my shoulders are strong, why does swimming still hurt?

Swimming long distances, excessive training, poor stroke mechanics and lack of rest can all demand more from the shoulder muscles than they have to give. It’s sometimes easy to forget that overworking our muscles and overtraining can interfere with what we are trying to achieve and instead lead to regression, poor performance and detrimental changes. When the rotator cuff is overworked it weakens and fails to stabilize the shoulder; often leading to subluxation of the joint.

3. What can I do to treat my shoulder so that I can return to swimming?

It is important to keep in mind that swimming demands much more than just the isolated function of the shoulder. We use our shoulder blades, back, trunk and legs to stabilize the body and help with the pulling motions. Overall, shoulder injuries can be prevented by adding in dry land exercises that are designed to strengthen these muscles.

At the Orthopedic Therapy Clinic, our physiotherapists determine the source of your shoulder injury by assessing your shoulder strength, range of motion and posture. We look for signs of glenohumeral instability, altered scapulohumeral   and poor neuromuscular control.

  1. Shoulder dislocation :
  2. Scapulo-humeral rhythm
  3. Poor neuromuscular control:

Each of these alterations can lead to training errors and restrictions which can cause and prolong the recovery from a painful swimmer’s shoulder.

Whether your shoulder pain is due to swimming or other causes, once the source of injury has been determined, our physiotherapists guide you through a comprehensive rehabilitation program that includes these five important steps:

Step 1: Injury Protection: The aim in this step is to decrease pain and inflammation and provide active rest from pain-provoking movement. Treatment includes modalities such as ultrasound, TENS, Interferential current, acupuncture, massage, heat/ice, rest and anti-inflammatory tips. In this step, we want to avoid painful movements while making sure the shoulder keeps moving in order to prevent other complications such as frozen shoulder.

       Also at this stage we want to keep the body moving and work on restoring the core as well as strengthen the areas that haven’t been affected. It is crucial to keep in shape and keep          active without straining the injured shoulder.

Step 2: Regain full shoulder range of motion: In this step, the goal is to help regain healthy, pain-free shoulder mobility. Our physiotherapists focus on stretching, myofascial release, joint mobilization and active/active assistive exercises. This is accomplished by lengthening shortened muscles, manually working on the joint and prescribing light strengthening exercises. Massage therapy can also be helpful in regaining motion and lengthening tissues.

Step 3: Restore scapulo-humeral movement: The shoulder is highly dependent on the scapula (shoulder blade) and its ability to control normal movement. An improper ratio of motion of the shoulder blade to the shoulder joint is a major cause of rotator cuff impingement and chronic shoulder pain. This step aims to correct this altered scapulohumeral rhythm and promote exercises to strengthen the shoulder blade and upper back muscles. This is an essential component for successful rehabilitation.

Step 4: Restore rotator cuff strength: In this step, our physiotherapists prescribe an exercise routine designed to regain the full strength of the rotator cuff muscles. Each exercise is individually tailored, progressing the athlete’s strength and endurance through the rehabilitation.

Step 5: Return to swimming: In this step, physiotherapists may suggest the professional coaching of a kinesiologist or work with your swim coach. This close interface will help to customize a training program designed to progressively increase speed, power, and agility. Athletes should work to perfect their technique as they slowly return to a full load.

4. Is swimming safe for my shoulders?

At the Orthopedic Therapy Clinic, we believe that prevention is the best medicine. We strongly suggest that all athletes undergo a screening evaluation prior to the start of their swimming season. Our physiotherapists focus on prevention and early treatment, identifying and addressing impairments prior to injury and evaluating our swimmers’ training methods and mechanics to ensure they are best suited for their goals. The screening evaluation of an uninjured athlete is as extensive and detailed as the one used for a swimmer with symptoms and in both cases, the goal is to determine if restrictions exist and then a plan is provided to prevent shoulder pain. The best prevention remains through specifically tailored exercises, good stroke mechanics and gradual increases in workload.

Svetlana’s background

In my practice I have had the privilege of working with many water based athletes as well as expanding my knowledge by completing a number of courses related to the shoulder and the rotator cuff muscles. In my experience, the prognosis for recovery is very good as long as the problem is caught in the early stage of injury and if all the steps of healing are successfully completed.

Swimming is an excellent sport that I encourage for many people. I am motivated to help those suffering from injuries so that they can get back in the water as soon as possible. If you are experiencing a swimming shoulder injury, a rotator cuff injury, or any shoulder pain and want to get it resolved, please contact me, Svetlana Marianer Registered Physiotherapist, at the Orthopedic Therapy Clinic in downtown Toronto.

This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment options are appropriate for your condition.

Reference :

Abelew T. Kinesiology of the shoulder. In: Tovin BJ .Evaluation and treatment of the shoulder: an integration of the guide to physical therapist practice, 2001. 

Becker, T. Components of a Dry land Exercise Program for Injury Prevention, A Scientific Approach To The Sport of Swimming, 1983.

Bell, K. Motivation, A Scientific Approach To The Sport of Swimming, 1983.

Ciullo, J. Swimmer’s Shoulder, Clinics in Sports Medicine, 1986.

Lewis, J.S., Green, A, Wright, C. Subacromial impingement syndrome: The role of posture and muscle imbalance, 2005.

Murphy TC. Shoulder injuries in swimming. In: Andrews JR, Wilk KE (eds). The Athlete’s Shoulder, 1994.

Richardson, A. The Shoulder in Swimming, A scientific approach to the sport of swimming 1983.

Seitz, A.L., McClure, P.W., Finucane, S., et al., Mechanisms of rotator cuff tendinopathy, Clinical Biomechanics, 2011.

Shapiro C. Swimming. In Shamus E, Shamus J (eds). Sports injury prevention and rehabilitation, 2001.


Do I Need Back Surgery?

backinjuryMaureen Dwight, Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spinal Practitioner ISAEC

When you are experiencing searing low back pain, sciatic leg pain or repeated episodes of back spasms, it is natural to wonder if surgery might be the answer. In the 30 years I have been working with spinal surgeons in downtown Toronto I have seen an evolution in our understanding of who benefits from back surgery and who is better off managing their symptoms with a cocktail of time, medication and therapy. We now know that even when your symptoms are intense, surgery is unlikely to be the solution. Long term studies tell us that given enough time there is a 95% chance that you will recover without surgery. In fact most people will see substantial improvement in their symptoms within 3 months.

That said, three months can seem endless when your back pain won’t let you get out of bed or the pain in your leg doesn’t let you sit for more than a few minutes. At this stage in your recovery it can be hard to hear that there is no instant solution however when the pain begins to lessen, and it will, most people are relieved that they avoided surgery. The right combination of medication and physical therapy can help many people manage until natural healing takes away the symptoms.

When is back pain an emergency?

Most experts agree that there is one back condition which should be treated as an emergency. The condition is called Cauda Equina syndrome. This uncommon condition results from pressure on the spinal nerves in the lumbar area where they fan out to look like a horse’s tail. Pressure on these nerves can result in loss of control in the bowel or bladder functions.

If your back pain is accompanied by a sudden loss in control of either of these functions this should prompt a trip to the emergency department. Left too long these changes can be permanent.
Discussion of this condition often prompts people to worry about their stress incontinence (peeing with strenuous activity, coughing, sneezing), or urinary frequency however these are not signs of cauda equine syndrome. With this condition you have:

• Uncontrolled urination and/or
• Uncontrolled defecation and/or
• Numbness, tingling in the anal and/or genital area

Despite the potential serious nature of this condition you still may not need surgery. Depending on the severity of the pressure on the nerves and on what your surgeon finds in the examination, he/she may choose to monitor the situation. Close monitoring of the symptoms is required and if you are receiving therapy, manipulation of the spine should be avoided. Once your symptoms stabilize a core exercise program should be instituted with a knowledgeable spine physical therapist.

Surgery for Sciatica

Sciatica is a particularly nasty condition which often starts with lower back pain but as it worsens the pain extends into the buttock and leg. It is typically caused by a pinched nerve and depending on the location of the pressure and the intensity of the symptoms, the pain can radiate down to your calf and foot.

Whether you are a candidate for surgery is determined by the cause of the pressure and your response to conservative treatment. Once again most episodes of sciatica will see substantial improvement within 3 months however if the pain persists and is caused by a herniated disc, or a narrowed spinal canal (stenosis), surgery can be an option.

Herniated disc and sciatica

The most common surgically treated sciatica is caused by a herniated disc. In this condition the center of the disc (nucleus) breaches the outer rings (annulus). If the disc protrusion is large or if it is located more to the side (laterally) it can pinch the nerve by pressing it against the walls of the spinal tunnels (canal and foramina).

Surgery for this condition is elective – meaning that once the surgeon confirms that you will benefit from a procedure you can decide whether you would prefer surgery or would like to try to manage your symptoms conservatively. In the most common type of procedure the surgeon removes the offending nucleus to relieve the pressure on the nerve (i.e. discectomy, microdiscectomy).

The intensity of the pain can prompt many people to choose surgery, and this option should help you to get rid of the pain more quickly, however if you decide that surgery is not for you the long term studies confirm that even with this condition most people get better. With time the pressure comes off the nerve as the herniation shrinks, much like a grape drying into a raisin. The pain abates once this natural process creates sufficient space in the spinal tunnels for the nerve to function.

Treatment of Disc Herniation Sciatica

While you are waiting to get better, or to see the surgeon, your therapy team’s focus should be on helping you to manage your pain. Your body needs time to heal and medication and/or other pain relieving types of therapy i.e. acupuncture, massage, physiotherapy, can be helpful to get you through the wait. Once the worst is over the focus should shift to physiotherapy to restore your core, correct your posture and education on long-term prevention strategies.

Therapy is also important if you decide to go the surgical route as it will help you to maximize your recovery. When opting for this type of surgery it is important to understand that the primary goal is to relieve your leg pain. After a successful procedure you still may have low back and/or buttock pain. When you are ready to begin therapy your physical therapist will work with you to restore core strength as this will help to manage these residual symptoms.

Sciatica and spinal stenosis

Sciatica can also be caused by an over-growth of bone which can be a result of wear and tear on the spine. For the pain to radiate down the leg this over-growth of bone is usually restricting the nerve as it exits the spinal canal (foramen). On your MRI the radiologist may differentiate the location of the narrowing by indicating it is at the foramen or in the lateral recess.

Some people are born with a congenitally smaller spinal canal. Inflammation or more minor bony over-growths can comprise the nerves in these restricted canals more quickly.

In this surgical procedure the surgeon typically elects a decompression to enlarge the space for the nerves to exit. They remove sufficient bone and/or soft tissue to provide enough room for the nerves to function.

Treatment of Sciatica caused by spinal stenosis

When your sciatica is caused by stenosis most people try to manage their pain conservatively before turning to the surgeon for help. This can be quite effective if this type of sciatica comes on suddenly as this presentation suggests that there may be dynamic elements contributing to the compression. Soft tissue protrusions (discs, ligaments, etc.), inflammation and posture can all put pressure on the nerves in the canal. These dynamic contributors can be temporary and should respond to therapy consisting of posture correction and exercises to reduce the lordosis (sway) in the back. If inflammation is suspected the addition of ice, medication, acupuncture and/or other physiotherapy modalities to reduce swelling can be useful.

Even when the X-rays and MRI’s show a nerve entrapment or a congenitally small canal these approaches can help you to control your symptoms. Once the pain improves it is important to continue your exercises and be aware of your posture as the size of the canal is still restricted and resuming old habits can cause the symptoms to reoccur.

If your decision is to have surgery, therapy is still an essential component of your recovery. The restriction of the nerve in the foramen often leaves specific muscle weaknesses which can remain even once the surgeon relieves the pressure off the nerve.

If the weakness has lasted more than a few months it can be difficult to restore this strength as your body may have started to compensate. You begin to adapt to the weakness and learn to function without the muscle. A knowledgeable spinal therapist will know where to look for these specific weaknesses and then can help you to learn to integrate this strength back into your everyday function. Without this type of therapy I find that symptoms are more likely to occur down the road as compensatory patterns cause postural adaptations that contribute to the recurrence of dynamic stenosis.

Neurogenic claudication and spinal stenosis

Spinal stenosis does not always present as sciatica. When the narrowing is located in the central canal, rather than as the nerves exit the foramina, some people will experience a heavy, numbing sensation in their legs as they walk. They may also feel tingling in their feet. If these symptoms are relieved by bending forward, crouching or walking with a shopping cart your stenosis may be causing neurogenic claudication1.

Surgery is typically considered when walking becomes quite restricted. It is important to discuss with your surgeon your expectations for function as some people can have quite a restriction in their canal and yet are able to walk for several miles. Other people can’t walk a block before feeling symptoms. Getting a good surgical outcome is often determined by your expectations as your goal is to walk further without symptoms following the procedure. You may choose to delay surgery if you are functioning at a high level.

Treatment spinal stenosis with neurogenic claudication

Although the presentation is slightly different, the treatment is essentially the same for neurogenic claudication as it is for sciatica caused by spinal stenosis. Posture is an important component of your program as the more swayed (lordotic) your back is, the more symptoms you will have while walking.

If your decision is to have surgery, therapy is still an important component of your recovery. Many people have been inactive for months or years as the pain limited activity. Add to this the fact that spinal stenosis typically affects us as we get older and many people find that they have lost substantial amounts of fitness by the time they have surgery. In addition to working on posture and muscle imbalances your post-operative program should focus on regaining your endurance for walking to help you to return to favorite activities such as golfing, traveling, bird watching and/or hiking.

1 Neurogenic claudication causes similar symptoms to another condition where the restriction is in the blood vessels in your legs. This condition is differentiated by the term vascular claudication.

Back Pain: Spondylolisthesis and Andre Agassi

Many of us who learned to play tennis in the ‘80’s and 90’s were taught to emulate Agassi’s mini-step style of movement. Small steps were believed to make you more adaptable, allowing you to adjust for the unexpected bounce of the ball. Then along came Pete Sampras with his long legs, loping gait and highly successful career. Almost overnight mini-steps were out and coaching focused on increasing the speed you could run to the ball. What a surprise for those of us who have lived through both of these style paradoxes to find out that Agassi’s movement was not a philosophy but rather the result of an impairment imposed on him by his back – spondylolisthesis.

What is Spondylolisthesis

Agassi and approximately 7% of the population suffer from a structural defect in the spine called spondylolisthesis. This condition is characterized by a fracture (lysis) that causes the front body of the vertebrae (spondylo) to separate (thesis) from the bone and joints located at the back of the spine. This defect allows the body of the vertebra to shift forward (thesis) in relation to the rest of the vertebral column, leaving this section of the spine inherently less stable than other areas of the spine.

What Causes Spondylolisthesis

When this conditions occurs in young people the cause has been attributed both to genetics and to injury. Injury has recently gained more support as it is well known that participants in certain sports are more at risk for this condition. Gymnasts, divers and football players all have a higher frequency of spondylolisthesis than what is typical for the rest of the population. It is speculated that immature bones cannot withstand the forces generated by these sports and the bone breaks under the stress. It is not known why the fracture never heals.

How serious is Spondylolisthesis?

Fortunately most spondylolistheses are stable, however when first diagnosed it is important to periodically monitor the condition to be sure that the shift is not increasing. The degree of instability can be quantified on X-ray by measuring the amount of shift in relation to the adjacent stable vertebra. The most common, and least unstable shift, is labelled as a grade 1 when the vertebral body shifts forward from 1-25% of its depth. There are a total of 5 grades with each level increasing by 25% until it reaches the extremely rare grade 5 where the front of the vertebrae has shifted completely forward of the spine.

Symptoms of Spondylolythesis

The age at which someone first experiences back pain can often be a marker for the presence of this condition. Whereas most people can expect to experience their first episode of back pain after age 30, the pain associated with a spondylolisthesis frequently manifests itself in our teens. The pain is often caused by certain movements straining the fracture site as it allows movement at the area commonly called a pseudoarthrosis (false joint). For example the sufferer may feel pain from the compression of the two surfaces while he or she is leaning back to serve the ball. It may also be caused by the increased stress on the disc. The firm attachment of the intervertebral disc to the margins of the adjacent bone is under more strain by the vertebra’s forward displacement.

Treatment of Spondylolithesis

The treatment for this condition depends on whether the condition is acute or chronic and the degree of instability. A highly unstable listheses will require surgery however most people with this condition do well with more conservative approaches. During the acute stage, the pain from the irritation of the pseudoarthrosis and/or the disc means that therapies which help to control pain are the priority. Ice, advice on modifying activity, rest, medication, acupuncture and/or a variety of electrical modalities can all be beneficial. Over the long term the goal shifts to strategies to prevent further strain on the weakened structure as this is what will ultimately limit future painful episodes and prevent additional damage.

Rehabilitation and prevention programs’ primary focus should be on posture and adequate muscle strength. This approach will help to ensure that the stress of everyday movements can be absorbed by the muscles rather than being transmitted to the mechanically challenged vertebral-disc complex. As with all back pain the importance of having a strong core cannot be overemphasized however in this condition you may also need to broaden the scope of exercises as depending on where the defect is located you will be more prone to specific muscular weaknesses. For example the most common location for a spondylolisthesis is in one of the bottom two vertebrae of the low back, L4-5 or L5-S1. The problem with this location is that it houses the nerves that supply the muscles of the buttock and outer hip and is a possible cause of sciatica. Damage in this area can cause compression to the nerves and this means it is more likely that strength will be lost in the muscles they supply.

Compensation and muscle weakness’

Although Agassi does not reveal the location of his spondylolistheses he alludes to having these specific muscle weaknesses when he attributes his back to the cause of his pigeon-toe gait. Having a toed-in position is often an indicator that the buttock muscles (gluteus maximus) and outer hip muscles (gluteus medius and minimus) are relatively weak. A postural and gait mal-alignment results when the muscles which turn the legs outward do not ounteract the pull of the muscles turning the legs in. Unfortunately this over-reliance on the inner thigh and groin muscles causes tightness and compensatory movement patterns which increase the risk of injury, particularly in someone like Agassi who competed at such a high level. His biography shows the outcome of these imbalances as he was often unable to finish matches once his over-worked groin muscles started to spasm.

Despite all of these anatomical stresses and strains many people who have a spondylolisthesis can be completely symptom free and may only find out that they have had this condition much later in life when they are being investigated for age related back pain. Having good core muscles is invaluable in counter-acting the effects of this condition and preventing pain.

The effects of a good training program can be seen in this example of Andre Agassi, as not only was he able to play tennis with this condition he was able to excel at it.