Rebates for Complementary Therapies

A couple of weeks ago, on Friday the 13th (yes, seriously), the Health Minister, Greg Hunt, quietly announced that the government intended to stop health funds paying rebates on "natural" therapies. This was quietly slipped in to a broader announcement of changes and many media outlets did not even pick up on it. These changes will take effect from April 1st (yes, again, seriously) 2019. This came without any warning to the peak complementary health bodies.

Where did this come from? This all started with John Howard's attempt to force Australians onto a user-pays health system like the US. He had a carrot-and-stick approach of the government paying 30% of private health insurance premiums (carrot) and charging people an increased Medicare levy (stick) if they didn't take out private health insurance, as well as an annual increase in premiums once you were older than 31.

Since the government pays 30% of most people's premiums, they now feel they can dictate what the funds reimburse people for, which seems a strange imposition on both business and individuals for a Liberal government to make.

They are using a review by the Chief Medical Officer as an excuse to remove the rebates. The terms for the review were very narrow, with good quality studies rejected for failing to tick one of many boxes. The CMO did find that more research was warranted, but oddly enough, no funding has been forthcoming. Conducting clinical trials is very expensive and requires participation at a university level, so funding is vital to produce enough evidence to satisfy these reviews.

What does this mean for you? At the moment, this is still a little uncertain. Bowen Therapy was in the list of things to be dropped, but it is still unknown if individual health funds will retain policies to cover complementary therapies that are not subject to the federal government's 30% rebate. There was no mention of massage therapy in the announcement, so the current presumption is that it is safe but this has not been stated categorically.

What can you do? Write letters! The Bowen Association Australia's committee of management has had advice that online petitions are pretty much considered spam by our elected representatives, so while I'm not suggesting you don't sign one, it's of limited use. A letter to your local member will go much further. The BAA has produced templates to base a letter on that can be accessed here and tailored to you. The letters broadly cover points around how this is an attack on individual choice in healthcare, an attack on small business and an attack on women in business, but you can include you own story to make it stronger. There is also a list of questions from which you can pick a couple for your member to put to the Health Minister. If you live in Liberal-held seat, you may be able to put some fear into your member that they won't retain their seat at the next election and stir a back-bench revolt. If it's Labor-held, give them ammunition with which to attack the government. If it's independent, even better - the current lack of a parliamentary majority gives your member lots of power!

Rotator Cuff

I’ve had a few people in with shoulder problems related to their rotator cuff. I’ve found injuries always come in “runs”, so I thought this’d be a good time to briefly discuss the group. A lot of people are diagnosed with a rotator cuff tear or dysfunction without anyone ever really going into what is happening or even specifically which muscle is involved.

The rotator cuff is made up of four muscles that both stabilise and move the shoulder joint. The glenohumeral (shoulder) joint is not overly stable due to the very shallow socket of the glenoid fossa but this is what allows the huge range of motion in this joint. As a result of the shallowness and instability, the muscles that cross the joint aid the ligaments of the area in strengthening the joint. Direct impacts to the shoulder or falling on an outstretched hand can easily dislocate or strain the joint damaging both ligaments and the tendons of the muscles.

The rotator consists of: the supraspinatus, which abducts (raises to the side) the arm; the infraspinatus and teres minor muscles, which both externally rotate (turn the hand palm out) the arm; and the subscapularis that internally rotates (turns the hand palm in) the arm.

Many of the patients I see with problem are troubled by having their arms stretched out for long periods. Hairdressers are commonly affected by having their arms at shoulder height all day. People who drive with extended arms and similarly people who work on laptops or with the keyboard pushed too far away can also experience problems. From a sleeping point of view, sleeping with your arms above your head can leave these muscles in spasm.

Most tightness and spasm will react well to Bowen therapy or remedial massage, however tears may need to be referred on to a surgeon depending on the grade of tear and any instability in the shoulder. Stretching these muscles isn’t overly easy due their attachment to the highly mobile scapula but there a few things that can be done.

Sciatica

I’ve had a few sciatica patients in the last little while, so I thought it’d be a good time to talk briefly about it. Sciatica is pain brought about by impingement or irritation of the sciatic nerve. It can manifest as pain anywhere from the buttock (and even lower back) to the foot and may produce neural symptoms in the foot (pins and needles etc). While this can result from injuries or structural problems in the lower back, by far the most common cause in my clinic is from piriformis syndrome.

Briefly looking at the anatomy of the nerve and surrounding tissue, the sciatic nerve originates from several nerves of the lower lumbar and sacral spine joining together. This nerve then comes from under the sacrum and passes almost vertically down, deep in the buttock. It continues down the rear of the leg innervating the back of the thigh, the entire lower leg and most of the skin on your leg.

Impingement of the nerve can occur at the spinal outlets from disc compression (bulge/herniation/degeneration) or from conditions such as spondylolisthesis (backwards or forwards displacement of the vertebrae). Downwards pressure of a swollen uterus during pregnancy can also cause it. The cause I see most frequently is referred to as piriformis syndrome. While the sciatic nerve passes almost vertically, the piriformis runs almost horizontally from the sacrum to the greater trochanter (that lump on the side of your hip) of the femur. The muscle sits adjacent to the nerve and in some people the nerve actually passes through the muscle. These people are particularly prone to piriformis syndrome. The upshot is that a tight piriformis can easily compress the nerve producing pain and nerve-related symptoms like pins and needles. Over a period the compression can lead to inflammation that can take time to recede.

The piriformis is used by your body to laterally rotate the femur – that is, turn your foot out. This will give some idea of things that can cause tightness. Do you walk with your feet turning out? Do you do squats with the feet turned out? These sort of activities encourage the tighening and shortening of the muscle and increase pressure on the nerve. It pays to keep the gluteus maximus (the big outer bum muscle) strong to take pressure off the deeper muscles.

Remedial massage and Bowen Therapy are both great for this, although Bowen has the advantage of being non-inflammatory. If the body is non-responsive after one or two sessions then scans may be required to check the health of the intervertebral discs and refer on if there is a problem.

Massage in Pregnancy

I’m often asked by pregnant women (and their partners) if they can have massage during pregnancy. They are often told by doctors, nurses or great aunty Valmai that massage is dangerous. That isn’t entirely true.

If your doctor or obstetrician has given you a direct instruction to not have massage then you must follow that, but if you have just found it amongst some general advice then appropriate massage should be safe.

There are certain pressure and reflex points on the body that can link to the uterus and should be avoided during pregnancy. As long as you go to a qualified therapist (you can always ask to see qualifications and association membership) and tell that therapist that you are pregnant, then massage should be perfectly safe for you. For this reason, it’s probably best to go to a professional rather than get your partner to give you a rub. Also, only a qualified aromatherapist should use essential oils with you during pregnancy as many are contra-indicated.

If you are still concerned, then maybe avoid massage during the first and third trimesters as these are least stable periods of gestation. Wait until after your 13 week check. And if you are ever concerned, talk to your therapist and your doctor. That’s what they are there for.

Why massage during pregnancy? Well, your body is undergoing many changes during this time and there is a great deal of stress on it. As well as hormonal changes and the possibility of tiredness, there is a great change in the weight-bearing of the structure. Swelling breasts and belly both put new stresses on the spine and associated muscles and can create much new tension. Also, as the pregnancy progresses, ligaments can soften and structures can move, creating new tensions, especially around the pelvic area. Finally, the way you use your body can also change. As the belly grows, many women adopt something of a duck-walk which can tighten the deeper glute muscles and create sciatic pain. Of course, the world doesn’t stop just because you’re pregnant, so there is still a job, stress, exercise and housework to all take their toll.

Some practitioners work with a special table with a hole cut for the belly. I tend to start the massage seated in a special chair for back and neck and then progress to side-lying for glutes, legs and lower back. This will vary from therapist to therapist – some are pregnancy specialists.

Just remember to always inform all practitioners that you are pregnant, even when tradition dictates to keep it to yourselves, and if you are at all concerned, talk to your doctor!