Whether you are reading a social media post, a blog, a newspaper article, or a journal paper it should always be read with a critical mind and never taken at face value.

In the world of medical and scientific journal articles it is all too easy to be drawn to an attractive title like “PRP superior to coritsone for lateral elbow pain: meta-anaylsis” to only read through the abstract taking the conclusion as gospel, because after all the title says it’s a meta-analysis which means the paper has to be solid right?

It is true that the strength of an article lies in its design with meta-analysis and systemic reviews at the top of the tree, followed by blinded randomised controlled trials, right down to case reports and editorials. Nevertheless, study design alone is not enough to be able to truly trust an article’s findings.

One must consider the methodology used and how easily it be can be reproduced, in addition to the strength and weaknesses of the selection (inclusion/exclusion) criteria including the outcome measures used. For example, if we are examining tendinopathy and the diagnosis is confirmed by physical examination alone without ultrasound, how many patients in the study will have confirmed tendinopathy? Even if those patients have been selected carefully, they are still at risk of dropping out of the study, which can have disastrous effects on the outcome of a study. As statistical power, or the number of participants required to be able to detect an effect is a vitally important.

Articles are also open to the risk of bias, confounders, errors, and chance which can all influence the outcomes of a study. It maybe the study has selected participants who are known non or strong responders to an intervention being tested, called selection bias. A strong study design aims to mitigate the risks of these occurring however, understanding their impact on a study is imperative when critically reviewing what you are reading. Additionally, articles often use statistical measurements such as, measures of associations and measures of heterogeneity including odds ratio, hazard ratio, relative risk, P value, I2 understanding these is crucial to be able to interpret the results.

Lastly, when consideration has been given to all of these aspects thought must then be given to the results and how they compare to other reputable research available in that area. Are the results consistent with other research, if not why? What research has been used to support their findings and is that research reputable and high quality? Do the results add weight to the existing research to further support an outcome? Do they give rise to a rethink about the existing research? Do they create a new higher standard or intervention? Or did the study use a weak design or were the results influenced by bias, confounders, errors, chance, or a high dropout rate, or poor selection criteria leading one to question the quality of the study’s findings?

Understanding what you are reading in this day in age where “authorities” are in endless supply is extremely important. Regardless of what you are reading, always sit back and ask yourself questions about what you are reading, who is writing it, why are they writing it, how robust is the article, what quality of evidence is it supported by, and are there any parties who will benefit from the results. 

For more interested blog articles check out the Shannon Clinic blog page.

With the current COVID-19 pandemic creating global disruption, uncertainty and with many countries enforcing society lockdowns, it is making physical activity and exercise more onerous. However, one of the few exceptions to the lockdown rules is exercise, so lets examine the evidence on exercise and immune function.

It is well known that regular bouts of exercise lasting up to 45 minutes of moderate to vigorous exercise is beneficial for immune defence, particularly in older adults and those with chronic diseases. This type of exercise is beneficial for the normal functioning of the immune system and is likely to help lower the risk of respiratory infections/illnesses. However, there is debate within the scientific community whether acute bouts of vigorous intensity exercise leads to a period of immune suppression post exercise.

There has been a long held concept in exercise immunology developed in the 1980s and 1990s called the “open window” hypothesis which proposes a J curve relationship between exercise intensity and infection risk. Which is supported by the belief that athletes who engage in high volume endurance training experience a greater incidence of Upper Respiratory Tract Infections (URTI) compared to those who are less active. Until recently this concept has remained relatively unchallenged.

The “open window” hypothesis suggests that following a prolonged (>1.5hr) and vigorous acute bout of exercise or following chronic intense training (>1.5hr on most days) there is an “open window” which results in an increased risk of opportunistic infections such as URTI’s. The three principles underpinning this concept are:

1). Infection risk increases after prolonged vigorous aerobic exercise

2). Acute bouts of vigorous exercise can lead to temporary reductions in salivary immunoglobulins resulting in higher risk of opportunistic infections

3). A period of post exercise reduction in peripheral blood immune cells resulting in a period of immune suppression.

J Curve – relationship between the risk of infection and level of exercise intensity

Recently though there has been emerging evidence suggesting this concept may be outdated. There is evidence, albeit small that indicates international athletes suffer from less URTI than national athletes. This raises the likelihood that infection susceptibility is more likely multifactorial including genetics, sleep, stress, nutrition, travel, circadian misalignment and increased exposure risks due to close proximity of crowds rather than being directly attributed to acute or chronic bouts of vigorous training. This also indicates that international athletes are potentially better supported, have access to better education helping them to improve their life-style behaviours over national athletes resulting in lower risks of infection.

Secondary to this, evidence supports the opposite of the three principles upholding the “open window” concept. With no changes seen in mucosal immunity which has previously been flagged as an indication of immune suppression. The reduction in blood immune cells (primarily lymphocytes) 1 to 2 hours post exercise reflects a transient and time dependent redistribution of immune cells to peripheral tissues resulting in a heighten state of immune surveillance and regulation leading to enhanced antibacterial and antiviral immunity, not suppression of the immune system.

Further research is needed to confirm or refute the “open window” concept however, it currently appears that the infection risk post vigorous exercise is more likely to be associated with a multitude of other factors rather than purely post exercise immune suppression. So for athletes and non-athletes the message remain the same during COVID-19, regular moderate to vigorous exercise is beneficial to enhance immune function to reduce the risk of bacterial and viral infections including URTI’s. And remember that good hygiene practices (washing hands regularly, not touching your face), physical distancing, getting good quality sleep, reducing stress levels and eating healthy wholefoods are the keys keeping your immune system in peak condition.

Find out more information on COVID-19 here.

COVID-19 Update

In light of the recent federal and state government announcements regarding the closure of non-essential businesses we wanted to notify our patients that as a primary health care service, we are an essential business and will remain open until otherwise informed. 

We receive daily updates from the Department of Health and Human Services and the Australian Chiropractic Association. As such we take infectious disease control very seriously and are doing all that we can to make our clinic as safe as possible including, making hand sanitiser available in our reception area for all patients, regularly wiping down all surfaces including our reception and treatment areas and employing physical distancing in our waiting area. We also ask that all patients undertake physical distancing, good hygiene practices and be aware of the COVID-19 symptoms which include:

  • A fever with or without acute respiratory symptoms
  • Acute respiratory symptoms include a dry cough, shortness of breathe, difficulty breathing.

Those at risk are patients who have travelled internationally in the last 14 days before the onset of symptoms or, who have had close contact in the last 14 days before the onset of symptoms with a confirmed case of COVID-19.

If patients fit this profile they need to be tested for COVID-19 and call the health department on 1300 651 160.

We therefore kindly ask that any patients who fit the case profile above with appointments at the clinic, to call and notify our reception staff to reschedule their appointment and then seek medical attention. We thank you for your understanding in these interesting times.

We have been watching the developments of the COVID-19 pandemic closely and decided that it was important to inform our patients, especially in light of the current media reporting.

There have been 6 coronaviruses to date that have been detected, including the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). To help put the current severity of COVID-19 into perspective with other coronaviruses these are the comparison infection and mortality rates to MERS and SARS.

  • SARS (2002) affected 8096 people with a mortality rate of 10%
  • MERS (2012) affected 2494 people with a mortality rate of 37%.

As COVID-19 continues to evolve, the numbers of those infection and the associated mortality rates will fluctuate however, the mortality rate at the time of writing this appears to be lower than that of SARS. Reducing the spread of COVID-19 is currently the key objective and primary concern, meaning patients shouldn’t feel alarmed but they should exercise common sense and good hygiene practices including, washing your hands regularly, not touching your face and maintaining a 1.5m distance to others to aid in controlling the spread of the virus.

The symptoms patients needs to be aware of are:

Those at risk are patients who have travelled internationally in the last 14 days before the onset of symptoms or, who have had close contact in the last 14 days before the onset of symptoms with a confirmed case of COVID-19.

If patients fit this profile they need to be tested for COVID-19 and call the health department on 1300 651 160.

We therefore kindly ask that any patients who fit the case profile above with appointments at the clinic, call and notify our receptionist to reschedule their appointment and then seek medical attention. We thank you for your understanding in these interesting times.

Pain is a complex subjective, sensory and emotional experience occurring as a result of damage or potential damage to tissue (skin, ligaments, muscles, bones). Pain is most commonly caused by a specific injury however, in some cases an injury mechanism is absent.

Types of Pain (Simplified)

There are three different types of generalised pain:

Nociceptive Pain

Nociceptive pain occurs when there is damage to a tissue (like burning your finger). This pain can be local or it can be referred (ie. the pain is felt away from where the tissue is damaged). An example of referred pain is, “sciatic” leg pain which is associated with tissue damage in the lower back.

Neurogenic Pain

Neurogenic pain occurs when the nerves behave abnormally by conducting nociceptive pain where there is no apparent tissue damage or pain source.

Psychogenic Pain

Psychogenic pain arises from the mind (such as the memory of a bad past experience).

Nociceptive Pain (Peripheral Pain)

Nociceptors are sensors found in the body which detect the possible threat of injury or actual injury to tissues such as bone, ligaments, skin etc. They then relay this information to the central nervous system (CNS) – spinal cord.

There are two types of nociceptive fibers, C fibers and A delta fibers which respond to different sorts of pain stimulation.

  • A delta fibers carry signals from the body’s periphery (such as the fingers or feet) back to the CNS very quickly and are responsible for the acute pain experienced when a tissue has been injured.
  • C fibers carry signals more slowly from the periphery to the CNS and are responsible for sub-acute/chronic pain.


When a tissue has been injured, the nociceptive fibers become sensitised. As a result, the nociceptives threshold for activation and subsequently sending pain signals back to the CNS is much lower. For example, following a bump on the head a light touch to the injured area will be painful. In the case of chronic pain, abnormal sensitisation of nociceptors contributes to why pain is easily triggered, why the pain is often disproportionate to the trigger and why pain is felt long after the initial injury stimulus has gone.

Spinal Cord and Brain Involvement

The information carried by the A delta and C fibers is then transmitted back into the CNS where it is processed in a part of the spinal cord called the “dorsal horn”. The dorsal then determines whether the information needs to be relayed up the CNS to a higher brain centre for processing and response. Or, it may determine the response can occur locally from the dorsal horn, called a “spinal reflex response”. An example of this would be the inflammatory reponse following an injury involving muscle spasm and increased blood flow.

Managing Pain

Non-pharmaceutical Interventions

Chiropractic adjustments are postulated to manage spinal pain by affecting the higher brain centre, the nocipetive fibers in the periphery of your body and through the spinal cord reflex response.

Acupuncture or dry needling is another treatment intervention for managing pain. Needling affects pain at the periphery by desensitizing the nociceptive fibers so they are not stimulated as easily, while also triggering a local muscle relaxation response.

Exercise therapy and physical activity is another intervention that is beneficial in the management of pain, including pain associated with musculoskeletal conditions like osteoarthritis and low back pain.

These are all interventions The Shannon Clinic use as a part of our holistic approach to patient care.

Read more about chiropractor Dr Nicholas Shannon. [Click through to About the Shannon Clinic page]

Pharmaceutical Interventions

Pain medication (analgesics) such as paracetamol (Panadol), ibuprofen (Nurofen) and diclofenac (Voltaren) work on desensitising the A delta and C fibers and hence reducing pain at the source (in the periphery). Pain medications which are codeine based (Opioids) like Panadeine work by affecting how the body interprets pain in the higher brain centres (centrally, rather than peripherally).

It is important to remember when taking pain medication that long term use of analgesics can have harmful side effects like gastric ulcers, renal disease and cardiovascular disease. In addition to this there is strong evidence indicating paracetamol and NSAID’s are ineffective in the treatment of low back pain.

The Benefits of HIT/HIIT Training

Exercise and physical activity are extremely important for our overall health and wellbeing. With evidence showing physical activity improves; quality of life, sleep, cognition, physical function, insulin sensitivity, while reducing the risks of; clinical depression, dementia, a raft of cancers and chronic preventable diseases, as well as anxiety, blood pressure, weight gain and falls. The current recommendations for physical activity are for 150 minutess per week of moderate to vigorous exercise, this means exercising to an intensity where it is still possible to maintain a conversation but with difficulty. High intensity (with/without intervals) training is a great way of efficiently reaching that 150 minutes per week mark with a host of added benefits.

High Intensity Training (HIT) / High Intensity Interval Training (HIIT)

HIIT refers to exercise that occurs in frequent short burst or “sprints” of high intensity exercise, with recovery periods. The sprints can last from 30 seconds to 4 minutes, with recovery periods lasting anywhere from 1 to 4 minutes and repeated sprints of 2 to 6 cycles per session. For true HIIT to be achieved, heart rate (HR) needs to reach 85-90%+ of max HR during the sprint effort. This is the key difference with moderate continuous training (MCT) where HR will only reach 60-70% of max HR.


In healthy individuals HIT/HIIT programs have been clearly shown enhanced exercise capacity, muscle strength and muscle oxidation compared to MCT. It may also improve cardiovascular fitness and function, as well as anxiety and depression severity. It has been associated with improvements in these same variable in individuals with cardiovascular disease, spinal arthritis and multiple sclerosis, in addition to reducing the disability associated with these diseases. In obese and overweight individuals it is as effective in the short-term as MCT at modest reductions in body fat and waist circumference, which suggests it may be a more time efficient way to exercise. Additionally there is also evidence showing it is well tolerated and has greater improvements in disability and exercise capacity in individuals with nonspecific low back pain when compared to MCT.

What Type of HIT/HIIT Program?

One of the appealing features of HIIT programs are how time efficient they are, especially when compared to MCT. In addition to this, HIIT programs appear to result in similar or greater endurance performances and VO2max (a measure of fitness) when compared to MCT.

Cardiovascular protocols utilizing short intervals (30 seconds or less), for 5 minutes or less, performed 4 or fewer times per week will assist in developing VO2max in the general population. However, the greatest improvements come from longer sprint intervals (2 minutes or longer), higher volume (15 minutes or longer) over a longer duration (4-12 weeks). Resistance training HIT protocols are typically defined as more than 70-80% of a 1 repetition maximum, performed at a maximum of 1 set of 12 repetitions.

Finally, for anyone considering a HIIT program it is important to note that even though HIIT appears to be safe for most individuals, consulting a health/medical practitioner to determine if a HIIT program is safe for you is extremely important before you start any HIIT program.